心、肺联合移植一例报告

目的对1例心、肺联合移植术进行总结分析。方法对1例患先天性心脏病、室间隔缺损合并艾森曼格综合征者施行同种异体原位心、肺联合移植术,手术在中低温、体外循环下进行。术后对受者进行密切监护,积极防治排斥反应和感染。结果术中体外循环时间240min,升主动脉阻断时间125min;患者术后第7、203d发生移植肺急性排斥反应,第177、228d发生移植心急性排斥反应,均经治疗逆转;第9d发生肺部及胸腔感染,经抗感染治疗痊愈;第265d发生肺部毛霉菌感染,经两性霉素B治疗后症状控制;目前受者的心功能为Ⅰ级,超声心动图提示心脏结构及瓣膜功能基本正常,肺部感染的临床表现基本消失,生活自理。结论良好的心肺保护、细致的外科操作和正确的围手术期处理是心、肺联合移植成功的关键。     

胰肾联合移植术后并发症的防治(附四例报告)

目的探讨肠腔引流式胰肾联合移植术后并发症的防治。方法对4例胰肾联合移植的患者,通过完善术前准备,术后加强抗感染、抗凝,抑制胰液分泌,合理使用免疫抑制剂,密切观察病情变化等措施来防止并发症的发生、发展;对出现的并发症及时地采用相应的治疗措施。结果4例患者中并发巨细胞病毒性肺炎1例、急性排斥反应3例、慢性排斥反应1例,血栓形成1例,1例因肺部感染、呼吸功能衰竭于术后23d死亡,1例移植肾因慢性排斥失功能,其余并发症均治愈。结论术后并发症严重影响着胰肾联合移植的效果,胰肾联合移植术后各种并发症的防治关键在于早期预防、早期诊断、合理治疗。     

体外循环下单肺移植一例的体会与教训

目的 总结体外循环下单肺移植的经验和教训。方法 在体外循环下给１例终末期双肺纤维化患者施行左侧单肺移植术,供肺采用Ｅｕｒｏ－Ｃｏｌｌｉｎｓ液灌洗,管道吻合时间为５５ｍｉｎ。术后联合应用环孢素Ａ、激素及硫唑嘌呤进行免疫抑制治疗。结果 移植肺术后即刻发挥功能,术后第１、２ｄ因出血致心脏压塞,２次剖胸止血,第３、７ｄ发生急性排斥反应,第９ｄ死于急性排斥反应。结论 肺移植术后应注重出血及急性排斥反应的监测     

人体右侧单肺移植围术期处理一例

探讨肺移植术的围术期处理，提高肺移植患者的生存率。方法对慢性阻塞性肺病（ＣＯＰＤ）合并右上肺癌（Ｔ１Ｎ０Ｍ０）患者施行了右侧单肺移植。结果患者术后恢复顺利，３天后经口进食，７天后能在室内步行３００～５００米。术后第９天和２１天发生两次急性排斥反应，均采用甲基强的松龙冲击治疗后好转。术后４８天死于肺部感染与多器官功能衰竭。结论肺移植术围术期处理对患者肺移植后的近、远期疗效起着重要的作用     

肺移植急性排斥反应的诊治(附三例报告)

目的观察和探讨肺移植急性排斥反应的临床表现、诊断方法、经支气管活检排斥反应的病理分类和治疗。方法2002年9月至2003年6月，分别为3例肺气肿、肺功能重度减损的患者进行了单肺移植。其中后2例为同一供者的左、右肺，第2例受者HLA无1个位点匹配。结果第1例左肺移植术后第9d发生1次急性排斥(A2b级)，经大剂量甲泼尼龙冲击治疗后症状消退；第2例右肺移植第7d持续发生急性排斥(A4c级)，经甲泼尼龙冲击并用OKT3治疗无效，术后第15d死亡；第3例左肺移植第9d、第15d发生2次急性排斥(A3a级)，经甲泼尼龙冲击并用OKT3治疗8d后缓解。结论选择组织相容性好的供、受者进行肺移植，是成功的保证。肺组织活检成为诊断急性排斥的金标准，对肺移植急性排斥反应的及时诊治是减少术后死亡率的关键。     

23例次肺移植术后受者的临床分析

目的 评估23例次肺移植术后受者的临床预后情况.方法 总结2003年1月至2007年8月施行的23例次(21例患者)肺移植的临床资料.分析存活率及并发症.结果 肺移植围手术期死亡率为13%;术后3个月、1年、2年和3年的累积存活率分别为82.6%、82.6%、69.7%和58.1%.受者术后2个月时的通气和换气功能较术前明显改善(P<0.05).有10例受者术后6个月内出现轻度急性排斥反应,经激素冲击治疗后均缓解.4例受者分别于术后8个月、9个月、14个月和24个月时出现慢性排斥反应;术后6、12和24个月时未发牛慢性排斥反应的受者分别为95%、78.2%和71.1%.术后肺部感染发生率为33.3%;气管吻合口软化和狭窄发生率为14.3%.结论 肺移植术后受者的中期存活率较高;肺部感染和支气管吻合口软化及狭窄是肺移植术后主要并发症.     

肺移植术后免疫治疗方案的探讨

目的总结肺移植术后急性排斥反应的诊断和治疗,探讨优化的免疫抑制方案对提高肺移植术后排斥反应的疗效。方法2002年11月至2006年6月,行肺移植手术16例,其中单肺移植7例、双肺移植9例,免疫抑制方案采用他克莫司（FK506）、霉酚酸酯（骁悉）和泼尼松为主的新三联和（或）辅以赛尼哌治疗。结果本组中除早期2例双肺移植术中因出现严重的肺水肿和早期移植肺失功能死亡外,其余14例手术成功,术后急性排斥反应发生率为21．4％（3／14）。应用赛尼哌辅助方案的8例患者术后6个月内无移植后急性排斥反应。在三联方案的6例中,术后有3例出现急性排斥反应。结论他克莫司、骁悉和泼尼松为主的新三联和（或）辅以赛尼哌治疗方案,在预防肺移植后患者早期急性排斥反应有较好疗效。     

原位心脏移植术后14例死亡病例分析

目的探讨心脏移植术后死亡的相关因素及其防治措施。方法对14例死亡患者的基本情况和死亡原因进行回顾性分析。结果8例死于术后1个月,5例死于术后17周至4年,1例心、肾联合移植患者死于术后38d。死于右心衰竭者4例,肺部感染者5例(合并真菌感染者3例),急性排斥反应者4例,急性肾功能衰竭者4例,心律失常者4例,成人呼吸窘迫综合征者2例,糖尿病者2例。8例患者术后死亡与多种因素有关。结论心脏移植术后患者死亡与多种因素有关。选择合适的受者,术前、术后及时发现和处理各种并发症,是降低心脏移植术后患者死亡率的关键。     

体外循环序贯式双肺移植术治疗肺纤维化一例

目的 总结体外循环（CPB）下序贯式双肺移植手术及围手术期处理的经验。方法 对1例双肺弥漫性间质纤维化伴感染的患者在CPB下行序贯式双肺移植术。术中采用游离肋间肌包埋支气管吻合口，术后用他克莫司、吗替麦考酚酯、强的松三联药物抗排斥反应。结果 患者术毕送层流病房，34h恢复自主呼吸。术后22d出现带状疱疹；26d出现右腹股沟压痛，右下肢深静脉栓塞，经治疗后恢复正常；术后65d做纤维支气管镜检查吻合口通畅。随访3个月，患者生活质量良好。结论 在CPB下行序贯式双肺移植具有整体双肺移植、改善肺功能等优点；用游离带蒂肋间肌包裹支气管吻合口是预防并发症发生的有效方法。他克莫司、吗替麦考酚酯、强的松三联药物抗排斥反应效果肯定。     

肺移植术后肺部菌群研究进展

肺移植是终末期肺痰病患者唯一有效的治疗手段, 但肺移植受者的长期存活率仍较低。随着细菌16s核糖体小亚基RNA(rRNA)基因测序、高通量测序技术的发展, 呼吸道样本中微生物的相对丰度得以量化, 潜在病原体和共生环境也得以识别, 揭示了健康肺部存在丰富的菌群。越来越多的证据表明, 肺部菌群不仅可以调节肺部免疫稳态, 而且在多种呼吸系统疾病的发生与发展中起重要作用。肺移植受者的肺部菌群有异于健康人群, 并与其术后并发症及预后相关。本文对近年来国际上关于肺移植受者的肺部菌群特点及其与肺部感染、慢性排斥反应的关系进行综述, 以期为肺移植术后并发症的发生与诊治提供新的思路。     

单肺移植同期行心内缺损修补术一例

目的探讨同种异体单肺移植同期行心内缺损修补治疗先天性心脏病室间隔缺损并艾森曼格综合征的可行性及围手术期的处理。方法2004年10月22日为1例先天性心脏病室间隔缺损合并艾森曼格综合征的患者在全麻低温体外循环下行右侧单肺移植，同期行室间隔缺损修补术。术中体外循环时间244min，供肺冷缺血时间6h。术后用他克莫司、霉酚酸酯和激素三联免疫抑制治疗。结果术后3d内移植肺出现中等度移植反应性肺水肿，术后7d气管切开，术后12d撤离呼吸机；术后14d出现急性排斥1次，治疗后缓解。术后肺动脉压力由术前的110／60mmHg降到53／39mmHg。术后30d胸片及胸部CT显示右侧移植肺清晰；肺通气／血流灌注扫描示右侧移植肺血流占90％；超声心动图检查示左心室内径较术前缩小17％，室间隔缺损修补完整，无残余分流；术后活动耐力明显改善，62d出院。结论对终末期左向右分流的先天性心脏病实施同种异体单肺移植的同期行心内畸形矫治是可行的。良好的供肺切取和保护以及完善的术后处理是成功的关键。     

Surgical management of heart-lung transplantation

Using cyclosporin A, long-term survival after heart-lung transplantation became possible. The drug blocks the immune system more selectively and leaves the tracheal wound healing unimpaired. Since 1981, 501 clinical cases have been collected by the registry of the International Society for Heart Transplantation. Candidates for heart-lung transplantation reveal signs of irreversible heart and lung diseases that may have been caused by cardiac lesions (valvular diseases, Eisenmenger reaction due to congenital malformations) or by pulmonic disorders (primary pulmonary hypertension, emphysema, fibrosis). The standard surgical procedure, which combines donor and recipient tracheas, right atria, and aortas, makes three anastomoses necessary. Immunosuppressive regimen includes cyclosporin A (blood trough levels of 300 to 500 ng/mL), azathioprine (1 to 2 mg/kg), and rabbit antithymocyte globulin (1 to 4 mg immunoglobulin G/kg). After the first two postoperative weeks, rabbit antithymocyte globulin is replaced by methylprednisolone (0.3 to 0.1 mg/kg; 500 mg are given intravenously after opening the aortic cross-clamp; 3 x 125 mg on postoperative day 1). After heart-lung transplantation an extreme variety of problems may evolve. Early postoperative complications (within the first postoperative month) comprise acute isolated lung rejection, multiorgan failure, and bacterial pneumonia. Diagnosis of acute lung rejection proves difficult; it includes clinical signs, chest radiographic appearances, and cytoimmunological monitoring. Transbronchial lung biopsies are of similar value for precise diagnosis as are endomyocardial specimens after heart transplantation. Late postoperative complications (after 1 postoperative month) comprise viral pneumonia, fungal infection, tuberculosis, and chronic obliterative bronchiolitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Airway complications after double lung transplantation. Toronto Lung Transplant Group

We have had success with en bloc double lung transplantation in the management of selected patients with end-stage parenchymal pulmonary disease. Airway complications have been more prevalent in our own experience with double lung transplantation than in reports of combined heart-lung transplantation from other centers. Between November 1986 and March 1989, 16 patients underwent double lung transplantation. Allografts were preserved by topical hypothermic immersion in 12 patients and by pulmonary artery flush with cold crystalloid solution in the most recent four patients. Thirteen patients underwent tracheal anastomosis and the most recent three patients underwent bilateral bronchial anastomoses. Fatal ischemic necrosis of the donor trachea and both main bronchi developed in three patients. Preterminal airway ischemia developed in a patient who had systemic sepsis. Partial anastomotic dehiscence, which went on to form fibrous strictures necessitating endoscopic placement of silicone rubber airway stents, developed in two additional patients. Two other patients had late strictures and required subsequent placement of bifurcation stents. There was no relationship between development of airway complications and gas exchange in the donor lungs, lung ischemic time, early postoperative gas exchange, early postoperative mean pulmonary artery pressure, or frequency of early postoperative rejection. Severe postoperative hypotension occurred in five of eight patients with airway complications and in three of eight patients without airway complications.     

单肺移植术治疗终末期肺疾病11例

目的总结单肺移植治疗终末期肺病的早期临床结果和经验。方法2003年1月至2005年9月，为11例终末期肺疾病患者施行了单肺移植术，其中右侧单肺移植7例，左侧单肺移植4例。有2例受者接受同一供者的左、右肺。结果目前有6例单肺移植受者术后生存1年以上，其中3例存活2年以上；3例存活6个月以上。9例存活的受者生活均能自理，活动良好。术后2个月肺功能复查：动脉血氧分压（PaO2）均〉80mmHg，较术前提高37．6％；有8例受者第1秒用力呼气量（FEV1）较术前提高165．2％。2例死亡的受者中，1例因术中大出血死亡；1例淋巴管平滑肌瘤受者术后3个月后死于顽固性乳糜胸。受者术后急性排斥反应平均发生率为1．2次；4例术后并发曲霉菌感染；3例术后出现支气管狭窄；2例术后并发严重肺部感染；1例术后36h出现缺血／再灌注损伤；1例术后7d并发胃底黏膜撕脱继发上消化道大出血；1例术后1年出现慢性排斥反应。结论单肺移植是治疗终末期肺疾病的有效方法。肺移植术后并发症发生率高，应进行有效的预防和治疗。     

Successful Liver Transplantation in a Patient With Quadriparesis: A Case Report

Major abdominal surgeries, including liver transplantation, are considered high-risk procedures for patients with respiratory muscle dysfunction, such as patients with quadriparesis, due to possible fatal postoperative pulmonary complications. We report on a 57-year-old male patient with longstanding quadriparesis due to fifth cervical spine injury from a traffic accident who suffered from decompensated liver cirrhosis related to hepatitis C infection and hepatocellular carcinoma. A preoperative pulmonary function test showed forced expiratory volume in 1 minute (FEV₁) 1.06 L, which was a risk for pulmonary complications. The patient required respiratory training. Cadaveric liver transplantation was performed successfully without surgical complications. The patient was extubated on the fourth day after surgery and initially did well. However, on the eighth postoperative day, an episode of status epilepticus from metabolic derangement developed. After controlling seizure with anticonvulsive medication and sedation, the patient was reintubated due to hypoventilation. Chest radiograph showed upper lung atelectasis. Due to this complication, tracheostomy was performed. The patient's condition gradually improved. He was ultimately discharged on the 45th postoperative day. Two months after the transplantation, liver functions were normal and the patient could breathe spontaneously without tracheostomy and had good quality of life. In conclusion, this is, to our knowledge, the first report of liver transplantation in a patient with quadriparesis. It shows that even with a very high risk for postoperative pulmonary complications, liver transplantation can be performed successfully with careful patient selection and effective respiratory care.     

Roentogenologic pathologic evaluation of allograft rejection in heart-lung transplantation--an experimental study in Japanese monkey

Experimental heart-lung transplantation was carried out in Japanese Monkey (Macaca fuscata). Twelve monkeys survived two to thirty-three days. Pathologic examination of the lung was performed at the time of open lung biopsy and autopsy. Postoperative chest roentogenogram was also studied in seven monkeys. In the early postoperative period, central cloudiness and enhancement of the interstitial change were observed, which started from the second or third postoperative day and reached their peak between the fifth and eighth postoperative day. Pathological study revealed no obvious monocyte infiltration in the lung of this stage. Two types of pulmonary rejection were observed, one is alveolar and vascular rejection. The other is vascular type of rejection, which started as early as in the twelfth postoperative day in a case. In the former, consolidation of the lung was noticed and useful in the diagnosis, but in the latter, no distinct change was observed in plain chest roentogenogram.     

肝或肾移植术后受者再次行一期肝肾联合移植三例报告

目的 探讨肝或肾移植术后受者再次行一期肝肾联合移植的手术适应证、术后并发症及存活情况.方法 对2003年10月至2008年12月施行的3例肝或肾移植术后再次行一期肝肾联合移植的受者进行随访,并进行文献复习.对其围手术期死亡率、术后并发症及存活情况进行总结.结果 围手术期死亡率为33.3%(1/3).术后并发症:1例因腹腔出血术后第29天死于肺部感染、急性移植肾功能衰竭和多器官功能衰竭;3例患者均发生了肺部感染;无急性排斥反应发生.2例存活患者,从首次移植计算,已经分别存活56个月和228个月;从一期肝肾联合移植计算,已经分别存活40个月和48个月.结论 肝肾联合移植是治疗终末期肝肾疾病的有效方法.肝或肾移植术后受者再次行一期肝肾联合移植是可行的.     

Histologic studies on canine lung transplantation

Histologic and functional investigation on lung allotransplantation was performed in 26 mongrel dogs divided into major two groups. In Group A left lung allotransplantation was carried out. These dogs were followed by administration of Cyclosporin A and Azathioprine. In dogs of Group B left lung allotransplantation and postoperative measurement of pulmonary artery (PA) pressure by contralateral PA occlusion test using modified Swan-Ganz catheter were performed. This group was subdivided into 4 groups; Group B-I: 6 hours preservation of donor's lung and administration of Cyclosporin A and Azathioprine. Group B-II: no preservation of donor's lung and administration of Cyclosporin A and Azathioprine. Group B-III: Group B-II + steroid and Group B-IV: Group B-I + steroid. In many dogs the prolongation of occurrence of acute rejection was observed Cyclosporin A. In Group A the fibrotic changes around the blood vessel and/or bronchus were detected occasionally. The appearance and desquamation of atypical type II cells were present in a few dogs. In Group B the characteristic features of acute rejection were observed. Histologic differences between groups of immediate transplantation (B-II & III) and groups with preserved lung for 6 hours (B-I & IV) were not demonstrated. There was no definite case of so-called "alveolar rejection". The mean-PA pressure of Group B rose up just after the transplantation in every dog. On postoperative 7th day the PA pressure after the right PA occlusion decreased, however it elevated again on 14th day except one dog, because of the diffuse mononuclear cell cuffing around blood vessel walls. We believe that this test is an useful examination for the evaluation of occurrence and intensity of rejection.