猪到猕猴异种心脏异位移植术的手术配合

目的：介绍猪到猕猴异位心脏移植的手术配合方法。方法：选用猪到猕猴为移植模型，配合完成异位心脏移植术21例。结果：异种移植手术受体猕猴平均存活11d，手术成功率70％。结论：要确保猕猴异种移植手术成功，除了常规方法外，充分的术前准备、术中配合是异种移植手术成功的重要环节。     

辅助性异位肝脏移植临床研究现况

目的总结辅助性异位肝脏移植在临床的应用现状。方法复习相关文献资料并作综述,总结辅助性异位肝脏移植的适应证、禁忌证、手术方式、治疗效果、存在的问题等。结果辅助性异位肝脏移植的适应证主要是暴发型肝脏功能衰竭,无绝对禁忌证,目前采用较多的是部分肝脏移植。辅助性异位肝脏移植的治疗效果已得到肯定,但仍存在一些问题。结论辅助性异位肝脏移植是治疗急、慢性肝脏功能衰竭的一种有效的方法及补充疗法。     

Heterotopic Ossification: Diagnosis and Management Current Concepts and Controversies

Abstract

Context

The user interface development of assistive robotic manipulators can be traced back to the 1960s. Studies include kinematic designs, cost-efficiency, user experience involvements, and performance evaluation. This paper is to review studies conducted with clinical trials using activities of daily living (ADLs) tasks to evaluate performance categorized using the International Classification of Functioning, Disability, and Health (ICF) frameworks, in order to give the scope of current research and provide suggestions for future studies.

Methods

We conducted a literature search of assistive robotic manipulators from 1970 to 2012 in PubMed, Google Scholar, and University of Pittsburgh Library System – PITTCat.

Results

Twenty relevant studies were identified.

Conclusion

Studies were separated into two broad categories: user task preferences and user-interface performance measurements of commercialized and developing assistive robotic manipulators. The outcome measures and ICF codes associated with the performance evaluations are reported. Suggestions for the future studies include (1) standardized ADL tasks for the quantitative and qualitative evaluation of task efficiency and performance to build comparable measures between research groups, (2) studies relevant to the tasks from user priority lists and ICF codes, and (3) appropriate clinical functional assessment tests with consideration of constraints in assistive robotic manipulator user interfaces. In addition, these outcome measures will help physicians and therapists build standardized tools while prescribing and assessing assistive robotic manipulators.     

“Left at Right” Adult Liver Transplantation: The Feasibility of Heterotopic Implantation of Left Liver Graft

Left liver grafts have been widely utilized in adult liver transplantation (LT) and yielded acceptable results. However, the conventional orthotopic implantation of a left liver graft imposes the potential risk of perioperative vascular complications. We report herein an alternative modified technique for adult left liver LT and evaluate its feasibility in LT. In this study, 10 recipients had their left liver graft rotated 180°, and heterotopically implanted at the right subphrenic space, which we termed “left at right” liver transplantation (LAR‐LT). The sequence of vascular and biliary reconstruction was performed as standard techniques, and no perioperative vascular complications related to LAR‐LT were encountered. There were two mortalities in this series, one due to a small‐for‐size graft dysfunction and the other due to postoperative internal hemorrhage. Two recipients had biliary strictures that were successfully managed by percutaneous biliary dilatation and Roux‐en‐Y hepaticojejunostomy. The clinical characteristics and outcomes of patients undergoing LAR‐LT were also compared with patients undergoing conventional orthotopic left liver LT (n = 14). Although the results showed no significant difference between the two groups, according to our experience, the satisfactory outcome and easier technical reconstruction suggest that the LAR‐LT modification could be a feasible alternative to left liver LT.     

小鼠-大鼠异位心脏移植的手术技巧及并发症的预防

目的改进小鼠-大鼠异位心脏移植的手术方式,总结手术技巧及并发症的预防方法.方法颈部套袖法建立NIH小鼠-Wistar大鼠异种异位心脏移植模型160只.改进麻醉方式为多次注射逐量增加及手术技巧,并对手术并发症进行分析.结果常规组和改进组手术成功率分别为55%(22/40)及84.17%(101/120).改进组总手术时间(65.31±4.56)min,取供体时间(7.75±2.21)min,分别短于常规组的(115.25±30.20)min和(15.74±5.54)min(P＜0.01).手术并发症主要为出血15例、供体保护不佳9例、麻醉意外9例及保暖不当6例.改进后的失血量为(0.32±0.17)ml明显低于改进的(0.82±0.24)ml(P＜0.01).结论手术技巧改进后手术时间短,出血少,手术成功率高.出血、供体保护不佳、麻醉意外及保暖不当是手术失败的主要原因.娴熟的显微外科技术和耐心细致的手术操作是成功的基本保证.     

西洋参二醇组皂甙对鼠心异位移植后心肌缺血再灌注损伤的保护作用

目的：了解西洋参二醇组皂甙（ＰＱＳ）作为心脏停搏液的添加剂对鼠心异位移植后心肌缺血再灌注损伤的保护作用。方法：以鼠心腹部异位移植模型为研究手段,以心肌细胞内钙含量及受体鼠血清中ＣＫ、ＣＫＭＢ活力为观察指标,以Ｓｔ．ＴｈｏｍａｓⅡ号心脏停搏液为对照组。结果：ＰＱＳ可降低移植心脏心肌细胞内钙含量,降低受体鼠血清中ＣＫ、ＣＫＭＢ活力。结论：ＰＱＳ抗缺血再灌注损伤的机理为钙拮抗剂样作用。     

原位心脏移植一例围手术期处理

１９９４年７月我们成功地完成了１例同种原位心脏移植，术后病人存活至今，并恢复了正常生活，现将围手术期的监测、治疗等处理作一简介，并回顾体会该病人围手术期处理与术后较顺利的可能关系，为进一步把好心脏移植病人围手术期这第一关总结经验。     

干细胞移植与心脏生物起搏

干细胞是一类具有高度自我复制和多向分化潜能的细胞,特定条件下干细胞可分化成具有自律性和传导性的细胞。心脏生物起搏即利用生物学及其相关技术,修复或替代受损的自律性节律点和/或特殊传导系统,使心脏的起搏和传导功能得以恢复。干细胞移植心脏生物起搏即诱导干细胞分化成具有起搏和传导功能的细胞,重建心脏的起搏和传导功能。研究干细胞移植实现心脏生物起搏,治疗缓慢型心律失常已成为研究热点。     

二例原位心脏移植成功的围术期处理

目的总结２例原位心脏移植成功的围术期处理经验，探讨供心保护、免疫抑制剂应用、早期诊治急性排斥反应、预防右心功能不全、抗感染和营养支持等问题。方法１９９５年８月和１９９７年４月先后为２例终末期扩张型心肌病患者施行了原位心脏移植术。术后免疫抑制剂应用环孢素Ａ（ＣｙｃｌｏｓｐｏｒｉｎＡ）、硫唑嘌呤（Ａｚａｔｈｉｏｐｒｉｎｅ）、强的松（Ｐｒｅｄｎｉｓｏｎｅ）三联疗法。结果２例患者目前已分别存活３年和１年半，心功能正常、生活质量良好。结论围术期的处理是否得当是术后早期顺利康复的关键，亦直接影响着手术患者的存活率     

First Experience with de novo Calcineurin-Inhibitor-Free Immunosuppression Following Cardiac Transplantation

The aim of this pilot study was to investigate whether de novo calcineurin-inhibitor-free immunosuppression after cardiac transplantation is efficacious and can prevent post-operative renal impairment. Eight patients were treated by combining trough level adjusted sirolimus and mycophenolate mofetil; corticosteroids were given for the first 6 post-operative months only. Survival data, acute rejection episodes and adverse events with a special emphasis on renal impairment, myelosuppression, hypercholesterolemia, hypertriglyceridemia and infections, were recorded. With a follow-up of 3–12 months, patient survival was 100% and freedom from rejection 75%. The mean creatinine levels initially decreased and remained stable thereafter. A moderate myelosuppressive effect did not necessitate dose reduction of immunosuppressants, intermittently elevated cholesterol- and triglyceride levels decreased over time. Most frequent adverse events were pericardial effusions and peripheral edema. Complete abandonment of calcineurin inhibitor therapy by de novo use of the combination sirolimus/mycophenolate mofetil resulted in low rejection rate and avoidance of renal impairment, but should not be used without further evaluation of potential complications in a lager setting.     

Multicenter Experience of ABO-Incompatible Pediatric Cardiac Transplantation

Although ABO blood group incompatible cardiac transplantation in neonates and infants reduces waiting list mortality without compromising outcome, the technique has not been adopted by all centers, and to date Toronto remains the only center to have published results from a large case series. We present a review of ABO-incompatible heart transplantation in the United Kingdom (UK) where current recipient selection criteria differ somewhat from those used in the United States (US) and Canada. Between February 2000 and November 2006, 21 ABO-incompatible cardiac transplants were performed in children aged 2–40 months (median 10.0). Immunosuppression followed standard regimens. Pretransplant donor-specific isohemagglutinins of >1:4, (the UNOS cutoff), were present in five patients and reduced by plasma exchange. After transplantation, 19/21 recipients demonstrated persisting deficiency of donor-specific isohemagglutinins. Significant donor-specific isohemagglutinins levels were detected repeatedly in 2/21 recipients who have shown no clinical or biopsy evidence of rejection. All recipients survive without retransplantation and there have been no episodes of humoral rejection. We conclude it is possible for other centers to replicate the excellent results achieved in Toronto and that ABO-incompatible transplantation may be performed successfully in some patients beyond infancy with established isohemagglutinin production providing preoperative antibody removing strategies are used.     

Kidney Transplantation from Donors after Cardiac Death: Uncontrolled versus Controlled Donation

Kidney donation after cardiac death has been popularized over the last decade. The majority of these kidneys are from controlled donors. The number of organs for transplantation can be further increased by uncontrolled donors after cardiac death. The outcome of uncontrolled compared to controlled donor kidney transplantation is relatively unknown. We compared the long‐term outcome of kidney transplantation from uncontrolled (n = 128) and controlled (n = 208) donor kidneys procured in the Maastricht region from January 1, 1981 until January 1, 2008, and transplanted in the Eurotransplant region. The incidence of primary nonfunction and delayed graft function in both uncontrolled and controlled donor kidneys is relatively high (22% vs. 21%, and 61% vs. 56%, p = 0.43, respectively). Ten‐year graft and recipient survival are similar in both groups (50% vs. 46%, p = 0.74 and 61% vs. 60%, p = 0.76, respectively). Estimated glomerular filtration rates 1 year after transplantation are 40 ± 16 versus 42 ± 19 mL/min/1.73 m², p = 0.55, with a yearly decline thereafter of 0.67 ± 3 versus 0.70 ± 7 mL/min/1.73 m²/year, p = 0.97. The outcome of kidney transplantation from uncontrolled and controlled donors after cardiac death is equivalent. This justifies the expansion of the donor pool with uncontrolled donors to reduce the still growing waiting list for renal transplantation, and may stimulate the implementation of uncontrolled kidney donation programs.     

Minimally Invasive Cardiac Surgery: Current Status and Perspective

Recently, the minimally invasive approach has become a growing aspect in the field of cardiac surgery with the goal of eliminating cardiopulmonary bypass (CPB) and/or median sternotomy. In coronary bypass surgery, the application of this approach is direct anastomosis, primarily of the left internal thoracic artery to the left descending coronary artery under a beating condition without the use of CPB through a small left thoracotomy minimally invasive direct coronary artery bypass (MIDCAB). In the repair of intracardiac lesions, CPB cannot be excluded, but a small right parasternal incision or small partial sternotomy (ministernotomy) has been applied for congenital defects and mitral and aortic valve lesions. With technological advances in CPB, these approaches may become more popular in the near future.     

An Extraperitoneal Technique for Murine Heterotopic Cardiac Transplantation

The mouse heterotopic cardiac transplantation model has been used extensively by investigators in the field of organ transplantation to study the rejection process, test new antirejection treatments, tolerance induction protocols or to understand basic immunological principles. Due to its extensive use, any small refinement of the technique would have a major impact on replacement, reduction and refinement (commonly known as the 3Rs). Here, we describe a novel approach to refine this model. The donor aorta and pulmonary artery are anastomosed peripherally to the femoral artery and vein of the recipient, respectively. The technical success rate is comparable to the conventional abdominal site, but it avoids a laparotomy and handling of the bowels making it less invasive method. As a result, recipients recover faster and require less postoperative analgesia. It is a major refinement under one of the 3Rs and would represent an advance in animal welfare in scientific research.     

Improved Outcomes of Renal Transplantation from Cardiac Death Donors: A 30-Year Single Center Experience

Outcomes of renal transplantation from donation after cardiac death (DCD) donors over 30 years were analyzed. Between 1975 and 2004, 256 renal transplantations from DCD donors were performed. The recipients were divided into four groups according to a time period as follows: 1975-1979 (Group 1; n = 18), 1980-1989 (Group 2; n = 81), 1990-1999 (Group 3; n = 84) and 2000-2004 (Group 4; n = 73). Of the 256 transplanted kidneys from DCD donors, 38 (15%) functioned immediately after transplantation. The incidence of delayed graft function (DGF) was 72%. Warm ischemic time and total ischemic time were 7.4 +/- 9.4 min and 11.9 +/- 5.6 h, respectively. The overall graft survival rates at 1, 5 and 10 years were 80%, 72% and 53%, respectively. Graft survival rates in each group have continually improved over time (5-year graft survival; 23% vs. 64% vs. 74% vs. 91%, respectively). However, there was no significant difference in graft survival rates between the groups of patients who survived with a functioning graft for more than 1 year. A multivariate Cox regression analysis showed acute rejection and donor age to be independently associated with graft outcome. DCD donors are a valuable source of kidneys for transplantation with promising long-term outcomes.     

DCD供肾肾移植及免疫诱导的单中心经验总结

目的探讨DCD捐献肾脏移植的经验及免疫诱导的临床效果观察。方法分析本院于2011年12月至2013年12月完成的40例DCD捐献肾移植患者的临床资料,根据免疫诱导药物的不同,分为舒莱组(10例)、ATG组(15例)和ATG-F组(15例)。结果 40例患者中除3例出现DGF外,其余患者术后血肌酐均平稳下降,恢复正常;3组患者中均有1例发生DGF,ATG组发生急排1例,其余组无急排发生;所有组均无原发肾无功能发生;CMV发生率:舒莱组4例(40%),ATG组10例(71%),ATG-F组11例(73%);ATG组发生肺部感染1例,其余组均无肺炎发生;ATG、ATG-F组分别有5、6例出现血小板及血红蛋白下降,无其他不良反应;除ATG组肺炎患者死亡外,其余均带功存活;术后恢复正常的肾脏病理表现为肾小球及肾小管结构清晰,而DGF的活检病理表现为肾小管肿胀,部分肾小管变性坏死。结论 DCD是解决我国器官移植界瓶颈的重要手段,中国三类(DBCD)是较理想的DCD供者。免疫诱导能够有效预防急性排斥的发生,但可引起机体广泛抑制,导致潜伏的CMV复活;取肾过程中尽量缩短热缺血时间,DGF发生率较低。供肾零点活检应该成为DCD供肾肾脏移植的常规检查项目,但慎重决定取舍。     

Heart Transplantation:

The gap between the number of potential recipients of a cardiac graft and the availability of donor hearts is still growing. A proper selection of heart transplant candidates is mandatory to ensure that patients in critical need, who are likely to benefit from this procedure, are identified. The work-up of a patient with terminal chronic heart failure includes a comprehensive cardiac and systemic evaluation. Critical in the decision is the exclusion of irreversible pulmonary hypertension. Furthermore, underlying diseases that could compromise short-and long-term prognosis after transplantation should be carefully assessed. The mortality on the waiting list and the growing pool of patients with chronic heart failure that is excluded from transplantation has stimulated the search for alternative treatment modalities. Besides a pharmacologic approach, the last few years have witnessed a tremendous evolution in so-called mechanical devices, designed to improve both morbidity and mortality of these patients. Although several of these devices have only just entered the clinical phase, internal cardioverter defibrillators, left ventricular assist devices and biventricular pacemakers can no longer be viewed as experimental tools.     

FK506和供体特异性输血在大鼠异位心脏移植中的作用

目的探讨FK506和供体特异性输血在大鼠异位心脏移植中的作用。方法利用大鼠异位心脏移植模型以了解在移植当天或移植术后第4日进行供者特异性输注（DST）的基础上,应用FK506能否延长移植物的存活。结果在移植当天行DST或单独用FK5061mg／kg连续10天,可将移植心中位存活时间从对照组的5天分别有效延长至7天和11天,而FK506与DST联合应用时并不产生增强效应。结论FK506和DST单独应用时虽均能延长大鼠同种移植心存活,但是它们没有协同作用。     

Human Heart Transplantation: Current Status

The overall survival rate for 97 heart transplant recipients operated on from 1968 to 1975 has been 49% at one year and 23% at five years. Progressive improvement in one-year survival has been achieved, from 22% in 1968 to 62% in 1974. The major factors responsible for increasing survival are better understanding and management of acute and chronic rejection. Current results suggest that heart transplantation deserves wider application in the treatment of selected patients with end-stage myocardial insufficiency.