Correction of cor triatriatum sinistrum in a Jehovah's Witness infant

A cor triatriatum sinistrum was successfully treated by operation in a 14-week-old infant of a Jehovah's Witness family. The child was pretreated with erythropoietin until a hemoglobin level of 14 g/dl was obtained. There was no cardiac catheterization before the operation. The operation was performed with cardiopulmonary bypass. No blood products were transfused and the hemoglobin level after performing modified ultrafiltration was 11.5 g/dl. The infant was extubated on the same day and discharged from our institution on the eighth day after surgery. Two years after surgery the child is in sinus rhythm and is developing well.     

Laparoscopic splenectomy in a Jehovah's Witness with profound anemia

Open surgery in a severely anemic patient may be complicated by a substantial blood loss from a large incision and subsequent poor wound healing secondary to the anemia. We report our success in performing a splenectomy laparoscopically in a profoundly anemic patient. A 50-year-old white male Jehovah's Witness who was HIV positive was referred for splenectomy after he developed profound, worsening anemia secondary to hypersplenism that was refractory to medical management. His preoperative hemoglobin and hematocrit levels were 2.7 g/dl and 8.8%, respectively, but his religious beliefs precluded transfusion. A laparoscopic splenectomy by the posterior gastric approach was performed. The patient tolerated the surgery well and experienced no additional morbidity. On postoperative day 7, his hemoglobin and hematocrit were 6.8 g/dl and 22%, respectively. We conclude that laparoscopic splenectomy is an attractive procedure in a severely anemic patient who requires splenectomy and refuses blood transfusion. Received: 29 March 1996/Accepted: 4 June 1996     

Hyperbaric oxygen therapy in the management of severe acute anaemia in a Jehovah's Witness

A case is described in which a Jehovah's Witness patient who refused blood transfusion suffered massive antepartum haemorrhage, her haemoglobin falling as low as 2.0 g.dl(-1). She was treated on an intensive care unit with intermittent positive pressure ventilation and general supportive measures, pulsed hyperbaric oxygen therapy and recombinant human erythropoietin.     

Successful Surgical Treatment of a Ruptured Abdominal Aortic Aneurysm Without Homologous Blood Transfusion in a Jehovah's Witness: Report of a Case

We report herein the case of a 47-year-old woman of the Jehovah's Witness faith in whom Y-grafting for a ruptured abdominal aortic aneurysm was successfully performed without a homologous blood transfusion. We used a Cell Saver (Haemonetics, Braintree, MA, USA) red cell salvaging device and an aortic occlusion balloon catheter, and performed gentle and minimal dissection during the operation. Postoperatively, the patient was kept heavily sedated and required hypothermic therapy for only 14 h. We treated her severe anemia using conventional drugs, including iron and folic acid, and her hemoglobin increased smoothly. Although her hemoglobin level decreased to 2.8 g/dl during the operation, her postoperative course was uneventful. Received: November 24, 2000 / Accepted: May 15, 2001     

Histologic bile duct invasion by a mass-forming intrahepatic cholangiocarcinoma

Abstract. Background/Purpose: Although curative surgical resection provides the best chance of long-term survival for patients with intrahepatic cholangiocarcinoma, the presence of bile duct invasion decreases postoperative survival rates in patients with mass-forming intrahepatic cholangiocarcinoma. We carried out this study to determine a surgical strategy for patients with bile duct invasion of these tumors. Methods: Forty-one patients with mass-forming intrahepatic cholangiocarcinoma were classified as either having bile duct invasion (n= 26) or not having bile duct invasion (n= 15). Clinicopathologic findings, including postoperative outcomes, were compared between these two groups. Results: Perineural invasion, lymphatic invasion, and a positive resection margin were more frequent in patients with ductal invasion. Patients with ductal invasion had lower survival rates than those without ductal invasion. Conclusions: Intraoperative frozen section examination of the bile duct stump to confirm a clear resection margin is required in patients with mass-forming tumors. Resection of the extrahepatic bile duct should be considered when tumor cells are identified at the surgical margin of the resected bile duct. Received: October 30, 2001 / accepted: November 16, 2001     

Laparoscopic liver resection for localized primary intrahepatic bile duct dilatation

Background

Primary intrahepatic bile duct dilatation (IHBD) may present as a localized form in which resection of the affected liver can prevent immediate and late complications. Laparoscopy has gained large interest in liver surgery. It also allows a safe and efficient exploration of the common bile duct.

Methods

We performed 10 laparoscopic liver resections for localized IHBD, on 7 women and 3 men (mean age 47 years). Resections were 2 right hepatectomies, 4 left hepatectomies, and 4 left lateral sectionectomies. Three patients had associated common bile duct stones that were treated through intraoperative cholangioscopy.

Results

The mean operative time was 303.9 minutes. The mean blood loss was 217 mL. None of these patients required hand assistance or conversion to open surgery. One patient suffered a residual collection that was drained percutaneously. The postoperative course was uneventful in the other patients. The mean hospital stay was 5.3 days. No recurrence of cholangitis was observed during the follow-up period.

Conclusions

The laparoscopic treatment of IHBD is safe and should be performed by teams with expertise in both hepatobiliary surgery and laparoscopy.     

肝切除在肝门部胆管癌手术中的应用和选择

目的 观察肝叶切除在肝门部肝管癌根治术中的疗效并探讨根治性切除术的范围。方法 自１９９５年２月至１９９７年３月手术切除肝门部胆管癌９例,姑息性切除２例,根治性切除７例,８例行各种类型肝切除。结果 姑息性切除１例术后１２个月发生肝内转移,存活１６个月;另１例仍存活,术后２７个月出现阻塞性黄疸。根治性切除１例术后１１ｄ死于肺部感染,其余存活至今。结论 肝切除术肝门部胆管癌根治性切除术中手重要组成部分,     

肝门胆管癌裙边式肝肠Roux－y吻合术

作者为１５例Ⅲ、Ⅳ型肝门胆管癌作了多肝段月牙形切除、裙边式肝肠Ｒｏｕｘ－ｙ手术。采取多肝段引流和周边胆管牵开技术，胆汁引流范围广、吻合口不易受肿瘤侵犯、引流胆管不易狭窄，而引流效果好。本组结果表明：术后胆汁引流量日平均７００ｍｌ，平均生存１８个月，病人舒适指数７７．８％，无手术死亡病例．本文提示，该术式是治疗Ⅲ、Ⅳ型肝门胆管癌的有效且可行的姑息性手术．     

骨骼化联合半肝切除治疗肝门部胆管癌

目的　探讨肝门部胆管癌的治疗方法。方法　回顾性分析我院近年来采取骨骼化联合半肝切除治疗肝门部胆管癌 8例的临床资料。结果　联合左半肝、尾叶切除 6例 ,联合右半肝切除 2例。无手术死亡病例。发生胆漏 1例 ,经非手术治愈。术后 9、1 7、2 1个月各死亡 1例 ,余病例生存至今4～ 38个月不等。结论　采用骨骼化联合半肝切除治疗肝门部胆管癌 ,能提高生存率 ,改善生活质量     

Staged repair for a chronic dissecting thoracic aortic aneurysm with no transfusion in a Jehovah's Witness patient

We present the case of a 59-year-old male Jehovah's Witness who underwent staged repair for a thoracic aortic aneurysm with no transfusion. The primary operation to replace the distal portion of the aortic arch and left subclavian artery reconstruction were performed. We applied axilla–femoral artery temporary external bypass. A second operation was carried out 8 months later. We replaced the descending aorta and reconstructed the intercostal arteries under temporary bypass in the same manner as was done during the previous operation. The blood losses and minimum hemoglobin values during the two operations were 2235 and 13 941 ml, respectively, 8.8 and 5.9 g/dl, respectively. Administration of erythropoietin and a drainage blood recovery device were useful. Surgical repair for a thoracic aortic aneurysm using a temporary bypass is thus considered a viable surgical option in such situations and is important for conducting effective perioperative management.     

联合精准半肝切除治疗肝门部胆管癌

目的 探讨联合精准半肝切除治疗肝门部胆管癌的疗效及术前精准评估的应用价值.方法 回顾性分析2009年1月至2012年10月西安交通大学医学院第一附属医院采用联合精准半肝切除术治疗38例肝门部胆管癌患者的临床资料.患者术前分别行B超、CT、MRCP、CT血管造影等影像学检查以及肝功能等实验室检查.7例梗阻性黄疸患者,5例行PTCD、2例行ENBD.根据影像学检查结果确定手术方式.分析肝门部胆管癌手术切除情况,比较手术前后肝功能指标变化,术后并发症情况,术后病理检查结果以及预后的影响因素.计数和计量资料分别采用x2和t检验,Kaplan-Meier法绘制生存曲线,生存分析采用Log-rank检验,多因素分析采用COX比例风险模型.结果 38例患者术前均行B超、CT、MRCP检查,其阳性检出率分别为65.8％ (25/38)、71.1％ (27/38)、89.5％ (34/38),5例行CT血管造影检查者均为阳性表现.全组患者行联合左半肝切除28例,联合右半肝切除10例,其中联合尾状叶切除22例、联合门静脉部分切除并重建4例(肝左静脉补片修补1例)、联合肝动脉切除12例(肝动脉重建3例).R0切除32例、R1切除4例、R2切除2例.全组患者术后肝功能指标TBil、DBil、ALP、GGT、ALT及AST较术前均显著改善,两者比较,差异均有统计学意义(t=7.799,8.445,5.697,6.633,4.469,4.140,P＜0.05).全组患者围手术期死亡2例,病死率为5.3％ (2/38);术后并发症主要为胆汁漏和肝功能不全,其发生率分别为28.9％ (11/38)和21.1％ (8/38).术后病理检查结果:浸润型腺癌31例、结节性腺癌5例、黏液腺癌1例、腺鳞癌1例.联合半肝切除术后患者第1、2、3年总体生存率分别为66％、37％、21％,半数生存时间为22.0个月,R0切除与R1/R2切除,N0期与N1/N2期患者生存率比较,差异有统计学意义(x2=4.516,10.397,P＜0.05).多因素分析结果显示:切缘癌细胞残留和淋巴结转移与预后相关.结论 联合精准半肝切除可提高肝门部胆管癌的根治性切除率和疗效.术前全面的影像学和肝功能检查精确评估肝门部胆管癌的可切除性,术前选择性减轻黄疸治疗是降低术后并发症和病死率的关键.     

肝内胆管结石行肝叶切除术患者围手术期营养支持

目的 探讨肝内胆管结石行肝叶切除术患者围手术期的肠内外营养支持对手术治疗效果的影响.方法 回顾性分析2011年3月-2015年3月重庆市涪陵中心医院收治的55例肝叶切除术患者,均为择期手术.根据围手术期营养支持方法的不同,随机分为肠内外营养组(n=25)和肠外营养组(n=30).结果 肠内外营养组术后并发症发病率及肠道功能恢复时间,明显优于肠外营养组(28％ vs 40％),[(4.50±0.50)d vs (5.50±1.00)d],差异有统计学意义(P＜0.05);两组手术前后体重指数变化[(22.10±1.80) vs (22.30±1.70)]、前白蛋白[(130.00±45.00) mg/Lvs (124.00±55.00) mg/L]和白蛋白[(35.50±2.72) g/L vs (36.50±2.70) g/L]改善情况,差异无统计学意义(P＞0.05).结论 围手术期肠内外营养支持可明显改善患者的营养状况,缩短术后肠道功能恢复时间及住院日,提高手术治疗效果.     

纤维胆道镜联合肝切除术治疗肝内胆管结石的临床研究

目的:探讨纤维胆道镜联合肝切除术治疗肝内胆管结石的临床疗效。方法:将2011年1月至2012年12月收治的70例肝内胆管结石患者按手术方式分为观察组(n=35例)与对照组(n=35例),两组均行胆管切开纤维胆道镜取石,观察组在对照组的基础上切除病变部位肝段,观察并对比两组手术有效率、术后并发症发生率、术后残石率、术后复发率。所得数据采用χ2检验。结果:观察组手术有效率为88.57%,显著高于对照组(65.71%),两组差异有统计学意义(P<0.05)。观察组手术并发症发生率低于对照组,但差异无统计学意义(P>0.05)。观察组患者术后残石率(5.71%)、复发率(5.71%)均显著低于对照组,差异有统计学意义(P<0.05)。结论:纤维胆道镜联合肝切除术治疗肝内胆管结石疗效显著,安全性肯定,是较理想的治疗手术。     

肝内胆管结石57例治疗体会

目的 探讨肝内胆管结石治疗方式的合理性及疗效.方法 回顾性分析自2006年11月至2010年8月为57例肝内胆管结石病人手术的临床资料.结果 全部57例中,行肝部分切除33例(57.89%),附加T管引流术48例(84.21%),附加胆肠Roux-en-Y吻合术9例(15.79%).术后复查残留结石7例(12.28%)...     

Live donor liver transplantation: staging hepatectomy in a Jehovah's Witness recipient

Orthotopic liver transplantation (OLT) is usually associated with significant blood loss and frequently requires the usage of blood products. OLT has been offered sparingly in Jehovahs Witness (JW) patients because of their refusal to accept blood products for religious reasons. Several innovations have made surgery safer in these patients. These include the pre-operative use of erythropoietin to increase red cell mass, the use of intraoperative cell salvage and acute normovolemic hemodilution, and judicious postoperative blood testing. Thoughtful perioperative decision-making and careful surgical techniques remain the cornerstone to a successful outcome. We report our experience in a two-stage hepatectomy done for a JW patient who underwent live donor liver transplant from his mother, also a JW, without blood transfusion. The recipient had an unusually enlarged left lateral segment of the liver which was densely adherent to the spleen. Removing these adhesions in the presence of significant portal hypertension would have resulted in considerable blood loss. This was successfully avoided by leaving this portion of the liver attached to the spleen while proceeding with the hepatectomy. The right lobe of the liver from the donor was then implanted uneventfully. Two weeks later the remaining segment of the recipient liver was removed without incident. The two-stage procedure was life-saving in this JW patient.     

肝移植治疗肝内胆管癌的研究进展

肝内胆管癌（ICC）是仅次于肝细胞癌的肝脏原发性恶性肿瘤,其发病率在全球范围内呈上升趋势。肝切除术一直是ICC患者外科治疗的首选,而ICC过去由于高肿瘤复发率和较差的生存结果,被视为肝移植禁忌证。目前,ICC肝移植治疗已经取得了诸多重要进展,对于严格筛选的ICC患者,肝移植或在新辅助治疗后肝移植取得了令人鼓舞的生存结果。同时,随着ICC肝移植治疗预后风险分层的完善,也将进一步优化ICC肝移植候选者的选择标准。此外,ICC现代多模式综合治疗的发展,也将进一步指导ICC肝移植术前新辅助治疗方案的选择。ICC肝移植前应用免疫检查点抑制剂也是未来重要的研究方向。本文从ICC肝移植治疗的预后、ICC肝移植的预后风险因素及候选者选择标准、正在进行的试验和挑战进行总结,以期为肝移植治疗ICC提供参考,提高ICC患者的生存质量。