Liver transplant from living relatives

Treatment of diseases: liver cancer, children, hepatoblastoma Indication 1. End-stage liver disease. 2. Liver malignant tumors. 3, fulminant liver failure. Contraindications 1. A malignant neoplasm other than the liver. 2. Serious infection of important organs other than the hepatobiliary system. 3, systemic diseases, such as congenital cardiovascular disease, renal insufficiency and so on. 4. Thrombosis of the portal vein system. 5, fulminant hepatic failure, hepatitis B antigen (HBsAg and HBeAg) positive, postoperative hepatitis recurrence rate is almost 100%, but still can survive long-term survival through effective medical treatment. Preoperative preparation 1, a comprehensive understanding of the general condition of sick children Measuring the body weight and height of the recipient, performing B-ultrasound and CT examinations to understand the size of the liver is necessary to select a donor of the right size. Compared with heart and kidney transplantation, the incidence of rejection after liver transplantation is low, so tissue matching is generally based on A, B, O blood group matching. Serum cytomegalovirus (CMV)-negative receptors are best received from CMV-negative donor livers. If CMV-positive donor livers are received, the chance of CMV infection after liver transplantation will increase significantly. If the small recipient of the disease needs to be implanted into the adult donor liver after hepatectomy, depending on the space, it may be considered to reduce the volume of the liver transplant or to have the indications to remove the spleen at the same time. The author's hospital used to implant an adult donor liver for a 14-year-old child. The spleen was removed at the same time as the diseased liver. It has been healthy for 3 years and 4 months. 2. Evaluation of the hepatobiliary system before surgery A variety of imaging methods and various experimental methods (B-ultrasound, CT, MRI, or MRCP) must be used to clarify the diagnosis of primary disease. The following blood tests should be routine, 1 hepatitis B serological markers, HBsAg, HBsAb, HBeAg, HBeAb, HBc-Ab and HBV-DNA; 2 hepatitis C virus markers, HCV-Ab and HCV-RNA; 3 anti-nuclear antibodies (ANA); 4 anti-mitochondrial antibody (AMA); 5EB virus antibody; 6 cytomegalovirus (CMV); 7 alpha fetoprotein (AFP); 8 carcinoembryonic antigen (CEA); 9 HIV antibody; 10 liver function, renal function, Blood glucose, blood coagulation, blood K+, Na+, Cl- determination. For children with suspected portal vein or mesenteric venous thrombosis, color Doppler ultrasonography is necessary to examine the above veins, including the vena cava. 3, preoperative receptors for comprehensive organ function tests Check heart, kidney, lung, blood system, gastrointestinal system, etc. 4. Psychological and sociological assessment of sick children and their families before surgery Ensure that they have a thorough understanding and cooperation on the complexity, risk and related issues of the surgery. 5, in the process of waiting for the liver, the various complications caused by the primary disease of the recipient must be actively and effectively treated. 6, the organization of the liver transplant team Liver transplantation is a very complicated and delicate work. The organization of preoperative liver transplantation team is very important. It usually consists of donor liver, liver and anesthesia. The departments involved in collaboration should include at least pediatric surgery, hepatobiliary surgery, and heart. Surgery, laboratory, hematology, microbiology and immunization, blood bank, pathology, radiology, pharmacy, etc., the cooperation between all these departments should be run through animal experiments before clinical liver transplantation. Surgical procedure 1, the acquisition of donor liver In adult liver transplantation, taking the left lobe of the liver as a donor liver is usually not sufficient, but it is feasible in children, adults with left or right hepatic liver transplantation. At present, there is no recognized standard for the minimum donor liver volume required for receptor survival at home and abroad. According to Professor Fan Shangda's experience, the minimum donor liver volume is 40% of the estimated liver volume of the recipient. At present, donor surgery has routinely eliminated autologous blood transfusion or no blood transfusion. The operation time has been greatly shortened compared with the initial stage of development. The recipient does not need to be transferred. The time of no liver and inferior vena cava can be controlled within 1 hour. After the abdomen, the liver should be freed according to the conventional hepatectomy method, and the first and second hepatic hilums should be dissected separately. If the right hepatic liver is prepared, the right hepatic vein, the middle hepatic vein, the right portal vein, the right hepatic artery and the right hepatic duct should be dissected. Be careful to free. When determining the tangential line of hepatectomy, the right hepatic hilum can be temporarily blocked, and the liver color change is used as a boundary, and it is cut with an ultrasonic knife. There is no uniform identification of whether the middle hepatic vein remains in the right hepatic liver transplantation. Normally, the middle hepatic vein should be included. Because of the drainage of the middle venous V and VIII segments, if the middle hepatic vein is not preserved, the right hepatic congestion may be caused. Affect its liver function. Cutting the liver parenchyma with an ultrasonic scalpel is a time-consuming task, but its greatest benefit is that it does not block the blood flow into the liver during surgery and avoid liver damage caused by ischemia and reperfusion. After the liver parenchyma was cut and separated, the right portal vein was infused (Lactate Ringer's solution), placed in a pot containing ice crumbs, and the UW solution was used to perfuse the right portal vein and biliary tract. The full perfusion of the biliary tract is beneficial to avoid or reduce. Postoperative biliary stricture occurred. In order to reduce the damage to the intima of the hepatic artery to reduce the possibility of thrombosis after surgery, the hepatic artery can be irrigated. Before the donor is placed, the small bile duct of the liver section should be carefully examined (can be observed through the gallbladder injection), and the corresponding suture treatment. The remaining left hepatic section must be carefully stopped to stop and open all open bile ducts. 2, donor liver implantation If the parental donor liver retains the hepatic vein, the right hepatic vein is first anastomosed to the recipient inferior vena cava or right hepatic vein, and then the hepatic vein is anastomosed to the left hepatic vein of the recipient. Before the completion of the anastomosis, albumin is perfused through the portal vein to eliminate the accumulation of gas in the lumen and the remaining preservation solution, to prevent possible air embolism and hyperkalemia, followed by anastomosis of the portal vein and hepatic artery. After the above three venous anastomosis is completed, the expansion factor technique should be used in the knotting to facilitate the expansion of the anastomosis after the blood flow is opened, and to prevent the anastomotic stenosis. The anastomosis of the hepatic vein should be appropriate for the length. If the right hepatic vein is too long, the blood flow may be distorted after recovery. Due to the small hepatic artery in children, microsurgical techniques can be applied during anastomosis. After all the vascular anastomosis is completed and the blood flow is restored, the blood flow is checked by ultrasound Doppler during the operation. The reconstruction of the bile duct can be performed by end-to-end anastomosis or biliary anastomosis. Regarding the intraoperative venous bypass problem, it has been shown that no transfusion technique is applied, and the circulation can be effectively maintained for 2 hours. As for renal dysfunction, it can gradually recover after surgery, and hemodialysis is feasible once renal failure occurs. complication The most common complications after liver transplantation are pulmonary complications, intra-abdominal hemorrhage and vascular complications, biliary complications, rejection, and non-functioning liver transplantation.

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