缩小供肝体积的风险：成人活体肝移植中降低 GRWR 并克服小肝综合征。
The Risk of Going Small: Lowering GRWR and Overcoming Small-For-Size Syndrome in Adult Living Donor Liver Transplantation.
机构信息
Department of Surgery, The University of Hong Kong, Hong Kong, China.
Department of Surgery, Queen Mary Hospital, Hong Kong, China.
出版信息
Ann Surg. 2021 Dec 1;274(6):e1260-e1268. doi: 10.1097/SLA.0000000000003824.
OBJECTIVE
The aim of this study was to determine the outcomes of living donor liver transplantation (LDLT) according to various graft-to-recipient weight ratio (GRWR).
BACKGROUND
The standard GRWR in LDLT is >0.8%. Our center accepted predicted GRWR ≥0.6% in selected patients.
METHODS
Data from patients who underwent LDLT from 2001 to 2017 were included. Patients were stratified according to actual GRWR (Group 1:GRWR ≤0.6%; Group 2: 0.6%<GRWR≤ 0.8%; Group 3:GRWR >0.8%).
RESULTS
There were 545 LDLT (group 1 = 39; group 2 = 159; group 3 = 347) performed. Pretransplant predicted GRWR showed good correlation to actual GRWR (R2 = 0.834) and these figures differed within a ± 10%margin (P = 0.034) using an equivalence test. There were more left lobe grafts in group 1 (33.3%) than group 2 (10.7%) and 3 (2.9%). Median donor age was <35 years and steatosis >10% was rare.There was no difference in postoperative complication, vascular and biliary complication rate between groups. Over one-fifth (20.5%) of group 1 patients required portal flow modulation (PFM) and was higher than group 2 (3.1%) and group 3 (4%) (P = 0.001). Twenty-six patients developed small-for-size syndrome (SFSS): 5 of 39 (12.8%) in group 1 and 21 of 159 (13.2%) in group 2 and none in group 3 (P < 0.001). There were 2 hospital mortalities; otherwise, the remaining patients [24/26 (92.3%)] survive with a functional liver graft. The 5-year graft survival rates were 85.4% versus 87.8% versus 84.7% for group 1, 2, and 3, respectively (P = 0.718). GRWR did not predict worse survivals in multivariable analysis.
CONCLUSIONS
Graft size in LDLT can be lowered to 0.6% after careful recipient selection, with low incidence of SFSS and excellent outcomes. Accurate graft weight prediction, donor-recipient matching, meticulous surgical techniques, appropriate use of PFM, and vigilant perioperative care is important to the success of such approach.
目的
本研究旨在根据不同的供肝与受者体重比（GRWR）来确定活体肝移植（LDLT）的结果。
背景
LDLT 的标准 GRWR 为>0.8%。本中心在选定的患者中接受预测 GRWR≥0.6%。
方法
纳入 2001 年至 2017 年期间接受 LDLT 的患者数据。根据实际 GRWR 将患者分为三组（组 1：GRWR≤0.6%；组 2：0.6%<GRWR≤0.8%；组 3：GRWR>0.8%）。
结果
共进行了 545 例 LDLT（组 1=39；组 2=159；组 3=347）。移植前预测的 GRWR 与实际 GRWR 具有良好的相关性（R2=0.834），并且在使用等效性检验时，两者之间相差 10%以内（P=0.034）。组 1 中有更多的左外叶供肝（33.3%），而组 2 为 10.7%，组 3 为 2.9%。供者年龄中位数<35 岁，脂肪变性>10%的情况很少见。各组之间的术后并发症、血管和胆道并发症发生率无差异。组 1 中有超过五分之一（20.5%）的患者需要门静脉血流调节（PFM），明显高于组 2（3.1%）和组 3（4%）（P=0.001）。26 例发生小肝综合征（SFSS）：组 1 中有 5 例（12.8%），组 2 中有 21 例（13.2%），组 3 中无（P<0.001）。有 2 例院内死亡；否则，其余患者[26 例中的 24 例（92.3%）]均存活并具有功能正常的肝移植物。5 年的移植物存活率分别为组 1、组 2 和组 3 的 85.4%、87.8%和 84.7%（P=0.718）。多变量分析显示 GRWR 并未预测生存率下降。
结论
在仔细选择受者后，LDLT 中的移植物大小可以降低至 0.6%，SFSS 的发生率较低，且结果良好。准确预测移植物重量、供者与受者匹配、精细的手术技术、适当使用 PFM 和密切的围手术期护理对于这种方法的成功至关重要。
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