Kim Hyeyoung, Yoon Kyung Chul, Lee Kwang-Woong, Yi Nam-Joon, Lee Hae Won, Choi YoungRok, Oh Dongkyu, Kim Hyo-Sin, Hong Suk Kyun, Ahn Sung Woo, Suh Kyung-Suk
Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
Liver Transpl. 2017 Jul;23(7):899-906. doi: 10.1002/lt.24783.
Patients with large spontaneous splenorenal shunts (SRSs) prove challenging during liver transplantation (LT), regardless of organizing portal vein (PV) thrombosis. Here, we detail the clinical outcomes of 26 patients who underwent direct ligation of large SRSs during LT. Direct ligation of large SRS was applied in poor portal flow during LT. We performed temporary test clamping of the SRS before direct ligation and applied PV pressure monitoring in patients who showed signs of portal hypertension, such as bowel edema. We retrospectively reviewed and evaluated their clinical outcomes. Among 843 patients who underwent LT between 2010 and 2015, 26 (3.1%) underwent direct ligation of SRS without any intraoperative event. Mean preoperative Model for End-Stage Liver Disease score was 16.7 ± 9.0. The main PV diameter on preoperative computed tomography was 8.3 ± 3.4 mm (range, 3.0-14.0 mm). SRS was easily identified at just below the distal pancreas and beside the inferior mesenteric vein in all patients. Accompanying PV thrombectomy was done in 42.3% of patients. Among 26 patients, massive and prolonged ascites was evident in 15.4% (n = 4) postoperatively. They were all living donor LT recipients with a small PV diameter (4.0-6.7 mm). Except for 1 patient who underwent splenic artery embolization, ascites was tolerable and well controlled by conservative management. There was a 7.7% rate of major complications related to direct ligation, including reoperation due to combined ligation of SRS along with a left renal vein at the confluence. Except for 1 hospital mortality due to sepsis, 25 patients (96.2%) are alive with no evidence of further PV complications. In conclusion, direct ligation of large SRS during LT is a safe and feasible method to overcome the effects of a large SRS. Liver Transplantation 23 899-906 2017 AASLD.
无论是否存在门静脉（PV）血栓形成，患有大型自发性脾肾分流（SRS）的患者在肝移植（LT）期间都具有挑战性。在此，我们详细介绍了26例在LT期间接受大型SRS直接结扎术的患者的临床结局。大型SRS的直接结扎术应用于LT期间门静脉血流不佳的情况。在直接结扎之前，我们对SRS进行了临时试验性夹闭，并对出现门静脉高压体征（如肠水肿）的患者进行了PV压力监测。我们回顾性地分析并评估了他们的临床结局。在2010年至2015年间接受LT的843例患者中，26例（3.1%）接受了SRS直接结扎术，且术中无任何事件发生。术前终末期肝病模型评分的平均值为16.7±9.0。术前计算机断层扫描显示的主要PV直径为8.3±3.4mm（范围为3.0 - 14.0mm）。所有患者的SRS均在胰腺远端下方和肠系膜下静脉旁很容易被识别。42.3%的患者同时进行了PV血栓切除术。在26例患者中，15.4%（n = 4）术后出现大量且持续时间较长的腹水。他们均为活体肝移植受者，PV直径较小（4.0 - 6.7mm）。除1例接受脾动脉栓塞术的患者外，腹水可耐受且通过保守治疗得到良好控制。与直接结扎相关的主要并发症发生率为7.7%，包括因在汇合处将SRS与左肾静脉联合结扎而进行的再次手术。除1例因败血症导致的医院死亡外，25例（96.2%）患者存活，且无进一步PV并发症的迹象。总之，LT期间大型SRS的直接结扎术是克服大型SRS影响的一种安全可行的方法。《肝脏移植》23 899 - 906 2017美国肝病研究学会
