高原地区体外肝切除联合自体肝移植术治疗晚期肝泡型包虫病的术后并发症及其防治策略

田青山; 冯少培; 郭亚民; 韩秀敏; 赵顺云; 叶成杰; 安永德; 吴世乐; 王向前; 郑海波; 朱文君; 阿吉德; 高伟; 潘洪帅

doi:10.3969/j.issn.1001-5256.2021.09.029

高原地区体外肝切除联合自体肝移植术治疗晚期肝泡型包虫病的术后并发症及其防治策略

DOI: 10.3969/j.issn.1001-5256.2021.09.029

1.
青海省人民医院普外科，西宁 810000
2.
青海大学研究生院，西宁 810000

基金项目:

青海省2020年重大公共卫生专项资金包虫病防治项目 (2305999901-1073)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：田青山负责文章的整体构思及关键部分的撰写；冯少培负责收集病例资料及文章的撰写；郭亚民、韩秀敏负责修改文章结构和部分关键内容；郭亚民、田青山、赵顺云、叶成杰、安永德、吴世乐、王向前、郑海波、朱文君、阿吉德、高伟、潘洪帅参与了对文中关于围术期处理与手术过程描述的校对与修改。

详细信息

通信作者:
郭亚民，gym135@yeah.net

田青山与冯少培对本文贡献相同，同为第一作者

中图分类号: R532.32;R617
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出版历程
- 收稿日期: 2021-01-29
- 录用日期: 2021-04-12
- 出版日期: 2021-09-20

Postoperative complications of ex vivo liver resection combined with autologous liver transplantation in treatment of advanced hepatic alveolar echinococcosis at high altitude and related prevention and treatment strategies

1.
Department of General Surgery, Qinghai Provincial People's Hospital, Xining 810000, China
2.
Graduate School of Qinghai University, Xining 810000, China

Research funding:

Project of Echinococcosis Prevention and Control with Special Fund for Major Public Health in Qinghai Province in 2020 (2305999901-1073)

摘要

摘要: 目的探讨高原地区体外肝切除联合自体肝移植术治疗终末期肝泡型包虫病的术后并发症并探讨防治策略。方法收集青海省人民医院2013年1月— 2019年3月接受自体肝移植术的11例终末期肝泡型包虫病患者的手术资料及随访资料，对术中及术后情况进行分析。结果 11例患者均成功行自体肝移植术，无术中死亡，其中2例(18.18%)行半离体肝切除，9例(81.82%)行全离体肝切除。肝后下腔静脉重建方式中，采用自体大隐静脉进行重建者2例(18.18%)，采用人造血管重建者4例(36.36%)，5例(45.45%)保留自体肝后下腔静脉。胆道重建方式中，8例(72.73%)行胆肠吻合术，3例(27.27%)行胆管端端吻合术。11例患者的术后并发症主要有出血2例(18.18%)；胆汁漏、腹腔感染4例(36.36%)，胆肠吻合口狭窄1例(9.09%), 血栓2例(18.18%)，肺部感染、胸腔积液2例(18.18%)；包虫复发1例(9.09%)。11例患者发生围术期死亡2例(18.18%)，其余9例(81.82%)患者均好转出院。结论出血、胆道并发症和感染是造成高原地区自体肝移植患者死亡的主要原因，精准把握手术适应证、术前仔细多学科评估、术中精湛的操作、外科技术流程的标准化及精细的围术期管理是降低自体肝移植术围术期病死率、避免和减少术后并发症以及使患者获得长期良好生存的关键。
- 棘球蚴病, 肝 /
- 体外肝切除联合自体肝移植术 /
- 手术后并发症
Abstract: Objective To investigate the postoperative complications of ex vivo liver resection combined with autologous liver transplantation in the treatment of end-stage hepatic alveolar echinococcosis at high altitude and related prevention and treatment strategies. Methods Surgical data and follow-up data were collected from 11 patients with end-stage hepatic alveolar echinococcosis who underwent autologous liver transplantation in Qinghai People's Hospital from January 2013 to March 2019, and intraoperative and postoperative conditions were analyzed. Results All 11 patients underwent autologous liver transplantation successfully, without intraoperative death, among whom 2(18.18%) underwent hemi-extracorporeal hepatectomy and 9 (81.82%) underwent total extracorporeal hepatectomy. For the reconstruction of the retrohepatic inferior vena cava, 2 patients (18.18%) underwent reconstruction with the autologous great saphenous vein, 4 patients (36.36%) underwent reconstruction with artificial vessels, and the autologous retrohepatic inferior vena cava was preserved in 5 patients (45.45%). For biliary reconstruction, 8 patients (72.73%) underwent choledochoenterostomy and 3 (27.27%) underwent choledochocholedochostomy. The main postoperative complications of the 11 patients included bleeding in 2 patients (18.18%), bile leakage and abdominal infection in 4 patients (36.36%), bilioenteric anastomotic stenosis in 1 patient (9.09%), thrombus in 2 patients (18.18%), pulmonary infection and pleural effusion in 2 patients (18.18%), and echinococcosis recurrence in 1 patient (9.09%). Of all 11 patients, 2 (18.18%) died during the perioperative period, and the other 9 patients (81.82%) were improved and discharged. Conclusion Bleeding, biliary complications, and infection are the main causes of death in patients undergoing autologous liver transplantation at high altitude. An accurate understanding of surgical indication, careful multidisciplinary evaluation before surgery, superb operation during surgery, standardized surgical procedures, and fine perioperative management are the key to reducing perioperative mortality, avoiding and reducing postoperative complications, and achieving good long-term survival in patients undergoing autologous liver transplantation.
- Echinococcosis, Hepatic /
- Ex Vivo Liver Resection and Autotransplantation /
- Postoperative Complications

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图 1 ELRA部分手术过程

注：a，探查腹腔及病灶位置；b，切除的肝脏置于放有冰块的修肝盆中，内衬无菌塑料膜(将冰块与肝脏隔开)，用4 ℃的灌洗液通过门静脉行肝脏灌洗，沿正常肝组织边缘完整切除病灶，然后进行修肝；c，人工血管重建肝后下腔静脉并与肝静脉吻合；d，吻合肝动脉。

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图 2 晚期HAE患者术前CT影像评估结果

注：a，包虫侵犯第一、第二肝门(箭头所示)；b，包虫病灶紧邻心包，下腔静脉受侵(箭头所示)；c，CT三维重建显示肝脏全貌(正面)；d，包虫病灶与下腔静脉、门静脉、肝动脉位置关系(背面)。

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表 1 11例行ELRA的晚期HAE患者一般资料

患者编号	性别	年龄(岁)	民族	BMI (kg/m²)	远隔转移	合并乙型肝炎	临床表现			减黄措施
患者编号	性别	年龄(岁)	民族	BMI (kg/m²)	远隔转移	合并乙型肝炎	黄疸	腹痛	下肢水肿	减黄措施
1	女	19	藏	22.15	肺	是	无	有	无	无
2	女	62	藏	21.33	无	否	无	有	无	无
3	男	50	汉	23.39	无	否	无	有	有	无
4	男	45	汉	20.96	无	否	有	无	无	药物
5	女	37	藏	20.08	肺	否	有	有	有	PTCD
6	男	21	藏	21.78	无	否	有	有	有	PTCD
7	男	46	藏	21.55	无	否	有	有	无	药物
8	男	33	汉	18.94	无	否	无	无	无	无
9	男	19	藏	19.38	无	否	无	有	无	无
10	女	34	汉	21.09	无	否	无	无	无	无
11	女	36	藏	23.83	无	否	有	有	无	药物
注：PTCD，经皮肝穿刺胆道引流术。

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表 2 11例行ELRA的晚期HAE患者术前评估结果

患者编号	术前Child- Pugh分级	WHO- IWGE PNM分型	XJHCRI PIVM分型	血管侵犯	外周侵犯	吲哚菁绿15分钟滞留率(%)	标准肝体积(ml)	40% SLV(ml)	CT三维移植肝体积(ml)	CT三维病灶体积(ml)	残肝比(%)
1	A	P3N1M1	PⅠ、Ⅳ-Ⅷ I1V1M2	第二、三肝门、肝后下腔静脉	右侧膈肌、右肾上级、右侧肾上腺、肺	10	978.47	391.39	750.6	4 386.0	12.9
2	A	P2N1M0	PⅠ-Ⅷ I2V1M1	第一、二肝门、肝后下腔静脉	右侧膈肌、右侧肾上腺	8	886.41	354.56	1 453.0	1 495.4	41.5
3	B	P2N1M0	PⅠ-Ⅳ、Ⅷ I1V1M1	第一、二、三肝门，肝右静脉及肝后下腔静脉	双侧膈肌、右肾上级、右侧肾上腺	11	1 139.58	455.83	1 123.6	700.0	51.1
4	A	P4N1M0	PⅠ、Ⅳ-Ⅷ I1V1M1	第一、二、三肝门，肝左静脉及肝后下腔静脉	右侧膈肌	5	1 047.52	419.01	1 099.3	2 317.9	29.4
5	A	P4N1M1	PⅤ-Ⅷ 11V1M2	第二、三肝门、肝后下腔静脉	右侧膈肌、肺	3.5	955.46	382.18	1 137.8	2 159.3	29.4
6	B	P4N1M0	PⅡ-Ⅳ I2V1M0	第二、三肝门、肝后下腔静脉	无	9	943.95	377.58	1 312.3	779.5	54.0
7	A	P3N0M0	PⅣ-Ⅷ I2V1M0	第二、三肝门、肝后下腔静脉	无	4	1 093.55	437.42	788.5	969.3	31.7
8	A	P3N1M0	PⅠ-Ⅴ、Ⅷ I1V1M1	第一、二肝门及肝后下腔静脉	右侧膈肌	5.5	1 001.49	400.59	801.1	736.5	69.7
9	A	P3N1M0	PⅡ-Ⅵ I1V1M1	第一、二、三肝门、肝后下腔静脉	右侧膈肌	4	897.92	359.17	2 507.5	4 047.1	16.5
10	A	P3N1M0	PⅠ、Ⅳ、Ⅴ、Ⅷ I1V1M1	第一、二、三肝门、肝后下腔静脉	右侧膈肌	3.5	955.46	382.18	930.5	907.5	73.4
11	A	P3N0M0	PⅠ、Ⅳ、Ⅴ、Ⅶ、Ⅷ I2V1M0	第二、三肝门、肝后下腔静脉	无	8	1 036.01	414.41	801.1	1 669.5	35.8
注：WHO-IWGE：世界卫生组织包虫病专家工作组；XJHCRI：新疆维吾尔自治区包虫病临床研究所。

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表 3 11例行ELRA的HAE患者手术情况

患者编号	术中出血(ml)	术中输红细胞悬液(U)	术中输血浆(ml)	手术时长(min)	无肝期时长(min)	病灶最大直径(cm)	含病灶切除肝重量(g)	移植肝重量(g)	手术方式
1	600	4	600	546	273	20	5811	640	离体肝切除+肝后下腔静脉移植+自体肝移植术
2	12 000	60	4300	729	366	16	2110	1380	离体肝切除+自体肝移植术
3	11 000	39	4300	964	451	18	2993	1010	离体肝切除+肝后下腔静脉移植+同种异体肝静脉移植+自体肝移植术
4	3000	6	950	607	187	18	4132	1300	离体肝切除+肝后下腔静脉移植+同种异体肝静脉移植+自体肝移植术
5	6000	20	2730	693	0	16	2500	1260	半离体肝切除+自体肝移植术
6	5000	20	2060	663	0	12	4132	1300	半离体肝切除+自体肝移植术
7	2600	5	1350	1070	430	16	1580	690	离体肝切除+自体肝移植术
8	2300	6	2020	835	344	16	905	1810	离体肝切除+自体肝移植术
9	2500	2	600	765	345	14	5932	730	离体肝切除+自体肝移植术
10	1200	6	5401	875	403	8	1030	2400	离体肝切除+自体肝移植术
11	2600	4	2280	900	467	18	1700	900	离体肝切除+肝后下腔静脉移植+自体肝移植术

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表 4 11例ELRA患者的胆道重建方式、肝后下腔静脉重建方式与术后并发症及预后情况

患者编号	总住院天数(d)	术后住院天数(d)	胆道重建方式	肝后下腔静脉重建方式	术后并发症	预后
1	44	30	胆肠吻合	人造血管	腹水、低蛋白血症	存活
2	23	2	胆肠吻合	保留自体肝后下腔静脉	腹腔活动性出血、低血容量性休克、DIC、代谢性酸中毒、电解质紊乱	死亡
3	47	36	胆肠吻合	人造血管	胆汁漏、腹腔感染、感染性休克、脓毒血症、多脏器功能衰竭	死亡
4	43	29	左肝管与胆总管端端吻合及T管引流	人造血管	胆汁漏、腹腔感染、感染性休克、脓毒血症、多脏器功能衰竭、门静脉血栓、凝血功能紊乱、混合型酸碱平衡紊乱、肝性脑病、肺部感染、低蛋白血症、电解质紊乱	死亡
5	38	24	胆肠吻合	大隐静脉	右侧胸腔积液、腹水、低蛋白血症	存活
6	38	19	胆肠吻合	大隐静脉	胆肠吻合口狭窄、急性胆管炎、肝脓肿、肺部感染、胸腔积液、低蛋白血症	存活
7	112	19	胆肠吻合	保留自体肝后下腔静脉	梗阻性黄疸、肺部感染、双侧胸腔积液	存活
8	29	19	胆肠吻合	保留自体肝后下腔静脉	包虫复发、右侧胸腔积液	存活
9	55	44	右肝管与胆总管端端吻合及T管引流	保留自体肝后下腔静脉	胆汁漏、腹腔感染、腹腔脓肿、急性肝功能损害、腹水、低蛋白血症、肺部感染、右侧胸腔积液、菌血症	存活
10	53	23	左肝管与胆总管端端吻合及T管引流	保留自体肝后下腔静脉	胆汁漏、肝周脓肿、局限性腹膜炎、腹腔积液、下腔静脉血栓	存活
11	69	26	胆肠吻合	人造血管	胆道出血、凝血功能紊乱、右侧胸腔积液	死亡

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