Kato H, Usui M, Iizawa Y, Tanemura A, Murata Y, Kuriyama N, Kishiwada M, Mizuno S, Sakurai H, Inoue M, Uchida K, Isaji S
Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Hospital, Mie, Japan.
Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Hospital, Mie, Japan.
Transplant Proc. 2016 May;48(4):1218-20. doi: 10.1016/j.transproceed.2016.01.029.
We report a rare case of 10-month-old female who underwent living donor liver transplantation (LDLT) for syndromic biliary atresia with preduodenal portal vein (PV) and its severe stricture owing to the previous Kasai portoenterostomy. Because we successfully performed "left at right liver transplantation (LAR-LT) and graft rerotation" in this case, we are present tips and pitfalls for this operation.
Preoperative computed tomography scan showed that her preduodenal PV was stenotic from the confluence of the superior mesenteric vein and splenic vein to hepatic hilum, which made us consider the necessity of ≥3 cm interposition vein graft to complete a safe PV anastomosis. To reduce a gap between donor and recipient's PV, we decided to put a left lateral section graft at the right subphrenic space called left-at-right liver transplantation. Thus, LDLT was performed with an identical lateral sectional graft from her father. After total hepatectomy, we implanted a graft in her right subphrenic space, and anastomosed the donor left hepatic vein to her inferior vena cava. Then, we anastomosed an interposition graft harvested from her left internal carotid vein to her PV.
Even after reflowing PV flow, because the duodenum compressed the interposition vein graft, PV flows were totally insufficient. Therefore, we flipped a liver graft 180° from right to left upper abdominal cavity, which could reduce the gap between PVs and acceptable PV flow was obtained.
In the present case, LAR-LT could reduce the distance of PVs. In addition, our rerotation method could be useful to alleviate tension on the PV anastomosis caused by preduodenal PV.
我们报告了一例罕见的10个月大女性患者，因综合征性胆道闭锁合并十二指肠前门静脉（PV）及其因先前的Kasai肝门空肠吻合术导致的严重狭窄而接受活体肝移植（LDLT）。由于我们在该病例中成功实施了“左肝在右肝移植（LAR-LT）及移植物旋转”，我们在此介绍该手术的技巧与陷阱。
术前计算机断层扫描显示，她的十二指肠前门静脉从肠系膜上静脉和脾静脉汇合处至肝门处狭窄，这使我们认为需要≥3 cm的间置静脉移植物来完成安全的PV吻合。为缩小供体和受体PV之间的差距，我们决定将左外侧叶移植物置于右膈下间隙，即左肝在右肝移植。因此，采用来自其父亲的相同外侧叶移植物进行了LDLT。全肝切除术后，我们将移植物植入她的右膈下间隙，并将供体左肝静脉与她的下腔静脉吻合。然后，将从她的左颈内静脉获取的间置移植物与她的PV吻合。
即使恢复PV血流后，由于十二指肠压迫间置静脉移植物，PV血流仍完全不足。因此，我们将肝移植物从右上腹翻转180°至左上腹，这可以缩小PV之间的差距并获得可接受的PV血流。
在本病例中，LAR-LT可缩短PV之间的距离。此外，我们的旋转方法可能有助于减轻十二指肠前门静脉导致的PV吻合处的张力。
