CC BY
10
I. ДИАГНОСТИКА И ЛЕЧЕНИЕ
МРНТИ 76.29.39
ABOUT THE АUTHORS
Sadykov Chingiz - ultrasound physician of the radiology department of NSCS named after A.N.Syzganov e-mail: [email protected]
Kunanbayeva Dinara - ultrasound physician of the radiology department of NSCS named after A.N.Syzganov e-mail: [email protected]
Bayguisova Dinara - head of the radiology department of NSCS named after A.N. Syzganov e-mail: [email protected]
ULTRASOUND DIAGNOSTICS AFTER ORTHOTOPIC LIVER TRANSPLANTATION US DIAGNOSIS OF VASCULAR COMPLICATIONS IN THE EARLY POST-TRANSPLANT PERIOD
Sadykov Ch.T., Kunanbaeva D.M., Baiguissova D.Z.
National Scientific Centre of Surgery named after A.N.Syzganov, Almaty, Kazakhstan
Keywords
Ultrasound diagnosis, Doppler sonography of the blood, vessels of the liver, vascular complications, vascular thrombosis of the graft,
АВТОРЛАР ТУРАЛЫ
Садыков Чингиз Тахирович -
А.Н. Сызранов атындары YFXO АКУДЗ басшысы
e-mail:[email protected]
Кунанбаева Динара Максутовна -
А.Н. Сызраов атындары YFXO АК УДЗ бел1мшесш1ц дэргер! e-mail:[email protected]
Байгуисова Динара Зулхарнаевна -
А.Н. Сызраов атындары YFXO АК Сэулелi зерттеу бeлiмшесiнiц мецгеруша. e-mail:[email protected]
Abstract
In shortage of cadaveric donor organs, orthotopic liver transplantation (OLT) is the only radical method of treatment in terminal stages of chronic diffuse liver diseases.
Ultrasonography (US), which includes gray-scale scan, color and spectral Doppler investigation, is considered as one of the leading methods of instrumental diagnostics and monitoring in liver transplantation.
Ортотопикалык бауыр трансплантациясынан кейшп ультрадыбыстык зерттеу. Кан тамырларыньщ аскынуларын ерте трансплантациядан кейшп кезецде ультрадыбыстык зерл^
Садыков Ч.Т., Кунанбаева Д.М., Байгуисова Д.З.
А.Н. Cbi3FaHOB атында?ы Улттык, ?ылыми хирургиялык, орталь™,Алматы, Казахстан
Туйш сездер
Ультрадыбыстык диагностика, бауыр тамырларыныц допплерографиясы,тамыр аскынулары, трансплантаттыц кан тамырларыныц тромбозы
Ацдатпа
МэйНгпк донорлык арзалардыц жетшшздк жардайында, бауырдыц ортотопиялык трансплантациясы бауырдыц созылмалы диффузды ауруларыныц терминальды сатысын емдеудц жал€ыз эрi тYбегейлi емдеу эдiсi болып табылады.
Сур т/ст шкалалык сканерлеу, т/ст жэне спектральды допплерлк зерттеулердi камтитын ультрадыбыстык зерттеу (УДЗ) бауырдыц трансплантациясы кезнде бакылау мен инструментальды зерттеу эдютерЩ арасында жетекшi орын алады.
ОБ АВТОРАХ
Садыков Чингиз Тахирович - врач УЗИ ННЦХ им.А.Н.Сызганова. e-mail:[email protected]
Кунанбаева Динара Максутовна - врач УЗИ отделения Лучевой диагностики ННЦХ им.А.Н.Сызганова. e-mail:[email protected]
Байгуисова Динара Зулхарнаевна -
заведующая отделением Лучевой диагностики ННЦХ им.А.Н.Сызганова. e-mail:[email protected]
Ультразвуковая диагностика после ортотопической трансплантации печени. УЗ диагностика сосудистых осложнений в ранний посттрансплантационный период.
Садыков Ч.Т., Кунанбаева Д.М., Байгуисова Д.З.
Национальный научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан
Ключевые слова
Ультразвуковая диагностика, допплерография сосудов печени, сосудистые осложне-ния,тромбоз сосудов трансплантата
Аннотация
Ортотопическая трансплантация печени (ОТП) является единственным радикальным методом ле-чения при терминальных стадиях хронических диффузных заболеваний печени в условиях дефи-цита трупных донорских органов[1,2].
Ультразвуковое исследование(УЗИ), включающее в себя серошкальное сканирование, цветовое и спектральное допплеровские исследования, рассматривается как один из ведущих методов инструментальной диагностики и мониторирования при трансплантации печени.
14
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1-2019
ULTRASOUND DIAGNOSTICS AFTER ORTHOTOPIC LIVER TRANSPLANTATION. US DIAGNOSIS OF VASCULAR COMPLICATIONS IN THE EARLY POST-TRANSPLANT PERIOD.
Introduction
Complications of the vascular anastomoses, which can lead to irreversible changes in the liver and the death of the recipient, are the severe complications after orthotopic liver transplantation (OLT) [3]. Therefore, timely diagnosis is an important factor for choosing the tactics of patient management after liver transplantation.
Among all methods of instrumental diagnostics, the safest and most easily accessible is ultrasound. The advantages of US: the mobility of ultrasound equipment, the absence of radiation exposure, the ability to conduct research in the course of the day.
Objective
The diagnosis of vascular complications in the early postoperative period.
Materials and methods
Ultrasound examination was performed on 30 patients in the early postoperative period, starting intraoperatively and subsequently twice a day for 5-6 days, then once a day for 7-10 days. The researches were conducted at the reanimation departments of the City Clinical Hospital №7 and NSCS named after A.N. Syzganov. The median age of recipients is 35-40 years old. Among them were four children (three girls and one boy) aged from 5 months to 7 years old, who underwent the transplantation of the left lateral segment of the liver. Ultrasound examination was performed on Philips HD11, GE Vivid I, Medison Ugeo H60 diagnostic systems using convex (3.5-5.0 MHz) and linear (7.0-10.0 MHz) transducers.
Liver graft (LG) ultrasound included an assessment of vascular anastomoses, intrahepatic bile ducts and perihepatic space.
Results
The state of the vascular anastomoses was assessed on the basis of the qualitative and quantitative indicators, developed described in the world literature [6-8].
1. Portal Vein (PV). Fig.1.
Qualitative indicators:
- clear visualization of the PV in the gray-scale mode and with the color flow mapping in the area and above the anastomosis, hepatopetal direction of blood flow.
Quantitative indicators:
- the blood flow volume above the anastomosis, normally in adults should not be below 1.0 liter per minute, in children under 1 year old not less than 0.5 liter per minute
- the velocity higher and before the anastomosis; the velocity distal to the anastomosis should not exceed the velocity proximal to the anastomosis more than three times
2. Artery of the graft. Fig.2.
Qualitative indicators:
- distinct visualization in color Doppler investigation of the hepatic artery in the area and distal to the anastomosis, hepatopetal direction of blood flow.
Quantitative indicators:
- maximal systolic velocity not more than 200 cm/sec; acceleration time <0.08 sec; index of resistance -> 0.5- <0.7; in the early postoperative period, 70% of recipients showed an increase in the resistance index to 1.0, which gradually decreased to the norm within 4-6 days, which causes by postoperative swelling of the parenchyma.
05082016083931
[20]
MCT2.3WU rapuoHMNecmM
Vc. 53
AA tU
KpT 10
y* 6
Oh.№ SDMR2
[HB]
Her 2-S Mfu Yc. 80 Hnn 40 kHz flfl 120 KpT 11 Am 90% yron -36' rxO 10 2 cu KO S mm
1 D 1.08 cm CCycpB 21.24 cm/» 06K-t<*(Pc) 1134.1 mlimtn
2 Vrt 47 89 em'«
HHUX mm. A.H.CburaHOM
riÉÉÉfeè ' •
n
Lv^l
fW ) I
Fig.1.
Doppler sonography of the PV. Blood flow volume 1.13 l/min
Fig.2.
Ultrasound image of the graft artery
30012016123120
ННЦХ иы. Л.Н.Сызганом Ml 0.4
Til 0.1
i " i ■ i < i i j M i 1.1 i , i , i , i , (
30-03-201« 12:44:5«
[20]
чет 4.7 МГц it 5«
дд 130
Крт 9 УК 6 Дм. 94% SOHR1
И
Чет 2.1 МГц * 60 ЧПИ 1.6 kHz Крт 7 Д»90%
(ПВ)
Чет 28 МГц Ус. Я ЧПИ 26 kHz
1 СЛ 4212 сям» КД 14.74 СМ ИС 0.К
3. Hepatic Veins. Fig.3.
Qualitative indicators:
- clear visualization, lack of local narrowings of the inferior vena cava, correctness of its course, correct direction of blood flow, hepa-tofugal direction of blood flow.
Quantitative indicators:
- the velocity should not exceed 100 cm/sec; three or two-phase blood flow
According to the above indicators, the following vascular complications were revealed during an ultrasound examination in the early post-transplant period:
Fig.3.
Right hepatic vein. Three-phase blood flow
2506201617544«
Hepatic artery thrombosis in 3 recipients (2 adults 40-45 years old and 1 child - 6 months), who had no blood flow in the gate and at the periphery of the graft in the CDI mode and in the Doppler investigation. All recipients had thrombosis of the arterial anastomosis confirmed by CTA of the liver. Changes in the structure, echogenicity of the liver and bile ducts at the time of thrombosis was not detected. In adult recipients, thrombosis was diagnosed on days 3 and 4 after transplantation. Both recipients, after confirming thrombosis on CTA, underwent the operation on an emergency basis:
ННЦХ им. Л.Н.Сызгаиом Ml 0.2
ТЫ 0.2
I • • i i 1 i i • i I i •
»i 111111
1 УМ -6610 an/«
[2D]
Чет 2.3 МГц
ItB**" ДД 1 и Крт 10
ук е
Дш.«4% SOUR з
га
Чет 2J МГц УС- 60 ЧПИ 2J kHz Крт7
PTBJ
Чет 2J МГц Ус. И ЧПИ 5 5 kHz
ДД 120 Крт 11 Д- (
Won -U' ГКО ».1см КО 2 mm
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1-2019
16
04082016192703
HHUX MM. A.H.CbUrSMOM Ml 0.3 Tls 0.3
[20)
4ct 23 Mf"u rapuoHHH*ciMM
Yc. 52 Afl 114
KpT 10
yx s
Aib.94% S DUR 1
ICI
Mer 2.1 Hru yc 56 HTIM 2.0 kHz KpT 7 flia. 90%
m —
Mct 2.1 MTu
vt so à
Mnn 4.0 kHU
M 120 W
Kpr 11 0*8.90%
yron 0" rxo 6 6 eu KO 1.6 mm
ny 9
i i I i i i
■ nL
■ff fttrfl i
Fig.4.
Proximal fragment of the artery of the graft, retrograde blood flow on CDI and Doppler investigation
- relaparotomy, revision of arterial anastomosis, thrombectomy, arterial reanastomosis In a child with thrombosis, an artery with retrograde blood flow proximal to the anastomosis and the absence of the blood flow distal to the anastomosis were recorded. Fig.4. Artery thrombosis occurred on day 15 after transplantation. The liver structure and laboratory data were within the normal range. A conservative treatment strategy with thrombolytic therapy was selected. Ultrasonography was performed during the week after thrombosis, with no changes in the liver parenchyma and bile ducts.
15082016091425
On the 11th day after the detection of arterial thrombosis (on the 26th day after orthotopic transplantation of the left lateral segment of the liver), during the next ultrasonography of the arterial anastomosis area did not change, but on CDI and intrahepatic dopplerometry, along the branch of the portal vein, a vessel with low resistant arterial blood flow is recorded, indicating recanalization of the graft artery. Fig.5.
Non-occlusive portal vein thrombosis proximal to the anastomosis was detected in 1 recipient (male, 30 years old) on the 3rd day after transplantation. In this case, a narrowing of
HHUX MM. A.H.CwirtHOM
Fig.5. Recanalization of the graft artery
I»]
Hct 7.6 llfu yc. 47 flfl 126 Kpr 8
yx s
A» 92% SOUR 3
|C]
HCT 6.8 MTu yt 50 HflMUkHz KpT 7 0«. 90%
m
MCT 8 8 Ml"u ye. 56 MHM 4 0 kH; № (2 KpT 10 QlS 90% yron 61' rxo 3.3 CM KO 1mm
I nOpTtnhHOM i
• A,
Fig.6.
Pulsating blood flow on PV
poi
Чет 4.7 МГц Ус 60 ДД 130 Крт 9 УК 6 ДМ. »4% SDMR 1
[ПВ]
Чет 2 « МГц Ус. M ЧЛИ 4.0 kHz M 120 Крт 11 Д»в.»0* Угол -1Г ГКО 8 4 сы КО 6 mm
ННЦХ им. А.Н.Сызганом mi 0.2 2304201620075« Т1» 0.3
• llllllll lllllllllllll* ■ , -»
1 О 1.13cm —. I
ССусрВ 10.46 crrV» ОбК-тоа(Рс) 630.7 mtfmln
Ок >■• V
* sni
the portal vein lumen was found proximal to the anastomosis, with an uneven inner contour. The volume of blood flow distal to the anastomosis was 0.6 liter per minute, the shape of the Dop-pler spectrum had a pulsating character. Fig.6; the velocity on the graft artery compensatory increased to 130 cm/sec.
With repeated ultrasound 5 hours after the start of thrombolytic therapy, the volume of blood flow increased to 1.4 liters per minute, the lumen expanded to 1.0 cm.
Conclusion
According to foreign sources, the sensitivity of ultrasound in vascular complications indetifying
is 85%, specificity is 92%, diagnostic accuracy is 88%. Graft artery thrombosis detecting sensivity is 69-96%. In our research, the sensitivity of ul-trasonography showed high informativity in graft artery thrombosis identifying (sensitivity, specific-ity-100%).
Venous complications of the hepatic graft requiring surgical correction during the research were not identified.
Comprehensive ultrasonography, which includes gray-scale scanning, color and spectral Doppler investigations, is one of the main instrumental methods of primary diagnostics, which allows timely and reliably assess the condition of the graft.
References
1. O' Leary J.G.,Lepe R.,Davis G.L. Indications for liver transplantation // Gastroenterology. 2008. V.134. No.6. P. 1764-1776
2. Wiesner R.,Edwards E.,Freeman R.,Harper A.,Kim R.,Kamath P.,Kremers W.,Lake J.,Howard T.,Merion R.M.,Wolfe R.A.,Krom R.,United Network for Organ Sharing Liver Disease Severity Score Committee.Model for end-stage liverdisease (MELD) and allocation of donor livers//Gastroenterology.2003.V.124.No.1.P. 91-96
3. Crossin JD, Muradali D, Wilson SR. Ultrasound of liver transplants: normal and abnormal. Radiographics 2003;23:1093-1114.
4. Nghiem HV. Imaging of hepatic transplantation. Radiol Clin North Am 1998;36:429-443.
5. Hussain H.K., Nghiem V.H. Imaging of hepatic transplantation // Clinics in liver disease. - 2002. - Vol. 6.
6. Miller C.M., Gongolesi G.E., Florman S. et al. One hundred nine living donor liver transplants in adults and children: a single.center experiance // Annuls of
Surgery. - 2001. - Vol. 234. - N 3.
7. Dalgic A., Dalgic B., Demirogullari B. et al. Clinical approach to graft hepatic thrombosis following living related liver transplantation // Pediatr.Transplant. -2003. - Vol. 7(2). - 149-52.
8. Dodd G. III, Memel D., Zajko A. et al. Hepatic artery thrombosis and stenosis in transplant recipients: Doppler diagnosis with resistive index and systolic acceleration time // Radiology. - 1994. - Vol. 192. - P. 657-661.
9. Marcos A., Fisher R.A., Ham J.R. et al. Right lobe living donor liver transplantation. // Transplantation. - 1999. - Vol. 68(6). - P. 798-803.
10. Broelsch C.E., Whitington P.F. Emond J.C. et al. Liver transplantation in children from living related donors // Annuls of Surgery.-1991.-Vol.214.-P428-439.
11. Kryjhanovskaya E.Y. A comprehensive ultrasound examination of the graft right lobe of the liver from a living related donor // Dis. - M., 2005. - 127 c.
18
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1-2019
