Lee SungGyu, Park KwangMin, Hwang Shin, Kim KiHoon, Ahn ChulSoo, Moon DukBok, Joo JungWoo, Cho SungHoon, Oh KiBong, Ha TaeYong, Yang HyunSeong, Choi KyuTaek, Hwang KyuSam, Lee EunJoo, Lee YoungSang, Lee HanJoo, Chung YoungHwa, Kim MyungHwan, Lee SungKoo, Suh DongJin, Sung KyuBo
Department of General Surgery, Division of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea.
J Hepatobiliary Pancreat Surg. 2003;10(1):16-25. doi: 10.1007/s10534-002-0789-5.
BACKGROUND/PURPOSE: A left lobe graft from a small donor will not usually fulfill the metabolic demands of a larger recipient in adult-to-adult living-donor liver transplantation (LDLT). One solution to this problem is to use a right lobe graft. However, the necessity of middle hepatic vein (MHV) outflow drainage from the anterior segment (AS) of a right lobe graft has not yet been clearly described in the literature. From July 1997 to February 1998, five right lobe grafts without MHV outflow drainage were implanted in five adult recipients. The graft weights ranged from 650 to 1000 g, and their volumes ranged from 48% to 83% of the ideal liver mass of the recipients. Two grafts showed severe congestion of the AS immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction in each patient postoperatively. Eventually, one patient died of sepsis, on posttransplant day 20, demonstrating progressive hepatic dysfunction.
Subsequently, since March 1998, 176 of 208 adult recipients who received a right lobe graft, while demonstrating sizable (greater than 5-mm diameter) MHV tributaries underwent reconstruction of MHV outflow drainage, using the recipient's own autogenous or cryopreserved cadaveric interposition vein grafts.
In 170 of the 176 recipients, AS congestion was not demonstrated on enhanced liver computerized tomography (CT) or Doppler ultrasonography (USG) postoperatively, and the patency rate of interposition vein grafts was 96.6% on day 30 posttransplant.
A right lobe graft without MHV outflow drainage might result in severe congestion of the AS, which could lead to the patient's death in an extreme situation. Preservation of MHV outflow drainage in a right lobe graft is possible by two harvesting methods: an extended right lobe (ERL)graft, in which the MHV trunk is included in the graft, and a modified right lobe (MRL) graft, in which venous tributaries of the MHV are reconstructed via interposition vein grafts into the recipient's hepatic venous system. From the viewpoint of donor safety, the ERL graft increases the donor's risk more than the MRL graft, because the remaining left liver lobe of the donor does not possess an MHV. Here, we introduce our experiences of MRL grafts in adult-to-adult LDLTs.
背景/目的：在成人活体肝移植（LDLT）中，来自小供体的左叶移植物通常无法满足较大受体的代谢需求。解决这一问题的一种方法是使用右叶移植物。然而，右叶移植物前段（AS）的肝中静脉（MHV）流出道引流的必要性在文献中尚未得到明确描述。1997年7月至1998年2月，五例无MHV流出道引流的右叶移植物被植入五例成年受体。移植物重量在650至1000克之间，其体积为受体理想肝脏质量的48%至83%。两例移植物在再灌注后立即出现AS严重充血，随后每名患者术后出现长期大量腹水和严重肝功能障碍。最终，一名患者在移植后第20天死于败血症，显示肝功能进行性恶化。
随后，自1998年3月起，在208例接受右叶移植物的成年受体中，有176例显示有较大（直径大于5毫米）的MHV属支，使用受体自身的自体或冷冻保存的尸体间置静脉移植物进行MHV流出道引流重建。
176例受体中的170例在术后肝脏增强计算机断层扫描（CT）或多普勒超声检查（USG）中未显示AS充血，间置静脉移植物在移植后第30天的通畅率为96.6%。
无MHV流出道引流的右叶移植物可能导致AS严重充血，在极端情况下可能导致患者死亡。通过两种切取方法可以保留右叶移植物的MHV流出道引流：一种是扩展右叶（ERL）移植物，其中MHV主干包含在移植物中；另一种是改良右叶（MRL）移植物，其中MHV的静脉属支通过间置静脉移植物重建进入受体的肝静脉系统。从供体安全的角度来看，ERL移植物比MRL移植物增加了供体的风险，因为供体剩余的左肝叶没有MHV。在此，我们介绍我们在成人对成人LDLT中使用MRL移植物的经验。
