De Carlis Luciano, Sguinzi Raffaella, De Carlis Riccardo, Di Sandro Stefano, Mangoni Jacopo, Aseni Paolo, Giacomoni Alessandro, Vanzulli Angelo
Hepatogastroenterology. 2014 Sep;61(134):1712-6.
BACKGROUND/AIMS: Mutual interactions between portal vein and hepatic artery can be documented during hepatobiliary surgery. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a recently introduced surgical technique which can also represent a unique living human model to investigate intrahepatic blood circulation. We report three consecutive cases in which a residual right portal branch flow was clearly detectable after first-step ALPPS, and try to further investigate this unexpected finding with intraoperative clamping tests.
Every patient was evaluated with CT scan 7 days after first-step ALPPS and Intraoperative Doppler Ultrasonography (IOUS) at both steps of the procedure.
In every patient, CT scan and second-step IOUS demonstrated a clear hepatopetal flow distally to the divided right portal branch. The flow was present after right biliary duct clamping and stopped after right total hilar clamping as well as after right hepatic artery occlusion.
Neither cross-portal circulation between the two hemilivers nor trans-sinusoidal backflow from the hepatic veins can explain these findings, which are rather consistent with a refilling of the occluded portal branch through the opening of intrahepatic arterioportal shunts (APS). APS could represent the simplest homeostatic mechanism that regulate intrahepatic blood flow.
背景/目的：在肝胆手术过程中，可以记录门静脉和肝动脉之间的相互作用。联合肝脏分隔和门静脉结扎分期肝切除术（ALPPS）是一种最近引入的手术技术，它也可以作为研究肝内血液循环的独特人体模型。我们报告了连续三例在第一步ALPPS后可清晰检测到右门静脉分支残留血流的病例，并试图通过术中钳夹试验进一步研究这一意外发现。
每位患者在第一步ALPPS后7天进行CT扫描，并在手术的两个步骤中进行术中多普勒超声检查（IOUS）。
在每位患者中，CT扫描和第二步IOUS均显示在离断的右门静脉分支远端有明显的向肝血流。在右胆管钳夹后血流存在，在右全肝门钳夹以及右肝动脉闭塞后血流停止。
两个半肝之间的门静脉交叉循环和肝静脉的经窦反流均不能解释这些发现，这些发现更符合通过肝内动门脉分流（APS）开放对闭塞门静脉分支的再充盈。APS可能是调节肝内血流的最简单的稳态机制。
