Yu Y-D, Kim D-S, Han J-H, Yoon Y-I
Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea.
Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea.
Transplant Proc. 2017 Jun;49(5):1202-1206. doi: 10.1016/j.transproceed.2017.03.066.
Portal vein thrombosis remains a challenging issue in liver transplantation. When thrombectomy is not feasible due to diffuse portosplenomesenteric thrombosis, other modalities are adapted such as the use of a jump graft or portal tributaries or even multivisceral transplantation. For patients with diffuse thrombosis of the splanchnic venous system, a large pericholedochal varix can be a useful vessel for providing splanchnic blood flow to the graft and for relieving portal hypertension. We report our experience of successfully treating a patient with diffuse portosplenomesenteric thrombosis using a pericholedochal varix for portal flow reconstruction during deceased donor liver transplantation and eventually preventing unnecessary multivisceral transplantation. A 56-year-old man diagnosed with liver cirrhosis due to hepatitis B underwent deceased donor liver transplantation due to refractory ascites. Preoperative imaging revealed diffuse portosplenomesenteric thrombosis with large amount of ascites. During the operation, dissection of the main portal vein was not possible due to the development of multiple large pericholedochal varices and cavernous change of the main portal vein. After outflow reconstruction, portal inflow was restored by anastomosing the graft portal vein to a large pericholedochal varix. Postoperatively, although abdominal computed tomography scan showed stenosis of portal vein anastomosis site, liver function tests improved, and Doppler sonogram revealed no flow disturbance. During follow-up, the patient repeatedly developed hydrothorax and ascites. In addition, stenosis of the portal vein anastomosis and thrombosis of the portomesenteric system still remained. The patient underwent transhepatic portal vein stent insertion. After portal vein stent insertion, hydrothorax and ascites improved and the extent of thrombosis of the portomesenteric system decreased without anticoagulation therapy. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins can be a source of useful inflow to restore portal flow and decrease the extent of thrombosis, thereby preventing unnecessary multivisceral transplantation.
门静脉血栓形成仍是肝脏移植中一个具有挑战性的问题。当由于弥漫性门静脉脾静脉肠系膜静脉血栓形成而无法进行血栓切除术时，可采用其他方法，如使用搭桥移植、门静脉分支，甚至多脏器移植。对于内脏静脉系统弥漫性血栓形成的患者，胆总管周围大的静脉曲张可能是一条有用的血管，可为移植物提供内脏血流并缓解门静脉高压。我们报告了在尸体供肝移植期间，使用胆总管周围静脉曲张进行门静脉血流重建，成功治疗一名弥漫性门静脉脾静脉肠系膜静脉血栓形成患者的经验，并最终避免了不必要的多脏器移植。一名56岁因乙型肝炎诊断为肝硬化的男性患者，因顽固性腹水接受了尸体供肝移植。术前影像学检查显示弥漫性门静脉脾静脉肠系膜静脉血栓形成并伴有大量腹水。手术过程中，由于多个胆总管周围大静脉曲张的形成以及门静脉主干的海绵样变，无法解剖门静脉主干。在流出道重建后，通过将移植门静脉与一个胆总管周围大静脉曲张吻合来恢复门静脉血流。术后，尽管腹部计算机断层扫描显示门静脉吻合口狭窄，但肝功能检查有所改善，多普勒超声检查未发现血流紊乱。在随访期间，患者反复出现胸腔积液和腹水。此外，门静脉吻合口狭窄和门静脉肠系膜系统血栓形成仍然存在。患者接受了经肝门静脉支架置入术。门静脉支架置入术后，胸腔积液和腹水得到改善，门静脉肠系膜系统血栓形成范围减小，无需抗凝治疗。总之，内脏静脉完全闭塞患者中增大的胆总管周围静脉曲张可作为有用的血流来源，以恢复门静脉血流并减少血栓形成范围，从而避免不必要的多脏器移植。
