Роль портокавальных шунтов в развитии осложнений после трансплантации печени

Актуальность. Портальный кровоток имеет ключевое значение в жизнеспособности трансплантата печени. Портокавальные шунты, образованные на фоне цирроза печени до трансплантации, могут стать причиной синдрома обкрадывания воротной вены, с последующим развитием ишемического некроза трансплантата. На сегодняшний день недостаточно разработана тактика лечения пациентов с синдромом обкрадывания воротной вены при трансплантации печени.

В данной работе наряду с анализом литературы представлен и собственный опыт, накопленный по столь важному, и в то же время малоизученному вопросу.

Цель. Изучить роль портокавальных шунтов в развитии осложнений после трансплантации печени на основе ретроспективного анализа клинических наблюдений.

Выводы. При трансплантации печени портокавальные шунты могут стать причиной развития синдрома обкрадывания воротной вены с последующим развитием печеночной недостаточности. Для диагностики синдрома обкрадывания воротной вены важно использовать данные, полученные на всех этапах трансплантации печени. Хирургическая коррекция синдрома обкрадывания воротной вены может проводиться во время трансплантации печени и в раннем послеоперационном периоде.

1. Colle I, Geerts AM, Van Steenkiste C, Van Vlierberghe H. Hemodynamic changes in splanchnic blood vessels in portal hypertension. Anat Rec (Hoboken). 2008;291(6):699–713. PMID: 18484617 https://doi.org/10.1002/ar.20667

2. Iwakiri Y, Groszmann RJ. The hyperdynamic circulation of chronic liver diseases: from the patient to the molecule. Hepatology. 2006;43(2 Suppl1):S121–131. PMID: 16447289 https://doi.org/10.1002/hep.20993

3. Bolognesi M, Sacerdoti D, Bom bonato G, Merkel C, Sartori G, Merenda R, et al. Change in portal flow after liver transplantation: effect on hepatic arterial resistance indices and role of spleen size. Hepatology. 2002;35(3):601–608. PMID: 11870373 https://doi.org/10.1053/jhep.2002.31352

4. Henderson JM, Gilmore GT, Mackay GJ, Galloway JR, Dodson TF, Kutner MH, et al. Hemodynamics during liver transplantation: the interac tions between cardiac output and portal venous and hepatic arterial flows. Hepatology. 1992;16(3):715–718. PMID: 1505914 https://doi.org/10.1002/hep.1840160316

5. Paulsen AW, Klintmalm GB. Direct measurement of hepatic blood flow in native and transplanted organs, with accompanying systemic hemodynamics. Hepatology. 1992;16(1):100–111. PMID: 1618464 https://doi.org/10.1002/hep.1840160118

6. Do i R, Inoue K, Kogire M, Sumi S, Takaori K, Suzuki T, et al. Simultaneous measurement of hepatic arterial and portal venous flows by transit time ultrasonic volume flowmetry. Surg Gynecol Obstet. 1988;167(1):65–69. PMID: 2968000

7. Braun MM, Bar-Nathan N, Shaharabani E, Aizner S, Tur-Kaspa R, Belenky A, et al. Postshunt hepatic encephalopathy in liver transplant recipients. Trans plantation. 2009;87(5):734–739. PMID: 19295319 https://doi.org/10.1097/TP.0b013e318196340d

8. De Carlis L, Del Favero E, Rondinara G, Belli LS, Sansalone CV, Zani B, et al. The role of spontaneous portosystemic shunts in the course of orthotopic liver transplantation. Transpl Int. 1992;5(1):9–14. PMID: 1580990 https://doi.org/10.1007/BF00337182

9. Duffy JP, Hong JC, Farmer DG, Ghobrial RM, Yersiz H, Hiatt JR, et al. Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg. 2009;208(5):896–903. PMID: 19476857 https://doi.org/10.1016/j.jamcollsurg.2008.12.032

10. Sadamori H, Yagi T, Matsukawa H, Matsuda H, Shinoura S, Umeda Y, et al. The outcome of living donor liver transplantation with prior spon taneous large portosystemic shunts. Transpl Int. 2008;21(2):156–162. PMID: 18005086 https://doi.org/10.1111/j.1432-2277.2007.00593.x

11. Ploeg RJ, D'Alessandro AM, Stegall MD, Wojtowycz M, Sproat IA, Knechtle SJ, et al. Effect of surgical and spontaneous portasystemic shunts on liver transplantation. Transplant Proc. 1993;25(2):1946–1948. PMID: 8470237

12. Sekido H, Matsuo K, Takeda K. Severe fatty change of the graft liver caused by a portosystemic shunt of mesenteric varices. Transpl Int. 2002;15(5):259–262. PMID: 12012048 doi: 10.1007/s00147-002-0409-x

13. Tallón Aguilar L, Jiménez Riera G, Suárez Artacho G, Marín Gómez LM, Serrano Díaz-Canedo J, Gómez Bravo MA. Posttransplantation portal thrombosis secondary to splenorenal shunt persistence. Transplant Proc. 2010;42(8):3169-3170. PMID: 20970639 https://doi.org/10.1016/j.transproceed.2010.05.075

14. Blei AT, Cordoba J. Hepatic Encephalopathy. Am J Gastroenterol. 2001;96(7):1968–1976. PMID: 11467622 https://doi.org/10.1111/j.1572-0241.2001.03964.x

15. Riggio O, Efrati C, Catalano C, Pediconi F, Mecarelli O, Accornero N, et al. High prevalence of spontaneous portal-systemic shunts in persistent hepatic encephalopathy: a case-control study. Hepatology. 2005;42(5):1158–1165. PMID: 16250033 https://doi.org/10.1002/hep.20905

16. Tarantino G, Citro V, Esposito P, Giaquinto S, de Leone A, Milan G, et al. Blood ammonia levels in liver cirrhosis: a clue for the presence of portosystemic collateral veins. BMC gastroenterology. 2009;9:21. PMID: 19292923 https://doi.org/10.1186/1471-230X-9-21

17. Aucejo FN, Hashimoto K, Quintini C. Triple-phase computed tomography and intraoperative flow measurements improve the management of portosystemic shunts during liver transplantation. Liver Transpl. 2008;14(1):96–99. PMID: 18161777 https://doi.org/10.1002/lt.21377

18. Simó n-Talero M, Roccarina D, Martínez J, Lampichler K, Baiges A, Low G, et al. Association between portosystemic shunts and increased complications and mortality in patients with cirrhosis. Gastroenterology. 2018;154(6):1694–1705. PMID: 29360462 https://doi.org/10.1053/j.gastro.2018.01.028

19. Moon DB, Lee SG, Ahn C, Hwang S, Kim KH, Ha TY, et al. Application of intraoperative cine-portogram to detect spontaneous portosystemic collaterals missed by intraoperative doppler exam in adult living donor liver transplantation. Liver Transpl. 2007;13(9):1279-1284. PMID: 17763379 https://doi.org/10.1002/lt.21252

20. Rasmussen A, Hjortrup A, Kirkegaard P. Intraoperative measure ment of graft blood flow – a necessity in liver transplantation. Transpl Int. 1997;10(1):74–77. PMID: 9002157 https://doi.org/10.1007/BF02044347

21. Новрузбеков М.С., Олисов О.Д. Сосудистые осложнения после ортотопической трансплантации печени. Трансплантология. 2017;9(1):35–50. https://doi.org/10.23873/2074-0506-2017-9-1-35-50

22. Lee M, Kim SK, Chung YE, Choi JY, Park MS, Lim JS, et al. Portal venous perfusion steal causing graft dysfunction after orthotopic liver transplan tation: serial imaging findings in a successfully treated patient. Ultrasonography. 2016;35(1):78–82. PMID: 25827474 https://doi.org/10.14366/usg.15012

23. Awad N, Horrow MM, Parsikia A, Brady P, Zaki R, Fishman M, et al. Perioperative management of spontaneous splenorenal shunts in orthotopic liver transplant patients. Exp Clin Transplant. 2012;10(5):475–481. PMID: 22891944 https://doi.org/10.6002/ect.2011.0201

24. Kim H, Yoon KC, Lee K-W, Yi N-J, Lee HW, Choi YR, et al. Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver trans plantation. Liver Transpl. 2017;23(7):899-906. PMID: 28481004 https://doi.org/10.1002/lt.24783

25. Castillo-Suescun F, Oniscu GC, Hidalgo E. Hemodynamic consequences of spontaneous splenorenal shunts in deceased donor liver transplantation. Liver Transpl. 2011;17(8):891–895. PMID: 21425432 https://doi.org/10.1002/lt.22304

26. Slater RR, Jabbour N, Abbass AA, Patil V, Hundley J, Kazimi M, et al. Left renal vein ligation: a technique to mitigate low portal flow from splenic vein siphon during liver transplantation. Am J Transplant. 2011;11(8):1743–1747. PMID: 21668639 https://doi.org/10.1111/j.1600-6143.2011.03578.x

27. Samson RH, Lepore MR Jr, Showalter DP, Nair DG, Lanoue JB. Longterm safety of left renal vein divi sion and ligation to expedite complex abdominal aortic surgery. J Vasc Surg. 2009;50(3):500–504. PMID: 19595540 https://doi.org/10.1016/j.jvs.2009.04.041

28. Lee SG, Moon DB, Ahn CS, Kim KH, Hwang S, Park KM, et al. Ligation of left renal vein for large spontaneous splenorenal shunt to prevent portal flow steal in adult living donor liver transplantation. Transpl Int. 2007;20(1):45–50. PMID: 17181652 https://doi.org/10.1111/j.1432-2277.2006.00392.x

29. Reddi MS, Rela M. Portosystemic collaterals in living donor liver transplantation: what is all the fuss about? Liver Transpl. 2017;23(4):537–544. PMID: 28073180 https://doi.org/10.1002/lt.24719

30. Matake K, Tajima T, Yoshimitsu K, Irie H, Aibe H, Nishie A, et al. Hepatic encephalopathy from dual splenorenal shunts treated with balloon-occluded retrograde transvenous obliteration by using a double-balloon technique. J Vasc Interv Radiol. 2007;18(11):1436-1440. PMID: 18003996 https://doi.org/10.1016/j.jvir.2007.07.024

31. Al hajjaj A, Bonatti H, Krishna M, Dickson R, McKinney JM, Nguyen J, et al. Percutaneous transfemoral embolization of a spontaneous splenorenal shunt presenting with ischemic graft dysfunction 18 months post-transplant. Transpl Intl. 2008;21(8):816-819. PMID: 18498312 https://doi.org/10.1111/j.1432-2277.2008.00691.x

32. Kim B, Kim KW, Song G-W, Lee S-G. Portal flow steal after liver transplan tation. Clin Mol Hepatol. 2015;21(3):314-317. PMID: 26523275 https://doi.org/10.3350/cmh.2015.21.3.314

33. Gupta A, Klintmalm GB, Kim PT. Ligating coronary vein varices: An effective treatment of "coronary vein steal" to increase portal flow in liver transplantation. Liver Transpl. 2016;22(7):1037-1039. PMID: 27028766 https://doi.org/10.1002/lt.24448