Fifteen millimeters of mercury
Fifteen millimeters of mercury
复制标题
十五毫米汞柱
DOI：
10.1002/lt.22087
复制
发表时间：
2010
影响因子：
4.6
通讯作者：
B. D. Campos
中科院分区：
文献类型：
--
作者：
J. Botha;B. D. Campos
成人到成人活体供肝移植(AALDLT)在过去的十年中有了显著的发展。由于大小的限制，右叶移植物成为首选移植物。然而，右肝切除术比左肝切除术风险更大。据估计，右叶捐献的死亡率在每1000例肝切除中有2到5例。这种风险使右叶捐赠在伦理上变得困难，特别是在能够获得身体器官的国家。供者的安全仍然是最令人担忧的问题，最近导致人们对左叶移植的使用重新产生了兴趣。较小的移植物会增加患小型化综合征(SFSS)的风险。过多和破坏性的门静脉血流通过的肝脏太小，无法容纳这种血流，似乎最终会影响移植肝的功能，并导致其失败。在过去的十年里，大量的动物数据强调门静脉高灌注是SFSS发生的关键因素。部分肝移植动物模型显示再灌注后多处微血管损伤与移植肝大小呈负相关。在动物模型中，门静脉血流的分流显示没有微血管损伤和移植物功能的改善。门静脉流入的影响导致了几种降低门静脉压力(PVP)的技术的临床发展，包括脾切除、脾动脉结扎(SAL)、脾肾分流、半门腔分流术(HPCS)和肠系膜上静脉下行结扎的肠系膜腔分流术。几个较小的关于手术调整PVP的报告显示，在小移植物的AALDLT中，总体患者存活率提高，SFSS的发生率降低。在本期《肝脏移植》杂志上，京都大学的Ogura及其同事回顾分析了他们在活体供肝移植中有意调节PVP的经验及其对移植物功能和存活的积极影响。尽管这项研究具有追溯性，但它有足够的统计学力量来得出有价值的结论。Ogura及其同事将他们的经验分为2006年之前和之后的两个阶段，在这一年中，他们的AA-LDLT方法发生了3个重大的概念变化：有意的PVP调制(PVP<；15 mm Hg)，使用较小的移植物(移植物重量/受体重量比>；0.7)，以及增加左叶移植物的选择。这两个时期之间的统计学差异如下：受者年龄较大，终末期肝病模型评分较高，移植物尺寸较小。这些差异强化了PVP调节的生存益处及其对移植物功能的积极作用。换句话说，这篇文章记录了当PVP降低到15毫米汞柱时，将较小的移植物移植到患有更晚期疾病的老年患者身上，可以提高存活率。两个时期的总生存率大致提高了10%(1年和3年生存率分别为76.2%和68.8%，87.9%和81.6%)。门静脉高压症被定义为门静脉和肝静脉或下腔静脉之间压力梯度的增加。生理PVP范围为5-8毫米汞柱。12 mm Hg的压力梯度被认为是临床上有意义的门静脉高压症。根据这些生理参数和这些新的PVP调节存活数据，我们可以假设PVP大于20 mm Hg的部分肝移植的受者最有可能有大于12 mm Hg的梯度。这个
Adult-to-adult living donor liver transplantation (AALDLT) has evolved significantly in the last decade. Because of size constraints, the right lobe has become the preferred graft. However, right hepatectomy carries a greater risk than left hepatectomy. The mortality of right lobe donation has been estimated to be between 2 and 5 per 1000 hepatectomies. This risk makes right lobe donation ethically difficult, particularly in countries that have access to cadaveric organs. Donor safety remains the overriding concern and has recently resulted in a resurgence of interest in the use of the left lobe graft. Smaller grafts lead to an increased risk of development of small-for-size syndrome (SFSS). Excessive and destructive portal flow through a liver graft that is too small to accommodate this flow appears to ultimately affect graft function and leads to its failure. Over the past decade, a significant amount of animal data has stressed portal hyperperfusion as the critical factor in the development of SFSS. Animal models of partial liver transplantation have demonstrated multiple microvascular injuries after reperfusion inversely related to graft size. The diversion of portal flow in animal models has shown an absence of microvascular injury and improved graft function. The impact of portal vein inflow has led to the clinical development of several techniques to decrease portal vein pressure (PVP), including splenectomy, splenic artery ligation (SAL), splenorenal shunting, hemiportocaval shunting (HPCS), and mesocaval shunting with downstream ligation of the superior mesenteric vein. Several smaller reports of surgical modulation of PVP have demonstrated improved overall patient survival as well as decreased occurrence of SFSS in AALDLT with small grafts. In this issue of Liver Transplantation, Ogura and colleagues from the University of Kyoto report a retrospective analysis of their experience with intentional modulation of PVP in living donor liver transplantation and its positive effect on graft function and survival. Despite the retrospective nature of the study, it has enough statistical power for valuable conclusions to be drawn. Ogura and colleagues divided their experience into 2 periods before and after 2006, a year in which 3 substantial conceptual changes took place in their approach to AA-LDLT: intentional PVP modulation (PVP <15 mm Hg), use of smaller grafts (graft weight/recipient weight ratio > 0.7), and increased selection of left lobe grafts. Statistically significant differences between these 2 periods were as follows: older recipient age, higher Model for End-Stage Liver Disease score, and smaller graft size. These differences strengthen the survival benefit of PVP modulation as well as its positive effect on graft function. In other words, this article documents that transplantation of smaller grafts into older patients with more advanced disease led to improved survival when PVP was reduced to <15 mm Hg. Overall survival rates were roughly improved by 10% between the 2 periods (1and 3-year survival of 76.2% and 68.8% versus 87.9% and 81.6%, respectively). Portal hypertension is defined as an increase in the pressure gradient between the portal vein and the hepatic veins or inferior vena cava. Physiological PVP ranges from 5 to 8 mm Hg. A pressure gradient of 12 mm Hg is regarded as clinically significant portal hypertension. On the basis of these physiological parameters and these new survival data with PVP modulation, we can assume that recipients of a partial liver graft with a PVP greater than 20 mm Hg will most likely have a gradient greater than 12 mm Hg. The
猪超小型肝移植中门脉血流过多导致移植失败
DOI：
--
发表时间：
2005
期刊：
World Journal of Gastroenterology Vol.11(44)
影响因子：
--
作者：
H.S.Wang;S.Satomi;et al.
通讯作者：
et al.