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肝动脉重建技术对肝移植预后的影响

李欣澄, 黄帆, 王国斌, 等. 肝动脉重建技术对肝移植预后的影响[J]. 器官移植, 2023, 14(1): 128-134. doi: 10.3969/j.issn.1674-7445.2023.01.017
引用本文: 李欣澄, 黄帆, 王国斌, 等. 肝动脉重建技术对肝移植预后的影响[J]. 器官移植, 2023, 14(1): 128-134. doi: 10.3969/j.issn.1674-7445.2023.01.017
Li Xincheng, Huang Fan, Wang Guobin, et al. Effect of hepatic artery reconstruction techniques on prognosis of liver transplantation[J]. ORGAN TRANSPLANTATION, 2023, 14(1): 128-134. doi: 10.3969/j.issn.1674-7445.2023.01.017
Citation: Li Xincheng, Huang Fan, Wang Guobin, et al. Effect of hepatic artery reconstruction techniques on prognosis of liver transplantation[J]. ORGAN TRANSPLANTATION, 2023, 14(1): 128-134. 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
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

Effect of hepatic artery reconstruction techniques on prognosis of liver transplantation

More Information
  • 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。

     

  • 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

    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

    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 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
    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
    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 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
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  • 收稿日期:  2022-08-22
  • 网络出版日期:  2023-01-17
  • 刊出日期:  2023-01-15

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