Design and clinical application of simplified "All in one" hepatic vein reconstruction in right split liver transplantation
-
摘要:
目的 介绍右半肝劈离式肝移植时采用的简化“All in one”的肝静脉重建手术方式，探讨该术式的临床适应证、操作方式和预后。 方法 回顾性分析2例完全右半肝劈离式肝移植的病例资料，就右半肝肝静脉采用简化“All in one”重建方式进行总结分析。2例右半肝均为在体劈离，例1采用劈离肝实质至第一、二肝门，离断右肝管后整体灌注获取，台下分割肝脏血管的方法。例2采用在体劈离时先行获取左半肝，右半肝行在体灌注后获取。2例供肝劈离时均将肝中静脉主干保留于左半肝，右半肝的S5、S8段肝静脉采用同一供者髂动脉重建，并直接吻合于下腔静脉上原肝左和肝中静脉离断后的缺口，重建了肝后下腔静脉的完整性。 结果 采用简化“All in one”右半肝肝静脉重建方式，2例肝移植无肝期分别为41、36 min。肝脏开放后供肝回流良好，搭桥的髂动脉血管充盈满意，无肝脏淤血肿胀等表现，术后肝功能恢复顺利。分别随访1年11个月和10个月，无肝静脉和下腔静脉等流出道相关并发症发生。 结论 完全右半肝劈离式肝移植时，采用“All in one”的肝静脉重建方式可以简化移植肝脏流出道重建步骤、缩短无肝期时间，减少术后肝静脉并发症的发生。 Abstract:Objective To introduce the simplified "All in one" hepatic vein reconstruction in right split liver transplantation, and to investigate the clinical indications, surgical procedures and clinical prognosis of this technique. Methods Clinical data of 2 recipients undergoing right split liver transplantation were retrospectively analyzed, and the simplified "All in one" hepatic vein reconstruction of right liver lobe was summarized and analyzed. In 2 cases, the right liver lobe was split in vivo. In case 1, the liver parenchyma was split until the first and second porta hepatis, and then the liver was obtained by whole-liver perfusion after cutting off the right hepatic duct, and the hepatic blood vessels were isolated ex vivo. In case 2, the left liver lobe was obtained during splitting in vivo and the right liver lobe was obtained after perfusion in vivo. During donor liver splitting in two cases, the common trunk of the middle hepatic vein was maintained in the left liver lobe, the S5 and S8 hepatic veins of the right liver lobe were reconstructed by the same donor iliac artery, and directly anastomosed with the gap between the left and middle hepatic veins of the inferior vena cava, thus reconstructing the integrity of the posterior inferior vena cava. Results The simplified "All in one" right hepatic vein reconstruction was adopted. The anhepatic phase of two recipients undergoing liver transplantation was 41 and 36 min. After the liver was incised open, the blood flow of the donor liver was normal, the iliac artery bypass was fully filled, liver congestion or swelling was not observed, and liver function was properly recovered after surgery. Two recipients were subject to postoperative follow-up for 23 and 10 months, respectively, No complications related to hepatic venous outflow tracts were noted, such as hepatic vein and inferior vena cava. Conclusions "All in one" hepatic vein reconstruction may simplify the procedures of hepatic venous outflow tract reconstruction, shorten the anhepatic phase and reduce the incidence of postoperative hepatic vein complications in complete right liver split transplantation. -
图 1 2例受者的肝静脉重建方案
注：A图为例1的肝静脉重建方案，S5、S8段肝静脉采用髂动脉搭桥直接吻合于下腔静脉缺口，重建了下腔静脉的完整性（原缺口过大予以部分缝闭）；B图为例2的肝静脉重建方案，S5、S8段肝静脉采用髂动脉搭桥直接吻合于下腔静脉缺口，重建了下腔静脉的完整性；C图为重建后完整的肝后下腔静脉，可以采用经典或背驮式肝移植术式。
Figure 1. Hepatic venous remodeling regimen of 2 recipients
图 2 2例受者的供肝回流情况
注：A图为例1右半肝开放后，搭桥的髂动脉内血液充盈满意；B图为例2右半肝开放后，搭桥的髂动脉内血液充盈满意。
Figure 2. Condition of donor liver reflux of 2 recipients
-
[1] 郭源, 蔡金贞, 罗毅, 等. 原位劈离式供肝儿童肝移植经验总结[J]. 中华器官移植杂志, 2019, 40(1): 18-21. DOI: 10.3760/cma.j.issn.0254-1785.2019.01.005.GUO Y, CAI JZ, LUO Y, et al. In-situ split liver transplantation for pediatric recipient: a single-center experience[J]. Chin J Organ Transplant, 2019, 40(1): 18-21. DOI: 10.3760/cma.j.issn.0254-1785.2019.01.005. [2] 易述红, 杨扬, 易慧敏, 等. 劈离式肝移植在儿童肝移植中的临床应用[J]. 中华器官移植杂志, 2019, 40(1): 22-25. DOI: 10.3760/cma.j.issn.0254-1785.2019.01.006.YI SH, YANG Y, YI HM, et al. Clinical research of deceased-donor split liver transplantation in pediatric recipients[J]. Chin J Organ Transplant, 2019, 40(1): 22-25. DOI: 10.3760/cma.j.issn.0254-1785.2019.01.006. [3] 赖彦华, 徐钰驹, 杨建荣. 劈离式肝移植技术及研究进展[J]. 中国临床新医学, 2020, 13(12): 1208-1212. DOI: 10.3969/j.issn.1674-3806.2020.12.06.LAI YH, XU YJ, YANG JR. The technique and research progress of split liver transplantation[J]. Chin J New Clin Med, 2020, 13(12): 1208-1212. DOI: 10.3969/j.issn.1674-3806.2020.12.06. [4] 朱建军, 罗毅, 夏雷, 等. 劈离式肝移植质量控制标准[J]. 武汉大学学报(医学版), 2021, 42(2): 224-227. DOI: 10.14188/j.1671-8852.2021.8013.ZHU JJ, LUO Y, XIA L, et al. Quality control standards for split liver transplantation[J]. Med J Wuhan Univ, 2021, 42(2): 224-227. DOI: 10.14188/j.1671-8852.2021.8013. [5] 曾志贵, 魏林, 孙丽莹, 等. 完全右半肝-左半肝劈离式肝移植的临床应用: 附四例报告[J]. 中华肝胆外科杂志, 2021, 27(2): 94-97. DOI: 10.3760/cma.j.cn113884-20200330-00171.ZENG ZG, WEI L, SUN LY, et al. Clinical use of 'full right-full left' split liver transplantation: a report of 4 cases[J]. Chin J Hepatobiliary Surg, 2021, 27(2): 94-97. DOI: 10.3760/cma.j.cn113884-20200330-00171. [6] SNEIDERS D, VAN DIJK ARM, POLAK WG, et al. Full-left-full-right split liver transplantation for adult recipients: a systematic review and Meta-analysis[J]. Transpl Int, 2021, 34(12): 2534-2546. DOI: 10.1111/tri.14160. [7] BROERING DC, BOK P, MUELLER L, et al. Splitting of the middle hepatic vein in full-right full-left splitting of the liver[J]. Liver Transpl, 2005, 11(3): 350-352. DOI: 10.1002/lt.20312. [8] CHAN KM, HUNG HC, LEE JC, et al. A review of split liver transplantation with full right/left hemi-liver grafts for 2 adult recipients[J]. Medicine (Baltimore), 2021, 100(39): e27369. DOI: 10.1097/MD.0000000000027369. [9] 国家卫生健康委员会脑损伤质控评价中心, 中华医学会神经病学分会神经重症协作组, 中国医师协会神经内科医师分会神经重症专业委员会. 中国成人脑死亡判定标准与操作规范(第二版)[J]. 中华医学杂志, 2019, 99(17): 1288-1292. DOI: 10.3760/cma.j.issn.0376-2491.2019.17.003.Brain Injury Evaluation Quality Control Centre of National Health Commission, Neurology Critical Care Cooperative Group of Neurology Branch of Chinese Medical Association, Neurology Critical Care Committee of Neurologist Branch of Chinese Medical Doctor Association. Criteria and practical guidance for determination of brain death in Chinese adults (2nd version)[J]. Natl Med J China, 2019, 99(17): 1288-1292. DOI: 10.3760/cma.j.issn.0376-2491.2019.17.003. [10] 中华医学会外科学分会外科手术学学组, 中华医学会外科学分会移植学组. 劈离式肝移植专家共识[J/CD]. 中华肝脏外科手术学电子杂志, 2020, 9(5): 429-434. DOI: 10.3877/cma.j.issn.2095-3232.2020.05.008.Operative Surgical Group of Branch of Surgery of Chinese Medical Association. Transplantation Group of Branch of Surgery of Chinese Medical Association. Expert consensus on split liver transplantation[J/CD]. Chin J Hepatic Surg (Electr Edit), 2020, 9(5): 429-434. DOI: 10.3877/cma.j.issn.2095-3232.2020.05.008. [11] 朱明强, 丁佑铭. 劈离式肝移植技术的临床应用[J]. 器官移植, 2022, 13(3): 404-410. DOI: 10.3969/j.issn.1674-7445.2022.03.019.ZHU MQ, DING YM. Clinical application of split liver transplantation technique[J]. Organ Transplant, 2022, 13(3): 404-410. DOI: 10.3969/j.issn.1674-7445.2022.03.019. [12] 夏强, 沙朦. 活体肝移植的进展与展望[J]. 中华消化外科杂志, 2022, 21(1): 39-42. DOI: 10.3760/cma.j.cn115610-20211205-00622.XIA Q, SHA M. Progress and prospect of living donor liver transplantation[J]. Chin J Dig Surg, 2022, 21(1): 39-42. DOI: 10.3760/cma.j.cn115610-20211205-00622. [13] TRAN L, HUMAR A. Current status of adult liver transplantation: utilization of living donor versus deceased donor graft[J]. Curr Opin Organ Transplant, 2021, 26(2): 133-138. DOI: 10.1097/MOT.0000000000000849. [14] LAU NS, JACQUES A, MCCAUGHAN G, et al. Addressing the challenges of split liver transplantation through technical advances. a systematic review[J]. Transplant Rev (Orlando), 2021, 35(3): 100627. DOI: 10.1016/j.trre.2021.100627. [15] HIBI T, WEI CHIEH AK, CHI-YAN CHAN A, et al. Current status of liver transplantation in Asia[J]. Int J Surg, 2020, 82S: 4-8. DOI: 10.1016/j.ijsu.2020.05.071. [16] IVANICS T, ABREU P, DE MARTIN E, et al. Changing trends in liver transplantation: challenges and solutions[J]. Transplantation, 2021, 105(4): 743-756. DOI: 10.1097/TP.0000000000003454. [17] 傅斌生, 易述红, 易慧敏, 等. 劈离式肝移植治疗儿童胆道闭锁的临床效果研究[J]. 中华外科杂志, 2022, 60(10): 900-905. DOI: 10.3760/cma.j.cn112139-20220712-00309.FU BS, YI SH, YI HM, et al. Clinical efficacy of split liver transplantation in the treatment of children with biliary atresia[J]. Chin J Surg, 2022, 60(10): 900-905. DOI: 10.3760/cma.j.cn112139-20220712-00309. [18] 赖彦华, 何俊鑫, 庞飞雄, 等. 原位劈离式肝移植单中心经验[J]. 中国临床新医学, 2020, 13(12): 1204-1207. DOI: 10.3969/j.issn.1674-3806.2020.12.05.LAI YH, HE JX, PANG FX, et al. In situ split liver transplantation: a single-center experience[J]. Chin J New Clin Med, 2020, 13(12): 1204-1207. DOI: 10.3969/j.issn.1674-3806.2020.12.05. [19] 张文杰, 徐庆祥, 李国强, 等. 劈离式多米诺供肝辅助性肝移植的临床价值[J]. 中华消化外科杂志, 2022, 21(2): 287-294. DOI: 10.3760/cma.j.cn115610-20211230-00694.ZHANG WJ, XU QX, LI GQ, et al. Clinical value of split domino donor auxiliary liver transplantation[J]. Chin J Dig Surg, 2022, 21(2): 287-294. DOI: 10.3760/cma.j.cn115610-20211230-00694. [20] 张良灏, 徐庆国, 王新, 等. 劈离式肝移植术后肝再生的影响因素及其对预后的影响[J]. 中华肝胆外科杂志, 2022, 28(6): 413-418. DOI: 10.3760/cma.j.cn113884-20220121-00036.ZHANG LH, XU QG, WANG X, et al. Influencing factors of liver regeneration and their prognostic impact after split liver transplantation[J]. Chin J Hepatobiliary Surg, 2022, 28(6): 413-418. DOI: 10.3760/cma.j.cn113884-20220121-00036. [21] BROERING DC, WILMS C, LENK C, et al. Technical refinements and results in full-right full-left splitting of the deceased donor liver[J]. Ann Surg, 2005, 242(6): 802-813. DOI: 10.1097/01.sla.0000189120.62975.0d. [22] HASHIMOTO K, QUINTINI C, AUCEJO FN, et al. Split liver transplantation using hemiliver graft in the MELD era: a single center experience in the United States[J]. Am J Transplant, 2014, 14(9): 2072-2080. DOI: 10.1111/ajt.12791. [23] ASENI P, DE FEO TM, DE CARLIS L, et al. A prospective policy development to increase split-liver transplantation for 2 adult recipients: results of a 12-year multicenter collaborative study[J]. Ann Surg, 2014, 259(1): 157-165. DOI: 10.1097/SLA.0b013e31827da6c9. [24] 吴胜东, 黄静, 房炯泽, 等. 活体肝移植技术用于成人完全半肝原位劈离式肝移植单中心25例报告[J]. 中华外科杂志, 2022, 60(10): 906-914. DOI: 10.3760/cma.j.cn112139-20220218-00069.WU SD, HUANG J, FANG JZ, et al. Efficacy of in-situ full-left/full-right split liver transplantation for adult recipients using the living donor liver transplantation technique: a single-center report of 25 cases[J]. Chin J Surg, 2022, 60(10): 906-914. DOI: 10.3760/cma.j.cn112139-20220218-00069. [25] ZAMBELLI M, ANDORNO E, DE CARLIS L, et al. Full-right-full-left split liver transplantation: the retrospective analysis of an early multicenter experience including graft sharing[J]. Am J Transplant, 2012, 12(8): 2198-2210. DOI: 10.1111/j.1600-6143.2012.04071.x. [26] ZIMMERMAN A, FLAHIVE JM, HERTL M, et al. Outcomes of full-right-full-left split liver transplantation in adults in the USA: a propensity-score matched analysis[J]. Int J Organ Transplant Med, 2016, 7(2): 69-76. [27] MARCOS A, ORLOFF M, MIELES L, et al. Functional venous anatomy for right-lobe grafting and techniques to optimize outflow[J]. Liver Transpl, 2001, 7(10): 845-852. DOI: 10.1053/jlts.2001.27966. [28] NEUMANN JO, THORN M, FISCHER L, et al. Branching patterns and drainage territories of the middle hepatic vein in computer-simulated right living-donor hepatectomies[J]. Am J Transplant, 2006, 6(6): 1407-1415. DOI: 10.1111/j.1600-6143.2006.01315.x. -
下载:
点击查看大图
图(4)
计量
- 文章访问数: 224
- HTML全文浏览量: 106
- PDF下载量: 77
- 被引次数: 0
