Vieira de Melo P S, Miranda L E C, Batista L L, Neto O C L F, Amorim A G, Sabat B D, Cândido H L L, Adeodato L C L, Lemos R S, Carvalho G L, Lacerda C M
Department of Surgery and Liver Transplantation, Oswaldo Cruz University Hospital, University of Pernambuco, Recife City, Pernambuco State, Brazil.
Transplant Proc. 2011 May;43(4):1327-33. doi: 10.1016/j.transproceed.2011.03.061.
Orthotopic liver transplantation is a widely used procedure for the treatment of irreversible liver diseases for which there is no possibility of medical treatment. When this procedure is performed by the conventional technique, the retrohepatic vena cava is removed along with the native liver. The inferior vena cava (IVC) remains clamped until the revascularization of the graft, and in this period there is a reduction in the venous return, which may induce a fall by up to 50% in the cardiac output with hemodynamic instability and a fall in renal perfusion pressure. The use of a portal-femoral-axillary venovenous bypass system, in which the blood from the femoral and portal veins returns to the heart via the axillary vein propelled by a centrifugal pump, is intended to minimize the effects of the IVC clamping. In the piggyback (PB) technique, the native liver is removed and the IVC of the recipient is preserved and only partially clamped. We have employed both techniques without the use of venovenous bypass for 10 years. The objective of this study was to compare the results obtained from the use of the two techniques.
A retrospective analysis was performed of 195 patients transplanted between 1999 and 2008: 125 by the conventional technique and 70, the PB technique. The intraoperative parameters were analyzed (surgical time, ischemia time, use of blood products, and diuresis), as well as intensive care support (duration of stay in intensive care unit and use of vasoactive drugs), period of intubation, length of hospital stay, renal function, graft function, postoperative complications, retransplantation, and patient survival.
The PB group showed a reduction in surgical time, warm ischemia time, the use of packed red blood cells concentrates, and fresh frozen plasma, as well as mortality at 30 days (P<.05). There were no differences in relation to cold ischemia time, intraoperative diuresis; length of stay and use of vasoactive drugs in the intensive care unit; the period of intubation; the duration of hospital stay; the renal function; the graft function; the need for reoperation; the incidence of sepsis, biliary complications, vascular complications; need for retransplantation; and 1-year mortality. The cumulative survival rate at 1 year was significantly better among the PB patients.
Orthotopic liver transplantation can be performed without venovenous bypass with good results, using either the conventional technique or the PB technique. Provided that there is no technical contraindication and a long ischemia period is not foreseen, the PB technique should be the technique of choice.
原位肝移植是一种广泛应用于治疗无法通过药物治疗的不可逆肝脏疾病的手术。当采用传统技术进行该手术时，肝后腔静脉会与病肝一同被切除。下腔静脉（IVC）在移植肝血管重建完成前一直处于钳夹状态，在此期间静脉回流减少，这可能导致心输出量下降高达50%，出现血流动力学不稳定以及肾灌注压降低。使用门静脉 - 股静脉 - 腋静脉静脉转流系统（即来自股静脉和门静脉的血液通过离心泵推动经腋静脉回流至心脏）旨在将IVC钳夹的影响降至最低。在背驮式（PB）技术中，病肝被切除，受体的IVC得以保留且仅部分钳夹。我们已经在不使用静脉转流的情况下应用这两种技术长达10年。本研究的目的是比较使用这两种技术所获得的结果。
对1999年至2008年间接受移植的195例患者进行回顾性分析：其中125例采用传统技术，70例采用PB技术。分析了术中参数（手术时间、缺血时间、血制品使用情况及尿量）以及重症监护支持情况（重症监护病房住院时间及血管活性药物使用情况）、插管时间、住院时间、肾功能、移植肝功能、术后并发症、再次移植及患者生存率。
PB组在手术时间、热缺血时间、浓缩红细胞悬液及新鲜冰冻血浆的使用量以及30天死亡率方面均有降低（P<0.05）。在冷缺血时间、术中尿量、重症监护病房住院时间及血管活性药物使用情况、插管时间、住院时长、肾功能、移植肝功能、再次手术需求、败血症、胆道并发症、血管并发症发生率、再次移植需求及1年死亡率方面无差异。PB组患者1年累积生存率明显更高。
原位肝移植无论采用传统技术还是PB技术，均可在不使用静脉转流的情况下取得良好效果。若不存在技术禁忌且预计不会出现长缺血期，PB技术应作为首选技术。
