Renz J F, Rosenthal P, Roberts J P, Ascher N L, Emond J C
Department of Surgery, University of California-San Francisco, USA.
Arch Surg. 1997 Sep;132(9):950-5; discussion 955-6. doi: 10.1001/archsurg.1997.01430330016002.
Pediatric liver transplantation (eg, orthotopic liver transplantation) has been associated with decreased graft survival compared with adult transplantation; this has been attributed to the increased difficulty of the procedure in small children and the increased number of technical variants that have been used to increase the supply of small livers.
To adopt a policy of planned exploration (PLANEX) of children on the seventh day after orthotopic liver transplantation, to obtain a liver biopsy specimen, to identify and treat potential technical problems at that time, and to evaluate the effect of this strategy on the length of hospitalization and morbidity rate in 60 children who underwent orthotopic liver transplantation.
The PLANEX was adopted progressively during a 3-year period. A retrospective study was conducted that compared outcomes between patients who did and did not undergo PLANEX. Data were collected from chart review with a complete follow-up of patients.
A university medical center at which 130 liver transplantations are performed annually in adults and children.
Sixty children who received primary transplants between October 1992 and December 1996 were studied.
Standard, partial, and living-donor transplantations were performed. Routine procedures performed at PLANEX included hematoma evacuation, tissue culture, inspection of all anastomoses, intraoperative ultrasonographic verification of vessel patency, open liver biopsy, and definitive abdominal closure.
The duration of the primary hospitalization was the main outcome measure. Surgical complications and graft and patient survival rates were also analyzed.
The mean +/- SD length of hospitalization for 24 recipients who underwent PLANEX was 16.5 +/- 5.7 days compared with 19.2 +/- 4.7 days for 6 patients (25%) who had significant findings at exploration (P = .34). In the 36 patients who did not undergo PLANEX, 10 patients (28%) required unplanned explorations (on median posttransplant day 13) that identified the following 13 complications: biliary (n = 4), undiscovered enterotomy (n = 6), hemoperitoneum (n = 2), and partial vascular thrombosis (n = 1). The mean length of hospitalization for recipients who did not require exploration was 19.3 +/- 3.9 days (PLANEX, P = .28); however, in patients who required unplanned exploration, the mean length of hospitalization increased to 41.2 +/- 15.5 days (median, 43 days). The mean length of hospitalization of recipients who underwent unplanned exploration was significantly increased compared with recipients who underwent PLANEX with significant intraoperative findings (P = .02).
In this series, early identification and repair of surgical problems in asymptomatic patients on day 7 significantly decreased the hospital stay and morbid consequences of surgical problems. This aggressive approach may improve overall graft and patient survival.
与成人肝移植相比，小儿肝移植（如原位肝移植）的移植物存活率较低；这归因于小儿手术难度增加以及为增加小肝脏供体数量而采用的技术变体数量增多。
对原位肝移植术后第7天的儿童采取计划性探查（PLANEX）策略，获取肝活检标本，识别并处理当时潜在的技术问题，评估该策略对60例接受原位肝移植儿童的住院时间和发病率的影响。
在3年期间逐步采用PLANEX。进行了一项回顾性研究，比较接受和未接受PLANEX的患者的结局。通过病历审查收集数据，并对患者进行完整随访。
一所大学医学中心，每年为成人和儿童进行130例肝移植手术。
研究了1992年10月至1996年12月期间接受初次移植的60例儿童。
进行了标准、部分和活体供体移植。PLANEX时进行的常规操作包括血肿清除、组织培养、检查所有吻合口、术中超声检查血管通畅情况、开放肝活检以及确定性腹壁关闭。
初次住院时间是主要结局指标。还分析了手术并发症以及移植物和患者存活率。
24例接受PLANEX的受者的平均住院时间为16.5±5.7天，而6例（25%）在探查时有显著发现的患者的平均住院时间为19.2±4.7天（P = 0.34）。在36例未接受PLANEX的患者中，10例（28%）需要进行非计划性探查（移植后中位第13天），发现了以下13种并发症：胆道（n = 4）、未发现的肠切开术（n = 6）、腹腔积血（n = 2）和部分血管血栓形成（n = 1）。不需要探查的受者的平均住院时间为19.3±3.9天（PLANEX组，P = 0.28）；然而，在需要非计划性探查的患者中，平均住院时间增加到41.2±15.5天（中位值，43天）。与术中发现显著问题且接受PLANEX的受者相比，接受非计划性探查的受者的平均住院时间显著增加（P = 0.02）。
在本系列研究中，对无症状患者在第7天早期识别并修复手术问题可显著缩短住院时间并减少手术问题的不良后果。这种积极的方法可能会提高总体移植物和患者存活率。
