腹腔内胃和食管异位发育形成囊肿

A 13-year-old female patient with a mass in the right upper quadrant of the abdomen for 2 months were admitted to the Southwest Hospital on February 1,2009.She was first misdiagnosed as with congenital choledochal cyst,while further examination revealed that there was no relationship between the cyst and bile duct,so exploratory laparotomy was carried out.The cyst was located at the mesentery,and was confirmed as abdominal cyst developed from the oesophagus and ectopic gastric mucosa.     

肝移植术后胆道并发症的内镜治疗

随着外科技术、麻醉和新型免疫抑制剂的发展，肝移植成功率已达到了一个较高的水准，但肝移植术后的胆道并发症仍然是肝移植的一大挑战，严重影响肝移植患者的生存率和生活质量。作为非手术治疗的主要形式，内镜治疗技术越来越多的用于肝移植术后胆道并发症的诊治。本文通过对13例内镜治疗的肝移植术后胆道并发症患者临床资料的回顾性分析，总结内镜治疗肝移植术后胆道并发症的经验。     

非生物人工肝联合肝移植治疗中晚期慢性重型肝炎

目的评价非生物人工肝支持系统（ALSS）联合肝移植治疗巾晚期慢性重型肝炎的临床应用价值。方法采用ALSS联合肝移植治疗28例中晚期慢性重型肝炎患者，观察治疗前后各项临床指标的变化与疗效，并就治疗后生存率与同期内科治疗组99例患者、内科联合ALSS治疗组30例患者比较。数据行t和x^2检验。结果28例患者共成功进行57次ALSS治疗，TBil、PT、胆汁酸、BUN、Cr、血氨等指标明显好转（P〈0．05），临床症状改善的中位时间为3d（1～153d）。28例均顺利完成肝移植术，等待到供肝的中位时间为20d（1～153d），术后3、6个月生存率（71．d％，71．4％）显著高于内科治疗组（18．2％，11．1％）和内科联合ALSS治疗组（36．7％，26．6％）（P〈0．01）。结论术前应用非生物人工肝治疗，可有效改善中晚期慢性重型肝炎患者的病情，为顺利过渡到肝移植发挥桥梁支持作用。人工肝联合肝移植是有效治疗中晚期慢性重型肝炎的可靠方法。     

绕肝提拉法的研究进展

绕肝提拉法最早由Belghiti提出,在行前入路右半肝切除时采用止血钳插入肝后下腔静脉前间隙,建立肝后隧道并留悬吊带提拉肝脏的方法.这种方法的难点是建立肝后隧道,其严重并发症是损伤血管引起出血.本文对肝后隧道建立的解剖学基础、手术技巧进行分析总结,为临床医师在肝切除、肝移植及肝外伤等肝脏外科手术中应用绕肝提拉法提供参考,旨在降低采用该方法行手术治疗的并发症,提高其应用的安全性和成功率.     

哑铃式肝门部胆管癌根治术

手术切除是目前治疗肝门部胆管癌最有效的手段,切除范围不足是术后肿瘤复发的主要因素之一.近年来国内外趋于实施扩大的根治性切除,能够提高远期生存率,但大范围肝叶切除的主要风险是术后发生肝功能衰竭.本文报道一种既保证足够的肝内外胆管切除范围、又最大限度地减少肝组织切除的肝门部胆管癌根治性切除术式.该术式的切除范围包括肝Ⅳb段、右肝蒂前部分肝Ⅴ段的肝组织,左右肝管、分叉部、肝外胆管及尾状叶(肝Ⅰ段),同时行肝门区血管骨髂化及至少包括第2站淋巴结的清扫.因所切除组织整体上形似哑铃状,我们称之为“哑铃”式肝门部胆管癌根治术.手术指征:(1) BisnuthⅡ型肝门部胆管癌,以及部分肿瘤局限于一级肝管内的Ⅲa、Ⅲb型肝门部胆管癌;(2)无门静脉分叉部或左右支受侵;(3)第3站淋巴结无转移;(4)无肝内或远处组织器官转移.本研究23例患者完成该术式,术前多数患者TBil＞ 300 μmol/L,均未行PTCD或胆管内支架引流.平均手术时间为355 min.术中平均出血量为350 ml.患者1、3年无瘤生存率分别为95.7％(22/23)和7/15.其结果表明:该术式适宜于我国目前条件下BismuthⅡ型肝门部胆管癌及部分肿瘤局限于一级肝管内的Ⅲa型或Ⅲb型的患者.     

肝移植治疗肝脏恶性肿瘤的长期疗效及预后危险因素

目的 总结肝移植治疗肝脏恶性肿瘤的长期疗效,筛选影响移植后肿瘤复发的危险因素.方法 对单中心189例肝脏恶性肿瘤患者行肝移植的临床资料进行回顾性分析.根据肿瘤临床病理类型分别计算受者累积存活率,分析肿瘤临床病理类型与肝移植术后肿瘤复发间的关系,筛选影响肿瘤复发的相关危险因素.结果 189例中围手术期死亡19例,170例进入随访期,随访率为98.8 %.其中166例的原发疾病为原发性肝癌,3例为肝门部胆管癌,1例肝转移癌.166例原发性肝癌肝移植者术后1、3、5和10年的总体存活率分别为52 %、38 %、36 %和36 %,其中符合米兰标准者(49例)的存活率分别为96 %、87 %、87 %和87 %,超出米兰标准者(136例)的存活率分别为42 %、26 %、24 %和24 %(P＜0.05).肿瘤复发是造成肝癌肝移植受者随访期死亡的最主要原因(92.5 %).3例肝门部胆管癌和1例肝转移癌肝移植受者均于术后2年内肿瘤复发.符合米兰标准的肝癌肝移植受者术后肿瘤复发率(10.2 %)显著低于超出米兰标准者(68.4 %,P＜0.05).而在超出米兰标准者中,无大血管侵犯者移植后肿瘤复发率(95.3 %)显著低于肿瘤侵犯大血管者(55.9 %,P＜0.05).以他克莫司为主要免疫抑制剂的受者的肿瘤复发率(46.2 %)低于应用环孢素A者(68.3 %,P＜0.05).移植术前肝肿瘤经皮穿刺射频消融(RF)治疗可降低受者术后肿瘤复发风险(P=0.039,OR=0.293),而术前外周血乙型肝炎病毒(HBV)DNA＞104拷贝/L是移植术后肿瘤复发的高危因素(P=0.016,OR=2.294).结论 对于符合米兰标准的肝癌患者而言,肝移植的远期疗效较好;而合并大血管侵犯者肝移植的预后不佳.移植前RF治疗有助于降低术后肿瘤复发风险,移植等待期应高度重视抗HBV治疗.

Abstract：

Objective To investigate the long-term survival of the recipients with liver malignant tumors receiving liver transplantation and determine the risk factors of tumor recurrence after liver transplantation.Methods The follow-up data of the orthotopic liver transplantation for liver malignant tumors during 1999-2010 were retrospectively analyzed.The survival rate of different pathological tumor types was analyzed respectively.The tumor recurrence rate,mortality and morbidity,and the risk factors of the tumor recurrence were also analyzed.Results 170 recipients were followed up.The follow-up duration ranged from 8-132 months.The general 1-,3-,5-,10-year survival rate was 52 %,38 %,36 %,and 36 % respectively.The 1-,3-,5-,10-year survival rate of HCC matching Millan Criteria was 96 %,87 %,87 %,87 %,while that of HCC exceeding Millan Criteria was 42 %,26 %,24 %,24 % respectively(P<0.05).Tumor recurrence was the main course of the death during follow-up period(92.5 %).The recurrence rate of HCC matching and exceeding Millan Criteria was 10.2 %,and 68.4 % respectively(P<0.05).Among the recipients exceeding Millan Criteria,the recurrence rate of HCC with and without blood vessel invasion was 95.3 %,55.9 % respectively(P<0.05).Radiofrequency ablation before transplantation could decrease the risk of tumor recurrence post-transplantation(P=0.039,OR=0.293),while the high HBV-DNA load (>104 copy/L)was the risk factor of tumor recurrence.Conclusion Orthotopic liver transplantation is an effective and safe treatment for hepatocellular carcinoma matching Millan criteria.Blood vessel invasion is regarded as the contraindication of the liver transplantation of HCC.RF is an effective bridging therapy for the HCC patients,and anti-virus therapy is important during transplant waiting period.     

肝移植治疗终末期肝病的单中心生存分析

目的 总结肝移植受者长期生存状态,探讨影响受者长期存活的因素.方法 对391例接受肝移植治疗的终末期肝病患者的临床资料进行回顾性分析.根据受者的基础疾病分类分别计算其存活率,并对随访期间原发疾病复发、死亡原因、并发症发生率及其病种和时间分布等资料进行分析,评价影响移植后原发疾病复发和并发症的相关因素.结果 进入随访期的受者共有331例,随访时间8～120个月.良性终末期肝病受者术后1、3、5和10年总体存活率分别为86%、85%、83%和83%,乙型肝炎病毒(HBV)相关肝硬化与重型肝炎受者术后长期存活率的差异无统计学意义(P＞0.05).符合米兰标准的肝癌患者术后1、3、5和10年存活率分别为96%、87%、87、%和87%,超出米兰标准的肝癌患者分别为42%、26%、24%和24%,二者间同期存活率的差异有统计学意义(P＜0.01).原发性肝癌患者肝移植后总体肿瘤复发率为54.3%,符合和超出米兰标准的肝癌患者肝移植后肿瘤复发率分别为4.3%和72.7%(P＜0.01),肿瘤复发是肝癌患者随访期主要的死亡原因,占所有死亡事件的95.5%.全组HBV再感染率为6.0%,且多存在HBV DNA的变异,调整抗病毒药物可有效控制HBV再感染.胆道并发症总体发生率为11.8%,肝内胆道狭窄为主要表现形式(占56.5%),严重影响移植肝功能及受者生存质量.钙调磷酸酶抑制剂相关性肾损害发生率为8.2%,早期发现和处理可避免进展为不可逆肾损害.结论 肝移植是治疗终末期肝病的安全、有效手段,在严格选择适应证、有序随访管理前提下,肝移植受者可长期存活,且存活质量良好.

Abstract：

Objective To investigate the survival condition of the liver transplant recipients and determine the factors which influence the long time survival. Methods Retrospective study of the follow-up data of the orthotopic liver transplantation recipients during 1999-2009 was performed.The survival rate of different primary disease was analyzed respectively. The recurrence of the primary disease, mortality and morbidity was also analyzed. Results 331 recipients were follwed up. The follow-up duration ranged from 8-120 months. The 1-, 3-, 5-, and 10-year survival rate of patients with benign end-stage liver disease was 86 %, 85 %, 83 %, and 83 %, respectively. There was no difference in the long- term survival rate between the patients with hepatitis B virus (HBV)-related cirrhosis and severe liver failure. The 1-, 3-, 5-, and 10-year survival rate of patients with HCC matching Millan criteria was 96 %, 87 %, 87 %, and 87 0%, while those of HCC exceeding Millan criteria were 42 % ,26 % ,24 % ,24 % resepectively. There was significant difference between them at the same period (P＜0. 01). The total recurrent rate of HCC recipient was 54. 3 %, and that of HCC matching and exceeding Millan criteria was 4.3 % and 72. 7 0% respectively (P＜0. 01 ). Tumor recurrence was the main cause of death of the malignancy. The HBV recurrent rate was 6. 0 0%, and all the cases were controlled by changing the antivirus regimen. The morbidity of billiary complication was 11.8 %, and intrahepatic biliary stricture was the most common type. CNIs-related renal impairment morbidity was 8. 2 % and the damage was reversible in condition of early diagnosis and treatment. Conclusion Orthotopic liver transplantation is an effective and safe treatment for end stage liver disease. The LTx recipients can get long time survival with perfect quallity life under proper medical supervision.     

肝移植术后转换为以吗替麦考酚酯胶囊为主的免疫抑制方案的临床应用

目的探讨肝移植术后长期生存受者转换为以吗替麦考酚酯胶囊(商品名:骁悉)为主的免疫抑制方案的疗效及安全性。方法回顾性分析我中心肝移植术后长期生存受者中22例因钙神经蛋白抑制剂(calcineurin inhibitors,CNI)所致肝肾功能损害、高血压等原因转换为以吗替麦考酚酯胶囊为主的免疫抑制方案前后肝肾功能的改善情况及排斥反应和副作用的发生率。结果 8例受者因肾功能损害而转换为以吗替麦考酚酯胶囊为主的免疫抑制方案,其中7例(87.5%)在2个月内肾功能明显好转;4例肝功能损害,其中3例(75%)肝功能明显改善;9例受者逐渐减少CNI剂量,其中8例(88.9%)肝肾功能良好,未出现排斥反应,1例(4.5%)减量后6个月出现排斥反应,增加CNI剂量后治愈;1例因移植后高血压难以控制换用吗替麦考酚酯胶囊,其后监测血压在正常范围。1例(4.5%)换药后8个月出现白细胞减少,减少吗替麦考酚酯胶囊用量后白细胞恢复正常。结论肝移植术后长期应用CNI类药物发生肝肾功能损害、高血压等副作用时,转换为以吗替麦考酚酯胶囊为主的免疫抑制方案能有效控制排斥反应,改善毒副作用,且可为CNI的减量或停药提供机会。