自体肝脏移植治疗终末期肝泡型包虫病合并继发性门静脉海绵样变
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摘要
目的探索自体肝脏移植治疗终末期肝泡型包虫病合并继发性门静脉海绵样变的可行性及安全性。方法对1例诊断为终末期肝泡型包虫病合并继发性门静脉海绵样变的患者,术前经过CT、MRI及超声检查评价肝脏占位病灶大小、范围及血管侵犯情况,使用IQQA肝脏系统(EDDA Technology,Inc.USA)重建肝脏模型,测量并记录剩余肝脏体积及第1肝门侵犯程度,经多学科协作讨论后拟采用自体肝脏移植对其进行治疗。结果经过充分术前评估,明确患者肝内病灶147 mm×134 mm×165 mm大,严重侵犯肝后下腔静脉及肝右和肝中静脉并造成三者闭塞,肝左静脉部分受侵,伴有门静脉海绵样变,剩余肝脏体积约912 m L,剩余肝脏体积与标准肝脏体积比为0.81,术前肝脏功能Child-Pugh评分为A级。按预期方案行自体肝脏移植术,术中应用患者自身大隐静脉做移植物重建部分流入及流出道,下腔静脉未予以重建,术后患者恢复良好并于术后第20天顺利出院。结论自体肝脏移植可成功治疗终末期肝泡型包虫病合并继发性门静脉海绵样变,其中充分的术前评估和第一肝门的处理是手术的关键。
Objective To explore feasibility and safety of ex vivo liver resection and autotransplantation in treating end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein.Methods The patient was diagnosed with the end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. The ultrasonography, computed tomography, and magnetic resonance imaging were used to access the characteristics of the lesions and the extent of involvement of the portal vein and its branches. The liver model was reconstructed using a three-dimensional imaging data analysis system(EDDA Technology, Inc. USA), the remnant liver volume and the extent of involvement of the first hepatic hilum were recorded. Then the multidisciplinary team repetitively discussed the risks and procedures involved in the surgery. Finally, the ex vivo liver resection and autotransplantation was proposed. Results The preoperative evaluation showed the patient had a large intrahepatic lesion which severely invaded the retrohepatic inferior vena cava, the right hepatic vein, and the middle hepatic vein and were completely occluded, the left hepatic vein was partially invaded, and the portal vein was spongiform. The remnant liver volume was 912 m L, the ratio of residual liver volume to standard liver volume was 0.81. The preoperative liver function Child-Pugh score was grade A. The ex vivo liver resection and autotransplantation was successfully managed according to the expected schedule. The autografts(made by patient's great saphenous vein) were used to reconstruct the hepatic vein and portal vein, and the retrohepatic inferior vena cava was not reconstructed. The patient recovered well and was discharged on day 20 after the operation. Conclusions Ex vivo liver resection and autotransplantation could successfully be applied in treating patient with end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. Adequate preoperative assessment and management of the first hepatic hilum are key to this operation.
Objective To explore feasibility and safety of ex vivo liver resection and autotransplantation in treating end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein.Methods The patient was diagnosed with the end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. The ultrasonography, computed tomography, and magnetic resonance imaging were used to access the characteristics of the lesions and the extent of involvement of the portal vein and its branches. The liver model was reconstructed using a three-dimensional imaging data analysis system(EDDA Technology, Inc. USA), the remnant liver volume and the extent of involvement of the first hepatic hilum were recorded. Then the multidisciplinary team repetitively discussed the risks and procedures involved in the surgery. Finally, the ex vivo liver resection and autotransplantation was proposed. Results The preoperative evaluation showed the patient had a large intrahepatic lesion which severely invaded the retrohepatic inferior vena cava, the right hepatic vein, and the middle hepatic vein and were completely occluded, the left hepatic vein was partially invaded, and the portal vein was spongiform. The remnant liver volume was 912 m L, the ratio of residual liver volume to standard liver volume was 0.81. The preoperative liver function Child-Pugh score was grade A. The ex vivo liver resection and autotransplantation was successfully managed according to the expected schedule. The autografts(made by patient's great saphenous vein) were used to reconstruct the hepatic vein and portal vein, and the retrohepatic inferior vena cava was not reconstructed. The patient recovered well and was discharged on day 20 after the operation. Conclusions Ex vivo liver resection and autotransplantation could successfully be applied in treating patient with end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. Adequate preoperative assessment and management of the first hepatic hilum are key to this operation.
引文
1Kumar A,Sharma P,Arora A.Review article:portal vein obstruction—epidemiology,pathogenesis,natural history,prognosis and treatment.Aliment Pharmacol Ther,2015,41(3):276-292.
2 De Leve LD,Valla DC,Garcia-Tsao G,et al.Vascular disorders of the liver.Hepatology,2009,49(5):1729-1764.
3Silva-Junior G,Turon F,Hernandez-Gea V,et al.Unexpected disappearance of portal cavernoma on long-term anticoagulation.J Hepatol,2014,61(2):446-448.
4 Hibi T,Nishida S,Levi DM,et al.When and why portal vein thrombosis matters in liver transplantation:a critical audit of 174cases.Ann Surg,2014,259(4):760-766.
5Khanna R,Sarin SK.Non-cirrhotic portal hypertension—diagnosis and management.J Hepatol,2014,60(2):421-441.
6 Qi X,Han G.Transjugular intrahepatic portosystemic shunt in the treatment of portal vein thrombosis:a critical review of literature.Hepatol Int,2012,6(3):576-590.
7de Franchis R,Baveno V Faculty.Revising consensus in portal hypertension:report of the BavenoⅤconsensus workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol,2010,53(4):762-768.
8 Molmenti EP,Roodhouse TW,Molmenti H,et al.Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation.Ann Surg,2002,235(2):292-296.
9Stieber AC,Zetti G,Todo S,et al.The spectrum of portal vein thrombosis in liver transplantation.Ann Surg,1991,213(3):199-206.
10 Hajdu CH,Murakami T,Diflo T,et al.Intrahepatic portal cavernoma as an indication for liver transplantation.Liver Transpl,2007,13(9):1312-1316.
11Li F,Yang M,Li B,et al.Initial clinical results of orthotopic liver transplantation for hepatic alveolar echinococcosis.Liver Transpl,2007,13(6):924-926.
12 Xia D,Yan LN,Li B,et al.Orthotopic liver transplantation for incurable alveolar echinococcosis:report of five cases from West China.Transplant Proc,2005,37(5):2181-2184.
13Baker MA,Maley WR,Needleman L,et al.Ex vivo resection of hepatic neoplasia and autotransplantation:a case report and review of the literature.J Gastrointest Surg,2015,19(6):1169-1176.
14 Yang X,Qiu Y,Huang B,et al.Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for endstage hepatic alveolar echinococcosis:A study of 31 cases.Am J Transplant,2017 Dec 12.doi:10.1111/ajt.14621.[Epub ahead of print].
15He YB,Bai L,Jiang Y,et al.Application of a three-dimensional reconstruction technique in liver autotransplantation for end-stage hepatic alveolar echinococcosis.J Gastrointest Surg,2015,19(8):1457-1465.
16 Tongyoo A,Pomfret EA,Pomposelli JJ.Accurate estimation of living donor right hemi-liver volume from portal vein diameter measurement and standard liver volume calculation.Am JTransplant,2012,12(5):1229-1239.
17De Gaetano AM,Lafortune M,Patriquin H,et al.Cavernous transformation of the portal vein:patterns of intrahepatic and splanchnic collateral circulation detected with Doppler sonography.AJR Am J Roentgenol,1995,165(5):1151-1155.
18 Alghofaily KA,Saeedan MB,Aljohani IM,et al.Erratum to:Hepatic hydatid disease complications:review of imaging findings and clinical implications.Abdom Radiol(NY),2017,42(2):671.
19Gonzalez EP,Gil-Grande L,del Arbol LR,et al.Presinusoidal portal hypertension secondary to portal invasive echinococcosis.J Clin Gastroenterol,2002,34(1):103-104.
20 Harmanci O,Bayraktar Y.How can portal vein cavernous transformation cause chronic incomplete biliary obstruction?World J Gastroenterol,2012,18(26):3375-3378.
21Valla DC,Condat B.Portal vein thrombosis in adults:pathophysiology,pathogenesis and management.J Hepatol,2000,32(5):865-871.
22 Pichlmayr R,Grosse H,Hauss J,et al.Technique and preliminary results of extracorporeal liver surgery(bench procedure)and of surgery on the in situ perfused liver.Br J Surg,1990,77(1):21-26.
23Lodge JP,Ammori BJ,Prasad KR,et al.Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases.Ann Surg,2000,231(4):471-479.
24 Wen H,Dong JH,Zhang JH,et al.Ex vivo liver resection followed by autotransplantation for end-stage hepatic alveolar echinococcosis.Chin Med J(Engl),2011,124(18):2813-2817.
25Lei JY,Hao JC,Wang WT,et al.Ex vivo liver resection followed by autotransplantation to a patient with advanced alveolar echinococcosis with a replacement of the retrohepatic inferior vena cava using autogenous vein grafting:a case report and literature review.Medicine(Baltimore),2015,94(7):e514.
26Wen H,Dong JH,Zhang JH,et al.Ex vivo liver resection and autotransplantation for end-stage alveolar echinococcosis:A case series.Am J Transplant,2016,16(2):615-624.
27 Yerdel MA,Gunson B,Mirza D,et al.Portal vein thrombosis in adults undergoing liver transplantation:risk factors,screening,management,and outcome.Transplantation,2000,69(9):1873-1881.
28Jochmans I,Fieuws S,Tieken I,et al.The impact of hepatectomy time of the liver graft on post-transplant outcome:A Eurotransplant Cohort Study.Ann Surg,2017 Nov 21.doi:10 .1097/SLA.0000000000002593.[Epub ahead of print].
29Watts JM,Douglas MC.Clinical applications and complications of umbilical vein cannulation.Br J Surg,1971,58(1):61-66.
30 Yamamoto H,Hayakawa N,Ogawa A,et al.Segmental resection and reconstruction of the inferior vena cava with an autogenous vein graft.Br J Surg,1997,84(1):51.
31Lee DY,Mitchell EL,Jones MA,et al.Techniques and results of portal vein/superior mesenteric vein reconstruction using femoral and saphenous vein during pancreaticoduodenectomy.J Vasc Surg,2010,51(3):662-666.
2 De Leve LD,Valla DC,Garcia-Tsao G,et al.Vascular disorders of the liver.Hepatology,2009,49(5):1729-1764.
3Silva-Junior G,Turon F,Hernandez-Gea V,et al.Unexpected disappearance of portal cavernoma on long-term anticoagulation.J Hepatol,2014,61(2):446-448.
4 Hibi T,Nishida S,Levi DM,et al.When and why portal vein thrombosis matters in liver transplantation:a critical audit of 174cases.Ann Surg,2014,259(4):760-766.
5Khanna R,Sarin SK.Non-cirrhotic portal hypertension—diagnosis and management.J Hepatol,2014,60(2):421-441.
6 Qi X,Han G.Transjugular intrahepatic portosystemic shunt in the treatment of portal vein thrombosis:a critical review of literature.Hepatol Int,2012,6(3):576-590.
7de Franchis R,Baveno V Faculty.Revising consensus in portal hypertension:report of the BavenoⅤconsensus workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol,2010,53(4):762-768.
8 Molmenti EP,Roodhouse TW,Molmenti H,et al.Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation.Ann Surg,2002,235(2):292-296.
9Stieber AC,Zetti G,Todo S,et al.The spectrum of portal vein thrombosis in liver transplantation.Ann Surg,1991,213(3):199-206.
10 Hajdu CH,Murakami T,Diflo T,et al.Intrahepatic portal cavernoma as an indication for liver transplantation.Liver Transpl,2007,13(9):1312-1316.
11Li F,Yang M,Li B,et al.Initial clinical results of orthotopic liver transplantation for hepatic alveolar echinococcosis.Liver Transpl,2007,13(6):924-926.
12 Xia D,Yan LN,Li B,et al.Orthotopic liver transplantation for incurable alveolar echinococcosis:report of five cases from West China.Transplant Proc,2005,37(5):2181-2184.
13Baker MA,Maley WR,Needleman L,et al.Ex vivo resection of hepatic neoplasia and autotransplantation:a case report and review of the literature.J Gastrointest Surg,2015,19(6):1169-1176.
14 Yang X,Qiu Y,Huang B,et al.Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for endstage hepatic alveolar echinococcosis:A study of 31 cases.Am J Transplant,2017 Dec 12.doi:10.1111/ajt.14621.[Epub ahead of print].
15He YB,Bai L,Jiang Y,et al.Application of a three-dimensional reconstruction technique in liver autotransplantation for end-stage hepatic alveolar echinococcosis.J Gastrointest Surg,2015,19(8):1457-1465.
16 Tongyoo A,Pomfret EA,Pomposelli JJ.Accurate estimation of living donor right hemi-liver volume from portal vein diameter measurement and standard liver volume calculation.Am JTransplant,2012,12(5):1229-1239.
17De Gaetano AM,Lafortune M,Patriquin H,et al.Cavernous transformation of the portal vein:patterns of intrahepatic and splanchnic collateral circulation detected with Doppler sonography.AJR Am J Roentgenol,1995,165(5):1151-1155.
18 Alghofaily KA,Saeedan MB,Aljohani IM,et al.Erratum to:Hepatic hydatid disease complications:review of imaging findings and clinical implications.Abdom Radiol(NY),2017,42(2):671.
19Gonzalez EP,Gil-Grande L,del Arbol LR,et al.Presinusoidal portal hypertension secondary to portal invasive echinococcosis.J Clin Gastroenterol,2002,34(1):103-104.
20 Harmanci O,Bayraktar Y.How can portal vein cavernous transformation cause chronic incomplete biliary obstruction?World J Gastroenterol,2012,18(26):3375-3378.
21Valla DC,Condat B.Portal vein thrombosis in adults:pathophysiology,pathogenesis and management.J Hepatol,2000,32(5):865-871.
22 Pichlmayr R,Grosse H,Hauss J,et al.Technique and preliminary results of extracorporeal liver surgery(bench procedure)and of surgery on the in situ perfused liver.Br J Surg,1990,77(1):21-26.
23Lodge JP,Ammori BJ,Prasad KR,et al.Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases.Ann Surg,2000,231(4):471-479.
24 Wen H,Dong JH,Zhang JH,et al.Ex vivo liver resection followed by autotransplantation for end-stage hepatic alveolar echinococcosis.Chin Med J(Engl),2011,124(18):2813-2817.
25Lei JY,Hao JC,Wang WT,et al.Ex vivo liver resection followed by autotransplantation to a patient with advanced alveolar echinococcosis with a replacement of the retrohepatic inferior vena cava using autogenous vein grafting:a case report and literature review.Medicine(Baltimore),2015,94(7):e514.
26Wen H,Dong JH,Zhang JH,et al.Ex vivo liver resection and autotransplantation for end-stage alveolar echinococcosis:A case series.Am J Transplant,2016,16(2):615-624.
27 Yerdel MA,Gunson B,Mirza D,et al.Portal vein thrombosis in adults undergoing liver transplantation:risk factors,screening,management,and outcome.Transplantation,2000,69(9):1873-1881.
28Jochmans I,Fieuws S,Tieken I,et al.The impact of hepatectomy time of the liver graft on post-transplant outcome:A Eurotransplant Cohort Study.Ann Surg,2017 Nov 21.doi:10 .1097/SLA.0000000000002593.[Epub ahead of print].
29Watts JM,Douglas MC.Clinical applications and complications of umbilical vein cannulation.Br J Surg,1971,58(1):61-66.
30 Yamamoto H,Hayakawa N,Ogawa A,et al.Segmental resection and reconstruction of the inferior vena cava with an autogenous vein graft.Br J Surg,1997,84(1):51.
31Lee DY,Mitchell EL,Jones MA,et al.Techniques and results of portal vein/superior mesenteric vein reconstruction using femoral and saphenous vein during pancreaticoduodenectomy.J Vasc Surg,2010,51(3):662-666.