【作者】 王光辉；

【导师】 吕国悦；

【作者基本信息】 吉林大学 ， 临床医学硕士（外科学）（专业学位）， 2020， 硕士

【摘要】 目的:总结正中弓状韧带综合征(MALS)的临床特征,探讨肝移植受体合并MALS时的动脉重建方式,以期为该疾病的诊疗提供参考。方法:2018年3月至2019年12月吉林大学肝移植中心实施原位肝移植172例,术前影像学检查不完善及行多次肝移植的患者予以排除,共纳入168例,6例患者合并有MALS。回顾性分析这6例患者的一般资料、影像学检查结果、术中动脉重建方式及随访结果。MALS诊断是依据患者术前的上腹部电子计算机断层血管造影(computed tomography angiography,CTA)检查。结果:6例患者术前CTA提示腹腔干不同程度受压、狭窄,呈现“鱼钩样”改变,肠系膜上动脉与腹腔干之间存在侧枝循环。第1例患者因为缺乏对MALS的认识,术中未针对正中弓状韧带综合征进行处理,受体使用肝固有动脉与胃十二指肠动脉分叉处做吻合,术后9天出现肝动脉血栓、肝动脉衰竭,二次移植术中行正中弓状韧带松解。5例选择保留肠系膜上动脉与腹腔干之间侧枝循环动脉弓,保留胃十二指肠动脉,不分离正中弓状韧带,受体选择合适动脉与供肝动脉进行吻合。其中3例吻合后,肝动脉搏动强度弱,术中彩超测肝动脉流速差,考虑存在脾动脉盗血可能,结扎脾动脉后肝动脉流速恢复正常。术后常规给予低分子肝素抗凝治疗。术后随访时间2~19月,例1术后2月出现胆道狭窄,余无动脉、胆道等并发症发生。结论:合并有MALS的患者行肝移植手术,术后发生肝动脉血栓的风险较大,然而MALS的临床症状不典型,容易被漏诊。重视术前上腹部CTA影像检查的评估,术前对于考虑为MALS的患者,应评估狭窄段的程度、长度、部位、有无侧枝循环,确定分型,做肝动脉-腹主动脉搭桥术前准备。保留侧枝循环动脉弓的重建方式并发症少,操作简单,可作为首选,必要时可结扎脾动脉增加肝动脉血流量,如以上措施肝血流血流仍不满意,可考虑行MAL松解或肝动脉-腹主动脉搭桥。更多还原

【Abstract】 Objective:To summarize the clinical features of median arcuate ligament syndrome(MALS)and to investigate the arterial reconstruction of liver transplantation recipients with MALS.Methods:from March 2018 to December 2019,172 cases of orthotopic liver transplantation were performed in the liver transplantation center of the First Hospital of Jilin University.Patients with incomplete preoperative imaging examination and multiple liver transplantation were excluded.A total of 168 cases were included,including 6 cases of patients with MALS.The preoperative imaging examination,the method of intraoperative arterial reconstruction and postoperative follow-up of 6patients were retrospectively analyzed to summarize the arterial reconstruction method of liver transplantation recipient combined with MALS.The diagnosis of MLAS is based on the preoperative patient’s upper abdomenal CTA imaging examination.Results:the preoperative CTA images of 6 patients suggested that the celiac trunk was compressed and narrowed to different degrees,presenting "fish-like" changes,and there was collateral circulation between the superior mesenteric artery and the celiac trunk.In the first patient,MAL was not treated intraoperatively due to the lack of understanding of MALS.Early postoperative hepatic artery thrombosis and liver failure occurred,and MAL release was performed during the second transplantation.In 5 cases,the collateral circulation arterial arch between the superior mesenteric artery and the celiac trunk was reserved,gastroduodenal artery was retained,and MAL was not release.The appropriate artery of receptor were selected for anastomosis.After anastomosis,the hepatic artery pulsation intensity were weak in 3 cases,and the flow velocity of the hepatic artery was poor by the intraoperative Doppler color ultrasound.The possibility of blood theft from the splenic artery was considered,and the flow velocity of the hepatic artery returned to normal after ligation of the splenic artery.Routine anticoagulant therapy with low molecular weight heparin was given postoperatively.The postoperative follow-up period ranged from 2to 19 months.In 1 case,biliary stricture occurred in two months after the operation,and there were no other complications such as artery and biliary tract.Conclusion:the clinical symptoms of MALS are not typical and easy to be ignored.For patients with MALS undergoing liver transplantation,there is a greater risk of postoperative hepatic artery thrombosis and transplantation failure.Preoperative Doppler color ultrasound and CTA examination should be performed routinely to assist the diagnosis,and a complete surgical plan should be made according to the preoperative imaging results.MAL release,GDA preservation,anastomosis at the left and right bifurcations of hepatic arteries and hepatic artery-abdominal aortic bypass are all feasible surgical methods.Appropriate surgical methods can be selected according to intraoperative hepatic artery pulsation and intraoperative Doppler color ultrasound monitoring of hepatic artery flow rate.更多还原