活体肝移植右半供肝切取的临床经验总结(附157例报告)  

Clinical experience of resection of right lobe graft in living donor liver transplantation(a report of 157 cases)

作　　者：文天夫[1] 米凯[1] 李川[1] 严律南[1] 李波[1] 杨家印[1] 王文涛[1] 徐明清[1] 

机构地区：[1]四川大学华西医院肝脏外科肝脏移植中心,成都610041

出　　处：《器官移植》2013年第1期28-32,共5页Organ Transplantation

基　　金：国家科技重大专项基金资助项目(2008ZX10002-026)

摘　　要：目的总结活体右半供肝切取的经验。方法对2002年1月至2009年8月在四川大学华西医院肝脏移植中心施行活体右半肝供体手术的157例患者的资料进行回顾性分析。全部供者均自愿无偿捐肝,其捐赠行为均经医院伦理学委员会批准。了解术前计算机体层摄影术(CT)评估供肝体积的效果:术前应用CT测定供体的全肝体积、右半肝体积(不含肝中静脉),从而计算残余左半肝体积比;术后测定切取的右半肝重量、应用华西严律南公式计算标准肝脏体积(standard liver volume,SLV),计算残余左半肝体积重量比,比较术前供肝CT测定全肝体积与SLV的差异。供体均行不含肝中静脉的右半供肝切除术。静脉复合麻醉,取双侧(后期改进为右侧)肋缘下并延至剑突的切口,游离右侧肝脏,确定切肝线,不阻断入肝血流,用超声吸引刀离断肝组织直至整个右半肝游离,依次阻断并切断肝右动脉,门静脉右支及肝右静脉,将供肝移至后台进行灌注及修整。了解供者术中情况,包括供体取肝手术时间、术中失血量、术中有否发现不适合作为供体的病例及其原因。了解供者术后随访情况,术后并发症采用Clavien系统分级评价。结果供体的术前CT供肝体积测定结果:全肝体积(1301±174)ml,右半肝体积(724±137)ml,残余左半肝体积比(45.5±6.9)%。实测值:右半肝重量(558±77)g,SLV(1055±129)ml,残余左半肝重量比(46.7±6.2)%,其中30%～35%者10例(6%),>35%者147例(94%)。CT测定供体全肝体积比SLV平均大23%。供体术中平均失血量493ml,手术时间(431±68)min。术中探查发现不适合作为供体而未完成右半肝切除4例,包括肝总管进入肝圆韧带左纵沟内再发出肝右管1例、多支肝右管1例、中度脂肪肝(超过30%的肝组织大泡型脂肪变性)1例和肝硬化1例。术后共54例发生61例次并发症,其中发生ClavienⅢ级及以上并发症18例次,包括胸腔积液12例次、肝功能不全2Objective To summarize the experience of liver resection of right hepatic lobe graft in living donor liver transplantation. Methods Clinical data of 157 living donors of right hepatic lobe graft were studied retrospectively from January 2002 to August 2009 in Liver Transplantation Centre of West China Hospital of Sichuan University. All the donors donated voluntarily and gratuitously and were approved by the ethics committee of the hospital. The effect of computed tomography （CT） to assess donor＇s liver graft volume before operation. The total liver volume, right lobe graft volume （middle hepatic vein excluded ） were estimated by CT and therefore the volume/weight ratio of residual left lobe graft was calculated before operation. The weight of resected right lobe graft was measured after resection. Standard liver volume （SLV） and volume ratio of residual left lobe graft were calculated by Equation of West China Yan Lyu-nan. The differences between total liver volume estimated by CT before operation and SLV were compared. Right liver graft without the middle hepatic vein resection was performed in all living donors. Laparotomy was performed with bilateral subcostal incision and extended to xiphoid bone under combined vein anesthesia condition. After dissociation of the right liver lobe, the demarcation line between the right and left lobes was determined. Liver tissue was sectioned by cavitron ultrasonic surgical aspirator （CUSA） without cutting off the blood flow into liver until the whole right liver lobe was dissociated. The right hepatic artery, right branch of portal vein and right hepatic vein were cut off orderly. Perfusion and trimming of the graft were performed on bench. The condition of donors in the operation was monitored, including spending time of donor＇s liver resection, the intra-operative blood loss, inappropriate case of being donor and its cause. The postoperative follow-up of the donors were observed. The postoperative complications were graded and evaluated by Clavien syst

关 键 词：活体肝移植 右供肝切取 计算机体层摄影术 标准肝脏体积 

分 类 号：R617[医药卫生—外科学]