存在门静脉血栓及癌栓的肝癌患者的肝移植

目的　探讨存在门静脉血栓或癌栓的肝癌患者进行肝移植的处理要点。方法　对10例存在门静脉血栓或癌栓的肝癌患者施行原位肝移植术,术前常规准备供者的髂静脉,供肝保留较长的门静脉;术中注意取尽受者门静脉内的血栓或癌栓,门静脉壁存在水肿、增厚、变硬者,尽可能切除这段门静脉;9例行低位门静脉对端吻合,1例行门静脉下腔静脉的对端吻合;术后根据患者的凝血功能状态决定是否进行抗凝治疗。结果　1例术后第6 d发生门静脉血栓形成,溶栓术后因腹腔内出血、失血性休克死亡;另9例术后门静脉血流通畅,随访2~31个月,其中1例术后2个月死于感染,4例术后7、12、13、25个月肿瘤复发,其余4例无肿瘤复发。结论　术前存在门静脉血栓或癌栓的肝癌患者,只要处理得当,采用肝移植治疗可以取得较好结果。     

如何做好肝切除术

近 1 0余年来 ,肝癌手术切除技术有较大提高。难切部位肝癌一期切除报道日益增多 ,肝门部肝癌切除和单独尾叶切除也不再是手术“禁区”;对侵及下腔静脉及肝静脉肝癌 ,也有用体外静脉转流离体或半离体状态下冷却灌注切除肿瘤和受累血管 ;对合并门静脉癌栓积极的手术治疗 ,如切开取栓术、气囊导管取栓术、门静脉吻合搭桥术、门静脉切除吻合术等 ;对合并下腔静脉癌栓的肝癌在切除肿瘤同时有人采用体外静脉转流技术切开下腔静脉取癌栓 ;对肝癌合并胆管癌栓或肿瘤压迫所致梗阻性黄疸 ,亦可考虑作肝癌切除和手术取癌栓 ;对肝癌合并门静脉高压、食…     

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.     

术中B超在肝癌全方位深部冷冻中的运用

我院1988年5月至1996年12月使用自制的全方位肝癌冷冻机对肝癌进行深部冷冻治疗,由于术中B超的使用及其他技术的改进,避免了术后胆瘘及肝表面出血,报道如下。临床资料一、一般资料：本组51例,均为中晚期肝癌。25例仅行全方位冷冻治疗,26例在行冷冻治疗的同时行术中B超监测。二、方法：手术在气管插管全麻下进行,手术切口同肝叶切除术,游离肝附着韧带,探查肝癌肿块及肝外情况。使用5－MHU术中探头（Siemans）检查肝脏及癌肿情况,确定癌肿范围及与大的血管、胆管之间的关系。B超引导下避开胆管及血管,分别向癌肿内刺入多个冷冻针…     

同种异体原位肝移植一例报告

为一肝脏巨大平滑肌肉瘤患者进行原位肝移植术。供者为一２５岁的男性脑死亡者。供肝用４℃ＵＷ液自腹主动脉灌注，快速切取肝脏，热缺血时间为８分钟。受者用＂Ｙ＂形管建立左侧股静脉、门静脉和左侧腋静脉的体外循环后切除病肝，供肝的肝上下腔静脉、肝下下腔静脉和门静脉与受者的相应血管行端端吻合。术后并发腹腔内出血、急性肾功能衰竭、肺部感染和黄疸等，于术后４７天死于脑溢血。该例移植肝功能良好，未出现排斥反应。应用ＵＷ液灌洗和保存肝脏，快速切取肝脏，能提高供肝质量。术后早期应测定血中环孢素Ａ的浓度，慎用广谱抗生素。     

肝移植术后血管并发症的预防及治疗

除部分肝癌肝移植患者外,绝大部分终末期肝病患者肝移植时均伴有不同程度的凝血机能障碍,且肝脏需要门静脉血流的滋养,肝移植一定要切除病肝,行原位肝移植。病肝周围存在广泛的曲张静脉,部分患者有门静脉高压症的分流术或断流术史,或已有肝、胆、胃部手术史,加之部分患者身材高大,病肝位置深,肝移植时血管吻合口多等,均是造成肝移植术后血管并发症多的原因。一、肝移植术后血管吻合口渗血或漏血的预防及治疗由于近几年血液学在抗凝及止血机制研究的长足进展,血液制品的丰富及研究的进展,肝移植前用新鲜冻干血浆行血浆置换的临床广泛应用,肝…     

小型猪原位肝移植模型的建立与评价

目的 探讨建立放弃静脉转流的小型猪原位肝移植模型的可行性。方法 选用广西巴马小型猪(3-6月龄,8-11kg)为实验动物,共实施原位肝移植10例次。供体肝脏游离、冷灌注、切取、修整以及UW保存按常规方法进行。受体术中肝脏游离后夹闭肝上、肝下下腔静脉和门静脉并切除受体肝脏,各血管断端与供肝相应血管进行端端吻合,肝上下腔静脉和门静脉吻合完毕即开放肝脏血流,在此过程中未使用静脉转流,此后吻合肝动脉、胆管。结果 本组10例次肝移植手术后一周存活率90％(9/10),无肝期时间31.3±2.67min,无肝期血压显著下降(MAP4.5±1.58kPa)但肝血流开放后能较快恢复并渐趋平稳。结论 本组结果表明,非静脉转流条件下的小型猪肝移植模型是一操作方便、易于复制同时又具有较好重复性和稳定性的大动物肝移植模型,能应用于肝移植的系列实验研究。     

原发性肝癌合并肝静脉/下腔静脉癌栓的综合治疗策略

原发性肝癌是一种常见的恶性肿瘤。早期肝癌适合行手术切除、局部消融、肝移植等根治性治疗, 预后相对较好。然而, 晚期肝癌常伴有肝静脉和下腔静脉癌栓, 治疗后复发、转移率高, 预后差。合并肝静脉和下腔静脉癌栓的晚期肝癌患者, 我国指南推荐包括局部治疗、系统治疗、手术切除等综合治疗模式。本文重点回顾了近十年来原发性肝癌合并肝静脉及下腔静脉癌栓在诊断、分型与治疗方面的进展。     

肝移植治疗肝硬化肝癌切除后肝功能衰竭

目的　评估肝硬化肝癌局部切除后肝功能衰竭 (肝衰 )行肝移植的疗效。方法　 1例重度肝硬化肝癌病人行局部切除后肝衰 ,行原位肝移植术 ;术后尽早予足量化疗 ;免疫抑制剂予最低有效剂量。结果　肝移植术使肝衰、门静脉高压症得到有效治疗 ,肿瘤得到根治性切除 ,术后 6个月未见复发征象。结论　肝硬化肝癌切除后肝衰行肝移植疗效较好。合并重度肝硬化的大肝癌可能是肝移植的手术指征     

背驮式原位肝移植及其并发症预防

目的探讨背驮式原位肝移植的手术方法及其并发症的预防。方法对1例原发性胆汁性肝硬化、1例肝癌术后复发病人实施了同种异体背驮式原位全肝移植手术。结果术中无肝期时间分别为90min、65min，出血量分别为1500ml、3500ml，术后恢复良好。结论背驮式肝移植手术要保留肝后下腔静脉及肝静脉，对切除病肝技术要求高，采用阻断肝下下腔静脉、肝上下腔静脉方法切除病肝，以及受体肝静脉及其肝后下腔静脉拼合的口径与供肝的肝上下腔静脉开口，及其肝后下腔静脉修剪口径吻合，可降低术中出血及移植肝静脉回流障碍并发症。     

Hemodynamic changes with initiation of veno-venous bypass in orthotopic liver transplant patients

Removal of the liver to start the anhepatic stage of liver transplantation requires cross-clamping of the portal vein, inferior vena cava, and hepatic artery. Adverse effects occur from engorged splanchnic beds and decreased venous return. A veno-venous bypass from the inferior vena cava and portal vein to the axillary vein is used in an attempt to ameliorate these changes. The purpose of this study was to evaluate the effect of institution of veno-venous bypass on hemodynamics. Eight randomly selected adult patients undergoing orthotopic liver transplantation had general anesthesia induced with thiamylal and maintained with nitrous oxide and isoflurane. Cardiopulmonary data and arterial and mixed venous blood gases were measured prospectively using radial artery and pulmonary artery catheters. Measurements were taken under four conditions: (1) 10 minutes before bypass; (2) after partial bypass (vena cava to the axillary vein); (3) after partial bypass with portal vein clamping; and (4) after full bypass (vena cava and portal vein to the axillary vein). Statistically significant changes seen were a 22% decrease in cardiac output and a 47% increase in systemic vascular resistance (SVR). Bypass flow was lower than predicted. Venovenous bypass ameliorates, but does not fully prevent, the reduction of cardiac output and rise in SVR seen with initiation of the anhepatic stage. However, bypass does prevent the hypotension experienced during cross-clamping and for these reasons should be used routinely.     

彩色多普勒超声及超声造影在肝移植术后血管并发症中的应用

目的探讨彩色多普勒超声（CDU）和超声造影（CEUS）在检测肝移植术后血管并发症中的应用价值并对两者进行比较。方法对肝移植术后患者常规行CDU检查，对CDU疑肝血管血流异常患者行超声造影检查，观察肝动脉、门静脉、下腔静脉及肝实质的血流灌注，对其中29例经数字减影血管造影术（DSA）或CT血管造影（CTA）／MR血管造影（MRA）证实病例的CDU及造影检查资料进行分析。结果术后血管并发症患者29例，其中肝动脉狭窄22例，肝动脉血栓闭塞3例（肝动脉血栓闭塞合并肝梗死2例），门静脉狭窄2例，下腔静脉狭窄1例，另1例为肝门部血肿并肝动脉、门静脉受压狭窄。CDU显示25例狭窄均有血流参数异常，但不能判断狭窄部位及程度，3例血栓闭塞者，动脉血流均未显示，但不能肯定诊断；超声造影可明确诊断肝动脉血栓闭塞，显示肝动脉、门静脉及下腔静脉狭窄，与DSA或CTA／MRA结果符合率分别为100％（3，3）、90．9％（20／22）、100％（2／2）及100％（1／1）。结论CDU与超声造影互为补充，有利于提高肝移植术后血管并发症的诊断准确性。     

彩色多普勒超声在诊断肝移植术后并发症中的价值

目的探讨彩色多普勒超声在肝移植术后并发症的诊断价值。方法回顾分析彩色多普勒超声对95例肝移植患者术后并发症的诊断结果。结果95例中发现肝动脉血栓形成3例（3.15%）,肝动脉狭窄2例（2.10%）,门静脉血栓形成1例（1.05%）,门静脉狭窄1例（1.05%）,下腔静脉狭窄2例（2.10%）,胆道并发症10例（10.52%）,排异反应7例（7.36%）,浆膜腔积液93例（97.89%）,肝周血肿7例（7.36%）,肿瘤复发5例（29.41%）。结论彩色多普勒超声在肝移植术后并发症诊断中具有重要的实用价值。     

门静脉-下腔静脉吻合术预防活体肝移植术后小肝综合征3例报道

目的探讨门静脉-下腔静脉吻合术用于预防活体肝移植术后小肝综合征(small-for-size liver syndrome,SFSS)的效果。方法 3例活体肝移植均采用不含肝中静脉的右半肝作为移植物。术中发现实测移植物(肝)重量/受体的体质量(体重)的比值(graft to recipient weight ratio,GRWR)为0.58%、0.77%及0.71%,均<0.8%,符合小移植物的诊断。处理:首先吻合肝静脉流出道,其次吻合门静脉,将受体门静脉右支与移植肝门静脉右支端端吻合,将受体门静脉左支与下腔静脉行端侧吻合达到门腔分流的作用,之后按顺序吻合动脉和胆道。术中均未行脾静脉结扎或脾切除等处理。术后定期随访。结果 3例患者术后均未发生SFSS并顺利出院,出院时间分别为术后25d、34d及56d。移植肝功能逐步好转,术后1d门静脉流速理想。移植肝增长良好。门静脉-下腔静脉短路通畅时间:除1例通畅持续仅104d,其余2例持续通畅。结论 LDLT术中进行门静脉-下腔静脉吻合术可以及时有效预防小移植物背景下的SFSS,受体门静脉左支与下腔静脉行端侧吻合的分流技术安全可靠。     

Renal transplantation with venous drainage through the superior mesenteric vein in cases of thrombosis of the inferior vena cava

Renal transplantation usually is performed by placing the graft in the iliac fossa, anastomosing the renal vein to the iliac vein or, when this is not possible, to the vena cava. When vascular complications occur, particularly on the venous side, the position of the graft may have to be changed. This report describes orthotopic renal grafts and positioning of the organ with anastomosis to the splenic vessels. Venous drainage was established directly into the mesenteric-portal territory, with two cases to the portal vein and one to the inferior mesenteric vein. A new technique for the venous drainage of the renal graft is shown. We have used this model in two cases of infrarenal inferior vena cava thrombosis. The kidney was located in a retroperitoneal position, with venous drainage to the superior mesenteric vein through an orifice in the posterior peritoneum.     

再次肝移植手术技巧:附24例报告

目的探讨再次肝移植的手术技巧。方法总结近4年多来24例行再次肝移植术患者的临床资料。全部采用改良背驮式原位肝移植术。6例采用体外静脉转流，18例未转流。肝上下腔静脉吻合应用附加腔静脉成形一改良背驮式。门静脉重建均为端端吻合。肝动脉的重建：7例为肝动脉、腹主动脉搭桥术，余均为肝动脉端端吻合术。胆道的重建：6例为胆管、胆管端端吻合术，余均为胆管、空肠吻合术（Roux—en—Y或Warren术式）。对所有患者进行随访。结果住院期间病死率为41．6％（10／24）。死亡原因：脓毒症7例；手术出血性休克2例；脑血管意外1例。痊愈率为58．4％（14／24）。痊愈患者并发症发生率为21．4％（3／14），包括胆道并发症2例，伤口裂开1例。结论再次肝移植与初次肝移植手术时间及出血量无显著差异。针对患者进行个体化处理是手术成功的关键。手术难点在于下腔静脉的显露与游离。肝动脉搭桥及胆肠吻合机率高于初次肝移植。     

布-加综合征大鼠动物模型的建立

目的探索采用下腔静脉缩窄术建立布-加综合征大鼠动物模型的可行性。方法将50只SD大鼠采用完全随机法随机分为实验组和假手术组,全麻开腹,分离肝上下腔静脉。实验组借鉴缩窄门静脉主干法,丝线环绕结扎肝后下腔静脉,使下腔静脉横截面积缩窄约80%。2组分别于术后不同时间点（第1、4、8、12周）行腹部彩超、肝功能、血常规及肝脏病理学检查。结果实验组在第4周时均出现肝后下腔静脉及主肝静脉梗阻,淤血性肝硬变,腹水,肝脾肿大,门静脉扩张,肝实质内交通支开放,而假手术组正常。模型建立后第4周时,实验组大鼠肝功能中ALB及血常规中WBC、PLT、RBC、HGB较假手术组明显降低（P〈0.05）,ALT、AST、AKP、TBIL、DBIL、TBA较假手术组明显升高（P〈0.05）。结论下腔静脉缩窄术可成功建立布-加综合征大鼠动物模型。     

The measurement of hepatic circulation before and after orthotopic liver transplantation in dog--by using transit-time blood flow meter and H2 clearance method

Orthotopic liver transplantation was successfully carried out in 40 mongrel dogs, in which hepatic circulation was investigated before and after grafting. Blood flows in hepatic artery, portal vein and intrahepatic inferior vena cava were measured by using transit-time ultrasonic blood flow meter and regional tissue blood flow was determined by hydrogen gas clearance method. Before transplantation the mean blood flows were 234 +/- 95mg/min in portal vein, 118 +/- 76ml/min in hepatic artery and 291 +/- 103ml/min in inferior vena cava in 40 recipients. The blood flow ratio of portal vein and hepatic artery was 2.9 +/- 2.2. The mean regional blood flow of the liver was 63 +/- 24ml/min/100g. After transplantation, the mean blood flows decreased to 189 +/- 86ml/min in portal vein, 77 +/- 51ml/min in hepatic artery and 179 +/- 111ml/min in inferior vena cava and the regional tissue blood flow was 57 +/- 25ml/min/100g. Hepatic arterial flow decreased by 37 percent after transplantation, however, portal venous flow decreased by 24 percent and the regional blood flow decreased by 9 percent after transplantation of the liver. These data suggested that the microcirculation of the liver was slightly disturbed after liver transplantation in dog, which was in part due to the decreased blood flows of the hepatic artery and portal vein.     

自体原位肝移植逆行灌注法对大鼠急性肾损伤的影响

目的探讨自体原位肝移植术中经下腔静脉逆行灌注对大鼠肾功能的影响,为临床肝移植应用经下腔静脉逆行灌注法提供实验依据。方法 60只自体原位肝移植大鼠随机分为逆行灌注组、门静脉灌注组与假手术组各20只。前两组建立自体肝移植模型,其中逆行灌注组采用经下腔静脉逆行灌注法,先开放下腔静脉,再开放门静脉,最后开放肝动脉。门静脉灌注组采用常规经门静脉正向灌注法,先开放门静脉,再开放下腔静脉,最后开放肝动脉。假手术组开腹后游离肝门处门静脉、肝动脉及肝上、下下腔静脉,不予阻断,17min后关腹。分别检测3组术前1h、术后1h、8h及术后1d、5d的血清肌酐(Scr)、血尿素氮(BUN)水平;无肝期结束后1h、8h、1d取左肾组织行光镜检查观察肾组织病理形态学变化。结果术前1h,各组肾功能指标比较差异均无统计学意义(均为P>0.05);与假手术组比较,逆行灌注组、门静脉灌注组术后1h、8h及1d的Scr、BUN水平显著增高,而且逆行灌注组上述两指标明显低于门静脉灌注组(均为P<0.05),但术后5d3组比较差异均无统计学意义(均为P>0.05)。无肝期结束后1h,逆行灌注组和门静脉灌注组肾组织病理学检查发现肾间质充血,8h出现明显的肾小管上皮细胞水肿及肾间质充血,逆行灌注组明显轻于门静脉灌注组;无肝期结束后1d两组肾组织损伤呈现好转趋势,且逆行灌注组明显优于门静脉灌注组。结论自体原位肝移植术中实施逆行灌注可减轻大鼠急性肾损伤,改善大鼠早期肾功能。     

Caval inflow to the graft: a successful way to overcome diffuse portal system thrombosis in liver transplantation

Portal vein thrombosis was considered to be a major contraindication to liver transplantation before the introduction of vessel grafts from the recipient's area of confluence of the splenic and superior mesenteric veins, behind the neck of the pancreas, to the graft's portal vein. Refinement in surgical technique has given rise to a large number of possibilities to overcome portal vein thrombosis in OLT recipients, ranging from portal vein thrombectomy to several different venous graft jump reconstructions. All these reconstructions require the presence of a patent vein of the portal system. When neither splanchnic veins nor sufficiently large venous collaterals are available, liver transplantation has been considered impossible. Salvage solutions include arterialization of the portal vein with the associated risk of liver damage in the longterm, a combined liver and bowel transplantation has been proposed but not yet reported (and in any case the results of combined liver and bowel transplants are not as good as those of liver transplantation alone) and finally the use of blood inflow from the inferior vena cava as first reported by Tzakis and coworkers. Portal flow from the inferior vena cava may be performed as a last resort. Although the consequences of severe pretransplantation portal hypertension remain and should be treated before, during, and after transplantation, liver function is normal in the short and midterm. With this new procedure, diffuse portal vein thrombosis is no longer an absolute contraindication to liver transplantation. But this needs to be confirmed in light of further experience and longterm followup.