Arterialization of the portal vein in pediatric liver transplantation

Portal vein arterialization (PVA) is an acquired concept in shunt surgery for portal hypertension. This technique, recently described as both a temporary and permanent procedure in adult liver transplantation, is reported by the authors in two cases of pediatric transplantation. The indication was low portal blood flow after reperfusion with poor graft function due to persistence of spontaneous retroperitoneal venous shunts. In both cases described, PVA allowed for satisfactory macroscopic liver reperfusion. The increase in portal blood flow from 150 to 500 ml/min in the second patient enabled the liver to be reperfused correctly and led to successful transplantation. The graft function in both cases improved in the 1st postoperative week, but thrombosis of the PVA occurred in the 1st patient 2 months after transplantation. Signs of hepatic hyperarterialization occurred in the second patient and this necessitated a dearterialization of the portal vein 2 weeks later. Although the benefit of this procedure appears to be beyond doubt in the immediate postoperative period, we have no data on long-term arterialization. We do think that PVA can be performed in pediatric liver transplantation, but it may need to be done only in special, individual situations when no valid alternative can be proposed, such as in the absence of a mesenteric vein and/or the presence of spontaneous retroperitoneal venous shunts. Received: 24 June 1997 Received after revision: 27 November 1997 Accepted: 28 November 1997     

A case report of extrahepatic portal vein aneurysm with thrombosis

Extrahepatic portal vein aneurysm (PVA) is very rare with only 17 previously reported cases.Methods of treatment include resection,thrombectomy,and portal venous decompression.We report herein the first case of large PVA with thrombosis which has been managed without surgical treatment over a long period.A PVA was detected in a 78-year-old woman by abdominal ultrasonography.Computed tomography revealed an aneurysm of 6 cm in a diameter in the porta hepatis.Portal venography showed obstruction of the portal vein and developed collateral vessels around the aneurysm.Since the patient had no symptoms of portal hypertension,we decided to carefully manage her clinical course without surgical treatment.At present,this patient is healthy and has developed no complications over the 5 years since leaving our hospital.This case suggests that surgical treatment is not required for PVA without portal hypertension.     

限制流量的门静脉动脉化对大鼠肝脏功能和结构的远期影响

目的 探讨限制流量的门静脉动脉化术后门静脉血液动力学改变，以及对肝脏功能和结构的远期影响。方法 建立大鼠门静脉完全动脉化（portal vein arterialization，PVA）以及限制流量的大鼠门静脉动脉化模型，观察术后1及6个月门静脉血流量、横截面积以及术后6个月门静脉压力及肝脏结构和功能的变化。结果 末采取限制流量措施的门静脉动脉化术后门静脉横截面积和血流量随时间延长呈增加的趋势，术后6个月血清ALT水平显著升高（F=7，72，P〈0，01）。肝内门静脉及其分支显著增宽、壁增厚、内膜胶原纤维增多。而限制流量的门静脉动脉化术后门静脉横截面积与血流量增加趋势不显著，血清GPT水平接近正常水平，术后6个月，3组大鼠动脉化门静脉压力、血浆内毒素、动脉血酮体比值以及血清白蛋白、总胆红素和碱性磷酸酶水平差异无统计学意义。结论 门静脉完全动脉化后，限制流量是必要的，保持一定流量的动脉化门静脉血，对于维持肝脏正常生理功能，防止过高血流量对肝脏功能和结构的损害，有重要意义。     

肝移植术后迟发性门静脉血栓形成12例

目的 总结肝移植术后迟发性门静脉血栓形成的治疗方法,并分析其预后.方法 单中心3100例次尸体全肝移植中发生迟发性门静脉血栓形成12例,发生时间平均为移植术后29.8个月.12例中,2例合并严重胆道并发症(肝内胆道狭窄),2例表现为移植肝功能衰竭,1例影像学检查可见肝门部肿物致门静脉受压,均接受再次肝移植;2例表现为急性上消化道出血,分别行经胃镜下套扎、注射硬化剂治疗;余5例无任何临床表现,口服抗凝或抗血小板药物治疗.结果 12例中,除1例失访外,其他患者至随访结束时存活8例,包括2例行再次肝移植者.存活者肝功能检查结果均正常.结论 肝移植术后发生迟发性门静脉血栓形成,应根据患者的临床表现不同采用不同的治疗方法.

Abstract：

Objective To summary therapeutic method for delayed portal vein thrombosis after liver transplantation. Methods In 3100 cases undergoing cadaveric whole liver transplantation in a single center, there were 12 cases of delayed portal vein thrombosis after liver transplantation.Average occurring time was 29. 8 months after liver transplantation. Among these 12 patients, 2 cases were complicated with severe biliary complication (intrahepatic stricture) , 2 cases presented with liver failure of transplanted liver, and one case had portal vein compression by hepatic hilum tumor under the image examination, who received liver re-transplantation; two patients presented upper gastrointestinal bleeding, and they experienced endoscopic ligation and sclerotherapy respectively; the rest five patients without any clinical presentation were subjected to anticoagulation and antiplatelet therapy. Results Among 12 cases, 8 patients survived by the time of follow-up, including two patients undergoing re-transplantation; one patient lost follow-up. The liver function tests of the patients who survived were all normal. Conclusion The individualized therapeutic methods should be adopted for the patients with delayed portal vein thrombosis after liver transplantation.     

肝移植中门静脉-内脏曲张静脉吻合在门静脉机化血栓患者的应用

目的:探讨门静脉-内脏曲张静脉吻合在门静脉机化血栓患者肝移植中的应用。方法:对门静脉和肠系膜上静脉均完全被机化血栓阻塞的7例患者实施肝移植,其中3例供体门静脉-曲张冠状静脉吻合;2例髂静脉搭桥供体门静脉和脾门旁曲张的静脉吻合;1例采用供体门静脉-胆总管前曲张静脉吻合;1例供体门静脉—曲张的胃网膜右静脉吻合。结果:7例手术全部成功。1例术后7d死于多脏器功能衰竭,但是门静脉血流一直通畅。1例术后6个月发现吻合口狭窄,术后9个月采用经皮肝穿刺门静脉支架置入治愈;其余患者分别随访12～22个月,门静脉血流均通畅,无狭窄或血栓形成,肝、肾功能正常。结论:肝移植中对门静脉和肠系膜上静脉均完全被机化血栓阻塞的患者,行供体门静脉-曲张内脏静脉吻合可取得良好疗效。     

Percutaneous treatment of portal vein thrombosis in a child who has undergone splenectomy

Thrombosis of the portal venous system is a well-recognized and potentially lethal complication after open or laparoscopic splenectomy. A 7-year-old girl with idiopathic thrombocytopenic purpura developed a portal vein thrombosis after open splenectomy. The portal vein thrombosis was diagnosed by color Doppler sonography. A percutaneous transhepatic thromboaspiration of the acute thrombus was done on the third postoperative day. Anticoagulation was continued for 6 months. The presented patient is the youngest patient to undergo percutaneous thromboaspiration of an acute thrombus via the transhepatic route. Percutaneous thromboaspiration via the transhepatic route is an effective means of treating a portal vein thrombosis.     

门静脉动脉化在肝胆外科中的应用现状与展望

自首次将门静脉动脉化(PVA)用于门静脉高压症患者治疗以来,PVA的概念一直受到关注.在某种特殊形式下,PVA技术在肝胆外科中仍有一定的应用价值.然而,PVA毕竟改变了正常的人体生理解剖关系,对于它在肝胆外科中应用也存在较多争议.文中综述门静脉动脉化在肝动脉切除和(或)损伤、急性肝功能衰竭以及肝移植中的应用现状,并对以后的研究进行初步的展望.     

肝移植术后门静脉并发症的诊断和治疗(附6例分析)

目的 探讨肝移植术后门静脉并发症的诊断和治疗。方法 回顾性分析160例原位肝移植临床资料。结果 肝移植术后门静脉并发症发生率为3．75％，与门静脉并发症相关死亡率为0。门静脉狭窄发生率为1．25％，门静脉栓塞发生率为2．5％，需治疗的门静脉并发症占33．3％。结论 术前有门脉高压症手术治疗史、移植术前门静脉血栓、门静脉手术史以及严重感染病史等是门静脉并发症的高危因素；彩色多普勒超声检查是监测门静脉并发症的有效方法，确诊门静脉并发症依赖门静脉造影；有症状的门静脉并发症需及时行再血管化手术。     

肝移植术中门静脉血栓和瘤栓的处理

目的 探讨肝移植时门静脉血栓和瘤栓的处理方法和临床效果.方法 2000年8月至2004年底我院施行的150例肝移植患者中5例为肝硬化伴门静脉血栓形成,21例为肝癌伴门静脉瘤栓及/或血栓形成,共26例.这些病例在术中清除了门静脉内的栓子,3例又行门静脉壁部分切除及低位门静脉对端吻合术,1例行门腔静脉半转位吻合术.结果 26例中1例术后门静脉又再发血栓形成.21例肝癌合并门静脉瘤栓者,术后近期死亡3例,分别死于：门静脉继发性血栓形成,移植肝原发性无功能和多器官衰竭.18例得到长期随访,术后1、2、3年生存率分别为：66.7%,38.9%,27.8%.结论 肝移植时受体门静脉合并血栓/瘤栓者在清除栓子后再行肝移植仍然可取得较好的疗效.     

门静脉动脉化在肝胆外科中的应用现状与展望

自首次将门静脉动脉化(PVA)用于门静脉高压症患者治疗以来,PVA的概念一直受到关注.在某种特殊形式下,PVA技术在肝胆外科中仍有一定的应用价值.然而,PVA毕竟改变了正常的人体生理解剖关系,对于它在肝胆外科中应用也存在较多争议.文中综述门静脉动脉化在肝动脉切除和(或)损伤、急性肝功能衰竭以及肝移植中的应用现状,并对以后的研究进行初步的展望.

Abstract：

Since portal vein arterialization(PVA) was firstly introduced as a treatment in patients with portal hypertension due to liver cirrhosis, the concept of PVA has drawn much attention. In special situations, in hepatobiliary surgery, this procedure remains useful. However, PVA is unphysiological and there is much controversy on its use.This article reviews the current status of PVA in hepatic artery resection or injury, in acute liver failure and in liver transplantation, and suggests future directions in research in PVA.     

门静脉和肝动脉结扎序贯二步法肝切除术治疗巨大肝癌

巨大肝癌切除术后剩余肝脏体积不足是发生肝衰竭的主要原因.通过阻断一侧的门静脉和肝动脉,使肿瘤降低分期,增加对侧术后剩余肝脏体积,成为目前切除巨大肝癌的方法之一.2013年3-4月厦门大学附属第一医院收治的1例原发性右半肝巨大肝癌患者,因肝脏剩余体积不足,术者一期行选择性门静脉及肝动脉结扎术后,序贯二期行肝切除术.患者2次手术均顺利完成,一期行门静脉右支及肝右动脉结扎术,术后肝肿瘤体积缩小,剩余左半肝代偿性增生良好,肝脏体积由术前488 mL增加到术后1个月689 mL.一期手术后33 d顺利实施二期巨大肝癌肝切除术,2次术后均无严重并发症发生.术后随访2个月,患者剩余肝脏未见肿瘤复发,AFP由术前425 mg/L降至26×10^-3mg/L.因此,选择性门静脉及肝动脉结扎后序贯二步法肝切除术可能是传统手术无法切除的巨大肝癌患者有效的治疗方法.     

Portal and mesenteric vein thrombosis after portal vein embolization in a patient with protein S deficiency

Portal vein embolization can be performed safely, and so far no major complications have been reported. We report an extremely rare complication of portal vein embolization, a case of portal and mesenteric thrombosis in a 65-year-old patient with protein S deficiency. Right portal vein embolization was carried out prior to extended right hepatectomy for advanced gallbladder carcinoma involving the hepatic hilus. Computed tomography 14 days after embolization revealed massive thrombosis of the portal and the superior mesenteric veins. A protein S deficiency was found by means of an extensive workup for hypercoagulable state. Portal vein embolization may have triggered a cascade of events that was expressed as portal and mesenteric vein thrombosis resulting from deficiency of protein S. It may be better to determine the concentrations of such coagulation regulators prior to portal vein embolization.     

Primary permanent arterialization of the portal vein in liver transplantation

Permanent total arterialization of the portal vein in liver transplantation has been described as a method of providing portal inflow after insufficient thrombectomy due to chronic occlusion of the portal-vein system. A specific problem is the restriction of the arterial inflow and its long-term adaptation after transplantation. We describe here the surgical techniques and clinical course of three patients who underwent portal-vein arterialization for liver transplantation. Two patients had an uneventful course. In one patient, a flow reduction by means of coil embolization of one arterial inflow branch was performed; thereafter, the patient recuperated well. Analysing the microcirculation of an arterialized graft in comparison with liver grafts with normal non-arterialized portal-vein inflow, we observed an increase in inter-sinusoidal distance and a decrease in sinusoidal red blood cell velocity. From a technical point of view, we recommend permanent portal-vein arterialization by an iliac artery graft interposition from the subdiaphragmatic aorta. The inflow to the portal vein can easily be reduced by the banding of the arterial graft interposition.     

利用右肾动脉行入肝门静脉动脉化加门腔分流术的实验研究

目的 建立利用右肾动脉行人肝门静脉动脉化加门腔分流术的大鼠模型,并研究此模型大鼠的门静脉压力、肝功能及肝组织病理学的变化.方法 实验组大鼠行右肾动脉与近端入肝门静脉主干端端吻合,右肾静脉与远端门静脉主干端端吻合,对照组大鼠仅行门静脉阻断10 nlill后关腹.观察大鼠术后2 d,2周和2个月时门静脉压力、肝功能及肝脏组织病理改变情况.结果 成功建立利用右肾动脉行门静脉完全动脉化加门腔分流术的大鼠模型30只,手术成功率为91%.术后2d大鼠入肝门静脉主干压力为(13.9±1.7)cm H_2O、术后2周为(12.8±2.7)cmH_2O、术后2个月为(12.6±1.6)cmH_2O,与对照组的(10.2±2.3)cm H_2O相比显著升高(P<0.05);术后大鼠各时间段血清丙氨酸转氨酶、总胆红素、总胆汁酸和肌酐水平与对照组相比差异均无统计学意义(P>0.05);术后2d和2周时大鼠肝脏组织病理结构无明显改变,术后2个月时出现肝窦间隙扩张,无其他病理性改变.结论 应用显微外科技术,利用右肾动脉行人肝门静脉完全动脉化加门腔分流术的大鼠模型是稳定可行的,成功率较高.术后大鼠入肝门静脉压力明显增高,并且在一定时间内保持在相对较高的水平,但未发现对肝脏功能及组织结构有明显的损害作用.     

经颈静脉肝内门体分流术治疗门静脉海绵样变并发门静脉高压

目的探讨经颈静脉肝内门腔静脉分流术治疗合并门静脉海绵样变的门静脉高压症的疗效。方法 8例反复上消化道出血患者(均有肝硬化、门静脉高压)术前均经B超及CT等影像学证实伴有门静脉海绵样变,门静脉主干及左右支有完全或部分闭塞,对其行TIPS治疗,并评价疗效。结果对7例患者均成功施行TIPS术,1例失败,6例为先经皮穿刺右肝门静脉分支,建立经门静脉右支至主干通道,并行球囊扩张成形治疗。其中4例经常规TIPS途径由肝右静脉穿刺门静脉右支建立门腔静脉分流道,2例由门静脉右支穿刺右肝静脉建立门腔静脉分流道。1例穿刺门静脉右支失败,改由常规TIPS途径穿刺门静脉左支建立门腔静脉分流道。门静脉压力由术前的(33.72±8.35)mmHg降低至术后的(21.43±7.64)mmHg;1例在术后6个月发现分流道狭窄,再次植入支架后恢复通畅。1例术后5个月再发黑便,复查提示分流道堵塞,并门静脉广泛血栓形成,放弃进一步治疗。另5例在12个月随访中分流道通畅,未再发消化道出血。结论 TIPS是治疗伴门静脉海绵样变的门静脉高压症的安全、有效的方法。     

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.     

Reconstruction of hepatic or portal veins by use of newly customized great saphenous vein grafts

Background and aims Segmental resection of major hepatic veins or the portal vein is sometimes required if one is to secure adequate surgical margins from hepatic or pancreatic malignancies. An external iliac vein is widely sacrificed as a vein graft to replace the defect, but this is associated with postoperative edema of the lower leg. We developed a new method for constructing the great saphenous vein to interpose the hepatic or portal veins.Patients and methods The great saphenous vein was divided transversely into three sections, which were aligned side-to-side. The three pieces were anastomosed to make a sheet 3 × 2 cm, which was rolled up into a cylindrical form of approximately 1 cm in diameter and 2 cm in length. We applied the finished vein grafts to interpose the major hepatic veins in three patients with metastatic liver tumors and the portal vein in two patients with pancreatic malignancies in cylindrical form and to reconstruct the portal vein in one patient with a pancreas cancer, using a three-row sheet as a patch graft.Results No patient developed venous thrombosis of the graft or edema of the lower leg.Conclusions The newly customized vein graft was safe and useful for the reconstruction of the major hepatic or portal veins.     

存在门静脉血栓及癌栓的肝癌患者的肝移植

目的　探讨存在门静脉血栓或癌栓的肝癌患者进行肝移植的处理要点。方法　对10例存在门静脉血栓或癌栓的肝癌患者施行原位肝移植术,术前常规准备供者的髂静脉,供肝保留较长的门静脉;术中注意取尽受者门静脉内的血栓或癌栓,门静脉壁存在水肿、增厚、变硬者,尽可能切除这段门静脉;9例行低位门静脉对端吻合,1例行门静脉下腔静脉的对端吻合;术后根据患者的凝血功能状态决定是否进行抗凝治疗。结果　1例术后第6 d发生门静脉血栓形成,溶栓术后因腹腔内出血、失血性休克死亡;另9例术后门静脉血流通畅,随访2~31个月,其中1例术后2个月死于感染,4例术后7、12、13、25个月肿瘤复发,其余4例无肿瘤复发。结论　术前存在门静脉血栓或癌栓的肝癌患者,只要处理得当,采用肝移植治疗可以取得较好结果。     

肝移植中门静脉血栓的处理经验

目的 探讨肝移植术中门静脉血栓的几种处理方法及其疗效.方法 回顾性分析773例次肝移植临床资料.773例中,107例病人有门静脉血栓,其中59例Ⅰ级;33例Ⅱ级;12例Ⅲ级;3例Ⅳ级.Ⅰ、Ⅱ级组行血栓切除或取栓术;Ⅲ级采用取栓术或肠系膜上静脉架桥的方式重建供肝门静脉;对Ⅳ级采用改良门腔静脉半转位术和门静脉胃冠状静脉吻合重建供肝门静脉.结果 Ⅰ、Ⅱ级组移植肝功能恢复良好,围手术期病死率为4.3%.Ⅲ级取栓组5例肝功能恢复良好,围手术期无死亡.静脉架桥组7例中有2例肝功能恢复不佳,围手术期病死率为28.6%.Ⅳ级组肝功能恢复良好,围手术期无死亡.结论 门静脉血栓已非肝移植禁忌证,根据血栓的不同情况采取合理的手术方式重建门脉系统可以获得良好的治疗效果.