Ringe B, Lübbe N, Kuse E, Frei U, Pichlmayr R
Medizinische Hochschule Hannover, Zentrum Chirurgie, Germany.
Ann Surg. 1993 Jul;218(1):3-9. doi: 10.1097/00000658-199307000-00002.
This article describes the experience with a bridging procedure for a prolonged anhepatic period during clinical liver transplantation in case of special emergency situations.
Hepatic necrosis due to fulminant hepatitis or acute graft failure, as well as severe liver trauma are well-known and accepted indications for urgent liver transplantation. Prerequisite is the allocation of a suitable donor organ. If no allograft is available in time, patients with "toxic liver syndrome" or exsanguinating hemorrhage have been shown to benefit from advanced total hepatectomy.
As a modification of the standard one-stage procedure, recipient hepatectomy and subsequent liver transplantation are performed in two separate operations. To bridge the prolonged anhepatic period and to allow decompression and return of venous blood, an end-to-side portocaval shunt is constructed temporarily.
Thirteen of thirty-two patients underwent hepatectomy but not transplantation subsequently, and died within 34 hours after progressive deterioration. In 19 of 32 patients, transplantation was realized 6-41 hours after hepatectomy; 9 of 19 patients died, mostly from sepsis. Ten of nineteen liver recipients survived the procedure including three unrelated late deaths; presently, seven patients are alive with a follow-up of 3 to 46 months.
Two-stage total hepatectomy with temporary portocaval shunt, and subsequent liver transplantation can be a life-saving approach in patients most likely to die of the sequelae of advanced liver or graft necrosis or exsanguination that cannot be controlled by conventional treatment or immediate liver transplantation.
本文描述了在临床肝移植过程中，针对特殊紧急情况延长无肝期时采用桥接手术的经验。
暴发性肝炎或急性移植物功能衰竭导致的肝坏死，以及严重肝外伤是紧急肝移植的公认指征。前提是分配合适的供体器官。如果不能及时获得同种异体移植物，已证明“中毒性肝综合征”或失血性出血患者可从晚期全肝切除术中获益。
作为标准一期手术的改良，受体肝切除术及随后的肝移植分两次独立手术进行。为了桥接延长的无肝期并允许静脉血减压和回流，临时构建端侧门腔分流术。
32例患者中有13例接受了肝切除术，但随后未进行移植，在病情逐渐恶化后34小时内死亡。32例患者中有19例在肝切除术后6 - 41小时进行了移植；19例患者中有9例死亡，主要死于败血症。19例肝移植受者中有10例手术成功存活，包括3例无关的晚期死亡；目前，7例患者存活，随访时间为3至46个月。
两阶段全肝切除联合临时门腔分流术及随后的肝移植，对于那些极有可能死于晚期肝或移植物坏死后遗症或失血性出血，而这些情况无法通过传统治疗或立即肝移植控制的患者来说，可能是一种挽救生命的方法。
