2021年 · 第59卷第06期

Liver transplantation is the most effective treatment for end-stage liver disease, and the shortage of donor liver is a global problem that restricts the development of liver transplantation. Split liver transplantation can effectively expand the utilization of donor liver and alleviate the contradiction of donor liver shortage. It was initially mainly used in children liver transplantation, and then gradually expanded to double adult recipients. However, the operation of left and right hemihepatic split liver transplantation is complicated, and the distribution of middle hepatic veins has been controversial. By drawing on the donor liver resection technology of living donor partial liver transplantation, and using the combination of in situ and in vitro splitting, our center adopted the complete splitting-reconstruction technology of middle hepatic vein in 2019 to form left and right liver transplants containing middle hepatic vein. Now, the case data are summarized and analyzed to explore the application effect of this technology in double adult split liver transplantation.

The patient, a 53-year-old male, was admitted to our hospital on January 9, 2018 due to "liver tumor found in physical examination for 3 days". The patient found that the lower right posterior lobe of the liver occupied space during physical examination 3 days ago. For further diagnosis and treatment, he went to our hospital for treatment. The patient had a history of chronic hepatitis B and did not receive regular treatment. Admission physical examination: dark complexion, flat and soft abdomen, no tenderness, rebound pain and muscle tension in the whole abdomen, and no percussion pain in the liver area. Laboratory tests : HbsAb (+), HbsAg (-), HbeAb (+), HbeAg (-), HbcAb (+); HBV-DNA: 16000 Iu/ml (reference: 50 Iu/ml); Alpha-fetoprotein 941.16 μ g/L (normal: 0-8.78 μ g/L), γ-glutamyltransferase negative (normal: negative), abnormal prothrombin 20 mAU/L (normal:<40 mAU/L); Indocyanine green 15 min retention rate<10%。 Upper abdominal enhanced CT examination showed a slightly low-density shadow of about 1.2 cm in diameter in the VI segment of the liver, mild enhancement in the arterial phase, and decreased enhancement in the portal and delayed phases, which was consistent with the manifestations of primary liver cancer. Upper abdominal enhanced MRI examination showed circular lesions about 1.1 cm in diameter in liver VI segment, showing low signal of T1WI and high signal of T2WI. After enhancement, the arterial phase was significantly enhanced and the venous phase was significantly reduced, which was in line with the manifestations of primary liver cancer (Figure 1）。 Combined with the patient's previous history of hepatitis B, imaging and laboratory tests. The admission diagnoses were: (1) primary liver cancer of segment VI of the liver (cT1N0M0 stage I; Barcelona stage 0; Chinese liver cancer stage IA), (2) chronic hepatitis B virus, cirrhosis (liver function compensated stage).

The patient, a 50-year-old male, was admitted to our center on September 4, 2015 due to "dull pain in the right upper abdomen for more than 1 year". The patient developed right upper abdominal pain more than 1 year ago, which was intermittent dull pain without fever, nausea, vomiting, and yellowing of the skin and sclera, which was not paid attention to at that time. Recently, I went to the local hospital for a physical examination. The results of MRI examination of the upper abdomen showed that the intrahepatic bile duct was dilated and the hilar bile duct was narrowed, thus considering the possibility of cholangiocarcinoma. The other past history and personal history of the patient were not special. Admission physical examination: No yellowing staining of skin and sclera, soft abdomen, no tenderness, rebound pain and muscle tension. Laboratory tests: ALT 260.0 U/L, AST 235.4 U/L, total bilirubin 29.8 μ mol/L, direct bilirubin 21.0 μ mol/L, alkaline phosphatase 434.7 U/L, γ-glutamyl transpeptidase 1 495.0 U/L, albumin 41.0 g/L; Tumor markers: CA19-9 and carcinoembryonic antigen were mildly elevated at 52.5 U/L and 5.5 μ g/L, respectively, negative for alpha-fetoprotein. Results of enhanced CT examination of upper abdomen: the right hepatic duct occupies space near the common hepatic duct, and the possibility of cholangiocarcinoma is high, which may involve the common hepatic duct; Intrahepatic bile duct dilatation; There is a slightly larger lymph node in the hilar; Fatty infiltration in the right lobe of the liver is possible; Abnormal perfusion of the left lobe of the liver. Clinical diagnosis: obstructive jaundice, space-occupying lesions of the hilar bile duct. Imaging assessment: The main body of the tumor lesion was biased to the right, invaded to the left to the initiation of the left hepatic duct, and did not reach the opening of the left secondary bile duct; The tumor invaded the right anterior branch of the hepatic artery and portal vein with atrophy of the right lobe of the liver, while the other branches of the hepatic artery and the left branch, bifurcation and main trunk of the portal vein were uninvaded (FIG. 1A，1B）； Regional lymph node metastasis possible. Hilar cholangiocarcinoma Bismuth type IIIA was diagnosed, and a combined right hemihepatic and total caudate lobe resection was proposed. Whole liver volume measured by 3D reconstruction software was 1 036 cm³The reserved left hemihepatic volume was 624 cm³(60.2% of the total liver volume). After repeated dynamic reading of the two-dimensional images, it was found that there was a cord-like duct structure between the Spiegel leaf and the portal vein in this patient and it directly joined into the common hepatic duct (Figure 1C）。 Computer 3D visualization reconstruction image shows that the duct structure is subportal caudate bile duct (Figure 2）。 Because the patient's bilirubin level was slightly elevated and the remaining liver was sufficient in volume, no biliary drainage of the remaining liver was performed preoperatively.

The patient, a 22-year-old female, went to the outpatient clinic of our hospital on April 11, 2020 due to "8 years after atrial septal defect repair + mitral valvuloplasty, and more than 2 months of chest tightness and discomfort after activity". Eight years ago, he was diagnosed with two-hole atrial septal defect, anterior mitral valve prolapse and severe regurgitation due to "discovery of heart murmur for more than 10 years" in an external hospital. On April 3, 2013, he underwent atrial septal defect patch repair + mitral valve annuloplasty + double-hole plasty. On May 6, 2013, external hospital echocardiography showed no atrial septal shunt, poor mitral valve closure alignment, mild regurgitation, left atrial diameter 32 mm, left ventricular end diastolic diameter 47 mm, ejection fraction 54%, and aortic sinus diameter 32 mm. After regular follow-up, there were no complaints of discomfort. In the past 2 months, the patient suffered from chest tightness and shortness of breath after conscious activity, no cough, expectoration, chest pain, inability to lie down or sit upright at night to breathe, denied the history of fever, and no edema in both lower limbs, so he went to our hospital for treatment. The patient's mother died suddenly at the age of 33. Physical examination: spider fingers, thoracic vertebra, lumbar scoliosis, refractive error-4.00 D, generally acceptable, old surgical scar can be seen in the precordial area, and systolic murmur of grade 3/6 can be reached at the apex. Echocardiography in our hospital showed that after atrial septal defect repair, there was no residual shunt at atrial level, bioral shape after mitral valvuloplasty with posterior lobe prolapse with moderate to severe mitral regurgitation, obvious widening of aortic sinus (48 mm), left atrial diameter 37 mm, left ventricular diameter 51 mm, ejection fraction 62% (Figure 1~3）。 Chest CT findings suggest that the aortic sinus is widened (Figure 4). Admission was diagnosed as Marfon's syndrome, atrial septal defect and post-mitral valvuloplasty, mitral insufficiency, aortic root tumor, and cardiac function (New York Heart Association classification) grade II.

The 53-year-old male patient was hospitalized in the emergency department of Shunyi District Hospital in Beijing on September 16, 2019 due to "nose and mouth bleeding caused by head and face injury after drunkenness". The next day, the patient was conscious and felt blurred vision in his left eye. Physical examination: bilateral pupils were 3 mm in diameter and sensitive to light reflection; The corrected visual acuity of the right eye was 0.6, and the left eye was 0.3; The left eye cannot be abducted. Craniomaxillofacial CT findings showed left mandibular branch fracture, maxillary LeFort type III fracture, left maxillary sinus anterior and lateral wall fracture, left orbital apex fracture, left simoid plate fracture and sella turcica fracture, without intracranial hemorrhage (FIG. 1A,1C）。 The patient's past history was not special. On the fourth day of hospitalization, the patient had two consecutive massive epistaxis, and an otolaryngologist was asked to perform tamponade to stop bleeding. The MRI of the head showed that 5 new lacunar infarctions were observed in the center of the left hemioval (Figure 1D）； The results of magnetic resonance angiography (MRA) showed obvious stenosis of the superior clinoid of the left internal carotid artery (Figure 1E）； The results of three-dimensional time leap MRA indicated that there were conical protrusions in the lumen of the artery, and the proximal and distal walls were smooth, without atherosclerotic changes, which highly suspected the formation of arterial dissection (Figure 1F）。 At the same time, the patient complained of persistent blowing-like murmur in his left ear, so he was admitted to the neurosurgery department for digital subtraction angiography (DSA) of the whole brain on September 20, 2019. The results of left internal carotid artery angiography showed 80% stenosis of the arterial lumen with retention of contrast medium, and no internal carotid cavernous fistula was seen; See also that the initial part of the posterior communicating artery is filled with contrast medium, while the distal part and the posterior cerebral artery are not developed (Figure 1G）。 3T high-resolution magnetic resonance black blood imaging technique was used to further understand the morphology of the arterial wall here. The results showed that there were two intimal flaps protruding into the lumen in the wall here; The lateral wall of the proximal vessel was thickened, and T1WI showed a crescent-shaped slightly high signal shadow; Both were mildly enhanced during the enhancement period, and traumatic dissection of the superior clinoid segment of the left internal carotid artery was confirmed (Figure 2）。

The patient, a 57-year-old female, was admitted to the hospital on September 14, 2020 due to "pain in the left knee joint for more than 4 years, aggravated for 4 months". Four years ago, the patient had mild left knee joint pain without obvious trigger, which was aggravated during activity, and there was no discomfort such as fever. He visited the outpatient department of our hospital and underwent CT and MRI examination of the left knee joint (May 2016). The results showed injury of the lateral collateral ligament of the left knee, calcification of the lateral femoral condyle, and degenerative osteoarthrosis of the left knee (FIG. 1A、1B）。 Considering the diagnosis of "left knee lateral collateral ligament injury", the pain was relieved after treatment with left knee immobilization and oral non-steroidal anti-inflammatory drugs, and no re-examination was performed. Four months ago, the patient experienced aggravation of left knee pain without obvious trigger, accompanied by "interlocking sensation", and went to the outpatient department of our hospital again. X-ray and MRI examination of the left knee were performed (August 2020), and the results showed that the calcification of the lateral femur paracondylar of the left knee was significantly larger than before, the lateral collateral ligament of the left knee was injured, and the medial meniscus was injured 2nd degree (Figure 1C、1D）。 Conservative treatment such as analgesia, TCM physiotherapy and rest was given for more than 3 months, but the effect was not good. Later, we were admitted to our department for further treatment. Physical examination: Vital signs were stable, there was no obvious swelling or deformity of the left knee joint, obvious tenderness of the left lateral femoral condyle, flexion and extension of the left knee was 0 ° ~90 °, and the pain was aggravated during activity, the internal and external valgus test was negative at 0 ° and 30 °, the blood supply of the extremities was sufficient, and there was no hypoesthesia. Laboratory tests: There were no abnormalities in blood routine, biochemical examination, high-sensitivity C-reactive protein and other indexes. Admission diagnosis: calcified popliteal tendonitis of the left knee.

Operating is a highly addicting habit.

Surgeons are the fighter pilots of the medical profession.