辅助性肝移植临床进展

辅助性肝移植是指在保留部分或整个原肝的情况下 ,将供肝的全部或部分植入受体内。根据其移植部不同分为原位和异位辅助性肝移植 ,按移植肝的大小可分为全肝或部分辅助性肝移植 ,根据供肝来源的不同分为来源于死体供肝和活体供肝。供肝来源于死体供体者 ,供肝可为全肝或部分供肝 ,供肝来源于活供体者 ,均为部分供肝。1　辅助性肝移植的历史Ｗｅｌｃｈ 195 5年首次提出辅助性肝移植的概念 ,随后在世界范围内就辅助性肝移植进行了大量动物实验 ,Ａｂｓｏｌｏｎ于196 4年施行了世界首例临床异位辅助性肝移植。进入 2 0世纪 80年代以后 ,随着新…     

猪辅助性部分肝移植模型制作及比较

目的建立猪的辅助性部分肝移植模型,观察其肝功能和术中血流动力学变化。方法 24头健康良种家猪,体质量23-30 kg,被随机分为供体(n=12)和受体(n=12)。气管插管 全麻,硫喷妥钠静脉维持。移植前切除受体肝左叶,供肝右叶作为植入肝。预实验2例行经体位转流的原位辅助性部分肝移植,对照组(5例)行简易转流下的原位辅助性部分肝移植。模型组(5例)行异位辅助性部分肝移植, 供肝被植入受体肝下间隙,供肝肝上下腔静脉与受体肝下下腔静脉端侧吻合,供肝门静脉与受体门静脉行端侧吻合,供肝肝动脉与受体脾动脉行端端吻合。供肝胆总管置管外引流。结果预实验中行体位静脉转流的原位辅助性部分肝移植的2例受体在肝上下腔静脉阻断后很快陷入血流动力学紊乱死亡。5例行简易静脉转流的原位辅助性部分肝移植的受体,2例在24 h内死亡,1例28 h,2侧超过48 h。而模型组受体 5例中有4例存活超过24 h。AST,ALT指标手术开始至术后24 h呈持续升高。模型组术中血流动力学较其他组稳定。结论该辅助性肝移植模型简明易建且具有不需静脉转流等优点,为研究辅助性部分肝移植原肝和供肝功能及血流变化提供了理想的平台。     

辅助性肝移植技术的发展与现状

辅助性肝移植是一种保留受者全部或部分肝脏的特殊移植术式, 其可分为异位辅助性和原位辅助性肝移植。辅助性肝移植存在对供肝体积需求小, 免疫排斥反应小、自体肝脏功能恢复后可以停用抗排斥药等优势, 在临床上如能常规开展能极大缓解供肝来源不足的问题, 使许多肝病患者获益。本文根据文献报道系统阐述辅助性肝移植术式发展和改进历程, 以及不同术式优缺点, 为临床上开展辅助性肝移植提供一定的理论参考。     

活体右半肝原位辅助肝移植术的围手术期配合体会(1例报告)

目的总结活体右半肝原位辅助肝移植术前与术中护理配合的体会。方法回顾性分析1例暴发性肝衰竭患者辅助性原位肝移植术前与术中的临床资料,总结护理体会。结果术前制定相应的管理程序,包括供体、手术环境、常规用品和特殊器械物品的准备。做好术中配合,包括供体供肝切取时的配合、受体病肝部分切除时的配合、供受体术中超声吸引刀使用时的配合、受体供肝植入的手术配合等。供受体手术过程顺利,术后无发生手术相关并发症。结论原位辅助性肝移植是一项操作过程极为复杂的手术,完善而充分的术前准备,熟练而准确的术中配合,可以保障手术的顺利进行和减少与手术相关的并发症。     

辅助性肝移植

辅助性肝移植指保留患者的肝脏或部分肝脏,将供体全肝或部分肝脏植入受体,使肝功能衰竭病人得到生命支持或使原肝缺失的代谢、解毒等功能得到代偿[1-5]。辅助性肝移植基本上是和原位肝脏移植和异位肾移植同时提出。异位肝脏移植由于避免了切除病肝降低了手术难度,病人本身的肝脏仍可能发挥功能,在移植肝脏不能正常发挥功能时将起很大作用[5]。1辅助性肝移植的发展及实验研究1.1辅助性肝移植的初期研究Welch[4]于1955年首先进行了辅助性肝脏异位移植的尝试。移植肝脏间置于受体肝下下腔静脉。移植肝脏肝上下腔静脉、门静脉和受体肝下下腔静…     

辅助性肝移植

辅助性肝移植指保留患者的肝脏或部分肝脏，将供体全肝或部分肝脏植入受体，使肝功能衰竭病人得到生命支持或使原肝缺失的代谢、解毒等功能得到代偿。辅助性肝移植基本上是和原位肝脏移植和异位肾移植同时提出。异位肝脏移植由于避免了切除病肝降低了手术难度，病人本身的肝脏仍可能发挥功能，在移植肝脏不能正常发挥功能时将起很大作用。     

猪急性缺血性肝衰模型的建立和辅助性异位部分肝移植的作用

目的: 探讨急性缺血性肝衰模型的制备、辅助性异位部分肝移植的作用. 方法: 用家猪配对开展辅助性异位部分肝移植.分三组,A组:受体肝脏和肝动脉保持原状,其门静脉缩窄;供肝植入受体右肝下,仅建立门静脉血供,不建立动脉血供.B组:受体肝动脉结扎,其他手术内容与A组相同.C组:受体肝动脉结扎,供肝动脉和门静脉血供均建立,其他手术内容与A组相同.监测各组受体存活情况,肝功能和肝脏血流情况,病理及供肝胆汁分泌情况. 结果: A组、C组受体3 d以上成活率显著高于B组.A组、C组手术前后胆红素无显著改变,B组术后胆红素显著高于术前,术后第二天B组胆红素显著高于A组、C组.C组供肝胆汁分泌和血供良好,肝细胞存活并有活跃的代偿性增生;A组、B组供肝无或仅有少量胆汁分泌,肝细胞大片坏死. 结论: 受体肝动脉结扎、门静脉缩窄足以造成急性肝衰模型;保留受体肝脏动脉血供、减少门静脉血供对受体肝脏功能无严重影响;辅助性异位部分肝移植能取得良好的效果,足以纠正急性肝衰.     

原位肝移植11例报告

目的探讨受体肝脏获取和原位肝移植的方法。方法获取11例供体肝脏,检查肝质量,观察肝植入后功能;对11例患者施行原位肝移植,总结手术情况及相关并发症,统计成功率和生存情况。结果成功获取供体肝脏,植入受体后发挥良好功能;11例肝移植全部成功,患者存活良好。结论供体肝脏功能良好,肝移植的成功率和受术者的生存情况都令人满意。     

辅助性部分原位肝移植的临床研究现状

辅助性部分原位肝移植主要用于治疗爆发性肝功能衰竭、非肝硬化的先天性代谢性疾病以及小体积供肝肝移植,与经典原位全肝移植相比,具有避免终身服用免疫抑制剂、适用于活体肝移植、扩大供肝来源等优点.本文就辅助性部分原位肝移植的临床研究现状作一综述.     

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

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...     

A Novel Technique for Auxiliary Partial Liver Transplantation With Reno-Portal Anastomosis and Avoidance of the Hepatoduodenal Ligament

Auxiliary liver transplantation (ALT) is a treatment for acute liver failure when regeneration of the native liver is possible or for metabolic disorders. In selected cases ALT and orthotopic liver transplantation (OLT) have similar survival when ALT is performed in the orthotopic position (auxiliary partial orthotopic liver transplantation, APOLT). Drawback of ALT with portal vein to portal vein anastomosis is the frequent occurrence of thrombosis, compromising both graft and native liver, and the necessity of a significant resection. To avoid division of portal flow we performed ALT with an end-to-end anastomosis between the graft portal vein and the left renal vein of the recipient (reno-portal ALT, REPALT). The hepatic artery was anastomosed to the aorta using an iliac arterial graft conduit. The bile duct was anastomosed to the stomach. In the two cases presented here excellent immediate graft function occurred with rapid regeneration of the graft and without early vascular complications.     

Simplified technique for auxiliary orthotopic liver transplantation using a whole graft

Background

Acute liver failure is associated with a high mortality rate and the main purposes of treatment are to prevent cerebral edema and infections, which often are responsible for patient death. The orthotopic liver transplantation is the gold standard treatment and improves the 1-year survival.

Aim

To describe an alternative technique to auxiliary liver transplant on acute liver failure.

Method

Was performed whole auxiliary liver transplantation as an alternative technique for a partial auxiliary liver transplantation using a whole liver graft from a child removing the native right liver performed a right hepatectomy. The patient met the O´Grady´s criteria and the rational to indicate an auxiliary orthotopic liver transplantation was the acute classification without hemodynamic instability or renal failure in a patient with deterioration in consciousness.

Results

The procedure improved liver function and decreased intracranial hypertension in the postoperative period.

Conclusion

This technique can overcome some postoperative complications that are associated with partial grafts. As far as is known, this is the first case of auxiliary orthotopic liver transplantation in Brazil.     

Auxiliary partial orthotopic liver transplantation in acute liver failure due to hepatitis B

Auxiliary partial orthotopic liver transplantation is an alternative therapeutic modality in acute liver failure, wherein the capacity of native liver to regenerate is preserved. A case of acute liver failure due to hepatitis B in an 18-year-old male patient treated with an auxiliary left lateral segment graft is described. There was no recurrence of hepatitis B in the auxiliary graft and the patient cleared the virus after 9 months whilst receiving lamivudine. Immunosuppression was withdrawn at 14 months, and the auxiliary graft atrophied secondary to hepatic arterial conduit thrombosis, possibly precipitated by immunosuppression withdrawal. The native liver regenerated completely, and the patient is well and off immunosuppressive and antiviral therapy 3 years after transplantation. Auxiliary partial orthotopic liver transplantation is an attractive treatment option in acute liver failure due to hepatitis B infection and allows a life free of long-term immunosuppression.     

Improved technique of heterotopic auxiliary rat liver transplantation with portal vein arterialization

BACKGROUND AND AIMS: In acute, potentially reversible hepatic failure, auxiliary liver transplantation is a promising alternative approach. Using the auxiliary partial orthotopic liver transplantation (APOLT) method--the orthotopic implantation of auxiliary segments--most of the technical problems (lack of space for the additional liver mass, the portal vein reconstruction, and the venous outflow) are avoided, but extensive resections of the native liver and the graft are necessary. Erhard described the heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA). Initial clinical results demonstrated that an adequate liver function can be achieved using this technique. We developed and improved a technique of HALT with flow-regulated PVA in the rat to perform further investigations. The aim of this paper is to explain in detail this improved experimental surgical technique. MATERIALS AND METHODS: Liver transplantations were performed in 122 male Lewis rats: After a right nephrectomy, the liver graft, which was reduced to about 30% of the original size, was implanted into the right upper quadrant of the recipient's abdomen. The infrahepatic caval vein was anastomosed end-to-side. The donor's portal vein was completely arterialized to the recipient's right renal artery in stent technique. Using a stent with an internal diameter of 0.3 mm, the flow in the arterialized portal vein was regulated to achieve physiologic parameters. The celiac trunk of the graft was anastomosed to the recipient's aorta, end-to-side. The bile duct was implanted into the duodenum. RESULTS: After improvements of the surgical technique, we achieved a perioperative survival of 90% and a 6-week survival of 80% in the last 112 transplantations. CONCLUSION: We developed a standardized and improved technique, which can be used for experiments of regeneration and inter-liver competition in auxiliary liver transplantation. Furthermore, this technique is suitable for the investigation of the influence of portal vein arterialization and portal hyperperfusion on liver microcirculation, function, and morphology.     

Auxiliary partial orthotopic living donor liver transplantation in a patient with alcoholic liver cirrhosis to overcome donor steatosis

The efficacy of auxiliary partial orthotopic liver transplantation (APOLT) to overcome the problems associated with a markedly steatotic graft in a living donor has not been fully explored. We have recently performed APOLT in a patient with alcoholic liver disease, where the only potential candidate donor was affected by 50% macrovesicular steatosis and 30% microvesicular steatosis. The recipient's left liver was resected and the donor's left liver, corresponding to a 0.46% graft-to-recipient weight ratio, was orthotopically transplanted. The postoperative course of this patient was uneventful, except for a transient large amount of ascites. Native liver volume in the recipient serially decreased, and the volume of the graft serially increased after transplantation. Four months after transplantation, the donor and recipient are doing well with a normal liver function. In conclusion, APOLT may be a feasible solution for a markedly steatotic living donor graft in patients with alcoholic liver disease.     

大鼠辅助性肝-小肠联合移植模型

目的　介绍一种新的大鼠辅助性肝 -小肠联合移植模型。方法　整块切取全部小肠和6 0 %的肝脏。同时切取腹腔动脉及肠系膜上动脉的动脉段以确保移植器官的血供。供体小肠的静脉血通过供体完整的门静脉回流。将供体左肾静脉水平肝下下腔静脉斜形切断吻合于受体两肾静脉之间的下腔静脉 ,供体腹主动脉和受体腹主动脉端侧吻合。切除受体的小肠 ,通过小肠端 -端吻合重建肠道。结果　整个手术时间平均为 130min。 3个月的生存率为 8% (16 2 0 )。移植后 90d ,对 3只大鼠行剖腹探查及组织学检查 ,观察到移植物的形态及功能均正常。观察移植后 12个月的 5只大鼠 ,肝功能正常 ,移植肝及小肠均呈正常的组织学结构。结论　大白鼠辅助性肝 -小肠联合移植是可行的。     

Severe late acute allograft rejection in a child after living-related auxiliary partial orthotopic liver transplantation for ornithine transcarbamylase deficiency

Auxiliary liver transplantation (ALT) is known to correct liver-based metabolic disorders. However, it remains unclear whether the presence of a native liver influences the long-term prognosis of ALT for metabolic diseases. We reported on a 4-yr-old girl who had undergone living-related auxiliary partial orthotopic liver transplantation (APOLT) for ornithine transcarbamylase deficiency and experienced severe late acute rejection 18 months after liver transplantation, during weaning of immunosuppressive agents. Results of histological analysis of the graft indicated very severe acute rejection (rejection activity index, 9/9), and computed tomography revealed graft liver atrophy. These observations suggest the possibility that severe rejection might occur in APOLT, especially during weaning of immunosuppression.     

Reuse of Auxiliary Liver Grafts in Second Recipients With Chronic Liver Disease

We describe the first cases of reuse of auxiliary liver grafts for orthotopic transplantation in chronic liver disease. A reduced liver graft (segments 2, 3, half of 4) was first transplanted auxiliary for acute liver failure using a new technique. After regeneration of both native liver and graft, the auxiliary graft was removed and immunosuppression discontinued in the first recipients. After informed consent of donors and recipients, both auxiliary grafts were then orthotopically transplanted into second recipients. Both grafts function normally. Reuse of auxiliary grafts may help to reduce the shortage or liver grafts available for transplantation.     

Native hepatectomy after auxiliary partial orthotopic liver transplantation

In countries where a living donor is the only source of the graft, the limited size of the graft is of serious concern when considering extending the procedure to adult recipients. In order to overcome this problem, auxiliary partial orthotopic liver transplantation (APOLT) was applied to the concept that the residual native liver would support the graft function until the graft expanded enough to work by itself. We herein report on a 20-year-old woman with primary sclerosing cholangitis (PSC), who received a small-size liver graft by APOLT. Computed tomography and scintigraphy showed that the graft had regenerated sufficiently 1 month after the operation. The diseased residual native liver is potentially carcinogenetic. Therefore, second-stage native hepatectomy was done 35 days after the first operation. Histopathologic examination of the resected native liver revealed biliary cirrhosis with PSC but no evidence of cholangiocarcinoma. Second-stage native hepatectomy after APOLT seems to be a curative treatment for chronic end-stage liver disease with graft size mismatch that may be as good as orthotopic liver transplantation. Received: 22 October 1998 Received after revision: 15 January 1999 Accepted: 26 February 1999