Anatomical variations and surgical strategies in right lobe living donor liver transplantation: Lessons from 120 cases
Anatomical variations and surgical strategies in right lobe living donor liver transplantation: Lessons from 120 cases
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DOI：
10.1097/00007890-200206270-00008
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发表时间：
2002-06-27
期刊：
影响因子：
6.2
通讯作者：
Uemoto, S
中科院分区：
文献类型：
--
作者：
Nakamura, T;Tanaka, K;Uemoto, S
背景资料。肝右叶的解剖变异很常见。然而，这些变异在活体供肝移植中的临床意义和外科处理尚未得到系统的分析。通过回顾术前(CT和多普勒超声)、术中(胆道造影)和手术所见，对120例右叶移植物的血管和胆管结构的外科解剖进行了重新评价。对这些数据与解剖变异的外科治疗进行了分析。变异导致多个门静脉吻合的发生率为7.5%。双肝右静脉的发生率为0.8%，30%的移植物有明显的副肝静脉(<5 mm)，其中13.9%为多支。除2例门静脉前段有多支门静脉实质内分支外，其余均经静脉成形术、静脉移植等技术改进成功重建。双肝动脉发生率为1.7%，但仅1条肝动脉重建成功，无不良后遗症。可能导致多个胆管吻合的变异的发生率为35.0%，最终39.2%的移植物具有多个开口。胆管成形术、肝管胆管吻合术、胆道支架置入术的总漏发生率为10.8%，狭窄发生率为9.2%。虽然导管成形术、内支架或不植入支架似乎与并发症风险增加有关，但解剖变异、多个胆管和管对管重建并不具有显著的风险。右叶移植物中血管和胆管结构的解剖变异是常见的。然而，通过技术修改，大多数都可以安全地进行管理。只有门静脉前静脉起源于实质内的病例(S)才可能形成相对禁忌症，特别是当合并类似的胆管变异时。否则，术中对胆道解剖的评估就足以成功处理。详细和准确的血管和胆道解剖评估对于适当的外科治疗是至关重要的。
Background. Anatomical variations in right liver lobe are common. However, clinical implications and surgical management of these variations in living donor liver transplantation have not been analyzed systematically.Methods. Surgical anatomy of vascular and biliary structures in 120 right lobe grafts were reevaluated by reviewing the results of preoperative (computerized tomography and Doppler ultrasonography) and intraoperative (cholangiography) imaging as well as surgical findings. The data were analyzed in relation to surgical management of anatomical variations.Results. The incidence of variants leading to multiple portal vein anastomoses was 7.5%. The incidence of dual right hepatic veins was 0.8%; 30% of the grafts had significant accessory hepatic veins (> 5 mm) and 13.9% of these were multiple. All of them were successfully reconstructed with technical modifications including venoplasty and venous grafts, except for two cases with multiple intraparenchymal portal vein branches to the anterior segment. The incidence of dual hepatic arteries was 1.7%, but only one of them was reconstructed without negative sequelae. The incidence of variants potentially leading to multiple bile duct anastomoses was 35.0%, and eventually 39.2% of the grafts had multiple orifices. With a variety of techniques including ductoplasty, hepaticohepaticostomy, and biliary stent, total incidence of leakage and stenosis was 10.8% and 9.2%, respectively. Although ductoplasty, internal stent or no stenting, seemed to be associated with increased risk of complications, anatomical variants, multiple bile ducts, and duct-to-duct reconstruction did not bear a significant risk.Conclusions. Anatomical variations of vascular and biliary structures in right lobe grafts are common. However, most can be managed safely with technical modifications. Only cases with intraparenchymal origin of the anterior portal vein(s) may form a relative contraindication, especially when combined with similar biliary variants. Otherwise, intraoperative assessment of biliary anatomy was enough for successful management. Detailed and precise assessment of vascular and biliary anatomy is vital for appropriate surgical management.