对肝切除术后肝功能衰竭的再认识

目的对肝切除术后肝功能衰竭的定义、危险因素及术前评估方法进行总结。方法收集国内外关于肝切除术后肝功能衰竭的文献并做综述。结果肝切除术后肝功能衰竭的定义并不统一,目前认可度较高的是"50-50标准"和国际肝脏外科学组(International Study Group of Liver Surgery,ISGLS)标准。肝切除术后肝功能衰竭的危险因素可大体分为患者相关、肝脏相关及手术相关三类。术前评估主要是基于肝脏功能以及肝脏体积两个方面。结论肝切除术后肝功能衰竭是肝切除术后短期死亡的主要原因,术前充分评估、术中采用积极有效的手段控制出血、缩短手术时间等均可以预防或减少术后肝功能衰竭的发生。     

对肝内胆管结石病理变化的再认识

对肝内胆管结石病理变化的再认识福建医科大学附属协和医院福建省肝胆外科研究所（福州，３５０００１）殷凤峙近年来，大量临床经验的积累及病理学方面的深入研究，使我们对肝内胆管结石的发生、发展及其转归的病理变化，有了新的认识。现结合临床介绍如下。１肝内胆管结...     

腹腔镜胆囊切除中对肝外胆管变异的认识及处置

目的:探讨腹腔镜胆囊切除术中对肝外胆管变异的认识和处置。方法 :分析2008年6月至2015年2月腹腔镜胆囊切除术中发现的42例肝外胆管变异。术中从胆囊壶腹部解剖胆囊管,明确三管关系,完成胆囊切除。结果:42例病人均顺利完成经腹腔镜胆囊切除术,无胆管损伤,效果良好,无胆管损伤并发症。结论:牢记肝外胆管变异的可能性,仔细正确处置,可有效帮助辨别肝外胆管的变异,避免医源性胆管损伤的发生。     

再论"Cockett综合征及对下肢主要静脉疾病的再认识"

近20多年来的研究证明Cockeu综合征（Cockett synzome，CS）不仅发病率比较高，而且又是继发下肢静脉曲张（varicose veins，VV）、深静脉瓣膜关闭不全（deep veins valvolar incompetence，DVI）和深静脉血栓形成（deep veins thrombosis，DVT）的主要原因，因而有对CS及下肢主要静脉疾病再认识的必要。然而，这一重要的临床课题，似乎仍属于少数学者的研究范畴。写此“再论”的目的，一是想对CS及其相关问题作些阐述，二是希望更多的医生对这一研究课题感到兴趣。     

静脉顺行造影在下肢慢性静脉疾病诊断中的再认识

目的分析下肢静脉曲张患者静脉顺行造影表现,总结其对诊断下肢慢性静脉疾病尤其是髂静脉压迫综合征的临床意义。方法 282例下肢静脉曲张患者(329条下肢),左下肢185例,右下肢50例,双下肢47例,术前常规行下肢静脉顺行造影,分析其下肢及髂静脉影像学表现。结果 329条下肢静脉造影成功率100%,下肢深静脉血栓后遗症21例(6.38%),单纯性大隐静脉瓣膜功能不全57例(17.33%),下肢深静脉瓣膜功能不全182例(55.32%),交通支瓣膜功能不全66例(20.06%),先天静脉畸形3例(0.91%);同时发现有髂静脉狭窄大于50%者19例(5.78%),髂静脉狭窄小于50%者57例(17.33%)。结论下肢慢性静脉疾病患者术前静脉造影检查,能够明确原发病因尤其是髂静脉压迫综合征,对于选择个体化的治疗方案具有重要的临床意义和实用价值。     

活体肝移植术前评估肝静脉引流域的临床价值

目的 探讨肝静脉属支的直径与引流域的相关性及活体肝移植术前评估肝静脉引流域的临床价值.方法 对68例供者术前行多层螺旋CT增强检查,并利用GE Advantage Windows 4.2工作站和IQQA(R)肝脏CT影像解读分析系统对图像进行重建与分析,标记肝静脉各属支,测定静脉直径与相应引流域,并对二者进行相关性分析.分别计算左、右半肝的功能肝体积,并依据术中血管重建情况计算有效肝体积及所对应的肝重量与体重比.结果 共测定了220支肝右静脉或肝中静脉的属支,其直径与引流域体积之间的相关系数为0.752(P＜0.01),二者呈一定的正相关性,但相同直径血管的引流域体积差异较大.将血管直径和引流域体积分别以5mm与50cm3进行分级和统计频数,二者差异有统计学意义(X2=61.97,P＜0.01).肝右静脉引流域体积为(510.80±168.33)cm3,右半肝功能肝体积为(577.26±156.72)cm3.肝左静脉引流域体积为(292.70±76.61)cm3,加上Ⅳ段属支的引流域体积为(551.26±111.82) cm3.25例不带肝中静脉的右半肝的有效肝体积为(405.52～1038.43)cm3,未保留肝中静脉的43例供者残肝的有效肝体积为(175.35～575.35)cm3.结论 相同直径血管的引流域差异较大,也并非直径越大,引流域就越大 ;活体肝移植术前评估供肝静脉引流域对于手术方案的制定具有重要的指导意义.     

下肢慢性静脉功能不全治疗的再认识

周围静脉疾病是临床上的常见病和多发病,其发病率为20%～40%,皮肤营养障碍占2%～5%[1,2],发病率比动脉疾病约高10倍,发病机理比动脉疾病复杂,分类方法亦不一致,至今存在着争论.     

肝门部胆管癌和胆囊癌诊治的再认识

肝门部胆管癌和胆囊癌的发病率近年来有上升趋势，是胆道系统最常见的恶性肿瘤。病情早期常由于缺乏特异的症状和体征，以往在术前作出正确的诊断和对治疗方案合理选择常有困难。近年来随着影像医学发展，如B－fill、CT、MRI、ERCP、PTC等检查手段广泛应用，术前即有可能对肝门     

Total drainage of the right lung into the right hepatic vein.

Report of a case oa anomalous venous drainage of the right lung into the right hepatic vein treated by disconnection of the anomalous pulmonary vein and end-to-side anastomosis to the left atrium. Following a review of 25 surgically treated patients with infracardiac drainage of the right lung the different surgical approaches are discussed.     

Total resection of the right hepatic vein drainage area with the aid of three-dimensional computed tomography

Purpose  

We analyzed the feasibility and safety of our preliminary surgical approach for total hepatic resection of the right hepatic vein drainage area (THR-RHV) with the aid of three-dimensional computed tomography (3D-CT) guidance.     

心内型完全性肺静脉畸形引流漏诊合并肝左静脉异常引流1例

患者女，19岁，自幼发现心脏杂音，生长发育较同龄人略迟缓，活动后胸闷、心慌、气短，无晕厥、喜蹲踞，紫绀（＋）。血压：96/60mmHg，心率：61次／分。心界向两侧扩大。律不齐，可闻及早搏、大炮音；胸骨左缘第二、三肋间4/6级收缩期杂音，传导广泛。并可触及震颤，周围血管征阴性。心电图：交界性心律，Ⅰ度岛室传导阻滞，频发房早二联律伴室内差异性传导。     

Relation between the middle hepatic vein drainage area volume and alanine aminotransferease after left liver harvesting

Complete outflow is impossible to maintain on both sides in donors undergoing hemiliver graft harvesting, because the middle hepatic vein (MHV) can be preserved on only one side. The area in which outflow veins are disrupted becomes congested and does not sufficiently regenerate. The relation between changes in alanine aminotransferase (ALT) and the congestive area volume of the congestive area is unknown. The 64 subjects presented herein were living donors who provided the left liver with the caudate lobe and MHV trunk. The midpoint between the tributaries of the MHV and the right hepatic vein was determined preoperatively using computed tomography. The midpoint between the tributaries of the MHV and right hepatic vein and the borderline between the right and left liver were used to predict the MHV drainage area volume. ALT was measured in donors on postoperative days 1, 3, 5, 7, 10, and 14. The patients were divided into three groups according to the ratio of calculated MHV drainage area volume in the remnant right liver: less than 15% (n = 21, group A); greater than 15% and less than 20% (n = 18, group B); greater than 20% (n = 25, group C). There were significant differences in the ALT levels between groups (P = .004). MHV drainage area volume, calculated using the present method, was associated with high ALT levels after left liver harvesting with the MHV. The present study suggests that persistently high ALT levels are associated with the volume of the interrupted MHV drainage area.     

Determination of the extent of feasible hepatic resection from hepatic blood flow

Blood flow in the residual liver after major hepatectomy is considered an important determinant factor of liver function. Presented here is a method of obtaining the whole and regional hepatic blood flow index from hepatic clearance of ¹⁹⁸ Au-colloid, which can predict the blood flow index of residual liver before operation and thereby prevent postoperative hepatic failure due to too large a resection. Hepatic resection was followed by a decrease of the hepatic blood flow index (K _LAu ) almost proportional to the amount of hepatic mass resected. An analysis of data from 34 patients who underwent hepatectomy showed that the preoperatively predicted value of the blood flow index in the unresected liver had a good correlation ( r =0.9) with that measured 1 month after hepatectomy. It also correlated well with the risk of death from liver failure among those patients whose K _L value of residual liver was under the critical level. Since 1981 the early death rate from liver failure after hepatectomy was reduced remarkably by preparing the resection boundary on the basis of the blood flow index of residual liver. With the use of our method in animal experiments, the hepatic blood flow index was found to be uninfluenced by reticuloendothelial system function and was considered to be a reliable indicator of blood flow in hepatic sinusoids.

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Resumen El flujo sanguíneo en al hígado residual después de una resección mayor es considerado como un factor de importancia determinante de la función hepática. Los autores han desarrollado un método para obtener el índice de flujo hepático total y regional a partir de la depuración hepática de¹⁹⁸Au-coloide, prediciendo el índice de flujo hepático del hígado residual antes de la operación con el propósito de prevenir la falla hepática postoperatoria que pueda presentar una resección demasiado extensa. La resección hepática fue seguida de una disminución en el índice de flujo hepático (K_Lau) casi proporcional a la cantidad de masa hepática resecada. Un análisis de los datos en 34 casos de hepatectomía mostró que el valor preoperatoriamente pronosticado del índice de flujo hepático en el hígado a ser preservado tuvo una buena correlación (r=0.9) con aquel medido un mes depués de la hepatectomía. También se correlacionó con el riesgo de muerte por falla hepática entre los pacientes cuyo valor de K_L en el hígado residual se halló por debajo del nivel crítico. A partir de 1981 se redujo en forma notoria la tasa de mortalidad temprana por falla hepática después de hepatectomía mediante la determinación de los límites de resección sobre la base del índice de flujo hepático en el hígado residual. En los animales en que se usó nuestro método se encontró que el índice de flujo hepático no fue influenciado por la función del sistema reticulo-endotelial y se consideró que era un indicador confiable de flujo sanguíneo en los sinusoides hepáticos.

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Résumé Le flux sanguin au niveau du foie restant après hépatectomie majeure est considéré comme un facteur essentiel du maintien de la fonction hépatique. Les auteurs ont imaginé une méthode qui permet de quantifier le flux portal ou régional à partir de la clairance du Au¹⁹⁸ ce qui permet d'apprécier avant l'intervention l'importance du flux au niveau du foie susceptible d'Être conservé et ainsi de prévenir la défaillance hépatique postopératoire qui pourrait Être déterminée par une hépatectomie trop large. La résection hépatique a été suivie d'une réduction de l'indicateur du flux portal (K^LAu) presque proportionnelle à l'importance de la masse du parenchyme hépatique réséqué. Une analyse des données fournies par l'étude de 34 cas d'hépatectomie a montré une bonne corrélation entre la valeur de l'indicateur qui avait été envisagé avant l'intervention et celui qui a été constaté après l'opération (r=0.9). De mÊme il a été constaté une relation directe entre le taux des décès dus à la défaillance hépatique postopératoire et la valeur de l'indicateur du flux portal lorsque celle-ci se situait au-dessous du seuil critique. Depuis 1981 le taux de la mort précoce par défaillance hépatique aiguË postopératoire a été remarquablement réduit en se fiant à la détermination préalable du flux portal au niveau du segment de foie susceptible d'Être laissé en place. Au cours de l'expérimentation animale employant la méthode originale décrite par les auteurs il a été constaté que l'index du flux portal est indépendant de la fonction du RES mais qu'il représente le flux sanguin au niveau des sinusoÏdes.

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Presented at the 8th World Congress of Collegium Internationale Chirurgiae Digestivae in Amsterdam, The Netherlands, September 1984.     

Ciliated hepatic foregut cyst of the left hepatic vein

Ciliated hepatic foregut cyst is an extremely rare condition observed most frequently in the left hepatic lobe of young men. This report describes an unusual case of ciliated hepatic foregut cyst with involvement of the left hepatic vein in a 68-year-old woman. Preoperative imaging studies demonstrated characteristics of a solid tumor that were suggestive of a leiomyosarcoma of the inferior vena cava. Magnetic resonance venography confirmed a mass in the anterolateral wall of the inferior vena cava or in the left hepatic vein. This report confirms the unusual occurrence of this tumor and the confusing factors related to the diagnostic workup.