Lerut J P, Mazza D, van Leeuw V, Laterre P F, Donataccio M, de Ville de Goyet J, Van Beers B, Bourlier P, Goffette P, Puttemans T, Otte J B
Department of Digestive Surgery-1401, University Hospital Saint-Luc, Brussels, Belgium.
Transpl Int. 1997;10(2):125-32. doi: 10.1007/s001470050025.
The aim of this study was to analyze the influence of technical problems resulting from splanchnic venous anomalies on the outcome of orthotopic liver transplantation. From February 1984 until December 1995, 53 (16.3%) of 326 adults underwent consecutive transplantations whilst having acquired anomalies of the splanchnic veins. These consisted of portal vein thrombosis (n = 32, 9.8%), thrombosis with inflammatory venous changes (phlebitis; n = 6, 1.8%) and alterations related to portal hypertension surgery (n = 15, 4.6%). Because of major changes in surgical technique, i.e., eversion instead of blind venous thrombectomy, immediate superior mesenteric vein approach in cases of extended thrombosis, and piggyback implantation with preservation instead of removal of the inferior vena cava, patients were divided into two groups: those who underwent transplantation during the period February 1984 to December 1990 (group 1) and those transplanted between January 1991 and December 1995 (group 2). Surgical procedures to overcome the anomalies consisted of venous thrombectomy (n = 26), implantation of the donor portal vein at the splenomesenteric confluence (n = 5) or onto a splenic (n = 1) or ileal varix (n = 1), interposition of a free iliac venous graft between recipient superior mesenteric vein and donor portal vein (n = 9), and interruption of surgical portosystemic shunt (n = 13). All patients had a complete follow-up. The 1- and 5-year actuarial patient survival rates were similar in patients with (n = 53) and without (n = 273) splanchnic venous abnormalities (75.5% vs 78.1% and 64.3% vs 66.9%, respectively). Early (< 3 months) post-transplant mortality was 24.5% (13/53 patients). Mortality was highest in the portal vein thrombophlebitis group (5/6, 83.3%), followed by the portal hypertension surgery group (5/15, 33.3%) and the portal vein thrombosis group (3/32, 9.4%). Technical modifications significantly reduced mortality in group 2 (10.3%, 3/29 vs 41.7%, 10/24 patients in group 1; P < 0.05) as well as the need for re-exploration for bleeding (13.8%, 4/29 patients in group 2 vs 15/24, 62.5% in group 1; P < 0.01). Mortality directly related to bleeding was also significantly lowered (1/29, 3.4% in group 2 vs 9/ 24, 37.5% in group 1; P < 0.01). We conclude that liver transplantation can be safely performed in the presence of splanchnic vein thrombosis and previous portal hypertension surgery.
本研究旨在分析内脏静脉异常导致的技术问题对原位肝移植结局的影响。1984年2月至1995年12月，326例成人患者中有53例（16.3%）在患有内脏静脉后天性异常的情况下接受了连续肝移植。这些异常包括门静脉血栓形成（n = 32，9.8%）、伴有炎症性静脉改变的血栓形成（静脉炎；n = 6，1.8%）以及与门静脉高压手术相关的改变（n = 15，4.6%）。由于手术技术发生了重大变化，即采用外翻而非盲视静脉血栓切除术、在广泛血栓形成时立即采用肠系膜上静脉入路以及采用背驮式植入术保留而非切除下腔静脉，患者被分为两组：1984年2月至1990年12月期间接受移植的患者（第1组）和1991年1月至1995年12月期间接受移植的患者（第2组）。克服这些异常的手术方法包括静脉血栓切除术（n = 26）、在脾肠系膜汇合处植入供体门静脉（n = 5）或植入脾静脉（n = 1）或回肠静脉曲张（n = 1）、在受体肠系膜上静脉和供体门静脉之间置入游离髂静脉移植物（n = 9）以及中断手术性门体分流（n = 13）。所有患者均进行了完整的随访。有（n = 53）和无（n = 273）内脏静脉异常的患者1年和5年实际患者生存率相似（分别为75.5%对78.1%和64.3%对66.9%）。移植后早期（< 3个月）死亡率为24.5%（13/53例患者）。门静脉血栓性静脉炎组死亡率最高（5/6，83.3%），其次是门静脉高压手术组（5/15，33.3%）和门静脉血栓形成组（3/32，9.4%）。技术改进显著降低了第2组的死亡率（10.3%，3/29对第1组的41.7%，10/24例患者；P < 0.05）以及因出血进行再次探查的必要性（第2组为13.8%，4/29例患者对第1组的15/24，62.5%；P < 0.01）。与出血直接相关的死亡率也显著降低（第2组为1/29，3.4%对第1组的9/24，37.5%；P < 0.01）。我们得出结论，在内脏静脉血栓形成和既往门静脉高压手术存在的情况下，肝移植可以安全进行。
