| Objective: Outflow tract complications and insufficient volume regeneration of the transplanted liver after ex vivo liver resection and auto-transplantation(ELRA)are one of the important causes of early postoperative liver dysfunction and even death.This study focuses on the key techniques of ELRA outflow tract reconstruction and the influence of liver sympathetic nerve on liver regeneration(liver fibrosis),aiming at reducing the incidence of early complications of liver insufficiency after ELRA surgery and providing theoretical guidance for improving the therapeutic effect of ELRA.(1)The classification of hepatic venous outflow tract vascular invasion and its corresponding vascular reconstruction mode were proposed,and its important role in preoperative evaluation and intraoperative reconstruction strategy was expounded.The clinical characteristics,treatment methods and results of outflow tract obstruction after ELRA operation were summarized.(2)To explore the effectiveness and safety of ligamenta teres hepatis as a vascular substitute for ELRA hepatic outflow tract vascular reconstruction.(3)To summarize the collateral circulation of portal vein,hepatic vein,inferior vena cava and hepatic artery caused by end-stage hepatic AE and its role in vascular reconstruction during ELRA surgery.(4)To observe the correlation between the degree of liver sympathetic nerve and liver regeneration(liver fibrosis)in patients with cirrhosis;To explore the effect of sympathetic nerve on liver regeneration(liver fibrosis)by using the model of de sympathetic nerve and spinal cord injury in rats.Methods: In the first part,(1)The medical records,preoperative CT,intraoperative photographs,pathological examination and angiography of 114 patients with hepatic alveolar echinococcosis disease(AE)who received ELRA treatment were collected.The invaded features(location,Angle and length)of hepatic vein and inferior vena cava in the intended reserved side liver were classified.On this basis,the vascular reconstruction methods corresponding to its classification were summarized.(2)The results of interventional therapy in patients with outflow tract obstruction(HVOO)during follow-up were described.Kaplan-Meier method was used for survival analysis and survival curve was drawn.In the second part,(1)The clinical data of 24 patients with ELRA who used ligamenta teres hepatis to repair the outflow tract on the healthy side were collected,the method of repairing the outflow tract with round hepatic ligament was described in detail,and the results of the operation were evaluated.(2)Review the foreign literatures on the use of ligamenta teres hepatis for vascular repair,and make a summary and review of the details and results of surgical repair.In the third part,enhanced CT and angiography imaging data of 51 patients with end-stage hepatic AE accompanied by collateral angiogenesis were collected,and the invasion of portal vein(PV),hepatic vein,inferior vena cava(IVC)and hepatic artery and the establishment of collateral vessels were observed and summarized,and the role of collateral vessels in vascular reconstruction during ELRA operation was discussed.In the fourth part,(1)Pathological specimens of patients with cirrhosis were collected to detect pathological changes,fibrosis and sympathetic nerve distribution in the lesion.(2)Rat models of drug de sympathetic nerve and sympathetic nerve excitation from spinal cord injury were established to detect liver regeneration(liver fibrosis)and related indicators.Results: In the first part,(1)hepatic veins were divided into H0-H5 and I0-I3 types,and their collateral circulation was divided into A and B types respectively.Based on the specific type of vascular invasion,it is necessary to make an initial decision about the mode of surgical reconstruction.Among 114 patients with ELRA,the mortality rate within 30 days was 7.0%(8/114),and seven patients died within 90 days.The most common postoperative complication was pleural effusion in 21 cases(25%).(2)A total of 11 cases of HVOO occurred,of which 1died of liver failure,and the other 10 patients received interventional therapy,and the effect was good.There was no significant difference in survival rate between patients with successful HVOO interventional revascularization and those without HVOO(P>0.05).In the second part,(1)Twenty-four patients(10 males and 14 females)were included.The median hepaticis-free period was 450(290,672)minutes.The ratio of residual liver volume to standard liver volume quartile was 0.71(0.43,0.97).Median blood loss was 1000(500,5000)ml.The mean postoperative hospital stay was 23(1-85)days.Of the 24 patients,3 died after surgery,but were not related to vascular complications.(2)Review of 6 relevant literatures,a total of 31 cases were reported,of which only 1 case was repaired with LTH portal vein,and postoperative vessel stenosis led to portal hypertension,and the other patients did not have vascular related complications.In the third part,there were 33 cases of portal vein,5 cases of hepatic vein,12 cases of inferior vena cava and 1 case of hepatic artery collateral circulation.PV collateral vessels were divided into two types according to different access: Type I:portal-portal vein access(13 cases).Type II: Type I combined with portal-systemic circulation(20 cases);The collateral vessels of hepatic veins were short hepatic veins,and 2 patients had communication branches of intrahepatic venous plexus.The lateral vessels of IVC showed dilatation of the vertebral venous plexus and lumbar venous plexus.In one patient,the main hepatic artery was invaded,and the healthy liver was supplied by arteries in abnormal anatomical position.Whether the source of this supplying artery was collateral vascularization or vascular variation is still worth discussing,but it does play a compensatory role in maintaining the blood supply of the healthy liver in the end-stage liver AE.In the fourth part,(1)Pathological sections of patients with cirrhosis were observed,and it was found that sympathetic nerve fibers in the liver were distributed in the fibrosis septa of the liver.(2)The sympathetic nerve in the rat liver was removed by chemical 6-OHDA,and the degree of liver fibrosis in the rat model with chemical sympathetic nerve removal was reduced,and the ability of liver regeneration was weakened and the degree of liver fibrosis was reduced in the rat model with chemical desympathetic nerves.After spinal cord injury,the liver sympathetic nerve of rats showed hyperactivity,liver regeneration ability was enhanced,liver fibrosis was aggravated.Conclusion: In the first part,the classification of outflow tract vascular invasion and corresponding vascular reconstruction methods are proposed,which is helpful for surgical decision-making and standardized approach,and conducive to reducing the occurrence of HVOO.When HVOO occurs,it should be treated immediately before liver failure.Vascular intervention is an effective method.In the second part,the ligamenta teres hepatis can be used as a vascular replacement graft for in vitro hepatectomy and autotransplantation.It has the advantages of convenient sampling,no donor damage and no immune rejection,and has a good clinical application prospect.In the third part,due to the special biological properties of HAE,liver vessels of HAE patients exhibit unique collateral vessels.In-depth study of HAE will help us to better understand the occurrence and development of collateral angiogenesis caused by intrahepatic lesions and their complications,and also provide a new idea for surgical treatment of end-stage HAE.The fourth part is the observation of the distribution of sympathetic nerve in patients with cirrhosis,and the influence of regulating liver sympathetic nerve on liver regeneration(liver fibrosis),indicating the importance of sympathetic nerve in the occurrence and development of liver diseases. |
PDF Full Text Request