虚拟肝技术在肝脏外科中的应用

<正>虚拟肝是利用外科学、临床解剖学、现代影像学、计算机图形学、图像处理和虚拟现实技术进行多学科交叉研究,研发出计算机软件系统,利用病     

Parenchymal liver injury in orthotopic liver transplantation

BACKGROUND: A 35-year period of clinical development resulted in orthotopic liver transplantation (OLT) becoming a standardized surgical procedure. Despite this progress, the rate of technical complications is still high. Although the main problem in most analyses is vascular or bile duct failure, we observed a remarkable number of parenchymal liver injuries that led to intraoperative problems. Our aim, therefore, is to present an overall report on the incidence, treatment, and clinical course of parenchymal liver injuries in OLT. METHODS: Five hundred seventy-two consecutive OLT procedures performed between 1988 and 1998 were analyzed in a retrospective study. Parenchymal liver injury was diagnosed by means of examination of the surgical reports. Donor- and recipient-related data followed the medical report. The lesions were classified according to the Organ Injury Scale. RESULTS: Parenchymal liver injury was diagnosed in 23 patients (4%). The lesions were classified as grade Ia (13.1%), grade Ib (13.1%), grade IIb (52.1%), grade IIIa (17.1%), and grade IIIb (4.3%). In 19 patients (82.6%), the lesion was detected during OLT, and in four patients (17.4%), during relaparotomy. The latter group showed significantly higher-grade injuries. Treatment was suture or fibringlue alone, 17.4%; fibringlue and hemostyptics, 26.1%, mesh wrapping 30.4%, and mesh packing 26.1%. Seven patients (30.4%) underwent relaparotomy. Further active bleeding was not found in any of them. Statistical analysis found a correlation between injury grade and relaparotomy rate. No patients died as a result of parenchymal liver injury. CONCLUSIONS: Parenchymal liver injuries can be treated well, with no adverse effect on patient or graft survival. An early decision concerning the surgical procedure for controlling hemorrhage is required. A basically aggressive therapeutic approach might avoid further complications relating to reperfusion edema.     

Indications for liver biopsy in liver tumors

Significant progress has been made in the assessment of liver dysfunction by application of non-invasive physical and biochemical test procedures. However, liver biopsy remains an important tool for diagnosis, evaluation and prognosis of chronic liver diseases and hepatic neoplasms. Liver biopsy results are most useful when the biopsy is performed for well-defined indications following a complete work-up of the patient. In case of lesions highly suspicious for hepatocellular carcinoma, a biopsy should be performed in case surgical (curative) treatment is no option. Thus for the planning of a surgical intervention, biopsy of the tumor is not necessary. In case of concomitant liver cirrhosis, a biopsy taken from the non-neoplastic (cirrhotic) liver may help to assess the functional capacity or to clarify the etiology. Metastases of the liver with unknown primary tumor should be biopsied to obtain information of the primary tumor and the potential for cytostatic therapy. In case of hemangioma or focal nodular hyperplasia, diagnosed and confirmed by radiology or ultrasound, biopsy is usually not necessary. Concern has been expressed about seeding of the needle tract with malignant cells. Indeed, such instances have been recorded with various carcinomas, but they remain rare events and are seldom of clinical importance. With the use of needles with diameter < 1.3 mm to minimise also the risk of bleeding, the procedure is simple, safe and painless.     

脂肪沉着供肝在肝脏移植中的应用

目的探讨供肝脂肪浸润程度与肝脏移植病人预后的关系。方法天津市第一中心医院2002年1～12月间供体采用UW液灌注的首次肝脏移植病人71例，根据供肝脂肪浸润程度分为四组，比较各组问术后谷丙转氨酶（ALT）、谷草转氨酶（AST）水平、ICU时间及1年移植物存活率等各项指标。结果轻度脂肪肝组与无脂肪肝组的术后ALT、AST、ICU时间、1年移植物存活率均无显著性差异，中度脂肪肝组的术后ALT、AST、ICU时间均高于轻度及无脂肪肝组，但1年移植物存活率一致，三组均无移植物原发无功（PNF）发生。重度脂肪肝组只有2例，故未作统计学分析，其中1例发生PNF，于术后第2天行再次移植手术。结论轻、中度脂肪肝均可应用于l临床肝移植，对病人预后无影响；重度脂肪肝PNF发生率较高，不宜应用。     

Role of liver progenitors in liver regeneration

During massive liver injury and hepatocyte loss, the intrinsic regenerative capacity of the liver by replication of resident hepatocytes is overwhelmed. Treatment of this condition depends on the cause of liver injury, though in many cases liver transplantation (LT) remains the only curative option. LT for end stage chronic and acute liver diseases is hampered by shortage of donor organs and requires immunosuppression. Hepatocyte transplantation is limited by yet unresolved technical difficulties. Since currently no treatment is available to facilitate liver regeneration directly, therapies involving the use of resident liver stem or progenitor cells (LPCs) or non-liver stem cells are coming to fore. LPCs are quiescent in the healthy liver, but may be activated under conditions where the regenerative capacity of mature hepatocytes is severely impaired. Non-liver stem cells include embryonic stem cells (ES cells) and mesenchymal stem cells (MSCs). In the first section, we aim to provide an overview of the role of putative cytokines, growth factors, mitogens and hormones in regulating LPC response and briefly discuss the prognostic value of the LPC response in clinical practice. In the latter section, we will highlight the role of other (non-liver) stem cells in transplantation and discuss advantages and disadvantages of ES cells, induced pluripotent stem cells (iPS), as well as MSCs.     

体外肝切除自体肝移植在复杂肝切除中的应用

目的 评估体外肝切除自体肝移植在巨大肝癌患者复杂肝切除中的临床价值.方法 回顾性分析2008年1月至2010年5月首都医科大学附属北京朝阳医院收治的4例巨大原发性肝癌患者的临床资料.肿瘤最大直径10 ～ 18 cm,病灶不同程度地累及了第一、二、三肝门.患者难以耐受常规肝切除,均行体外肝切除自体肝移植.结果 4例患者顺利完成手术,手术时间690 ～840 min,无肝期250～300 min,术中出血量400～1400 ml,术中无肝期未行门、腔静脉转流术.4例患者在体外肝切除后行下腔静脉或肝静脉及门静脉修复成型,均应用成型异体血管来延长剩余肝脏肝上腔静脉以利于腔静脉吻合及第一肝门的重建.本组患者1例术后肝功能正常,1例出现腹腔出血再次手术止血,1例发生肝功能不全,1例出现肝肾功能不全于术后5d放弃治疗而死亡.3例术后生存的患者术后1～2个月间剩余肝脏均发生不同程度的代偿增生.术后生存的3例患者中2例分别于术后8、9个月发现肺部多发转移瘤,分别于术后13个月及15个月死亡.随访截至2012年4月,1例患者无瘤生存37个月.结论 体外肝切除自体肝移植为复杂肝切除的巨大肝癌患者提供了技术上的可行性,术后肝功能代偿不全及近期肿瘤的复发是限制该手术发展的主要问题.     

不规则肝切除术和规则肝切除术在肝癌手术切除中的比较

【摘要】 目的〓探究不规则肝切除术和规则肝切除术在巨大肝癌手术切除中的临床应用及比较。方法〓本研究回顾性分析2006年6月至2014年6月罗定市人民医院收治的原发性肝癌肝切除手术患者,对已实施的不规则性肝切除术与规则性肝切除术两组病例进行比较。包括两组手术的围手术期各个指标及术中、术后各个指标进行比较。结果〓规则肝切除组中的手术时间、术中出血、输血浆、输红细胞量、住院时间及并发症发生率均明显地高于不规则肝切除组的情况,差异有统计学意义(P<0.05),而肿瘤能完整切除的最大直径显著小于不规则肝切除(P<0.05);二者在死亡率的比较上无明显差异,无统计学意义(P>0.05)。结论〓与规则肝切除相较,不规则肝切除在腹部手术史引起严重腹腔内组织粘连、肝功能分级较差、肿瘤数目较多及小肝癌中均体现了明显的优势。而对于肿瘤体积较大的肝癌患者,规则肝切除则更为有效。     

Temporary liver transplantation in acute liver failure.

The ability of a heterotopic graft to prolong life in animals dying in hepatic coma due to liver necrosis has never been definitely established. Acute hepatic failure was produced in 15 dogs by an hour of total interruption of the hepatic blood supply. Nine dogs received an intrathoracic hepatic homograft concurrently. Nontransplanted dogs died within 21 hours in hepatic coma, while transplanted dogs survived significantly longer (P less than .001). In all transplanted dogs, biological signs of hepatic failure were corrected in 24 hours. In four animals, the graft was removed on the fifth postoperative day. Two of those survived for 10 and 15 days respectively with normal hepatic function. These results demonstrate that a temporary heterotopic liver transplant is able to support life during the acute, normally lethal phase in dogs with massive liver necrosis.     

人工肝联合肝移植治疗急性肝功能衰竭

急性肝功能衰竭（acute liver failure，ALF）疾病凶险，自然死亡率高达80％以上。20世纪80年代中期肝移植开始应用于治疗急性肝功能衰竭。现今，结合肝移植治疗急性肝功能衰竭病人存活率大大提高，英国伯明翰伊丽莎白医院一组110例ALF结合肝移植病人1年存活率达到81％，5年存活率高达73%。笔者一组86例ALF结合肝移植资料表明病人的1年存活率为88％，5年存活率达71％。这些数据表明现代外科干预处理ALF可获得满意疗效。     

腹腔镜肝切除治疗肝脏肿瘤15例临床分析

目的 探讨完全腹腔镜肝切除治疗肝脏肿瘤的安伞性及有效性.方法 不阻断肝脏血流的情况下,联合采用超声刀、Ligasure及血管夹进行完伞腹腔镜下肝切除15例,其中肝海绵状血管瘤9例,直径5.0～15.0 cm(平均直径7.9 cm),肝囊肿纤维化3例,其中2例为引流术后复发,均位于左外叶,左外叶明显缩小.原发件肝癌3例,直径1.0～5.0 cm,肝功能均为Child A级.结果 15例患者腹腔镜肝切除均获成功,其中左外叶切除6例,其余患者为肝不规则切除,无中转手术.平均手术时间110 min,术中出血虽30～500 ml,平均251 ml.术后平均住院时间6.5 d,无术后死亡,术后除1例患者肝癌创面渗血,保守治愈外,其余无并发症,全部治愈.结论 对位于Ⅱ、Ⅲ、Ⅳa、Ⅴ、Ⅵ段肝脏肿瘤患者,采用完全腹腔镜肝切除是一种安全有效的微创治疗方法.     

Adult-to-adult living donor liver transplantation in acute liver failure

BackgroundLiving Donor Liver Transplantation(LDLT) in acute liver failure(ALF) patients has been limited by concerns regarding donor safety, consent process and recipient outcomes. Our objective was to conduct a systematic review(SR) and meta-analysis to address the concerns about subpar LDLT outcomes in patients with ALF.MethodsWe retrieved a total of 5965 literature references in our SR. United Network for Organ Sharing (UNOS) database was queried for patients over the age of 18, who underwent LDLT for “status 1” or “status 1A” listing.ResultsOf 427 articles reviewed, 3 studies comprising 2574 patients (192 underwent LDLT and 2382 DDLT), were included in the meta-analysis. One, 3,5-year patient and graft survival demonstrated no difference between LDLT and DDLT group: 1-year patient survival OR1.51; 95%CI [0.58,1.90]; 1-year graft survival OR 1.19; 95%CI [0.65–2.18]; 3-year patient survival OR 0.97;95%CI [0.52–1.88]; 3-year graft survival OR 1.21 95%CI [0.67–2.16]; 5-year patient survival 0.9; 95%CI [0.37–2.20]; 5-year graft survival OR 1.30; 95%CI [0.57–2.97]. UNOS database search returned only 3 patients that underwent LDLT for ALF compared to 1562 with DDLT, precluding comparison.ConclusionOne, 3, and 5-year patient and graft survival following LDLT vs DDLT transplantation were not statistically significantly different; however, due to limited number of studies further studies are warranted.     

The impact of liver reductions in pediatric liver transplantation

Reduced-size liver transplantation (RSLT) in children was introduced to alleviate a shortage of small-organ donors. The impact of RSLT on the waiting time for an organ and on morbidity and mortality was investigated. Between March 25, 1988, and August 11, 1990, 61 hepatic transplantations were performed in 55 children at the Pacific Transplant Institute in San Francisco, Calif. Full-size liver transplantation was performed in 41 cases and RSLT in 20 cases. The overall 30-month actuarial patient and graft survival rates were 89% and 73%, respectively. A comparison between full-size liver transplantation and RSLT showed no difference in patient and graft survival, reoperations, infections, or rejection. Benefits of RSLT were an increase in the donor pool size, a decrease in waiting time for a suitable donor, and a decrease in the rate of arterial thrombosis. The main morbidity of RSLT was an increase in perioperative blood requirement. We conclude that RSLT offers small children with end-stage liver disease a chance for long-term survival.