肝移植术后神经系统并发症

肝移植后神经系统并发症是影响患者预后的重要因素，其发生率为８％～４７％。其中最严重和常见的并发症为肝移植后脑病、癫痫、脑血管病、颅内感染、周围神经病及锥体外系疾病等。本文就上述并发症的有关病因学研究、临床表现、诊断及治疗现状做一阐述。     

肝移植术后胆道并发症33例分析*

目的：胆道并发症是肝移植术后常见的并发症,严重影响肝移植患者的生存率和生活质量。课题拟进一步明晰认识肝移植术后胆道并发症的病因并确立早期防治措施。 方法：①对象：解放军总医院第二附属医院全军器官移植中心于2002-04/2007-09完成的254例原位肝移植患者中,术后发生胆道并发症者33例,回顾分析患者的临床资料。②方法：胆管重建方式为胆总管端端吻合术。并发胆漏者,予置管充分引流;吻合口狭窄者经皮肝穿刺胆道造影或经内镜逆行胰胆管造影球囊扩张术,必要时放置胆道支架;非吻合口狭窄者行经皮肝穿刺胆道造影联合胆道镜治疗,严重者行二次肝移植术。 结果：18例胆漏患者均通过腹腔引流、鼻胆管引流治愈;9例吻合口狭窄患者经内镜逆行胰胆管造影或经皮肝穿刺胆道造影球囊扩张术治愈,其中3例放置了胆道支架;6例非吻合口狭窄患者中,2例经皮肝穿刺胆道造影联合胆道镜治疗后痊愈,2例接受了二次肝移植,2例恢复不佳。 结论：改进手术方法、缩短移植物冷热缺血时间及保护胆管血供可降低肝移植术后胆道并发症的发生,治疗的关键在于早期诊断、合理选择治疗方法,处理得当患者可长期存活。     

肝移植后胰腺炎的诱因分析

背景：肝移植后并发症中急性胰腺炎的发生率相对较低,但移植后重症胰腺炎的致死率确高达50%,加强对移植后并发胰腺炎的预防和治疗,对提高移植存活率具有重要意义。 目的：回顾性分析肝移植后并发胰腺炎的治疗经验。 设计、时间及地点：单中心抽样,回顾性病例分析,于2004-03/2008-03在解放军第二军医大学东方肝胆外科医院完成。 对象：选取解放军第二军医大学东方肝胆外科医院单个医疗组同期内收治的肝移植患者117例,供者均为男性脑死亡志愿捐献者,供受者ABO血型符合。 方法：肝移植患者后常规化验血淀粉酶,根据淀粉酶的最高值及临床表现分为正常组、淀粉酶偏高组(正常上限2倍以内)、单纯高淀粉酶血症组(正常上限2倍以上且无胰腺炎证据)及急性胰腺炎组(有明显临床症状及CT表现)。出现移植后高淀粉酶血症或怀疑胰腺炎的患者均予以抗胰腺炎治疗;对于诊断为急性胰腺炎的患者均予以血管活性物质治疗。 主要观察指标：分析各组患者中各种风险因素的比例,总结移植后胰腺炎的预防及治疗经验。 结果：117例肝移植患者中,移植后淀粉酶增高51例(占43.6%),移植后单纯高淀粉酶血症24例(占20.5%),急性胰腺炎3例(占2.6%,包括1例急性重症胰腺炎)。3例急性胰腺炎患者经抗胰腺炎治疗7~10 d后,其中2例患者症状消失、血淀粉酶下降;1例患者持续腹胀、发热、血象升高,影像检查发现胰腺改变及胰腺周围积液,经2次开腹手术后逐渐痊愈,整个治疗时间40 d。 结论：充分地认识,积极地控制和治疗诱发因素,对降低肝移植后胰腺炎发生率具有重要意义。     

彩色多普勒超声对肝移植后胆道并发症的诊断价值

背景：肝移植后胆道并发症是引起移植后移植肝失功的重要原因,彩色多普勒超声是目前公认的肝移植后患者随访首选简便的检查方法,可以为临床上对肝移植后并发症的诊治提供较可靠的证据。 目的：探讨彩色多普勒超声在肝移植后胆道并发症诊断中的应用价值。 方法：回顾性分析126例肝移植后常规超声检查时胆道并发症的发生情况及彩色多普勒超声检查结果。以磁共振胆胰管成像或超声造影或穿刺引流或临床诊断性治疗等诊断胆道并发症为标准,使用彩色多普勒超声观察肝移植后胆总管及肝内胆管是否有胆漏、狭窄、扩张、胆泥及结石形成。 结果与结论：126例中超声诊断胆道并发症的共33例,其中胆漏4例(3.2%),胆道狭窄11例(8.7%),胆道结石或(和)胆泥18例(14.3%)。提示彩色多普勒超声对肝移植后胆道并发症的诊断具有重要价值,可为临床的诊治提供依据。     

原位肝移植术后弥漫性脑病的临床研究

目的观察肝移植术后弥漫性脑病的发生及临床表现,探讨其易发因素及防治方法。方法回顾性分析自2003年10月至2005年9月完成的467例肝移植患者的临床资料,对肝移植术后并发弥漫性脑病的病例进行统汁分析并结合文献进行讨论。结果术后共有72例患者发生弥漫性脑病,发生率为15．41%；平均发生时间在术后(8．4±4．3)d。高龄、术前高胆红素坦率血症、高渗透压、低血小板、肺部严重感染与弥漫性脑病密切相关。68例患者痊愈,3例死于感染．1例死于移植物抗宿主病。结论弥漫性脑病是肝移植术后常见并具有潜在危险性的并发症,产生的原因是多因素的,钙调神经蛋白抑制剂的神经毒性只是一个促进因素。针对病因的综合治疗和免疫抑制剂的及时调整有利于改善预后。     

肝移植患者术后住院期间的中枢神经系统并发症

目的探讨肝移植术后住院期间中枢神经系统并发症的发病情况、临床和神经影像学特征及可能的危险因素及预后。方法对中山大学附属第一医院1996年1月至2005年6月间共337例患者的358次肝移植手术进行回顾性研究。结果术后住院期间患者出现中枢神经系统并发症共58例，发生率16．2％，病死率41．4％。最常见的表现为肝移植脑病（10．3％），次之为癫痫（4．5％）和脑血管疾病（2．8％）。与无中枢神经系统并发症的肝移植患者相比，术后发生中枢神经系统并发症者的年龄、是否再次肝移植及病死率差异有统计学意义（P〈0．05）。结论肝移植术后住院期间中枢神经系统并发症的发生率及病死率较高，直接影响患者的生活质量及预后。年龄偏大、再次肝移植可能是其危险因素。     

肝移植后肺部细菌合并真菌感染的诊治

背景：肝移植患者因常规服用免疫抑制剂,免疫力低下,极易发生肺部病原微生物感染。目的：回顾分析1例肝移植后突发肺部细菌联合真菌感染患者诊疗经过,总结相关临床治疗经验。方法：1例乙肝肝硬化失代偿期女性患者行同种异体原位肝移植后8个月余突发畏寒高热入院,经实验室检查结合胸部CT检测考虑为细菌引起的肺部感染,给予头孢哌酮钠舒巴坦钠抗菌治疗。结果与结论：治疗后临床症状缓解。1周后复查胸部CT提示：双肺下叶片状渗出较前有所吸收,但背段出现片状“毛玻璃样改变”,考虑合并真菌感染,停用头孢哌酮钠舒巴坦钠,改用氟康唑针,治疗1周后行胸部CT：双肺下叶背段渗出较前吸收,出院继续口服氟康唑10 d,复查CT：双肺渗出性改变完全吸收。     

肝移植后肾功能不全37例

背景：肝移植后,由于手术创伤和免疫抑制剂的应用极易造成急性肾功能不全,其诊断和治疗,目前尚无统一诊断标准。 目的：分析肝移植后肾功能不全的相关因素和诊治经验。 设计、时间及地点：2004-01/2006-12在解放军第四五八医院完成。 对象：肝移植37例,男35例,女2例,年龄37~67岁,平均(48.5±8.9)岁。根据原发病分为肝硬化组21例,包括乙型肝炎后肝硬化16例,丙型肝炎后肝硬化4例,酒精性肝硬化1例,均为肝硬化失代偿期;肝癌组16例。移植后均经病理检查确诊。 方法：按背驮式改进方法实施供肝和病肝病切除及肝脏血液流出道重建。移植后每天查血和引流物细菌培养1次,每天查动脉血气分析、血常规、肾功能及肝功能检查2次以上。肝移植患者术后常规应用三代头孢雷素、大扶康及更昔洛韦或并用万古霉素等药5~7 d预防细菌、霉菌及病毒感染。 主要观察指标：急性肾功能不全发生率、患者的临床特征、尿量变化、治疗转归情况等。 结果：肝移植后发生急性肾功能不全19例,死亡5例,14例患者于术后两三周内肾功能恢复正常。肝移植相关肾功能不全的发生与感染、失血性休克,呼吸衰竭和急性呼吸窘迫综合征有关(P < 0.05)。 结论：肝移植相关肾功能不全的发生率高为51.35%。死亡率为26.32%,早期诊断和治疗肝移植相关肾功能不全是提高肝移植后急性肾功能不全患者治疗成功率的关键。     

肝移植术后并发颅内出血

近10年来，随着移植技术的不断提高，肝移植已在国内外广泛开展，并成为治疗各种终末期肝脏疾病最有效的方法。然而，术后并发症是造成肝移植后患者死亡的重要原因之一，其中颅内出血是肝移植术后一种严重的神经系统并发症，虽然临床上发生率并不高，但治疗困难，病死率很高。我们综述肝移植术后并发颅内出血的国内外研究报道，以期引起对此致命性并发症的重视。     

肝移植后彩色多普勒超声的应用

背景：肝移植后监测移植肝脏并发症的发生情况,对肝移植的成功率及延长患者生存时间具有十分重要的意义。 目的：评价彩色多普勒超声对肝移植后并发症的监测效果。 方法：由作者采用电子检索的方式,在万方数据库(http://www.wanfangdata.com.cn/)及Medline数据库(http://www.ncbi.nlm.nih.gov/pubmed/)中以“彩色多普勒超声,肝移植,移植后并发症”为关键词,检索1990-01/2010-12有关彩色多普勒超声对肝移植后并发症监测效果的文章,共查到相关文献60余篇。经阅读标题、摘要、全文,排除内容重复、普通综述、Meta分析类文章后,筛选纳入22篇文献进行评价。 结果与结论：彩色多普勒超声检查具有无创、简便、直观、定位准确及可动态观察等优点,在肝移植后不仅能有效地检测肝脏大小、移植肝形态,而且可以从内部回声及血流动力学方面为肝移植后并发症的早期诊断提供线索,对临床及早治疗、保证肝移植成功具有重要的作用,是肝移植后监测的首选影像学检查方法。     

肝移植后淋巴漏3例

背景：肝移植后淋巴漏为少见的并发症。但门脉高压可导致腹腔淋巴回流障碍,因而术中应重视预防淋巴管的损伤。目的：回顾性分析肝移植后淋巴漏的防治经验。方法：总结分析3例肝移植后淋巴漏患者的临床资料。术前诊断丙肝后肝硬化2例,原发性肝癌合并乙肝肝硬化1例,均接受经典原位肝移植术。记录分析3例患者的诊治经过。结果与结论：3例患者均于肝移植后6~8 d,恢复正常饮食后,肝周引流管处引流量突然增多,为乳白色,改为低蛋白饮食后引流液性状趋向清亮。无腹痛、腹胀及发热等表现,腹部压痛及反跳痛均为阴性。3例患者引流液苏丹Ⅲ染色均为阳性,引流液中三酰甘油及总胆固醇水平接近血清水平,腹部超声均提示腹腔积液。肝移植后淋巴漏患者经先禁食,而后给予低脂饮食加全胃肠外营养的保守治疗方案1周左右均获治愈。结果提示,肝移植中游离解剖应尽量结扎,以避免淋巴漏;移植后出现淋巴漏,给予积极的饮食控制及全胃肠外营养后可自愈。关键词：淋巴漏;肝移植;并发症;全胃肠外营养;淋巴管损伤     

恒河猴肝移植后急性排斥反应中热休克蛋白70的早期诊断价值

背景：热休克蛋白是生物体在不利环境因素刺激下应激合成的一种特殊蛋白质,热休克蛋白70参与移植免疫反应并发挥重要作用。 目的：探讨热休克蛋白70在恒河猴肝移植后急性排斥反应中的早期诊断价值。 方法：选用健康恒河猴采用改良二袖套+肝动脉重建的方法进行同种异体原位肝移植16例,移植后受体分为急性排斥组和对照组,每组8只,急性排斥组围手术期不行免疫抑制治疗,对照组围手术期使用免疫抑制治疗,分别在移植后6,12,24,72 h 4个时间点取移植后肝脏组织进行苏木精-伊红染色以判断排斥反应程度,western blotting检测肝组织中热休克蛋白70表达水平,免疫组化检测肝组织热休克蛋白70表达情况。 结论与结论：肝移植后72 h时段内急性排斥组肝脏急性排斥反应的组织学表现重于对照组,Baff分级水平高于对照组(P < 0.05),从移植后开始至移植后72 h两组移植肝经免疫组化和western blotting检测热休克蛋白70表达水平均有所升高,但急性排斥组要明显高于对照组(P < 0.05)。提示,未使用免疫抑制治疗的情况下,恒河猴肝移植后早期急性排斥反应在移植后72 h内即可明显观察到,热休克蛋白70在移植肝组织中表达水平也随着急性排斥反应的发生进展呈现明显上升趋势,对肝移植后早期急性排斥具有较高的预测和诊断价值。     

Neurological complications in liver transplantation

To define the incidence and type of neurological complications and associated factors, we reviewed 41 consecutive patients who had 45 procedures for liver transplantation. Encephalopathy occurred after 28 procedures (62%) with immediate onset and no significant recovery before death or re-transplantation in 11 (24%), slow recovery in eight (18%) and delayed onset (1-50 days, average 11) in six (13%). Intermittent confusion and agitation with full recovery followed three (6.6%), and focal and generalized seizures followed five (11%) procedures with multifocal myoclonus in two and status epilepticus in one; isolated focal seizures followed two and myoclonus or unclassified seizures, one each. All patients with seizures had encephalopathy. Three patients had neuropathy (2 generalised and 1 focal). Other complications included headache (2), tremors (2), fatigue (2), restlessness, nervousness, transient enuresis, intermittent dizziness, critical illness myopathy and detached retina. Brain imaging showed atrophy in three (6.6%) instances, intracerebral haemorrhage in two, multiple infarctions in one, and intracerebral and subarachnoid haemorrhage with infarction in one. Cerebrospinal fluid analysis showed increased protein in three, hemorrhage in one, and no abnormality in one patient. Of 12 patients (29%) who died before discharge, five in the first and three in the second week post-transplantation, 11 (92%) had encephalopathy post-operatively. Neurological complications after transplantation were associated with increased mortality. Post-operative hypomagnesaemia was associated with the development of nervous system complications. We did not identify any clear pre-operative predictors of development of post-operative neurological complications.     

Neurological complications of liver transplantation

We examined 199 consecutive patients who underwent 220 liver transplantations, to define the type, frequency and aetiology of posttransplant neurological complications and their prognostic value. We found neurological complications in 63 patients (32%), mostly involving the central nervous system. The most frequent complications were mental status changes ranging from delirium to coma and seizures. The aetiology was multifactorial, cyclosporin A neurotoxicity being the main cause. Patients with neurological complications had a higher mortality rate than those without. In our series, neurological complications represented a major medical problem with increased morbidity and mortality.     

肝移植后慢性排异反应1例

背景：慢性排异反应进展缓慢,往往呈隐匿性,移植肝功能逐渐减退或丧失。这种损伤是不可逆的,目前尚无有效的治疗办法。 目的：分析1例肝移植后慢性排异反应病例,以早期作出正确诊断。 方法：分析1例肝移植后3次入院诊断治疗的经过。B超显示：①肝实质回声增高,粗,不均匀。②胆囊切除术后。③脾大。④腹水。腹部CT显示：①肝移植术后。②脾大。住院期间积极给予护肝、支持、对症治疗,丙氨酸转氨酶、天门冬氨酸转氨酶无下降,总胆红素持续不降并有上升,反复腹腔感染。排除其他肝损害原因,经肝组织病理证实为肝移植术后慢性排异反应。 结果与结论：病例提示肝移植后不明原因肝脏损害,慢性排异反应应引起重视并应作为鉴别诊断之一,且肝组织病理检测将有助于诊断。对于肝移植后慢性排异反应除外其他肝损害病因并及时进行肝组织病理检测将有助于诊断。     

Neurological complications following liver transplantation.

Neurological complications occurred in 4 (19%) of 21 consecutive patients (Group II) undergoing orthotopic liver transplantation, compared with a 47% (9/19) incidence in our initial series (Group I). In Group II, the neurological problems included new recurrent headaches and delayed intracerebral hemorrhage (1 patient), partial third nerve palsy and brachial plexopathy (1 patient), and ataxic dysarthria with encephalopathy (2 patients). Seizures, noted in 8 of 9 neurologically affected Group I patients, were not encountered in Group II. Of the 4 patients in the entire series with the cerebrocerebellar syndrome, 2 had partial recovery after stopping treatment with cyclosporine, 1 stabilized when cyclosporine was discontinued but later worsened when rechallenged, and 1 had full recovery but died following a second transplantation. Brain magnetic resonance images appeared normal in 3 of the 4 patients. Complications affecting vision included cortical blindness in 2 patients and occipital lobe hemorrhage in 1. All completely recovered. Survival was comparable for patients with and those without neurological complications (69% and 63%, respectively). Immediate withdrawal of cyclosporine at the onset of a change in mental status or dysarthria and improvement in intra- and postoperative management may have contributed to the decreased incidence of neurological complications.     

Neurological complications after living-donor liver transplantation in children

AimLiver transplantation (LT) has been used as a definitive management for children with end-stage liver disease or acute liver failure. Living-donor LT (LDLT) has been a common type of LT performed in Asian countries, including Japan, where deceased donors are rarely available. However, the neurological complications (NCs) associated with LDLT remain unknown. The purpose of this study was to clarify the characteristics of NCs in children after LDLT.MethodsThis study is a retrospective observational study carried out at a tertiary children’s hospital in Japan. We studied children who had undergone LDLT between January 2001 and January 2020.ResultsWe examined 602 cases of LT, of which 559 were LDLT cases (92.9%). NCs after LT were present in 21 cases (3.8%). The most common neurological symptoms were seizure (n = 17), whereas disturbance of consciousness without seizure was observed in four cases. The frequency of NCs for each of the indications was 12.2% for fulminant hepatic failure, 6.5% for metabolic liver disease, and 0.7% for cholestatic liver disease.InterpretationWe report the characteristics of NCs after LDLT in children. The frequency of NCs after LT was high in cases of fulminant hepatic failure and metabolic diseases, who might have had neurological symptoms or impaired consciousness before LT.     

Neurological complications after cadaveric and living donor liver transplantation

Problems related to the central nervous system have a major impact on survival and quality of life. The aim of this retrospective study was to evaluate the incidence of neurological complications after liver transplantation (LT), including both cadaveric and living donor liver transplantation. Between April 2001 and March 2004 174 patients (120 cadaveric liver transplantations, 54 living donor transplantations) were admitted to our intensive care after liver transplantation. Of the transplanted patients 24.7% developed neurological complications. These patients’ stay in the intensive care (14.2 ± 17.2 days) was much longer than that of all admitted patients (8.4 ± 10.5 days, p < 0.05). The most common neurological complications were encephalopathy (72.1%) and seizures (11.6 %). The incidence of neurological complications in living donor liver transplanted patients was significantly lower than in cadaveric transplantation patients (20.4% vs 26.7 %). The cold ischemia time in living donor transplanted patients was significantly shorter in comparison with cadaveric transplanted patients (215 ± 119.3 vs. 383.7 ± 214.7). The survival rate after liver transplantation of patients with neurological complications was lower than that of patients without, but not significantly different (79.1 % vs. 82.4%, p > 0.05). The incidence of neurological symptoms was found to be similar between the patients treated with cyclosporine (25%) and tacrolimus (23.8 %) in this study. In conclusion, there was a high incidence of neurological complications after LT, prolonging the patients’ stay in intensive care significantly. The major neurological manifestation in our patients was encephalopathy followed by seizures. Living donor liver transplantation was associated with a significantly lower incidence of neurological complications compared with patients who had received a cadaveric graft. This might be due to the good quality of the organ and the much shorter cold ischemia time of the graft when the donor was alive.     

Neurosurgical complications of pediatric orthotopic liver transplantation

Liver transplantation is the only definitive treatment of end-stage liver disease. The University of Nebraska began its hepatic transplantation program in July 1985. Since that time, 43 children and 48 adults have undergone orthotopic liver transplantation (OLTx) with survival rates to date of 79.1% and 79.2%, respectively. Eight children developed complications of neurosurgical interest (18.6% incidence). Hemorrhagic complications were the most frequent. Neurosurgical salvage was achieved in five patients, but delayed complications of the transplant caused the death of two of these children. Two survivors are functioning well at home and in kindergarten, one child is doing well but is still hospitalized, and one child is vegetative. Aggressive management of life-threatening CNS problems is thus appropriate in this population. The authors review the pathophysiology of these complications, as well as potential pitfalls in their management.