Schmitz Volker, Schoening Wenzel, Jelkmann Ines, Globke Brigitta, Pascher Andreas, Bahra Marcus, Neuhaus Peter, Puhl Gero
Department of General, Visceral and Transplantation Surgery, Charite, Campus Virchow, Berlin, Germany.
Hepatobiliary Pancreat Dis Int. 2014 Jun;13(3):242-9. doi: 10.1016/s1499-3872(14)60250-2.
Originally, cava reconstruction (CR) in liver transplantation meant complete resection and reinsertion of the donor cava. Alternatively, preservation of the recipients inferior vena cava (IVC) with side-to-side anastomosis (known as "piggyback") can be performed. Here, partial clamping maintains blood flow of the IVC, which may improve cardiovascular stability, reduce blood loss and stabilize kidney function. The aim of this study was to compare both techniques with particular focus on kidney function.
A series of 414 patients who had had adult liver transplantations (2006-2009) were included. Among them, 176 (42.5%) patients had piggyback and 238 had classical CR operation, 112 (27.1%) of the patients underwent CR accompanied with veno-venous bypass (CR-B) and 126 (30.4%) without a bypass. The choice of either technique was based on the surgeons' individual preference. Kidney function [serum creatinine, calculated glomerular filtration rate (GFR), RIFLE stages] was assessed over 14 days.
Lab-MELD scores were significantly higher in CR-B (22.5+/-11.0) than in CR (17.3+/-9.0) and piggyback (18.8+/-10.0) (P=0.008). Unexpectedly, the incidences of arterial stenoses (P=0.045) and biliary leaks (P=0.042) were significantly increased in piggyback. Preoperative serum creatinine levels were the highest in CR-B [1.45+/-1.17 vs 1.25+/-0.85 (piggyback) and 1.13+/-0.60 mg/dL (CR); P=0.033]. Although a worsening of postoperative kidney function was observed among all groups, this was most pronounced in CR-B [creatinine day 14: 1.67+/-1.40 vs 1.35+/-0.96 (piggyback) and 1.45+/-1.03 mg/dL (CR); P=0.102]. Accordingly, the proportion of patients displaying RIFLE stages ≥2 was the highest in CR/CR-B (26%/19%) when compared to piggyback (18%).
Piggyback revealed a shorter warm ischemic time, a reduced blood loss, and a decreased risk of acute kidney failure. Thus, piggyback is a useful technique, which should be applied in standard procedures. When piggyback is unfeasible, cava replacement, which displayed a lower incidence of vascular and biliary complications in our study, remains as a safe alternative.
最初，肝移植中的下腔静脉重建（CR）意味着完全切除并重新植入供体下腔静脉。或者，可以进行保留受体下腔静脉（IVC）并进行端侧吻合（即“背驮式”）。在此过程中，部分钳夹可维持IVC的血流，这可能改善心血管稳定性、减少失血并稳定肾功能。本研究的目的是比较这两种技术，特别关注肾功能。
纳入了一系列414例接受成人肝移植的患者（2006 - 2009年）。其中，176例（42.5%）患者接受了背驮式手术，238例接受了经典CR手术，112例（27.1%）患者在CR的同时进行了静脉 - 静脉转流（CR - B），126例（30.4%）未进行转流。技术的选择基于外科医生的个人偏好。在14天内评估肾功能[血清肌酐、计算的肾小球滤过率（GFR）、RIFLE分级]。
CR - B组的实验室终末期肝病模型（Lab - MELD）评分（22.5±11.0）显著高于CR组（17.3±9.0）和背驮式组（18.8±10.0）（P = 0.008）。出乎意料的是，背驮式手术中动脉狭窄（P = 0.045）和胆漏（P = 0.042）的发生率显著增加。CR - B组术前血清肌酐水平最高[1.45±1.17 vs 1.25±0.85（背驮式）和1.13±0.60 mg/dL（CR）；P = 0.033]。尽管所有组术后肾功能均有恶化，但在CR - B组中最为明显[术后第14天肌酐：1.67±1.40 vs 1.35±0.96（背驮式）和1.45±1.03 mg/dL（CR）；P = 0.102]。因此，与背驮式组（18%）相比，CR/CR - B组中显示RIFLE分级≥2的患者比例最高（26%/19%）。
背驮式手术显示出较短的热缺血时间、较少的失血以及较低的急性肾衰竭风险。因此，背驮式手术是一种有用的技术，应应用于标准手术程序中。当背驮式手术不可行时，在我们的研究中显示血管和胆并发症发生率较低的下腔静脉置换术仍是一种安全的替代方法。
