再次肝移植32例次的手术技巧

目的 探讨再次肝移植的手术技巧及其临床效果.方法 回顾性分析31例患者接受32次再次肝移植手术的临床资料,手术方式均采用附加腔静脉整形的改良背驮式原位肝移植,其中11例采用了股静脉-颈内静脉转流术.肝动脉的重建采用供肝动脉通过供者髂动脉间置搭桥与受者腹主动脉行端侧吻合24例次,采用供肝动脉与受者肝固有动脉行端端吻合8例次.胆道的重建采用胆管-空肠Roux-en-Y吻合28例次,采用胆道端端吻合4例次.术后常规使用抗排斥反应和抗感染治疗,并对患者进行了长期随访.结果 术后死亡17例,死亡时间为术后2周～28个月,死亡原因为术后严重感染8例、多器官功能衰竭和肝癌复发各3例、血管并发症和心肌梗塞以及颅内出血各1例,其中首次肝移植术后8～30 d行再次肝移植者围手术期死亡率最高,为66.7%.其余14例均痊愈出院,随访至今已存活1～29个月,肝功能及生活质量良好.再次肝移植与首次肝移植的手术时间及术中出血量比较,差异无统计学意义.结论 附加腔静脉整形的改良背驮式肝移植是再次肝移植的最佳术式,正确掌握手术时机,并针对患者进行个体化的处理是手术成功的关键.与首次肝移植相比,再次肝移植面临着较高的并发症发牛率和死亡率.

Operative techniques of liver re-transplantation: a report of 32 cases

Objective To explore the operative techniques and clinical effectiveness of liver re-transplantation. Methods The clinical data of 31 patients undergoing 32 liver re-transplantations were analyzed retrospectively. All the patients received modified piggyback liver transplantation with venacavaplasty,and extracorporeal venous bypass was used in 11 cases. For arterial reconstruction,the artery jump graft with the aorta was done in 24 patients, except end-to-end in 8 patients. Biliary reconstruction was performed by Roux-en-Y choledochojejunostomy in 28 patients,except duct-to-duct without T-tube in 4 patients. All of the patients routinely received anti-rejection and anti-infection treatments after operation,and long-term follow-up. Results Over all, 17 patients died after operation with the survival time ranging from 2 weeks to 28 months. The most common causes of death after operation were sepsis (8 cases),multiple organ failure and recurrence of HCC (3 cases each) .vascular complications and intracranial hemorrhages (1 case each). The mortality rate of during operation in these patients receiving re-transplantation between 8 and 30 days after their initial transplantation was the highest (66. 7 %). Other 14 patients were cured with the survival time being from 1 to 29 months with good liver function and quality of life. No significant difference was found in operative time and blood loss between liver re-transplantation and primary transplantation. Conclusion Modified piggyback liver transplantation with venacavaplasty is especially advantageous for liver re-transplantation. Proper indication and individualized treatments are the key for success of liver re-transplantation. Compared to primary liver transplantation, liver re-transplantation has higher morbidity and mortality.