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肾门静脉吻合术作为肝移植术后门静脉血栓形成的一种挽救技术。

Renoportal anastomosis as a rescue technique in postoperative portal thrombosis in liver transplantation.

作者信息

González-Pinto I M, Miyar A, García-Bernardo C, Vázquez L, Barneo L, Cortés E, Díaz P, Gutiérrez N, Fernández L, Moreno M

机构信息

Hospital Universitario Central de Asturias, Celestino Villamil, Oviedo, Spain.

出版信息

Transplant Proc. 2009 Apr;41(3):1057-9. doi: 10.1016/j.transproceed.2009.02.026.

Abstract

Renoportal anastomosis has been used as the primary portal revascularization technique in grade 4 portal thrombosis, but never after posttransplant portal thrombosis. A cirrhotic patient with hepatocellular carcinoma and partial portal thrombosis of two-thirds of the lumen was transplanted. The thrombus was removed and good portal flow obtained upon reperfusion (2.8 L/min). On the ninth postoperative day Doppler ultrasound revealed complete portal thrombosis extending from the splenomesenteric confluence. At emergency reoperation, we removed the newly formed thrombus. Portal vein branches were flushed with heparin and urokinase. After reconstruction of the anastomosis, we achieved a flow of 1.1 L/min. Rethrombosis occurred again on day 13. At reoperation, thrombus was removed again. However, this time portal flow was not recovered, due to hepatofugal flow associated with both the presence of collaterals and pancreatic edema. A left renoportal anastomosis was performed using an interposed iliac vein graft. A catheter was placed into the portal vein through a recanalization of the umbilical vein of the graft. After urokinase perfusion, portal inflow was 1.7 L/min. The postoperative course was satisfactory, with progressive normalization of liver tests and no further thrombosis. Persistent ascites improved with treatment. Angiography on day 41 showed good portal flow from the renal vein, with uniform distribution within the liver. A renoportal anastomosis can be useful for recovery of liver failure after posttransplant portal thrombosis, in the absence of portal flow.

摘要

肾门静脉吻合术已被用作4级门静脉血栓形成的主要门静脉血运重建技术,但在移植后门静脉血栓形成后从未使用过。一名患有肝细胞癌且三分之二管腔部分门静脉血栓形成的肝硬化患者接受了移植。血栓被清除,再灌注时获得了良好的门静脉血流(2.8升/分钟)。术后第9天,多普勒超声显示门静脉完全血栓形成,从脾肠系膜汇合处延伸。在急诊再次手术时,我们清除了新形成的血栓。门静脉分支用肝素和尿激酶冲洗。重建吻合术后,我们获得了1.1升/分钟的血流。第13天再次发生再血栓形成。再次手术时,血栓再次被清除。然而,这次由于存在侧支循环和胰腺水肿导致的肝外血流,门静脉血流未能恢复。使用一段髂静脉移植物进行了左肾门静脉吻合术。通过移植物脐静脉再通将导管置入门静脉。尿激酶灌注后,门静脉流入量为1.7升/分钟。术后过程令人满意,肝功能检查逐渐恢复正常,未再发生血栓形成。持续的腹水经治疗后有所改善。第41天的血管造影显示肾静脉有良好的门静脉血流,在肝内分布均匀。在没有门静脉血流的情况下,肾门静脉吻合术对于移植后门静脉血栓形成后肝衰竭的恢复可能有用。

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