肝动脉重建技术对肝移植预后的影响

李欣澄; 黄帆; 王国斌; 余孝俊; 吴若林; 侯刘进; 叶征辉; 张兴华; 王伟; 耿小平; 赵红川

doi:10.3969/j.issn.1674-7445.2023.01.017

肝动脉重建技术对肝移植预后的影响

doi: 10.3969/j.issn.1674-7445.2023.01.017

230022 合肥，安徽医科大学第一附属医院器官移植中心

基金项目:

安徽省自然科学基金青年基金项目 2008085QH361

详细信息

作者简介:

通讯作者:
赵红川，博士，主任医师，研究方向为器官移植，Email：zhc0117@sina.com

中图分类号: R617, R619
计量
- 文章访问数: 201
- HTML全文浏览量: 61
- PDF下载量: 73
- 被引次数: 0
出版历程
- 收稿日期: 2022-08-22
- 网络出版日期: 2023-01-17
- 刊出日期: 2023-01-15

Effect of hepatic artery reconstruction techniques on prognosis of liver transplantation

Organ Transplantation Center, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China

More Information

Corresponding author: Zhao Hongchuan, Email: zhc0117@sina.com

摘要

摘要: 目的探讨肝动脉不同重建方式对肝移植术后肝动脉并发症和预后的影响。方法回顾性分析140例肝移植受者的临床资料，根据肝动脉重建方式分为常规类型肝动脉重建组(123例)及特殊类型肝动脉重建组(17例)，比较两组受者术中和术后的各项临床指标以及术后肝动脉并发症发生率和生存率。结果特殊类型肝动脉重建组术后1 d丙氨酸转氨酶(ALT)和天冬氨酸转氨酶(AST)、术后7 d总胆红素(TB)、术后30 d凝血酶原时间国际标准化比值(PT-INR)均高于常规肝动脉重建组，差异均有统计学意义(均为P < 0.05)。两组的手术时间、无肝期、术中失血量、术中输入红细胞量、冷或热缺血时间、重症监护室(ICU)入住时间、总住院时间、术后移植肝血流情况差异均无统计学意义(均为P > 0.05)。常规组发生肝动脉并发症5例，而特殊组未见肝动脉并发症，两组比较差异无统计学意义(P > 0.05)。特殊类型肝动脉重建组术后1、3、5年累积生存率均为82.4%，常规重建组术后1、3、5年累积生存率分别为85.0%、78.9%、75.6%，两组术后生存率差异均无统计学意义(均为P > 0.05)。结论当供受者肝动脉存在变异和(或)病变时，采用特殊方法行肝动脉重建可有效恢复移植肝动脉血流，并不会影响肝移植受者术后肝动脉并发症的发生率和生存率。
- 肝移植 /
- 肝动脉重建 /
- 肝动脉并发症 /
- 重症监护室 /
- 总胆红素 /
- 丙氨酸转氨酶 /
- 天冬氨酸转氨酶 /
- 凝血酶原时间国际标准化比值
Abstract: Objective To evaluate the effect of different techniques of hepatic artery reconstruction on postoperative hepatic artery complications and clinical prognosis in liver transplantation. Methods Clinical data of 140 liver transplant recipients were retrospectively analyzed. All recipients were divided into the conventional hepatic artery reconstruction group (n=123) and special hepatic artery reconstruction group (n=17) according to hepatic artery reconstruction methods. Intraoperative and postoperative clinical indexes, the incidence of postoperative hepatic artery complications and survival rate were compared between two groups. Results The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels at postoperative 1 d, total bilirubin (TB) at postoperative 7 d and prothrombin time international normalized ratio (PT-INR) at postoperative 30 d in special hepatic artery reconstruction group were higher than those in conventional hepatic artery reconstruction group, and the differences were statistically significant (all P < 0.05). There were no significant differences in the operation time, anhepatic phase, intraoperative blood loss, intraoperative transfusion volume of red blood cells, cold or warm ischemia time, the length of intensive care unit (ICU) stay, the length of hospital stay and postoperative blood flow of liver allograft between two groups (all P > 0.05). In the conventional hepatic artery reconstruction group, 5 recipients developed hepatic artery complications, whereas no hepatic artery complications occurred in the special hepatic artery reconstruction group, with no significant difference between two groups (P > 0.05). In the special hepatic artery reconstruction group, the 1-, 3- and 5-year cumulative survival rates were equally 82.4%, compared with 85.0%, 78.9% and 75.6% in the conventional hepatic artery reconstruction group, respectively. There was no significant difference between two groups (all P > 0.05). Conclusions When hepatic artery variations and (or) lesions are detected in donors and recipients, use of special hepatic artery reconstruction may effectively restore the hepatic arterial blood flow of liver allograft after liver transplantation, and will not affect the incidence of hepatic artery complications and survival rate of the recipients following liver transplantation.
- Liver transplantation /
- Hepatic artery reconstruction /
- Hepatic artery complication /
- Intensive care unit /
- Total bilirubin /
- Alanine aminotransferase /
- Aspartate aminotransferase /
- Prothrombin time international normalized ratio

HTML全文

下载: 全尺寸图片幻灯片

图 1 肝动脉重建方式

注：A图为后台修肝发现肝动脉变异，RRHA发自SMA; B、C图为后台完成供肝RRHA与供肝GDA显微吻合，测试吻合口无渗透(白色箭头); D图为供肝CHA与受者CHA端端吻合，开放动脉血流后，血管走行顺畅，血流良好(白色箭头显示肝动脉两处吻合口)。E图为后台修肝发现肝动脉变异，RRHA发自SMA; F、G图为后台完成供肝RRHA与供肝SA显微吻合，测试吻合口无渗漏(白色箭头); H图为供肝腹腔干与受者CHA端端吻合，开放动脉血流后，血管走行顺畅，血流良好，图中白色箭头显示肝动脉两处吻合口; I图为术前评估发现正中弓状韧带综合征(白色箭头); J图为预制供肝搭桥髂动脉; K图为完成供肝髂动脉与受者腹主动脉端侧吻合(白色箭头); L图为供肝髂动脉经结肠系膜根部进入胰腺前方，经十二指肠球部后方向右到达肝门部与移植肝CHA完成端端吻合(白色箭头); M、N图为开放动脉血流后，见重建肝动脉走行顺畅，血流良好; O、P图为肝移植术后1周复查CT血管造影显示移植搭桥的肝动脉血流通畅; Q图为初次肝移植术后肝动脉栓塞，导致缺血性胆道病变，移植肝左右肝管经皮经肝胆道引流术后，SA完整; R图为后台修肝发现肝左动脉(LHA)变异起自腹腔干; S图为术中供肝腹腔干与受者SA吻合，重建后血流良好，术中白色箭头所示; T图为术后2周CT血管造影显示重建肝动脉走行正常，血流充分。

Figure 1. The method of hepatic artery reconstruction

下载: 全尺寸图片幻灯片

图 2 两组肝移植受者术后生存曲线

Figure 2. Postoperative survival curves of liver transplant recipients in two groups

下载: 全尺寸图片幻灯片

表 1 特殊类型肝动脉重建方式

Table 1. Special types of hepatic artery reconstruction

特殊类型肝动脉重建方式	原因	n
RRHA分别与GDA或SA吻合后重建供受者肝动脉	粗大的替代右肝动脉或副右肝动脉从SMA发出	7
供肝髂动脉搭桥供受者肝动脉重建	受者肝动脉内外膜分层、纤细或MALS^①	3
供肝腹腔干与受者脾动脉重建	脾动脉窃血或受者肝动脉病变	3
供肝肝动脉延长或搭桥肝动脉重建	供受者肝动脉长度不匹配	2
供肝肝固有动脉与受者变异肝动脉	受者肝动脉变异从SMA发出	1
供肝脾动脉与受者肝总动脉	供受者肝动脉管径不匹配	1
注：①MALS为正中弓状韧带综合征。

下载: 导出CSV

表 2 两组术中和术后资料比较

Table 2. Comparison of intraoperative and postoperative data between two groups[M(P₂₅, P₇₅)]

指标	特殊类型肝动脉重建组(n=17)	常规类型肝动脉重建组(n=123)	P值
手术时间(min)	470(408，490)	410(375，480)	0.11
无肝期(min)	59(48，65)	53(49，63)	0.58
术中失血量(mL)	1 000(550，1 150)	800(500，1 000)	0.48
术中输入红细胞量(U)	7(4，10)	5(3，10)	0.33
热缺血时间(min)	22(15，28)	19(15，24)	0.29
冷缺血时间(min)	296(281，394)	306(238，420)	0.75
ICU入住时间(h)	60(33，108)	49(33，72)	0.36
总住院时间(d)	24(19，32)	25(18，35)	0.52

下载: 导出CSV

表 3 两组受者术后肝功能和凝血功能比较

Table 3. Comparison of liver function and coagulation function between two groups [M(P₂₅, P₇₅)]

指标	特殊肝动脉重建组(n=17)	常规肝动脉重建组(n=123)	P值
PT-INR
术后1 d	1.4(1.2，1.9)	1.4(1.3，1.7)	0.26
术后3 d	1.4(1.2，1.8)	1.2(1.2，1.4)	0.13
术后7 d	1.2(1.1，1.6)	1.2(1.1，1.3)	0.08
术后30 d	1.3(1.1，1.4)	1.1(1.0，1.2)	0.03
TB(μmol/L)
术后1 d	73(52，102)	66(66，106)	0.20
术后3 d	52(40，93)	47(25，82)	0.06
术后7 d	53(30，126)	33(32，60)	0.01
术后30 d	21(14，39)	17(11，28)	0.20
ALT(U/L)
术后1 d	994(201，2 067)	387(246，645)	0.04
术后3 d	409(118，592)	221(140，366)	0.11
术后7 d	102(56，124)	87(51，152)	0.60
术后30 d	20(14，34)	26(14，52)	0.20
AST(U/L)
术后1 d	1 217(239，2 988)	533(268，1 018)	0.04
术后3 d	104(44，218)	119(62，258)	0.83
术后7 d	31(19，59)	39(22，59)	0.35
术后30 d	23(11，30)	24(17，39)	0.35
PSV(cm/s)
术后1 d	68(53，85)	60(47，77)	0.16
术后7 d	69(41，85)	67(55，84)	0.72
RI
术后1 d	0.61(0.60，0.70)	0.67(0.60，0.72)	0.50
术后7 d	0.68(0.60，0.80)	0.65(0.60，0.72)	0.17

下载: 导出CSV

表 4 5例肝移植受者术后肝动脉并发症发生情况

Table 4. Postoperative hepatic artery complications in 5 liver transplant recipients

肝动脉并发症	发病时间及症状	诊断方法	治疗措施	预后	死亡原因
急性移植肝动脉弥漫性栓塞	术中肝动脉重建后	肉眼+术中超声	急诊早期再移植	存活	―
肝动脉吻合口假性动脉破裂	术后10 d引流管大量新鲜血液引出伴休克	DSA^②	肝动脉栓塞术	死亡	术后21个月缺血性胆道病变、脓毒症
供肝GDA残端假性动脉瘤破裂入十二指肠球部	术后2个月出现反复消化道大出血伴休克	DSA	内镜、开腹、栓塞和覆膜支架植入术	存活	―
供肝肝动脉破裂	术后7 d引流管大量血液引出伴休克	腹部穿刺见不凝血+休克	肝动脉修补术	死亡	术后10 d脓毒症
肝动脉吻合口破裂出血	术后12 d引流管大量血液引出伴休克	腹部穿刺见不凝血+休克	再手术修补肝动脉	死亡	术后20个月缺血性胆道病变、脓毒症
注：①—为无数据。 ②DSA为数字减影血管造影。

下载: 导出CSV

参考文献(30)

[1]	AKBULUT S, KUTLUTURK K, YILMAZ S. Hepatic artery reconstruction technique in liver transplantation: experience with 3, 000 cases[J]. Hepatobiliary Surg Nutr, 2021, 10(2): 281-283. DOI: 10.21037/hbsn-21-2.
[2]	NG SW. Hepatic artery anastomosis in liver transplantation[J]. Ann Acad Med Singap, 2021, 50(9): 666-668. DOI: 10.47102/annals-acadmedsg.2021332.
[3]	BEAUREPAIRE JM, ORLANDO F, LEVI SANDRI GB, et al. Comparison of alternative arterial anastomosis site during liver transplantation when the recipient's hepatic artery is unusable[J]. Hepatobiliary Surg Nutr, 2022, 11(1): 1-12. DOI: 10.21037/hbsn-20-10.
[4]	TAN BK, FONG HC, TAN EK, et al. Strategies for a successful hepatic artery anastomosis in liver transplantation: a review of 51 cases[J]. Ann Acad Med Singap, 2021, 50(9): 679-685. DOI: 10.47102/annals-acadmedsg.2020635.
[5]	何博, 王新, 王峰, 等. 肝移植供肝动脉变异与重建方式对术后早期动脉并发症的影响[J]. 临床肝胆病杂志, 2021, 37(8): 1901-1904. DOI: 10.3969/j.issn.1001-5256.2021.08.030. HE B, WANG X, WANG F, et al. Influence of arterial variation and reconstruction of the donor hepatic artery in liver transplantation on early postop-erative arterial complications[J]. J Clin Hepatol, 2021, 37(8): 1901-1904. DOI: 10.3969/j.issn.1001-5256.2021.08.030.
[6]	LIN TS, LIN CH, KUO PJ, et al. Management of difficult hepatic artery reconstructions to reduce complications through continual technical refinements in living donor liver transplantations[J]. Int J Surg, 2022, 104: 106776. DOI: 10.1016/j.ijsu.2022.106776.
[7]	曹阳, 张洪涛, 彭伟, 等. 公民逝世后器官捐献肝移植发生肝动脉并发症的影响因素分析[J]. 中华消化外科杂志, 2021, 20(10): 1055-1060. DOI: 10.3760/cma.j.cn115610-20210901-00429. CAO Y, ZHANG HT, PENG W, et al. Analysis of influencing factors for hepatic artery complications of liver transplantation from donation after citizen's death[J]. Chin J Dig Surg, 2021, 20(10): 1055-1060. DOI: 10.3760/cma.j.cn115610-20210901-00429.
[8]	LI PC, THORAT A, JENG LB, et al. Hepatic artery reconstruction in living donor liver transplantation using surgical loupes: achieving low rate of hepatic arterial thrombosis in 741 consecutive recipients-tips and tricks to overcome the poor hepatic arterial flow[J]. Liver Transpl, 2017, 23(7): 887-898. DOI: 10.1002/lt.24775.
[9]	KARAKOYUN R, ROMANO A, YAO M, et al. Impact of hepatic artery variations and reconstructions on the outcome of orthotopic liver transplantation[J]. World J Surg, 2020, 44(6): 1954-1965. DOI: 10.1007/s00268-020-05406-4.
[10]	CIROCCHI R, D'ANDREA V, LAURO A, et al. The absence of the common hepatic artery and its implications for surgical practice: results of a systematic review and meta-analysis[J]. Surgeon, 2019, 17(3): 172-185. DOI: 10.1016/j.surge.2019.03.001.
[11]	郭亚飞, 刘国岩, 朱泽斌, 等. 解剖性肝动脉重建在肝移植中的应用价值[J/CD]. 中华肝脏外科手术学电子杂志, 2021, 10(4): 376-380. DOI: 10.3877/cma.j.issn.2095-3232.2021.04.008. GUO YF, LIU GY, ZHU ZB, et al. Application value of anatomical hepatic artery reconstruction in liver transplantation[J/CD]. Chin J Hepatic Surg (Electr Edit), 2021, 10(4): 376-380. DOI: 10.3877/cma.j.issn.2095-3232.2021.04.008.
[12]	HIATT JR, GABBAY J, BUSUTTIL RW. Surgical anatomy of the hepatic arteries in 1000 cases[J]. Ann Surg, 1994, 220(1): 50-52. DOI: 10.1097/00000658-199407000-00008.
[13]	GEHA JA, GEHA JD, O'MAHONY CA, et al. Recons-truction of the replaced right hepatic artery using donor iliac arterial Y-graft in orthotopic liver transplantation[J]. Liver Transpl, 2019, 25(1): 167-170. DOI: 10.1002/lt.25380.
[14]	JIANG WT, YANG J, XIE Y, et al. Simultaneous partial splenectomy during liver transplantation for advanced cirrhosis patients combined with severe splenomegaly and hypersplenism[J]. World J Gastroenterol, 2021, 27(7): 654-665. DOI: 10.3748/wjg.v27.i7.654.
[15]	KIM EN, LAMB K, RELLES D, et al. Median arcuate ligament syndrome-review of this rare disease[J]. JAMA Surg, 2016, 151(5): 471-477. DOI: 10.1001/jamasurg.2016.0002.
[16]	NAKADA S, ALLARD MA, LEWIN M, et al. Ischemic cholangiopathy following transcatheter arterial chemoembolization for recurrent hepatocellular carcinoma after hepatectomy: an underestimated and devastating complication[J]. J Gastrointest Surg, 2020, 24(11): 2517-2525. DOI: 10.1007/s11605-019-04409-4.
[17]	TSURUSAKI M, MURAKAMI T. Surgical and locoregional therapy of HCC: TACE[J]. Liver Cancer, 2015, 4(3): 165-175. DOI: 10.1159/000367739.
[18]	PANARO F, RAMOS J, GALLIX B, et al. Hepatic artery complications following liver transplantation. does preoperative chemoembolization impact the postoperative course?[J]. Clin Transplant, 2014, 28(5): 598-605. DOI: 10.1111/ctr.12358.
[19]	王光辉. 肝移植受体合并正中弓状韧带综合征时的动脉重建研究(附6例报告)[D]. 吉林: 吉林大学, 2020.
[20]	HORTON KM, TALAMINI MA, FISHMAN EK. Median arcuate ligament syndrome: evaluation with CT angiography[J]. Radiographics, 2005, 25(5): 1177-1182. DOI: 10.1148/rg.255055001.
[21]	SNEIDERS D, HOUWEN T, PENGEL LHM, et al. Systematic review and meta-analysis of posttransplant hepatic artery and biliary complications in patients treated with transarterial chemoembolization before liver transplantation[J]. Transplantation, 2018, 102(1): 88-96. DOI: 10.1097/TP.0000000000001936.
[22]	GOSS MB, GALVÁN NTN, GEHA JD, et al. Splenic artery transposition for liver transplantation: an underutilized technique?[J]. Transplant Direct, 2021, 7(2): e661. DOI: 10.1097/TXD.0000000000001103.
[23]	LLADO L, RAMOS E, BRAVO A, et al. Short- and long-term outcomes of arterial reconstruction on recipient splenic artery in adult liver transplantation. single-center prospective study 25 years after first description[J]. Transpl Int, 2019, 32(10): 1053-1060. DOI: 10.1111/tri.13447.
[24]	KAZEMI K, SAMIDOOST P, DEILAMI HN, et al. A new consideration in hepatic artery reconstruction in adult liver transplant: arterial transposition versus extra-anatomic jump grafts[J]. Exp Clin Transplant, 2017, 15(Suppl 1): 204-207. DOI: 10.6002/ect.mesot2016.P82.
[25]	李晓航, 张佳林, 吴刚, 等. 应用供者髂动脉行腹主动脉搭桥重建移植肝动脉的临床分析[J/CD]. 中华移植杂志(电子版), 2019, 13(3): 215-218. DOI: 10.3877/cma.j.issn.1674-3903.2019.03.011. LI XH, ZHANG JL, WU G, et al. Hepatic artery reconstruction using donor's iliac artery through abdominal aorta bypass graft in orthotopic liver transplantation[J/CD]. Chin J Transplant (Electr Edit), 2019, 13(3): 215-218. DOI: 10.3877/cma.j.issn.1674-3903.2019.03.011.
[26]	HIBI T, NISHIDA S, LEVI DM, et al. Long-term deleterious effects of aortohepatic conduits in primary liver transplantation: proceed with caution[J]. Liver Transpl, 2013, 19(8): 916-925. DOI: 10.1002/lt.23689.
[27]	FANG J, CHEN Z, JIANG N, et al. Reconstruction of the hepatic artery using the superior mesenteric artery for liver transplantation[J]. Ann Transl Med, 2020, 8(22): 1520. DOI: 10.21037/atm-20-7200.
[28]	张春, 刘司南, 师建华, 等. 成人原位肝移植后肝动脉血栓的诊断与治疗[J]. 中华消化外科杂志, 2021, 20(10): 1061-1067. DOI: 10.3760/cma.j.cn115610-20210913-00456. ZHANG C, LIU SN, SHI JH, et al. Diagnosis and treatment of hepatic artery thrombosis after adult orthotopic liver transplantation[J]. Chin J Dig Surg, 2021, 20(10): 1061-1067. DOI: 10.3760/cma.j.cn115610-20210913-00456.
[29]	CRAIG EV, HELLER MT. Complications of liver transplant[J]. Abdom Radiol (NY), 2021, 46(1): 43-67. DOI: 10.1007/s00261-019-02340-5.
[30]	中华医学会器官移植学分会围手术期管理学组. 肝移植围手术期血管并发症诊治专家共识(2021版)[J]. 临床肝胆病杂志, 2021, 37(9): 2054-2057. DOI: 10.3969/j.issn.1001-5256.2021.09.010. Perioperative Management Group of Branch of Organ Transplantation of Chinese Medical Association. Expert consensus on perioperative vascular complications for liver transplantation (2021)[J]. J Clin Hepatol, 2021, 37(9): 2054-2057. DOI: 10.3969/j.issn.1001-5256.2021.09.010.