Clinical research on pathogenesis and treatment of posttransplant portal hypertension and intrahepatic circulatory disorder in adult living donor liver transplantation

成人活体供肝移植术后早期门静脉压力(PVP)与每体重移植物重量呈负相关，但也受肝硬变、肝动脉血流和循环容量的影响。另一方面，移植后早期PVP与移植后预后有因果关系：PVP和GT平均为20毫米汞柱的受者存活率降低50%。移植后早期门脉高压症(PH)患者腹水和胆红素增加，蛋白质合成减少，与PVP成正比。革兰氏阴性菌血症的发生率也有所增加。然而，随着右肝旁正中段组织充血时间的延长，其预后影响逐渐减小，这是由于静脉流出中断，对PVP没有显著影响，即与窦前PH相反，它是窦后充血。因此，内脏血流增加进入小体积移植物会导致PVP升高和肝内门脉系统的损伤，并建立一个长期的病理状态。单位组织门静脉血流量(PVF)与相对移植物大小呈负相关，但PVF增加本身并不导致组织损伤，反而有助于血清胆红素的降低。肝组织PVF与PVP呈正相关。但这在移植后早期就消失了，依赖于门静脉顺应性(PVC)。供体年龄和移植物热缺血对移植物的PVC影响很大，为防止移植后早期PH造成的组织损伤，行脾动脉结扎术(SAL)或部分门腔分流术(PPCS)。SAL能降低PVP，但不能降低PVF，PPCS还能降低PVP、胆红素和腹水。两者都能改善预后，降低因腹水丢失而产生的医疗费用。PPCS引起的移植物再生和蛋白质合成减少的影响有待阐明。

Portal venous pressure(PVP) early after adult living donor liver transplantation showed an inverse correlation with graft weight per body weight, although affected also by cirrhosis, hepatic arterial flow, and circulatory volume. On the other hand, PVP early days after transplantation had a causative relationship with posttransplant prognosis : recipients with averaged PVP>20 mmHg showed 50% reduction of survival. In patients with early posttransplant portal hypertension(PH), ascites and bilirubin increased and protein synthesis decreased in proportion to PVP. Incidence of gram-negative bacteremia also increased. However, its prognostic impact decreased with time Tissue congestion in the paramedian sector of right liver graft, attributable to interrupted venous outflow, gave no significant impact on PVP, i.e., it is post-sinusoidal congestion in contrast to presinusoidal PH.Thus it was suggested that increased splanchnic flow running into a small-for-size graft causes elevation of PVP and injury to intrahepatic portal system, and establishes a prolonged pathological condition. Portal venous flow volume(PVF) per unit tissue showed an inverse relationship with relative graft size However, increased PVF per se did not lead to tissue injury, but rather contributed a reduction of serum bilirubin. PVF and PVP showed a positive correlation in the native liver. But this was lost in early posttransplant period and dependent on portal venous compliance(PVC). PVC was highly variable among grafts and affected by donor age and graft warm ischemia.To prevent tissue injury due to early posttransplant PH, splenic artery ligation(SAL) or partial porto-caval shunt(PPCS) was done. SAL led to PVP reduction but not PVF reduction and PPCS also led to reduction of PVP, bilirubin, and ascites. Both led to better prognosis and reduction of medical costs due to ascites loss Impact of some reduction in graft regeneration and protein synthesis caused by PPCS is to be elucidated.(299 words)