活体肝移植肝中静脉的重建

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肝移植具体方法-崔子林

肝移植具体方法根据移植肝植入位置分原位肝移植和异位肝移植。

根据移植肝的来源分为脑死亡供肝肝移植、无心跳供肝肝移植、活体供肝肝移植及多米诺肝移植。

根据静脉重建方式分为经典式肝移植和背驮式肝移植。

根据移植肝是否为完整肝脏还可分为全肝移植和部分肝移植，部分肝移植包括减体积肝移植、劈离式肝移植及活体供肝肝移植。

肝移植手术分两组进行，即供肝切取组和受者手术组。

供肝切取组负责将供肝完整切取，做降温灌洗、低温保存，并在植入前做必要的休整。

受者手术组则先切除病肝，然后植入休整好的供肝，吻合血管和重建胆道。

尸肝肝移植供肝获取手术：目前国内多采用快速供肝切取术，尤其适用于供者血流动力学不稳定或心跳已经停止的情况。

供者死亡后立即做大十字形切口剖腹，将小肠翻向左侧，靠近腹主动脉分叉处游离，结扎远端，剪开前壁，插入气囊导管至腹腔动脉开口上方。

充气囊后立即以UW液或肾保存液2500～3000ml行腹主动脉灌注。

保证尸体肝热缺血时间不超过5分钟。

同时，提起横结肠，拨开小肠，在系膜根部解剖出肠系膜上静脉，远端夹闭，其近端插入灌注管。

立即开始以1～4℃ UW 液或肾保存液行门静脉灌注。

随即在同一平面即双肾静脉以下水平剪断肝下下腔静脉。

如只收获肝脏脏器，灌注门静脉即可达到有效灌注的目的。

联合脏器获取，切开将十二指肠和胰掀起，显露双肾，在肾血管平面以下，切断腹主动脉和肝下下腔静脉，同时切取双肾与肝脏。

肝脏装入充满1～4℃ UW液的无菌塑料袋内密封，以冰屑保持低温，快速送入移植手术室。

活体肝移植供肝切取手术以右半肝切取为例，多选用右肋缘下切口，常规取肝脏活检。

应用术中B超了解血管解剖，肝左、中、右静脉及门静脉主要分支的走行情况。

经胆囊管置管行术中胆道造影了解胆道解剖。

进行肝周游离，游离第1、2、3肝门，尽量不要损伤肝动脉及胆道血运，注意保留位置良好的胆囊动脉。

在不阻断肝血流的情况下用超声乳化吸引刀切肝，肝断面直径1mm以下血管双极电凝处理，1mm以上的管道结扎。

猪活体肝脏移植的应用解剖

猪活体肝脏移植的应用解剖
蒲淼水;钟世镇;石瑾
【期刊名称】《中国临床解剖学杂志》
【年(卷),期】2003(21)1
【摘要】目的 :探讨猪活体肝移植解剖学基础。

方法 :在 10例新鲜成年猪肝大体
和管道铸型标本上 ,观测猪肝分叶、分段 ,动脉、肝门静脉、胆管和肝静脉的分布
和汇注规律。

结果 :猪肝外观由三大叶组成 ,即左外叶、中叶和右后叶 ,尾状叶与邻叶界限不明显。

中叶的中分线是左右半肝的真正分界线 ,此界面内无重要的管道结构。

结论:猪活体肝移植是一个良好的实验动物模型,猪肝移植物应以左半肝为好。

【总页数】3页(P74-75)
【关键词】活体肝移植;应用解剖;猪
【作者】蒲淼水;钟世镇;石瑾
【作者单位】广州军区广州总医院普通外科;第一军医大学临床解剖学研究所
【正文语种】中文
【中图分类】R657.3
【相关文献】
1.尸体肝脏横断面解剖与CT增强影像对比研究对活体肝移植的术前评估 [J], 汪洋;朱斌;靳晶;范海健
2.尸体肝脏横断面解剖与CT影像对照对活体肝移植的术前评估价值 [J], 汪洋;朱斌;靳晶;范海健
3.尸体肝脏横断面解剖与CT影像对照对活体肝移植的术前评估价值 [J], 汪洋;朱斌;靳晶;范海健
4.肝脏血管解剖与活体肝移植供者选择 [J], 朱志军;李俊杰;张建军;淮明生;张玮晔;蒋文涛;沈中阳
5.现代肝脏局部解剖在活体部分肝移植应用的研究进展 [J], 方驰华;朱新勇
因版权原因，仅展示原文概要，查看原文内容请购买。

成人—成人活体肝移植一例报告

切断；门静脉右支全开放灌流，时 ⑤ 同
ｃ重２５０ｇ（）后资料：体：ｍ．５。３术供术毕麻醉即清醒，后３ｈ拔除气管插术管，术后第２天开始血清总胆红质上升
至９ｍｏＩ，３、Ｔ２。术８ｎｌＡＩ２０ＡＳ１Ｔ５
摘除供肝并移至盛有４ｕｗ液的保 ℃
存容器（ａｋｔｂｅ中换成４Ｕｗ液ｂｃａｌ） ℃ 进行灌洗；修整供肝；关腹。整个 ⑥ ⑦ 供体手术共耗时５５ｍｉ，中失血量４ｎ术
８０ｍｌ出供肝为１ｍＸ１ｍＫ１０，取ｃ２ｃ０５
弥漫性大小不等的囊肿、大。诊断为脾先天性肝内胆管弥漫性囊性扩张伴反
后第５天恢复正常．后第４天开始进术食，下床活动，５大拔除腹腔引流管．第１后开始恢复正常生活．同院一周３受体：后３ｈ麻醉清醒，０ｈ拔除气术１管插管，中、后血压、搏呼吸均一术术脉直平稳．中血流开放后即有月汁流术日
声刀在不阻断肝血流的情况下切肝．
１８９８年１２月巴西的Ｒｉａａ等开
脉吻合；停止门静脉转流后行门静脉吻
合．然后开放肝静脉及 ¨ 静脉血流．供肝恢复血流灌注。于手术显微镜下用１— ｒｌｎ线行右肝动脉与受者肝固００ｐｏｅｅ有动脉对端吻合，成后肝色泽、地完质恢复正常。彩超查肝动脉、静脉及肝门静脉血流通畅。鉴于受者胆总管ｌ．Ｆ常

成人间活体扩大右半肝移植治疗急性肝功能衰竭

成人间活体扩大右半肝移植治疗急性肝功能衰竭何晓顺;黄洁夫;朱晓峰;胡安斌;王东平;马毅;王国栋;鞠卫强;巫林伟;邰强【期刊名称】《中华外科杂志》【年(卷),期】2007(045)005【摘要】目的介绍成人间活体扩大右半肝移植治疗急性肝功能衰竭的临床经验.方法对1例42岁男性急性肝功能衰竭合并肝性脑病Ⅲ期患者行活体扩大右半肝移植治疗.其45岁姐姐为供者,CT评估供者包含肝中静脉的扩大右半肝体积为728.4 cm3(801 g),供肝/受者体重比为1.3%.供肝之肝右、中静脉整形后与受者整形后之肝右静脉行端-侧吻合;供受者门静脉、肝动脉行端-端吻合.供肝胆管整形后与受者胆总管行端-端吻合.结果供、受者手术均成功.供者术后恢复顺利,受者术后8 h恢复意识,14 d后丙氨酸转氨酶、总胆红素等指标首次下降至正常水平.术后16 d曾出现转氨酶明显升高,给予甲泼尼龙1000 mg冲击治疗后恢复正常.随访至今,供受者已健康生存8个月,均未出现胆管、肝动脉及静脉回流等并发症.结论扩大右半肝移植在技术上完全可行,能为成人患者提供足够重量的移植物,尤其对于急性肝功能衰竭患者具有重要意义,术前精确的影像学评估,熟练的肝切除和肝移植技术是确保该类手术成功的关键因素.【总页数】4页(P309-312)【作者】何晓顺;黄洁夫;朱晓峰;胡安斌;王东平;马毅;王国栋;鞠卫强;巫林伟;邰强【作者单位】510080,广州,中山大学附属第一医院器官移植中心;中国医学科学院,中国协和医科大学,北京协和医院肝脏外科;510080,广州,中山大学附属第一医院器官移植中心;510080,广州,中山大学附属第一医院器官移植中心;510080,广州,中山大学附属第一医院器官移植中心;510080,广州,中山大学附属第一医院器官移植中心;510080,广州,中山大学附属第一医院器官移植中心;510080,广州,中山大学附属第一医院器官移植中心;510080,广州,中山大学附属第一医院器官移植中心;510080,广州,中山大学附属第一医院器官移植中心【正文语种】中文【中图分类】R6【相关文献】1.扩大右半肝移植治疗急性肝功能衰竭的观察和护理 [J], 叶海丹;陈雪霞;廖苑;张红霞;李向芝2.超声检查对成人间右半肝活体肝移植桥静脉及其引流区域微循环灌注的动态观察[J], 陈芬;赵齐羽;蒋天安;王伟林;郑树森3.ENBD 治疗成人间活体右半肝移植术后胆漏一例 [J], 张毅;黄建钊;范伟;石承先;张莹;荀欣4.成人间活体肝移植右半肝移植物切取的临床分析 [J], 陶开山;赵青川;窦科峰;Koichi Tanaka5.成人间活体肝移植供体行改良扩大右半肝切除的安全性 [J], 陈拥军;彭承宏;沈柏用;詹茜;邓侠兴;杨卫平;陈皓;申川;严佶祺;万亮;李勤裕;祝哲诚;谢俊杰;程东峰;周光文;李宏为因版权原因，仅展示原文概要，查看原文内容请购买。

肝中静脉及其属支解剖在肝脏外科中的应用

·学术讲座·Academic Lecture·早在1952年Elias 就提出了肝静脉在肝脏外科手术中的重要性,以及在进行部分肝切除时保护肝静脉的必要性。

肝静脉包括肝左、中、右、肝右后静脉和尾状叶静脉,在肝内独立构成肝静脉系统,是肝脏血流的唯一流出通道。

而肝中静脉(middlehepatic vein ,MHV )是左右半肝的分界,其前壁和两侧壁有左内叶和右前叶属支静脉注入,因其特殊的解剖学位置,在半肝切除术及活体肝移植(living donor liver transplantation ,LDLT )中具有重要地位。

1MHV 及其属支的解剖1.1MHV 起源与胆囊床MHV 多起源于胆囊窝附近,部分起源于肝脏左内叶,偶尔起源于右前叶下部,被致密的结缔组织所包绕,沿途收集左内叶和右前叶回流静脉分支,循正中裂走行于肝脏深面约2.6~4.0cm ,于第二肝门处常与LHV 共干后汇入下腔静脉(inferior vena cava ,IVC )肝后段。

罗安定等[1]观察51例肝脏标本发现,96%的MHV 起源于胆囊窝,4%起源于肝脏Ⅳ段。

蔡昌平等[2]通过解剖并观察128例尸体肝脏标本的胆囊窝发现,有12.5%的MHV 及其属支部分或全部突入胆囊床,在胆囊窝内的平均长度为(17.0±5.3)mm 。

MHV 在向第二肝门走行过程中,在距胆囊切迹中点约(41.2±5.7)mm 处由左内叶属支及右前叶属支汇合而成MHV 主干,汇合处的夹角为27.0°±5.3°。

1.2MHV 汇入IVC 的情况肝左、中、右静脉出肝处构成第二肝门,被冠状韧带上层所遮盖。

MHV 汇入IVC 的形式有4种,国内外报道各型差距较大[3-4]。

(1)MHV 与肝左静脉(left hepatic vein ,LHV )共干后汇入IVC ,即Goldsmith 主肝静脉分型Ⅰ型[5],此型最为常见;(2)MHV 单独汇入IVC ,而不与LHV 或肝右静脉(right hepatic vein ,RHV )共干,即Gold ⁃smith 分型Ⅱ型;(3)MHV 与RHV 共干汇入IVC ,即Goldsmith 分型Ⅲ型;(4)MHV 、LHV 、RHV 三者共干后汇入IVC 。

血管移植在活体右半肝移植中应用

血管移植在活体右半肝移植中应用作者：常浩生张金辉赵晋明曹峻来源：《中国保健营养·下旬刊》2012年第11期【关键词】右半肝供肝切除；异体血管于肝中静脉分支断段吻合；异体肝中静脉于下腔吻合现今，重症肝脏疾病患者处于终末期时多应用肝移植手术方式进行治疗，此治疗措施现今已经在三甲级医院广泛应用，但是因为肝源的问题严重影响手术治疗，故众多学者都在研究替代肝源的可能性，Yamaoka等研究人员于1994年第一次开展右半肝LDLT手术治疗，并取得了成功[1]，从此之后众多地区都开展了此手术治疗项目，我国由范上达等[2]研究人员在1996年开展此手术治疗项目，疗效理想。

此治疗为在供肝切开中一般沿肝中线位置切开，必然将肝中静脉切开，右半肝第Ⅴ段血液回流到肝中静脉，在移植中如何解决肝中静脉断端于下腔静脉吻合，我们在2007年6月1日和2008年6月12日对2例患者实施此手术治疗，2例患者血管吻合完成后，均行术中多普勒显示血流通畅，移植肝第Ⅴ段无淤血表现，效果理想，现总结如下。

1病例资料2007年6月1日和2008年6月12日笔者所在医院收治肝病患者2例，所有患者都为男性患者。

例1，年龄31岁，患有乙型肝炎、肝硬化、肝功能衰竭疾病，对患者进行Child分级结果为C级。

例2，年龄57岁，患有肝内胆管结石、肝硬化、肝功能衰竭疾病，进行Child分级同样为C级。

2例患者均由亲属供肝，行右半肝移植术。

2手术方式及术后处理采用显微外科缝合技术，在右半肝灌注时适当修剪肝中静脉分支及肝中静脉断段，一般断面有2个直径约3毫米左右分支，和肝中静脉主干直径0.5厘米左右椭圆型切面，在3.5倍手术放大镜下行异体血管分支于肝中静脉分支吻合，血管主干于肝中静脉断面主干吻合。

术后吻合门静脉，及肝动脉，开放血管后，本研究中2例患者血管吻合完成后，均行术中多普勒显示血流通畅，移植肝第Ⅴ段无淤血。

3讨论Cheng等[3]对200例患者进行B超检查，结果显示约70%的患者为肝左静脉、MHV共干表现，独自流入下腔静脉表现的患者约30%患者。

活体部分供肝获取法

活体部分供肝获取法随着儿童肝移植的兴起和操作技术的日臻完善，在行儿童肝移植手术时，越来越多的肝移植中心采用切取活体的部分肝脏（一般为左外叶）作为供肝。

在行活体部分供肝切取前，有必要对供体行动脉造影以明确供体的血管解剖，在具体手术操作上，与规则性左外叶切除一致。

但有几个需注意的问题。

（1）肝门阻断：行肝左外叶切除时，不宜行肝门阻断，因为这样可以保证不存在热缺血时间，但可预置一阻断管备意外时使用。

切肝时，用蚊式钳钳夹两侧小量肝组织，两侧创面的管道组织同时给予结扎或缝扎。

（2）可以在镰状韧带右侧挤压剩余之肝脏，但切不可挤压用于移植之左侧肝脏。

（3）一般应先游离肝脏，即先剪开左三角韧带、左冠状韧带、镰状韧带，使整个肝左外叶游离后再解剖肝门。

（4）肝动脉处理：解剖出肝门后，往上游离肝动脉，在左肝动脉发出营养左内叶的动脉支的近心端游离左外叶动脉。

由于左内叶通常有足够的侧支血管为其提供动脉血，所以，如果肝动脉左内支不太粗时，可以将其结扎，这样一般不会出现肝左内叶缺血，同时可以获得较长的左外叶动脉。

另外，对起源于胃左动脉的左外叶动脉，必须加以保留。

（5）门静脉的处理：在肝动脉的后方，将门静脉从周围纤维组织中分离出来。

因为门静脉无弹性，分离时必须小心。

门静脉应该保留尽可能长的长度。

（6）肝动脉和门静脉游离完成后，再分离肝左静脉。

在肝左静脉和肝中静脉之间仔细解剖，可将肝左静脉游离出来。

同时可将一脐带线绕过肝左静脉，这样既可以控制但又不阻断肝左外叶的出汗血流（图5-9）。

图5-9 活体部分供肝获取法1. 胆总管2.肝动脉3.门静脉4.肝左静脉（7）肝实质切开一半后，直视下在肝圆韧带的基底部可见到胆管。

要仔细解剖胆管，明确是单独一支胆管还是两支小胆管。

（8）肝创面处理。

两侧肝创面直接缝扎止血后，采用褥式缝合法加强。

但近肝静脉处不可采用褥式缝合，以防肝静脉回流受阻。

肝创面也可以采用纤维胶粘贴。

（9）整个手术过程应维持肝左外叶的正常血流，直至快速将肝动脉、门静脉和肝静脉切断。

超声评估活体肝移植供体肝静脉临床价值的研究

ＬＶＹｈＲＥＮｅＬＡ０ｉＳＺｏｇｈｎＺａ，，ＩＭｅ，Ｕｈｎｚｅ，ＨＥＮＧＲｏｇｉｎｑｎ
（ｅａｔｅｔｆＵｔｓｕｄＤｖｉ，ｈｈｒｆｌｔｄＨｓｉｌｆＳｎＹ－ｅｎｖｒｔＧａｇｈｕ５０３，ｈｎＤｐｒｎｏｌａｏｎｉｓｎｔＴｉＡｉｅｏｐｔｕａｓｎＵｉｓｙｕｎｚｏ１６０Ｃｉｍｒｉｏｅｄｉａａｏｔｅｉ，￣
【ｅｏｄ】ＬｖｎｏｏｖｒａｓｌｔｎＤｎｒＨｅａｉｖｉ；ｌａｏｎＫｙｗｒｓｉｉｇｎｒｉｎｐａｉ；ｏｏ；ｐｔｅＵｔｓｕｄｄｌｅｔｒｎｏｃｎｒ
在活体肝移植术中，为保障移植肝流出道畅通．避免术后确ＭＨＶ属支及ＩＨＲＶ情况。
图２位于近场的ＭＨ７分支．ＶＳ管壁清晰
一
图３位于远场的ＭＨＳＶ８分管壁模糊
综上所述，彩色超声评估活体肝移植供肝肝静脉系统
变异较多，且主干之间无较大有效吻合支［４３］－，所以，术前对行的，与ｃ相比尽管存在远场图像准确率偏低等不足，ｆＴ』供肝肝静脉系统进行详细、全面的评估，有助于术中ＭＨＶ和着超声医生经验的积累。超声检查技术的提高以及超声造是ＩＨＲＶ的取舍，这关系到供体和受体的肝脏血液回流，如处理的逐步应用，其准确率必将进一步提高；且超声具有ｃＴ不当，轻者可造成肝功能异常，严重者会发生小肝综合征，造比拟的优势，如简便、无辐射、可术中及床边扫查等，故走

背驮式肝移植血管并发症的预防及处理

理结合文献一一阐明。
一
发性无功能鉴别。检查方法有多普勒超声、ＴＣＡ、ＭＲＡ和肝动脉造影。当肝动脉血流速度小于４ｍｓ峰值越来越低，脉频谱变低钝，至动脉０ｃ／，动直
血流信号完全消失即可诊断为肝动脉栓塞。据报道
所谓的胆汁瘤。反复败血症常表现为发热、转氨酶轻度升高、白细胞增多、菌培养阳性，及时治疗细不
易发展为肝坏死和脓毒血症。极少数肝动脉栓塞的患者可无任何症状，在常规检查时发现。仅
发性肝脏无功能难以鉴别。迟发性胆漏多发生在术后１周至２个月内，由移植肝胆管缺血性损伤和多坏死所致。此时肝脏已有较多的侧支循环，一般不
统一规范，多以供体和受体下腔静脉的吻合方式而
命名。笔者把Ｔａｉ首次报道的将供体肝上下腔静ｚｋｓ脉与受体肝静脉或共干成型后端侧吻合的肝移植方
式称经典式背驮式肝移植，而其他衍生出的统称为
会出现广泛的肝细胞坏死，但可影响胆管的血供，从
术后２个月内，见于肝动脉吻合处及附近。移植多
广阔的应用前景。报道３ＭＲ对血管并发症诊断ＤＡ率为１０。超声及其他影像学怀疑肝动脉栓塞时，０％应结合临床表现进行血管造影。影像学检查受经验和患者自身条件限制，目前报道诊断标准不一，管血

肝中静脉属支解剖及其在活体肝移植中的意义

ＣＨＩＥＪＮＥＳＯＵＲＮＡＬＯＦＡＮＡＴＯＭＹ１３ｏ２２１Ｖｏ．３Ｎ．００
解剖学杂志
２１００年第３３卷第２期
肝中静脉属支解剖及其在活体肝移植中的意义
张琳周庭永刘呖。钱学华刘本菊王剑华吕发金 △
ｖｎｕｌｏｆｓｇｎｓｍｏｔｙｒｃｒｕａｅｙｍｉｄｅｈｐｔｅｎｅｏｓｂｏｄｏｅｍｅｔｌｗａｓｌｅｉｌｔｄｂｄｌｅａｉｖｉ．ＴｈｄｌｅａｉｖｉｎｉｅｙｐｒｉｉａｅｈＶｃｃｅｍｉｄｅｈｐｔｃｅｎｅｔｒｌａｔｃｐｔｄｔｅ
（．ＤｅａｔｎｆＡｎｔ１ｐｒｍｅｔａｏｏｍｙ，ａｏａｏｙｏｏｅｓｄｃｅｎｏｄｃｅＩｆｒａｉｎ．ＲａｉｌｇＬｂｒｔｒＦｒｎｉＭｅｉｉｄＢｉｆｃｎａｍｅｉｎｒｏｍｔ；２ｉｆｏｄｏｏｙ
４０１￣００６
３装甲兵技术学院门诊部，春长１０１）３１７
（重庆医科大学，１解剖学教研室法医学与生物医学信息研究室，２第供有关肝中静脉属支的形态学资料。方法：采用５Ｏ例无病变成人尸体肝标本进行解剖
３Ｏｕ－ａｉｎｐｒｍｅｔ．ｔｔｅｔＤｅａｔｎ，ＡｒｒｄＭｉｉｒｃｎｑｅＣｏｌｇ，Ｃｈｎｃｕ１０１ｐｍｏｅｌｔｙＴｅｈｉｕｌｅｅａａｇｈｎ３１７，Ｃｈｎ）ｉａ
ＡｂｔａｔＯｂｅｔｅｓｒｃｊｃｉ：Ｔｏｐｏｉｅｍｏｐｏｏｉａａａｏｒｕａｉｓｏｈｄｌｅａｉｅｎｆｒｌｉｇｄｎｒｌｅｒｎｐａ — ｖｒｖｄｒｈｌｇｃｌｔｆｉｔｒｅｆｔｅｍｉｄｅｈｐｔｃｖｉｏｉｎｏｏｉｒｔａｓｌｎｄｔｂｖｖ

活体肝移植后小肝综合征的研究进展

体积和重量。相对可以避免小肝综合征的发生＿】。
认为单独的ＧＲＷＲ＞Ｏ．８％并不能影响生存率。但
不管ＧＲＷＲ是否影响生存率或者ＧＲＷＲ值是多少．移植物大小在小肝综合征的发生中仍起着非常重要的作用。然而在ＬＤＬＴ术中，供体的安全是最为
肝脏穿刺活检。（３）移植物的生理状态。当移植物脂肪程度 ≥３Ｏ％（即中度脂肪变）时，术后移植物发生原发性无功能及功能障碍的可能性明显增加，即使轻度的脂肪变也会影响术后肝功能的恢复＿ｌ５］。因此，ＬＤＬＴ术应优先选择年轻的、ＢＭＩ＜２５ｋｇ／ｍ的供体，且应当保证移植物的生理状态良好，以降低术
２．５其他因素
ＬＤＬＴ术后小肝综合征的发生还可
能受到肝内微循环＿１等因素的影响．目前尚处于探
讨阶段，未达成共识。３小肝综合征的防治
目前，ＬＤＬＴ术后小肝综合征的防治主要包括选择良好的移植物、调控受体门静脉压力和流量以
胞及胆管细胞坏死．从而再次减少有效肝体积。

２－３流出道问题
ＬＤＬＴ流出道重建问题一直备受
后小肝综合征的发生率。
３．１．２移植物的大小有研究表明术前增加供肝

活体肝移植肝静脉重建

Original ArticleImpact of Short Hepatic Vein Reconstruction in Living Donor Adult Liver Transplantation Using a Left Liver Plus Caudate Lobe GraftYasushi Yamauchi, Tomoaki Noritomi, Koji Mikami,1Seiishiro Hoshino, Tetsuo Shinohara,Yoshiaki Takahashi, Nobuhide Matsuoka,2Naotaka Noda, Takafumi Maekawa 1and Yuichi Yamashita,Department of Gastroenterological Surgery, Fukuoka University School of Medicine, 1Department of Surgery,Fukuoka University Chikushi Hospital, and 2Department of Regenerative Medicine and Transplantation, Fukuoka University School of Medicine, Fukuoka, Japan.OBJECTIVE:To investigate the impact of short hepatic vein reconstruction in the transplanted left liver plus caudate lobe graft.METHODS:Six left liver plus caudate lobe grafts used for living donor adult liver transplantation were included in this study. The liver grafts were divided into two groups: those with (V1 group; n =4) or without (control group; n =2) short hepatic vein reconstruction. The changes in the transplanted left lobe (seg-ments II–IV) and caudate lobe were compared between the two groups at 1 month after transplantation.RESULTS:The addition of the caudate lobe increased the graft volume by 15 mL, which corresponded to a 4.3% gain of graft volume at the time of transplantation. Although the graft volume/standard liver volume ratio of the whole grafts after transplantation showed no difference between the two groups, the regeneration rate of the caudate lobe in the V1 group was significantly greater than that in the control group (p =0.04).CONCLUSION:Although no definite advantage from the V1 reconstruction was demonstrated, hepatic vein reconstruction with a significantly-sized short hepatic vein might provide an additional margin of safety for marginally-sized liver grafts during the early phase of graft regeneration. [Asian J Surg 2010;33(1):8–13]Key Words:caudate lobe, left liver graft, liver transplantation, short hepatic vein, venoplastyIntroductionThe large volume of right liver grafts in living donor adult liver transplantation (LDALT) provides a significant ben-efit to recipients, and is thus used most commonly world-wide. However, more extensive hepatectomy imposes a greater surgical risk on living donors.1In contrast, left hemi-hepatectomy has a lower surgical risk for donors, but left liver grafts have a selection restriction for transplantcandidates because they frequently yield small size grafts.To resolve this dilemma, concomitant resection of the caudate lobe (CL) with the left liver (LL) is applied in LDALT to enlarge the graft volume (GV).2Based on the priority basis for living donor safety, LL plus CL grafts have been used routinely for LDALT in our institution.A functional GV in LDALT is dependent largely on ade-quate venous drainage of the liver graft. Hepatic venous outflow block in a marginally-sized liver graft, especiallyin an LL graft, is associated with serious complications such as progressive graft dysfunction and septic compli-cations in a transplant recipient. Therefore, most drain-ing veins should be reconstructed for maximum use of LL plus CL grafts. However, there is no consensus on whether V1 (short hepatic vein) which drains the CL should be reconstructed or not.3Thus, the present study investi-gated the impact of V1 reconstruction in the transplanted LL plus CL graft.Patients and methodsPatients and graftsBetween May 2005 and February 2008, six consecutive LDALTs using LL plus CL graft were performed at our institute. The significantly-sized V1 (>5mm in diameter) that drained the CL was reconstructed in four of these grafts (V1 group). V1 was not reconstructed in the other two grafts (control group) because of a small-sized vein (<5mm in diameter) or the unavailability of an appropri-ate vein graft for venoplasty. The indications for LDALT in those patients were hepatitis C virus cirrhosis with hepa-tocellular carcinoma (n=2), fulminant hepatitis (n=1), primary sclerosing cholangitis (n=1), Wilson’s disease (n=1), and cholestatic liver disease (n=1). Preoperative evaluation for a potential donor graft included laboratory data, abdominal computed tomography (CT), and three-dimensional (3D)-CT angiography. The branching type of the hepatic artery, the portal vein, and the hepatic veins were assessed by 3D-CT angiography. The branching type of the biliary tract was assessed by magnetic resonance cholan-giopancreatography or drip infusion cholangiographic CT.Graft estimationThe standard liver volume (SLV) of the recipient was cal-culated according to the formula of Urata et al.4The pre-dicted volume of the graft in each donor was calculated using the CT volumetric analysis before transplantation. The GV/SLV ratio was then calculated. The actual volume of the liver graft was measured on the back table immedi-ately after procurement. The CT scans obtained from the recipients at 1 month after transplantation were sub-jected to volumetric analysis for the implanted grafts. The CL and other LL segment (segments II–IV) values were each determined with and without V1 reconstruction set-tings. The regeneration rate of the transplanted CL was determined by the following formula: (CL volume 1 month after transplantation—predicted CL volume before trans-plantation)/predicted CL volume before transplantation×100%. The regeneration rate of the LL was calculated in a similar fashion.Surgical techniquesThe donor left hemi-hepatectomy was performed as pre-viously reported.5Although the indication for LL graft procurement with or without the middle hepatic vein (MHV) was based on the dominancy of the hepatic vein, the LL grafts were procured with the MHV. When the MHV trunk was not harvested, during the dissection of the liver parenchyma, MHV tributaries (V4)>5mm in diameter were preserved for vein reconstruction. Likewise, the V1 which drained the CL and was>5mm in diameter, was preserved. Venoplasty of the liver graft was performed on the back table. The trunks of the left hepatic vein (LHV) and MHV were connected to make a single orifice using the septoplasty technique or by a simple continu-ous suture.6If the orifices of V4 or V1 were completely separate and far from the common orifice of the major hepatic veins, the conduit vein and patch vein grafts were used for venoplasty, to create a single wide orifice at the common orifice of the major hepatic veins (Figures 1A and 1B). The conduit vein grafts were obtained from the recipient’s superficial femoral vein, right hepatic vein, great saphenous vein, or cryopreserved venous graft pro-vided by the University of Tokyo Tissue Bank. The distal side of a conduit vein graft was first cut longitudinally and then anastomosed to the orifice of V4 or V1. The prox-imal side of a vein graft was anastomosed half-way around to the posterior border of the common orifice of the major hepatic veins. A circular or redundant (dome-shaped) vein cuff was attached to the common orifice of the major hepatic veins of the graft. All of the sutures were carried out using a continuous suturing technique with 6-0 Prolene (Ethicon Inc., Somerville, NJ, USA).In the recipient, total hepatectomy was performed, leaving the vena cava in the usual manner. The septum between the MHV and LHV was incised to create a com-mon trunk. The single newly-created orifice of the hepatic veins of the liver graft was then anastomosed to this com-mon trunk. The anastomosis was made using a continuous everted mattress or over-and-over suture using 6-0 Prolene (Ethicon Inc.). After reconstruction of the inflow, Doppler ultrasonography was performed to assess thehepatic venous drainage and patency.Statistical analysisStatistical analysis was performed using the Mann-Whitney U test. Data were expressed as the median with range. A p value<0.05 was considered to be statistically significant.ResultsThe predicted median GV of all grafts and the GV/SLV ratio were 361.8mL (277.0–427.0mL) and 31.2% (25.4–34.9%), respectively. Concomitant resection of the CL resulted in a median gain of GV by 4.3% at the time of transplantation. The actual volume of the graft at the back table did not differ from these values (data not shown).Table 1 summarizes the procedure of venoplasty in each donor graft. Single V1s were preserved in four grafts (V1 group). These V1s were all reconstructed concurrently with the major hepatic veins. The preserved V1s had a median diameter of 5.3mm (5.0–8.0mm), and were lo-cated apart from the common orifice of the major hepatic veins by a distance of 27.5mm (20.0–35.0mm).In the V1 group, two grafts connected V1s with the MHV and LHV orifices using the conduit vein grafts to make a single orifice. For the remaining two grafts, al-though the MHV trunk was not harvested, V1s were con-nected with the LHV orifices concurrently with the MHV tributaries (V4s) using branched-type conduit vein grafts. In the control group, the grafts only connected the MHV with the LHV. The conduit vein grafts for the V1 and V4 reconstructions were obtained from recipient’s superficial femoral vein, right hepatic vein, great saphenous vein, Patch vein grafts V1Conduit vein graft(femoral vein)Figure 1.(A) Operative techniques for venoplasty of left liver (LL) plus caudate lobe (CL) graft without the middle hepatic vein (MHV). (B) Intraoperative photograph after venoplasty of a LL plus CL graft without MHV trunk. LHV=left hepatic vein.Vein grafts for venoplasty Cold preservation time (min)Patch vein: recipient PV195or a cryopreserved venous graft kindly provided by the University of Tokyo Tissue Bank. The patch vein grafts attached to the common orifice were obtained from the recipient’s portal vein or great saphenous vein. The median cold preservation time of the liver graft was 184 minutes (142–227 minutes). Hepatic vein waveforms in all of the grafts showed a biphasic or triphasic pattern and graft congestion was not observed immediately after venoplasty.All of the patients survived the operation. No graft was lost because of hepatic venous outflow block after a median follow-up of 12.9 months. There were no compli-cations among the donors. The predicted LL volume and the GV/SLV ratio in the V1 group were 356.9mL (335.5–410.4mL) and 31.5% (29.4–33.6%); the predicted CL vol-ume and GV/SLV ratio were 16.7 mL (12.4–17.4mL) and 1.4% (1.1–1.6%), respectively. At 1 month after transplan-tation, the LL volume and GV/SLV ratio in the V1 group were 836.5 mL (722.4–1243 mL) and 72.3% (63.2–107.1%); the CL volume and GV/SLV ratio were 33.2mL (21.2–57.6mL) and 2.8% (1.9–5%), respectively (Table 2). On the other hand, the predicted LL volume and GV/SLV ratio in the control group were 310.0 mL (265.5–354.5mL) and 26.8% (24.4–29.2%); the predicted CL volume and GV/SLV ratio were 13.6mL (11.0–16.2mL) and 1.2% (1–1.3%), re-spectively. At 1 month after transplantation, LL volume and GV/SLV ratio in the control group were 1073.0mL (774.5–1371.5mL) and 92.1% (71.3–112.9%); the CL volume and GV/SLV ratio were 4.5mL (2.7–6.3mL) and 0.4% (0.2–0.5%), respectively (Table 3).Figure 2 shows the regeneration rate of the trans-planted LL and CL with or without V1 reconstruction settings. The LL volume increased 1 month after trans-plantation in both groups with no significant difference. The regeneration rate of the LL was 138.5% for the V1 group and 239.3% for the control group. On the other hand, the CL exhibited a different pattern of regeneration 1 month after transplantation between the two groups. Namely, the regeneration rate of the transplanted CL in the V1 group was significantly greater than that in the control group (125% for the V1 group and 68.3% for the control group;p=0.04). However, the regeneration rate ofthe whole graft did not differ significantly between the two groups (134.9% for the V1 group and 226.4% for the control group; p≥0.05).DiscussionSmall-for-size graft syndrome after transplantation is a serious problem, especially for marginally-sized liver grafts in LDALT.7,8To overcome this problem, right liver grafts with a larger volume have been introduced and are now used commonly worldwide. However, more extensive hepatectomy poses a greater surgical risk on living donors.1 Recently, the feasibility of left liver grafts for good-risk adult recipients in LDALT has been documented fully, successful results have been reported.9,10To increase the functional volume in the left liver grafts, concomitant resection of the CL with the LL has been devised and has extended the indications for LDALT.2For maximum use of liver grafts without increasing the surgical risk for do-nors, LL plus CL grafts, with or without MHV trunk, are used routinely in our institution. The CL provides a 2–8% gain in left liver graft weight.2,3,5The present data showed that concomitant resection of the CL resulted in a median 4.3% gain in GV at the time of transplantation.Hepatic venous drainage is the most important factor for the success of LDALT. Hepatic venous congestion in a LL graft can lead to a significant decrease in full graft via-bility and regeneration, unless the significantly-sized he-patic veins are reconstructed effectively. The indication for procurement of the MHV with the graft is based on the ram-ification patterns of the MHV, and the relationship between the hepatic venous drainage of the right anterior and the left paramedian (segment IV) sectors. A large part of the left paramedian sector is usually drained through the MHV.11 Thus, preservation of the venous outflow drainage from the left paramedian sector plays an important role in LDALT using the left liver graft. Leaving the MHV with the remnant liver places the left paramedian sector at risk for congestion. In such cases, the significantly-sized MHV tributaries should be reconstructed. In the current series, three MHV tributaries (V4s) were reconstructed effectively in two grafts using the conduit vein grafts.On the other hand, there is no consensus on recon-structing the V1 that drains the CL, and little is known about the fate of the CL after V1 reconstruction. The ini-tial series of LL plus CL grafts had no V1 reconstruction.2,3 These studies have shown that concomitant CL harvest-ing in left liver transplantation results in a modest in-crease in the CL, even if the V1 is not reconstructed. In contrast, the Tokyo group has recommended reconstruc-tion of the V1 that drains the CL.12,13In accordance with our principles, significantly-sized V1 were reconstructed in four grafts to achieve complete drainage of the hepatic veins. The results showed that the transplanted CLs with V1 reconstruction (V1 group) had proportionally regen-erated with the LLs 1 month after transplantation. In contrast, the transplanted CLs without V1 reconstruction (control group) presented poor regeneration (atrophicFigure 2.(A) The regeneration rate of the transplanted left liver and (B) caudate lobe with (V1 group) or without (control group) V1 reconstruction. NS=not significant.change) 1 month after transplantation. One possible rea-son may have been insufficient venous (V1) drainage from the harvested CL in the control group. Ikegami et al3have also shown only a modest increase, but not a decrease in the CL in comparison to other segments for LL plus CL grafts without V1 reconstruction. There may be individual differ-ences in graft regeneration after transplantation, which might result from individual anatomical variation in venous drainage. Couinaud14has reported that some of the CL parenchyma is drained directly into the V1s, and some of that is drained through the major hepatic veins. Therefore, if there is a significantly large V1, it must be reconstructed because a vein of such size is large enough to drain the CL. On the other hand, although the CL with no sizable V1 vein to reconstruct might be drained through the major hepatic vein, such a drainage vein might be not enough to regenerate the CL.Meanwhile, the current data showed no significant dif-ference between the groups for the whole GV (LL plus CL) after transplantation, suggesting that other factors in-cluding graft quality, graft flow, technical issues, recipient conditions, and post-transplant complications might have affected graft regeneration. Although it is difficult to pre-dict its long-term luminal patency after V1 reconstruc-tion, concomitant resection of the CL, with V1 preservation, apparently has some beneficial gain in GV during the early stage of graft regeneration. However, there are technical difficulties associated with V1 reconstruction. As a result of variations in the anatomy of the CL and technical com-plexity, most V1s cannot be preserved without difficulty. Several techniques of outflow reconstruction dealing with recipient hepatic veins and the V1s that drain the CL have been devised.5,12,13,15Sugawara et al12have reported the conjoined reconstruction of the V1 to the MHV-LHV trunk orifice in LL plus CL grafts. Hashimoto et al13have made a large venous reservoir by gathering the LHV, MHV and V1, using a conduit homograft vein. A conduit vein and patch vein grafts for single orifice vein reconstruction of multiple hepatic veins, including V1, have been employed in our institution as an effective means of simplifying graft-to-recipient cava anastomosis and avoiding unfavourable tension in the anastomosis. Furthermore, this technique of using the conduit vein graft should be useful when the distance between the orifice of the V1 and the common orifice of the major hepatic veins is large.In conclusion, concomitant resection of the CL could produce a beneficial gain in GV at the time of transplantation. However, in the present study, no defi-nite advantage, including liver function, was demon-strated clearly after V1 reconstruction, due to the limited number of cases, the volume variability of liver grafts and disease variability in patients. Although the impact of V1 reconstruction on overall graft outcome is still unclear, it might still be important to try to obtain a larger and more effective liver volume to prevent small-for-size syndrome during the early stage of graft regeneration.References1.Sugawara Y, Makuuchi M, Takayama T, et al. Small-for-sizegrafts in living-related liver transplantation. J Am Coll Surg2001;192:510–3.2.Miyagawa S, Hashikura Y, Miwa S, et al. Concomitant caudatelobe resection as an option for donor hepatectomy in adult liv-ing related liver transplantation. Transplantation1998;66:661–3.3.Ikegami T, Nishizaki T, Yanaga K, et al. Changes in the caudatelobe that is transplanted with extended left lobe liver graft from living donors. Surgery2001;129:86–90.4.Urata K, Kawasaki S, Matsunami H, et al. Calculation of childand adult standard liver volume for liver transplantation.Hepatology1995;21:1317–21.5.Takayama T, Makuuchi M, Kubota K, et al. Living-related trans-plantation of left liver plus caudate lobe. J Am Coll Surg2000;190: 635–8.6.Concejero A, Chen CL, Wang CC, et al. Donor graft outflowvenoplasty in living donor liver transplantation. Liver Transpl 2006;12:264–8.7.Ikegami T, Shimada M, Imura S, et al. Current concept of small-for-size grafts in living donor liver transplantation. Surg Today 2008;38:971–82.8.Imura S, Shimada M, Ikegami T, et al. Strategies for improving theoutcomes of small-for-size grafts in adult-to-adult living-donor liver transplantation. J Hepatobiliary Pancreat Surg2008;15:102–10.9.Sugawara Y, Makuuchi M, Kaneko J, et al. MELD score for selectionof patients to receive a left liver graft.Transplantation2003;75:573–4.10.Akamatsu N, Sugawara Y, Tamura S, et al. Regeneration andfunction of hemiliver graft: right versus left. Surgery2006;139: 765–72.11.Nakamura S, Tsuzuki T. Surgical anatomy of the hepatic veinsand the inferior vena cava. Surg Gynecol Obstet1981;152:43–50.12.Sugawara Y, Makuuchi M, Kaneko J, et al. New venoplasty tech-nique for the left liver plus caudate lobe in living donor liver transplantation. Liver Transpl2002;8:76–7.13.Hashimoto T, Sugawara Y, Tamura S, et al. One orifice vein re-construction in left liver plus caudate lobe grafts. Transplantation 2007;83:225–7.14.Couinaud C. The paracaval segments of the liver. J HepatobiliaryPancreat Surg1994;2:145–51.15.Takemura N, Sugawara Y, Hashimoto T, et al. New hepatic veinreconstruction in left liver graft. Liver Transpl2005;11:356–60.。

肝中静脉解剖在活体肝移植中的应用

１２实验设备及仪器．
右半肝切除可能会导致四段的静脉回流障碍。要求术者对肝中静这就脉的解剖结构及其通过影像学治疗充分了解其属支在肝内的走向。
关于肝中静脉与左肝静脉公干的情况，各家报道不一Ｃａ通过ｈｎ超声检测２Ｏ０例患者的肝中静脉发现两者共干者在７％；０刘静等人通过对５例肝脏的解剖发现其二者共干为６．％。２７３本研究发现其二者共干为８％，０可能是由于解剖标本过少而导致的两者共干比例较高。其两者是否共肝影响到活体肝移植的手术选择。两者不共干时，行包含在
【关键词】肝中静脉活体肝移植形态学观测
【图分类号ｌＲ６４中１
【献标识码】Ａ文
【章编号】１７ —０４（００（）０７－１文６４７２２１）１ｈ－０９００
１试验材料１１实验标本．随机选取本单位实验室常规福尔马林固定１以上的成人尸年体肝脏标本，中男性标本ｌ例，性标本５。入标准：脏外其５女例纳肝观及肝门部无破损，肝胆胰脾胃疾病。无
进行半肝的劈离会容易的很多。同时有文献报道，供肝肝中静脉的异常是供体排除标准的重要因素。
将２例（１Ｎ，５）脏标本沿下腔静脉汇入第二肝门充Ｏ男女例肝５
分分离第二肝门部位的肝脏实质，显示第二肝门部位的肝静脉及其分支，其骨骼化。续沿下腔静脉后壁正中剖开管腔，测肝将继观中静脉在下腔静脉的开口部位然后从肝膈面肝中静脉汇入下腔静脉处逆向／，Ｅ解剖，露肝中静脉及其属支，察起源、ｊｂ￣离，ｌ显观走向并分别测量肝中静脉主干及其分支的长度、部的直径等数根

肝移植中基于门静脉重建方案的门静脉血栓分类及处理策略

第９卷第４期２０１８年７月Ｖｏｌ．　９Ｎｏ．　４　Ｊｕｌ．　２０１８器官移植Ｏｒｇａｎ　Ｔｒａｎｓｐｌａｎｔａｔｉｏｎ作者简介：傅志仁，教授、主任医师、博士研究生导师。

现任海军军医大学附属长征医院解放军器官移植研究所所长，兼任中国医师协会器官移植医师分会移植外科技术专委会及上海市　医学会器官移植专科分会主任委员、解放军器官移植专业委员会及中国免疫学会移植免疫分会　副主任委员、中华医学会器官移植学分会及中国医师协会器官移植医师分会常务委员等。

从事肝胆外科３０余年，在各种肝叶段切除、肝癌复杂手术以及肝移植方面拥有丰富的经验。

１９９６年成功实施了国内首例儿童肝移植，保持着国内单次肝移植最长存活记录（２０年）。

承担国家及省部级课题１０余项，以第一或通讯作者发表ＳＣＩ论文１８篇，以第一完成人获得省部级二等以上成果奖励４项，主编或参编专著６部。

【摘要】　门静脉血栓（PVT ）的处理目前仍然是肝移植手术技术方面的一大挑战，复杂的PVT 需要根据血栓的范围、机化及其与血管壁的粘连程度、侧支血管的代偿分流情况等，选择最适合的处理方案，以达到最佳的疗效。

本文提出了一种基于门静脉取栓后血流再通情况和门静脉重建方案的PVT 分类方法,并进一步分析了3类PVT 相应的处理方案。

采用基于门静脉重建方案的PVT 分类，对PVT 患者肝移植的预后具有较为准确的评估价值，可以尝试在临床治疗中推广应用。

【关键词】　肝移植；门静脉血栓；门静脉重建；分类；分流血管；结扎；吻合【中图分类号】R617，R364.1+5　【文献标志码】 A 【文章编号】 1674-7445（2018）04-0001-05肝移植中基于门静脉重建方案的门静脉血栓分类及处理策略滕飞傅志仁DOI: 10.3969/j.issn.1674-7445.2018.04.001基金项目：国家自然科学基金（81470900、81702923）；上海市“科技创新行动计划”医学领域科技支撑项目（15411950403）；海军军医大学精准医学转化应用研究专项（2017JZ50）作者单位：200003　上海，海军军医大学附属长征医院器官移植科解放军器官移植研究所作者简介：滕飞，男，1982年生，博士，主治医师，研究方向为肝癌肝移植的临床与基础，Email ：ﬂyteng5635@ 通讯作者：傅志仁，男，主任医师，博士研究生导师，研究方向为肝胆外科、肝移植，Email ：zhirenf@·述评·肝移植作为终末期肝病最为有效的治疗手段，其疗效已经得到普遍的认可，随着经验的积累和技术的进步，早期一些极为棘手的技术难题如活体肝移植或儿童肝移植中动脉的显微重建、变异血管或胆道的整形处理等已经得到妥善的解决，但门静脉血栓（portal vein thrombosis ，PVT ）的处理在最近10年来进展有限，广泛或者复杂的PVT 仍然是肝移植的相对禁忌证。

肝脏手术中的缝合吻合技术和材料选择专家共识_2008_

指南与共识文章编号:1005-2208(2008)10-0800-03肝脏手术中的缝合吻合技术和材料选择专家共识(2008)中华医学会外科学分会外科手术学学组中图分类号:R6　文献标志码:C 现代的肝脏外科手术,不仅包括简单的局部肝切除术,而且包括半肝切除及肝三叶切除术,甚至肝移植术。

而术中控制出血是肝脏外科手术成功的关键。

手术中需熟练运用正确的缝合和吻合技术及合适的材料方能有效控制术中出血,避免术后出血的发生。

其中肝脏管道与肝创面的处理方法显得尤为重要,直接影响术后出血、胆漏等并发症的发生与否,甚至影响病人的预后。

1　肝外伤的缝合技术1.1　单纯对拢缝合　对于单纯肝实质浅表裂伤,可采用单纯对拢缝合。

彻底清除裂口处凝血块和失活肝组织。

如有断裂的血管和胆管,应予钳夹,220或320人工合成多股编织可吸收缝线(如抗菌薇乔V icryl Plus)结扎或缝扎。

对于肝创缘,以320人工合成多股编织可吸收缝线连同肝包膜一起行间断缝合,缝线距创缘110～115c m,针距110c m,缝线穿过裂口底部,不留死腔。

对于较深的肝裂伤,若裂伤处仍有渗血或周围组织脆弱不能直接缝合,可用钝针用320人工合成多股编织可吸收缝线在距创缘115c m处做与创缘平行的褥式缝合,此后在褥式缝合外侧间断缝合对拢伤口。

1.2　填塞缝合术　适于单纯肝脏挫裂伤,但裂口较深,单纯缝合不能止血;肝组织缺损较多,清除失活肝组织后遗留较大腔隙,对拢缝合困难;各种原因导致病人不能耐受复杂手术。

将填塞物填入肝组织缺损处,再行缝合结扎,以起到止血及防止胆汁渗漏的作用。

填塞物主要包括大网膜、止血海绵及可吸收止血纱布等。

如有可能,最好取带蒂大网膜作为填塞材料,它不仅能消灭死腔,还可让新生的血管长入缺血的肝组织,建立侧支循环。

2　肝切除术中肝静脉的处理随着肝脏大肿瘤切除率的不断提高,涉及肝静脉的处理也随之增加,尤其是第二肝门区域的肿瘤,肝静脉能否妥善处理,是手术成功的关键。

同种异体静脉在活体右半肝肝移植流出道重建中的作用

ｗｒｅｒｓｅｔｅｙａａｙｅｏｅａｕｔｈｔｏｆｏｔｏｅｏｓｕｔｎｏｅｅｒｔｐｃｉｌｎｌｚｄｔｖｌａｅｔｅｍｅｈｄｏｕｗｒｃｎｔｃｉｆＭＨＶｂａｃｓｇｃｏｒｓｒｅｅｎａｌｇｎｉｏｖｌｆｒｏｒｎｈｕｉｒｐｅｅｖｄｖｉｏｅｅｃｎｙｌｈｍｏｒｆｎｈｆｃ．ＲｅｕｔＡｌｏｈｏｏｎｅｉｉｎｓｒｃｖｒｄｓｏｈｙａｔｒｏｅａｉｎｗｔｏｔａｙｃｍｐｉａｉｎ．ｏｇａｔａｄｔｅｅｅｔｓｓｌｓｌｆｔｅｄｎｍａｄｒｃｐｅｔｅｏｅｅｍｏｔｌｆｐｒｔｉｕｎｏｌｔｓｅｏｈｃｏ
ｈｐｔｉＢＭｅｏＴｅｃｎａｄｔｏｐｔｎｓｒｃｉｉ — ＬＬｓｇｒｈｂｒｆｗｔｏｔｉｄｅｈｐｔｅＭＨ）ｅａｔ．ｔｄｈｌｉｌａａｆａｅｔｅｅｎＡＡＤＴｕｉｇｔｏｅｇａｉｕｍｄｌｅａｃｖｉｉｓｈｉｃ３ｉｖｇｎｉｌｔｈｉｎ（Ｖ
【摘要】目的探讨在乙型肝炎（乙肝）相关性肝癌患者成人间行活体肝移植中，采用冷冻同种异体静脉行肝脏流出道重建的可行性及安全性。方法回顾乙肝相关性肝癌成人患者中３例不含肝中静脉的右半肝移植活体肝移植资料，分析手术中采用冷冻同种异体静脉行肝中静脉分支血管重建的方法及效果。结果供者和受者术后均恢复顺利，并发症发生；无随访ｌ８个月，重建静脉流出道血流正常，元血栓、狭窄等并发症发生。结论采用冷冻同种异体静脉行肝脏流出道重建是安全可靠的，它既可保证供者的安全，又可避免小肝综合征的发生，从而使活体右半肝移植成为安全的手术。【关键词】活体肝移植；冷冻同种异体静脉；出道重建流

肝脏移植技术的最新发展与应用

肝脏移植技术的最新发展与应用近年来，随着医疗技术的不断进步，肝脏移植技术也在不断发展。

本文将介绍肝脏移植技术的最新发展与应用。

一、背景介绍肝脏移植是一种治疗严重肝病的有效手段。

在过去的几十年中，肝脏移植已经成为一项成熟的临床技术，并被广泛应用于临床。

但是，在很长时间里，供体数量有限一直是制约肝脏移植发展的主要因素。

二、活体肝移植1. 活体肝移植活体肝移植是指从亲属或无关人士中选择出合适的健康捐赠者，获取部分健康肝脏进行移植手术。

这种方法极大地解决了供体数量不足问题，同时也提高了手术成功率。

2. 双排列动静脉吻合双排列动静脉吻合是活体肝移植中常用的一种方法。

传统上，采用单排列动静脉吻合会导致动静脉压力不均，增加了手术的难度。

而双排列动静脉吻合可以更好地保持动静脉压力平衡，提高了术后肝功能恢复的效果。

三、脑死亡供体器官捐献1. 脑死亡供体器官捐献脑死亡供体器官捐献是指将脑部功能不可逆转的患者作为供体，通过器官移植进行救治。

这种方法可以从一个供体中获取整个肝脏，相比于活体肝移植，手术风险更低。

2. 器官冷贮保存技术为了保证捐献肝脏的质量，器官冷贮保存技术被广泛应用于肝脏移植中。

这种技术可以延长肝脏在离体条件下的存活时间，减少移植过程中的缺血再灌注损伤。

四、微创手术技术随着医学技术的进步，微创手术技术也被引入到肝脏移植中。

1. 腔镜辅助下的肝脏切除术腔镜辅助下的肝脏切除术是一种微创手术技术，可以减少对患者的伤害，缩短手术恢复时间。

通过腹部小切口进行手术，在视觉上更便于操作。

2. 机器人辅助下的肝脏移植机器人技术在肝脏移植中也有广泛应用。

机器人手术系统可以提供精确的运动控制和立体视觉效果，使得手术具有更高的安全性和操作性。

五、免疫抑制治疗1. 免疫抑制治疗免疫抑制治疗是由于异体器官移植后会出现排斥反应而采取的强迫性药物干预措施。

随着医学技术的发展，免疫抑制治疗逐渐从广谱化向个体化转变。

目前能够根据受者个体对不同药物敏感性进行分析和检测，在此基础上合理调整用药方案，提高了移植肝存活率。

肝移植围手术期门静脉血栓管理的研究进展

肝移植围手术期门静脉血栓管理的研究进展
吕少诚;贺强
【期刊名称】《器官移植》
【年(卷),期】2024(15)1
【摘要】门静脉血栓是肝硬化的常见并发症之一,其发生率随着疾病的发展而增加。

门静脉血栓的发生发展与多种因素有关,抗凝治疗的指征仍需进一步研究探索。

门
静脉血栓目前已不再认为是肝移植手术的禁忌,但是复杂的门静脉血栓会增加肝移
植围手术期风险,如何恢复门静脉系统血流是临床手术方案决策的难点,合理的术前
分型、手术规划和门静脉重建方式是保障肝移植受者远期良好预后的关键。

本文就门静脉血栓的流行病学现状、危险因素、分型与鉴别,肝移植术前门静脉血栓管理
和术中处理,以及门静脉血栓对肝移植结局的影响进行综述,为肝移植围手术期门静
脉血栓的管理提供参考。

【总页数】7页(P26-32)
【作者】吕少诚;贺强
【作者单位】首都医科大学附属北京朝阳医院肝胆外科
【正文语种】中文
【中图分类】R617;R364.15
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内蒙古医学杂志ＩｎｒＭｏｇｆｄＪ２１年第４ｎｅｎｏａＭｅ０１ｉ３卷第７期
８２７
成人供受体的体内有着极相似或相同的血管变异，是进行活体肝移植及静脉重建的有利前提。２肝中静脉的取舍在活体肝移植中肝中静脉应该保留在供者的左肝还是在植入受体的右肝内，也是目前活体肝移植中讨论的热点话题。如果供体中包含肝中静脉可能会导致供肝者的肝脏回流障碍，果不包含肝中静如脉可能会导致供肝体积过小。现一般认为包括肝中
脉（ｉｆｒｒｅｔ（ｖｓＶ ’ ｎｅｉｎｓ：ｅ，Ｉ（）ｏｖａ节杆研究发现在
的活体肝移（分第 Ⅳ段加Ｖ、 Ⅶ、段，部 Ⅵ、 Ⅷ 包括肝中静脉）：９６年由香港的Ｆｎ等【成功完成１９ａ２Ｊ了。对于｜厂体肝移ｎ而言，活体供肝肝源相对较多，很大程度上降低＿ｆ子待供肝的时间，以早期ｒ望彳等可手术从而挽救更多ｎ生命。虽然移植物的体积可能偏小，但可ｊ｝先保证移植物的质量，这是活体肝移植的优势，吲时也要看到活体肝移植要牺牲另但个人的健康，旌ｆ能存在生命危险，世界有过报全道，供体死１牢（５，１Ｏ、．１ ‰ ～．‰ ｊ右半肝移植ｌ。物是使用最的移｛部位，就其是否应切取供体但的肝中静脉（Ｉｉｈｈｐｔｅ，ＭＨＶ）移植时ｌｄｅａｉｖｉｌｄｃｎ和
Ｒｅｏｎｎ２０，３（）３３—３９ｓｒｍｕ，０５３３２：８Ｃ８．［］ＢｎｌＬ，ｉｇｅｏＢｎｌＣＤ．ｈｕａｖｖｒｎｔｍｒ９ｉｇｅＳｎｌｎＶ，ｉｇｅＴｅｐｔｔｅｏａｉｕｏｔｉａ
ｔｐｓｒｉｅｅｔｓａｅｉｌａｉｓｆｒｉｍａｋｒｔｄｅ［］ｙｅｅｄｆｒｎｅｓ：ｍｐｉｔｎｏｒｅｕｓＪ．ａｆｉｄｃｏｏｂｓｉ
Ｐｏｄ２０，（２：２２ＬｓＭｅ，０８５１）ｅ３
【５Ｈｕｔｅ，ｕｔ，ｉａＪｅＳｒｍ４ｃｎｅｔｔｎ１ＪｈｉｎＭＳｉｅＰＨｉｓ，ｔａｎｉｓ１ｅｕＨＥｏｃｎｒｉａｏ
［］ＣａｓＡ，ａ，ｔｄｌＡ．ｈｖｌｉｆａｇｎｔｃｓ８ｌｕｓＬＬｊｈＬｍｗａＴｅｅｏｕｏｏｅｅｉｌｕｌｔｎｃｏｅｃｄｎｍａｅｉｅｐｏｅａｅｉｈｂｔｒ［］ＢｏｈｍｉｐｙｎｏｉｇｓｌｓｒｒｔｉｓｎｉｉｓＪ．ｉｅＢｏｈｓｌｎｎｏｃ
ｏｅｅｖｒｘｒｓｄｉｖｒｎｃｒｉｍａ［］ｅｅ１９，３ｆｎｓｅｅｐｅｅｏａａｃｏｓＪ．Ｇｎ，９９２８ｇｏｓｎｉａｎ
（）３５８．２：７ —３５
［３ｒｐｉＶｏｒｔｎＨＩｎ，ｔ．ｍａｐｉｙｉｐｏ１］ＤａｋｎＲ，ｎＨｏｓｅＨ，ｙｅａＨｕｎｅｉｄｍｒ— １ｄｓ
【６ＭｏｔｇａａＧＬｐｉＥＤｎｅＭ，ｔ．Ｕｓｆｎｓｆｓｒｍ１Ｍｎａｎｎ，ｉｐ，ａｓ，ｅａＪ１ｅｕｅｓｏｅｕｌ
Ｈ４ｉｅｄｍｅｒｔｙｔ［］ｒｉｏｒａｏａｃｒ２０，ＥｎｎｏｔｉｉｃｓＪ．ＢｔｈＪｕｎｆＣｎｅ，０９ｏｃｓｉｓｌ
ｍａｋｒｅｅＨ（Ｄ２，ｉｅｐｅｓｄｉｏｌｔｓｅｄｒｅｇｎＥ４ＷＦＣ）ｓｘｒｓｎｎｍａｉｕｓａｅｓｎ
ｕｄｒｏｓｃｍｐｅａｔｒａｉｅｓｌｉｇｔｉｌｌｉｌｒｔｉｎｅｇｅｏｌｘｌｅｎｔｐｉｎｏｙｅｄｍｕｔｐｅｐｏｅｎｖｃ
Ｇｎ，９９２９１）１１—１８ｅｅ１９，２（ —２：００．
【７１］张文辉，少强．清ＨＥ吴血４检测在腹腔肿瘤诊断中应用价值研究［］中国卫生检验杂志．００２（）１５ —１１．Ｊ．２１，０６：４２５６［８１］张海荣，高荣凯．子宫腺肌症和子宫肌瘤患者血清Ｈ４测定的Ｅ意义［］人民军医，０９５（２：１２Ｊ．２０。２０）００．
ｔｉ４Ｈ４ｓａｓｃｅｅｌｃｐｏｅｉｔａｉｏｅｅｐｅｓｄｂｅ（Ｅ）ｉｅｒｔｄｇｙｏｒｔｈｔｓｖｒｘｒｓｅｙｎｎ
［稿日期］２１一Ｏ —１收０１３４［者简介］张雅（９３一）女，古族，作１８，蒙内蒙古呼和浩特市人。在读硕士研究生。
ｄｆｅｅｔｔｓｍａｉｎａｔｏａｉｎｔｍｏｒｒｍｖｉｎｏｔｉｉｆｒｎｉｅｌａｇｎｖｒａｕｕｓｆｏｏａａｅｄｍｅｒ— ｒｎ
ｉｆｒ［］Ｏｎｏｅｅ２０，１１）２６ｓｏｍｓＪ．ｃｇｎ，０２２（７：７８—２７．ｏ７３［０ｌａｏＭＴＨａｔｎＧ，ｒｒｏＦＪ．ｏｒｈｎｉａ１］Ｇａｎ，ｍｐｏＭＦｉａｎＨｒＣｍｐｅｅｓｅａｌｇｅｖｎ —
ｄｎｒｌｅｒｎｐａｔｔｎ于１９ｏｏｖｒｔｓｌａｉ，ＩＴ）ｉａｎｏＤＩ９３年在日本成功完成ｌ世界首例成人间采用扩大右半肝 ¨；
受体ＭＨＶ的重建仍没有统一的准则，就此作一现综述。
８６２
（１：３Ｐｔ）２３—２２４
内蒙古医学杂志ＩｎｒｎｏｉＭｅ２１年第４ｎｅｇｌｄＪ０１Ｍｏａ３卷第７期
ｓｒｕｎｈｏｔｏｄｏａｉａｃｏｓＪ．ＣｎｅＲｅ。ｅｏｓａｄｅｄｍｅｒｌｖａｃｒｉｍａ［］ｉｒｎｎａｃｒｓ２０，５６：１２—２６．０５６（）２６１９【４ｏｄＭ，Ｕｇｒ，ＢｙｌＫｂＫａｏｅＥｏｄＮ，ｅａＪＳｌｌＯｖｉａｃｏｕ＋ｒｎａａｃｒｉｍａｓｂｎ
１：４０１５８．
［］ＭｏＰｔｏ，０６１（）８７—８３Ｊ．ｄａｈｌ２０，９６：４５．［１１］ＷａｇＫ，ＡＮＬＪｆｒＹＥｅＭｏｉｒｇｇｎｘｒｓｎｎＧ，ｅｆ，ｔａｅｌｎｔｉｅｅｅｐｅｉｏｎｓｏｐｏｉｈｎｅｖｒｎｃｒｉｏｓｓＤＮｍｃａｒｙＪ．ｒｆｅｃａｇｓｎｏａｉｃｍａｉｅＡｉｒｒａ［］ｌｉａａｎｕｎｇｏ
［图分类号］５．［献标识码］中Ｒ６７３文Ａ［文编号］１０９１２１）７０２ —３论０４０５（０１０．８６０
供体器官短缺一直是全世界肝移植所面临的共同难题。随着移植受体的增多，体紧缺问题日益供突显。为了缓解这种情况，Ｏ世纪末活体肝移植应２运而生。世界上苗例成人间活体肝移植（ｉｉ１ｎｖｇ
［２ＳｈｍｍｅＮｗＶ，ｕａｎｒＥｅａ．ｏ — ｐｒｔｅｈ — １］ｃｕｒＭ，ｇＢｍｇｒｅ。ｔ１ｃｍＲａａｉｙｖ
ｂｉｉａｉｎｏｎａｒｙｏ１．０ｏａｉｎｅｒｄｚｔｏｆａｒａｆ２５０ｖｒａＤＮＡｏｈｉｃｖｒｓｆｒｔｅｄｓｏｅｙ
１肝中静脉的解剖研究
ＭＨＶ多数起源于胆囊窝附近，由左、两支汇右合而成，引流范围主要是肝左内叶和右前叶，也可能引流右后叶的肝前下缘和右前下角， Ⅳ、 Ⅷ 即Ｖ、段＿。刘静、忠华等＿进行厂５６Ｊ李７Ｊｏ多例标本的解剖研究，现肝巾静脉与肝左静脉合干者占发６．％．７３ＭＨｖ与肝短静脉引流肝右后下叶者约为７７左外叶下段肝静脉也汇入ＭｔＶ，。％，｛ＭＨＶ由左外叶下段支、内支、左右时艾汇合而成。Ｃｅｇｈｎ等［运用超声对２０例病人体内ＭＨ和左肝静脉ｊ０Ｖ（ｆｈｐｔｅｎ．１ｔｅａｉｖｉ，ＩｅｃＨＶ）的解剖研究发现，者共干两者占７％，中静脉（１ｆｍｅｉｆｌ，０左ｅｔｄａＶＩＭＶ）入ｎＨ，Ｉ流ＭＨＶ者占７有３％患各自独流入Ｉ腔静％，（）