供肝热缺血损伤对大鼠肝移植术后胆汁淤积的影响

目的探讨肝移植中供肝热缺血损伤对肝移植术后胆汁淤积的影响。方法实验分为4组：对照组（C）和移植组,移植组根据供肝获取前经历供体心脏停搏时间的不同分为三组：热缺血0min（W0）、热缺血15rain（W15）和热缺血30min（W30）,其后建立大鼠动脉化原位肝移植模型,每组均为30只大鼠,分别于术后3d、7d、14d和30d处死,每个时间点各取6只大鼠,分别测定移植肝组织学、血清ALP和ALT变化。此外,移植组各组随机选取6只大鼠观察长期生存率（〉100d）。结果随着供肝热缺血时间的延长,术后血清ALP逐渐增高,14天达到高峰后逐渐下降。术后第3d、7d、14d、30d血清ALP与供肝热缺血时间具有显著相关性。随着供肝热缺血时间的延长,移植肝损伤加重,并且恢复过程也延长。移植组和对照组术后血清ALT无显著性改变。W0、W15和W30术后长期生存率无明显差别。结论肝移植术后存在胆汁淤积,供肝热缺血时间的延长明显加重胆汁淤积的程度。但是,供肝热缺血30min以内造成的大鼠肝移植术后胆汁淤积并不影响预后。     

供体热缺血时间对移植肝的影响

目的 探讨大鼠动脉化原位肝移植中供体热缺血时间对移植肝的影响.方法 实验分为4组:对照组(C)和移植组,移植组根据供肝获取前经历供体心脏停搏时间的不同分为三组:热缺血0 min(W0)、热缺血15 min(W15)和热缺血30 min(W30),其后建立近交系大鼠动脉化原位肝移植模型,每组均为30只大鼠,分别于术后3、7、14和30 d处死,每个时间点各取6只大鼠,分别测定移植肝组织学、肝功能的变化.此外,移植组各组随机选取6只大鼠观察长期生存率(＞100 d).结果 随着供肝热缺血时间的延长,移植肝损伤加重,恢复过程延长.移植组和对照组术后3、7、14和30 d血清丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)变化无显著性差异.血清碱性磷酸酶(ALP)随着供肝热缺血时间的延长逐渐增高,14 d达到高峰后逐渐下降.术后3、7、14和30 d ALP与供肝热缺血时间具有显著相关性.术后热缺血0、15、30 min长期生存率组分别为100.0%(6/6)、83.3%(5/6)、66.7%(4/6),3组间比较差异无统计学意义(P=0.285).结论 肝移植过程中供肝热缺血主要损伤肝细胞,并随着供肝热缺血时间的延长移植肝细胞损伤加重,肝细胞功能恢复早于其形态学恢复.肝移植术后早期存在胆汁淤积,供肝热缺血时间的延长明显加重胆汁淤积的程度,胆汁淤积的恢复明显晚于肝细胞损伤指标的恢复.在热缺血30 min内来自于心脏停搏的供肝肝移植术后是安全的.     

大鼠心脏停搏供体动脉化原位肝移植模型制作体会

目的 建立一个稳定的大鼠心脏停搏供体动脉化原位肝移植模型.方法 根据供肝荻取前经历供体心脏停搏时间的不同分为热缺血0 min(W0组)、热缺血15 min(W15组)和热缺血30 min(W30组)3组,其后用Engemann法建立大鼠动脉化肝移植模型,比较术后肝功能、病理、手术成功率(>3d)和长期生存率(>100d).结果 W0、W15和W30组手术成功率分别为100.0%(15/15)、93.3%(14/15)和86.7%(13/15),术后长期生存率分别为100.0%(6/6)、83.3%(5/6)和66.7%(4/6),二者在3组间差异均无统计学意义.常规组织病理结果显示:随着供肝热缺血时间的延长,移植肝损伤加重.3组术后第3天血清丙氨酸转氨酶ALT和AST均无显著性改变.结论 来自于无心跳供体的大鼠肝脏在热缺血30 min以内是安全的,移植术后可以长期存活.该模型有助于肝移植热缺血损伤的研究.     

外源性三磷酸腺苷-氯化镁预处理对大鼠供肝热缺血损伤的保护作用

目的 观察三磷酸腺苷-氯化镁(ATP-MgCl2)预处理对无心跳大鼠供肝热缺血损伤的保护作用.方法 根据ATP-MgCl2预处理与否及供肝获取前经历的供体心脏停搏时间(即热缺血时间)30min或45min,将实验动物分为4组,即非预处理的30min(N-30min)组和45min(N-45min)组,以及ATP-MgCl2预处理的30min(tN-30min)组和45min(tN-45min)组行原位肝移植,观察存活状况,取材行光学显微镜及电子显微镜检查,移植术后1、3、7d 采集血样检测肝功能.结果 N-30min组和N-45min组的1周存活率分别为50.0%和16.7%,而tN-30min组和tN-45min组的1周存活率分别为83.3%和66.7%,预处理组移植肝脏的病理及肝功能明显好于非预处理组.结论 ATP-MgCl2预处理能够减轻供肝的热缺血损伤,改善肝功能,减轻病理损害,提高大鼠肝移植的存活率.     

供肝热缺血后对冷保存的耐受时限初步探讨

目的探讨供肝热缺血后耐受冷保存的安全时限。方法利用本组所建立的小型猪肝移植模型,设定供肝热缺血时间为20min,根据在UW液中的冷保存时间不同分为3组,分别冷保存12、16、20h,于肝移植术中及术后检测肝功能、肝脏病理、肝组织ATP含量、移植肝脏再灌注后微循环血流量及动物术后1周存活率。结果UW液冷保存12h组肝移植后小型猪1周内全部存活,而冷保存16、20h组存活率分别为20%、0%;随着冷保存时间的从12h延长到20h,ALT、AST逐渐上升,肝脏ATP含量、肝脏微循环血流量逐渐下降,形态学结果显示肝组织细胞变性、坏死及超微结构损害的程度逐渐加重。冷保存12h组与后两组上述指标存在显著性差异,生化及肝脏微循环指标的改变与病理结果及动物生存率相符合。结论在本实验条件下,热缺血时间为20min的供肝耐受冷保存的安全时限约为12h。     

热缺血损伤对大鼠移植肝组织能量代谢及存活期的影响

目的：探讨不同热缺血时间下大鼠肝组织能量代谢变化规律,预测供肝耐受热缺血的安全时限。方法：实验动物按供肝热缺血时间分别为0、10、15、20、30、45和60min,随机分为7组。采用反相高效液相色谱法测定单纯热缺血后肝组织能量代谢指标并进行超微结构的观察。然后按各组条件分别作原位肝移植,观察移植后24、48h各组肝组织能量代谢指标的恢复性变化,并统计生存时间。结果：供肝经受热缺血损伤后,肝组织ATP含量和EC水平远逐渐下降,其中前30min下降比较急剧,以后趋向平缓。热缺血30min内肝组织ATP含量和EC水平在肝移植再复流24h后基本得到恢复,术后大鼠仍可以获长期存活。45min组,移植肝在48h后能量代谢的功能也基本恢复,虽不足以影响术后的1周存活率,但对大鼠肝移植术后的3个月存活率影响显著。60min组,肝脏能量代谢储备功能难以恢复,大鼠术后生存天数显著降低。结论：供肝组织三磷酸腺苷（ATP）含量和能荷（EC）水平以及其移植术后恢复的潜能是衡量供肝质量的重要标准。供肝热缺血损伤的时间与肝组织能量代谢功能的恢复及术后动物生存情况密切相关。     

大鼠DCD供肝热缺血时间对移植肝的影响

目的评价大鼠心脏死亡器官捐献(DCD)供肝热缺血时间对移植肝的影响。方法建立大鼠DCD供肝原位肝移植模型。根据供肝获取前经历心脏停搏时间的不同,将54只受体大鼠分为3组:对照组(W0组,未经历热缺血)、热缺血10 min组(W10组)、热缺血20 min组(W20组),每组18只。各组大鼠分别于术后1、3、7 d检测血清肝功能[丙氨酸转氨酶(ALT)和天冬氨酸转氨酶(AST)],电子显微镜观察肝细胞及其细胞器,用蛋白质免疫印迹(Western blot)法检测肝组织细胞色素C(Cyt C)和凋亡诱导因子(AIF)的蛋白表达水平。结果随着热缺血时间的延长,肝移植术后1 d,各组大鼠ALT和AST水平急剧上升,与W0组相比,W10组和W20组的ALT和AST水平均明显升高(均为P0.05)。术后3 d,各组大鼠ALT和AST水平均稍稍下降,与W0组相比,W10组和W20组的ALT和AST水平仍明显较高(均为P0.05)。术后7 d,各组大鼠ALT和AST水平均再次上升,与W0组相比,W10组和W20组的ALT和AST水平升高更显著(均为P0.05)。电子显微镜观察发现,随着热缺血时间的延长,肝细胞水肿程度逐渐加重,内质网扩张逐渐加重,线粒体损伤程度加重,W20组尤为严重。术后1 d,3组大鼠肝组织中的AIF和Cyt C蛋白表达水平的比较,差异均无统计学意义(均为P0.05)。术后3、7 d,与W0组比较,W10组和W20组的AIF与Cyt C蛋白表达水平均较高,差异均有统计学意义(均为P0.05),且W20组的AIF与Cyt C蛋白表达水平均高于W10组(均为P0.05)。结论 DCD供肝热缺血主要损伤肝细胞,随着热缺血时间的延长,移植肝肝细胞内线粒体和其他细胞器形态、及线粒体凋亡相关蛋白水平均出现明显变化。     

供肝热缺血后对冷保存的耐受时限初步探讨

目的探讨供肝热缺血后耐受冷保存的安全时限。方法利用本组所建立的小型猪肝移植模型，设定供肝热缺血时间为20min，根据在UW液中的冷保存时间不同分为3组，分别冷保存12、16、20h，于肝移植术中及术后检测肝功能、肝脏病理、肝组织ATP含量、移植肝脏再灌注后微循环血流量及动物术后1周存活率。结果uw液冷保存12h组肝移植后小型猪1周内全部存活，而冷保存16、20h组存活率分别为20％、0％；随着冷保存时间的从12h延长到20h，ALT、AST逐渐上升，肝脏ATP含量、肝脏微循环血流量逐渐下降，形态学结果显示肝组织细胞变性、坏死及超微结构损害的程度逐渐加重。冷保存12h组与后两组上述指标存在显著性差异，生化及肝脏微循环指标的改变与病理结果及动物生存率相符合。结论在本实验条件下，热缺血时间为20min的供肝耐受冷保存的安全时限约为12h。     

缺血预处理对大鼠移植肝脏缺血再灌注损伤的保护作用

目的　探讨缺血预处理 (ischemicpreconditioning ,IP)对大鼠移植肝脏缺血再灌注损伤的保护作用。 方法　采用SD大鼠原位肝移植动物模型 ,供肝冷保存时间 10 0min ,无肝期 2 5min。 64只SD大鼠随机均分成两组 :对照组 ,获取供肝前仅以肝素生理盐水经门静脉灌注 ;IP组 ,获取供肝前阻断肝门血供 10min ,再灌注 10min ,然后再以肝素生理盐水经门静脉灌注。每组受体的一半 (n =8)用于观察存活率 ,另一半 (n =8)用于移植肝脏再灌注 2h后取血及肝脏检测。结果　IP组的 1w存活率、胆汁分泌量、抗氧化酶活力、血清NO水平均明显高于对照组 (P<0 .0 5 ) ,血清ALT、AST、LDH、TNF及肝组织中的过氧化产物含量均明显低于对照组 (P<0 .0 5 ) ,组织的病理改变也轻于对照组。结论　IP能够提高血清NO水平 ,降低血清TNF含量 ,对大鼠移植肝脏的缺血再灌注损伤具有保护作用     

冷缺血时间对脑-心双死亡供肝移植术后早期肝功能的影响

目的 探讨冷缺血时间(cold ischemic time,CIT)对脑-心双死亡(donation after brain plus cardiac death,DBCD)供肝肝移植术后早期肝功能的影响.方法 前瞻性地评估DBCD供肝肝移植术后1周肝功能的变化,通过与心脏死亡(donation after cardiac death,DCD)供肝肝移植比较,分析CIT与术后1周肝功能受损程度的相关性以及早期肝功能受损程度与术后早期并发症的相关性.结果 DBCD组CIT时间较DCD组明显缩短(4.6±1.8h比7.9±3.7h,P=0.002).DBCD组术后第1、3天ALT明显低于DCD组(535±227 IU/L比864±386 IU/L,P=0.026;254±94 IU/L比519±165 IU/L,P=0.003),相应的DBCD术后早期相关并发症发生率也明显低于DCD组(26.7％比57.1％,P=0.03).CIT时间长短与术后1周肝功能受损程度明显正相关(r2=0.914,P＜0.001),而术后早期肝功能的受损程度则与术后早期并发症的严重程度明显正相关(rs=0.791,P=0.002).结论 DBCD供肝肝移植具有较短的冷缺血时间,移植术后早期肝功能受损程度明显减轻,术后早期相关并发症也相应减少.DBCD是当前较为理想的供肝肝移植治疗模式.     

雷帕霉素对大鼠胆管缺血术后肝功能及生存的影响

目的 探讨雷帕霉素对大鼠肝内胆管缺血术后肝功能、营养状态及生存率的影响.方法 120只雄性SD大鼠随机分为4组,A组为对照组(假手术组)28只;B组为假手术+雷帕霉素组28只;C组为缺血组32只,D组为缺血+雷帕霉素组32只.雷帕霉素按每天2.0 mg/kg胃内注入.术前、术后7d及术后14 d分别测量实验大鼠体质量.各实验组于术后第1、3、7天分别处死6只大鼠,术后14天处死全部大鼠.处死前下腔静脉抽血2～3ml,分别检测血清总胆红素(TBIL)、碱性磷酸酶(ALP)、γ－谷氨酰胺转移酶(GGT)及谷丙转氨酶(ALT).多个独立样本比较采用Kruskal-Wallis H检验,两独立样本间的比较经秩转换后行One Way Anova检验.Kaplan-Meier方法分析各实验组动物生存率.结果 缺血组与缺血+雷帕霉素组术后血清TBIL升高,其中缺血+雷帕霉素组术后TBIL水平升高更为显著,术后14 d达(46.99±2.68) mmol/L明显高于缺血组(P＜0.01).术后1～7d,缺血组ALP明显升高,随后趋于平稳;缺血+雷帕霉素组术后血清ALP水平持续上升,术后14 d达(588.74±14.95) U/L,明显高于缺血组(P＜0.05);术后14 d缺血+雷帕霉素组血清GGT为(10.78 ±0.97)U/L,明显高于缺血组(P＜0.01).缺血组术后体质量下降明显,给予雷帕霉素后,术后7、14d体质量下降幅度增加(P＜0.01).Kaplan-Meier生存分析结果显示:缺血组术后14d累积生存率为68.3％,与照组差异无统计学意义,缺血+雷帕霉素组累积生存率下降明显(55.5％,P＜0.05).结论 雷帕霉素加重胆管缺血后肝内胆汁淤积及胆管损伤,影响肝功能恢复,并对大鼠术后营养状态及生存率造成影响.     

熊去氧胆酸减轻移植肝缺血再灌注损伤的临床前瞻性随机对照研究

目的 探讨熊去氧胆酸(UDCA)减轻移植肝缺血再灌注损伤(IRI)的临床效果.方法 将80例终末期肝病成人患者随机分为两组,一组42例,肝移植术后第1天起给予UDCA 10～15 mg·kg-1·d-1,维持治疗3个月,为UDCA组;另一组38例肝移植患者不使用UDCA,作为对照.分析两组术后3周内的肝生化指标、"严重IRI致移植物功能恢复延迟"、急性细胞性排斥反应(ACR)及药物性肝损伤的发生情况,以及术后3个月内血管及胆管并发症、患者死亡率、病毒性肝炎和原发性肝病复发情况.结果 UDCA组供肝热缺血时间和冷缺血时间分别为(3.33±0.92)min和(10.3±1.9)h,对照组分别为(3.68±1.16)min和(9.8±2.4)h,两组间的差异无统计学意义.UDCA组术后第7、14及21天的血清丙氨酸转氨酶显著低于对照组(P＜0.05),第7天的天冬氨酸转氨酶(AST)和γ-谷氨酰转移酶(γ-GT)也显著低于对照组(P＜0.05);两组其它时段AST、γ-GT及各时段胆红素总量、直接胆红素及碱性磷酸酶水平的差异均无统计学意义.UDCA组"严重IRI致移植物功能恢复延迟"发生率为9.5%(4/42),对照组为26.3%(10/38),两组比较,差异有统计学意义(P＜0.05).两组术后3周内ACR发生率和严重程度、药物性肝损伤发生率及术后3个月内胆管和血管并发症发生率的差异无统计学意义,患者死亡率的差异也无统计学意义.结论 UDCA可有效减轻移植肝的缺血再灌注损伤,降低"严重IRI致移植物功能恢复延迟"的发生率;但在冷缺血时间＜12 h的情况下,未能显示出保护胆管的临床效果.     

The role of bile salt toxicity in the pathogenesis of bile duct injury after non-heart-beating porcine liver transplantation

BACKGROUND: Intrahepatic bile duct strictures are a serious complication after non-heart-beating (NHB) liver transplantation. Bile salt toxicity has been identified as an important factor in the pathogenesis of bile duct injury and cholangiopathies. The role of bile salt toxicity in the development of biliary strictures after NHB liver transplantation is unclear. METHODS: In a porcine model of NHB liver transplantation, we studied the effect of different periods of warm ischemia in the donor on bile composition and subsequent bile duct injury after transplantation. After induction of cardiac arrest in the donor, liver procurement was delayed for 0 min (group A), 15 min (group B), or more or equal to 30 min (group C). Livers were subsequently transplanted after 4 hr of cold preservation. In the recipients, bile flow was measured, and bile samples were collected daily to determine the bile salt-to-phospholipid ratio. Severity of bile duct injury was semiquantified by using a histologic grading scale. RESULTS: Posttransplantation survival was directly related to the duration of warm ischemia in the donor. The bile salt-to-phospholipid ratio in bile produced early after transplantation was significantly higher in group C, compared with group A and B. Histopathologic condition showed the highest degree of bile duct injury in group C. CONCLUSION: Prolonged warm ischemia in NHB donors is associated with the formation of toxic bile after transplantation, with a high biliary bile salt-to-phospholipid ratio. These data suggest that bile salt toxicity contributes to the pathogenesis of bile duct injury after NHB liver transplantation.     

Liver Transplant Donation After Cardiac Death: Experience at the University of Liege

Objective

Donation after cardiac death (DCD) has been proposed to overcome in part the organ donor shortage. In liver transplantation, the additional warm ischemia time associated with DCD procurement may promote higher rates of primary nonfunction and ischemic biliary lesions. We reviewed the results of liver transplantation from DCD.

Patients and Methods

From 2003 to 2007, we consecutively performed 13 controlled DCD liver transplantations. The medical records of all donors and recipients were retrospectively reviewed, evaluating in particular the outcome and occurrence of biliary complications. Mean follow-up was 25 months.

Results

Mean donor age was 51 years, and mean intensive care unit stay was 5.4 days. Mean time between ventilation arrest and cardiac arrest was 9.3 minutes. Mean time between cardiac arrest and arterial flushing was 7.7 minutes. No-touch period was 2 to 5 minutes. Mean graft cold ischemia time was 295 minutes, and mean suture warm ischemia time was 38 minutes. Postoperatively, there was no primary nonfunction. Mean peak transaminase level was 2546 UI/mL. Patient and graft survival was 100% at 1 year. Two of 13 patients (15%) developed main bile duct stenosis and underwent endoscopic management of the graft. No patient developed symptomatic intrahepatic bile duct strictures or needed a second transplantation.

Conclusions

Our experience confirms that controlled DCD donors may be a valuable source of transplantable liver grafts in cases of short warm ischemia at procurement and minimal cold ischemia time.     

Evaluation of Pringle maneuver during liver resection in a rat model of surgical obstructive jaundice.

Temporary portal triad clamping (Pringle maneuver) during liver resection reduces intraoperative blood loss. A normal liver can safely tolerate normothermic ischemia for up to 60 min. However, its safety in patients with surgical obstructive jaundice (SOJ) is not known. Therefore, we investigated the effect of hepatic ischemia in an experimental rat model of SOJ created by ligating the bile duct. Four groups of rats were created: Group I (sham operation, 10 days later, liver resection); Group II (sham operation, 10 days later, liver resection with 5 min of hepatic ischemia); Group III (bile duct ligation, 10 days later, liver resection); and Group IV (bile duct ligation, 10 days later, liver resection with 5 min of hepatic ischemia). The ischemic injury was assessed by the survival of rats, liver tissue malondialdehyde and total glutathione (markers of free radical injury), serum alanine aminotransferase, aspartate aminotransferase, and liver histology. The results showed decreased survival (47.6% vs. 90% [p = .046]), increased liver tissue malondialdehyde (161 +/- 35 vs. 129 +/- 33 microg/gm liver tissue [p = .05]), and decreased liver tissue total glutathione (565 +/- 169 vs. 1075 +/- 276 nmol/gm liver tissue [p = .05]) in rats with SOJ subjected to hepatic ischemia when compared to nonjaundiced rats. The changes in serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase showed an increasing trend in the SOJ group but were not statistically significant. Ischemic changes in liver histology were seen more often in the SOJ group but were not statistically significant. These data suggest that temporary portal triad clamping in an experimental model of SOJ is detrimental to the outcome of liver resection.     

The impact of donor variables on the outcome of orthotopic liver transplantation for hepatitis C

Morphologic characteristics of the graft have been proposed as a major contributor to the long-term outcomes in orthotopic liver transplantation (OLT). Our objective was to determine the impact of donor variables, including donor age, donor-recipient HLA match, and type of donation (DCD vs donation after brain death [DBD]), on the outcome of OLT in 192 patients with hepatitis C virus (HCV). Fourteen patients underwent OLT from donation after cardiac death (DCD) donors and 188 from DBD donors. Mean donor age, warm ischemia time at recovery, and cold ischemia time were similar between the groups. Overall graft survival rate at 1 year (55% DCD vs 85% DBD) and 5 years (46% DCD vs 78% DBD) was significantly lower in the DCD group (P = .0003). Similarly, patient survival rate at 1 year (62% DCD vs 93% DBD) and 5 years (62% DCD vs 82% DBD) was significantly lower in the DCD group (P = .0295). Incidences of hepatic artery thrombosis, portal vein thrombosis, and primary nonfunction were similar between the DCD and DBD groups. The incidence of liver abscess with ischemic-type biliary stricture was higher in recipients from DCD as compared with DBD (42% vs 2%). A trend toward lower graft survival was noted in recipients from donors older than 60 years of age in the HCV population (P = .07), with statistically lower patient survival (P = .02). Donor- recipient HLA matching did not appear to correlate with OLT outcome in patients with HCV. DCD donors and donors older than 60 years of age significantly impact patient and graft survival. Lower graft and patient survival in recipients from DCD donors does not appear to be related to early disease recurrence.     

多烯磷脂酰胆碱对大鼠移植肝缺血再灌注损伤的保护作用

目的 探讨多烯磷脂酰胆碱对大鼠肝移植术中相对热缺血(relative warm ischemia time,RWIT)造成胆道损伤的保护作用.方法 将60只SD大鼠分为胆道相对热缺血0 min(A组)、胆道相对热缺血60 min(B组)、胆道相对热缺血60 min并于术后每日腹腔注射多烯磷脂酰胆碱注射液(C组).建立大鼠自体原位肝移植胆道外引流模型,检测各组术后2 h及术后第1、3、5天胆汁中总胆汁酸(total bilirubin,TBA)浓度、磷脂(phospholipid,PL)浓度、TBA/PL值,并留取胆道标本进行组织病理学检测,并检测胆汁碱性磷酸酶(alkaline phosphatase,ALP)及谷氨酰基转移酶(gamma glutamyltransferase,γ-GT)水平作为观察胆管损伤的指标.结果 A组术后TBA、PL及TBA/PL均稳定,未出现明显变化;TBA浓度:术后早期B、C组明显低于A组(F=19.662,P＜0.05),此后逐渐升高,到第3天各组之间已无明显差异(F=1.244,P＞0.05).PL浓度:术后B组较C组下降明显,此后缓慢升高,至术后第5天仍低于C组(t=2.832,P＜0.05).TBA/PL值:术后早期B组明显高于A组,并于术后逐渐升高,至术后第3天达到最高,术后第5天开始下降.C组术后未出现明显变化,在各个时间点A、C组之间比较差异无统计学意义(t=0.307,P＞0.05).胆道损伤评分(胆汁ALP水平、γ-GT水平、胆道病理形态学评分、线粒体平均体积及胆道上皮细胞微绒毛密度)组间两两比较差异有统计学意义,A组(对照组)大致正常,B组(相对热缺血组)最重,C组(干预组)较轻.结论 胆道相对热缺血再灌注损伤使肝移植术后早期分泌的胆汁中胆盐及磷脂分泌均降低,其中胆盐早期恢复分泌,而磷脂恢复分泌较迟,导致了早期TBA/PL值增高,胆汁毒性增强,是导致胆道损伤的因素之一;多烯磷脂酰胆碱注射液可增加胆汁中磷脂浓度,并降低TBA/PL值,减少胆汁毒性,减轻因相对热缺血导致的胆道损伤.     

Liver transplantation from donation after cardiac death donors: initial Belgian experience 2003–2007

The Belgian experience with donation after cardiac death (DCD) liver transplantation (LT) was retrospectively reviewed, particularly evaluating patient and graft survivals, and biliary complications. From 2003 to 2007, 58 DCD‐LT were performed in Belgium. Mean procurement total warm ischemia time was 25 ± 2 min (mean ± SEM). Mean cold ischemia time was 451 ± 18 min. Mean follow‐up was 23 ± 2.2 months. Post‐transplant peak aspartate aminotransminases was 2241 ± 338 UI/l. Patient survivals at 1 month, 1 and 3 years, were 91.3%, 83.3% and 66.9% respectively. Graft survivals at 1 month, 1 and 3 years, were 84.4%, 72.4% and 48.8% respectively. Two patients (3.4%) developed primary nonfunction. Regarding the biliary complications, seven grafts (12%) were lost because of intrahepatic cholangiopathy, and 12 other patients (20.6%) developed bile duct stenoses requiring endoscopic and/or surgical management. The rate of symptomatic ischemic biliary lesions for grafts surviving more than 3 months was 38% (19/50). Although DCD organ donors may be a source of viable liver grafts, results were inferior to those obtained with donation after brain death LT in this series. Prognostic criteria have to be developed to improve results of DCD‐LT.     

不同冷保存时间的热缺血供肝在肝移植中的疗效

目的 探讨不同冷保存时间的热缺血供肝在肝移植中的疗效.方法 回顾性分析2006年1月至2007年12月中山大学附属第一医院收治的154例肝移植受者采用热缺血时间≤10 min的无心跳供者肝脏进行肝移植的疗效.根据冷保存时间将患者分为3组:<8 h为Ⅰ组,58例;8～12 h为Ⅱ组,62例;>12 h为Ⅲ组,34例.采用方差分析、t检验和X~2检验分析3组肝移植术后ALT峰值、并发症、移植肝存活和受者生存情况的差异.结果 3组受者术后均未发生原发性移植肝无功能.随访时间8～32个月,Ⅰ组受者的ALT峰值、感染发生率、胆道并发症发生率、移植肝存活率和生存率分别为(482±357)U/L、12%(7/58)、12%(7/58)、86%(50/58)和88%(51/58),Ⅲ组受者分别为(1274±608)U/L、29%(10/34)、26%(9/34)、68%(23/34)和71%(24/34),两组比较差异有统计学意义(t=5.X~2=4.28,6.77,4.51,4.28,P<0.05);而Ⅱ组受者仅ALT峰值达到(953±424)U/L,与Ⅰ组比较差异有统计学意义(t=4.76,P<0.05).结论 热缺血时间≤10 min的供肝能够耐受12 h的冷保存损伤,超过此时限,移植术后胆道并发症和感染的发生率显著升高,移植肝存活率和受者生存率显著降低.     

大鼠移植肝胆道系统不同部位异质性对缺血再灌注损伤耐受性差异的比较

目的 研究胆道系统不同部位胆管上皮细胞的异质性以及胆管周围血管丛构筑形式的不同,对缺血再灌注损伤耐受性的差异.方法 30只SD大鼠随机分成3组,Ⅰ组(假手术组),Ⅱ组(胆道缺血1 h再灌注1 h组),Ⅲ组(胆道缺血1 h再灌注2 h组).对肝门部胆管、胆总管近端及小叶间胆管的上皮细胞行凋亡(TUNEL法)检测、病理形态学评分和超微结构的定量分析.结果 Ⅱ组的细胞凋亡及病理形态评分在胆总管近端与小叶间胆管无统计学差异(P＞0.05),但肝门部损伤较重(P＜0.05);线粒体平均体积(V)及微绒毛面积密度(AMv)比较在肝门部最重,胆总管近端最轻(P＜0.05).在Ⅲ组以上各指标都表现为肝门部最重,小叶间胆管次之,胆总管近端最轻(P＜0.05).结论 胆管上皮细胞的异质性以及周围血管丛不同部位构筑形式的不同导致了胆道系统各部位损伤程度的差异.该结果为解释肝门部胆管狭窄高发率的临床表现提供了一定的实验基础.胆总管近端损伤最轻这一结果提示,在临床肝移植中,应尽量以胆总管近端作为最佳吻合部位.