Botkin医院的肝脏移植项目100例手术体会

A. Shabunin, I. Parfenov, M. Minina, V. Bedin, P. Drozdov, O. N. Levina, G. S. Mikhayliants, I. Nesterenko, D. A. Makeev, O. S. Zhuravel, N. A. Ongoev
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During the period under study, 119 potential liver transplant donors were evaluated. The mean age of the donors was 44.2 ± 11.12 (21–63) years. Median levels of sodium, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin were 141 (138–146) mmol/L, 27 (20.7–47.4) units/L, 25 (17–41.5) units/L, and 9.65 (6.42–13.7) μmol/L, respectively. The median graft hepatic steatosis was 10% (5–15). LTx was performed using the piggyback technique (99/100 cases) and classic technique with inferior vena cava resection (1/100). End-to-end porto-portal vein anastomosis was performed (99/100 cases). Anastomosis of the donor organ’s portal vein with the recipient’s left gastric vein due to occlusive thrombosis of the recipient’s portal vein was carried out (1/100). In all cases, a continuous end-to-end arterial anastomosis was formed. End-to-end choledochocholedochal anastomotic strictures (95/100) and end-to-side hepaticojejunostomy (5/100) were formed. Results. Median cold ischemia time was 312.5 minutes (280–380). Mean operative time was 488.91 ± 65.34 (95% CI: 475.9–501.9) minutes, median intraoperative blood loss was 1000 (600–1500) mL. Thirty-day mortality was 2% (Clavien–Dindo class V). Early postoperative complications (Clavien–Dindo class IIIa–IVa) developed in 12/100 patients (12%). Graft arterial thrombosis occurred in 3 cases (3%), biliary anastomotic strictures in 6 (6%), and subhepatic hematoma in 2 (2%). The average intensive care unit (ICU) bed day was 2.34 ± 1.67 (1–8). Total postoperative bed-day was 14.63 ± 5.35 (10–39). During case follow-up, a prolonged form of calcineurin inhibitor (CNI) was administered as immunosuppressive therapy in mono regimen (85 patients), in combination with mycophenolic acid derivatives (7), and in combination with everolimus (6). Of the 93 patients, 46 patients (49.46%) had the new coronavirus infection (COVID-19) before or after transplantation; in no case did COVID-19 lead to death. 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引用次数: 1

摘要

目的:分析2018年7月至2021年10月在Botkin医院进行的100例尸体肝移植的结果。材料和方法。从2018年7月到2021年10月,在Botkin医院的外科诊所进行了100例来自已故供体的原位肝移植(LTx)。其中男性58人(58%),女性42人(42%)。患者平均年龄为48.73±8.56(24 ~ 66)岁,平均MELD为19.54±4.35(15 ~ 33)岁。LTx的主要适应症是慢性病毒性肝炎(CVH) C(52%)、营养毒性肝硬化(20%)、自身免疫性肝脏和胆管疾病(18%)、CVH B(7%)和肝细胞癌(HCC)(3%)引起的肝硬化。在研究期间,对119名潜在的肝移植供体进行了评估。献血者平均年龄为44.2±11.12(21-63)岁。钠、天冬氨酸转氨酶(AST)、丙氨酸转氨酶(ALT)和胆红素的中位数分别为141 (138 ~ 146)mmol/L、27 (20.7 ~ 47.4)units/L、25 (17 ~ 41.5)units/L和9.65 (6.42 ~ 13.7)μmol/L。移植肝脂肪变性中位数为10%(5-15)。LTx采用背驮式技术(99/100例)和经典技术联合下腔静脉切除(1/100例)。行端到端门静脉吻合(99/100)。因受体门静脉闭塞血栓形成,将供器官门静脉与受体胃左静脉吻合(1/100)。所有病例均形成连续的端到端动脉吻合。形成端到端胆总管吻合狭窄(95/100)和端到端肝空肠吻合(5/100)。结果。中位冷缺血时间为312.5 min(280 ~ 380)。平均手术时间488.91±65.34 (95% CI: 475.9 ~ 501.9)分钟,术中出血量中位数为1000 (600 ~ 1500)mL, 30天死亡率为2% (Clavien-Dindo V级),术后早期并发症(Clavien-Dindo IIIa-IVa级)发生率为12/100(12%)。移植物动脉血栓3例(3%),胆道吻合口狭窄6例(6%),肝下血肿2例(2%)。重症监护病房(ICU)平均床位数为2.34±1.67(1-8)。术后总卧床日14.63±5.35(10-39)。在病例随访中,延长形式的钙调磷酸酶抑制剂(CNI)作为单一方案的免疫抑制治疗(85例),与霉酚酸衍生物(7例)联合,与依维莫司(6例)联合。在93例患者中,46例(49.46%)患者在移植前后发生了新型冠状病毒感染(COVID-19);在任何情况下,COVID-19都没有导致死亡。因新冠肺炎住院6例(13.04%)。迄今为止,93名患者中有33名(25.48%)接种了疫苗,导致75名(75%)肝移植受者对COVID-19免疫。总1年生存率为95%,3年生存率为91%。结论。在多学科医院引入LTx,可以在项目开始时实现与领先移植中心相当的即时和长期治疗结果(失代偿性弥漫性肝病)。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Liver transplant program at Botkin Hospital. Experience of 100 surgeries
Objective: to present an analysis of the results of 100 cadaveric liver transplants performed at Botkin Hospital from July 2018 to October 2021. Materials and methods. From July 2018 to October 2021, 100 orthotopic liver transplantation (LTx) from a deceased donor were performed at the surgical clinic of Botkin Hospital. The recipients were 58 males (58%) and 42 females (42%). The mean age of the recipients was 48.73 ± 8.56 (24–66) years, while their mean MELD was 19.54 ± 4.35 (15–33). The main indications for LTx were cirrhosis resulting from chronic viral hepatitis (CVH) C (52%), nutritional-toxic cirrhosis (20%), autoimmune liver and bile duct disease (18%), CVH B (7%), and hepatocellular carcinoma (HCC) (3%). During the period under study, 119 potential liver transplant donors were evaluated. The mean age of the donors was 44.2 ± 11.12 (21–63) years. Median levels of sodium, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin were 141 (138–146) mmol/L, 27 (20.7–47.4) units/L, 25 (17–41.5) units/L, and 9.65 (6.42–13.7) μmol/L, respectively. The median graft hepatic steatosis was 10% (5–15). LTx was performed using the piggyback technique (99/100 cases) and classic technique with inferior vena cava resection (1/100). End-to-end porto-portal vein anastomosis was performed (99/100 cases). Anastomosis of the donor organ’s portal vein with the recipient’s left gastric vein due to occlusive thrombosis of the recipient’s portal vein was carried out (1/100). In all cases, a continuous end-to-end arterial anastomosis was formed. End-to-end choledochocholedochal anastomotic strictures (95/100) and end-to-side hepaticojejunostomy (5/100) were formed. Results. Median cold ischemia time was 312.5 minutes (280–380). Mean operative time was 488.91 ± 65.34 (95% CI: 475.9–501.9) minutes, median intraoperative blood loss was 1000 (600–1500) mL. Thirty-day mortality was 2% (Clavien–Dindo class V). Early postoperative complications (Clavien–Dindo class IIIa–IVa) developed in 12/100 patients (12%). Graft arterial thrombosis occurred in 3 cases (3%), biliary anastomotic strictures in 6 (6%), and subhepatic hematoma in 2 (2%). The average intensive care unit (ICU) bed day was 2.34 ± 1.67 (1–8). Total postoperative bed-day was 14.63 ± 5.35 (10–39). During case follow-up, a prolonged form of calcineurin inhibitor (CNI) was administered as immunosuppressive therapy in mono regimen (85 patients), in combination with mycophenolic acid derivatives (7), and in combination with everolimus (6). Of the 93 patients, 46 patients (49.46%) had the new coronavirus infection (COVID-19) before or after transplantation; in no case did COVID-19 lead to death. Six patients (13.04%) were hospitalized due to COVID-19. To date, 33/93 (25.48%) patients have been vaccinated, resulting in 75 (75%) liver transplant recipients immune to COVID-19. The overall 1-year survival rate was 95% and the 3-year survival rate was 91%. Conclusion. Introduction of LTx in multidisciplinary hospitals allows to, already at the start of the program, achieve immediate and long-term treatment outcomes (in decompensated diffuse liver disease) that are comparable to those of leading transplantation centers.
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