肝移植术中脾肾分流的个体化处理
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摘要
目的评估肝移植术中个体化处理脾肾分流的安全性和有效性。方法回顾性分析2例行原位肝移植并术中处理脾肾分离的受者临床资料,根据脾肾分流和供肝复流后灌注情况,2例受者术中分别行左肾静脉结扎术和脾肾分流血管结扎术。观察受者的术后一般情况,包括手术相关并发症、门静脉血流峰值速度、肝功能和肾功能指标。通过腹部超声监测受者术后情况。结果 2例受者术中及术后均未出现手术相关并发症。病例1和病例2脾肾分流前后门静脉血流峰值速度的变化分别为22.9～35.1 cm/s、24.3～58.8 cm/s。2例受者术后丙氨酸转氨酶(ALT)未出现延迟恢复。病例1受者术后出现一过性血清肌酐(Scr)升高,于术后13 d恢复正常。术后随访过程中,超声检查显示门静脉血流方向和速度正常,肝脏灌注良好。结论肝移植术中对合并严重脾肾分流的受者选择性结扎其左肾静脉或脾肾分流血管是安全和有效的。
Objective To evaluate the safety and efficacy of individualized treatment of splenorenal shunt during liver transplantation. Methods Clinical data of 2 recipients who underwent orthotopic liver transplantation and splenorenal shunt intraoperatively were retrospectively analyzed. According to the perfusion status after splenorenal shunt and donor liver reflow, the left renal vein ligation and splenorenal shunt vessel ligation were performed in two recipients during liver transplantation. The general postoperative conditions of the recipients were observed, including surgical related complications, peak portal blood flow velocity, liver and renal function indexs. The postoperative conditions of the recipients were monitored by abdominal ultrasound. Results No intraoperative or postoperative complications occurred in two recipients. The changes of peak portal blood flow velocity before and after splenorenal shunt in two recipients were 22.9-35.1 cm/s and 24.3-58.8 cm/s respectively. No delayed recovery of alanine aminotransferase(ALT) level was observed in two patients after operation. Case 1 experienced a transient increase in the serum creatinine(Scr), which was recovered to normal at postoperative 13 d. During the postoperative follow-up, ultrasound examination demonstrated that the direction and velocity of portal blood flow were normal and liver perfusion was excellent. Conclusions It is safe and effective to selectively ligate the left renal vein or splenorenal shunt vessels of the recipients with severe splenorenal shunt during liver transplantation.
Objective To evaluate the safety and efficacy of individualized treatment of splenorenal shunt during liver transplantation. Methods Clinical data of 2 recipients who underwent orthotopic liver transplantation and splenorenal shunt intraoperatively were retrospectively analyzed. According to the perfusion status after splenorenal shunt and donor liver reflow, the left renal vein ligation and splenorenal shunt vessel ligation were performed in two recipients during liver transplantation. The general postoperative conditions of the recipients were observed, including surgical related complications, peak portal blood flow velocity, liver and renal function indexs. The postoperative conditions of the recipients were monitored by abdominal ultrasound. Results No intraoperative or postoperative complications occurred in two recipients. The changes of peak portal blood flow velocity before and after splenorenal shunt in two recipients were 22.9-35.1 cm/s and 24.3-58.8 cm/s respectively. No delayed recovery of alanine aminotransferase(ALT) level was observed in two patients after operation. Case 1 experienced a transient increase in the serum creatinine(Scr), which was recovered to normal at postoperative 13 d. During the postoperative follow-up, ultrasound examination demonstrated that the direction and velocity of portal blood flow were normal and liver perfusion was excellent. Conclusions It is safe and effective to selectively ligate the left renal vein or splenorenal shunt vessels of the recipients with severe splenorenal shunt during liver transplantation.
引文
[1]BALDUCCI G,STERPETTI AV,VENTURA M.A short history of portal hypertension and of its management[J].J Gastroenterol Hepatol,2016,31(3):541-545.DOI:10.1111/jgh.13200.
[2]CHIKAMORI F,NISHIDA S,SELVAGGI G,et al.Effect of liver transplantation on spleen size,collateral veins,and platelet counts[J].World J Surg,2010,34(2):320-326.DOI:10.1007/s00268-009-0314-x.
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[4]RYU TH,JUNG JY,CHOI DL,et al.Optimal central venous pressure during the neohepatic phase to decrease peak portal vein flow velocity for the prevention of portal hyperperfusion in patients undergoing living donor liver transplantation[J].Transplant Proc,2015,47(4):1194-1198.DOI:10.1016/j.transproceed.2014.10.071.
[5]赵文.经皮经肝血管成形术治疗肝移植术后门静脉狭窄的护理[J/CD].实用器官移植电子杂志,2014,2(1):41-43.DOI:10.3969/j.issn.2095-5332.2014.01.012.ZHAO W.Nursing of the perioperative care of percutaneous transhepatic stent angioplasty for portal vein stenosis following liver transplant[J/CD].Pract J Organ Transplant(Electr Vers),2014,2(1):41-43.DOI:10.3969/j.issn.2095-5332.2014.01.012.
[6]赵雅莹,俞陌桑,王哲民,等.门静脉高压自发性分流患者食管胃底静脉曲张特点[J].浙江大学学报(医学版),2016,45(1):75-80.DOI:10.3785/j.issn.1008-9292.2016.01.12.ZHAO YY,YU MS,WANG ZM,et al.Comparison of characteristics of esophageal gastric varices in portal hypertension patients with and without spontaneous shunts[J].J Zhejiang Univ(Med Sci),2016,45(1):75-80.DOI:10.3785/j.issn.1008-9292.2016.01.12.
[7]FRANZONI LDE C,DE CARVALHO FC,GARZONRG,et al.Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy[J].World J Gastroenterol,2014,20(42):15910-15915.DOI:10.3748/wjg.v20.i42.15910.
[8]AOYAMA T,OKA S,AIKATA H,et al.Major predictors of portal hypertensive enteropathy in patients with liver cirrhosis[J].J Gastroenterol Hepatol,2015,30(1):124-130.DOI:10.1111/jgh.12658.
[9]OZDEMIR F,KUTLUTURK K,BARUT B,et al.Renoportal anastomosis in living donor liver transplantation with prior proximal splenorenal shunt[J].World JTransplant,2017,7(1):94-97.DOI:10.5500/wjt.v7.i1.94.
[10]PULITANO C,ROGAN C,SANDROUSSI C,et al.Percutaneous retroperitoneal splenorenal shunt for symptomatic portal vein thrombosis after liver transplantation[J].Am J Transplant,2015,15(8):2261-2264.DOI:10.1111/ajt.13243.
[11]SAKS K,JENSEN KK,MCLOUTH J,et al.Influence of spontaneous splenorenal shunts on clinical outcomes in decompensated cirrhosis and after liver transplantation[J].Hepatol Commun,2018,2(4):437-444.DOI:10.1002/hep4.1157.
[12]GOLSE N,MOHKAM K,RODE A,et al.Surgical management of large spontaneous portosystemic splenorenal shunts during liver transplantation:splenectomy or left renal vein ligation?[J].Transplant Proc,2015,47(6):1866-1876.DOI:10.1016/j.transproceed.2015.06.019.
[13]GOLSE N,BUCUR PO,FAITOT F,et al.Spontaneous splenorenal shunt in liver transplantation:results of left renal vein ligation versus renoportal anastomosis[J].Transplantation,2015,99(12):2576-2585.DOI:10.1097/TP.0000000000000766.
[14]GOLSE N,MOHKAM K,RODE A,et al.Splenectomy during whole liver transplantation:a morbid procedure which does not adversely impact long-term survival[J].HPB(Oxford),2017,19(6):498-507.DOI:10.1016/j.hpb.2017.01.020.
[15]GENZINI T,TREVIZOL AP,YAMASHITA ET,et al.Left renal vein ligation during liver transplantation in a recipient with a single kidney[J].Liver Transpl,2013,19(5):563-564.DOI:10.1002/lt.23636.
[16]UCHIDA H,FUKUDA A,MASATOSHI M,et al.A central approach to splenorenal shunt in pediatric living donor liver transplantation[J].Pediatr Transplant,2015,19(6):E142-E145.DOI:10.1111/petr.12543.
[17]MATSUMOTO Y,IKEGAMI T,MORITA K,et al.Renoportal anastomosis in right lobe living donor liver transplantation:report of a case[J].Surg Today,2013,43(11):1316-1320.DOI:10.1007/s00595-012-0351-1.
[18]MARTINO RB,JúNIOR ER,MANUEL V,et al.A case of left renal vein ligation in a patient with solitary left kidney undergoing liver transplantation to control splenorenal shunt and improve portal venous flow[J].Am J Case Rep,2017,18:1086-1089.
[19]TANG R,HAN D,LI M,et al.Left renal vein ligation for large splenorenal shunt during liver transplantation[J].ANZ J Surg,2017,87(10):767-772.DOI:10.1111/ans.14044.
[20]KIM H,YOON KC,LEE KW,et al.Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation[J].Liver Transpl,2017,23(7):899-906.DOI:10.1002/lt.24783.
[21]ZHAO H,TSAUO J,LI X.Percutaneous retroperitoneal splenorenal shunt:an alternative to transjugular intrahepatic portosystemic shunt?[J].Am J Transplant,2016,16(1):374.DOI:10.1111/ajt.13563.
[22]KOUSOULAS L,RINGE KI,WINKLER M,et al.Ligation of left renal vein for spontaneous splenorenal shunt to prevent portal hypoperfusion after orthotopic liver transplantation[J].Case Rep Transplant,2013:842538.DOI:10.1155/2013/842538.
[23]GRAHAM JA,SAMSTEIN B,EMOND JC,et al.Functional distal splenorenal shunt and splenic artery ligation as portal flow modulation in left lobe living donor transplantation[J].Liver Transpl,2014,20(2):245-246.DOI:10.1002/lt.23790.
[24]滕飞,傅志仁.肝移植中基于门静脉重建方案的门静脉血栓分类及处理策略[J].器官移植,2018,9(4):245-249.DOI:10.3969/j.issn.1674-7445.2018.04.001.TENG F,FU ZR.Classification and processing strategy of portal vein thrombosis based on the program of portal vein reconstruction in the liver transplantation[J].Organ Transplant,2018,9(4):245-249.DOI:10.3969/j.issn.1674-7445.2018.04.001.
[25]杨强,杜英东.原位肝移植术后早期急性肾功能衰竭的防治[J].中国继续医学教育,2018,10(7):67-68.DOI:10.3969/j.issn.1674-9308.2018.07.035.YANG Q,DU YD.Prevention and treatment of early acute renal failure after orthotopic liver transplantation[J].Chin Contin Med Educ,2018,10(7):67-68.DOI:10.3969/j.issn.1674-9308.2018.07.035.
[26]陈云浩,易述红.肝移植术后第7天综合征[J].器官移植,2017,8(1):78-81.DOI:10.3969/j.issn.1674-7445.2017.01.0015.CHEN YH,YI SH.Seventh day syndrome after liver transplantation[J].Organ Transplant,2017,8(1):78-81.DOI:10.3969/j.issn.1674-7445.2017.01.0015.
[2]CHIKAMORI F,NISHIDA S,SELVAGGI G,et al.Effect of liver transplantation on spleen size,collateral veins,and platelet counts[J].World J Surg,2010,34(2):320-326.DOI:10.1007/s00268-009-0314-x.
[3]SLATER RR,JABBOUR N,ABBASS AA,et al.Left renal vein ligation:a technique to mitigate low portal flow from splenic vein siphon during liver transplantation[J].Am J Transplant,2011,11(8):1743-1747.DOI:10.1111/j.1600-6143.2011.03578.x.
[4]RYU TH,JUNG JY,CHOI DL,et al.Optimal central venous pressure during the neohepatic phase to decrease peak portal vein flow velocity for the prevention of portal hyperperfusion in patients undergoing living donor liver transplantation[J].Transplant Proc,2015,47(4):1194-1198.DOI:10.1016/j.transproceed.2014.10.071.
[5]赵文.经皮经肝血管成形术治疗肝移植术后门静脉狭窄的护理[J/CD].实用器官移植电子杂志,2014,2(1):41-43.DOI:10.3969/j.issn.2095-5332.2014.01.012.ZHAO W.Nursing of the perioperative care of percutaneous transhepatic stent angioplasty for portal vein stenosis following liver transplant[J/CD].Pract J Organ Transplant(Electr Vers),2014,2(1):41-43.DOI:10.3969/j.issn.2095-5332.2014.01.012.
[6]赵雅莹,俞陌桑,王哲民,等.门静脉高压自发性分流患者食管胃底静脉曲张特点[J].浙江大学学报(医学版),2016,45(1):75-80.DOI:10.3785/j.issn.1008-9292.2016.01.12.ZHAO YY,YU MS,WANG ZM,et al.Comparison of characteristics of esophageal gastric varices in portal hypertension patients with and without spontaneous shunts[J].J Zhejiang Univ(Med Sci),2016,45(1):75-80.DOI:10.3785/j.issn.1008-9292.2016.01.12.
[7]FRANZONI LDE C,DE CARVALHO FC,GARZONRG,et al.Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy[J].World J Gastroenterol,2014,20(42):15910-15915.DOI:10.3748/wjg.v20.i42.15910.
[8]AOYAMA T,OKA S,AIKATA H,et al.Major predictors of portal hypertensive enteropathy in patients with liver cirrhosis[J].J Gastroenterol Hepatol,2015,30(1):124-130.DOI:10.1111/jgh.12658.
[9]OZDEMIR F,KUTLUTURK K,BARUT B,et al.Renoportal anastomosis in living donor liver transplantation with prior proximal splenorenal shunt[J].World JTransplant,2017,7(1):94-97.DOI:10.5500/wjt.v7.i1.94.
[10]PULITANO C,ROGAN C,SANDROUSSI C,et al.Percutaneous retroperitoneal splenorenal shunt for symptomatic portal vein thrombosis after liver transplantation[J].Am J Transplant,2015,15(8):2261-2264.DOI:10.1111/ajt.13243.
[11]SAKS K,JENSEN KK,MCLOUTH J,et al.Influence of spontaneous splenorenal shunts on clinical outcomes in decompensated cirrhosis and after liver transplantation[J].Hepatol Commun,2018,2(4):437-444.DOI:10.1002/hep4.1157.
[12]GOLSE N,MOHKAM K,RODE A,et al.Surgical management of large spontaneous portosystemic splenorenal shunts during liver transplantation:splenectomy or left renal vein ligation?[J].Transplant Proc,2015,47(6):1866-1876.DOI:10.1016/j.transproceed.2015.06.019.
[13]GOLSE N,BUCUR PO,FAITOT F,et al.Spontaneous splenorenal shunt in liver transplantation:results of left renal vein ligation versus renoportal anastomosis[J].Transplantation,2015,99(12):2576-2585.DOI:10.1097/TP.0000000000000766.
[14]GOLSE N,MOHKAM K,RODE A,et al.Splenectomy during whole liver transplantation:a morbid procedure which does not adversely impact long-term survival[J].HPB(Oxford),2017,19(6):498-507.DOI:10.1016/j.hpb.2017.01.020.
[15]GENZINI T,TREVIZOL AP,YAMASHITA ET,et al.Left renal vein ligation during liver transplantation in a recipient with a single kidney[J].Liver Transpl,2013,19(5):563-564.DOI:10.1002/lt.23636.
[16]UCHIDA H,FUKUDA A,MASATOSHI M,et al.A central approach to splenorenal shunt in pediatric living donor liver transplantation[J].Pediatr Transplant,2015,19(6):E142-E145.DOI:10.1111/petr.12543.
[17]MATSUMOTO Y,IKEGAMI T,MORITA K,et al.Renoportal anastomosis in right lobe living donor liver transplantation:report of a case[J].Surg Today,2013,43(11):1316-1320.DOI:10.1007/s00595-012-0351-1.
[18]MARTINO RB,JúNIOR ER,MANUEL V,et al.A case of left renal vein ligation in a patient with solitary left kidney undergoing liver transplantation to control splenorenal shunt and improve portal venous flow[J].Am J Case Rep,2017,18:1086-1089.
[19]TANG R,HAN D,LI M,et al.Left renal vein ligation for large splenorenal shunt during liver transplantation[J].ANZ J Surg,2017,87(10):767-772.DOI:10.1111/ans.14044.
[20]KIM H,YOON KC,LEE KW,et al.Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation[J].Liver Transpl,2017,23(7):899-906.DOI:10.1002/lt.24783.
[21]ZHAO H,TSAUO J,LI X.Percutaneous retroperitoneal splenorenal shunt:an alternative to transjugular intrahepatic portosystemic shunt?[J].Am J Transplant,2016,16(1):374.DOI:10.1111/ajt.13563.
[22]KOUSOULAS L,RINGE KI,WINKLER M,et al.Ligation of left renal vein for spontaneous splenorenal shunt to prevent portal hypoperfusion after orthotopic liver transplantation[J].Case Rep Transplant,2013:842538.DOI:10.1155/2013/842538.
[23]GRAHAM JA,SAMSTEIN B,EMOND JC,et al.Functional distal splenorenal shunt and splenic artery ligation as portal flow modulation in left lobe living donor transplantation[J].Liver Transpl,2014,20(2):245-246.DOI:10.1002/lt.23790.
[24]滕飞,傅志仁.肝移植中基于门静脉重建方案的门静脉血栓分类及处理策略[J].器官移植,2018,9(4):245-249.DOI:10.3969/j.issn.1674-7445.2018.04.001.TENG F,FU ZR.Classification and processing strategy of portal vein thrombosis based on the program of portal vein reconstruction in the liver transplantation[J].Organ Transplant,2018,9(4):245-249.DOI:10.3969/j.issn.1674-7445.2018.04.001.
[25]杨强,杜英东.原位肝移植术后早期急性肾功能衰竭的防治[J].中国继续医学教育,2018,10(7):67-68.DOI:10.3969/j.issn.1674-9308.2018.07.035.YANG Q,DU YD.Prevention and treatment of early acute renal failure after orthotopic liver transplantation[J].Chin Contin Med Educ,2018,10(7):67-68.DOI:10.3969/j.issn.1674-9308.2018.07.035.
[26]陈云浩,易述红.肝移植术后第7天综合征[J].器官移植,2017,8(1):78-81.DOI:10.3969/j.issn.1674-7445.2017.01.0015.CHEN YH,YI SH.Seventh day syndrome after liver transplantation[J].Organ Transplant,2017,8(1):78-81.DOI:10.3969/j.issn.1674-7445.2017.01.0015.