儿童劈离式肝移植术后肝动脉血栓形成的预防策略

Prevention of hepatic artery thrombosis after pediatric split liver transplantation

目的探讨儿童劈离式肝移植(SLT)术后肝动脉血栓形成(HAT)的预防策略。方法回顾性分析2014年7月至2022年1月中山大学附属第三医院接受SLT的连续88例儿童受者临床资料。受者家属均签署知情同意书,符合医学伦理学规定。其中受者男56例,女32例;年龄2~208个月,中位年龄9个月。供肝类型包括右三叶供肝11例,右半肝供肝5例,左半肝供肝9例,左外叶供肝63例。供受者动脉在3.5倍手术放大镜下用8-0血管缝线间断端端吻合,尽量吻合所有动脉分支,吻合完成后、关腹前、关腹后常规使用彩超和血流仪监测血管血流情况,术后按肝素钠桥接华法林方案抗凝。结果2例患儿术后第1天发生HAT,HAT发生率2%(2/88),其供肝类型分别为儿童右三叶供肝和儿童左外叶供肝,均立即予介入下溶栓及肝动脉支架置入。1例支架置入后肝动脉复通,规律随访48个月,无血管、胆道并发症;另1例术后第2天因多器官功能衰竭死亡。结论合理的供受者动脉匹配、手术放大镜下间断吻合所有动脉分支、标准化抗凝方案和规范化围手术期血流监测等综合策略可有效预防儿童SLT受者术后发生HAT。

Objective To investigate the strategies of preventing hepatic artery thrombosis(HAT)after pediatric split liver transplantation(SLT).Methods Clinical data of 88 consecutive pediatric recipients undergoing SLT in the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to January 2022 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them,56 recipients were male and 32 female,aged from 2 to208 months,with a median age of 9 months.The types of donor livers included right triple lobes in 11 cases,right liver in 5 cases,left liver in 9 cases and left lateral lobes in 63 cases,respectively.The donors'arteries were anastomosed end-to-end to the recipients'arteries discontinuously with 8-0 suture under a 3.5×magnification surgical microscope,and the arterial branches were anastomosed as much as possible.The blood flow after anastomosis,before and after abdominal closure was monitored by color Doppler ultrasound and blood-flow meter.Postoperatively,heparin sodium bridges warfarin was performed for anticoagulation.Results 2 children developed HAT after SLT at postoperative 1 d with an incidence of 2%(2/88).These 2 children underwent SLT using the right triple lobes and left lateral lobe,respectively,and interventional thrombolysis and hepatic artery stent implantation were immediately performed.In one recipient,the hepatic artery was recanalized after stent implantation.During 48-month regular follow-up,no vascular or biliary complication was reported.The other recipient died of multiple organ failure at postoperative 2 d.Conclusions Appropriate matching of the donor-recipient arteries,intermittent anastomosis of all arterial branches under surgical microscope,standard anticoagulation regimen and perioperative blood flow monitoring can effectively prevent the incidence of HAT in pediatric SLT recipients.