Saad S, Tanaka K, Inomata Y, Uemoto S, Ozaki N, Okajima H, Egawa H, Yamaoka Y
Second Department of Surgery, Kyoto University Faculty of Medicine, Japan.
Ann Surg. 1998 Feb;227(2):275-81. doi: 10.1097/00000658-199802000-00018.
The authors analyze the surgical pattern and the underlying rationale for the use of different types of portal vein reconstruction in 110 pediatric patients who underwent partial liver transplantation from living parental donors.
In partial liver transplantation, standard end-to-end portal vein anastomosis is often difficult because of either size mismatch between the graft and the recipient portal vein or impaired vein quality of the recipient. Alternative surgical anastomosis techniques are necessary.
In 110 patients age 3 months to 17 years, four different types of portal vein reconstruction were performed. The portal vein of the liver graft was anastomosed end to end (type I); to the branch patch of the left and right portal vein of the recipient (type II); to the confluence of the recipient superior mesenteric vein and the splenic vein (type III); and to a vein graft interposed between the confluence and the liver graft (type IV). Reconstruction patterns were evaluated by their frequency of use among different age groups of recipients, postoperative portal vein blood flow, and postoperative complication rate.
The portal vein of the liver graft was anastomosed by reconstruction type I in 32%, II in 24%, III in 14%, and IV 29% of the cases. In children <1 year of age, type I could be performed in only 17% of the cases, whereas 37% received type IV reconstruction. Postoperative Doppler ultrasound (mL/min/100 g liver) showed significantly (p < 0.05) lower portal blood flow after type II (76.6 +/- 8.4) versus type I (110 +/- 14.3), type III (88 +/- 18), and type IV (105 +/- 19.5). Portal vein thrombosis occurred in two cases after type II and in one case after type IV anastomosis. Portal stenosis was encountered in one case after type I reconstruction. Pathologic changes of the recipient native portal vein were found in 27 of 35 investigated cases.
In living related partial liver transplantation, portal vein anastomosis to the confluence with or without the use of vein grafts is the optimal alternative to end-to-end reconstruction, especially in small children.
作者分析了110例接受活体亲体供肝部分肝移植的儿科患者使用不同类型门静脉重建的手术方式及潜在原理。
在部分肝移植中，由于供肝与受体门静脉大小不匹配或受体静脉质量受损，标准的端端门静脉吻合术常常难以实施。因此需要其他手术吻合技术。
对110例年龄在3个月至17岁的患者进行了四种不同类型的门静脉重建。肝移植的门静脉端端吻合（I型）；与受体左右门静脉的分支补片吻合（II型）；与受体肠系膜上静脉和脾静脉的汇合处吻合（III型）；与置于汇合处和肝移植之间的静脉移植物吻合（IV型）。通过不同年龄组受体的使用频率、术后门静脉血流和术后并发症发生率来评估重建方式。
肝移植的门静脉采用I型重建的占32%，II型占24%，III型占14%，IV型占29%。在1岁以下儿童中，仅17%的病例可采用I型重建，而37%接受IV型重建。术后多普勒超声（mL/min/100g肝脏）显示，II型（76.6±8.4）术后门静脉血流明显低于I型（110±14.3）、III型（88±18）和IV型（105±19.5）（p<0.05）。II型吻合术后发生2例门静脉血栓形成，IV型吻合术后发生1例。I型重建术后有1例出现门静脉狭窄。在35例接受调查的病例中，有27例发现受体自身门静脉有病理改变。
在活体亲属供肝部分肝移植中，门静脉与汇合处吻合，无论是否使用静脉移植物，都是端端重建的最佳替代方法，尤其是在幼儿中。
