使用小体积供肝的活体肝移植：体积真的重要吗？
Living Donor Liver Transplantation Using Small-for-Size Grafts: Does Size Really Matter?
作者信息
Sethi Pulkit, Thillai Manoj, Thankamonyamma Binoj Sivasankarapillai, Mallick Shweta, Gopalakrishnan Unnikrishnan, Balakrishnan Dinesh, Menon Ramachandran Narayana, Surendran Sudhindran, Dhar Puneet, Othiyil Vayoth Sudheer
机构信息
Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Ponekkara, Kochi, Kerala, India.
出版信息
J Clin Exp Hepatol. 2018 Jun;8(2):125-131. doi: 10.1016/j.jceh.2017.06.004. Epub 2017 Jun 20.
BACKGROUND
In living donor liver transplantation (LDLT), graft-to-recipient weight ratio (GRWR) > 0.8% is perceived as the critical graft size. This lower limit of GRWR (0.8%) has been challenged over the last decade owing to the surgical refinements, especially related to inflow and outflow modulation techniques. Our aim was to compare the recipient outcome in small-for-size (GRWR < 0.8) versus normal-sized grafts (GRWR > 0.8) and to determine the risk factors for mortality when small-for-size grafts (SFSG) were used.
METHODS
Data of 200 transplant recipients and their donors were analyzed over a period of two years. Routine practice of harvesting middle hepatic vein (MHV) or reconstructing anterior sectoral veins into neo-MHV was followed during LDLT. Outcomes were compared in terms of mortality, hospital stay, ICU stay, and occurrence of various complications such as functional small-for-size syndrome (F-SFSS), hepatic artery thrombosis (HAT), early allograft dysfunction (EAD), portal vein thrombosis (PVT), and postoperative sepsis. A multivariate analysis was also done to determine the risk factors for mortality in both the groups.
RESULTS
Recipient and donor characteristics, intraoperative variables, and demographical data were comparable in both the groups (GRWR < 0.8 and GRWR ≥ 0.8). Postoperative 90-day mortality (15.5% vs. 22.85%), mean ICU stay (10 vs. 10.32 days), and mean hospital stay (21.4 vs. 20.76 days) were statistically similar in the groups. There was no difference in postoperative outcomes such as occurrence of SFSS, HAT, PVT, EAD, or sepsis between the groups. Thrombosis of MHV/reconstructed MHV was a risk factor for mortality in grafts with GRWR < 0.8 but not in those with GRWR > 0.8.
CONCLUSION
Graft survival after LDLT using a small-for-size right lobe graft (GRWR < 0.8%) is as good as with normal grafts. However, patency of anterior sectoral outflow by MHV or reconstructed MHV is crucial to maintain graft function when SFSG are used.
背景
在活体肝移植（LDLT）中，移植物与受者体重比（GRWR）>0.8%被视为关键的移植物大小。在过去十年中，由于手术技术的改进，尤其是与流入和流出调节技术相关的改进，GRWR的这一下限（0.8%）受到了挑战。我们的目的是比较小体积移植物（GRWR<0.8）与正常体积移植物（GRWR>0.8）的受者结局，并确定使用小体积移植物（SFSG）时的死亡风险因素。
方法
对两年内200例移植受者及其供者的数据进行分析。在LDLT期间，遵循常规做法采集肝中静脉（MHV）或将肝前叶静脉重建为新的MHV。比较两组在死亡率、住院时间、重症监护病房（ICU）住院时间以及各种并发症（如功能性小体积综合征（F-SFSS）、肝动脉血栓形成（HAT）、早期移植物功能障碍（EAD）、门静脉血栓形成（PVT）和术后脓毒症）发生情况方面的结局。还进行了多变量分析以确定两组的死亡风险因素。
结果
两组（GRWR<0.8和GRWR≥0.8）的受者和供者特征、术中变量及人口统计学数据具有可比性。两组术后90天死亡率（15.5%对22.85%）、平均ICU住院时间（10天对10.32天）和平均住院时间（21.4天对20.76天）在统计学上相似。两组在SFSS、HAT、PVT、EAD或脓毒症发生等术后结局方面无差异。MHV/重建的MHV血栓形成是GRWR<0.8的移植物死亡的风险因素，但在GRWR>0.8的移植物中不是。
结论
使用小体积右叶移植物（GRWR<0.8%）进行LDLT后的移植物存活率与正常移植物一样好。然而，当使用SFSG时，通过MHV或重建的MHV保持肝前叶流出道通畅对于维持移植物功能至关重要。
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