Study of an appropriate volume of jejunectomy to reduce elevated portal pressure after major hepatic resection-aiming at tactics for small-for-size graft in liver transplantation

大范围肝切除会使门脉压力升高，并对残肝造成损害。窦内压升高被认为是导致内皮细胞和肝细胞损伤的原因。在肝移植中，小于受体体重0.8%的小体积移植物会导致移植物综合征，并伴有高胆红素血症、肝酶升高、凝血障碍和功能恢复延迟。为解决门静脉高压症，人们提出了脾动脉结扎、脾切除或门腔分流术等治疗方法。此外，肝移植外科医生还进行了左叶移植、肠系膜腔分流术和辅助性部分原位肝移植。对于这些方法，后来的讨论各有优缺点，因此，我们设计了小肠切除和随后的动物大范围肝切除，以解决在大范围肝切除或小…中门静脉压力过高的临床问题。更多的是大小移植物肝移植。材料与方法：15只SD大鼠随机分为3组，A组：仅行80%(内侧2叶、左外侧叶加左侧尾状叶)肝切除；B组；50%空肠切除(占小肠的25%)后行肝切除；C组：空肠切除(占小肠的50%)后行肝切除。用自制的细导管留置回结肠静脉，测量门静脉压力。结果：A组(n=5)80%肝切除后门脉压力显著升高(n=5，10.24±2.12 mm Hg)，B组门静脉压力明显降低(n=5，6.21±0.80 mm Hg)。C组(n=5)术后门静脉压降至低于标准门脉压(n=15，6.61±0.75)的水平(n=5，4.54±2.57 mm Hg)。肝切除当天切除的残肝组织学显示充血，而B组和C组未见。表现为肝细胞肿胀，肝窦间隙变窄，门脉面积增大，中心静脉扩张。A组1周后基本稳定，B组和C组肝切除后第1、2天残肝细胞凋亡周观察基本正常，B组和C组未见细胞凋亡。结论：50%空肠切除(25%切除小肠)可控制大鼠肝切除门静脉高压症。空肠切除可预防肝移植术后远期小移植物综合征。较少

Portal pressure will be elevated by massive hepatectomy, and induce damage to the remnant liver. The elevated intra-sinusoidal pressure is thought to cause injury of the endothelial cells and hepatocytes. In liver transplantation, a small-for-size graft less than 0.8% of recipient body weight will cause the graft syndrome with hyper-bilirubinemia, elevated liver enzymes, coagulopathy and delayed functional recovery. To solve the portal hypertension, several tactics are issued such as splenic arterial ligation, splenectomy or porto-caval shunting. In addition, liver transplantation surgeons showed dual left lobe graft transplantation, mesocaval shunting, and auxiliary partial orthotopic liver transplantation. About these methods discussions come out with merits and demerits later Therefore, we designed resection of the small intestine and subsequent massive hepatectomy using animals to solve the clinical problem of excessively elevated portal pressure in massive hepatectomy or in small- … More for-size graft liver transplantation. Aiming at an appropriate volume of the jejunectomy to reduce the excessively elevated portal pressure, we designed different sizes of the jejunectomy followed by 80% hepatectomy on rats.MATERIALS & METHODS : Fifteen SD rats were divided into 3 groups, Group A ; performed with only 80% (medial 2 and left lateral lobes plus left caudate lobe) hepatectomy, Group B ; 50% jejunectomy (25% of the small intestine) followed by the hepatectomy, and Group C ; jejunectomy (50% of the small intestine) followed by the same hepatectomy. The ileocolic vein was cannulated with a handmade thin indwelling catheter to measure the portal pressure. The effects of the jejunectomy on portal hypertension induced by the hepatectomy were studied with hemodynamics and histology of the remnant liver concerning congestion and apoptosis.RESULTS : Portal pressure was significantly elevated by 80% hepatectomy in Group A (n=5, 10.24±2.12mmHg), whereas Group B showed the pressure decreased by jejunectomy, then the pressure returned to neutral level after the hepatectomy (n=5,6.21±0.80mmHg). Group C (n=5) showed the suppression of the portal pressure to the lower level (n=5,4.54±2.57mmHg) after the hepatectomy than the standard portal pressure (n=15, 6.61±0.75mmHg)Histology of the remnant liver removed on the day revealed congestion in Group A, but not in Groups B and C. The findings consist of hepatocytic swelling, narrowing of the sinusoidal space, enlargement of the portal area, and dilation of the central vein. These findings of Group A settled down in 1 week, while Groups B and C specimens showed almost normal histology through the week Study of apoptosis in the remnant liver at day 1 and 2 after the hepatectomy showed apoptosic cells in Group A and none in Group B or C.CONCLUSION : 50% jejunectomy (25% resection of the small intestine) can control the portal hypertension induced by massive hepatectomy. And the jejunectomy may prevent the small-far-size graft syndrome in liver transplantation. Less