摘要
目的探讨活体肝移植(LDLT)技术应用于成人完全劈离式肝移植(fSLT)的疗效并比较左半供肝(LHG)和右半供肝(RHG)移植的特点。方法回顾性收集2021年3—12月宁波市医疗中心李惠利医院肝胆胰外科实施的25例fSLT的供受者资料。13例fSLT供者中男性11例,女性2例,年龄[M(IQR)]38(19)岁(范围:25~56岁),身高168(5)cm(范围:160~175 cm),体重65(9)kg(范围:50~75 kg)。25例受者中男性17例,女性8例,年龄52(14)岁(范围:35~71岁);原发性肝癌15例,良性终末期肝病10例;终末期肝病模型评分10(9)分(范围:7~23分)。按供肝类型将受者分为LHG组和RHG组,比较两组的手术疗效及技术特点。随访截至2022年1月。定量资料的组间比较采用Mann-Whitney U秩和检验。分类资料的组间比较采用χ^(2)检验或Fisher确切概率法。结果按LDLT技术实施原位完全左右半肝劈离,获取有效左半供肝和右半供肝13对,获取时间230(53)min(范围:125~352 min),获取出血量250(100)ml(范围:150~1000 ml)。经中国人体器官分配与共享计算机系统分配13个LHG和12个RHG用于本中心25例等待者。与RHG组(12例)相比,LHG组(13例)女性和良性终末期肝病占比高,体重和供肝质量较轻(P值均<0.05)。总移植物和受者体重比(GRWR)为1.2(0.4)%(范围:0.7%~1.9%),其中LHG组为1.1(0.5)%(范围:0.7%~1.6%),RHG组为1.3(0.5)%(范围:0.9%~1.9%),差异无统计学意义(P>0.05)。在脉管分配方面,肝中静脉主干均归LHG组,腹腔干、门静脉主干和胆总管分配给LHG和RHG的比例分别为10∶3(P=0.009)、9∶4(P>0.05)和4∶9(P=0.027);腔静脉前期12例归LHG,后期1例分别归LHG和RHG(P<0.01)。总体冷缺血时间和无肝期分别为240(90)min(范围:138~420 min)和50(16)min(范围:31~98 min),手术时间和术中出血量分别为474(138)min(范围:294~680 min)和800(640)ml(范围:200~5000 ml),差异均无统计学意义(P值均>0.05)。LHG组3例受者的GRWR≤0.8%,术后有小肝综合征表现,经处理后好转。术后发生Clavien-Dindo并发症分级系统≥Ⅲ级并发症6例(24.0%),其中LHG组4例(4/13),RHG组2例(2/12),经再手术及介入等处理好转5例,术后2周死于继发严重感染1例,术后住院病死率为4.0%,两组并发症的差异无统计学意义(P>0.05)。结论依赖精准的供受者评估和LDLT技术的应用,成人间原位fSLT的并发症发生率和病死率是可以接受的。
Objective To evaluate the efficacy of in-situ full size split liver transplantation(fSLT)for adult recipients using the living donor liver transplantation(LDLT)technique and to compare the characteristics of the left hemiliver graft(LHG)and the right hemiliver graft(RHG)transplantation.Methods Deceased donor and recipient data of 25 consecutive cases of fSLT at Department of Hepatopancreatobiliary Surgery,Ningbo Medical Center Lihuili Hospital from March to December 2021 was retrieved and the patients divided into two groups:LHG group and RHG group.Among the 13 donors,11 were male and 2 were female,aged(M(IQR))38(19)years(range:25 to 56 years),with height of 168(5)cm(range:160 to 175 cm)and weight of 65(9)kg(range:50 to 75 kg).The median age of the 25 recipients was 52(14)years(range:35 to 71 years),17 were male and 8 were female,15 had primary liver cancer and 10 had benign end-stage liver disease,model for end-stage liver disease score was 10(9)points(range:7 to 23 points).Of the 25 recipients,10 recipients had previously undergone hepatobiliary surgery.The follow-up period was to January 2022.Demographic,clinicopathological,surgical outcomes and postoperative complications were evaluated and compared between the two groups.Continuous quantitative data were compared using Mann-Whitney U test.Classification data were expressed as frequencies,and were compared between groups usingχ^(2) test or Fisher exact probability method.Results Using LDLT technique,in-situ full-left/full-right liver splitting was performed and 13 viable pairs of hemiliver grafts were harvested with acquisition time of 230(53)minutes(range:125 to 352 minutes)and blood loss of 250(100)ml(range:150 to 1000 ml).A total of 25 hemiliver grafts(13 LHG and 12 RHG)were allocated to patients listed for liver transplantation in our center by China Organ Transplant Response System.In the LHG group(13 cases),there were more females and more patients with benign end-stage liver disease than in the RHG group(12 cases)(P<0.05).The body weight and graft weight of recipients in the LHG group were lower than that in RHG group(both P<0.05).There were no significant differences in other baseline data between the two groups(all P>0.05).The graft to recipient weight ratio(GRWR)was 1.2(0.4)%(range:0.7%to 1.9%)for 25 recipients,1.1(0.5)%(range:0.7%to 1.6%)for the LHG group and 1.3(0.5)%(range:0.9%to 1.9%)for the RHG group.There was no significant difference between the two groups(P>0.05).Sharing patterns of hepatic vessels and the common bile duct are as follows:all the trunk of middle hepatic vein were allocated to the LHG group.The proportion of celiac trunk,main portal vein and common bile duct assigned to LHG and RHG was 10∶3(P=0.009),9∶4(P>0.05)and 4∶9(P=0.027),respectively.The vena cava of 12 donors in early stage retained in LHG and that of last one was shared between LHG and RHG(P<0.01).The median cold ischemia time of 25 hemiliver grafts was 240(90)minutes(range:138 to 420 minutes).For the total of 25 fSLT,the median anhepatic phase was 50(16)minutes(range:31 to 98 minutes)and the operation time was 474(138)minutes(range:294 to 680 minutes)with blood loss of 800(640)ml(range:200 to 5000 ml).There were no significant differences in all of operation data between two groups.In the LHG group,3 patients with GRWR≤0.8%had postoperative small-for-size syndrome which improved after treatment.Postoperative Clavien-Dindo grade≥Ⅲcomplications were observed in 6 cases(24.0%),4 cases(4/13)in the LHG group and 2 cases(2/12)in the RHG group,respectively.The difference was not statistically significant.Among them,5 cases improved after re-operation and intervention,1 case in LHG group died of secondary infection 2 weeks after operation,and the mortality was 4.0%.Analysis of serious postoperative complications and death has suggested that conventional caval interposition should not be used for LHG transplantation.Conclusion Relying on accurate donor-recipient evaluation and the apply of LDLT technique,the morbidity and mortality of in-situ fSLT in adults is acceptable.
作者
吴胜东
黄静
房炯泽
卢长江
王高卿
王珂
叶盛
江伟
朱宏达
胡杨科
毛书奇
陆才德
Wu Shengdong;Huang Jing;Fang Jiongze;Lu Changjiang;Wang Gaoqing;Wang Ke;Ye Sheng;Jiang Wei;Zhu Hongda;Hu Yangke;Mao Shuqi;Lu Caide(Department of Hepatopancreatobiliary Surgery,Ningbo Medical Center Lihuili Hospital,Ningbo University,Ningbo 315041,China)
出处
《中华外科杂志》
CAS
CSCD
北大核心
2022年第10期906-914,共9页
Chinese Journal of Surgery
基金
浙江省医药卫生科技项目(2019ZD047)
宁波市医疗卫生品牌学科(PPXK2018-03)。
关键词
肝移植
肝肿瘤
劈离式肝移植
原位肝劈离
成人间移植
Liver transplantation
Liver neoplasms
Split liver transplantation
In-situ liver splitting
Adult recipients
作者简介
通信作者:陆才德,Email:lucaide@nbu.edu.cn。
