对现行右半肝供肝活体肝移植中肝中静脉取舍标准的研究
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摘要
【目的】研究是否保留肝中静脉对活体肝移植供体的影响,为保障供体的安全性奠定理论基础,并且为今后临床工作提供参考。
【方法】回顾性分析我院活体肝移植供者(右半供肝)30例,按照是否保留肝中静脉分为2组。A组为供肝带肝中静脉组(n=15),B组为供肝不带肝中静脉组(n=15),两组间一般特征均无统计学差异。两足供者行活体肝移植右半供肝切除术,按照我中心现行肝中静脉分配原则,A组肝中静脉保留在供肝侧,B组肝中静脉保留在供者侧。我们收集并比较了两组患者的数据包括:CT测量肝脏体积、右半肝体积、GRWR、手术时间、失血量、术后腹水量、并发症发生情况、生存率等;我们还测量了供肝实际重量;术中乳酸峰值;术后1d,3d,5d,7d,9d,11d肝功能;B超监测肝切除前后肝动脉、门静脉血流变化。
【结果】(1)CT测量供体全肝体积A组平均1274.79±144.60mm~3,B组平均1406.56±186.76 mm~3,两组间有统计学差异。我们还发现两组间有统计学差异的数据是:CT测量右半肝体积。GRWR、CT测右半肝体积/受体估计肝重两组间有显著性差异。而术中测量实际供肝体积两组间无统计学差异。(2)两组供者术中总手术时间、肝切除时间、失血量均无统计学差异。两组肝切除后术中乳酸峰值分别为3.72±0.38mmol/L及3.16±0.71mmol/L,两组相比有统计学差异,A组高于B组,P＜0.05。(3)根据术中B超监测,切肝后,左肝动脉流速A组高于B组;切肝后,门脉左支流速A组高于B组。(4)术后情况:两组供者腹水量、胆红素峰值、ALT、AST、ALB水平在术后早期均有统计学差异。两组FIB在术后1d有统计学差异,B组略高于A组,P＜0.05,但3d后再无统计学差异。两组供者的差异在术后两周左右时间均消失。两组患者术后均未出现胆瘘、出血、血栓等相关并发症。两组患者术后随访3月-1年,均健康存活,未出现术后并发症。
【结论】(1)本实验证实,按照我中心现行肝中静脉分配原则,是否保留肝中静脉对供者安全性无明显影响。
(2)对于供肝保留肝中静脉供者,术后肝功能恢复较慢,腹水减少速度较慢,保留腹引时间偏长,FIB较低,应该注意及时对症处理。
【Objective】The research about the influence to donors in right lobe donator LDLT with or without middle hepatic vein,find the theoretical basis for protect the safety of the donor and provide reference for our future clinical work.
【Method】30 donors were divided into two groups according to the position of MHV when they donation their right lobe.Group A(n=15)with their MHV and group B(n=15)without.There are no significant statistical difference in the character of these two groups.After the donors were performed right lobe hepatectomy for donation.We collect and compare the data include:whole liver volume,right lobe volum,GRWR,operation time,blood loss volume,ascites volume of postoperative, complication and survival rate.We still measured actual volume,the peak value of lactic acid,liver function of 1,3,5,7,9,11 days postoperation.And we overview the blood flow of HA,PV.
【Results】(1)CT measured total hepatic volume in group A is 1274.79±144.60mm3 and 1406.56±186.76 mm3 in group B;the two groups have statistics differences,we still found statistical difference of two groups in CT measured right lobe volume and significant statistics differences in GRWR,CT measured right liver volume/receptor estimated liver volume.The actual volume of graft we test during operation has not statistical difference.(2)There are no significant difference in total operation time,liver resection time and blood loss After graft be removed the lactate peak during operation were 3.72±0.38mmol/L and 3.16±0.71mmol/L,there is a significant difference between the two groups.(3)According to ultrasound during-operation the group A faster than group B of the left hepatic artery blood flow speed,Left branch of portal vein flow rate after graft removed.(4)We found some significant statistics differences of ascites,drainage volume,total bilirubin,ALT,AST and ALB level in the ealy stage after operation.We only found statistics differences of FIB level at first day after operation and after that there is no statistics differences between two groups.However,almost all indicators between the two groups difference disappeared in about two weeks after operation.There are no biliary fistula, bleeding,thrombosis,and other related complications in all donors.After 3 month～1 year follow up does not appear postoperative complications.
【Conclusion】(1)This experiment confirmed,according to my current center in the vein of liver allocation principle,whether to retain in the vein of the liver donor had no effect on security.(2)The donor hepatic vein for reservations,slower recovery after operation,ascites reduced slower,with reservations abdominal partial long time, FIB lower,we should pay attention to treatment in time.
【方法】回顾性分析我院活体肝移植供者(右半供肝)30例,按照是否保留肝中静脉分为2组。A组为供肝带肝中静脉组(n=15),B组为供肝不带肝中静脉组(n=15),两组间一般特征均无统计学差异。两足供者行活体肝移植右半供肝切除术,按照我中心现行肝中静脉分配原则,A组肝中静脉保留在供肝侧,B组肝中静脉保留在供者侧。我们收集并比较了两组患者的数据包括:CT测量肝脏体积、右半肝体积、GRWR、手术时间、失血量、术后腹水量、并发症发生情况、生存率等;我们还测量了供肝实际重量;术中乳酸峰值;术后1d,3d,5d,7d,9d,11d肝功能;B超监测肝切除前后肝动脉、门静脉血流变化。
【结果】(1)CT测量供体全肝体积A组平均1274.79±144.60mm~3,B组平均1406.56±186.76 mm~3,两组间有统计学差异。我们还发现两组间有统计学差异的数据是:CT测量右半肝体积。GRWR、CT测右半肝体积/受体估计肝重两组间有显著性差异。而术中测量实际供肝体积两组间无统计学差异。(2)两组供者术中总手术时间、肝切除时间、失血量均无统计学差异。两组肝切除后术中乳酸峰值分别为3.72±0.38mmol/L及3.16±0.71mmol/L,两组相比有统计学差异,A组高于B组,P＜0.05。(3)根据术中B超监测,切肝后,左肝动脉流速A组高于B组;切肝后,门脉左支流速A组高于B组。(4)术后情况:两组供者腹水量、胆红素峰值、ALT、AST、ALB水平在术后早期均有统计学差异。两组FIB在术后1d有统计学差异,B组略高于A组,P＜0.05,但3d后再无统计学差异。两组供者的差异在术后两周左右时间均消失。两组患者术后均未出现胆瘘、出血、血栓等相关并发症。两组患者术后随访3月-1年,均健康存活,未出现术后并发症。
【结论】(1)本实验证实,按照我中心现行肝中静脉分配原则,是否保留肝中静脉对供者安全性无明显影响。
(2)对于供肝保留肝中静脉供者,术后肝功能恢复较慢,腹水减少速度较慢,保留腹引时间偏长,FIB较低,应该注意及时对症处理。
【Objective】The research about the influence to donors in right lobe donator LDLT with or without middle hepatic vein,find the theoretical basis for protect the safety of the donor and provide reference for our future clinical work.
【Method】30 donors were divided into two groups according to the position of MHV when they donation their right lobe.Group A(n=15)with their MHV and group B(n=15)without.There are no significant statistical difference in the character of these two groups.After the donors were performed right lobe hepatectomy for donation.We collect and compare the data include:whole liver volume,right lobe volum,GRWR,operation time,blood loss volume,ascites volume of postoperative, complication and survival rate.We still measured actual volume,the peak value of lactic acid,liver function of 1,3,5,7,9,11 days postoperation.And we overview the blood flow of HA,PV.
【Results】(1)CT measured total hepatic volume in group A is 1274.79±144.60mm3 and 1406.56±186.76 mm3 in group B;the two groups have statistics differences,we still found statistical difference of two groups in CT measured right lobe volume and significant statistics differences in GRWR,CT measured right liver volume/receptor estimated liver volume.The actual volume of graft we test during operation has not statistical difference.(2)There are no significant difference in total operation time,liver resection time and blood loss After graft be removed the lactate peak during operation were 3.72±0.38mmol/L and 3.16±0.71mmol/L,there is a significant difference between the two groups.(3)According to ultrasound during-operation the group A faster than group B of the left hepatic artery blood flow speed,Left branch of portal vein flow rate after graft removed.(4)We found some significant statistics differences of ascites,drainage volume,total bilirubin,ALT,AST and ALB level in the ealy stage after operation.We only found statistics differences of FIB level at first day after operation and after that there is no statistics differences between two groups.However,almost all indicators between the two groups difference disappeared in about two weeks after operation.There are no biliary fistula, bleeding,thrombosis,and other related complications in all donors.After 3 month～1 year follow up does not appear postoperative complications.
【Conclusion】(1)This experiment confirmed,according to my current center in the vein of liver allocation principle,whether to retain in the vein of the liver donor had no effect on security.(2)The donor hepatic vein for reservations,slower recovery after operation,ascites reduced slower,with reservations abdominal partial long time, FIB lower,we should pay attention to treatment in time.
引文
1. Lo CM, Fan ST, Liu CL, Wei WI, Lo RJ, Lai CL, Chan JK, et al. Adult-to-adult living donor liver transplantation using extended right lobe graft. Ann Surg 1997;226:261-270.
2. Sugawara Y, Makuuchi M, Sano K, Imamura H, Kaneko J, Ohkubo T, Matsui Y, et al. Vein reconstruction in modified right liver graft for living-donor liver transplantation. Ann Surg 2003;237:180-185.
3. Sano K, Makuuchi M, Miki K, Maema A, Sugawara Y, Imamura H, Matsunami H, et al. Evaluation of hepatic venous congestion:proposed indication criteria for hepatic vein reconstruction. Ann Surg 2002;236:241-247.
4. Lee SQ Park KM, Hwang S, Kim KH, Ahn CS, Moon DB, Joo J, et al. Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion. J Hepatobiliary Pancreat Surg 2003;10:16-25.
5. Lo CM, Fan ST, Liu CL, Wong J. Hepatic venoplasty in livingdonor liver transplantation using right lobe graft with middle hepatic vein. Transplantation 2003;75:358-360.
6. Fan ST, Lo CM, Liu CL, Yong BH, Chan JK, Ng IO. Safety of donors in live donor liver transplantation using right lobe grafts.Arch Surg 2000;135:336-340.
7. Belghiti J, Guevara OA, Noun R, Saldinger PF, Kianmanesh R. Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization. J Am Coll Surg 2001;193:109-111.
8. Losanoff JE-, Richman BW, Jones JW. Safety of liver transaction before mobilization. J Am Coll Surg 2001;193:714-716.
9. Park KM, Lee SG, Lee YG, Hwang S, Nam CW, Choi KM, Nam CH, et al. Adult to adult living donor liver transplantation at Asian medical center, Seoul, Korea. Transplant Proc 1999;31:456-458.
10. Fan ST, De Villa VH, Kiushi T, Lee SG, Makuuchi M. Right anterior sector drainage in right-lobe live-donor liver transplantation. Transplantation 2003;75:S25-S27.
11. De Villa VH, Chen CL, Chen YS, Wang CC, Lin CC, Cheng YF, et al. Right lobe living donor liver transplantation-addressing the middle hepatic vein controversy. Ann Surg 2003;238:275-282.
12. Kido M, Ku Y, Fukumoto T, Tominaga M, Iwasaki T, Ogata S,et al. Significant role of middle hepatic vein in remnant liver regeneration of right-lobe living donors. Transplantation 2003;75:1598-1601.
13. Lo CM. Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers. Transplantation 2003;75:S12-S15.
14. Sommacale D, Dondero F, Lacaille F, Durand F, Farges O,Sauvanet A, Revillon Y, et al. Surgical issues related to donor selection and recipient risk. Transplant Proc 2003;35:918-919.76 Scatton et al.
15. Kakazu T, Makuuchi M, Kawasaki S, et al. Reconstruction of the middle hepatic vein tributary during right anterior segmentectomy. Surgery 1995; 117:238-240.
16. Kaneko T, Kaneko K, Sugimoto H, et al. Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography. Transplantation 2000; 70:982-985.
17. Rappaport AM. Hepatic venography. Acta Radiol 1951; 36:165-171
[1].Raia S,Nery J R,Mies S.Liver transplantation from live donors.Lancet,1989,2(8661):497.
[2].Lo C M,Fan S T,Liu C L,et al.Adult-to-adult living donor liver transplantation using extended right lobe grafts.Ann Surg,1997;226(3):261-269.
[3l.Malago M,Testa G,Marcos A,Fung JJ,Siegler M,Cronin DC,Broelsch CE.Ethical considerations and rationale of adult-to-adult living donor liver transplantation.Liver Transpl 2001;7:921-927.
[4].Belghiti J,Durand F.Living donor liver transplantation:Present and future.Br J Surg 2000;87:1441-1443
[5].Marcos A.Right lobe living donor liver transplantation:a review.Liver Transpl,2000,6(1):3-20.
[6].Sugawara Y,Makuuchi M,Akamatsu N,et al.Refinement of venous reconstruction using cryopreserved veins in right liver grafts.Liver Transpl,2004,10(4):541-547.
[7].Lee S G,Park K M,Hwang S,et al.Modified right liver graft from a living donor to prevent congestion.Transplantation,2002,74(1):54-59
[8].Tanaka K,Ogura Y."Small-for-size graft"and "small-for-size syndrome"in living donor liver transplantation.Yonsei Med J,2004,45(6):1089-1094.
[9].刘静,李忠华,王兴海,等.右叶部分肝移植肝静脉的临床应用解剖.中国临床解剖学杂志,2004,22(3):234-236.
[10].Cheng YF,Huang TL,Chen Cl,et al.Variations of the left and middle hepatic veins:application in living related hepatic transplan-tation.J Clin Ultrasound,1996,24:11-16.
[11].Nakamura S,Tsuzuki T.SurgGynecol Obstet,1981,152(1):43-50.
[12].Chan SC,Lo CM,Liu CL,et al.Tailoring donor hepatectomy per segment 4venous drainage in right lobe live donor liver transplanta-tion.Liver Transpl,2004,10:755-762.
[13].Erbay N,Raptopoulos V,Pomfi'et EA,et al.Living donor liver transplantation in adults:vascular variants important in surgical planning for donors and recipients.AJR Am J Roentgenol,2003,181:109-114.
[14].Sugawara Y,Makuuchi M,Takayama T,et al.Safe donor hepatectomy for living related liver transplantation.Liver Transpl,2002,8(1):58.
[15].Fan ST,Lo CM,Liu CL,et al.Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation.Ann Surg,2003,238:137-148.
[16].Scatton O,Belghiti J,Dondero F,et al.Harvesting the middle hepatic vein with a right hepatectomy does ont increase the risk for the donor.Liver Transpl,2004,10:71-76.
[17].Sano K,Makuuchi M,Miki K,et al.Evaluation of hepatic venous congestion:prorosed indication criteria for hepatic vein reconstruction.Ann Surg,2002,236:241-247.
[18]. Lee SG, Park KM, Hwang S, et al. Modified right liver graft from a living donor to prevent congestion. Transplantation, 2002, 74:54-59.
[19].Lee SQ Park KM, Hwang S, et al. Modified right liver graft from a living donor to prevent congestion. Transplantation, 2002, 74(1): 54.
[20].Lo CM, Fan ST, Liu CL, et al. Extending the limit on the size of adult recipient in living donor liver transplantation using extended right lobe graft. Transplantation, 1997,27: 1524.
[21].Suh KS, Yi NJ, Kwon CH, et al. Modified extended right hepatectomy-focus on technical aspect. Transplantation, 2004, 78(2):117.
[22].Sato K, Sekiguchi S, Fukumori T, et al. The usefulness of MHV reconstruction with superficial femoral vein in right-lobe living donor liver transplantation. Transplantation, 2004,78(2): 368.
[23].Kornberg A, Heyne J, Schotte U, et al. Hepatic venous outflow reconstruction in right lobe living-donor liver graft using recipient's superficial femoral vein. Am J Transpl, 2003, 3(11): 1444-1447.
[24].Taniai N, Tajiri T, Akimaru K, et al. Middle hepatic vein recon struction of graft for a patient with intrahepatic portosystemic shunt. Hepatogastroenterology, 2004, 51:589-591
2. Sugawara Y, Makuuchi M, Sano K, Imamura H, Kaneko J, Ohkubo T, Matsui Y, et al. Vein reconstruction in modified right liver graft for living-donor liver transplantation. Ann Surg 2003;237:180-185.
3. Sano K, Makuuchi M, Miki K, Maema A, Sugawara Y, Imamura H, Matsunami H, et al. Evaluation of hepatic venous congestion:proposed indication criteria for hepatic vein reconstruction. Ann Surg 2002;236:241-247.
4. Lee SQ Park KM, Hwang S, Kim KH, Ahn CS, Moon DB, Joo J, et al. Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion. J Hepatobiliary Pancreat Surg 2003;10:16-25.
5. Lo CM, Fan ST, Liu CL, Wong J. Hepatic venoplasty in livingdonor liver transplantation using right lobe graft with middle hepatic vein. Transplantation 2003;75:358-360.
6. Fan ST, Lo CM, Liu CL, Yong BH, Chan JK, Ng IO. Safety of donors in live donor liver transplantation using right lobe grafts.Arch Surg 2000;135:336-340.
7. Belghiti J, Guevara OA, Noun R, Saldinger PF, Kianmanesh R. Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization. J Am Coll Surg 2001;193:109-111.
8. Losanoff JE-, Richman BW, Jones JW. Safety of liver transaction before mobilization. J Am Coll Surg 2001;193:714-716.
9. Park KM, Lee SG, Lee YG, Hwang S, Nam CW, Choi KM, Nam CH, et al. Adult to adult living donor liver transplantation at Asian medical center, Seoul, Korea. Transplant Proc 1999;31:456-458.
10. Fan ST, De Villa VH, Kiushi T, Lee SG, Makuuchi M. Right anterior sector drainage in right-lobe live-donor liver transplantation. Transplantation 2003;75:S25-S27.
11. De Villa VH, Chen CL, Chen YS, Wang CC, Lin CC, Cheng YF, et al. Right lobe living donor liver transplantation-addressing the middle hepatic vein controversy. Ann Surg 2003;238:275-282.
12. Kido M, Ku Y, Fukumoto T, Tominaga M, Iwasaki T, Ogata S,et al. Significant role of middle hepatic vein in remnant liver regeneration of right-lobe living donors. Transplantation 2003;75:1598-1601.
13. Lo CM. Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers. Transplantation 2003;75:S12-S15.
14. Sommacale D, Dondero F, Lacaille F, Durand F, Farges O,Sauvanet A, Revillon Y, et al. Surgical issues related to donor selection and recipient risk. Transplant Proc 2003;35:918-919.76 Scatton et al.
15. Kakazu T, Makuuchi M, Kawasaki S, et al. Reconstruction of the middle hepatic vein tributary during right anterior segmentectomy. Surgery 1995; 117:238-240.
16. Kaneko T, Kaneko K, Sugimoto H, et al. Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography. Transplantation 2000; 70:982-985.
17. Rappaport AM. Hepatic venography. Acta Radiol 1951; 36:165-171
[1].Raia S,Nery J R,Mies S.Liver transplantation from live donors.Lancet,1989,2(8661):497.
[2].Lo C M,Fan S T,Liu C L,et al.Adult-to-adult living donor liver transplantation using extended right lobe grafts.Ann Surg,1997;226(3):261-269.
[3l.Malago M,Testa G,Marcos A,Fung JJ,Siegler M,Cronin DC,Broelsch CE.Ethical considerations and rationale of adult-to-adult living donor liver transplantation.Liver Transpl 2001;7:921-927.
[4].Belghiti J,Durand F.Living donor liver transplantation:Present and future.Br J Surg 2000;87:1441-1443
[5].Marcos A.Right lobe living donor liver transplantation:a review.Liver Transpl,2000,6(1):3-20.
[6].Sugawara Y,Makuuchi M,Akamatsu N,et al.Refinement of venous reconstruction using cryopreserved veins in right liver grafts.Liver Transpl,2004,10(4):541-547.
[7].Lee S G,Park K M,Hwang S,et al.Modified right liver graft from a living donor to prevent congestion.Transplantation,2002,74(1):54-59
[8].Tanaka K,Ogura Y."Small-for-size graft"and "small-for-size syndrome"in living donor liver transplantation.Yonsei Med J,2004,45(6):1089-1094.
[9].刘静,李忠华,王兴海,等.右叶部分肝移植肝静脉的临床应用解剖.中国临床解剖学杂志,2004,22(3):234-236.
[10].Cheng YF,Huang TL,Chen Cl,et al.Variations of the left and middle hepatic veins:application in living related hepatic transplan-tation.J Clin Ultrasound,1996,24:11-16.
[11].Nakamura S,Tsuzuki T.SurgGynecol Obstet,1981,152(1):43-50.
[12].Chan SC,Lo CM,Liu CL,et al.Tailoring donor hepatectomy per segment 4venous drainage in right lobe live donor liver transplanta-tion.Liver Transpl,2004,10:755-762.
[13].Erbay N,Raptopoulos V,Pomfi'et EA,et al.Living donor liver transplantation in adults:vascular variants important in surgical planning for donors and recipients.AJR Am J Roentgenol,2003,181:109-114.
[14].Sugawara Y,Makuuchi M,Takayama T,et al.Safe donor hepatectomy for living related liver transplantation.Liver Transpl,2002,8(1):58.
[15].Fan ST,Lo CM,Liu CL,et al.Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation.Ann Surg,2003,238:137-148.
[16].Scatton O,Belghiti J,Dondero F,et al.Harvesting the middle hepatic vein with a right hepatectomy does ont increase the risk for the donor.Liver Transpl,2004,10:71-76.
[17].Sano K,Makuuchi M,Miki K,et al.Evaluation of hepatic venous congestion:prorosed indication criteria for hepatic vein reconstruction.Ann Surg,2002,236:241-247.
[18]. Lee SG, Park KM, Hwang S, et al. Modified right liver graft from a living donor to prevent congestion. Transplantation, 2002, 74:54-59.
[19].Lee SQ Park KM, Hwang S, et al. Modified right liver graft from a living donor to prevent congestion. Transplantation, 2002, 74(1): 54.
[20].Lo CM, Fan ST, Liu CL, et al. Extending the limit on the size of adult recipient in living donor liver transplantation using extended right lobe graft. Transplantation, 1997,27: 1524.
[21].Suh KS, Yi NJ, Kwon CH, et al. Modified extended right hepatectomy-focus on technical aspect. Transplantation, 2004, 78(2):117.
[22].Sato K, Sekiguchi S, Fukumori T, et al. The usefulness of MHV reconstruction with superficial femoral vein in right-lobe living donor liver transplantation. Transplantation, 2004,78(2): 368.
[23].Kornberg A, Heyne J, Schotte U, et al. Hepatic venous outflow reconstruction in right lobe living-donor liver graft using recipient's superficial femoral vein. Am J Transpl, 2003, 3(11): 1444-1447.
[24].Taniai N, Tajiri T, Akimaru K, et al. Middle hepatic vein recon struction of graft for a patient with intrahepatic portosystemic shunt. Hepatogastroenterology, 2004, 51:589-591