成人间活体肝移植供体右半肝切取的麻醉管理

活体肝移植基于供体的短缺,最早将供者左半肝或左外侧叶应用于儿童.对于成人受者,左半肝移植易导致小肝综合征,因此越来越多的成人与成人间的活体肝移植采用右半肝作为供体.右半肝切除相对左半肝而言,手术难度和术后并发症的发生率增加.因此,笔者对本院供体的麻醉管理进行总结,以期对提高该类患者临床手术的安全性提供一定的参考作用.     

活体肝移植供体的选择与评估

目的探讨活体肝移植中供体的选择与评估内容。方法对32例活体供肝者的临床资料进行回顾性分析。结果49名拟供体,最终行32例活体肝移植,有17例拟供体被排除。其中,病毒性肝炎是最重要的排除原因(10／17),另一个主要原因是因为志愿者受到家庭、亲属及社会的影响而放弃最初的献肝意愿,共4例,占23.5％(4／17);重度脂肪肝2例,占11.8％(2／17),其它肝外疾病1例,占5.9％(1／17)。供肝选择:扩大左半肝20例,左半肝4例,右半肝8例;切取供肝重量(447±148)g;供肝重量与受体体重之比均数为(1.39±0.45)％,最低仍超过0.8％。结论只有在对供体进行仔细的选择与评估后,才能确保活体肝移植的成功开展。     

活体右半肝供者肝脏血管和胆道解剖变异分析

目的:探讨活体肝移植右半肝供者血管、胆道解剖学特点。方法:依据门静脉分型、肝静脉解剖分型、胆道分型及肝动脉解剖分型,观察90例右半肝活体肝移植供者的肝静脉、门静脉、肝动脉及胆道的解剖学特点。结果:正常门静脉的比例为94.4%(85/90),三叉型门静脉的比例为5.6%(5/90);肝动脉变异率较高;正常胆道的比例为66.7%(60/90),三叉型胆道占20%(18/90),3型胆道的比例为12.2%(11/90),4型胆道占1.1%(1/90);肝中静脉和肝左静脉共干的比例为70.0%(63/90),大于5mm的肝右下静脉出现概率为26.6%(24/90),左内叶上段静脉汇入肝左静脉的比例为68.8%(62/90),共同汇入肝左静脉和肝中静脉的比例为21.1%(19/90),汇入肝中静脉的比例为10.0%(9/90)。结论:肝脏血管和胆道的解剖变异很常见,准确的术前评估对于活体肝移植至关重要。     

活体右半肝移植中供肝肝中静脉取舍对供体安全的影响

目的:探讨依照剩余肝体积比(%RLV)、供肝受体体质量比(GRWR)和Ⅳ段静脉汇人情况来决定供肝切取时肝中静脉(MHV)的取舍对供体安全的影响.方法:43例供者拟行活体右半肝切取,当%RLV<35%且GRWR>1.0%时,入选B组;当%RLV≥35%且GRWR<1.0%时,入选A组;当%RLV≥35%且GRWR>1.0%时,如Ⅳ段静脉汇入肝左静脉为主入选A组,如Ⅳ段静脉汇入MHV为主入选B组.A组15例行带MHV的右半肝切取,B组28例行不带MHV的右半肝切取,分析比较2组供者术前和术中的一般情况以及术后血清丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、白蛋白(ALB)和剩余肝脏的再生情况.结果:2组供者除%RLV和GRWR外,其他一般状况差异无统计学意义,2组供体的术后ALT、AST、TBIL的最高值和ALB的最低值差异无统计学意义,2组状态与时间的交互效应差异均无统计学意义,2组所有供者均于术后2周痊愈出院,恢复正常生活.结论:依照以上预案来决定行是否带MHV右半肝切取,可以保障供体安全.     

活体肝移植肝动脉重建技术与并发症

目的 探讨活体肝移植中肝动脉重建的显微外科技术，以降低肝动脉栓塞的发生率，提高患移植后的生存率。方法 本组24例，其中右半肝活体肝移植6例，左半肝移植16例，左外叶2例；采用显微外科技术行肝动脉吻合。吻合的方式是端端吻合。结果11例肝动脉直径＜2mm，重建肝动脉时间为24～88min。行单支动脉吻合20例，两支动脉吻合4例；2例患术后出现肝动脉血栓形成，均须行再次肝移植后恢复。本组肝动脉血栓的发生率为8．3％。结论 显微外科技术重建肝动脉可减少肝移植术后肝动脉栓塞的发生。     

活体肝移植胆道并发症相关危险因素的研究

目的 对我院活体右半肝移植术后胆道并发症的发生率及其影响因素进行初步评估,筛选术后胆道并发症的危险因素,为降低本中心术后胆道并发症的发生率提供理论依据。方法 本研究选取2007年3月至2009年1月在我中心行活体右半肝移植手术的75例病例进行回顾性研究。分析了供、受者年龄、手术时间、门脉开放至肝动脉开放时间、无肝期、移植物与受者质量比（GRWR）、冷保存时间、供肝是否带肝中静脉、供肝胆道开口数量、胆道吻合口数量、是否行胆道成型术、胆道开口尺寸大小、是否存在肝动脉闭塞、是否出现急性排斥反应等14个因素,进行单因素分析确定各因素与术后胆道并发症的相关性,采用二项分类回归分析筛选术后胆道并发症的危险因素。结果 本研究中术后出现胆道并发症20例（26.7%）。二项分类回归分析显示：门静脉开放至肝动脉开放时间间隔（P=0.018）、肝动脉闭塞（P=0.047）是活体右半肝移植术后胆道并发症的重要危险因素。结论 门静脉开放至肝动脉开放时间间隔、肝动脉闭塞为活体右半肝移植术后胆道并发症的危险因素。     

供者年龄超过55岁的成人间活体肝移植四例

为了克服肝源短缺和扩大供肝来源,活体肝移植(living related liver transplantation,LRLT)已成为可补充原位尸肝移植的一种新的手术方式.通过严格的筛选,在原位尸体肝移植中使用大于60岁的供体,甚至大于70或80岁的供体,也可以获得满意的临床效果[1].许多移植中心为了供者的安全一般设定活体肝移植供者年龄上限为55岁.本研究通过对2007年6月-2008年3月4例年龄为55岁以上的活体肝移植患者资料进行分析,评价供者的年龄因素对活体肝移植的影响.     

ENBD 治疗成人间活体右半肝移植术后胆漏一例

患者,男性,42岁,因原发性肝癌、乙肝后肝硬化于年5月15日在全麻下行成人间活体右半肝移植术.供体为25岁的健康男性,血型为B型、Rh( ),术前胰胆管磁共振成像(MRCP)检查提示右肝前、后叶肝管分别开口于肝总管.术中切取右半供肝时,胆道造影及手术均证实右半供肝的前、后叶肝管为分别开口,于后台将左右肝管整形与受体肝总管作端端吻合,7-0的无损伤可吸收缝线间断缝合,未放置T管.     

儿童活体和尸体肝移植的临床效果比较

目的 分析和评价儿童活体和尸体肝移植的效果。 方法 回顾性分析 320 例终末期肝病儿童肝移植的预后及影响因素。 根据肝移植手术方式的不同, 将 320 例受者分为活体肝移植组（活体组）252 例和尸体肝移植组（尸肝组）68 例。 活体组所有供者均为 3 代以内的直系亲属; 尸肝组所有供者均为心脏死亡或脑死亡供者。 比较两 组受者术后存活情况和并发症情况。 结果 活体组受者 1、2、3 年的总体存活率分别为 95.1%、93.5%和 93.5%, 尸肝组分别为 92.3%、92.3%和 82.4%, 两组间比较差异无统计学意义（Log-rank χ2=0.69, P=0.41）。 随访期间, 活体组死亡14 例（5.56%）, 其中 8 例死于呼吸系统并发症, 3 例死于多器官功能衰竭, 3 例死于移植肝功能衰竭; 尸肝组死亡 5 例（7.35%）, 其中 1 例死于呼吸系统并发症, 2 例死于多器官功能衰竭, 1 例死于腹腔出血, 1 例死于其他原因。 两组门静脉血栓（PVT）、流出道梗阻、胆道并发症、肺部感染差异无统计学意义（均 P＞ 0.05）, 活体组肝动脉血栓（HAT）比例低于尸肝组（1.98% vs. 10.29%, χ2=10.245, P < 0.01）。 结论 活体肝移植作为治疗终末期肝病的有效手段, 疗效较好。     

活体肝移植应用脂肪肝供肝的疗效分析

目前,活体肝移植呈增多趋势,在活体供者评估过程中,经常遇到脂肪肝供肝的应用问题.有研究认为尸体供肝脂肪变若为中度脂肪肝(肝细胞脂肪浸润程度<60%)以下的可以安全利用,重度脂肪肝供体将增加受体风险.     

Efficacy of gut lavage,hemodialysis, and hemoperfusion in the therapy of paraquat or diquat intoxication

Clinical and in vitro investigations were carried out to test the efficacy of gut lavage, hemodialysis, and hemoperfusion in the treatment of poisoning with paraquat or diquat. In a patient suffering from diquat intoxication 130 times more diquat was removed by gut lavage 30 h after ingestion than was removed by complete aspiration of the gastric contents.Determination of in vitro clearances for paraquat and diquat by hemodialysis showed that, at serum concentrations of 1–2 ppm, such as are frequently encountered in poisoning in man, toxicologically relevant quantities of herbicide cannot be removed from the body. At a concentration of 20 ppm, on the other hand, hemodialysis proved to be effective, the clearance being 70 ml/min at a blood flow rate of 100 ml/min. The efficacy of hemoperfusion with coated activated charcoal was on the whole better. Especially at concentrations around 1–2 ppm, the clearance values for hemoperfusion were some 5–7 times higher than those for hemodialysis.In a patient suffering from paraquat poisoning, both hemodialysis as well as hemoperfusion were carried out. The in vitro results could be confirmed: At serum concentrations of paraquat less than 1 ppm no clearance could be obtained by hemodialysis while by hemoperfusion with activated charcoal quite high clearance values were measured and the serum level dropped down to zero.

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Zusammenfassung Klinische Untersuchungen und Laboratoriumsversuche wurden durchgeführt, um die Wirksamkeit von Darmspülung, Hämodialyse und Hämoperfusion bei Paraquat- und Deiquat-Vergiftungen zu prüfen.Bei einem Patienten wurde 30 Std nach Deiquat-Aufnahme durch Darmspülung 130mal mehr Deiquat entfernt als durch vollständige Aspiration des Mageninhaltes. In vitro-Versuche ergaben, daß bei Blutserumkonzentrationen von 1–2 ppm, die bei Vergiftungen oft gemessen werden, durch Hämodialyse keine toxikologisch relevanten Paraquat- oder Deiquat-Mengen entfernt werden können. Dagegen erwies sich die Hämodialyse bei 20 ppm und einer Blutumlaufgeschwindigkeit von 100 ml/min mit einer Clearance von 70 ml/min als wirksam. Die Hämoperfusion mit beschicheter Aktivkohle war in diesen Versuchen aber eindeutig überlegen, denn insbesondere bei Konzentrationen um 1–2 ppm waren die Clearance-Werte 5–7mal höher als bei der Hämodialyse.Die in vitro-Ergebnisse wurden bei einem Patienten mit einer Paraquat-Vergiftung bestätigt: Bei Konzentrationen unter 1 ppm war die Hämodialyse wirkungslos, während durch Hämoperfusion relativ hohe Clearance-Werte erreicht wurden, so daß der Serumspiegel rasch unter die Nachweisgrenze abfiel.

     

In vitro studies on sterically stabilized liposomes (SL) as enzyme carriers in organophosphorus (OP) antagonism

This study describes a new approach for organophosphorous (OP) antidotal treatment by encapsulating an OP hydrolyzing enzyme, OPA anhydrolase (OPAA), within sterically stabilized liposomes. The recombinant OPAA enzyme was derived from Alteromonas strain JD6. It has broad substrate specificity to a wide range of OP compounds: DFP and the nerve agents, soman and sarin. Liposomes encapsulating OPAA (SL)* were made by mechanical dispersion method. Hydrolysis of DFP by (SL)* was measured by following an increase of fluoride ion concentration using a fluoride ion selective electrode. OPAA entrapped in the carrier liposomes rapidly hydrolyze DFP, with the rate of DFP hydrolysis directly proportional to the amount of (SL)* added to the solution. Liposomal carriers containing no enzyme did not hydrolyze DFP. The reaction was linear and the rate of hydrolysis was first order in the substrate. This enzyme carrier system serves as a biodegradable protective environment for the recombinant OP-metabolizing enzyme, OPAA, resulting in prolongation of enzymatic concentration in the body. These studies suggest that the protection of OP intoxication can be strikingly enhanced by adding OPAA encapsulated within (SL)* to pralidoxime and atropine.     

Synthesis,Cytotoxicity and Antileishmanial Activity of Some N-(2-(indol-3-yl)ethyl)-7-chloroquinolin-4-amines

We report herein the condensation of 4,7-dichloroquinoline (1) with tryptamine (2) and D-tryptophan methyl ester (3) . Hydrolysis of the methyl ester adduct (5) yielded the free acid (6) . The compounds were evaluated in vitro for activity against four different species of Leishmania promastigote forms and for cytotoxic activity against Kb and Vero cells. Compound (5) showed good activity against the Leishmania species tested, while all three compounds displayed moderate activity in both Kb and Vero cells.     

Steroidal sapogenin contents in some domestic plants

In order to find out the values of the steroid resources for the future use. the compositions and contents of steroidal sapogenins from 13 domestic plants have been investigated. As a result,Dioscorea nipponica, D. quinqueloba andSmilax china were found to have large amount of diosgenin. And pennogenin inTrillium kamtschaticum andParis verticillata, yuccagenin inAllium fistulosum, hecogenin inAgave americana and neochlorogenin inSolanum nigum were appeared to be major steroidal sapogenins.     

Aquatic Insects and Trace Metals: Bioavailability,Bioaccumulation, and Toxicity

Abstract

The uptake of metals from food and water sources by insects is thought to be additive. For a given metal, the proportions taken up from water and food will depend both on the bioavailable concentration of the metal associated with each source and the mechanism and rate by which the metal enters the insect. Attempts to correlate insect trace metal concentrations with the trophic level of insects should be made with a knowledge of the feeding relationships of the individual taxa concerned. Pathways for the uptake of essential metals, such as copper and zinc, exist at the cellular level, and other nonessential metals, such as cadmium, also appear to enter via these routes. Within cells, trace metals can be bound to proteins or stored in granules. The internal distribution of metals among body tissues is very heterogeneous, and distribution patterns tend to be both metal and taxon specific. Trace metals associated with insects can be both bound on the surface of their chitinous exoskeleton and incorporated into body tissues. The quantities of trace meals accumulated by an individual reflect the net balance between the rate of metal influx from both dissolved and particulate sources and the rate of metal efflux from the organism. The toxicity of metals has been demonstrated at all levels of biological organization: cell, tissue, individual, population, and community. Much of the literature pertaining to the toxic effects of metals on aquatic insects is based on laboratory observations and, as such, it is difficult to extrapolate the data to insects in nature. The few experimental studies in nature suggest that trace metal contaminants can affect both the distribution and the abundance of aquatic insects. Insects have a largely unexploited potential as biomonitors of metal contamination in nature. A better understanding of the physico-chemical and biological mechanisms mediating trace metal bioavailability and exchange will facilitate the development of general predictive models relating trace metal concentrations in insects to those in their environment. Such models will facilitate the use of insects as contaminant biomonitors.