原位保留部分残余肝脏的离体肝切除联合辅助性自体肝移植治疗复杂肝泡型包虫病
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摘要
目的探讨原位保留部分残余肝脏在体的离体肝切除联合离体残余肝辅助性自体肝移植术在复杂肝泡型包虫病中的应用价值。方法回顾性分析四川省人民医院于2019年1月收治的1例术中切除右三肝、原位保留左肝S2、S3段在体内、离体切除中肝S4、S5、S8段泡型包虫、联合右肝S6、S7段残余肝辅助性自体肝移植术病例的临床资料。结果经术前评估及术中探查发现,患者包虫主要位于中肝S4、S5、S8段并紧贴第一肝门,第二、三肝门肝静脉系统广泛受侵,肝后下腔静脉前壁受侵,侵蚀肝中静脉,包绕侵蚀肝右静脉背侧支及腹侧支根部,侵蚀左肝静脉根部右侧壁。根据"在体优先"原则,先循镰状韧带平面在体劈裂包虫左侧肝实质,修补肝左静脉,原位保留左肝外叶;循肝右叶间裂平面在体劈裂包虫右侧肝实质至受侵肝静脉流出道处,分别离断右肝动脉、门静脉右支及右肝管,将右三肝及尾叶整体切除;继续离体切除中肝的包虫病灶,利用异体血管重建右肝流出道,将重建储囊式流出道与下腔静脉前壁行广口侧侧吻合,并行右肝残余肝辅助性自体肝移植。患者手术时间为12 h,术中出血量约800 mL。肝切除术后行常规治疗,患者随访2个月,一般情况良好。结论辅助性自体肝移植术在实施离体肝切除阶段原位保留了部分功能肝脏在体内,能够维护体循环和门静脉系统循环稳定,维持术中部分肝功能,最大限度地保留功能肝脏,降低术后肝功能衰竭风险,可作为治疗终末期肝包虫病的有效尝试。
Objective To explore value of partial liver preservation in situ for ex-vivo liver resection and auxiliatry autologous liver transplantation in end-stage hepatic alveolar echinococcosis. Methods The clinical data of one patient with end-stage hepatic alveolar echinococcosis treated with auxiliatry autologous liver transplantation combined partial liver preservation in situ were analyzed retrospectively. This patient was admitted on January 2019. During the auxiliatry autologous liver transplantation procedure, the S1, S4-S8 segments of the liver were resected for mass dissection,whereas the S2 and S3 segments of left liver were preserved in situ. Results The preoperative evaluation and intraoperative exploration indicated that the mass located in the S4, S5, S8 segments, which was adjacent to the first hepatic portal and involved the anterior wall of posterior inferior vena cava, middle hepatic veins, the opening of right hepatic veins and the right wall of left hepatic veins. Based on the "in situ first" principle, the left lesion was slit using the anterior approach, the left hepatic vein was repaired and the S2 and S3 segments were preserved in situ. Then, the right lesion to involved hepatic vein was slit along the right interlobar fissure. The right hepatic artery, right portal vein and right bile duct were divided separately. The S1 and S4-S8 segments were removed completely. Next, the mass was resected,the out flow of the right liver was reconstructed using the allogeneic veins during the ex-vivo liver resection. Then, the auxiliatry autologous right liver transplantation was initiated by the wide-caliber hepatic vein-artificial inferior vena cava anastomosis. The surgical procedures lasted for 12 h, and the intraoperative bleeding was approximately 800 mL. The patient was routinely treated and smoothly recovered after the operation. Conclusions Procedure of auxiliatry autologous liver transplantation preserved part functional liver in situ during ex-vivo resection, which could maintain stability of systemic and portal vein circulation, hold part liver function during operation, preserve functional liver furthest, and reduce risk of hepatic failure, is an effective attempt for end stage hepatic alveolar echinococcosis.
Objective To explore value of partial liver preservation in situ for ex-vivo liver resection and auxiliatry autologous liver transplantation in end-stage hepatic alveolar echinococcosis. Methods The clinical data of one patient with end-stage hepatic alveolar echinococcosis treated with auxiliatry autologous liver transplantation combined partial liver preservation in situ were analyzed retrospectively. This patient was admitted on January 2019. During the auxiliatry autologous liver transplantation procedure, the S1, S4-S8 segments of the liver were resected for mass dissection,whereas the S2 and S3 segments of left liver were preserved in situ. Results The preoperative evaluation and intraoperative exploration indicated that the mass located in the S4, S5, S8 segments, which was adjacent to the first hepatic portal and involved the anterior wall of posterior inferior vena cava, middle hepatic veins, the opening of right hepatic veins and the right wall of left hepatic veins. Based on the "in situ first" principle, the left lesion was slit using the anterior approach, the left hepatic vein was repaired and the S2 and S3 segments were preserved in situ. Then, the right lesion to involved hepatic vein was slit along the right interlobar fissure. The right hepatic artery, right portal vein and right bile duct were divided separately. The S1 and S4-S8 segments were removed completely. Next, the mass was resected,the out flow of the right liver was reconstructed using the allogeneic veins during the ex-vivo liver resection. Then, the auxiliatry autologous right liver transplantation was initiated by the wide-caliber hepatic vein-artificial inferior vena cava anastomosis. The surgical procedures lasted for 12 h, and the intraoperative bleeding was approximately 800 mL. The patient was routinely treated and smoothly recovered after the operation. Conclusions Procedure of auxiliatry autologous liver transplantation preserved part functional liver in situ during ex-vivo resection, which could maintain stability of systemic and portal vein circulation, hold part liver function during operation, preserve functional liver furthest, and reduce risk of hepatic failure, is an effective attempt for end stage hepatic alveolar echinococcosis.
引文
1四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.
2 Craig PS,Li T,Qiu J,et al. Echinococcosis and Tibetan communities.Emerg Infect Dis,2008,14(10):1674-1675.
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.
5 McManus DP,Zhang W,Li J,et al. Echinococcosis.Lancet,2003,362(9392):1295-1304.
6 Li 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.
7 Haider HH,Nishidas,Selvaggi G,et al. Alveolar echinococcosis induced liver falure:salvage by liver transplantation in an otherwise uniformly fatal disease.Clin Transplant,2008,22(4):664-667.
8 Gruttadauria S,Marsh JW,Bartlett DL,et al. Ex situ resection technique and liver autotransplantation:last resource for otherwise unresectable malignancy.Dig Dis Sci,2005,50(10):1829-1835.
9沈中阳.中国肝移植10年成就与展望.华夏医药,2009,4(6):419-420.
10邵英梅,蒋铁民,吐尔干艾力·阿吉,等.根治性及准根治性手术治疗终末期肝泡型包虫病.中华消化外科杂志,2011,10(4):296-298.
11吐尔洪江·吐逊,李玉鹏,张皓,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.
12张宇,杨冲,王燚,等.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.中国普外基础与临床杂志,2018,25(10):1236-1241.
13 Li FG,Yan LN,Li B,et al.Estimation of standard liver volume in Chinese adult living donors.Transplant Proc,2009,41(10):4052-4056.
14 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.
15 Wen 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.
16 Wang 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.
17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.
18 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,2018,18(7):1668-1679.
19吐尔洪江·吐逊,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.
20 He 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.
23 Hu H,Huang B,Zhao J,et al. Liver autotransplantation and retrohepatic vena cava reconstruction for alveolar echinococcosis.J Surg Res,2017,210:169-176.
24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.
25 Lei 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.
26 Cheng F,Yang Z,Zeng J,et al.Anesthesia management of modified ex vivo liver resection and autotransplantation.Ann Transplant,2018,23:274-284.
27 Ito 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.
28 Ogura 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):718-728.
29 Ikegami 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.
30 Wu 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.
31 Ikegami T,Shirabe K,Yoshiya S,et al.One-step reconstruction of the right inferior hepatic veins using auto-venous grafts in livingdonor liver transplantation.Surg Today,2013,43(7):769-776.
2 Craig PS,Li T,Qiu J,et al. Echinococcosis and Tibetan communities.Emerg Infect Dis,2008,14(10):1674-1675.
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.
5 McManus DP,Zhang W,Li J,et al. Echinococcosis.Lancet,2003,362(9392):1295-1304.
6 Li 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.
7 Haider HH,Nishidas,Selvaggi G,et al. Alveolar echinococcosis induced liver falure:salvage by liver transplantation in an otherwise uniformly fatal disease.Clin Transplant,2008,22(4):664-667.
8 Gruttadauria S,Marsh JW,Bartlett DL,et al. Ex situ resection technique and liver autotransplantation:last resource for otherwise unresectable malignancy.Dig Dis Sci,2005,50(10):1829-1835.
9沈中阳.中国肝移植10年成就与展望.华夏医药,2009,4(6):419-420.
10邵英梅,蒋铁民,吐尔干艾力·阿吉,等.根治性及准根治性手术治疗终末期肝泡型包虫病.中华消化外科杂志,2011,10(4):296-298.
11吐尔洪江·吐逊,李玉鹏,张皓,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.
12张宇,杨冲,王燚,等.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.中国普外基础与临床杂志,2018,25(10):1236-1241.
13 Li FG,Yan LN,Li B,et al.Estimation of standard liver volume in Chinese adult living donors.Transplant Proc,2009,41(10):4052-4056.
14 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.
15 Wen 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.
16 Wang 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.
17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.
18 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,2018,18(7):1668-1679.
19吐尔洪江·吐逊,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.
20 He 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.
23 Hu H,Huang B,Zhao J,et al. Liver autotransplantation and retrohepatic vena cava reconstruction for alveolar echinococcosis.J Surg Res,2017,210:169-176.
24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.
25 Lei 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.
26 Cheng F,Yang Z,Zeng J,et al.Anesthesia management of modified ex vivo liver resection and autotransplantation.Ann Transplant,2018,23:274-284.
27 Ito 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.
28 Ogura 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):718-728.
29 Ikegami 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.
30 Wu 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.
31 Ikegami T,Shirabe K,Yoshiya S,et al.One-step reconstruction of the right inferior hepatic veins using auto-venous grafts in livingdonor liver transplantation.Surg Today,2013,43(7):769-776.