2 orthotopic liver transplantation alias classic orthotopic liver transplantation; Orthotopic liver transplantation; Orthotopic liver transplantation
Classification 3 Pediatric Surgery/Liver Surgery/Liver Transplantation
4 ICD coding 50.59
5 Overview Liver transplantation was first proposed by Tack Cannon in 1956. Moore et al completed the experimental study of animal liver transplantation in 1960. 1963 Starzl completed the world's first orthotopic liver transplantation for a child with congenital biliary atresia. At that time, due to lack of clinical experience and effective anti-rejection drugs, the initial 1 year survival rate of liver transplantation was less than 20%. After 1980s, due to the progress of transplantation technology, the bypass technique and cyclosporine (CsA) were adopted in anhepatic stage, which increased the 1 year survival rate to 60% ~ 75%, especially for children, and the 2-year survival rate reached 80%. Besides age, the difference of primary disease is the more important reason. The main target of liver transplantation in children is biliary atresia, followed by metabolic diseases and sclerosing diseases. Malignant liver tumors in children are rare. With the improvement of survival rate, liver transplantation has really become an acceptable treatment for end-stage liver disease. From 65438 to 0987, the University of Wisconsin developed the organ preservation solution-UW solution, which extended the cold ischemia time of the liver to 24 hours. The results of this study greatly improved the quality of donor liver preservation and significantly reduced the complications caused by donor liver preservation, such as primary graft dysfunction. The appearance of UW solution prolonged the preservation time of donor liver, and some new technologies, such as reduced size liver transplantation, split liver transplantation and living donor liver transplantation, came into being. 65438-0989 Japan introduced a new immunosuppressant FK506 for clinical application. It has a high reversal rate for refractory acute and chronic rejection, and can be used alone or in combination with hormones, especially for refractory rejection of CsA and hormones. With the introduction of new potent immunosuppressants into clinic, the success rate of liver transplantation has been greatly improved. Tzakis first reported piggyback technique in 1989, which was later praised by many scholars, especially in orthotopic liver transplantation in children. Because bypass technique is not used in anhepatic period, all kinds of pathophysiological interference caused by bypass process are avoided, and the incidence of postoperative complications is greatly reduced. The current data show that the clinical effect of orthotopic liver transplantation in children is better than that in adults, which may be related to the short onset time of children and the difference of immune status between children and adults. In recent years, due to the improvement of surgical techniques and the application of new immunosuppressants, the clinical application of orthotopic liver transplantation in children has developed rapidly and the curative effect has improved year by year.
Orthotopic liver transplantation, or classic orthotopic liver transplantation, refers to the removal of the diseased liver of the recipient together with the inferior vena cava, and the reconstruction and restoration of the continuity of the outflow tract and inferior vena cava of the donor liver. This kind of operation is often used in the early stage of liver transplantation. Because it is different from piggyback liver transplantation later, it is called traditional or classic operation. In orthotopic liver transplantation, the inferior vena cava must be blocked and extracorporeal bypass of the inferior vena cava and portal vein system should be used at the same time. Bypass technology is not only complicated, but also may lead to many complications. In 1987, Wall et al reported 50 cases of orthotopic liver transplantation, of which 47 cases did not adopt bypass. They think that orthotopic liver transplantation can be performed without routine venous bypass (figure12.6438+08.8.338+01).
Indications for orthotopic liver transplantation are as follows:
6. 1. 1. End-stage liver disease In theory, liver transplantation can be considered for children with liver diseases that can't be cured by all conventional internal and surgical treatments and can't be expected to avoid death in a short time. Where is the serum bilirubin > 256.5? Molar/liter; If the prothrombin time is prolonged for more than 5s, vitamin K can't be corrected, serum albumin is less than 25g/L or hepatic encephalopathy can't be maintained normal after drug treatment, all these are indications for liver transplantation. In children, biliary atresia and congenital metabolic abnormalities are the main diseases, such as α 1 antitrypsin deficiency, glycogen storage disease and hepatolenticular degeneration syndrome, accounting for about 18% of children's liver transplantation. Followed by primary or secondary biliary cirrhosis, Buka syndrome, sclerosing cholangitis, hepatic cystic fibrosis with liver cancer and so on.
6.2 2. Hepatoblastoma is more common in children's liver malignant tumor, and it is usually appropriate to treat the tumor with conventional hepatectomy and no distant metastasis outside the liver. Generally, the liver function of these children is not seriously damaged, and the success rate of operation and short-term survival rate after operation are high, but they are easy to relapse after transplantation.
6.3 3. The prognosis of fulminant liver failure is extremely poor. Liver transplantation may save the lives of some sick children. Because it is difficult to obtain an ideal donor liver for emergency liver transplantation, living donor liver transplantation can be used at present.
No matter what causes the end-stage changes of liver disease, liver transplantation should be performed before extreme liver failure to reduce mortality and postoperative complications.
According to some data, the main targets of liver transplantation under 15 years old are biliary atresia (50%), metabolic diseases (16%) and various sclerosis diseases (12%), while malignant tumors only account for 7%. Due to the lack of donor liver in children, living donor liver transplantation has been adopted in recent years, that is, a part of adult liver (usually the left lateral lobe of liver) has been removed, and orthotopic transplantation of children recipients has been successful. This method opens up a new prospect for pediatric liver transplantation (figure12.18.8.12 ~12.18.8.14).
7 contraindications 1. Malignant tumor diseases other than liver.
2. Serious infection of important organs outside the hepatobiliary system.
3. Systemic diseases, such as congenital cardiovascular diseases and renal insufficiency.
4. Portal vein thrombosis.
5. The fulminant liver failure is positive for hepatitis B antigens (HBsAg and HBeAg), and the recurrence rate of hepatitis after operation is almost as high as 100%, but it can still survive for a long time through effective medical treatment.
8. Preoperative preparation 8. 1. 1. It is very necessary to fully understand the general situation of sick children, measure the weight and height of the recipients, conduct B-ultrasound and CT examinations, and understand the size of the liver. Compared with heart and kidney transplantation, the incidence of rejection after liver transplantation is lower, so the tissue matching is generally dominated by blood group A, B and O. It is best for recipients with negative serum cytomegalovirus (CMV) to receive CMV-negative donor liver. If they receive CMV-positive donor liver, the chances of CMV infection after liver transplantation will increase significantly. If a sick child needs to transplant an adult donor liver after hepatectomy, due to space constraints, reduced-size liver transplantation or simultaneous splenectomy can be considered. The author's hospital once implanted adult donor liver for children aged 14, and removed spleen at the same time. Now he has survived healthily for 3 years and 4 months.
8.2 2. Preoperative evaluation of hepatobiliary system must be based on various imaging methods and experimental detection methods (B-ultrasound, CT, MRI or MRCP) to diagnose the primary disease. The following blood tests should be routine: ① serological markers of hepatitis B, HBsAg, HBsAb, HBeAg, HBeAb, HBcAb and HBVDNA；; ② HCV markers, HCVAb and HCVRNA；; ③ Anti-nuclear antibody; ④ Anti-mitochondrial antibody (AMA); ⑤EB virus antibody; ⑥ Cytomegalovirus (CMV); ⑦ Alpha fetoprotein (AFP); Carcinoembryonic antigen (CEA); Pet-name ruby ⑨HIV antibody; Attending the determination of liver function, renal function, blood sugar, coagulation, blood K+, Na+ and Cl-.
For children with suspected portal vein or mesenteric vein thrombosis, it is necessary to check the above veins and even vena cava by color Doppler ultrasound.
8.3 3. Before operation, the recipient was examined for organ function, including heart, kidney, lung, blood system and gastrointestinal system.
8.4 4. Preoperative psychological and sociological evaluation should be made for children and their families to ensure that they have full understanding and cooperation on the complexity, danger and a series of related problems of the operation.
8.5 5. In the process of waiting for the donor liver, all kinds of complications caused by the recipient's primary disease should be dealt with actively and effectively. 8.6 6. Tissue liver transplantation of liver transplantation team is a very complicated and delicate work. The preoperative organization of liver transplantation team is very important. It usually consists of donor group, recipient group and anesthesia group. The departments participating in the cooperation should at least include pediatric surgery, hepatobiliary surgery, cardiac surgery, laboratory, hematology, microbiology, immune room, blood bank, pathology, radiology and pharmacy. Before clinical liver transplantation, all these departments should cooperate.
General anesthesia or continuous epidural anesthesia plus inhalation general anesthesia is usually used for anesthesia and * *. Intraoperative anesthesia monitoring is very important, including electrocardiogram (ECG), oxygen saturation (SPO2), end-expiratory carbon dioxide concentration (EtCO2), airway pressure, ventilation, arterial pressure through radial artery, and a set of hemodynamic parameters of inserting a floating catheter (SwanGanz) through central vein. During anesthesia, it is necessary to accurately grasp the amount of blood transfusion, accurately record the amount of urine per hour, and ensure the balance of body fluids.
10 Steps The key to the success of children's liver transplantation is to obtain excellent donor liver as much as possible, fine surgical operation and mature perioperative management.
10. 1. 1. Obtaining donor liver There is no brain death legislation in China, and donor liver can only come from dead bodies without heartbeat. This requires that the donor liver must be obtained in the shortest time (usually less than 5 minutes). Once the thoracoabdominal cavity is opened, the abdominal aorta (above iliac artery) and superior mesenteric vein (or portal vein) are perfused immediately, and the perfusion fluid is usually 4℃ lactate Ringer's solution or UW solution. 2000ml was perfused through abdominal aorta and 1000ml through superior mesenteric vein, and the perfusion pressure was maintained at 100mmHg. Attention should be paid to controlling the amount of liquid during perfusion to prevent the donor liver from edema due to too much liquid, which will lead to liver function damage. During perfusion, sterile ice cubes were placed around the liver, and the liver was free when the perfusion solution reached 2/3 or nearly complete. At the same time, UW solution was used to rinse the biliary tract repeatedly. Simple gallbladder irrigation may not be enough for intrahepatic biliary irrigation, so it should be washed again after cutting off the lower end of the common bile duct to ensure the bile removal of the whole intrahepatic and extrahepatic bile ducts. Incomplete biliary tract irrigation may lead to biliary complications after transplantation, such as bile duct stenosis and gallstone formation.
After entering the abdomen, release and cut off all ligaments of the liver, expose the superior and inferior hepatic vena cava, and at least keep the inferior hepatic vena cava of 1cm or longer. The inferior hepatic vena cava is usually cut off above the level of renal vein. When the donor liver is removed, the hepatoduodenal ligament is cut as close as possible to the duodenum to preserve the long blood vessels and bile ducts. Because the hepatic artery is small, although the donor-recipient hepatic artery anastomosis can be completed, it is easy to form thrombus or embolism, which leads to the failure of liver transplantation. Therefore, the hepatic artery must be free from the abdominal aorta, and a part of the abdominal aorta must be cut off to enlarge it, which can greatly reduce thrombosis or embolism. When the donor hepatic artery has branches, its shape should be convenient for anastomosis. When the celiac artery is separated, sometimes two or more phrenic arteries can be found and should be treated (Figure12.18.8.15).
0 ~ 4℃ liver perfusion solution (containing heparin 1000U) was injected into portal vein through catheter, and the flow rate was 100ml/min until the liver was bloodless and cooled, and the perfusion solution containing enough plasma protein continued to maintain lavage. After lavage, the rapidly resected liver should be put into frozen normal saline, and the dissected liver, especially the phrenic artery, must be found and ligated, otherwise there may be bleeding after hepatic vascular reconstruction, which is difficult to handle. In this process, continue to lavage the biliary tract until there is no bile. It must be pointed out that liver resection time and cooling time are closely related to liver function after liver transplantation, and the time of donor liver, recipient liver resection and donor liver cold preservation should be shortened as much as possible.
The repair of donor liver should be very detailed, and the surface of the liver should be thoroughly examined to remove all ligament tissue, diaphragm tissue and connective tissue attached to the liver. At the same time, the superior hepatic vena cava and inferior hepatic vena cava were controlled by noninvasive vascular forceps, and the perfusion solution (UW solution) was dripped to check whether the hepatic artery, portal vein and vena cava were leaking. All the loopholes that can be found must be sutured with non-invasive thread. When trimming the common bile duct, the connective tissue around it should be preserved to avoid affecting the blood supply of the bile duct after anastomosis. In the process of repairing the liver, pay attention to protecting the short hepatic vein. In order to save the dosage of UW solution, some hospitals in China also used UW solution and Ringer solution for cross lavage, and achieved ideal results. But in principle, UW solution should be used as preservation solution.
10.2 2. When resecting the diseased liver, use multifunctional or suspended retractor to ensure good exposure. After entering the abdomen, the perihepatic ligaments were cut off respectively, and then the first hepatic portal, the second hepatic portal and the inferior vena cava were dissected in turn. Classical liver transplantation does not need to dissect the third hepatic portal, but only needs to free the posterior wall of the superior and inferior hepatic vena cava and keep enough length for anastomosis. The anatomy of the first hepatic portal should be as close to the liver as possible, and the bile duct disconnection should be above the cystic duct level, which is equivalent to the bifurcation of the left and right hepatic ducts. The anatomy of hepatic artery should follow the proper hepatic artery upward, divide the left and right hepatic arteries and cut them off at the bifurcation. The portal vein can be seen behind the portal vein, which should be separated from the surrounding lymphoid tissue and cut off at the high position of the hepatic portal. If the patient needs intraoperative bypass, the bypass pump can be turned on at this time. The vena cava can be dissected at the beginning of bypass. Some children with advanced liver disease have a large number of collateral vessels on the surface peritoneum of the inferior vena cava due to portal hypertension, so these vessels must be carefully ligated. The three hepatic veins at the second hepatic portal need not be dissected and separated, only the superior and inferior vena cava can be completely separated, which is different from piggyback liver transplantation. The separation of inferior hepatic vena cava is relatively easy than the separation of superior and inferior hepatic vena cava. It is usually cut off at the level of renal vein. Once the inferior hepatic vena cava is cut off, the liver can be turned upside down, and the superior and inferior hepatic vena cava can be cut off above the hepatic vein, thus the diseased liver can be removed (Figure12.6438+08.8.606 ~12.50060.000000000001
After the beginning of anhepatic period, special attention should be paid to electrolyte monitoring and possible metabolic acidosis should be corrected in time. Hemostasis of wound and diaphragm after hepatectomy is particularly important. Before achieving a satisfactory hemostasis effect, the donor liver must not be blindly implanted, otherwise it will be difficult to stop bleeding after implantation.
The application of bypass technique is a great technological progress in classical orthotopic liver transplantation, which has the advantages of solving the congestion of portal vein and inferior vena cava and reducing the oozing caused by excessive portal vein pressure. But at the same time, it also has its inherent shortcomings, such as long time consuming, increased blood transfusion, especially coagulation dysfunction and pathophysiological interference caused by systemic heparinization. In recent years, due to the rapid development of liver transplantation technology in China, the anhepatic period of liver transplantation has been significantly shortened, which makes some scholars begin to re-understand the bypass technology. At present, quite a few hospitals have not adopted this technology. Practice shows that the operation can be carried out smoothly without bypass.
10.3 3. After donor liver repair, once the diseased liver is removed, it can be implanted into the donor liver. The superior and inferior hepatic vena cava should be anastomosed first, and the posterior wall and anterior wall should be sutured continuously with acrolein line 30 or 40. Pay special attention to the sewing of the back wall, and sew it back and forth twice if necessary. If the posterior wall anastomosis is not accurate, it will be difficult to deal with the leak once it is loosened. The anastomosis method of inferior hepatic vena cava is the same as above. The anastomosis of portal vein and hepatic artery usually uses 50 or 60 sutures. Portal vein is usually anastomosed end to end. If the donor portal vein and the recipient portal vein are too long, they should be trimmed so that they will not be distorted or strained due to too short (Figure12.18.816.5438+02.18.838+06.538. Hepatic artery anastomosis is very important. It is necessary to ensure that the hepatic artery has enough blood flow and the intima of the artery is not damaged. Usually, the donor celiac artery trunk is anastomosed with the recipient's common hepatic artery by continuous suture. After hepatic artery anastomosis, the hepatic artery blood flow should be measured when conditions permit, and if the blood flow is not smooth, the reason should be found immediately (Figure12.18.8.12.18.8.13). The above-mentioned blood vessels should not be tied too tightly during anastomosis, so as to facilitate the expansion of the anastomosis after blood flow is opened and prevent the stenosis of the anastomosis after operation. Before you are ready to open the blood flow, you should first bleed 50 ~ 100 ml. The classic liver transplantation usually draws blood from the inferior hepatic vena cava to drain the UW fluid accumulated in the liver, and then opens the superior hepatic vena cava, inferior hepatic vena cava and portal vein occlusion forceps in turn. If the donor's liver function is good, bile outflow can be seen within a few minutes after perfusion. If the diameters of donor and recipient bile ducts are similar, end-to-end anastomosis is generally used for bile duct reconstruction, and RouxY anastomosis of common bile duct can also be considered if the recipient bile duct is thin or diseased. If T-tube is needed, it should be led out from the common hepatic duct above the anastomosis (distance from the anastomosis 1 ~ 1.5 cm). After biliary anastomosis, the whole liver transplantation process was completed, and multiple drainage tubes were placed under the diaphragm and liver respectively.
If the donor liver is an adult liver (figure12.18.8.16.5438+04 ~12.16.5438+07).
Complications 1 1 The most common complications after liver transplantation are pulmonary complications, intra-abdominal bleeding and vascular complications, biliary complications, rejection and graft dysfunction.
11.1.1.Prevention of pulmonary complications After returning to ICU, tracheal intubation could not be removed. The ventilator should be set according to the spontaneous breathing frequency, continuous detection of blood oxygen saturation and blood gas analysis results. Adults generally need auxiliary ventilation twice every three spontaneous breaths, and children can refer to it. Oxygen saturation should be kept above 95%, and oxygen concentration should reach 40% ~ 70%. In order to make sick children wake up as soon as possible, heat preservation measures should be taken. Tracheal intubation is usually removed within 24 hours. At the initial stage after operation, the results of blood gas analysis should be obtained as soon as possible so as to adjust the settings of ventilator immediately. After each ventilator is set, the blood gas analysis should be reviewed regularly and the ventilator settings should be fine-tuned. The detection of minimum ventilation and maximum airway pressure is helpful to judge the lung condition. Postoperative atelectasis is most likely to occur, mostly due to weak spontaneous breathing and ineffective discharge of tracheal secretions. Therefore, routine chest X-ray examination should be performed every day after operation. Once atelectasis occurs, it is necessary to strengthen the assistance to the sick child in expectoration, turn over and pat the back regularly, and let the sick child blow balloons to make the lungs expand better. The best way to prevent atelectasis is to avoid premature extubation, and the timing of extubation should be to keep the airway unobstructed until the lung function is enough to fully inflate the lung. Of course, you should also refer to the oxygen analysis parameters after shutdown.
After liver transplantation, the reopening of blood flow significantly increased the blood entering the inferior vena cava through the hepatic vein, resulting in a significant increase in cardiac preload. In the compensatory period of right heart function, it only shows pulmonary hypertension and pulmonary congestion. Once decompensated, heart failure occurs. Therefore, medication should be taken to dilate veins and reduce preload. At this time, the participation of cardiologists is essential. The management of tracheal intubation is very important at the stage when tracheal intubation has not been removed. Once the chest X-ray shows changes in lung inflammation, effective antibiotics should be selected. The dosage of immunosuppressants is large, and long-term use of broad-spectrum antibiotics after operation can lead to fungal or viral pneumonia. To avoid the above problems, the best way is to find out the best dose of immunosuppressant as soon as possible after operation and avoid long-term use of broad-spectrum antibiotics. Once it happens, antifungal and antiviral drugs should be selected.
1 1.2 2. Liver function evaluation is an important link in postoperative management. Generally, comprehensive judgment can be made according to the amount and color of bile, the mental state of the sick child, the changes of acidosis, and the recovery of liver and kidney function and coagulation function. The quantity and color of bile is a very important index to judge the new liver function. For a well-functioning transplanted liver, the amount of bile should exceed 100ml within 24 hours, and the bile is golden yellow and sticky, with little bile. Light green or watery usually indicates poor liver function. Serum transaminase (ALT and AST) levels are positively correlated with the degree of hepatic ischemic injury. Transaminase reached its peak 2 ~ 3 days after operation, and then decreased rapidly, indicating that liver function was good. If transaminase does not drop but rises, it will exceed 500U/L or even jaundice will deepen, indicating poor liver function. Children with preoperative renal insufficiency can recover renal function immediately or gradually if the new liver function is good after transplantation. However, renal insufficiency occurs immediately after operation, which often indicates the early hepatic insufficiency of the new liver. For the imbalance of water, electrolyte and acid-base that may occur in the early stage of transplantation, the liver function is good and can be corrected within 24 ~ 48 hours, while intractable acidosis indicates early abnormal liver function. Whether the coagulation function is normal before operation and the transplanted new liver function is good, the coagulation function can be normal the next day after operation. The early manifestations of liver transplantation are coma, renal failure, acidosis, persistent abnormal coagulation function, little or no bile and progressive increase of serum transaminase. The main reasons for the non-function of the transplanted liver can be summarized as follows: ① The warm ischemia time is too long when the donor liver is harvested; ② The donor liver was preserved by cold perfusion; ③ Great vascular embolism after transplantation, mainly hepatic artery embolism. The second liver transplantation should be done as soon as possible.
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1 1.3 3. The treatment of intra-abdominal hemorrhage is a common problem after liver transplantation, which may be caused by the lack of some technical links in the operation or the failure to synthesize coagulation factors in the early newborn liver after transplantation. The diagnosis of intra-abdominal hemorrhage is mainly through careful and continuous observation of vital signs, hemodynamics, hematocrit and peritoneal drainage. If there is a large amount of bleeding in a short time and it is judged that there may be active bleeding, we should decisively open the abdomen to stop bleeding and suture or clamp the bleeding point found. If there is a large area of bleeding on the wound and there is no active bleeding point, it should be bandaged and compressed with hot physiological saline gauze for 20 ~ 30 min, and then sprayed with argon knife or fibrin gel. After the above treatment, we can stop bleeding. The combined application of fresh frozen plasma, platelets, fresh blood and various hemostatic drugs after operation is also very important. The most important thing to prevent postoperative bleeding is to stop bleeding strictly in every link of the operation, and the anastomosis of each blood vessel should be foolproof.
1 1.4 4. The incidence of preventing hepatic artery thrombosis during liver transplantation for children with vascular occlusion is higher than that of adult liver transplantation, because the hepatic artery in children is thin, and anastomotic stenosis may lead to thrombosis due to improper anastomosis or arterial spasm. Complete occlusion of hepatic artery may lead to liver necrosis, elevated serum transaminase, sudden decrease of bile secretion and severe acute liver failure. Hepatic artery thrombosis may also be a recessive process. After operation, children have repeated fever and transaminase increases progressively. Because the nutrient vessels of the common bile duct mainly come from the hepatic artery, once hepatic artery thrombosis occurs, it can lead to ischemic necrosis of the common bile duct, bile leakage and finally bile duct stenosis and other complications. The most effective method for clinical diagnosis of hepatic artery embolism is color Doppler ultrasound. If there is no pulsatile blood flow in the hepatic artery, it means that the hepatic artery is not smooth, and celiac arteriography can make a definite diagnosis. To prevent hepatic artery thrombosis, dextran 40( 10ml/h, continuous intravenous drip 1 ~ 2 weeks) or subcutaneous injection of heparin, and oral aspirin (150mg, thrice /d) and dipyridamole (75mg, thrice /d) are generally given after operation. Once hepatic artery embolism occurs, it should be treated urgently, and hepatic artery reconstruction is feasible, that is, the donor hepatic artery is end-to-side anastomosed with the recipient abdominal aorta, and a second liver transplantation should be carried out when conditions permit.
Portal vein thrombosis is less likely to occur than hepatic artery thrombosis, which is mostly caused by improper operation, such as portal vein wall injury, anastomotic stenosis or deformation after anastomosis. Its main clinical manifestations are hepatic ischemia, portal hypertension, hepatic insufficiency, jaundice and rapid formation of abdominal ascites. The diagnosis can be confirmed by B-ultrasound, and it is feasible to remove thrombus by surgery. When liver failure occurs, a second liver transplantation can be carried out.
1 1.5 5. The causes of bile leakage after bile leakage transplantation are as follows: ① when the common bile duct is anastomosed end to end, the anastomosis operation is wrong or the anastomosis tension is too high; ② Ischemic necrosis of bile duct wall is often caused by excessive detachment around the common bile duct during donor liver repair or recipient liver resection, which damages its blood supply. Once bile leakage occurs, the sick child may have signs of peritonitis, fever and ascites. The leakage site is most common at the anastomotic site or other parts of bile duct far from the anastomotic site, and can also be located at the exit of T tube. Small bile leakage can be cured by effective abdominal drainage, and severe bile leakage, such as biliary peritonitis, should be operated immediately, re-anastomosed or switched to RouxY anastomosis of common bile duct and jejunum. If bile leakage is caused by incomplete ligation of hepatic bile duct branches in liver transplantation, it must also be treated surgically.
1 1.6 6. The key to the success of liver transplantation is to effectively control the immune rejection. Acute rejection usually occurs at 6 ~ 10 days after operation or at any time within 3 months after operation. Its clinical manifestations are fever, listlessness, epigastric pain, jaundice, serum transaminase, alkaline phosphatase, γ -glutamic acid transpeptidase and bilirubin increase. B-ultrasound can indicate that the volume of liver increases rapidly, and the amount of bile drained by T-tube decreases sharply, and the color is light and thin. When acute rejection is suspected clinically, fine needle aspiration biopsy should be performed. The typical histological changes are that a large number of activated lymphocytes infiltrate around the portal area and extend to the liver parenchyma, bile duct epithelium and vascular endothelium damage around the central vein, interstitial edema and cholestasis around the hepatic lobule. Once diagnosed, methylprednisolone 1000mg was given immediately for 2 ~ 3 days, and then reduced to the maintenance dose. For refractory rejection caused by hormone resistance, anti-thymocyte immunoglobulin (ATG) pulse therapy can be used for 4 ~ 5 days, and OKT3 can also be used. Conventional anti-rejection therapy after operation mostly adopts "triple therapy", that is, methylprednisolone+cyclosporine A+ azathioprine. The initial dose of methylprednisolone is 200mg per intravenous injection, four times a day, and then it is maintained at a decreasing rate of 40mg to 20mg per day, and then decreases after 1 month. Intravenous injection of cyclosporine A3 ~ 5 mg/(kg d), azathioprine1~1.5 mg/(kg d). The above drugs are used for 2 ~ 4 weeks. Blood concentration should be monitored during medication.
1 1.7 7. Controlling infection Generally speaking, bacterial and fungal infections mostly occur 2-4 weeks after liver transplantation, while viral infections are mainly cytomegalovirus (CMV) infections, which mostly occur within 3 months after transplantation. The main reasons are as follows: ① The use of immunosuppressants, especially high-dose hormones, reduces the body's immunity and is prone to infection; ② Intraoperative portal vein occlusion leads to intestinal hyperemia and hypoxia, and intestinal defense barrier is damaged, which leads to intestinal bacteria migrating into abdominal cavity; ③ After the blood flow into the liver was reconstructed and opened, a large number of bacteria and endotoxin entered the portal vein; ④ Contamination during cholangioenterostomy; ⑤ Long-term use of broad-spectrum antibiotics leads to fungal infection.
Among bacterial infections, the most common bacteria are Escherichia coli, Proteus, Enterococcus, Pneumococcus and Staphylococcus aureus. But most of them are mixed infections. The clinical manifestations may include lung infection, incision and intra-abdominal infection, liver abscess and biliary tract infection, and in severe cases, systemic bacteremia and septicemia may occur. According to bacterial culture and drug sensitivity test, antibiotics should be selected reasonably for infections in the above different parts. When there is a localized abscess in abdominal cavity or liver, it should be drained immediately.
Fungal infection mostly occurs in children with abnormal liver function or early bacterial infection after liver transplantation. Common fungi are Candida and Aspergillus. The clinical manifestation is high fever, and general anti-infection treatment is ineffective. There are shadows in the lungs on the chest film, and there are fungi in the incision, drainage bile and ascites. In order to prevent fungal infection, perioperative intestinal decontamination treatment is feasible, and fluconazole can be taken orally. When fungal infection occurs, Dafukang can be used. The drug is toxic to liver and kidney, so it should not be used for a long time, and it should not exceed 2 weeks at most.
Cytomegalovirus infection still occurs frequently after liver transplantation in children. The reason is that 2/3 of the natural population are asymptomatic CMV carriers, which are activated due to low immune function after transplantation or virus brought in during blood transfusion. When the donor CMV antibody is positive and the recipient CMV antibody is negative, the incidence rate is high. The main clinical manifestations are fever, leukopenia, thrombocytopenia and abnormal liver function. Sick children may have diarrhea, namely cytomegalovirus enteritis, or focal pneumonia. The diagnosis adopts the method of combining monoclonal antibody with early virus antigen. Indirect immunofluorescence test can detect CMV positive, and combined with clinical manifestations, the diagnosis can be made. At present, ganciclovir intravenous drip and CMV immunoglobulin are widely used in treatment.
1 1.8 8. Prevention and treatment of renal insufficiency