劈离式供肝儿童肝移植门静脉并发症的诊断与治疗

曾凯宁; 杨卿; 姚嘉; 唐晖; 傅斌生; 冯啸; 吕海金; 易慧敏; 易述红; 杨扬

doi:10.3969/j.issn.1674-7445.2023241

劈离式供肝儿童肝移植门静脉并发症的诊断与治疗

doi: 10.3969/j.issn.1674-7445.2023241

*.
510630　广州，中山大学附属第三医院肝脏外科暨肝脏移植中心中山大学器官移植研究所广东省器官移植研究中心广东省移植医学工程实验室
2.
器官移植重症监护室

基金项目: 国家自然科学基金（81972286、82270690）；国家重点研发计划（2017YFA0104304）；广东省自然科学基金（2019B020236003）；广东省科技计划项目（2020B1212060019）；广州市科技计划项目（2023A04J1083）

详细信息

作者简介:

通讯作者:
杨扬（ORCID 0000-0003-4981-4745），博士，主任医师，教授，研究方向为肝移植，Email：yysysu@163.com

中图分类号: R617, R575
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- 被引次数: 0
出版历程
- 收稿日期: 2023-11-10
- 录用日期: 2023-11-27
- 网络出版日期: 2023-11-30
- 刊出日期: 2024-01-11

Diagnosis and treatment of the portal vein complications for children undergoing spilt liver transplantation

*.
Department of Hepatic Surgery , Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-Sen University, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangdong Province Engineering Laboratory for Transplantation Medicine, Guangzhou 510630, China

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Corresponding author: Yang Yang, Email: yysysu@163.com

摘要

摘要: 目的探讨劈离式供肝儿童肝移植门静脉并发症的诊断及治疗策略。方法回顾性分析接受劈离式肝移植的88例儿童受者的临床资料。术中根据受者门静脉内径、发育情况，利用门静脉左右分支处进行吻合或间置供者髂静脉搭桥吻合，围手术期采用规范化的门静脉血流监测，术后按肝素钠桥接华法林的方案进行抗凝治疗。经增强CT或门静脉造影确诊门静脉狭窄或血栓形成后，予切开取栓、全身抗凝、介入下取栓、球囊扩张和（或）支架置入等处理。结果 88例受者中共10例患儿确诊门静脉并发症，其中4例门静脉狭窄，确诊时间分别为术后1 d、2个月、8个月、11个月，6例门静脉血栓形成，确诊时间分别为术中、术后2 d、术后3 d（2例）、术后6 d、术后11个月。1例门静脉狭窄者和1例门静脉血栓形成者于围手术期死亡，门静脉并发症相关病死率为2%（2/88）。其余8例患者中，1例行全身抗凝治疗、2例行门静脉切开取栓术、1例行介入下球囊扩张、4例行介入下球囊扩张及支架置入，术后均长期随访，未再出现门静脉相关症状，复查门静脉血流参数正常。结论规范化的术中及术后门静脉血流监测有助于早期发现门静脉并发症，及时采取术中门静脉切开取栓，术后介入下球囊扩张、支架置入等手段可有效治疗门静脉并发症，减少门静脉并发症导致的移植物丢失和受者死亡。
- 儿童肝移植 /
- 劈离式肝移植 /
- 门静脉并发症 /
- 门静脉狭窄 /
- 门静脉血栓 /
- 活化部分凝血活酶时间 /
- 球囊扩张 /
- 支架置入
Abstract: Objective To investigate the diagnosis and treatment strategy of the portal vein complications in children undergoing split liver transplantation. Methods The clinical data of 88 pediatric recipients who underwent split liver transplantation were retrospectively analyzed. Intraoperative anastomosis at the bifurcating site of the portal vein or donor iliac vein bypass anastomosis was performed depending on the internal diameter and development of the recipient's portal vein. A normalized portal venous blood stream monitoring was performed during the perioperative stage. After operation, heparin sodium was used to bridge warfarin for anticoagulation therapy. After portal vein stenosis or thrombosis was identified with enhanced CT or portography, managements including embolectomy, systemic anticoagulation, interventional thrombus removal, balloon dilatation and/or stenting were performed. Results Among the 88 recipients, a total of 10 children were diagnosed with portal vein complications, of which 4 cases were diagnosed with portal vein stenosis at 1 d, 2 months, 8 months, and 11 months after surgery, and 6 cases were diagnosed with portal vein thrombosis at intraoperative, 2 d, 3 d (n=2), 6 d, and 11 months after surgery, respectively. One patient with portal vein stenosis and one patient with portal vein thrombosis died perioperatively. The fatality related to portal vein complications was 2% (2/88). Of the remaining 8 patients, 1 underwent systemic anticoagulation, 2 underwent portal venous embolectomy, 1 underwent interventional balloon dilatation, and 4 underwent interventional balloon dilatation plus stenting. No portal venous related symptoms were detected during postoperative long term follow up, and the retested portal venous blood stream parameters were normal. Conclusions The normalized intra- and post-operative portal venous blood stream monitoring is a useful tool for the early detection of portal vein complications, the early utilization of useful managements such as intraoperative portal venous embolectomy, interventional balloon dilatation and stenting may effectively treat the portal vein complications, thus minimizing the portal vein complication related graft loss and recipient death.
- Pediatric liver transplantation /
- Split liver transplantation /
- Portal vein complication /
- Portal vein stenosis /
- Portal vein thrombosis /
- Activated partial thromboplastin time /
- Balloon dilatation /
- Stenting

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表 1 发生门静脉并发症的受者的临床资料

Table 1. Clinical data of recipients with portal venous complications

例序	性别	年龄	供者血型	受者血型	移植物类型	GRWR^① （%）	并发症类型	诊断时间	处理方式	结局	随访时间
1	男	4岁2个月	A	B	儿童右三叶	5.6	PVS	术后1 d	抗凝治疗	死亡	16 d
2	女	7个月	B	AB	成人左半肝（S2、S3减体积）	3.8	PVS	术后2个月	抗凝治疗	无并发症生存	64个月
3	男	13岁5个月	O	O	儿童右三叶	2.2	PVS	术后11个月	门静脉球囊扩张（2次）+支架置入	无并发症生存	61个月
4	男	6个月	B	O	成人左外叶	3.2	PVS	术后8个月	门静脉球囊扩张（2次）	无并发症生存	57个月
5	男	9个月	O	AB	成人左外叶	2.5	PVT	术后2 d	二次肝移植	死亡	8 d
6	男	4个月	A	A	成人左外叶减体积	4.3	PVT	术中	门静脉切开取栓+ 髂静脉间置搭桥	无并发症生存	17个月
7	女	5个月	O	A	成人左外叶	3.9	PVT	术后3 d	门静脉切开取栓	无并发症生存	64个月
8	女	1岁1个月	O	O	成人左外叶减体积	3.3	PVT	术后3 d	门静脉球囊扩张+ 支架置入	无并发症生存	51个月
9	男	8个月	O	B	儿童左外叶	2.6	PVT	术后6 d	门静脉球囊扩张+ 支架置入	无并发症生存	65个月
10	男	9个月	B	O	儿童左外叶减体积	3.6	PVT	术后11个月	门静脉球囊扩张+ 支架置入	无并发症生存	14个月
注：①GRWR为移植物与受者质量比。

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