离体肝切除和自体肝移植联合复杂肝静脉重建治疗终末期肝泡型包虫病
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摘要
目的总结离体肝切除、自体肝移植术联合复杂肝静脉重建在治疗终末期肝泡型包虫病中的效果。方法回顾性分析四川省人民医院于2017年12月收治的1例行离体肝切除、自体肝移植联合复杂肝静脉重建术的泡型肝包虫患者的临床资料。结果经术前评估及术中探查发现,患者的下腔静脉及肝静脉广泛受侵,故于在体包虫病灶切除结合离体包虫病灶切除后,重建门静脉,切取自体大隐静脉重建肝右静脉、肝短静脉及右后下静脉肝静脉流出道为一完整广口流出道,将重建之流出道大补片与下腔静脉人工血管行侧侧吻合,残余肝行"背驮式"自体肝移植。患者的手术时间为16 h,术中出血量约1 000 mL。术后行肝切除术后常规治疗,24 h后以低分子肝素抗凝,无胆汁漏、出血、感染、肝功能衰竭等并发症发生,于术后14 d顺利出院。术后随访6个月,一般情况良好。结论离体肝切除自体肝移植术是治疗终末期肝泡型包虫病的有效手术方式,术中肝脏劈裂及个体化的管道重建尤其是流出道重建是手术的难点及关键步骤。
Objective To explore the effect of ex-vivo liver resection and autologous liver transplantation(ERAT)combined with complicated hepatic venous reconstruction for end stage hepatic alveolar echinococcosis(AE). Method The clinical data of one case with hepatic AE who treated in Organ Transplantation Center of Sichuan Provincial People's Hospital in December 2017 was analyzed retrospectively. Results Pre-operative examination and intraoperative exploration revealed the hepatic vein(HV) and retrohepatic inferior vena cava(RHIVC) were invaded widely. We successfully initiated operation through vivo and ex-vivo hepatic AE resection, portal vein reconstruction, right/short/right inferior HV reconstruction into a wide mouth outflow with the assist of autogenous saphenous vein, and then piggyback autologous liver transplantation by wide mouth outflow-artificial inferior vena cava anastomosis(side to side). The operative time was 16 hours, and blood loss was 1 000 mL approximately. The patient was admitted routine treatment after hepatectomy. The inject low-molecular-weight heparin sodium was admitted for anticoagulant therapy 24 hours after operation. This patient recovered smoothly without bile leakage, bleeding, infection and liver failure, and so on. The patient was discharged uneventfully 14 days after operation, and there was no special situation during the 6 months follow-up period. Conclusions ERAT is an ideal surgical method for end stage hepatic AE. Hepatic parenchymal transection and individual duct reconstruction, especially hepatic outflow reconstruction, are the key steps for ERAT.
Objective To explore the effect of ex-vivo liver resection and autologous liver transplantation(ERAT)combined with complicated hepatic venous reconstruction for end stage hepatic alveolar echinococcosis(AE). Method The clinical data of one case with hepatic AE who treated in Organ Transplantation Center of Sichuan Provincial People's Hospital in December 2017 was analyzed retrospectively. Results Pre-operative examination and intraoperative exploration revealed the hepatic vein(HV) and retrohepatic inferior vena cava(RHIVC) were invaded widely. We successfully initiated operation through vivo and ex-vivo hepatic AE resection, portal vein reconstruction, right/short/right inferior HV reconstruction into a wide mouth outflow with the assist of autogenous saphenous vein, and then piggyback autologous liver transplantation by wide mouth outflow-artificial inferior vena cava anastomosis(side to side). The operative time was 16 hours, and blood loss was 1 000 mL approximately. The patient was admitted routine treatment after hepatectomy. The inject low-molecular-weight heparin sodium was admitted for anticoagulant therapy 24 hours after operation. This patient recovered smoothly without bile leakage, bleeding, infection and liver failure, and so on. The patient was discharged uneventfully 14 days after operation, and there was no special situation during the 6 months follow-up period. Conclusions ERAT is an ideal surgical method for end stage hepatic AE. Hepatic parenchymal transection and individual duct reconstruction, especially hepatic outflow reconstruction, are the key steps for ERAT.
引文
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2四川省包虫病诊疗专家组.四川省肝包虫病诊治规范.中国普外基础与临床杂志,2017,24(7):798-803.
3陈哲宇.复杂肝包虫病的外科治疗.中国普外基础与临床杂志,2017,24(7):785-787.
4赵海平.复杂肝包虫病的诊治.中国普外基础与临床杂志,2017,24(7):788-791.
5McManus DP,Zhang W,Li J,et al.Echinococcosis.Lancet,2003,362(7):1295-1300.
6Gruttadauria S,Marsh JW,Bartlett DL,et al.Ex situ resection techniques and liver autotransplantation:last resource for otherwise unresectable malignancy.Dig Dis Sci,2005,50(10):1829-1835.
7Li 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.
8Haider HH,Nishida S,Selvaggi G,et al.Alveolar echinococcosis induced liver failure:salvage by liver transplantation in an otherwise uniformly fatal disease.Clin Transplant,2008,22(5):664-667.
9Wen 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.
10Wang H,Liu Q,Wang Z,et al.Clinical outcomes of ex vivo liver resection and liver autotransplantation for hepatic alveolar echinococcosis.J Huazhong Univ Sci Technolog Med Sci,2012,32(4):598-600.
11杨先伟,黄斌,邱逸闻,等.离体肝切除联合自体肝移植治疗晚期肝泡型包虫病21例报道.中国普外基础与临床杂志,2017,24(6):685-690.
12Yang 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 JTransplant,2018,18(7):1668-1679.
13吐尔洪江·吐逊,阿卜杜萨拉木·艾尼,李玉鹏,等非原位肝切除技术安全性、可行性和有效性的系统评价.中华医学杂志,2016,96(28):2251-2257.
14Li FG,Yan LN,Li B,et al.Estimation of standard liver volume in Chinese adult living donors.Transplant Proc,2009,41(10):4052-4056.
15方丹,杨康明,陈哲宇,等.分期切除治疗多发泡型肝包虫病的初步经验.中国普外基础与临床杂志,2017,24(7):804-807.
16沈中阳.中国肝移植10年成就与展望.华夏医药,2009,4(6):419-420.
17Ji XW,Zhang JH,Zhao JM,et al.Liver transplantation for the treatment for end-stage hepatic alveolar echinococcosis.Chin J Dig Surg(Chin),2011,10(6):296-298.
18Lin RY,Wang JH,Lu XM,et al.Components of the mitogenactivated protein kinase cascade are activated in hepatic cells by Echinococcus multilocularis metacestode.World J Gastroenterol,2009,15(17):2116-2124.
19吐尔干艾力·阿吉,邵英梅,赵晋明,等肝泡型包虫病自体肝移植中提升功能肝“量与质”的临床实践:附12例临床病例分析.中华医学杂志,2017,97(4):270-275.
20He 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.
21何翼彪, 白磊, 吐尔干艾力·阿吉, 等 数字化三维重建技术在肝泡型包虫病肝移植中的应用. 中华肝脏外科手术学电子杂志,2015, 4(5): 279-283.
22何翼彪, 白磊, 李涛, 等. 三维可视化技术在肝泡型包虫病外科治疗中的应用. 中华外科杂志, 2016, 54(9): 704-709.
23Hu H, Huang B, Zhao J, et al. Liver autotransplantation and retrohepatic vena cava reconstruction for alveolar echinococcosis. J Surg Res, 2017, 210: 169-176.
24Ikegami T, Soejima Y, Taketomi A, et al. Explanted portal vein grafts for middle hepatic vein tributaries in living-donor liver transplantation. Transplantation, 2007, 84(7): 836-841.
25Wu H, Yan LN, Li B, et al. Hepatic venous outflow reconstruction in right lobe graft without middle hepatic vein. Hepatol Res, 2007,37(12): 1044-1051.
26Ikegami T, Shirabe K, Yoshiya S, et al. One-step reconstruction of the right inferior hepatic veins using auto-venous grafts in living-donor liver transplantation. Surg Today, 2013, 43(7): 769-776.
27Lei 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.
28Cheng F, Yang Z, Zeng J, et al. Anesthesia management of modified ex vivo liver resection and autotransplantation. Ann Transplant, 2018, 23: 274-284.
29Qin Y, Li X, Zhang Q, et al. Analysis of the clinical value of 18F-FDG PET/CT in hepatic alveolar echinococcosis before and after autologous liver transplantation. Exp Ther Med, 2016, 11(1):43-48.
30Ito T, Kiuchi T, Yamamoto H, et al. Changes in portal venous pressure in the early phase after living donor liver transplantation: pathogenesis and clinical implications. Transplantation, 2003, 75(8): 1313-1317.
31Ogura Y, Hori T, El Moghazy WM, et al. Portal pressure <15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before. Liver Transpl, 2010, 16(6):718-72.
2四川省包虫病诊疗专家组.四川省肝包虫病诊治规范.中国普外基础与临床杂志,2017,24(7):798-803.
3陈哲宇.复杂肝包虫病的外科治疗.中国普外基础与临床杂志,2017,24(7):785-787.
4赵海平.复杂肝包虫病的诊治.中国普外基础与临床杂志,2017,24(7):788-791.
5McManus DP,Zhang W,Li J,et al.Echinococcosis.Lancet,2003,362(7):1295-1300.
6Gruttadauria S,Marsh JW,Bartlett DL,et al.Ex situ resection techniques and liver autotransplantation:last resource for otherwise unresectable malignancy.Dig Dis Sci,2005,50(10):1829-1835.
7Li 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.
8Haider HH,Nishida S,Selvaggi G,et al.Alveolar echinococcosis induced liver failure:salvage by liver transplantation in an otherwise uniformly fatal disease.Clin Transplant,2008,22(5):664-667.
9Wen 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.
10Wang H,Liu Q,Wang Z,et al.Clinical outcomes of ex vivo liver resection and liver autotransplantation for hepatic alveolar echinococcosis.J Huazhong Univ Sci Technolog Med Sci,2012,32(4):598-600.
11杨先伟,黄斌,邱逸闻,等.离体肝切除联合自体肝移植治疗晚期肝泡型包虫病21例报道.中国普外基础与临床杂志,2017,24(6):685-690.
12Yang 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 JTransplant,2018,18(7):1668-1679.
13吐尔洪江·吐逊,阿卜杜萨拉木·艾尼,李玉鹏,等非原位肝切除技术安全性、可行性和有效性的系统评价.中华医学杂志,2016,96(28):2251-2257.
14Li FG,Yan LN,Li B,et al.Estimation of standard liver volume in Chinese adult living donors.Transplant Proc,2009,41(10):4052-4056.
15方丹,杨康明,陈哲宇,等.分期切除治疗多发泡型肝包虫病的初步经验.中国普外基础与临床杂志,2017,24(7):804-807.
16沈中阳.中国肝移植10年成就与展望.华夏医药,2009,4(6):419-420.
17Ji XW,Zhang JH,Zhao JM,et al.Liver transplantation for the treatment for end-stage hepatic alveolar echinococcosis.Chin J Dig Surg(Chin),2011,10(6):296-298.
18Lin RY,Wang JH,Lu XM,et al.Components of the mitogenactivated protein kinase cascade are activated in hepatic cells by Echinococcus multilocularis metacestode.World J Gastroenterol,2009,15(17):2116-2124.
19吐尔干艾力·阿吉,邵英梅,赵晋明,等肝泡型包虫病自体肝移植中提升功能肝“量与质”的临床实践:附12例临床病例分析.中华医学杂志,2017,97(4):270-275.
20He 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.
21何翼彪, 白磊, 吐尔干艾力·阿吉, 等 数字化三维重建技术在肝泡型包虫病肝移植中的应用. 中华肝脏外科手术学电子杂志,2015, 4(5): 279-283.
22何翼彪, 白磊, 李涛, 等. 三维可视化技术在肝泡型包虫病外科治疗中的应用. 中华外科杂志, 2016, 54(9): 704-709.
23Hu H, Huang B, Zhao J, et al. Liver autotransplantation and retrohepatic vena cava reconstruction for alveolar echinococcosis. J Surg Res, 2017, 210: 169-176.
24Ikegami T, Soejima Y, Taketomi A, et al. Explanted portal vein grafts for middle hepatic vein tributaries in living-donor liver transplantation. Transplantation, 2007, 84(7): 836-841.
25Wu H, Yan LN, Li B, et al. Hepatic venous outflow reconstruction in right lobe graft without middle hepatic vein. Hepatol Res, 2007,37(12): 1044-1051.
26Ikegami T, Shirabe K, Yoshiya S, et al. One-step reconstruction of the right inferior hepatic veins using auto-venous grafts in living-donor liver transplantation. Surg Today, 2013, 43(7): 769-776.
27Lei 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.
28Cheng F, Yang Z, Zeng J, et al. Anesthesia management of modified ex vivo liver resection and autotransplantation. Ann Transplant, 2018, 23: 274-284.
29Qin Y, Li X, Zhang Q, et al. Analysis of the clinical value of 18F-FDG PET/CT in hepatic alveolar echinococcosis before and after autologous liver transplantation. Exp Ther Med, 2016, 11(1):43-48.
30Ito T, Kiuchi T, Yamamoto H, et al. Changes in portal venous pressure in the early phase after living donor liver transplantation: pathogenesis and clinical implications. Transplantation, 2003, 75(8): 1313-1317.
31Ogura Y, Hori T, El Moghazy WM, et al. Portal pressure <15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before. Liver Transpl, 2010, 16(6):718-72.