背驮式肝移植静脉回流道重建的改进和血流动力学探讨

目的 探讨合理的背驮式肝移植（PBLT）静脉回流道重建方式。方法 将74例PBLT按不同的静脉回流道重建方式分为5组：肝上下腔静脉－肝静脉端端吻合（A组）、肝上下腔静脉－肝后下腔静脉端侧吻合（B组）、肝后下腔静脉－肝后下腔静脉侧侧吻合（C组）、肝上下腔静脉－右心房端侧吻合（D组）、肝后下腔静脉、肝后下腔静脉全口吻合（E组）。比较各组受者的中心静脉压（CVP）、肝后下腔静脉压（RHIVC）及供者肝上下腔静脉靠近吻合口部压力（GIVC），并观察术中布加氏综合征发生情况。结果 C组无论是CVP、RHIVC、GIVC，还是压力差均较A组与B组为小，D组与E组血流动力学测定与C组相似。说明该种术式的供肝静脉回流通畅度令人满意，其术中布加氏综合征发生率也较低。结论 供肝静脉回流道重建方式改进后，供肝静脉回流更通畅，布加氏综合征等并发症发生机率减小。故推荐使用供肝肝后下腔静脉与受者肝后下腔静脉侧侧吻合术式。     

保留门静脉-腔静脉血流的肝移植实验研究

为探讨犬肝移植的新术式，以及不采取静脉转流的可行性，施行了犬保留门静脉－腔静脉（门－腔）血流的背驮式肝移植术。受体在切除自体肝之前先将肠系膜下静脉与右肾平面以下的下腔静脉行侧侧吻合，建立门－腔血流通路，然后再行原位肝移植术；测定受体切肝及植肝等５个时限的血流动力学参数。结果５只犬有４只存活，在下腔静脉及门静脉吻合后５～１０分钟即有胆汁分泌。血流动力学的有关指标表明，造成心血管系统不平衡、肾瘀血、胃肠瘀血等危险因素被解除。认为本术式更符合人的内环境及生理，避免了静脉转流术的各种弊端，为无转流泵的中心施行肝移植找到了新的途径。     

经典原位非转流肝移植

历经半个多世纪的发展,肝移植已成为治疗终末期肝病的最有效手段,其中经典原位非转流肝移植是目前临床最常用的、传统的肝移植术式。经典原位是指,整块切除病肝及其肝后腔静脉段,原位对端重建供肝下腔静脉;非转流是指,术中不采用静脉-静脉转流技术。经典非转流技术之所以成为目前临床主流术式,离不开外科技术的日益成熟,尤其是无肝期的缩短,极大地减少了对受者血流动力学的扰动和各脏器的损伤。     

50例次背驮式肝移植技术回顾分析

目的：总结背驮式肝移植术的经验,力求进一步完善经典式背驮式肝移植技术。方法：50例次背驮式肝移植中,17例次采用经典式背驮式肝移植（SPBLT）,24例次采用改良式背驮式肝移植（APBLT,供受者的下腔静脉行端侧吻合或侧侧吻合）,其它肝移植式的改良9例次。结果：17例次经典式背驮式肝移植均存在供,受者血管口径不匹配,供肝放置棘手,血管重建后肝静脉回流道易扭曲及压迫重建的回流血管等问题,而改良式背驮式肝移植中,下腔静脉与下腔静脉行端侧吻合者仍存在不同程度的上述缺陷,而侧侧吻合术式则可完全改善经典式背驮式肝移植的技术并发症,结论：改良式背驮式肝移植修正了经典式背驮式肝移植存在的技术缺陷,减少了技术并发症。     

附加腔静脉成形的背驮式原位肝移植术

目的　探讨腔静脉成形术在背驮式原位肝移植中的应用价值及在防止移植肝流出道阻塞并发症中的作用。方法　 3例终末期肝病病人选为肝移植受者。供肝的下腔静脉及受体的肝后下腔静脉 (包括肝静脉 )均作了成形术 ,在单独股 -腋静脉转流术下行改良背驮式肝移植术。结果　 3例病人术中均较平稳 ,手术时间和无肝期缩短 ,出血量减少 ,术后肝功能恢复快 ,恢复顺利 ,无并发症发生。结论　腔静脉成形术可防止背驮式肝移植肝静脉流出道阻塞 ,术中对受体的血流动力学干扰小 ,并可缩短无肝期和减少腔静脉梗阻并发症的发生。     

全肝与选择性肝静脉阻断术在肝切除术中的应用比较

目的累及肝静脉或下腔静脉的肝肿瘤切除最严重的并发症是术中大出血,全肝血流阻断术（THVE）能有效控制术中大出血,但由于阻断下腔静脉,易引起全身血流动力学紊乱。选择性肝血流阻断术（SHVE）仅阻断入肝与出肝血流而保持下腔静脉通畅,不会引起全身血流动力学紊乱。本文就这两种肝血流阻断技术在肝切除术中的应用作一比较。方法2000年1月至2006年6月,共施行包括入肝与出肝血流同时阻断切肝术197例,其中THVE87例,SHVE110例。比较两组病人术前情况、肝切除范围、术中情况、术后并发症等指标。结果所有肿瘤均压迫或侵犯1根以上主肝静脉或下腔静脉,两组病人术前一般情况、肝切除范围、肿瘤病理类型无明显差别,术中出血量、肝热缺血时间、手术时间,THVE组明显高于SHVE组。THVE组有15例同时行下腔静脉癌栓取出术,4例肝静脉癌栓取出术,7例行下腔静脉壁修补术,SHVE组有7例同时行肝静脉取栓术,有1例因肿瘤侵犯下腔静脉壁而改行THVE。术后并发症THVE组明显高于SHVE组,前者有2例术后死于肝功能衰竭,SHVE组无1例死亡。术后ICU时间及住院时间THVE组明显高于SHVE组。结论THVE与SHVE均能有效控制术中肝静脉破裂大出血,THVE对伴有下腔静脉癌栓或静脉壁受侵犯的病人是唯一的选择方法,但THVE对全身血流动力学影响大,对未侵犯下腔静脉而仅侵犯肝静脉的病人更适合采用SHVE。     

部分或完全门腔静脉分流治疗酒精性肝硬化(前瞻随机临床试验结果)(英)

门腔静脉分流术可有效地控制门静脉高压症之静脉曲张出血。但标准的门腔静脉分流术可诱发术后肝性脑病及促使肝功能衰竭。1967年Warren等提出选择性脾肾静脉分流，同时结扎相关侧支循环，可改善非酒精性肝硬化病人的血流动力学，降低肝性脑病发生率。但此术式对酒精性肝硬化病人效果不能肯定。     

活体肝移植时利用冷保存尸体静脉重建肝后下腔静脉二例

活体肝移植时一般采用保留受者的肝后下腔静脉的背驮式肝移植术式,但在某些疾病情况下,无法保留受者的肝后下腔静脉.对此,我们采用冷保存尸体静脉重建肝后下腔静脉,采用此术式共行活体肝移植2例,现报告如下.     

内脏反位成年人肝移植方法的探讨

目的 结合病例和综合文献探讨内脏反位的成年人肝移植的可行性和方法.方法 1例45岁内脏反位的男性患者,因肝内多发结石、梗阻性黄疸、门脉高压、肝硬化所致进行性肝功能衰竭,于2004年7月在我院行肝移植.术前行CT三维重建和血管造影检查进行解剖学定位.手术采用改良背驮式移植方式,供肝顺时针旋转45度,使供肝左叶朝向受者左结肠旁沟,右叶正好位于受者的左上腹,供肝上下腔静脉与受者腔静脉行端-侧吻合,供肝的肝下下腔静脉连续缝合后关闭.结果 患者术后恢复顺利,随访75个月,移植肝脏的血流和功能均正常.结论 内脏反位成年人进行肝移植是安全和可行的.精确的解剖、完善的术前准备和恰当的手术时机、方式至关重要.     

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。     

门静脉-下腔静脉吻合术预防活体肝移植术后小肝综合征3例报道

目的探讨门静脉-下腔静脉吻合术用于预防活体肝移植术后小肝综合征(small-for-size liver syndrome,SFSS)的效果。方法 3例活体肝移植均采用不含肝中静脉的右半肝作为移植物。术中发现实测移植物(肝)重量/受体的体质量(体重)的比值(graft to recipient weight ratio,GRWR)为0.58%、0.77%及0.71%,均<0.8%,符合小移植物的诊断。处理:首先吻合肝静脉流出道,其次吻合门静脉,将受体门静脉右支与移植肝门静脉右支端端吻合,将受体门静脉左支与下腔静脉行端侧吻合达到门腔分流的作用,之后按顺序吻合动脉和胆道。术中均未行脾静脉结扎或脾切除等处理。术后定期随访。结果 3例患者术后均未发生SFSS并顺利出院,出院时间分别为术后25d、34d及56d。移植肝功能逐步好转,术后1d门静脉流速理想。移植肝增长良好。门静脉-下腔静脉短路通畅时间:除1例通畅持续仅104d,其余2例持续通畅。结论 LDLT术中进行门静脉-下腔静脉吻合术可以及时有效预防小移植物背景下的SFSS,受体门静脉左支与下腔静脉行端侧吻合的分流技术安全可靠。     

豚鼠至大鼠肝移植肝下下腔静脉套管方法的改进

目的探讨豚鼠至大鼠异种原位肝移植中应用改进的肝下下腔静脉套管方法的手术效果。方法豚鼠和SD大鼠各30只分别作为供、受体,并随机配对分为实验组和对照组。实验组采用改进的肝下下腔静脉套管进行肝下下腔静脉袖套管法吻合。对照组采用常规方法进行肝下下腔静脉袖套法吻合。比较两组的供肝切取时间(切、修肝时间)、受体手术时间、无肝期时间、手术成功率、肝下下腔静脉袖套吻合口附近出血发生率以及术后生存时间。结果实验组和对照组的供肝切取时间分别为(32.2±3.5)min、(45.4±5.7)min,修肝时间分别为(14.5±2.1)min、(9.2±1.8)min,切、修肝总时间分别为(46.7±4.8)min、(54.6±6.9)min,比较差异均有统计学意义(均为P0.05)。两组受体的手术时间分别为(52.7±6.1)min、(53.2±6.5)min,无肝期分别为(16.8±2.1)min、(17.2±2.5)min,比较差异没有统计学意义(均为P0.05)。实验组与对照组的手术成功率分别为93%、53%,比较差异有统计学意义(P0.05)。两组的肝下下腔静脉袖套吻合口附近出血发生率分别为0、38%,比较差异有统计学意义(P0.05)。两组手术成功的动物的术后生存时间分别为(115±24)min、(95±29)min,比较差异无统计学意义(P0.05)。结论应用改进的肝下下腔静脉套管方法进行豚鼠至大鼠原位肝移植,手术成功率高,可用于豚鼠至大鼠原位肝移植实验研究模型的制作。     

肝移植治疗晚期肝硬化

目的 肝移植治疗肝脏终末期病变。方法 采用改良的背驮式肝移植技术即保留肝后下腔静脉的全病肝切除,将供肝植于受肝原位,供、受体肝上下腔静脉,供、受体门静脉,供、受肝动脉行对端吻合;结扎供肝肝下下腔静脉。用ＦＫ５０６、晓翻和强的松三联免疫抑制剂抗排斥反应,加强术后监护和感染的控制。结果 例１、例２目前分别存活１１个月、８个月余,生活自理,例３因术后并发急性肾功能衰竭死亡,存活１４d。结论 肝移植是治愈肝脏终末期病谱的可靠方法。     

Replacement of the vena cava with aortic graft for living donor liver transplantation in budd-Chiari syndrome associated with hydatid cyst surgery: a case report

A 12-year-old girl, operated because of a hydatid cyst of the liver, with Budd-Chiari syndrome was evaluated for postoperative development of ascites and paraumbilical varicose veins. A vena caval stent was placed for the relief of inferior vena caval obstruction. The patient was admitted because of progressive deterioration in ascites and liver functions. Imaging techniques showed degeneration adjacent to the right hepatic vein in liver segments 7 to 8, a partially calcified 5-cm hydatid cyst, and a thrombosis in the inferior vena cava was that addressed with a 10-cm metal stent. A living donor segments 2 to 3 liver transplantation was obtained from the patient's mother. After completion of the donor operation without complications, the vena caval stent was removed following the recipient hepatectomy. Suprarenal flow continued after resection of the fibrotic vena cava and placement of a cadaveric cryopreserved aortic graft for the vena cava, anastomosed between the suprarenal and subdiaphragmatic segments of the vena cava. An end-to-side anastomosis was performed between the left hepatic vein of the donor liver and the aortic graft. There was no complication and the patient was discharged on postoperative day 19. Follow-up Doppler ultrasonography showed the aortic vena caval graft to be open, along with the hepatic/portal vein and hepatic artery. This case demonstrated that operations for liver hydatid cyst surgeries can iatrogenically induce Budd-Chiari syndrome; a cryopreserved aortic graft can be an alternative to ensure the continuity of the vena cava in living donor liver transplantation.     

Short hepatic vein reconstruction in biliary atresia patients with absent inferior vena cava

Liver transplantation in patients with biliary atresia and polysplenia syndrome requires some technical adjustments. During eight yr, 75 biliary atresia patients underwent living donor liver transplantation. Of these, two patients were complicated by absent inferior vena cava with azygos continuation. Both patients received hemi-liver grafts with short hepatic veins. Outflow was reconstructed using a cryopreserved vena cava. In both patients, the short hepatic vein was anastomosed to the vein graft end-to-end and the end of the vein graft was anastomosed with the common orifices of recipient's hepatic veins. Both of the patients survived the operation with satisfactory graft function. A hemi-liver graft with short hepatic veins can be used for patients with biliary atresia with inferior vena cava agenesia using the current technique.     

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation?

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.     

Evaluation, operative management, and outcome after liver transplantation in children with biliary atresia and situs inversus.

INTRODUCTION: Biliary atresia, a common indication for liver transplantation, can be associated with situs inversus. Our experience with liver transplantation in children (n = 6) was reviewed retrospectively. PATIENTS AND METHODS: Preoperative duplex sonography, computerized tomography, and visceral angiography were obtained. Vascular anomalies identified included preduodenal portal vein (6/6), interrupted inferior vena cava (5/6), and aberrant hepatic artery (4/6). RESULTS: The liver graft was placed in a midline position. Venous continuity was achieved by donor suprahepatic inferior vena cava to recipient hepatic cloaca and direct end-to-end portal anastomosis. The donor infrahepatic inferior vena cava was oversewn. Arterial continuity was restored using either a direct branch-patch anastomosis (3/6) or a supraceliac aortic interposition graft (3/6). In retrospect, preoperative diagnostic work-up was noncontributory and outcome was not complicated by pre-existing situs inversus. CONCLUSION: Situs inversus in liver recipients requires operative technical modifications, but does not change outcome. Furthermore, extensive preoperative work-up should be avoided.     

下腔静脉膈上段解剖特征及毗邻关系的尸体研究

目的明确腹腔镜手术中下腔静脉膈上段的解剖特点及毗邻关系。方法2018年12月于南方医科大学基础医学院选取成人尸体、新鲜尸体各2例。对冰冻尸体进行解剖。沿双侧锁骨中线打开胸腔,翻开心包前壁,解剖分离上腔静脉、下腔静脉。沿腹正中线打开腹腔,翻左、右肝叶,显露肝后段下腔静脉、第二肝门,剖开腔静脉裂孔进入心包,观察下腔静脉膈上段的解剖特点及毗邻关系,测量下腔静脉膈上段长度。对新鲜尸体行腹腔镜手术试验,于脐旁、右侧腹直肌旁距脐约4 cm、腹正中线脐上约6 cm、右侧腋前线肝下缘下方约2 cm、左侧锁骨中线肝下缘下方约2 cm置入5个12 mm套管。腹腔镜辅助下翻左、右肝叶,显露肝后段下腔静脉、第二肝门,剖开腔静脉裂孔进入心包,观察下腔静脉膈上段的解剖特点及毗邻关系。结果2例尸体解剖中可见,下腔静脉经肝的腔静脉沟,穿膈的腔静脉孔进入胸腔,再穿纤维心包注入右心房。测量下腔静脉膈肌至右心房入口的长度分别为1.67 cm和2.57 cm。2例腹腔镜手术试验,可很好地显露肝后段下腔静脉、第二肝门、下腔静脉膈肌入口;沿腔静脉裂孔打开膈肌存在一个相对无血管的脂肪组织解剖层次;心包与右心房之间有较大的解剖间隙,可很好地显露下腔静脉、上腔静脉及右心房,可完整连续地显露整个膈下至右心房入口节段的下腔静脉。结论下腔静脉旁存在一个相对无血管的解剖层次,腹腔镜手术中经腹腔打开膈肌可较安全地进入心包,很好地显露下腔静脉、上腔静脉及右心房,为经该入路行MayoⅣ级下腔静脉癌栓取出术提供了可能。     

Alternatives to the double vena cava method in partial liver transplantation.

Minimizing graft congestion in partial liver transplantation is important, especially when the graft weight is marginal for the recipient metabolic demand. We prefer the double vena cava technique for reconstructing middle hepatic vein tributaries with thick, short hepatic veins because the technique can reduce the warm ischemic time of the graft and make a wide anastomosis. This technique requires a cryopreserved superior or inferior vena cava. We devised an alternative double vena cava method using iliac or femoral vein grafts and applied it to two right liver transplantation patients. There was no postoperative hepatic venous outflow block in either patient. In conclusion, application of this technique, even in the absence of a suitable vena cava, can help to minimize graft congestion.