Karademir S, Astarcioglu H, Ozbilgin M, Ozkardesler S, Yilmaz T, Akarsu M, Akan M, Ozzeybek D, Obuz F, Astarcioglu I
HPB and Liver Transplantation Study Group, Dokuz Eylul University Hospital, Inciralti, Izmir, Turkey.
Transplant Proc. 2006 Dec;38(10):3582-4. doi: 10.1016/j.transproceed.2006.10.043.
Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial.
Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 +/- 6, 16 +/- 4, 18 +/- 7), graft weight (817 +/- 181, 838 +/- 152, and 855 +/- 159 g), and graft/ideal liver weight ratio (0.54 +/- 0.12, 0.57 +/- 0.13, and 0.57 +/- 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21.
Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 +/- 8.14) was significantly higher than in the minor ligatation group (29.6 +/- 8.6) but not in the major reconstruction group (33.7 +/- 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 +/- 0.18), which was significantly better than the major reconstruction (2.7 +/- 0.1) but not the major ligation (3.1 +/- 0.14) cohorts (P = .02 and P = .13).
In this study of a limited number of cases, right-lobe liver grafts with GRWR of > or =1.1% displayed optimal graft function without additional venous reconstruction to the AS.
在右叶肝移植中若不将肝中静脉（MHV）纳入移植肝，肝前段（AS）的静脉引流一直是个问题。对于移植肝的存活和功能而言，AS额外静脉重建的有效性和必要性仍存在争议。
自2002年2月起，将57个右叶肝移植植入成年受者体内。移植肝与理想受者体重比（GRWR）的平均值为1.3%（最小值：0.8%，最大值2.1%）。所有直径小于5mm的汇入MHV的小静脉分支均予以结扎。MHV分支的处理分为三组：（A）无主要分支（n = 33）；（B）主要分支结扎（n = 11）；（C）主要分支重建（n = 13）。重建采用血管移植物（PTF，n = 8；尸体血管，n = 2）或与右肝静脉开口吻合（n = 6）。三组在年龄、性别、终末期肝病模型评分（MELD）（分别为17±6、16±4、18±7）、移植肝重量（分别为817±181、838±152和855±159g）以及移植肝/理想肝脏重量比（分别为0.54±0.12、0.57±0.13和0.57±0.1）方面具有同质性。我们在术后第4天（POD4）和第21天（POD21）调查了腹水体积、血清胆红素、白蛋白、肝酶水平以及国际标准化比值（INR）。
2例患者在初次移植肝功能恢复后分别于POD18和POD23死于耐甲氧西林金黄色葡萄球菌败血症（MELD：24和28）。他们的移植肝重量分别为800g和980g，体积分别为受者理想肝脏体积的47%（B组）和62%（A组）。1个PTF血管移植物和另1个尸体血管移植物在植入后4天和7天被发现堵塞，但未产生任何不良后果。在6个月的随访中，其余55例患者的移植肝存活。除2例早期堵塞外，血管重建均通畅。在三组中，POD4时未发现显著差异。移植后三周，主要结扎组的平均谷草转氨酶（AST）水平（46.7±8.14）显著高于次要结扎组（29.6±8.6），但与主要重建组（33.7±3.7）无显著差异（P = 0.03和P = 0.29）。次要结扎组后的平均白蛋白水平最高（3.2±0.18），显著优于主要重建组（2.7±0.1），但与主要结扎组（3.1±0.14）无显著差异（P = 0.02和P = 0.13）。
在这项有限病例数的研究中，GRWR≥1.1%的右叶肝移植在未对AS进行额外静脉重建的情况下显示出最佳的移植肝功能。
