肝切除术中肝血流阻断技术的合理应用

血流阻断是肝肿瘤切除术中减少及控制出血的重要手段,但血流阻断也会在不同程度上影响血流动力学的变化,因此,在肝切除手术中必须合理、灵活地运用肝血流控制方法。Pringle第一肝门血流阻断法是目前肝脏切除中最常用的肝血流阻断方法,对肿瘤巨大需行半肝切除术、合并严重肝硬化或肝储备功能严重不足者可考虑用半肝血流阻断法,以避免残留肝脏因血流阻断缺血和再灌注受到伤害;对位于肝静脉主干,如肝、腔静脉结合部病变切除,各种全肝血流阻断方法因对血流动力学的严重影响而被逐渐慎用,目前以选择性血流性出入血流阻断法为首选。SHVE方法的应用完全改变了以往因害怕损伤肝、腔静脉而放弃手术切除的消极局面。笔者认为只要熟练掌握肝静脉和腔静脉的解剖特点,分离阻断右肝静脉及左、中静脉干并非难事,采用SHVE血流阻断技术对于第二、三肝门部肝肿瘤的手术切除是安全可行的血流阻断方法。     

肝硬变门静脉高压症病人门静脉-腔静脉分流术前后生长激素水平的动态观察

为研究肝硬变门静脉高压症患者门静脉-腔静脉分流术前后生长激素水平变化,作者应用放射免疫分析方法测定了22例肝硬变门静脉高压症患者行门静脉-腔静脉分流术和16例无肝脏和肾脏疾病的对照组患者行胃肠道肿瘤切除手术前后门静脉、外周静脉和动脉血浆中GH水平结果,发现肝硬变组术前、术中、术后3天,术后7天的门静脉、周围静脉和动脉血浆中GH水平都明显高于对照组(P<0.01),肝硬变组术前、术中和术后动脉、周围静脉和门静脉的差异无显著性(P>0.05)。肝硬变组门静脉血中GH水平与门静脉压力无明显相关性(r=0.02,P>0.05)。肝硬变门静脉高压症患者血中GH明显增高。行门静脉-腔静脉分流术后GH水平无明显变化。     

蝮蛇抗栓酶治疗布-加综合征2例

布-加综合征(Budd-Chiuri)为肝静脉或肝段下腔静脉狭窄或阻塞,使肝静脉或下腔静脉血液回流障碍而表现门脉高压和下腔静脉高压综合征。我们应用蝮蛇抗栓酶治疗2例,疗效满意。现报告如下。1 临床资料 例1,男,40岁,病程2年;例2,女,46岁,病程3年。2例均为HBsAg阳性,都具有腹胀,纳差,肝脾肿大,顽固性腹水,下肢浮肿,下肢色素沉着,上行性腹壁浅静脉曲张。彩超提示肝脏以右叶和尾叶增大为主,     

超声引导下门静脉穿刺介入治疗肝硬化门静脉系统血栓的疗效分析

目的 探讨超声引导下门静脉穿刺介入治疗肝硬化门静脉系统血栓的临床疗效。方法 54例肝硬化门静脉系统血栓患者,均行超声引导下门静脉穿刺介入治疗。观察术后患者门静脉通畅及转归情况,比较手术前后门静脉血栓Yerdel分级、肝门静脉指标、静脉压变化,分析影响患者预后相关因素。结果 54例患者术后门静脉完全通畅率70.37%、部分通畅率27.78%,失败率1.85%;术后消化道出血复发率为9.26%,总生存率为88.89%;术后门静脉血栓Yerdel分级情况优于术前,差异有统计学意义(P<0.05)。术后患者门静脉内径(15.14±2.30)mm、脾静脉内径(11.26±0.37)mm、脾脏肋间厚度(47.84±3.96)mm小于术前的(16.10±2.18)、(12.84±0.85)、(52.53±5.75)mm,血流速度(35.75±8.82)cm/s快于术前的(26.59±8.47)cm/s,差异均有统计学意义(P<0.05)。手术前后患者的肝静脉自由压比较,差异无统计学意义(P>0.05);术后肝静脉楔压(10.39±3.11)mm Hg(1 mm Hg=0.133 k...     

经阴道超声在盆腔静脉淤血综合征诊断中的价值

目的探讨经阴道超声在盆腔静脉淤血综合征诊断中的价值。方法对经阴道超声检查的89例临床拟诊盆腔静脉淤血综合征患者及同期行经阴道超声检查的231例健康育龄妇女声像图进行回顾性分析。结果盆腔静脉淤血综合征超声表现子宫轻度增大,迂曲、扩张的盆腔静脉呈串珠样或蜂窝状,静脉内径(0.66±0.13)cm,CDFI示红蓝相间的彩色团状血流信号,部分呈"蚯蚓"状或相互连接成"湖泊"状,内为连续、低速血流,流速为(7.72±2.99)cm/s,对照组盆腔静脉内径(0.35±0.15)cm,流速(9.85±0.52)cm/s,两组比较差异有统计学意义(P<0.05)。结论经阴道超声对于盆腔静脉的检查具有安全、无创、可重复等优点,在辅助盆腔淤血综合征诊断中具有较高价值。     

经皮球囊导管成形支架植入术治疗布加综合征的临床观察

目的探讨运用经皮下腔静脉球囊成形、支架植入术治疗布加综合征的临床疗效。方法本组病例136例,其中男64例,女72例,其中肝静脉阻塞4例,余均为下腔静脉阻塞或狭窄,均经彩色多普勒超声、下腔静脉及肝静脉造影等检查证实,并进行经皮下腔静脉球囊成形(PTA)、支架植入术(EMS)治疗。所有患者随访1至120个月。结果扩张前静脉狭窄段内径0～6mm(平均3mm),肝静脉内径0～2mm;扩张并放血管支架后,腔静脉、肝静脉内径分别为18～20mm和7～8mm,扩张前下腔静脉至右心房压力差为18～35cmH2O(1.7～3.43kPa),平均20.3CmH2O(1.99kPa),扩张后压力差消失,134例手术顺利,2例失败。术后118例主要症状及体征消失或基本消失,22例明显改善,4例肝静脉阻塞病人,2例主要症状及体征明显改善,2例未见明显。125例患者在随访期间血管内支架形态良好,支架内血流通畅。4例肝静脉阻塞在术后半月、2、5、6个月发生再阻塞转为手术治疗,5例下腔静脉阻塞可狭窄术后于6、17、36、96、98个月发生再阻塞转为手术治疗。结论经皮下腔静脉球囊成形、支架植入术是非长段阻塞型布加综合征良好治疗方法,但经皮下腔静脉球囊成形、支架植入术治疗肝静脉疗效差。     

彩色多普勒超声监测正常晚期妊娠胎儿门静脉及静脉导管血流改变

胎儿的血液循环，主要靠六个通道；一条脐静脉，一条静脉导管，卵圆孔及动脉导管和二条脐动脉。而只有静脉导管是把脐静脉内高含氧量血流直接运入下腔静脉，进入右心房的通道。胎儿时期的肝内血管系统供血复杂，一方面门脉主干分出左、右分支供应肝右叶及部分左叶的供血。另一方面，胎儿脐静脉入肝后分出二支，一支直接由静脉导管入下腔静脉后入右房，另一支入肝脏门脉左支囊部，供应肝左叶大部分。     

原位肝脏移植一例麻醉处理

１９９４年５月１０日我院在动物实验的基础，成功地完成了１例同种原位肝脏移植术，受者为晚期肝硬化合并门静脉高压症患者，采用无肝体外静脉转流术，即采用进口离心式生物泵进行无肝期门静脉、右股静脉向左腋静脉的转流，此方法在很大程度上防止阻断门静脉及下腔静脉后循环的非生理状态，而对血流动力这和肾功能影响甚微，术后无手术并发症发生，增加了围手术期的安全性，术后病人顾活至今，现将手术期麻醉的监测，处理等作一简介     

裸花紫珠颗粒联合奥曲肽治疗肝硬化上消化道出血的临床研究

目的探讨裸花紫珠颗粒联合奥曲肽治疗肝硬化上消化道出血的临床疗效。方法选取2018年3月-2019年3月在琼海市人民医院治疗的肝硬化上消化道出血患者88例,根据用药的差别分为对照组(44例)和治疗组(44例)。对照组患者静脉滴注醋酸奥曲肽注射液,0.1 mg加入生理盐水250 mL,1次/d;治疗组在对照组的基础上口服裸花紫珠颗粒,3 g/次,4次/d。两组患者均经4d治疗。观察两组患者临床疗效,同时比较治疗前后两组患者门静脉血流、脾静脉血流、门静脉内径、脾静脉内径、止血时间、输血量、肝静脉游离压(FHVP)、肝静脉锲入压(WHVP),及血清超敏C反应蛋白(hs-CRP)、血管紧张素Ⅱ(AT-II)、肾素活性(PRA)、抗利尿激素(ADL)和一氧化氮(NO)水平。结果治疗后,对照组和治疗组临床有效率分别为81.82%和97.73%,两组比较差异具有统计学意义(P<0.05)。经治疗,两组门静脉血流、脾静脉血流、门静脉内径及脾静脉内径均明显减小(P<0.05),且治疗组明显小于对照组(P<0.05)。经治疗,治疗组患者止血时间明显短于对照组(P<0.05),且输血量明显小于对照组(P<0.05)。经治疗,两组患者FHVP、WHVP均明显降低(P<0.05),且治疗组患者降低更显著(P<0.05)。经治疗,两组患者血清hs-CRP、AT-II、NO、PRA、ADL水平均明显降低(P<0.05),且治疗组明显低于对照组(P<0.05)。结论裸花紫珠颗粒联合奥曲肽治疗肝硬化上消化道出血疗效好,可改善机体血流动力学指标,具有一定的临床推广应用价值。     

下腔静脉肝后段与肝尾状叶腔静脉旁部的应用解剖观察

下腔静脉肝后段作为肝脏静脉血注入血液循环的唯一通路,其形态结构和走行特点的变化在不同程度上决定着肝静脉血回流状况甚至肝脏功能;同时对下腔静脉前间隙的解剖定位、经下腔静脉肝后段肝内穿刺、下腔静脉肝后段损伤的修复、肝移植及肝段切除等手术操作都会产生深远影响,因而备受国内外学者关注[1].然而,下腔静脉穿行于肝后缘时,部分管腔甚至全部管腔被肝组织包绕[2],而包绕该段下腔静脉的肝组织主要来自肝右叶和尾状叶,其中尾状叶形态相对独立,由左前向右后形成一腔静脉后突[3],压迫甚至包绕下腔静脉,从而使下腔静脉肝后段在肝脏后缘腔静脉沟内穿行时,其管径、形态及走行方向均发生了一定的改变.本研究旨在阐明尾状叶旁部形态与下腔静脉形状、走行的关系,为临床相关疾病的诊断、治疗及手术提供解剖学依据.     

彩色多普勒检测肝外阻塞性黄疸肝脏血流动力学改变

目的：应用彩色多普勒研究阻黄患者肝血流动力学的改变。方法：用彩色多普勒检测阻黄患者１８例（对照组正常人１０名）的门静脉、肝动脉管径,门静脉血流速度,肝动脉收缩期峰值速度（Ｖｍａｘ）,舒张末期峰值速度（Ｖｍｉｎ）及其时间平均速度（Ｖｍｅａｎ）和其阻力指数（ＲＩ）。结果：阻黄时,门静脉管径及其流速、流量与正常人比较无统计学意义（Ｐ＞０．０５）;肝动脉管径明显扩张,肝动脉流速、流量与正常人比较有统计学意义（Ｐ＜０．０５）。肝动脉阻力指数与正常人比较无统计学意义（Ｐ＞０．０５）。结论：阻黄时,肝脏血流量明显增多,门静脉血流量与正常人无明显差异。     

银杏内酯对大鼠移植肝缺血再灌注损伤保护作用的研究

目的:观察银杏内酯对大鼠自体原位肝移植缺血再灌注损伤的影响,探讨其对大鼠移植肝缺血再灌注损伤的保护作用。方法:通过银杏内酯在门静脉-左肾静脉搭桥、肝后下腔静脉内置管分流法建立的大鼠自体原位肝移植模型上的应用,采用硝酸酶还原法测定肝脏缺血前和再灌注后5min、30min、2h血清血管活性递质一氧化氮(NO)和血浆内皮素(ET1)的水平变化;测定血清谷丙氨基转移酶(ALT)、谷草氨基转移酶(AST)、碱性磷酸酶(ALP)、乳酸脱氢酶(LDH)的酶学差异和肝组织三磷酸腺苷(ATP)及丙二醛(MDA)的含量变化;再灌注2h取肝组织,用甲醛固定制成电镜标本,观察肝细胞、肝小叶超微结构。结果:银杏内酯能提高再灌注后血NO水平,并对ALT、AST、LDH的病理性升高有降低作用,且能改善肝脏缺血再灌注损伤的微循环,减轻肝细胞内超微结构的损害程度。结论:肝移植术前施行门腔分流是预防术后发生肝缺血再灌注损伤的有效措施;NO/ET1平衡可能是影响移植肝脏微循环血流量变化的调节因素。银杏内酯对大鼠肝缺血再灌注损伤有保护作用。     

Characteristics of liver circulation and the outflow of bile and lymph in acute carbon tetrachloride poisoning]

In acute tests set up on 13 dogs the pressure and blood flow in the portal vein and hepatic artery, the pressure in the inferior vena cava along with lymph- and bile currents were registered following intraportal introduction of CCI4. Subject to determination were also the resistance of venous and arterial hepatic vessels and of the splachnic zone, as well as the summary blood flow. The rising pressure and diminished blood flow in the portal vein were found to be the result of the growing resistance of venous vessels in the liver. Falling pressure and reduced blood flow in the hepatic artery bore witness to the general toxic effect of CCl4 on the animal organism. Increased portal pressure and disturbed permeability of biological membranes was attended by a greater lymph outflow. The inhibition of bile secretion came as a result of hypoxic and toxic damage of the liver.     

永久性腔静脉滤器的临床应用

目的探讨下肢深静脉血栓形成患者植入永久性腔静脉滤器的临床应用。方法下肢深静脉血栓形成患者24例,单侧21例,双侧3例。术前均经血管彩色多普勒超声确诊,并明确栓塞范围、栓尾位置、解剖条件和腔静脉情况。手术在DSA室局麻下进行,经健侧股静脉或右颈内静脉穿刺植入永久性腔静脉滤器于下腔静脉,捕捉血栓和预防肺血栓栓塞症。随访行血管彩色多普勒超声及X线胸片检查。结果永久性腔静脉滤器植入全部成功,术后即刻造影,滤器形态及位置佳。随访3～17个月无肺血栓栓塞症相关症状,无后期死亡。结论永久性腔静脉滤器预防肺血栓栓塞症安全有效,为预防肺血栓栓塞症,对下肢深静脉血栓形成患者植入永久性腔静脉滤器是必要的。     

家兔下腔静脉血栓模型建立的实验研究

目的：探讨通过手术在家兔下腔静脉内置入螺旋铜丝建立下腔静脉血栓模型的可行性及成功率。方法将30只家兔分为血栓组（25只）与对照组（5只）。血栓组实验兔通过手术暴露下腔静脉,将自制长约3 cm直径约3 mm螺旋铜丝穿刺置入下腔静脉,止血后将自制U形铜丝夹于螺旋铜丝近心端下腔静脉收紧,留缝隙约2 mm,缝合腹膜、肌肉及皮肤。对照组进行与血栓组相同的手术过程,但下腔静脉不置入螺旋铜丝。1d后处死解剖2组实验兔,观察血栓组下腔静脉血栓形成情况,计算造模成功率,对照组观察下腔静脉血流情况。血栓组取血栓行HE染色病理检查确定血栓性质。结果血栓组25只实验兔下腔静脉管壁完好。23只实验兔下腔静脉内可见血栓形成,红色血栓与白色血栓沿螺旋铜丝间或存在,造模成功率92％（23/25）。2只实验兔造模失败。对照组5只实验兔下腔静脉内未见血栓形成。血栓组血栓病理证实均为新鲜混合血栓。结论本方法建立下腔静脉血栓模型成功率高,血栓病理符合深静脉血栓特点,可用于静脉血栓的实验研究。     

A regional difference in endothelium-dependent relaxation responses to acetylcholine in the canine venous system

Endothelium-dependent relaxations of canine veins isolated from 15 different sites were examined. Acetylcholine (ACh, 10(-10)-10(-6) M) caused marked endothelium-dependent relaxations in the external jugular vein, superior vena cava, brachiocephalic vein, segment A (supradiaphragmatic portion) and D (infrarenal portion) of the inferior vena cava. However, only contractile responses were induced by ACh in the portal, mesenteric veins and the segment C of the inferior vena cava (between liver and renal veins) with or without endothelium. The other 7 veins showed only small endothelium-dependent relaxations (10-20%). These results indicated that the endothelium-dependent responses of canine veins to ACh are regionally different.     

Splanchnic uptake of haloperidol and release of reduced haloperidol in vivo in the guinea pig.

Splanchnic uptake of haloperidol (HAL) and release of reduced haloperidol (RHAL) were studied in vivo in guinea pigs. Anesthetized animals with implanted cannulae in the aorta, the hepatic vein and the inferior vena cava were infused intravenously with HAL at a rate of 9.6 micrograms/min/animal for 90 min. Plasma HAL and RHAL in samples taken from the arterial and hepatic venous cannulae were measured by HPLC with an electrochemical detector. Contamination of the hepatic venous samples by blood from the inferior vena cava was ruled out by the validation method of tritiated water washout [Huang MT, J Appl Physiol 71: 359-364, 1991]. HAL concentrations plateaued at 70-80 ng/mL in the aorta and 5-7 ng/mL in the hepatic vein during the final 30 min of infusion. Splanchnic extraction of HAL was 91%. Hepatic blood flow was estimated to be 1.95 +/- 0.40 (SD) mL/min/g. If assuming that splanchnic uptake of HAL took place in the liver, a rate of uptake of HAL in the liver of 79.2 +/- 18.6 (SD) ng/min/g could be calculated by the Fick principle. The uptake in the whole liver accounted for 14% of the rate of HAL infusion into the animal. Plasma RHAL in the aorta, 6.4 +/- 6.6 (SD) ng/mL at 60 min and 9.4 +/- 4.6 (SD) ng/mL at the end of HAL infusion, was about 10-12-fold less than aortic HAL. The concentrations of RHAL in the hepatic vein were not significantly different from those in the aorta, indicating that splanchnic tissues including the liver are not responsible for plasma RHAL secretion. The highly efficient uptake of HAL as well as the ketone reductases found previously in vitro in liver microsomes of guinea pigs were probably involved only in biliary excretion of HAL.     

A regional difference in the distribution of postsynaptic alpha-adrenoceptor subtypes in canine veins

The responsiveness of helical venous strips isolated from fifteen different sites in the body of dogs to relatively selective alpha 1- and alpha 2-adrenoceptor agonists was studied, as well as to a non-selective alpha-adrenoceptor agonist. Longitudinal strips of the portal and mesenteric veins and the inferior vena cava between the liver and the renal vein (segment C) were also investigated. All veins contracted to noradrenaline or phenylephrine whereas only seven veins responded significantly to clonidine: the saphenous, cephalic, jugular and femoral veins and longitudinal strips of the portal and mesenteric veins and the segment C of the inferior vena cava. The brachiocephalic, azygos, pulmonary and splenic veins and the superior vena cava and the supradiaphragmatic portion (segment A) and the infrarenal portion (segment D) of the inferior vena cava responded little to clonidine. Unlike the longitudinal strips, the helical strips of the portal and mesenteric veins and the segment C of the inferior vena cava did not respond to clonidine. According to the relative sensitivities to phenylephrine and clonidine, those veins which responded to clonidine could be divided into three groups. (1) The veins in which the sensitivity to phenylephrine was higher than to clonidine: longitudinal strips of the portal vein and segment C of the inferior vena cava, (2) the veins whose sensitivity to phenylephrine was lower than to clonidine: the saphenous, cephalic, femoral and external jugular veins, (3) the vein whose sensitivity to the two agonists was comparable: longitudinal strips of the mesenteric vein. Subtype characteristics were further analyzed in the saphenous vein and in the portal vein using prazosin, phentolamine and yohimbine as antagonists. Analysis of Schild plots to noradrenaline suggested that a mixed population of alpha-adrenoceptor subtypes might be present in the saphenous vein, whereas a rather homogeneous population of a single subtype might occur in the portal vein. The results of the antagonism experiment against phenylephrine and clonidine suggested that contractions of the saphenous vein are mediated by both alpha 1- and alpha 2-adrenoceptors whereas contractions of the portal vein are exerted mainly through alpha 1-adrenoceptors. The results suggest that there may be a distinct regional difference with respect to postsynaptic alpha- adrenoceptor subtypes in the canine venous system.     

背驮式肝移植无肝期的细分与容量管理对策

目的探讨对背驮式肝移植手术的无肝期做进一步细分和容量管理的对策。方法67例背驮式肝移植手术患者,无肝期划分为门静脉阻断期和下腔静脉阻断期,以尿量为指标,采用不同的输液管理方法。结果与无肝前期比较,下腔静脉阻断期尿量显著降低,新肝期尿量显著增加;下腔静脉阻断期和新肝期少尿发生率显著增多、少尿纠正率显著降低;9例达到ARF诊断标准、占13.4%,术中无肝期时间、术中低血压时间、术后低血压时间无显著延长,但出血量显著增多、术中少尿时间显著延长。结论将无肝期再细分,有区别地补充容量维持正常尿量是可行的,术中血液动力学比较稳定,术后肾脏功能恢复比较满意。     

Metabolic fate of gallic acid orally administered to rats

The metabolic behavior of orally administered gallic acid was investigated by HPLC and 4-O-methyl gallic acid was found to be the main metabolite in rat peripheral blood and urine. After oral administration of gallic acid, maximum concentration in portal vein and inferior vena cava occurred at 15 and 30 min, respectively. In portal vein, gallic acid was preferentially detected relative to 4-O-methyl gallic acid, whereas gallic acid and 4-0-methyl gallic acid were equally detected in inferior vena cava. On the other hand, 4-O-methyl gallic acid but not gallic acid was found in liver. The contents of gallic acid and 4-O-methyl gallic acid in urine were nearly 100 times higher than those in blood. The ratio of 4-O-methyl gallic acid to total gallic acid metabolites in urine was from 0.55 to 0.76, indicating that a considerable amount of gallic acid was excreted without being metabolized. In this study we found that gallic acid administered orally existed in the blood for 6 h at most, and more than half was metabolized to 4-O-methyl gallic acid, followed by excretion into urine.