肝移植术后早期腹腔内出血的防治

目的 分析原位肝移植术后早期腹腔内出血的原因及防治方法.方法 回顾性分析本科204例原位肝移植的临床资料,术后早期腹腔内出血患者共10例,其中6例接受2次探查手术,术中见其出血部位分别为:下腔静脉前壁肝短静脉结扎线脱落出血1例、右侧肾上腺创面出血1例、肝周创面渗血1例、肝动脉吻合口出血1例、腹壁动脉出血1例、未见明确活动性出血1例.结果 6例2次手术止血患者均顺利恢复.4例保守治疗患者中2例出血停止,顺利恢复,1例出血停止,术后腹腔内感染,经穿刺引流和抗感染治疗后康复,1例再次移植患者术后凝血功能障碍,于术后第3日死亡.结论 肝移植术后早期腹腔内出血多由于外科因素所致,外科技术的改进、正确诊断和及时处理是防治的关键.     

肝移植术后消化道出血的原因及处理

目的 探讨肝移植术后消化道出血的原因和处理方法.方法 对中山大学附属第一医院2000年1月至2006年12月施行的776例同种原位肝移植（OLT）患者的临床资料进行回顾性分析,总结原位肝移植术后消化道出血的诊治经验.结果 776例肝移植患者中共发生术后消化道出血18例（2.3%）.其中消化性溃疡出血8例（44.5%）,胃底食管静脉曲张急性出血3例（16.7%）,胃十二指肠炎出血3例（16.7%）,胆道出血3例（16.7%）,空肠憩室出血伴穿孔1例（5.6%）.分别采取积极的非手术治疗和经内镜直视下局部止血治疗、血管栓塞治疗和手术探查等措施,除死亡5例（27.8%）外,13例患者临床治愈,术后平均随访3.5年,除1例于术后2年死于移植肝癌复发外,其余均健康存活.结论 OLT术后可能出现不同部位的消化道出血,病死率较高：一旦发生,应尽快寻找出血部位并及时做出正确的治疗选择.     

肝移植术后腹腔出血的原因与防治

目的探讨原位肝移植(OLT)术后腹腔出血的原因和有效的防治措施。方法回顾性分析和总结1999年2月至2004年6月OLT术后13例腹腔出血患者的临床资料。结果腹腔出血发生率为7.2%(13/181),病死率为15.4%(2/13)。出血发生在OLT术后24h内7例(53.8%),7d内9例(69.2%),7d后4例(30.8%)。出血部位包括供肝活检部位渗血3例、腹壁出血3例、肝动脉吻合口出血2例、胆总管吻合口出血2例、腹腔渗血2例和下腔静脉壁的分支出血1例。结论OLT术后近期腹腔出血的主要原因是凝血功能紊乱和术中止血不妥;腹腔感染或胆漏引起血管破裂是致使后期腹腔出血的主要原因。纠正凝血功能紊乱,精细的手术操作和控制腹腔感染或胆漏可有效的预防OLT术后的腹腔出血。     

重症肝炎行原位肝移植术及肝肾联合移植术的疗效比较

目的 总结重症肝炎患者行原位肝移植或肝肾联合移植的结果,探讨肝肾联合移植的手术适应证.方法 分析52例重症肝炎患者单纯行原位肝移植(orthotopic liver transplantation,OLT)和肝肾联合移植(combined liver-kidney transplantation,CLKT)两组患者死亡率、术后肾功能不全的发生率、ICU天数、住院天数等.结果 CLKT组患者术前肾功能明显差于OLT组,术后发生严重感染的患者明显多于OLT组.但OLT组中28例(70％)患者术后早期发生肾功能不良,其中11例需血液透析;而CLKT组患者中需血液透析仅2例,两组比较差异有统计学意义(P＜0.01).CLKT组患者在围手术期2例(16.7％)死亡.OLT组围手术期死亡16例(40％),其中死于急性肾衰9例,两组死亡率比较差异有统计学意义(P＜0.01).结论 重症肝炎患者若术前肾功能较差,术后易并发严重感染,肝移植后急性肾衰的发病率和死亡率较高,可考虑行CLKT术.     

重组活化Ⅶ因子在普通外科手术出血并发症中的应用

目的 研究观察出现手术中出血并发症后使用或者预防使用重组活化人凝血因子Ⅶ(γFVKa)的止血效果.方法 回顾分析56例外科患者(53例为肝胆外科疾病患者,3例胃肠疾病患者)使用重组活化人凝血因子Ⅶ(γfⅦa)的止血效果,分析术中使用(12例),肝移植术前预防(30例)以及术后使用(14例)的治疗效果.结果 12例患者术中出血时使用.11例患者使用后迅速止血.其中1例肝移植患者以及1例肝癌患者术中成功止血,但术后发生肝功能衰竭死亡.另外1例肝移植患者用药后仍有继续渗血,血流动力学不稳定,无法完成手术,死亡.30例行肝移植术患者术前使用预防出血,手术均成功,患者顺利出院.14例患者术后出血使用,11例用后腹腔血性引流液减少至用药前50%以下.3例使用后,血性引流液减少不明显,血流动力学指标以及生命体征仍不稳定,死亡.总体上56例患者使用γFⅦa后,有50例患者达到救治,救治率达到89%.结论 γFⅦa可以安全地应用于多种外科手术中以及手术相关的出血并发症.     

原位肝移植术后消化道出血的病因与治疗

目的 探讨原位肝移植术后消化道出血的病因与治疗.方法 回顾性分析16例肝移植术后消化道出血患者的临床资料,总结其病因与治疗经验.结果 16例患者发生消化道出血的时间在肝移植术后2 d～4.5年.经检查发现患者的出血原因主要为食道静脉曲张破裂出血4例,急性胃黏膜病变出血3例,门脉高压性胃病出血3例,十二指肠球部多发性溃疡出血2例,十二指肠降段黏膜下小动脉出血、十二指肠乳头肌切开后出血、胆道出血及不明原因出血各1例.有2例经止血治疗无效而死亡,1例在肝移植围手术期死于多器官功能衰竭,1例死于急性心肌梗死,2例死于晚期肿瘤,其他患者经过积极止血治疗后好转,并长期存活.结论 肝移植术后消化道出血的病因主要为食道静脉曲张破裂出血、急性胃黏膜病变、门脉高压性胃病及消化性溃疡等.采用及时的止血治疗,必要时行剖腹探查手术止血是治疗成功的关键.     

胰十二指肠切除术后出血12例临床分析

目的总结胰十二指肠切除术后出血的诊疗经验。方法回顾性分析行胰十二指肠切除手术且术后合并出血的12例患者的临床资料。结果 12例患者中早发性出血2例,迟发性出血10例。按出血部位分为消化道出血9例,腹腔内出血3例。死亡3例,死亡率25%。7例患者行保守治疗,成功止血5例,死亡2例;2例行手术止血,成功1例,死亡1例;3例患者行内镜下止血治疗,其中1例止血成功、1例内镜止血失败后行介入栓塞治疗止血成功、1例内镜止血成功后再发出血,行手术治疗止血成功。结论术前充分评估、术中精细操作和术后规范治疗是减少术后出血发生的关键。出血发生后,应该根据出血部位、出血量、患者生命体征是否平稳等因素,个体化地采取相应的治疗措施。     

肝移植术后胆道并发症的相关病因分析

目前,肝脏移植已成为治疗终末期肝病的重要手段,而胆道并发症是导致移植肝失功并最终导致患者死亡的主要原因之一,文献报道接受原位肝移植术(orthotopic liver transplantation,OLT)的患者术后胆道并发症发生率为7%～51%,使得胆道成为OLT 后最常发生并发症的部位.胆道并发症包括胆漏、胆管狭窄、奥迪括约肌功能失调、黏液囊肿、胆道出血、胆泥以及胆石形成等,由于其发生机制复杂,从移植术前供肝保存到移植术中手术方式、吻合方式的选择,再到术后排斥和感染等非胆道因素的影响,均可能导致胆道并发症的发生,使得临床处理起来相当棘手,严重影响了患者的生活质量和术后长期存活,已引起广大移植学界人士和患者的广泛关注.现就肝移植术后胆道并发症的发生原因进行综述.     

肝硬变肝功能衰竭患者行肝移植时

目的探讨肝功能衰竭患者行同种原位肝移植（OLT）时术前准备的原则和方案。方法回顾性比较分析7例因肝硬变肝功能衰竭行OLT和3例因非硬变性肝病行OLT术前凝血功能、一般状况、内环境状况、术中出血量与术后过程的关系。结果7例肝硬变患者血小板计数均下降,凝血功能差,而3例因非硬变性肝病者血小板下降不明显;7例肝硬变患者术前均进行了利尿和保肝支持治疗,而3例因非硬变性肝病者除2例进行了保肝支持、输少量全血和人白蛋白外,未输注凝血因子和血浆,也未进行利尿治疗。术中7例肝硬变患者平均出血8455ml,除补充相应量的血以外,还平均输注人白蛋白88.5g和血浆957.1ml,但术毕血白蛋白仅26.1g/L,术后48h内内环境紊乱较明显,术后1个月内5例发生真菌感染,3例发生腹腔内出血,而3例非硬变肝病患者平均出血2660ml,术中仅输很少人白蛋白,术毕血白蛋白30.7g/L,内环境紊乱不明显,术后1月内无感染和腹腔内出血发生。结论肝硬变肝功能衰竭患者行肝移植术前完全纠正凝血功能障碍、低蛋白血症、贫血和内环境紊乱是保证手术和术后顺利的重要因素。     

肝移植术后慢性排斥反应的临床与病理分析

目的 探讨原位肝移植术后慢性排斥反应的病理组织学特点、临床表现以及诊治经验.方法 回顾性分析2004年1月至2006年12月收治的516例原位肝移植患者的临床病理资料;对肝移植术后发生慢性排斥反应患者的病理组织学改变、临床表现、诊治方案加以分析.结果 516例肝移植患者中,发生慢性排斥反应12例(2.3%,12/516),其中早期慢性排斥反应7例,晚期慢性排斥反应5例.其主要组织学特征是移植肝组织内的胆管严重减少或缺失和累及中等动脉的闭塞性动脉炎;其中早期慢性排斥反应可表现为小叶间胆管的细胞变性和其数量进行性减少以及形成小叶中央坏死性炎症.12例慢性排斥反应患者中,7例早期慢性排斥反应患者经激素冲击治疗和调整免疫抑制药物后病情得到控制(包括2例接受抗CD3抗体治疗,2例接受抗胸腺细胞球蛋白治疗)且近期疗效满意;5例晚期慢性排斥反应患者肝功能迁延不愈最终至肝功能衰竭而行再次肝移植,其中2例伴术后严重腹腔内感染而死亡,1例死于术后多脏器功能衰竭,另外2例再移植病例获临床治愈.本组慢性排斥反应发生的时间为术后4～26个月;与慢性排斥相关的病死率为25.0%(3/12).结论 肝移植术后发生慢性排斥反应的患者缺乏典型的症状和体征,其病理改变可以有重叠和复合存在;移植肝连续穿刺活检和再次移植术后病理仍是目前诊断慢性排斥反应的"金标准".如能及时发现早期慢性排斥反应并积极进行合理的治疗,病情则具有潜在的可逆性;晚期阶段慢性排斥反应所致的移植肝功能衰竭需要再次肝移植治疗.     

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??Causes and treatment of intracranial hemorrhage after orthotopic liver transplantation MA Yi, YE Zhi-ming, SUN Can-hui, et al. Department of Transplantation Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
Corresponding author??MA Yi, E-mail??anhuimayi2002@163.com
Abstract Objective To investigate the clinical features and prophylactico-therapeutic measures of intracranial hemorrhage after orthotopic liver transplantation (OLT). Methods The clinical data of 638 patients after OLT between January 2004 and December 2008 at the First Affiliated Hospital of Sun Yat-Sen University were analyzed retrospectively. The accumulated experiences in diagnosis and treatment of postoperative intracranial hemorrhage after OLT were reviewed. Results Among the 638 patients, 10 patients (1.6%) suffered from intracranial hemorrhage. One patient happened within the first week after transplantation, 3 within 2 weeks, 6 within 4 weeks. Once the diagnosis is confirmed, dehydrative measures were taken immediately to decrease the intracranial pressure, and antibiotics were applied to control infection at the same time. Four patients underwent emergency craniotomy to clear the intracranial hematoma. Among 10 patients, 6 patients (60.0%) died. Conclusion Intracranial hemorrhage after OLT is extremely dangerous with high mortality. Common causes of postoperative intracranial hemorrhage should be well known. Once the patients show any sign of abnormal consciousness, craniocerebral CT should be done immediately and appropriate treatments should be applied. Craniotomy should be performed to clear the hematoma when needed.     

原位肝移植术后颅内出血原因和处理

目的 探讨肝移植术后颅内出血的临床特点以及防治措施。 方法 回顾性分析中山大学附属第一医院2004年1月至2008年12月施行的638例肝移植病人的临床资料。总结原位肝移植术后颅内出血的诊治经过。结果 638例肝移植病人中共发生术后颅内出血10例（1.6%）;其中发生于移植术后1周内1例,2周内3例,2周至1个月6例。10例病人一经确诊,均立即采取脱水降低颅内压治疗,并应用抗生素控制感染,其中有4例病人急诊施行了开颅血肿清除术。10例中死亡6例,与术后颅内出血相关的病死率为60.0%。结论 肝移植术后颅内出血发病凶险、病死率高。应掌握术后颅内出血的常见原因,对术后意识和精神状态发生改变者要及时进行头颅CT检查,一旦发生颅内出血应积极抢救,及时做出正确的治疗选择,必要时施行开颅血肿清除术。     

Delayed hemorrhage after pancreaticoduodenectomy

BACKGROUND: Postoperative hemorrhage, particularly delayed hemorrhage after pancreaticoduodenectomy, is a serious complication and one of the most common causes of mortality after pancreaticoduodenectomy. STUDY DESIGN: The medical records of 500 patients who underwent pancreaticoduodenectomy between October 1994 and December 2002 were analyzed with regard to postoperative hemorrhagic complications. Delayed hemorrhage was defined as bleeding at the operation site after 5 or more postoperative days. RESULTS: Delayed hemorrhage occurred in 22 patients (4.4%), with a median time of 13 days (range 7 to 32 days) after pancreaticoduodenectomy, and developed more frequently (9/77 versus 13/423, p = 0.003) in patients with preceding intraabdominal complications such as pancreatic fistula, bile fistula, and intraabdominal abscess. In 17 of these 22 patients, angiography and laparotomy revealed bleeding foci at 14 arterial and 3 anastomotic sites. In nine patients, hemorrhage developed from pseudoaneurysms of the major arteries around the pancreaticojejunostomy. Hemostatis was attempted by transcatheter arterial embolization in 14 patients and with laparotomy in 4 patients. Four of 14 patients who received transcatheter arterial embolization eventually required laparotomy. Overall, 4 of the 22 delayed hemorrhage patients died (18.2%) of complications related to massive bleeding or transcatheter arterial embolization. CONCLUSIONS: Delayed hemorrhage after pancreaticoduodenectomy is associated with a high mortality. Intraabdominal complications after pancreaticoduodenectomy should be evaluated properly and guidelines for the diagnosis and treatment of delayed hemorrhage should be established in advance. Clinicians must be alert to the possibility of pseudoaneurysm hemorrhage.     

Early postoperative hemorrhage requiring urgent surgical reintervention after orthotopic liver transplantation

Hemorrhage is a common complication in the early postoperative period after orthotopic liver transplantation (OLT) and surgical reintervention may be necessary. We sought to assess the incidence as well as to identify potential risk factors for bleeding requiring surgical reintervention in the early postoperative period. From January 2003 to December 2005, we retrospectively reviewed the courses of 261 patients who underwent OLT. We analyzed the pretransplantation parameters, transplantation features, and clinical data for surgical reintervention due to early postoperative hemorrhage. Twenty-two of 261 patients (8.4%) had early postoperative hemorrhage requiring urgent surgical reintervention during the initial hospital stay. In-hospital mortality of the patients with hemorrhage (9/22; 41%) was significantly higher than that of other patients (29/239; 12.1%; P < .001). The surgical problem was the main cause of hemorrhage (18/22; 81.8%). More intraoperative blood transfusions were necessary for patients with hemorrhage than for other patients. Furthermore, a greater number of blood transfusions, including red blood cells, plasma, and platelet concentrates, during the transplantation procedure correlated with a greater mortality. In conclusion, early postoperative hemorrhage requiring urgent surgical reintervention is a severe complication with a high mortality. It is mainly caused by errors in surgical technique. Blood transfusion during transplantation was correlated with a higher mortality.     

Spontaneous bleeding from liver after open heart surgery

INTRODUCTIONIntra-abdominal hemorrhage after open heart surgery is very uncommon in routine clinical practice. There are case reports of having bleeding from spleen or liver after starting low molecular weight heparin (LMWH) postoperatively.PRESENTATION OF CASEOur patient is a 58-year-old man with mitral valve regurgitation, who underwent mitral valve repair and developed intra-abdominal hemorrhage 8 h after open heart surgery. The exploratory laparotomy revealed the source of bleeding from ruptured sub-capsular liver hematoma and oozing from raw areas of the liver surface. Liver packing was done to control the bleeding.DISCUSSIONThe gastrointestinal complications after open heart surgery are rare and spontaneous bleeding from spleen has been reported. This is the first case from our hospital to have intra-abdominal hemorrhage after open heart surgery.CONCLUSIONSpontaneous bleeding from liver is a possible complication after open heart surgery. We submit the case for the academic interest and to discuss the possible cause of hemorrhage.     

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??Analysis of risk factors for prognosis of postoperative hemorrhage after pancreaticoduodenectomy: a report of 60 cases ZHU Qi-cong??WU Peng-fei??LU Zi-peng??et al. Pancreas Center??the First Affiliated Hospital of Nanjing Medical University??Nanjing 210029??China
Corresponding authors??JIANG Kui-rong??E-mail??jiangkuirong@njmu.edu.cn??MIAO Yi??E-mail??miaoyi@njmu.edu.cn
Abstract Objective To analyze common risk factors and treatment strategy for prognosis of postoperative hemorrhage after pancreaticoduodenectomy. Methods The clinical data of 60 patients who underwent pancreaticoduodenectomy in the First Affiliated Hospital of Nanjing Medical University from January 1??2012 to December 31??2015 were analyzed retrospectively. The risk factors for prognosis of postoperative hemorrhage were analyzed. Results Among them, 8 patients died after surgery??others were alive. Early bleeding appeared in 10 patients and delayed hemorrhage occurred in 50 patients. Bleeding site included 23 gastrointestinal hemorrhage patients and 37 abdominal hemorrhage patients. Mild bleeding occurred in 37 patients and severe bleeding in 23 patients. Among them, 3 patients were grade A??40 patients grade B??17 patients grade C. Postoperative complications included postoperative pancreatic fistula in 28 patients??intra-abdominal infection in 5 patients and biliary fistula in 3 patients. Treatment strategies contained 41 patients with bleeding were treated conservatively, 9 patients received endoscopy or angioembolization while 10 patients underwent reoperation. Intra-abdominal infection and bleeding degree were important risk factors of clinical outcomes of hemorrhage after pancreaticoduodenectomy. ROC curve analysis showed that the 5th day of after surgery was a clear demarcation point of clinical prognosis. Conclusion Intra-abdominal infection, bleeding degree and grade are important risk factors of hemorrhage after pancreaticoduodenectomy. The 5th day after surgery may be a clear demarcation point of clinical prognosis, which has certain significance for the bleeding grade.     

肝胆胰术后迟发性出血的诊治分析

目的 探讨肝胆胰术后迟发性出血的原因和诊断治疗方法。方法 回顾性分析宁夏回族自治区人民医院2015年1月至2022年3月收治的13例肝胆胰腺术后出血患者的临床资料和诊治方法,总结其出血的原因和治疗经验。结果 13例患者均有失血性休克临床表现,其中8例为消化道出血：7例为肝动脉分支假性动脉瘤破裂,1例为胆道出血;5例腹腔出血。13例患者动脉造影明确出血部位后行出血部位动脉栓塞治疗,12例出血停止痊愈。另1例患者动脉栓塞治疗失败后,行开腹行肝右动脉结扎止血术后止血。结论 假性动脉瘤形成、胰漏和腹腔感染是肝胆胰患者术后迟发性出血的主要原因。血管造影术是诊断患者术后出血重要的检查方法,动脉栓塞术是治疗术后出血的有效方法。