解剖性肝动脉重建在肝移植中的应用价值

doi:10.3877/cma.j.issn.2095-3232.2021.04.008

目的

探讨解剖性肝动脉重建在肝移植中的应用价值。

方法

回顾性分析2017年4月至2019年12月在中国科学技术大学附属第一医院接受原位肝移植的50例患者临床资料。其中男37例，女13例；平均年龄（46±9）岁；供肝均来源于公民逝世后器官捐献。患者均签署知情同意书，符合医学伦理学规定。按不同动脉重建方式将患者分为解剖性肝动脉端侧吻合组（端侧组，16例）和端端吻合组（端端组，34例）。端侧组保留受体胃十二指肠动脉。比较两组术后1周内超声下肝动脉峰值流速（PSV）、阻力指数（RI）、术后肝动脉及胆道并发症发生情况。两组PSV等比较采用t检验，率的比较采用χ²检验。

结果

端侧组术后1周PSV为（43±24）cm/s，明显低于端端组的（62±30）cm/s（t=-2.301，P<0.05）。端侧组术后RI为0.51±0.26，端端组为0.64±0.15，差异无统计学意义（t=1.758，P>0.05）。端侧组术后发生并发症3例，其中肝动脉并发症1例，胆道并发症2例；端端组8例，其中肝动脉并发症2例，胆道并发症6例，差异无统计学意义（χ²=0.145，P>0.05）。

结论

解剖性肝动脉重建保留受体胃十二指肠动脉，符合解剖生理及重建要求，血流动力学方面优于传统重建方式，可作为肝移植术一种新的动脉重建方式供选择。

关键词: 肝移植, 肝动脉重建, 手术后并发症

Objective

To evaluate the application value of anatomical hepatic artery reconstruction in liver transplantation.

Methods

Clinical data of 50 patients who underwent orthotopic liver transplantation in the First Affiliated Hospital of University of Science and Technology of China from April 2017 to December 2019 were retrospectively analyzed. Among them, 37 patients were male and 13 female, aged (46±9) years on average. All donor livers were obtained from organ donation after death of citizen. The informed consents of all patients were obtained and the local ethical committee approval was received. All patients were divided into the anatomical hepatic artery end-to-side anastomosis group (end-to-side group, n=16) and end-to-end anastomosis group (end-to-end group, n=34) according to different artery reconstructions. The gastroduodenal artery of the recipients was preserved in the end-to-side group. The peak systolic velocity (PSV) of hepatic artery, resistance index (RI) 1 week after operation and the incidence of postoperative complications of hepatic artery and biliary tract were statistically compared between two groups. Comparison of the PSV between two groups was conducted by t test. The rate comparison was performed by using Chi-square test.

Results

In the end-to-side group, the PSV at postoperative 1 week was (43±24) cm/s, significantly lower than (62±30) cm/s in the end-to-end group (t=-2.301, P<0.05). In the end-to-side group, postoperative RI was 0.51±0.26, which did not differ from 0.64±0.15 in the end-to-end group (t=1.758, P>0.05). In the end-to-side group, 3 patients developed postoperative complications, including 1 case of hepatic artery complication and 2 cases of biliary complications. In the end-to-end group, 8 cases presented with postoperative complications, including 2 cases of hepatic artery complications and6 cases of biliary complications. No statistical significance was observed between two groups (χ²=0.145, P>0.05).

Conclusions

Anatomical hepatic artery reconstruction preserves the gastroduodenal artery of receipient, which meets the requirements of anatomical physiology and reconstruction. It has advantages over traditional reconstruction in terms of hemodynamics, which can serve as a novel alternative artery reconstruction for liver transplantation.

Key words: Liver transplantation, Hepatic artery reconstruction, Postoperative complications

表1 端侧组与端端组肝移植供受体临床基线特征比较

参数		端侧组	端端组	统计值	P值
供体捐献类型（例）				χ²=5.013	0.082
	DBD	3	14
	DCD	12	14
	DBCD	1	6
供体年龄（岁，±s）		50±7	43±12	t=2.742	0.009
供体CIT（min，±s）		275±75	258±147	t=0.540	0.592
供体肝动脉直径（mm，±s）		3.61±0.63	3.26±0.62	t=1.833	0.073
供体巨细胞病毒				-	1.000
	阳性	0	1
	阴性	16	33
受体年龄（岁，±s）		48±7	45±10	t=1.145	0.258
受体性别（例）				χ²=2.616	0.106
	男	9	28
	女	7	6
受体BMI（kg/m²，±s）		22±4	23±4	t=-0.614	0.542
受体肝动脉直径（mm，±s）		3.64±0.76	3.61±0.86	t=0.116	0.908
受体术前TACE				χ²=0.098	0.754
	是	1	3
	否	15	31
供受体血型相符				χ²=0.368	0.544
	是	15	30
	否	1	4
受体原发病（例）				-	0.092
	肝细胞癌	5	5
	乙肝肝硬化失代偿期	5	15
	肝衰竭	0	7
	其他疾病	6	7
受体MELD评分（分，±s）		19±11	22±8	t=-0.848	0.401
受体Child-Pugh评分（分，±s）		10±3	12±2	t=-2.031	0.055

表1 端侧组与端端组肝移植供受体临床基线特征比较

参数		端侧组	端端组	统计值	P值
供体捐献类型（例）				χ²=5.013	0.082
	DBD	3	14
	DCD	12	14
	DBCD	1	6
供体年龄（岁，±s）		50±7	43±12	t=2.742	0.009
供体CIT（min，±s）		275±75	258±147	t=0.540	0.592
供体肝动脉直径（mm，±s）		3.61±0.63	3.26±0.62	t=1.833	0.073
供体巨细胞病毒				-	1.000
	阳性	0	1
	阴性	16	33
受体年龄（岁，±s）		48±7	45±10	t=1.145	0.258
受体性别（例）				χ²=2.616	0.106
	男	9	28
	女	7	6
受体BMI（kg/m²，±s）		22±4	23±4	t=-0.614	0.542
受体肝动脉直径（mm，±s）		3.64±0.76	3.61±0.86	t=0.116	0.908
受体术前TACE				χ²=0.098	0.754
	是	1	3
	否	15	31
供受体血型相符				χ²=0.368	0.544
	是	15	30
	否	1	4
受体原发病（例）				-	0.092
	肝细胞癌	5	5
	乙肝肝硬化失代偿期	5	15
	肝衰竭	0	7
	其他疾病	6	7
受体MELD评分（分，±s）		19±11	22±8	t=-0.848	0.401
受体Child-Pugh评分（分，±s）		10±3	12±2	t=-2.031	0.055

图1 肝移植患者肝动脉重建方式

[1]	Frongillo F, Grossi U, Lirosi MC, et al. Incidence, management, and results of hepatic artery stenosis after liver transplantation in the era of donor to recipient match[J]. Transplant Proc, 2013, 45(7):2722-2725.
[2]	Cirocchi R, D'Andrea V, Lauro A, et al. The absence of the common hepatic artery and its implications for surgical practice: results of a systematicreview and meta-analysis[J]. Surgeon, 2019, 17(3):172-185.
[3]	Németh K, Deshpande R, Máthé Z, et al. Extrahepatic arteries of the human liver-anatomical variants and surgical relevancies[J]. Transpl Int, 2015, 28(10):1216-1226.
[4]	Gkaragkounis A, Fanariotis M, Tepetes K, et al. Celiac trunk and hepatic arteries: anatomical variations of liver arterial supply as detected with multidetector computed tomography in 1,520 patients and its clinical importance[J]. Clin Anat, 2020, 33(7):1091-1101.
[5]	López-Andújar R, Moya A, Montalvá E, et al. Lessons learned from anatomic variants of the hepatic artery in 1,081 transplanted livers[J]. Liver Transpl, 2007, 13(10):1401-1404.
[6]	Kornasiewicz O, Dudek K, Lewandowski Z, et al. Low incidence of hepatic artery thrombosis after hepatic artery reconstruction during liver transplantation[J]. Transplant Proc, 2009, 41(8):3138-3140.
[7]	Liao FM, Chang MH, Ho MC, et al. Resistance index of hepatic artery can predict anastomotic biliary complications after liver transplantation in children[J]. J Formos Med Assoc, 2019, 118(1 Pt 2):209-214.
[8]	Mun HS, Kim KW, Song GW, et al. Evaluation of the hepatic artery anastomosis by intraoperative sonography with high-frequency transducer in right-lobe graft living donor liver transplantation[J].J Clin Ultrasound, 2010, 38(1):10-16.
[9]	郭亚飞，黄德好，吴维等. ERCP在原位肝移植术后早期胆道并发症中的应用[J/OL]. 中华肝脏外科手术学电子杂志, 2020, 9(4):360-364.
[10]	Dokmak S, Aussilhou B, Landi F, et al. The recipient celiac trunk as an alternative to the native hepatic artery for arterial reconstruction in adult liver transplantation[J]. Liver Transplant, 2015, 21(9):1133-1141.
[11]	Herrero A, Souche R, Joly E, et al. Early hepatic artery thrombosis after liver transplantation: what is the impact of the arterial reconstruction type?[J]. World J Surg, 2017, 41(8):2101-2110.
[12]	Ma L, Lu Q, Luo Y. Vascular complications after adult living donor liver transplantation: evaluation with ultrasonography[J]. World J Gastroenterol, 2016, 22(4):1617-1626.
[13]	Crossin JD, Muradali D, Wilson SR. US of liver transplants: normal and abnormal[J]. Radiographics, 2003, 23(5):1093-1114.
[14]	毛永江，郑荣琴，曹君妍等. 肝移植术后胆管并发症的肝动脉彩色多普勒超声表现[J/CD]. 中华肝脏外科手术学电子杂志, 2015, 4(1)：46-49.
[15]	Saad WE, Lin E, Ormanoski M, et al. Noninvasive imaging of liver transplant complications[J]. Tech Vasc Interv Radiol, 2007, 10(3):191-206.
[16]	Ren X, Guan J, Gao N, et al. Evaluation of pediatric liver transplantation-related artery complications using intra-operative multi-parameter ultrasonography[J]. Med Sci Monit, 2016(22): 4495-4502.
[17]	Sneiders D, Houwen T, Pengel LHM, et al. Systematic review and meta-analysis of posttransplant hepatic artery and biliary complications in patients treated with transarterial chemoembolization before liver transplantation[J]. Transplantation, 2018, 102(1):88-96.
[18]	Spetzler VN, Schepers M, Pinnschmidt HO, et al. The incidence and severity of post-hepatectomy bile leaks is affected by surgical indications, preoperative chemotherapy, and surgical procedures[J]. Hepatobiliary Surg Nutr, 2019, 8(2):101-110.
[19]	Hildebrand T, Pannicke N, Dechene A, et al. Biliary strictures and recurrence after liver transplantation for primary sclerosing cholangitis: a retrospective multicenter analysis[J]. Liver Transpl, 2016, 22(1):42-52.

[1]	夏效泳, 王立超, 朱治国, 丛云海, 史宗新. 深度塌陷性胫骨平台骨折的形态特点和治疗策略[J]. 中华关节外科杂志(电子版), 2023, 17(05): 625-632.
[2]	李坤河, 寇萌佳, 邝立挺. 肝移植术后二次气管插管的危险因素及预测模型的建立[J]. 中华普通外科学文献(电子版), 2023, 17(05): 366-371.
[3]	李建美, 邓静娟, 杨倩. 两种术式联合治疗肝癌合并肝硬化门静脉高压的安全性及随访评价[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 41-44.
[4]	逄世江, 黄艳艳, 朱冠烈. 改良π形吻合在腹腔镜全胃切除消化道重建中的安全性和有效性研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 66-69.
[5]	杨体飞, 杨传虎, 陆振如. 改良无充气经腋窝入路全腔镜下甲状腺手术对喉返神经功能的影响研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 74-77.
[6]	陈大敏, 曹晓刚, 曹能琦. 肥胖对胃癌患者手术治疗效果的影响研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 651-653.
[7]	陈垚, 徐伯群, 高志慧. 改良式中间上入路根治术治疗甲状腺癌的有效性安全性研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 619-622.
[8]	中华医学会器官移植学分会, 中国医师协会器官移植医师分会, 上海医药行业协会. 中国肝、肾移植受者霉酚酸类药物应用专家共识(2023版)[J]. 中华移植杂志(电子版), 2023, 17(05): 257-272.
[9]	陆闻青, 陈昕怡, 任雪飞. 遗传代谢病儿童肝移植受者术后生活质量调查研究[J]. 中华移植杂志(电子版), 2023, 17(05): 287-292.
[10]	潘冰, 吕少诚, 赵昕, 李立新, 郎韧, 贺强. 淋巴结清扫数目对远端胆管癌胰十二指肠切除手术疗效的影响[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 608-612.
[11]	严庆, 刘颖, 邓斐文, 陈焕伟. 微血管侵犯对肝癌肝移植患者生存预后的影响[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 624-629.
[12]	廖梅, 张红君, 金洁玚, 吕艳, 任杰. 床旁超声造影对肝移植术后早期肝动脉血栓的诊断价值[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 630-634.
[13]	李秉林, 吕少诚, 潘飞, 姜涛, 樊华, 寇建涛, 贺强, 郎韧. 供肝灌注液病原菌与肝移植术后早期感染的相关性分析[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 656-660.
[14]	吕垒, 冯啸, 何凯明, 曾凯宁, 杨卿, 吕海金, 易慧敏, 易述红, 杨扬, 傅斌生. 改良金氏评分在儿童肝豆状核变性急性肝衰竭肝移植手术时机评估中价值并文献复习[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 661-668.
[15]	崔佳琪, 吴迪, 陈海艳, 周惠敏, 顾元龙, 周光文, 杨军. TACE术后并发肝脓肿的临床诊治分析[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 688-693.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Application value of anatomical hepatic artery reconstruction in liver transplantation

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Application value of anatomical hepatic artery reconstruction in liver transplantation