慢性HBV携带者的肝组织损伤研究

目的:分析慢性HBV携带者的肝组织病理改变,为慢性HBV携带者的诊治提供依据。方法:113例慢性HBV携带者进行肝组织学检查和血清学、病毒核酸检测。结果:57.52%的慢性HBV携带者肝组织炎症(G)在2级以上,HBeAg阴性携带者G≥2占70.59%,符合抗病毒治疗指征。肝组织炎症活动程度分级与HBV-DNA滴度无相关性(P>0.05),肝组织炎症分级与纤维化分期显著相关(χ2=51.589,P<0.001)。结论:对慢性HBV携带者应建议行肝脏穿刺检查,尤其是HBeAg阴性的慢性HBV携带者,以提高诊断的准确性并进行合理治疗。     

The APRI may be enhanced by the use of the FIBROSpect II in the estimation of fibrosis in chronic hepatitis C

BACKGROUND: Multiple serum markers to estimate hepatic fibrosis in chronic liver disease have been proposed. The AST/Platelet Ratio Index (APRI) is a simple biochemical index that has been shown to be useful and accurate in about 50% of patients with chronic hepatitis C. We determined if the combination of the APRI and the FIBROSpect II, a commercially available hepatic fibrosis marker that measures 3 components of the extracellular hepatic matrix, would further help distinguish mild from significant fibrosis in a group of patients with chronic hepatitis C. METHODS: In an outpatient setting, 93 consecutive patients were studied who were undergoing staging liver biopsy for chronic hepatitis C who had a liver biopsy length>or=1.5 cm. All had blood drawn at the time of the biopsy. Liver biopsies were staged for fibrosis by the Batts Ludwig criteria (F0-F4). Patients with previous anti-viral therapy, hepatocellular carcinoma, an organ transplant, or co-infection with HIV or hepatitis B were excluded. The APRI was calculated and FIBROSpect II determined. RESULTS: The AUC of the ROC curve for the APRI and FIBROSpect II were 0.887 and 0.879 respectively. Using cutoffs of or=1.2 for significant fibrosis, the APRI correctly estimated 19 of 20 patients with mild fibrosis for an NPV of 95.0%, and 31 of 33 patients with significant fibrosis for a PPV of 93.6%. The FIBROSpect II also works best utilizing 2 cutoffs, and using cutoffs of or=85 it correctly identified 18 of 18 patients with mild fibrosis and all 26 patients with significant fibrosis for an NPV and PPV of 100% for both. Among the 40 patients who could not be classified by the APRI, an additional 16 could be correctly classified using the FIBROSpect II with cutoffs of or=85. This lowered the indeterminate zone from 43.0 to 25.8%. By combining the APRI and the FIBROSpect II, the AUC for the ROC curve improved significantly to 0.931 (p=0.013). CONCLUSIONS: The APRI and the FIBROSpect II are both accurate tests for separating mild from significant fibrosis. By using the APRI as the initial screen, >50% of patients with mild or significant fibrosis can be correctly identified. If the patient falls in the indeterminate zone, then the more expensive FIBROSpect II could be obtained. This strategy could decrease the number of liver biopsies.     

MR弥散加权成像在兔肝纤维化模型中的初步实验研究

目的 讨MR弥散加权成像（MR-DWI）检测早期肝纤维化及定量肝纤维化程度的能力。方法对以CCl4导产生的肝纤维化模型兔和对照兔行MR常规扫描及DWI检查，以病理学肝纤维化分期为基础将其划分为无肝纤维化组（S0）、轻中度纤维化组（S1-2）和重度纤维化／肝硬化组（S3～S4），在b取300、600、1000s／mm^2，比较各组DWI图像信号强度（SI）、表观弥散系数（ADC）和指数表观弥散系数（EADC）的变化情况。结果在b取300、600s／mm^2无肝纤维化组、轻中度纤维化组和重度纤维化／肝硬化组的SI与EADC值依次升高，ADC值依次降低，差异存在统计学意义（P〈0．01）；在b取1000s／mm^2，仅SI值随肝纤维化组别升高而升高（P（0．01）。b取300s／mm^2，ADC与EADC值三组间两两比较差异均有统计学意义（P〈0．01）。结论初步实验研究表明，肝纤维化时肝内水分子弥散受限，且随肝纤维化程度增高，水分子弥散能力逐渐减低。在选择合适b值的情况下，MR-DWI可成为检测早期肝纤维化及定量肝纤维化程度的有效手段。     

猪肝移植术中无肝期前后的护理

目的探讨原位猪肝移植无肝期前后的病理生理变化 ,并提出相应的护理措施。方法共行 5 5例原位猪肝移植 ,在无肝期前和无肝期后 (包括无肝期和新肝期 )检测体温、血流动力学、血气、生化、肝肾功变化情况。结果平均动脉压 (MAP)、中心静脉压 (CVP)以及心排出量 (CO)在无肝期后下降明显 (与无肝期前相比 ,P <0 .0 5 )。无肝期后出现明显的代谢性酸中毒、低血糖、低体温 ,供肝复流后出现一过性高血钾。新肝期谷草转氨酶 (AST)、谷丙转氨酶 (ALT)、总胆红素 (TB)升高明显 (与无肝期前相比 ,P <0 .0 1)。结论　猪原位肝移植术中受者经历了一系列的病理生理变化。明确以上危险因素的发生发展 ,并给予正确的护理 ,可以极大地提高手术成功率 ,延长术后存活时间     

Radiofrequency ablation of neuroendocrine liver metastases—the Middlesex experience

Background Current treatment options for neuroendocrine liver metastases are not widely applicable or not that effective. Image-guided thermal ablation offers the possibility of a minimally invasive, albeit palliative, treatment that decreases tumor volume, preserves most of the normal liver, and can be repeated several times. We report our experience with image-guided thermal ablation in 25 patients with unresectable liver metastases.Methods Since 1990 we have treated 189 tumors at 66 treatment sessions in 25 patients (12 female, 13 male; median age, 56 years; age range, 26–78 years). Thirty treatments were performed with a solid-state laser, and 36 treatments were performed with radiofrequency ablation. All but one treatment was performed percutaneously under image guidance. Sixteen patients had metastases from carcinoid primaries, three from gastrinoma, two from insulinoma, and four from miscellaneous causes. Fourteen of 25 had symptoms from hormone secretion.Results Imaging follow-up was available in 19 patients at a median of 21 months (range, 4–75 months). There was a complete response in six patients, a partial response in seven, and stable disease in one; hence, tumor load was controlled in 14 of 19 patients (74%). Relief of hormone-related symptoms was achieved in nine of 14 patients (69%). The median survival period from the diagnosis of liver metastases was 53 months. One patient with end-stage cardiac disease died after a carcinoid crisis. There were eight (12%) complications: five local and three distant, four major and four minor.Conclusions As a minimally invasive, readily repeatable procedure that can be used to ablate small tumors, preferably before patients become severely symptomatic, radiofrequency ablation can provide effective control of liver tumor volume in most patients over many years.     

Bilateral Lower Limb Edema Caused by Compression of the Retrohepatic Inferior Vena Cava by a Giant Hepatic Hemangioma

Hemangiomas are the most common benign primary tumors of the liver and their prevalence ranges from 0.4% to 20%. Approximately 85% of hemangiomas are clinically asymptomatic and are incidentally detected in imaging studies performed for other causes. In a very small minority of patients, nausea, vomiting, abdominal pain, distension, palpable mass, obstructive jaundice, bleeding, and signs and symptoms of Budd-Chiari syndrome may develop due to compression of bile duct, hepatic vein, portal vein, and adjacent organs. Occasionally, external compression of inferior vena cava may lead to edema and/or indirect symptoms such as deep vein thrombosis of the lower limbs. In this report, we present a case of giant hepatic hemangioma that completely filled the right lobe of the liver. The patient presented with bilateral lower limb edema and pain. A computed tomography scan detected a 9 × 11 × 12 cm mass indicative of a hemangioma in the right lobe of the liver that compressed the inferior vena cava. The patient refused treatment initially but returned 6 months later presenting with the same symptoms. At that time, the mass had increased in size and a hepatectomy was performed, preserving the middle hepatic vein. By postoperative month 13, the swelling in the lower extremities had decreased significantly and the inferior vena cava appeared normal.     

Balloon Venoplasty for Liver Failure Due to Stenosis of the Left Hepatic Vein After Right Tri-Segmentectomy

A 41-year-old male patient with hepatitis B underwent right tri-segmentectomy and total caudate lobectomy for a huge hepatocellular carcinoma associated with complete occlusion of the inferior vena cava with thrombosis of the infrahepatic inferior vena cava due to tumor compression. Five months later, he was readmitted for ascites and hyperbilirubinemia. Venography revealed stenosis and tortuosity of the left hepatic vein and the inferior vena cava, for which balloon angioplasty of the left hepatic vein and the inferior vena cava was performed using an 8-mm and 10-mm balloon, respectively. The left hepatic venous pressure decreased from 65 mmHg to 25 mmHg after dilatation. The patient made a satisfactory recovery thereafter and remains well with normal liver functions and without ascites. Balloon angioplasty may be useful for liver failure due to hepatic vein stenosis after hepatic resection.     

Factors influencing jaundice-free survival with the native liver in post-portoenterostomy biliary atresia patients: Results from a single institution

Purpose

We reviewed post-portoenterostomy (PE) biliary atresia (BA) patients who became “jaundice-free” (JF; total bilirubin (T-bil) ≤ 1.2 mg/dL) to determine factors associated with survival with the native liver (SNL).

Methods

We reviewed 76 BA patients treated by PE at our institute between 1989, when liver transplantation (LTx) became available in Japan, and 2012, prospectively. Of these, 60 who became JF and remained JF were divided into two groups, SNL (n = 44) and LTx (n = 16). Age and weight at PE, pre- and post-PE T-bil, AST, γ-GT, time taken to become JF, corticosteroid requirements, incidence of cholangitis, and micro-bile duct size were compared between the two groups.

Results

The SNL patients became JF significantly earlier: 58 vs. 115 days (p < .05). Corticosteroid requirement, cholangitis, and postoperative AST/γ-GT were significantly lower in the SNL patients (p < .05). SNL was significantly higher if patients became JF ≤ 60 days post-PE (p < .01). LTx was performed from 0.5 to 11 years post-PE (mean = 3.4). All patients who had cholangitis within 3 months of PE eventually required LTx (p < .05).

Conclusions

Becoming JF ≤ 60 days post-PE would appear to be a factor associated with SNL, while cholangitis within 3 months of PE would appear to be associated with LTx. Elevation of AST and γ-GT would also appear to be early indicators of risk for LTx during follow-up of JF patients after successful PE.     

受体蛋白质酪氨酸激酶和血管内皮生长因子在人胚胎卵黄囊和胎肝中的表达

目的研究人胚胎发育不同时期卵黄囊和胎肝内受体酪氨酸激酶(KDR)、血管内皮生长因子(VEGF)和CD34的分布及表达,为胚胎造血分化提供理论依据。方法取15份不同胎龄的胎儿卵黄囊和胎肝,固定、切片,进行免疫组织化学SP法染色,观察KDR、VEGF和CD34的表达及分布。结果在卵黄囊和胎肝中均有KDR+、VEGF+和CD34+细胞。在中期胎肝组,KDR和VEGF的灰度值分别为103.8±6.1和96.4±6.3,表达强于晚期胎肝组(KDR和VEGF的灰度值分别为90.4±6.0和87.4±6.3)(P<0.05),KDR与VEGF的表达具有一定相关性(P<0.05)。结论KDR和CD34在胎肝和卵黄囊中广泛表达,提示在胎肝和卵黄囊中可能有成血管血液干细胞存在,KDR和VEGF相互作用,可能介导成血管血液干细胞的存活、扩增和分化。