小体积移植物辅助性肝移植治疗门静脉高压症的临床效果

Utilizing ultra-small volume graft in auxiliary liver transplantation for portal hypertension

目的探讨小体积移植物辅助性肝移植治疗门静脉高压症的临床效果。方法回顾性收集2014年12月至2022年3月首都医科大学附属北京友谊医院肝脏移植中心连续收治的接受小体积移植物辅助性肝移植治疗的12例门静脉高压症患者的临床和影像学资料。其中男性8例,女性4例;年龄14~66岁。受者终末期肝病模型评分为1~15分,Child评分为6~11分。供肝来源于活体供肝9例,来源于尸体供肝劈离2例,来源于儿童尸体供肝1例。3例尸体供肝的移植物和受者体重比(GRWR)为0.79%~0.90%,9例活体供肝的GRWR为0.31%~0.55%。在辅助性肝移植术中,切除受者的左半肝或右半肝,原位植入左叶或右叶供肝,或用左叶供肝置换受者的右叶肝脏。观察受者生存和移植物存活情况、并发症发生情况、自体余肝和移植肝门静脉血流速度、腹腔引流量和肝脏功能生化指标等。结果12例患者的移植肝功能稳定,患者均存活。移植术后发生流出道扭转2例、急性排斥反应1例、胆瘘1例、远期出现的甲状腺癌1例,经相应治疗均治愈。流出道扭转与供肝生长后吻合口角度变化相关,改良吻合方式后,该并发症未再次出现。门静脉血流速度测定结果提示,术后早期自体余肝血流速度明显降低,术后远期保持极低的血流速度或血管发生闭塞,移植肝血流稳定。结论小体积移植物辅助性肝移植治疗门静脉高压症可取得较好的临床效果,但技术难度较大,并发症诊治复杂。因此,该方法目前仍限于在活体肝移植技术熟练、并发症监测处置能力完备的中心进行推广。

Objective To examine the clinical effect of auxiliary liver transplantation with ultra-small volume graft in the treatment of portal hypertension.Methods Twelve cases of portal hypertension treated by auxiliary liver transplantation with small volume graft at Liver Transplantation Center,Beijing Friendship Hospital,Capital Medical University between December 2014 and March 2022 were studied retrospectively.There were 8 males and 4 females,aged 14 to 66 years.Model for end-stage liver disease scores were 1 to 15 points and Child scores were 6 to 11 points.The grafts was derived from living donors in 9 cases,from split cadaveric donors in 2 cases,from whole cadaveric liver of child in 1 case.The graft recipient body weight ratios of 3 cadaveric donor livers were 0.79%to 0.90%,and of 9 living donor livers were 0.31%to 0.55%.In these cases,ultra-small volume grafts were implanted.The survivals of patient and graft,complications,portal vein blood flow of residual liver and graft,abdominal drainage and biochemical indexes of liver function were observed.Results All the grafts and patients survived.Complications included outflow tract torsion in 2 cases,acute rejection in 1 case,bile leakage in 1 case,and thyroid cancer at the later stage of follow-up in 1 case,all of which were cured.The torsion of outflow tract was attributed to the change of anastomotic angle after the growth of donor liver.After the improvement of anastomotic method,the complication did not recur in the later stage.There was no complication of portal hypertension.The measurement of ultrasonic portal vein blood flow velocity showed that the blood flow of residual liver decreased significantly in the early stage after operation,and maintained a very low blood flow velocity or occlusion in the long term after operation,and the blood flow of transplanted liver was stable.Conclusions Auxiliary liver transplantation can implant ultra-small donor liver through compensation of residual liver.This method may promote the development of living donor left lobe donation and split liver transplantation.However,the auxiliary liver transplantation is complex,and it is difficult to control the complications.Therefore,this method is currently limited to centers that are skilled in living related liver transplantation and that have complete ability to monitor and deal with complications.