LIVER TRANSPLANTATION

From Big Medical Encyclopedia

LIVER TRANSPLANTATION (synonym transplantation of a liver) — operation of substitution of a liver of the recipient a transplant from the donor.

Fig. 1. Diagrammatic representation of orthotopical liver transplantation: 1 — an upper anastomosis of the lower vena cava, 2 — an anastomosis of the general hepatic artery, 3 — an anastomosis of a portal vein, 4 — an anastomosis of the general bilious channel on the T-shaped drainage, 5 — the lower anastomosis of the lower vena cava, 6 — a transplant of a liver.
Fig. 2. Diagrammatic representation of heterotopic liver transplantation: 1 — a liver of the recipient, 2 — a transplant of a liver in left hypochondrium (after removal of a spleen), 3 — an anastomosis of a gall bladder with a loop of a small bowel, 4 — an anastomosis of splenic and portal veins, 5 — an anastomosis left the general ileal and the general hepatic arteries, 6 — a stump of the left general ileal artery, 7 — an anastomosis of the lower vena cava of the recipient and the lower vena cava of a transplant.

The pct can be orto-or heterotopic. At orthotopical change the transplant is placed to the place of a remote liver of the recipient and recover normal topografo-anatomic relationship (fig. 1). Heterotopic change assumes preservation of the affected liver of the recipient and placement of a transplant in an abdominal cavity, in the right juxtaspinal channel, in a basin, in left hypochondrium, instead of a remote spleen (fig. 2) or a kidney.

For the first time orthotopical the Pct in clinic executed in 1963 Starzdom (T. E. Starzl), and heterotopic — in 1964 Absolonom (To. Absolon).

Indications — primary malignant tumors of a liver, final stages of cirrhosis and an acute hepatitis (virus, medicamentous or toxic), and also the biliary atresia and inborn fermentopatiya connected with a liver (Wilson's disease — Konovalova, Nimann's disease — Peak, etc.).

The hepatectomy at the donor is carried out after a crosswise laparotomy. The liver will be mobilized from all directions, consistently allocate the general bilious channel, a portal vein, a hepatic artery, over - and podiyechenochny departments of the lower vena cava. A remote transplant preserve idle time cold perfusion (see) through a portal vein the balanced electrolytic solution in number of 1500 ml with t ° 4 ° under pressure of 70 — 100 cm w.g. After washing and cooling of a liver its vascular bed is filled with solution of protein fractions of plasma or 5% solution of albumine.

At a podshivaniye of a donor liver to the recipient impose an upper anastomosis of the lower vena cava (kavo-caval) in the beginning, connect the ends of portal veins and open a portal blood stream, then impose arterial and lower kavo-caval an anastomosis. For removal of bile impose ho-letsistoyeyuno-, holetsistoduodeno-, holedokhokholedokho-or a holedokhoyeyuno-anastomosis in combination with outside drainage.

In the period of a break of a blood-groove on portal and lower hollow to veins there is a deposition of blood in the pool of a portal vein and the lower half of a trunk. Venous return of blood to heart decreases approximately by 50%, in this regard the hypovolemia develops that can lead to a considerable lowering of arterial pressure.

For the purpose of prevention of hypotension Kan (R. Y. Caine, 1979) recommends to make massive hemotransfusions, especially at the time of imposing of a clip on epinephral department of the lower vena cava and during recovery of a blood-groove in a transplant.

Before start-up of a blood-groove the transplant is repeatedly washed from products of metabolism perfuzionnsh solution.

Heterotopic the Pct is technically simpler since at it the liver of the recipient which residual function can support life activity of an organism during adaptation of a transplant or at its rejection (see is not removed. Nesovmestimost immunological ). However heterotopic the Pct has a number of the shortcomings connected as with difficulty of placement of a transplant in limited space, and with «competitive» fiziol, the relations developing between own liver (in the presence of its residual function) and a transplant.

Ways of vascular reconstruction at heterotopic liver transplantation can be with a complete recovery of inflow of blood to it and with partial due to inflow only arterial or only a venous blood (in particular, portal).

Fig. 3. The diagrammatic representation of heterotopic retroperitoneal liver transplantation across Shumakov and Galperin (with inflow of portal blood): 1 — a transplant of a liver, 2 — a liver of the recipient, 3 — an anastomosis portal and upper mesenteric veins, 4 — the general bilious channel in a hypodermic tunnel of a front abdominal wall (on the right it is visible holedokhoyeyunoanastomoz), 5 — an anastomosis hepatic and lower hollow veins, 6 — an anastomosis of the general hepatic and right ileal arteries.

In Research in-those transplantologies and artificial organs of M3 of the USSR under the leadership of V. I. Shumakov and E. I. Galperin the technique of a fence and extra peritoneal change of the left hepatic lobe (II and III segments) in the right or left ileal pole with inflow of portal blood (fig. 3) or without inflow is developed.

One of the main complications at Pct is the bleeding caused by disturbance of coagulant system of blood, a cut, as a rule, arises owing to ischemic damage of a transplant and is followed by an intravascular thrombogenesis. In such cases use of all complex of styptic drugs is justified.

For prevention and treatment of crisis of rejection use immunodepressantny drugs, cyclophosphamide, Azathioprinum, Prednisolonum, a hydrocortisone, anti-lymphocytic globulin (see. Immunotherapy ). At several recipients Starzl (1979) with success applied long catheterization of a chest channel.

By 1977 318 operations of the Pct executed in various clinics of the world are registered, and 16 patients transferred repeated change. 47 recipients lived after orthotopical change more than 9 years, and after heterotopic — more than 5,5 years. In spite of the fact that by Pct it is mastered in clinic better, than change of a lung (see) and pancreas (see), in this area there are unresolved problems concerning capture of body at the living donor at so-called brain death that is forbidden in the USSR. There are many unresolved technical and immunological aspects which are sharply limiting use of this operation in clinic.

See also Transplantation (bodies and fabrics) .



Bibliography: Shumakov V. I., etc. Change of the left hepatic lobe in an experiment and clinic, Surgery, No. 6, page 22, 1978; Calne R. Y. Transplantation of the liver, Ann. Surg., v. 188, p. 129, 1978; D a 1 o z e P. o. Enzyme replacement in Niemann — Pick disease by liver homotransplantation, Proc. 5th Int. congr. Transplant. soc., p. 607, N. Y. a. o., 1975; S t a r z 1 T. E. a. o. Liver transplantation — 1978, Transplant. Proc., v. 11, p. 240, 1979; S t a r z 1 T. E. a. o. The quality of life after liver transplantation, ibid., p. 252.


V. I. Shumakov.

Яндекс.Метрика