肝移植术的常见并发症及处理

目前肝移植在手术技术以及围手术期处理上已基本成熟，并已成为终末期肝病及暴发性肝炎的常规治疗手段。尽管如此，肝移植术后形形色色的并发症仍难以避免，严重时可造成移植物丢失和受者死亡。因此移植术后并发症的成功防治成为提高肝移植受者生存率的重要条件。现将肝移植术后常见并发症的临床表现、诊断、处理做一简要的介绍。     

肝门部占位病变的讨论

1 临床资料 患者男性,55岁.因"全身乏力、皮肤黄染及瘙痒、尿黄1个月"于2007年10月14日入院.     

门静脉冷灌注下全胰切除术

Cold perfusion of liver can significantly alleviate the ischemia-reperfusion injury caused by hepatic blood flow occlusion. We have modified the technique of cold perfusion of liver and applied it to total pancreatectomy for patients with pancreatic head carcinoma complicated with metastasis to the body and tail of pancreas and with portal invasion. After skeletonization of the hepatoduodenal ligament, the amputation of the portal vein and blockage of the superior mesentoric vein were performed before portal perfusion. Meanwhile, pancreatic head resection, duodenectomy, subtotal gastrectomy and partial resection of the superior mesenteric vein and portal vein were carried out. Superior mesenteric vein and portal vein bypass grafting was achieved with artificial vessels. The digestive tract was reconstructed after it was freed of the spleen and resection of the body and tail of pancreas to the left side of superior mesenteric vein, greater omentum and intestine from the end of the colon to splenic flexure of colon. The patient was followed up for 3 months, and the general condition was good, although diarrhea frequently occurred. No tumor metastasis occurred.     

冷保存供肝肝移植大鼠肝窦内皮细胞损伤机制的研究

目的 探寻肝移植大鼠肝窦内皮细胞(SEC)损伤的详细过程、方式及机制,为冷保存再灌注损伤的保护研究开辟新的途径.方法 雄性SD大鼠随机分为假手术组(n=6)、UW 1 h肝移植组(n:48)、Uw 12 h肝移植组(n=48).大鼠原位肝移植采用双袖套法,分别于术后不同时相点采取血液及组织标本,检测血清丙氨酸氨基转移酶(ALT)及透明质酸(HA)水平;HE染色观察肝脏病理学变化;TUNEL法检测凋亡,免疫组化法检测Bcl-2及Cleaved Caspase-3的表达状况.结果 UW 1 h、UW 12 h组肝移植后血清ALT、HA均较假手术组明显升高(P<0.05),UW 12 h组又明显高于Uw 1 h组(P<0.05).UW 12 h组ALT水平于术后6 h达高峰,而HA水平却在术后1 h、24 h呈双峰表现.Uw 12 h组首先出现SEC的凋亡继而出现肝细胞的坏死,且UW 12 h组细胞凋亡指数(apoptosis index,AI)明显高于UW 1 h组(P<0.01).两组大鼠SEC的AI均于术后6 h达高峰,与血中ALT的高峰时相点一致.肝移植术后Bcl-2表达明显减弱(P相似文献   

肝移植血管异常及并发症的处理

肝脏具有动静脉双重供血系统和一套静脉回流系统,血液循环系统的重建是肝移植中困难而关键的技术环节,肝移植时血管异常及血管并发症的发生直接影响着肝移植的疗效.     

腹腔镜胰腺外科的应用现状与展望

自 198 7年法国的Ｍｏｕｒｅｔ医生成功地开展了腹腔镜胆囊切除术后 ,在世界范围内兴起了腔镜外科的热潮 ,我国的腹腔镜外科由此也取得了长足的进步 ,最新资料显示自 1991年我国开展腹腔镜胆囊切除术以来到 1998年 3月 ,累计完成腔镜外科手术 14 2 94 6例 ,开展手术项目近百余种 ,其中腹腔镜胰腺手术共10 0例 ,包括急性胰腺炎引流术 98例 ,胰腺假性囊肿引流术 2例 ,与国际水平仍有较大差距 ,尚处在一个起步阶段[1] 。国际上腹腔镜在胰腺外科的应用已较为广泛 ,并有逐步扩大的趋势 ,主要包括以下几个方面的问题 :(1)胰腺恶性肿瘤的分期 ;(2 )…     

腹腔镜胆囊切除术胆管损伤的预防

目的通过病例分析总结预防腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)胆管损伤发生的成功经验.方法回顾性分析2001年3-8月完成的LC手术843例.结果共完成LC手术826例,手术成功率97.98%,中转开腹17例,中转率2.02%,发生术后并发症2例,发生率0.24%,迟发性胆囊管残端胆漏1例,肝下包裹性积液1例,无胆管损伤发生、术后腹腔内出血等其它并发症.结论良好的胆道外科意识、科学精细的手术操作和准确的术中判断是避免LC术中胆管损伤的关键.     

梗阻性黄疸大鼠血浆NO与ET改变及其意义

目的 探讨大鼠梗阻性黄疸时血浆ＮＯ和ＥＴ的改变及其意义。方法 胆总管结扎法建立梗阻性黄疸模型,用放射免疫分析法和比色法测定血浆ＮＯ和ＥＴ的水平,生理记录仪测定心率（ＨＲ）、平均动脉压（ＭＡＰ）、心输出量（ＣＯ）。结果 胆总管结扎组（ＢＤＬ组）大鼠血浆ＮＯ含量明显增高,ＥＴ含量下降,平均动脉压（ＭＡＰ）下降,心率（ＨＲ）减慢,心输出量（ＣＯ）增加,与ＳＯ组、Ｎ组相比,ＳＯ组与Ｎ组之间差异不明显。结论     

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.