A. S. Soin, R. Kakodkar, S. Saigal, S. Nundy.肝脏移植部,甘格伦勋爵医院,新德里,印度

背景：大多数施行成人-成人活体肝移植(AALDLT)的移植中心把肝脏/体重百分比(GRWR)控制在0.8或更高，因为目前普遍认为，肝脏体积小于该标准将不能满足受体代谢的需求。但是，也有一些肝脏/体重百分比低于该标准且终末期肝病模型（MELD）得分很低的成功移植案例。

目的：评定成人-成人活体肝移植中，肝脏/体重百分比小于0.8是否安全

方法：在2004年7月至2006年11月期间施行活体肝移植的连续87个案例（男66，女21）构成了该研究组，其中包括68例肝右叶移植和19例肝左叶移植。经康斯特保护液（HTK液）灌注后的移植肝脏秤重。尽管原则上肝脏/体重百分比至少应为0.8，依然有10例患者因以下原因致使肝脏/体重百分比小于0.8 (0.56-0.78，平均0.66)：术前状态良好（Child B级，6例）、缺少可供选择的捐赠者（2例）、不准确的术前CT容量分析（2例）。这10例患者中，有5例肝左叶，4例伴中肝静脉的肝右叶，1例无中肝静脉但伴肝静脉流出道重建的肝右叶。A组患者的肝脏/体重百分比低于0.8，B组77例患者的肝脏/体重百分比为0.8或高于0.8，两组的初期转归指标是受体的手术死亡率（死亡发生在同一家有移植资格的医院），次要指标是胆红素，凝血酶原时间（国际标准化比值）即PT (INR)，成人-成人活体肝移植后1天、3天、7天的天门冬氨酸转氨酶值（AST），住院时间等。

结果：经过配对样本检验，两对照组的平均住院时间（A组21，B组 22天，p=0.7）、胆红素和术后1、3、7天的AST均无明显差别（见表）； 但是，A组第1天的PT (INR)明显高于B组（p=0.007），但术后第3天这种差别就变得不再明显了（p=0.86）。A组无手术死亡率，B组手术死亡率为9% （7/77）。

结论：对成人-成人活体肝移植受体来说，在静脉回流良好和术后护理良好的情况下（精细的手术可以保证上述两点），肝脏/体重百分比小于0.8不会对早期疗效和手术死亡率带来负面影响。

Adult to Adult Living Donor Liver Transplantation: Is A Graft/body Weight Ratio Less than 0.8 Safe
A. S. Soin, R. Kakodkar, S. Saigal, S. Nundy. Department of Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India

Background: Majority of centres performing adult to adult live donor liver transplantation (AALDLT) ensure graft to recipient weight ratio (GRWR) of 0.8 or more since lesser liver volumes are considered inadequate for the metabolic demands of recipients. However, there are some reports of successful transplants with lower ratios in patients with low MELD scores.

Aim: To assess whether a GRWR of <0.8 can be safely used in recipients of AALDLT.

Methods: The last 87 (66 males, 21 females) consecutive AALDLTs performed from July 2004 to November 2006 constituted the study group. Sixty-eight right lobe and 19 left lobe transplants were performed. Graft weight was measured on the bench after perfusion with HTK solution. Although the policy was to ensure a GRWR of at least 0.8, 10 patients (5 left lobes, 4 right lobes with middle hepatic vein, 1 right lobe without middle hepatic vein with 4 reconstructed outflow veins) had GRWR of less than 0.8 (0.56-0.78, mean 0.66) due to the following reasons: favourable preoperative status of the recipients (Child's B, n=6), lack of an alternative donor (2) and inaccurate preoperative CT volumetry (2).

The outcome of patients with GRWR ratios lower than 0.8 (Group A) was compared with that of 77 patients with GRWR ratios of 0.8 or more (Group B). The primary outcome measure was recipient operative mortality (death within the same hospital admission as the transplant), and secondary outcomes were bilirubin, PT (INR) and AST on days 1, 3 and 7 after AALDLT, and hospital stay.

Results: Using paired-samples t test, there was no significant difference between the two groups in mean hospital stay (21 vs 22 days, p=0.7); and bilirubin and AST on day 1, 3 and 7 (see table). However, PT (INR) on day 1 was significantly higher in group A (p=0.007), but the difference became insignificant by postoperative day 3 (p=0.86). There was no operative mortality in group A, though group B had a mortality of 9% (7 out of 77).

Conclusion: For selected recipients of AALDLT, with meticulous surgery ensuring good venous outflow, and good postoperative care, a GRWR <0.8 does not have an adverse impact on early results and operative mortality.

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