Organ Transplantation 器官移植手術

Living Donor Liver Transplantation

Overview

Living donor liver transplantation is a highly complex procedure requiring thorough preoperative evaluations for both the healthy donor and recipient, precise coordination during surgery, and intensive postoperative care. The procedure involves removing 60–70% of the donor's liver (right lobe) for adult recipients or 15–40% (left lobe) for pediatric recipients. Donors must be blood relatives or in-laws.

Indications

End-stage liver cirrhosis: Common causes in adults include chronic hepatitis, alcoholism, Wilson's disease, and autoimmune liver diseases. In children, biliary atresia is a common cause.
Metabolic liver diseases: In cases not controlled by special diets or medications.
Liver cancer: Hepatocellular carcinoma within UCSF criteria; chemotherapy-resistant, unresectable hepatoblastoma.
Other conditions requiring liver replacement for cure.

Surgical Features

Liver transplantation involves replacing the patient's diseased liver with a healthy whole or partial liver (partial in living donations). With proper immunosuppressive therapy, the transplanted liver can function normally. This is a life-saving procedure.

Surgical Process

Donor and recipient surgeries occur simultaneously in two operating rooms with separate surgical and anesthetic teams. Donor surgery includes laparoscopic dissection of liver ligaments, midline incision to expose hepatic hilum, and liver parenchymal transection. The donor liver is only removed after the recipient's diseased liver is excised, followed by cold perfusion and transfer to the recipient's OR.

Donor surgery: ~8 hours
Recipient surgery: ~12 hours

Potential Complications

Donors

Minor: Bile leak (1–2%), reoperation for bleeding (0.5%), right pleural effusion (1–2%), postoperative ileus (1–2%), dyspepsia (5–10%)
Major: Biliary stricture (0.5%), hepatic blood flow thrombosis/stenosis (0.5%)
Mortality: 0.1–0.3% (adult donation), 0.1% (pediatric donation)

Recipients

Minor: Bile leak (5%), reoperation for bleeding (5–10%), pleural effusion (10%), ileus (5–10%), biliary anastomotic stricture (20–30%)
Major: Hepatic inflow/outflow obstruction (3–5%), sepsis (3–5%), other severe complications (5%)
Mortality: 3% (non-acute liver failure), 10–20% (acute liver failure)

活體肝臟移植

特色簡介
活體肝臟移植不是一個簡單的手術，需要對健康的活體捐贈者和病患接受者進行術前的詳細評估，捐贈與接受者手術的精細配合，以及術後的複雜照護。活體捐贈手術是從捐贈者體內取出60-70%的肝臟（右肝）用於成人接受者，或15-40%的肝臟（左肝）用於兒童接受者。捐贈者應為血親或姻親關係。

活體肝臟移植適應症：

末期肝硬化：成人常見原因為慢性肝炎、酗酒、威爾森氏症、自體免疫疾病等。兒童則多為膽道閉鎖。
代謝性肝病：使用特殊配方與藥物無法有效控制者。
肝癌：符合UCSF標準的肝細胞癌、抗化療且無法手術的肝母細胞瘤。
其他需肝臟置換才能治療的疾病。

手術特點
肝臟移植是將患者自身的肝臟替換為健康的全肝或部分肝臟（活體捐贈為部分肝臟）。透過規律服用免疫抑制劑，植入的肝臟能正常運作，具備正常肝臟功能。此手術具有救命性質。

手術流程
捐贈者與接受者的手術會在兩個手術室同步進行，分別由兩組外科與麻醉團隊執行。捐贈者手術包括：腹腔鏡分離肝臟韌帶、正中切口解剖肝門、肝實質分離。當接受者病肝已被切除後，才取出捐贈肝臟，並進行低溫灌洗後送往接受者手術室。接受者手術為弓形切口，全肝切除，植入捐贈肝臟。手術時間：捐贈者約8小時，接受者約12小時。

注意事項
捐贈者併發症：

輕微併發症：膽汁滲漏1-2%、出血需再次手術0.5%、右側胸水需抽胸水1-2%、術後腸阻塞1-2%、消化不良5-10%。
嚴重併發症：膽道狹窄0.5%、剩餘肝臟血流栓塞或狹窄0.5%。
手術死亡率：捐贈給成人者為0.1-0.3%，捐贈給兒童者為0.1%。

接受者併發症：

輕微併發症：膽汁滲漏5%、出血需再次手術5-10%、胸水10%、腸阻塞5-10%、膽道吻合狹窄20-30%。
嚴重併發症：肝臟血流進出阻塞或狹窄3-5%、敗血症3-5%、其他5%。
手術死亡率：非急性肝衰竭為3%、急性肝衰竭者為10-20%。

Living Donor Kidney Transplantation

Donor Eligibility Criteria

Aged 20 or older, in good physical and mental health
Must be a blood relative within five degrees or a legal spouse (married ≥2 years, with shared children, or married at least one year before diagnosis of end-stage renal disease)
Normal bilateral kidney function
No history of diabetes, hypertension, tuberculosis, malignancy, or notifiable infectious diseases (e.g., HIV)
Voluntary donation with altruistic intent
Blood type compatibility:
- Type O donors can give to any blood type; type O recipients can only receive from type O
- Type AB recipients can receive from any type
- ABO-incompatible transplants are possible but involve higher rejection risks

Pre-transplant Treatment for ABO-Incompatible Cases

Antibody removal: Plasma exchange + IVIG
B-cell suppression: Rituximab (7–10 days pre-op)
T-cell suppression: Tacrolimus, Mycophenolate mofetil ± steroids, Basiliximab, Alemtuzumab, ATG
If antibody titers are <1:512, outcomes can be comparable to ABO-compatible transplants. Higher titers require closer monitoring.

Outpatient / Inpatient Evaluation Process (4–8 weeks)

Phase 1

Blood tests: Liver/kidney function, Hep B/C, syphilis, HIV, blood type, coagulation profile, tissue matching
Imaging: Chest X-ray, abdominal ultrasound, breast ultrasound/mammogram (female)
Others: ECG, urinalysis, urinary cytology

Phase 2

Blood tests: Viral antibodies, tumor markers, thyroid function, TB screening
Imaging: Kidney CT scan, ERPF renal function test

Phase 3

Psychological and social work evaluations
Lymphocyte crossmatch test
Ethics Committee Review: As per the Human Organ Transplantation Act, all donations must be approved by the hospital's ethics committee.

Surgery and Postoperative Care

Surgical Approach

Under general anesthesia with central venous and arterial lines and urinary catheter placement.

Two surgical methods:

Traditional open surgery: Incision on abdomen/flank to dissect renal vessels and ureter
Laparoscopic surgery: Minimally invasive with 3 small incisions and final retrieval through right lower abdomen. Faster recovery, less pain.

Donor Risks and Outcomes

With full evaluation, remaining kidney function is normal and life expectancy is unaffected
Surgery: ~4–6 hours, hospital stay 5–7 days
Mortality: <0.1%
Complication rate: 8–16% (infections 2.4%, pneumothorax 1.5%, major bleeding <1%, pulmonary embolism 1%, ureteral stenosis/incontinence 2–10%, mild proteinuria/hypertension in ~30% after 10 years)

Follow-up

Weekly outpatient visits after discharge, then biweekly or monthly
Monitoring kidney function and immunosuppressant levels

Kidney Transplant Recipients

Eligibility Criteria

Must have end-stage renal disease and be on dialysis (except living donor cases)
No severe comorbidities (e.g., cancer, infections) beyond original kidney disease
Willing and able to understand surgical risks and outcomes
Normal bladder and urinary tract function (must be treated if abnormal)

Evaluation Items

Blood tests: Liver/kidney function, hepatitis virus load, syphilis, HIV, tumor markers, coagulation, thyroid function, TB, immune profile, HLA typing
Imaging: Chest X-ray, abdominal/breast ultrasound
Other tests: ECG, urinalysis, cytology
Enhanced evaluation: Diabetics, elderly, women (breast/cervical screening), men (prostate/bladder), dental check-up

Surgery and Post-op Care

Lower abdominal incision; kidney placed in the pelvic cavity and connected to blood vessels and ureter
Native kidneys may be removed if necessary
Hospital stay: 10–14 days if no complications/rejections
Lifelong immunosuppressants needed; monitor side effects and disease recurrence
Blood transfusions may be required during surgery
Acute rejection: 10–20%, mostly controlled with drugs; may lead to graft failure
Delayed graft function: ~10% (living), ~30% (deceased); some may never function
Complications (5–10%): Infection, urine leak, vascular thrombosis, hernia, etc.
Original kidney disease may recur in the graft

Immunosuppressant Side Effects

Cyclosporine/Tacrolimus: Hypertension, nephrotoxicity, hair loss, hyperkalemia
Prednisolone: Moon face, buffalo hump, osteoporosis
Mycophenolate: Leukopenia, nausea, hepatotoxicity
Sirolimus/Everolimus: Leukopenia, edema, skin rash
Basiliximab: Rare side effects; occasional liver enzyme elevation

Post-op Monitoring

Weekly follow-ups initially; then biweekly/monthly
Regular blood tests, liver/kidney function checks, drug level monitoring
Abdominal ultrasound every 3–6 months

活體腎臟移植

捐贈者條件審查

年滿20歲、身心健康，與接受者為五親等以內的血親或配偶。依法，需與接受者結婚滿2年、有共同子女，或在接受者被診斷需要移植前1年結婚。
雙側腎功能正常。
無糖尿病、高血壓、結核病，無惡性腫瘤病史，無法定傳染病（如愛滋）。
自願捐贈，動機純正。
血型需相容：
- O型捐贈者可給任意血型接受者，但O型接受者只能接受O型捐贈。
- AB型接受者可接受任意血型。
- 在某些情況下可進行血型不合移植，但排斥率與風險較高。

血型不合移植前處置

降低抗體：血漿置換+IVIG。
抑制B細胞：術前7-10天使用Rituximab。
抑制T細胞：Tacrolimus、Mycophenolate mofetil ± 類固醇、Basiliximab、Alemtuzumab、抗胸腺球蛋白等。

若抗體效價<1:512，手術結果可與血型相容移植相近，但效價高者需更謹慎追蹤，避免慢性排斥。

門診／住院流程（需4-8週完成評估）

第一階段：

血液檢查：肝腎功能、B/C型肝炎、梅毒、愛滋、血型、凝血、組織配對
影像：胸部X光、腹部超音波、女性需乳房超音波／攝影
其他：心電圖、尿液分析與尿細胞檢查

第二階段：

血液檢查：病毒抗體、腫瘤指數、甲狀腺功能、結核
影像檢查：腎臟CT與腎功能ERPF測試

第三階段：

心理評估
社工評估
淋巴細胞交叉配對測試

醫療倫理委員會審查：
根據《人體器官移植條例》，所有捐贈與接受資訊須經院內倫理審查通過後方可進行。

手術與照護

活體腎臟捐贈採全身麻醉，手術過程中會插入中心靜脈導管與動脈導管並使用導尿管。

手術方式有兩種：

傳統開刀手術： 由腹部或後腹部切開，分離腎動／靜脈與輸尿管後取出腎臟。
腹腔鏡手術： 傷口小、疼痛少、恢復快，使用氣體充腹並由3個小傷口進行手術，最後從右下腹取出腎臟。

捐贈者照護與風險

經完整評估者，剩餘腎功能正常，壽命與未接受手術者無異。
手術時間約4-6小時，住院5-7天。死亡率<0.1%。
併發症率8%-16%：感染（2.4%）、氣胸（1.5%）、大出血(<1%)、肺栓塞（1%）、輸尿管狹窄或尿失禁（2-10%）、術後10年約30%有輕微蛋白尿或高血壓。

術後回診與追蹤

出院後每週回診一次，穩定後每2週或每月1次，檢查腎功能與抗排斥藥濃度。

腎臟移植接受者

資格審查

需為尿毒症患者，正在接受透析，並符合重大傷病資格（活體移植者除外）。
除原有腎病外，無其他重大疾病（如癌症、感染等）。
自願接受移植，並能理解手術風險與預後。
膀胱與泌尿道功能正常（如異常需先處理）。

評估項目

血液檢查： 肝腎功能、肝炎病毒量、梅毒、愛滋、腫瘤指數、凝血、甲狀腺功能、結核菌、免疫指數、組織配對
影像檢查： 胸X光、腹部／乳房超音波
其他檢查： 心電圖、尿液分析與細胞學檢查

術前加強評估對象：
糖尿病、老年、女性需乳房／子宮頸檢查，男性需攝護腺與膀胱功能檢查。牙齒健康亦需檢查。