肝移植病人术中危险因素分析及护理对策

我国是世界上终末期肝病发病率最高的地区之一,许多严重的肝脏疾病,在进入终末期的病程中,只有求助于肝移植才有获愈的希望.     

重视围手术期处理,提高肝移植技术水平

肝移植技术的飞跃进步是现代外科水平达到一个巅峰的标志。我国是世界上肝脏疾病发病率最高的国家之一,各类肝炎、肝硬化、肝癌、先天性与代谢性肝病等造成不可逆的肝脏损害,最终发展成为终末期肝病,严重困扰人民健康。今天,中国的肝移植事业已取得不菲成绩,肝移植作为目前唯一有效治疗终末期肝病的方法,使得人们多年来希冀更新器官的梦想得以实现。然而,与国际水准相比,在肝移植围手术期处理方面尚存在若干薄弱之处,     

评价终末期肝病肝脏储备功能的进展

准确评价终末期肝病患者的肝脏储备功能有利于临床医生为患者选择个体化的治疗方案,特别是近年来肝移植技术的发展迫切需要一个精确、简便和客观的标准。肝功能分级(Child-Turcotte-Pugh,CTP)分级用于临床已有40多年了,在判断终末期肝病的肝脏储备功能上越来越显示其局限性。终末期肝功病模型(Model for End-stage Liver Disease,MELD)是近年来创立的判断终末期肝病患者的肝脏储备功能的新方法,其在临床应用尤其在肝移植方面已显示出许多优越性。该文主要对CTP分级和MELD评分的产生、特点、临床应用及存在的问题作一综述。     

肝脏相关干细胞的临床应用

肝脏疾病仍是一个世界性难题,我国肝病发病率高,目前还无有效的治愈措施。现在治疗终末期肝病最理想的方法是原位肝移植,而肝供体缺乏等限制了其应用。不同来源的干细胞具有自我更新、高度增殖和定向分化为肝细胞的特性,因而干细胞移植治疗可成为替代肝移植的最佳治疗手段,并有效改善患者的肝脏功能和生活质量。肝脏相关干细胞移植和基因综合治疗可望治愈肝癌和遗传代谢性肝病等肝脏疾病。     

肝移植后乙型肝炎复发的预防

自 1 96 7年Ｓｔａｒａｌ成功地施行首例肝移植以来 ,肝移植得到了迅速的发展 ,现已成为治疗急慢性终末期肝病的常用方法。对于肝移植的适应证 ,理论上可以这样认为 :一切肝脏疾病 ,如果用目前其它所有疗法不能治愈 ,而且预计在短期内无法避免死亡者 ,都是肝移植的适应证 ,按其病变性质可分为两类 :肝脏的恶性肿瘤和终末期良性肝病。在终末期良性肝病中 ,争论最大的是乙型病毒性肝炎 (以下简称乙肝 ) ,以前许多移植中心都将其视为禁忌证 ,原因主要为肝移植术后近 80 %于半年后复发。由于近年来乙肝病人围手术期处理的进展 ,逐渐改变了这种看…     

背驮式原位肝移植的护理体会

肝移植是指对于终末期肝病患者,通过手术植入一个健康的肝脏,使患者肝功能得到良好的恢复.自1963年美国Starzl实行世界上第一例人体原位肝移植开始,40多年来随着手术方式的改进、安全有效的免疫抑制剂的开发以及器官保存液的改进,肝脏移植已经进入了成熟时期,已成为终末期肝病的治疗手段[1].我科自2003年4月至2005年10月以来实行6例背驮式原位肝移植,现将护理体会报告如下.     

肝移植术后患者的健康之路

肝移植是目前临床治疗各种终末期肝病最有效的方法,我国肝移植技术已经非常成熟,肝移植术后患者的生存率很高。对于肝衰竭患者,肝移植治疗的生存概率要远远高于内科综合治疗,尤其是对于肝硬化基础上出现肝脏衰竭的患者而言,肝移植是唯一的有效治疗手段。肝移植手术虽然手术创伤大、手术的技术含量高、治疗过程复杂,但肝移植成功实施后,     

肝脏移植患者的术前病情评估

终末期肝病的严重程度与肝脏移植手术的风险性和围手术期存活率密切相关。为了减少手术的危险性并延长术后存活时间,提高成本效率和供体器官的更合理分配使用,对等待肝脏移植的终末期肝脏疾病(End-stageLiver Disease)病人的病情进行一个准确的评估,寻找恰好的肝移植手术时机一直是器官移植医师研究的热点。本义以研究进展为序,介绍目前主要使用的三个终末期肝病病情评估系统。     

肝移植术后胆道并发症的病因分析及治疗对策

肝移植是目前治疗终末期肝病、原发性肝癌、爆发性肝功能衰竭以及代谢性肝病的最有效方法.近年来我国的肝移植事业飞速发展, 全国每年可完成肝移植超过2000例.     

应重视我国活体肝移植的基础研究

由于我国传统观念、现实国情以及器官移植供体制度和法规还不完善等因素的影响,供肝数量远远不能满足等待肝移植患者的需要,严重制约了我国肝脏移植进一步发展。随着活体肝移植外科技术逐步成熟,活体肝移植已成为治疗成人终末期肝病的重要手段之一。和全肝移植相比,活体肝移植在临床和基础研究中均有显著不同的特点,但是有关活体肝移植的基础研究非常薄弱,在国际上很多研究也是刚刚起步。     

Liver

<正>209087 Clinical analysis of outcome of invasive fungal infection after kidney transplantation/Chen Guodong(陈国栋,Dept Transplant Surg,1st Hosp,Sun Yat sen Univ, Guangzhou 510080)…∥Chin J Organ Transplant. -2009, 30(10). -616～619 Objective To explore the outcome of invasive fungal infection in kidney transplantation and the influencing factors.     

Liver

<正>209461 Intraoperative ligation of recipient’s portasystemic shunt in liver transplantation/Chen Litian(,Organ Transplant Center,Tianjin 1st Centr Hosp Tianjin 300192)…∥Chin J Gen Surg.-2009,25(4).-489～491Objective To investigate the clinical significance of ligating the portasystemic shunt confirmed by preoperative CT evaluation during orthotopic liver transplantation.Methods From January 2007 to August 2008,35 patients in Tianjin First Central Hospital underwent preoperative three-dimensional CT scan,among them 23 patients had spontaneous major portasystemic shunts,the other 12 patients did not have portasystemic shunts.16 out of the 23 cases with significant shunts underwent shunt ligation based on portal blood flow volume measured by intraoperative portal vein flowmetry.The shunt of the other 7 patients were left untreated.Results The portal blood flow in the 12 patients without portasystemic shunt judged by preoperative CT scanning were(1 101±70)ml/min.The shunts in 7 patients with portal blood flow greater than 1 000 ml/min were not ligated,that of the 16 patients with portal blood flow volume lower than 1 000 ml/min were ligated.The portal blood flow volume in those 16 patients before and after ligating the shunt were(657±112)ml/min and(1 136±161)ml/min,respectively(P<0.05).Postoperatively 2 patients suffered from portal vein thrombosis,among them 1 patients suffered from intermittent disturbance of consciousness,2 patients died within 3 months,with one died of respiratory failure from pulmonary aspergillus infection,one died of hepatic failure in 2 months after operation because of graft dysfunction.The other 19 patients with normal blood flow and well-functioning graft were alive.Conclusion The ligation of portasytemic shunt is mandatory in patients when pretransplant CT evaluation showing a major porto-systemic shunts and portal blood flow volume was less than 1 000 ml/min.5 refs,2 figs.     

Liver

<正>209293 Probing into indication of living-related Liver Transplantation for Wilson’s disease/Cheng Feng(Liver Transplant Center,1st Hosp Nanjing Med Univ,Key Lab Living Donor Liver Transplant,Minist Public Health,Nangjing 210029)…∥Chin J Surg.-2009,47(6).-437~440Objective To probe into indication of living-related liver transplantation(LRLT)for Wilson’s Disease.Methods From January 2001 to February 2007,thirty-seven living-related liver transplants were performed.A retrospective analysis was carried on outcome of those patients.The indications for LRLT were acute hepatic failure in 3 patients and chronic advanced liver disease in 32 patients including 13 patients with Wilsonian neurological manifestations.Two patients presented with severe Wilsoian neurological manifestations even though their liver functions were stable.According to the scoring system for evaluation of the neurological impairment in Wilsion disease based on neurological signs and functions(total score was 30),the pre-transplantation score of those patients with neurological manifestations was 15.9±4.3(n=15).Results Thirty-seven patients were followed up for 20-93 months.The survival rates of post-transplant patients and grafts at 1,3,and 5 year were 91.9%,83.8%,75.7%,and 86.5%,78.4%,75.7%,respectivly.Postoperative surgical complications occurred in 2 donors with bile leakage required drainage,in 2 recipients with hepatic thormbosis underwent retransplantation of cadeveric liver and in 1 recipient with hepatic stenosis required balloon dilatation.Neurological function was improved in all recipients and the score of posttransplantation at 6,12,18,24,and 30 months was 17.5±3.7(n=13);21.0±4.3(n=12);23.9±3.9(n=10);26.6±2.2(n=10)and 28.1±1.9(n=7)respectively.Conclusion Patients with acute hepatic failure or patients with severe liver disease unresponsive to chelation tratment should be treated with LRLT.Early transplantation in patients with an unsatisfactory response medical tratment may prevent irreversible neurologica     

Liver

Alleviation of ischemia-reperfusion injury in rat liver donors by induction of exogenous hTERT gene;Effects of surgical technique on acute renal failure after orthotopic liver transplantation in patients with end-stage liver disease at high risk： a report of 90 eases;Timing for liver transplantation for chronic severe hepatitis;Analysis of bacterial variance and drug resistance after orthotopic liver transplantation;The influence of splenectomy on orthotopic liver transplantation and its management     

Liver

Prevention and treatment of artery complication after liver transplantation by HBO , Clincal feature of cytomegabvirus pneumonia in orthtopic liver-transplantation and treatments, Risk factors of diabetes mellitus following orthotopic liver transplantation , Re-infection of hepatitis B virus after liver transplantation , Diagnosis and treatment of fungal infection after orthotopic liver transplantation , Two successful adult-to-adult living donor liver transplantation using dual grafts     

Liver

<正>209604 The suppressive effect of CD8+ CD28-regulatory T cells from spontaneous tolerance models on the acute rejection responses in rat liver transplantation/Chen Ning(陈宁,Dept Gastroenterol,Peking Univ Peop Hosp,Beijing 100044)…∥Chin J Organ Trans-plant. -2009,30(9). -524 ～526     

探讨脂肪肝供肝在肝脏移植中的价值

目的探讨应用不同脂肪沉着程度供肝对肝移植患者预后的影响。方法选取64例进行肝移植术患者,依据供肝浸润程度,随机分为轻度脂肪肝组、中度脂肪肝组、重度脂肪肝组、无脂肪肝组共四组,每组各16例,比较四组患者肝功能(主要观察ALT、AST指标)、入住ICU的平均时间、1年移植物成活率、移植物原发无功发生率。结果轻度脂肪肝组入住ICU的平均时间、ALT和AST水平、移植物原发无功发生率与无脂肪肝组接近;中度脂肪肝组入住ICU平均时间、ALT和AST水平均较轻度组和无脂肪肝组明显增高,P0.05;重度脂肪肝组入住ICU平均时间、ALT和AST水平、移植物原发无功发生率明显较前三组为高,P0.05。结论轻、中度肝脏脂肪浸入可作为肝移植供肝,重度脂肪肝不能作为供肝的选择目标。     

Microenvironment of Liver Regeneration in Liver Cancer

The occurrence and development of liver cancer are essentially the most serious outcomes of uncontrolled liver regeneration. The progression of liver cancer is inevitably related to the abnormal microenvironment of liver regeneration. The deterioration observed in the microenvironment of liver regeneration is a necessary condition for the occurrence, development and metastasis of cancer. Therefore, the use of a technique to prevent and treat liver cancer via changes in the microenvironment of liver regeneration is a novel strategy. This strategy would be an effective way to delay, prevent or even reverse cancer occurrence, development and metastasis through an improvement in the liver regeneration microenvironment along with the integrated regulation of multiple components, targets, levels, channels and time sequences. In addition, the treatment of "tonifying Shen (Kidney) to regulate liver regeneration and repair by affecting stem cells and their microenvironment" can regulate "the dynamic imbalance between the normal liver regeneration and the abnormal liver regeneration"; this would improve the microenvironment of liver regeneration, which is also a mechanism by which liver cancer may be prevented or treated.     

化肝汤1号治疗酒精性肝纤维化症状及肝功能改变

目的观察活血化瘀、软坚散结药配伍治疗肝纤维化时对患者主、次症状改变及肝功能的影响。方法将确诊为酒精性肝纤维化患者90例,随机分为三组,治疗组采用自制方剂化肝汤1号(醋鳖甲、黄芩、柴胡、赤芍等),对照组1采用凯西莱治疗,对照组2采用化肝汤1号和凯西莱联合治疗,疗程3个月。观察三组患者治疗前后主、次症状改善情况,血清天冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)、γ谷氨酰转肽酶(γ-GT)变化。结果三组治疗后的临床疗效比较差异无统计学意义(H=2.5897,P>0.05)。三组治疗后肝功能指标均有改善,与治疗前比较,差异有统计学意义(P<0.05)。结论化肝汤1号可有效地降低肝细胞的损害程度,促进受损细胞修复,从而改善肝功能。     

异种肝移植

目前,由于临床器官移植的迅速发展,供体不足的矛盾越来越突出,医学工作者对异种移植研究的兴趣日趋复苏。异种器官移植（xenotransplantation）系指不同种系动物的器官（组织或细胞）进行移植或移植给人类。