2023年 · 第61卷第07期

Donor liver shortage is the main obstacle that limits the development of liver transplantation. Split liver transplantation and domino liver transplantation, as special types of liver transplantation, can alleviate the problem of donor liver shortage and shorten the waiting time of recipients^{［1, 2］}。 However, there are few reports of split liver transplantation and domino liver transplantation at home and abroad. In December 2021, the organ transplantation center of our hospital completed one case of left and right hemihepatic split liver transplantation, and at the same time, one case of domino liver transplantation was completed by using the diseased liver of one patient as domino donor liver. All patients recovered smoothly after operation. The summary experience is reported below.

The patient, a 63-year-old female, came to our hospital on August 16, 2017 mainly because of "skin sclera yellowing for more than 1 month". One month ago, the patient developed skin yellowing without obvious trigger, accompanied by decreased appetite, nausea, no vomiting, dark yellow urine, lighter stool color, no abdominal pain and abdominal distension. On August 3rd, an abdominal ultrasound examination was performed in an external hospital, and the results showed that the gallbladder was enlarged, and the intrahepatic bile duct and the upper segment of extrahepatic bile duct were dilated. The results of MRI showed thickening of the biliary duct wall in the hilar and local soft tissue mass. Laboratory tests: ALT 154 U/L, AST 150 U/L, total bilirubin 388.6 μ mol/L, direct bilirubin 282.1 μ mol/L. On August 14th, he was treated with percutaneous hepatic puncture biliary drainage in a foreign hospital. About 500 ml of bile was drained daily, and his jaundice improved. He was consulted in our hospital for further treatment. Previous history of hypertension and diabetes for more than 10 years, all of which were controlled by oral drugs. There was no history of surgery and family history of tumor. Enhanced CT examination was performed when admitted to the hospital, and the results showed that the wall of the hilar bile duct was localized and thickened, with the possibility of malignant space occupation; Magnetic resonance cholangiopancreatography findings suggested segmental stenosis of the hilar bile duct with cystic duct involvement (Figure 1). Laboratory test: platelet count 188×10⁹/L, hemoglobin 109 g/L, white blood cell count 8.06×10⁹/L, neutrophils 5.98×10⁹/L; Tumor markers: carcinoembryonic antigen 2.78 μ g/L, alpha-fetoprotein 4.73 μ g/L, CA19-9 630.4 U/ml, CA125 16.6 U/ml. ALT 69 U/L, AST 56 U/L, alkaline phosphatase 321 U/L, glutamyltransferase 326 U/L, albumin 33 g/L, total bilirubin 229.51 μ mol/L, direct bilirubin 148.32 μ mol/L.

The 49-year-old male patient was admitted to our hospital on February 28, 2020 due to "intermittent dull pain in the right upper abdomen for more than 2 months". Two months ago, the patient had intermittent dull pain in the right upper abdomen without obvious trigger, without radiation pain. Taking "anti-inflammatory and choleretic tablets" orally, during which the symptoms worsened, went to the local hospital for enhanced CT examination of the upper abdomen, and the results showed that the liver was solid and occupied, so liver cancer was considered; Hepatitis B was diagnosed by laboratory tests, and oral entecavir tablets (0.5 mg/d) were given as antiviral therapy. He was consulted in our hospital for further treatment. Nothing special in the past. My mother had suffered from liver cirrhosis and died of "liver disease". Physical examination after admission showed no obvious positive signs. Laboratory test: alpha-fetoprotein>1 210.00 μ g/L, carcinoembryonic antigen and CA19-9 were in the normal range, hepatitis B surface antigen, surface e antibody and core antibody were positive, and hepatitis B virus DNA quantitative detection was 549 IU/ml. The Child-Pugh classification for liver function was A. The results of abdominal enhanced MRI on admission showed that the right lobe of the liver occupied space, the size was about 10.3 cm ×10.7 cm ×14.3 cm, with uneven enhancement in the arterial phase, decreased enhancement in the venous phase and delayed phase, and multiple embolization in the vena cava, right hepatic vein, right branch of the hepatic portal vein and main trunk; Liver cirrhosis, splenomegaly (Figure 1). According to the "Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2019 Edition)", the preliminary diagnosis is: (1) primary liver cancer, Chinese liver cancer stage IIIA; The clinical stage of liver cancer in Barcelona is stage C; (2) Chronic hepatitis B; (3) Liver cirrhosis; (4) Splenomegaly and hypersplenism.

The patient was a 29-year-old female who was admitted to the hospital on 15-Aug-2022 due to "Physical examination found that the pancreatic head occupied space for 3 weeks". The patient claimed that he had no abdominal distension, abdominal pain, vomiting and hematemesis on weekdays, and ultrasound examination found a cystic mass in the head of the pancreas during physical examination. Further enhanced MRI examination of the pancreas showed that there was a round-like space occupying the head of the pancreas with a maximum diameter of about 4.7 cm, which was clearly divided from the surrounding structures, and no obvious abnormal signals were found in the remaining pancreatic tissues. The results of magnetic resonance cholangiopancreatography (MRCP) showed no obvious abnormalities in intrahepatic bile duct, common bile duct and pancreatic duct. A cyst with a maximum diameter of about 47 mm was seen in the uncinate process area of the pancreatic head (Figure 1). Physical examination at admission: No tenderness and rebound pain in the abdomen. There were no other positive signs. Past history: 5 years after cesarean section. Laboratory test: carcinoembryonic antigen 6.45 μ g/L, remaining negative; Negative fecal occult blood. Gastrointestinal endoscopy results showed no obvious abnormalities. Preoperative diagnosis: pancreatic head mass (mucinous cystadenoma?); After cesarean section. After excluding contraindications, duodenal papilla intubation + endoscopic retrograde cholangiopancreatography + sphincterotomy + pancreatic duct stenting + bile duct stenting was performed under electronic cholangiopancreatoscopy on August 19, 2022. No obvious abnormalities in pancreatic duct and bile duct were observed during the operation. At the same time, a 9 cm pancreatic duct stent at 5 F (1 F ≈ 0.33 mm) and a 7 cm bile duct stent at 8.5 F were placed (Figure 2). This was followed by robot-assisted laparoscopic resection of pancreatic head tumor + intestinal adhesiolysis under general anesthesia (Video 1). Intraoperative findings: There was no obvious ascites in the abdominal cavity, the pancreas was soft in texture, and a cystic mass with a maximum diameter of about 5 cm was seen on the head of the pancreas (Figure 3). The cyst envelope was intact, and jelly-like material was seen inside after incision (Figure 4).

Professor Liu Yongfeng, director of the Institute of General Surgery of China Medical University, director of the Institute of Organ Transplantation of China Medical University, and editorial member of the 11th, 12th and 13th editorial boards of Chinese Journal of Surgery, passed away on June 5, 2023 at the age of 70 due to ineffective treatment of his illness.