Clinical research on the pathogenesis and treatment of portal hemodynamics and pathological regeneration in small-for-size liver grafts after living donor liver transplantation: Pathogenesis and clinical innovation

虽然活体供肝移植(LDLT)已被广泛接受为终末期肝病的首选治疗方法，但小体积肝移植及其病理学在许多项目中留下了许多争议。本研究旨在探讨小体积移植物相关症状的发病机制，旨在建立安全有效的治疗模式。术中经受者肠系膜下静脉置入抗血栓导管，术后2周直接监测门静脉压力(PVP)。在小体积移植物中，与适当大小的移植物相比，常见的是大量腹水，移植物再生延迟，长期凝血障碍和胆汁淤积。在小体积移植物中，细菌易位可能是由于降低了肝脏网状内皮功能或改变了肠粘膜免疫。这些现象与…期间和小体积移植物的PVP升高密切相关。术后More显著高于适型移植物。基于PVP升高具有很强的预后价值的结果，在手术时开始脾动脉结扎术(SAL)。SAL不仅可立即降低PVP，还可改善小体积移植物的累积受者存活率。同时，利用磁共振成像研究移植物组织充血情况。在没有额外引流重建的情况下，80%-90%的右移植物出现了与前段充血相容的形态变化。然而，在几个月后，大多数移植物的充血逐渐改善。移植物充血与肝功能恶化或PVP升高无关。然而，术后第三周或第四周的腹水量与第一个月的移植物充血呈显著正相关。综上所述，早期PVP升高与小尺寸移植物的不良预后密切相关。然而，SAL可以立即和持续地降低PVP，并对移植肾和患者的预后产生积极影响。较少

Although living donor liver transplantation (LDLT) has been widely accepted as a treatment of choice for end-stage liver diseases, small-for-size grafts and their pathology leave many controversies in many programs. This study focused on pathogenesis of symptoms associated with small-for-size graft and aimed to establish the effective and safe treatment modality.An antithrombotic catheter was inserted via the inferior mesenteric vein of recipient during operation, and portal vein pressure (PVP) was directly monitored for two weeks after surgery. In small-for-size grafts, compared with appropriate-size grafts, massive ascites, delay of graft regeneration, prolonged coagulopathy and cholestasis were observed commonly. Bacterial translocation possibly attributable either to reduce hepatic reticuloendothelial function or to alter mucosal immunity of intestine occurred in small-for-size grafts. These phenomena closely associated with elevated PVP, and PVP in small-for-size grafts during and … More after operation was significantly higher than that in appropriate-size grafts. Based on the results suggesting that elevated PVP serve a strong prognostic value, splenic artery ligation (SAL) was initiated at operation. SAL induced not only an immediate reduction of PVP, but also cumulative recipient survival in small-for-size grafts was improved.In parallel, graft tissue congestion was investigated using magnetic resonance imaging. Morphologica1 changes compatible with congestion in the anterior segment occurred in 80-90% of right grafts without additional drainage reconstruction. However, congestion improved gradually in most grafts after several months. Graft congestion was associated with neither deteriorated liver function nor elevated PVP. However a tentative but significant positive correlation was observed between amount of ascites in the third or fourth week after surgery and total graft congestion in first month.In conclusion, elevated PVP in the early phase is strongly associated with poor prognosis attributable to small-for-size graft. However SAL induces an immediate and persistent reduction of PVP and gives positive effects on graft and patient prognosis. Less