肝移植术后神经精神系统并发症的预防和治疗

目的 探讨原位肝移植术后神经精神系统并发症的预防和治疗。方法 对2004年1月至2006年12月中山大学附属第一医院施行的516例同种原位肝移植病人神经精神系统并发症的临床资料进行回顾性分析。结果 全组神经精神系统并发症83例（16.1%）,其中弥漫性脑病67例（13.0%）,脑血管意外8例（1.6%）,癫痫发作7例（1.4%）,脑桥中央髓鞘溶解症2例（0.4%）,中枢神经系统感染2例（0.4%）,部分病例合并两种以上并发症,包括7例癫痫发作中,3例合并颅内出血。分别采取了病因治疗和对症处理相结合的综合防治措施,其中有7例脑病病人给与持续的人工肝替代治疗,2例颅内出血病人施行了开颅血肿清除术。83例病人中,死亡12例,与术后神经精神系统并发症相关病死率为14.5%（12/83）。结论 肝移植术后神经精神系统并发症发生率较高,临床表现形式多样;颅内出血和中枢神经系统感染的发生多提示预后不良;重视围手术期的预防,及时采取针对病因的综合治疗和调整免疫抑制药物可降低病死率。     

Pretransplant left ventricular hypertrophy in association with postoperative myocardial injury in liver transplantation

Pretransplant left ventricular hypertrophy (LVH) is a common finding during preoperative cardiac evaluation. We hypothesized that patients with pretransplant LVH were associated with a higher risk of postoperative myocardial injury (PMI) in adult patients undergoing liver transplantation (LT). A retrospective cohort analysis was performed by reviewing the medical records of adult patients who underwent LT between January 2006 and October 2013. Of 893 patients, the incidences of mild, moderate, and severe LVH were 7.8%, 5.6%, and 2.5%, respectively. Propensity match was used to eliminate the pretransplant imbalance between the LVH and non-LVH groups. In after-match patients, 23.5% of LVH patients developed PMI compared to 11.8% in the control group (P = .011). The incidence of PMI in patients with moderate-severe degrees of LVH was significantly higher compared with that in patients with mild LVH (27.9% vs 19.1%, P = .016). When controlling intraoperative variables, patients with LVH had 4.5 higher odds of developing PMI (95% CI1.18-17.19, P = .028). Patients experiencing PMI had significantly higher 1-year mortality (37.5% vs 15.7%, log-rank test P < .001). Our results suggest that patients with pretransplant LVH were at a high risk of developing PMI and should be monitored closely in the perioperative period. More studies are warranted.     

Bilateral brachial plexus injury after liver transplantation

We report a case of bilateral brachial plexus injury following living-donor liver transplantation. A 35-year-old man with hepatitis C cirrhosis underwent liver transplantation under general anesthesia, performed in the supine position with 90 degrees arm abduction. The surgery lasted for 14 h, and the anesthesia for 16 h. On postoperative day 1, it was noticed that he had brachial plexus injuries. We investigated the cause of the nerve injuries, in particular, the possible involvement of stretching, compression, or nerve ischemia, which can often result from excessive abduction, the use of shoulder braces, compression by the poles used in the operating theater or compression caused by surgeons leaning on the patient, or serious general status (e.g., hypotension or hypoxemia). Our findings were inconclusive, but we postulated that 90 degrees abduction of the arms per se may have resulted in excessive stretching of the brachial nerves, causing his injuries.     

肝移植术后患者早期呼吸机脱机延迟的术前及术中危险因素

Objective To evaluate the pre- and intra-operative risk factors associated with delayed weaning from ventilator during the early postoperative period in patients undergoing liver transplantation.Methods Two hundred and twelve patients (152 male, 60 female) aged 22-69 yr undergoing liver transplantation from Sept 2004to Aug 2006 were enrolled in this study and were divided into 2 groups according to the time when the patients were weaned from ventilator: normal weaning group (Group A, the patients weaned from ventilator within 24 h after operation) and delayed weaning group (Group B, the patients weaned from ventilator more than 24 h after operation). Routine anesthesia wes performed. Blood and blood products were transfused according to the guidelines for blood transfusion to maintain the mean arterial pressure (MAP)≥60 mm Hg during operation. Sixteen preoperative variables (age＞64 yr, gender, BMI ≥ 30kg/m2, PaO2＜75 mm Hg,pleural effusion, a history of asthma, smoking, drinking alcohol, coronary artery disease, diabetes mellitus, encephalopathy＞grade 3, spontaneous bacterial peritonitis, preoperative MELD score, serum albumin, ascites≥20 ml/kg and moderate hepatopulmonary hypertension) and 7 intraoperative variables (duration of operation, duration of anhepatic stage, transfusions of RBC,fresh frozen plasma (FFP), crystalloid and colloid, and urine output＜ 1 ml·kg-1·h-1) were recorded and compared between the two groups.Results There were significant differences in 9 preoperative variables (age ＞ 64 yr, PaO2＜75 mm Hg, pleural effusion,encephalopathy＞grade 3, spontaneous bacterial peritonitis, preoperative MELD score, serum albumin, ascites≥20 ml/kg and moderate hepato-pulmonary hypertension) and 5 intraoperative variables (transfusions of RBC, FFP, crystalloid and colloid, and urine output＜1 mi·kg-1·h-1) between the two groups (P＜0.05 or 0.01). And logistic regression analysis showed that 5preoperative variables (age＞64 yr, PaO2＜75 mm Hg, encephalopathy ＞ grade 3, preoperative MELD score, and moderate hepato-pulmonary hypertension) and 2 intraoperative variables (transfusion of RBC and urine output＜1 ml·kg-1·h-1) were confirmed to be associated with delayed weaning from ventilator.Conclusion Such variables es age ＞ 64 yr, preoperative PaO2 ＜ 75 mm Hg, encephalopathy ＞ grade 3, preoperative MELD score, moderate hepato-pulmonary hypertension, transfusion of RBC during operation and urine output ＜ 1 ml· kg-1 · h-1 are associated with delayed weaning from ventilator during early postoperative period after liver transplantation.     

胆道内镜对肝移植术后胆管损伤变化的观察

目的 对原位肝移植术后胆道并发症进行内镜观察和治疗,为肝移植胆管损伤机制的研究提供参考和帮助.方法 利用胆道内镜技术,对肝移植术后正常组、胆管损伤组、肝动脉损伤组的病例进行观察,内镜下取活检进行病理分析.对于无T管者,应用子母胆道镜进行.结果 正常的9例肝内外胆管解剖正常,无狭窄、瘢痕,胆管黏膜颜色正常,供-受体胆管吻合口愈合佳.病理学检查均可见修复性的黏膜组织,被覆上皮完整,上皮下纤维组织和小血管增生,散在浆细胞、淋巴细胞浸润.胆管损伤组的12例中,胆管内有各种类型的单发、多发及铸型结石,胆管均有不同程度的损伤,经内镜取净结石、解除梗阻后,胆管黏膜均有不同程度的修复,造影检查胆树恢复正常.肝动脉损伤组3例:胆管壁缺血坏死,丧失胆管的组织结构,仅见纤维样组织构成的管道,明显充血,胆泥和结石完全灌满供体胆树,Ⅲ级胆管间断具有胆管的组织结构;病理学检查:胆管壁弥漫坏死,结构不清,大量胆汁渗入,可见增生的肉芽组织和化脓灶.结论 原位肝移植并胆管损伤、缺血的病例术后胆管均有不同程度的损伤,胆道内镜是诊治肝移植术后胆道并发症的首选方法.     

Biliary complications after orthotopic liver transplantation in rats

P = 0.0001). The nonarterialized bile duct, which becomes ischemic soon after liver transplantation, appears to be susceptible to infections. Such opportunistic infections may prevent the development of arterial collaterals, causing bile duct necrosis and the subsequent leakage of bile juice. When biliary complications frequently occur after nonarterialized liver transplantation in rats, the possibility of an opportunistic infection should thus be considered. (Received for publication on May 7, 1998; accepted on Mar. 11, 1999)     

Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary strictures after living donor liver transplantation (LDLT) with duct-to-duct (D-D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long-term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D-D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77–2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first-line therapy for patients with biliary stricture after LDLT.     

肝移植术后神经精神并发症的临床诊治

目的探讨肝移植术后神经精神并发症的诊断、病因和防治：方法回顾性分析127例肝移植患者的临床资料,分析肝移植术后神经精神并发症的发生原因结果有症状组和无症状组在年龄上相比较差异无统计学意义（P〉0．05）;但在性别、手术时间、术前血氨水平、术中输血量、血总胆红素、血肌酐、住ICU时间．免疫抑制剂浓度、术后感染等方面,两组相比较,差异有统计学意义（P〈0．01）：结论肝移植术后神经精神并发症的发生率较高,病因及临床表现形式多样,需积极预防及时处理,提高肝移植手术的效果。     

肝移植术后引起腹内压增高的相关因素分析

目的 探讨原位肝移植(OLT)诱发腹内高压(IAH)的影响因素,为防治OLT术后腹腔室隔综合征(ACS)提供理论依据.方法 对2002年9月至2006年9月共88例OLT患者进行腹内压监测,将患者的相关资料进行单因素和非条件Logistic回归分析.结果 本组OLT患者中出现IAH 28例,发生率31.81%;是否出现IAH的患者在术中补液量、术前长期使用广谱抗生素、手术并发症、肠道功能延迟恢复等差异具有统计学意义(P＜0.05).结论 OLT易诱发IAH;补液量大、手术并发症、肠道功能延迟恢复等是OLT诱发IAH的最常见危险因素,减少各种危险因素有利于预防OLT并发ACS.     

High incidence of postoperative pulmonary complications after orthotopic liver transplantation in children

Postoperative pulmonary complications were investigated in a total of 41 pediatric recipients who underwent orthotopic liver transplantation (OLT) between January, 1990 and March, 1992 at the Royal Children's Hospital, Brisbane. Atelectasis was seen in 40 cases (98%) of the 41 recipients, and occurred in the left lower lobe in 28 cases (68%), and in the right upper lobe in 25 cases (61%). Radiographic pulmonary edema occurred on 23 occasions in 18 recipients (45%). Pulmonary edema was observed just after operation in 9 cases, and in the later stage from the 3rd to 25th postoperative day in 14 cases. Five recipients experienced two episodes of pulmonary edema during their ICU stay. The duration of mechanical ventilatory support was significantly longer in the patients with pulmonary edema than in those without (9.6±3.8vs 3.9±2.2 days,P<0.01). Pleural effusions were observed in 21 cases (52%), of which 18 had right-sided effusion and 3 had bilateral effusions. Pneumothorax occurred in three cases. Pyothorax, hemothorax, bronchial asthma, and subglottic granulation occurred in one case each. The present study demonstrated that postoperative pulmonary complications are frequently observed in pediatric recipients undergoing OLT.     

肝癌肝移植围手术期死亡10例分析

目的 分析肝癌肝移植围手术期死亡的原因,总结肝癌切除术后行肝移植的临床经验。方法 回顾性分析2003年10月至2008年10月中山大学附属第三医院肝移植中心81例肝癌肝移植的临床资料,对其中10例围手术期（≤30d）死亡原因进行分析。 结果 肝癌切除术后病人肝移植总病死率为12.3%（10/81）。首次肝切除术后肝移植病死率为12.7%（9/71）;再次肝癌肝移植病死率为10%（1/10）。补救性肝移植病死率为10%（4/40）,超越补救性肝移植病死率16.1%（5/31）。肺部感染（6例）和术中腹腔大出血（5例）是围手术期的主要死亡原因。手术相关死亡5/10,5例术中腹腔出血量均＞10 000 mL。 结论 肝癌肝移植围手术期病死率仍较高;肺部感染和术中腹腔大出血是围手术期的主要死亡原因。     

Dyslipidemia during sirolimus therapy in patients after liver transplantation

INTRODUCTION: Sirolimus (SRL) is an immunosuppressive agent of potential benefit in clinical liver transplantation (LTX). One of the major side effects of SRL is hyperlipidemia, which is reported in up to 44% of patients. In this report, we describe the lipid profiles of 20 stable liver transplant recipients who received SRL for immunosuppression. METHODS: The study group received SRL in combination with tacrolimus and/or mycophenolate mofetil (MMF). The control group was administered calcineurin inhibitor (CI) and MMF. Fasting serum cholesterol level, high-density lipoproteins (HDL) and low-density lipoproteins (LDL) were measured regularly. Furthermore, the total cholesterol/HDL ratio and the LDL/HDL ratio were evaluated. Diabetes and hypertension were monitored as well. RESULTS: In the SRL group, hypercholesterolemia was found in three patients (15%) and hypertriglyceridemia in two patients (10%). There was no marked difference from the control group, although a higher association of SRL with hyperlipidemia was described in the literature. Furthermore, HDL and LDL levels were similar in both groups, as well as total cholesterol/HDL ratio and LDL/HDL ratio. Diabetes and hypertension had a similar incidence in both the groups. Thus, there was no difference concerning the cardiovascular atherosclerosis risk between the immunosuppressive protocol with SRL or with CI. DISCUSSION: The results of our retrospective study demonstrated that the immunosuppressive regimen can potentially influence the incidence of hyperlipidemia in patients after LTX. SRL in combination with tacrolimus and/or MMF had no higher incidence of hyperlipidemia than CI and MMF. The combination of immunosuppressive therapy with low dose and low levels of each immunosuppressive agent could decrease the risk of atherosclerosis and its complications in long-term survivors after LTX.     

肝移植术后复杂胆汁淤积型肝损伤的多学科综合诊疗

目的  探讨多学科综合诊疗（MDT）在肝移植术后复杂胆汁淤积型肝损伤中的作用。 方法  对吉林大学第一医院肝移植中心2020年6月23日收治的1例肝移植术后复杂胆汁淤积型肝损伤病例进行MDT讨论,明确病因及治疗策略,并总结MDT在肝移植术后复杂胆汁淤积型肝损伤治疗中的作用。 结果  患者肝移植术后肝功能异常,先后明确诊断为胆道狭窄、排斥反应及胆道感染,内镜逆行胰胆管成像（ERCP）支架内外双引流、糖皮质激素冲击、抗感染等治疗效果不佳。经MDT讨论,明确诊断为肝移植术后复杂胆汁淤积型肝损伤,建议在病理辅助排除排斥反应基础上优化免疫抑制方案,行针对性抗感染治疗,并预防可能伴随出现的药物性肝损伤。后患者恢复良好,治愈出院。 结论  肝移植术后复杂胆汁淤积型肝损伤病因复杂,病情动态变化,通过MDT讨论可提高对该疾病的认知和加强对诊治思路的梳理,提高治疗的针对性和有效性。     

原位肝移植术后颅内出血原因和处理

目的 探讨肝移植术后颅内出血的临床特点以及防治措施。 方法 回顾性分析中山大学附属第一医院2004年1月至2008年12月施行的638例肝移植病人的临床资料。总结原位肝移植术后颅内出血的诊治经过。结果 638例肝移植病人中共发生术后颅内出血10例（1.6%）;其中发生于移植术后1周内1例,2周内3例,2周至1个月6例。10例病人一经确诊,均立即采取脱水降低颅内压治疗,并应用抗生素控制感染,其中有4例病人急诊施行了开颅血肿清除术。10例中死亡6例,与术后颅内出血相关的病死率为60.0%。结论 肝移植术后颅内出血发病凶险、病死率高。应掌握术后颅内出血的常见原因,对术后意识和精神状态发生改变者要及时进行头颅CT检查,一旦发生颅内出血应积极抢救,及时做出正确的治疗选择,必要时施行开颅血肿清除术。     

肝移植术后多重耐药菌感染分布特征及危险因素

目的 探讨肝移植术后多重耐药菌感染的分布特征和危险因素，为制定更合理的感染控制策略提供依据。方法 收集西安交通大学第一附属医院2014 年1 月至2018 年12 月接受肝移植手术的患者临床资料，采集多重耐药菌感染相关数据，并通过单因素分析和多元Logistic回归分析确定独立危险因素。结果 431例肝移植患者中发生多重耐药菌感染53例，3例死亡与其相关。其中肺部感染最多见，占54.72%；耐碳青霉烯类鲍曼不动杆菌（CR-AB）是最常见菌株，占34.62%。术后ICU留置时间≥7 d（OR 2.303，95%CI 1.123～4.725，P=0.023）、急性肾功能衰竭（OR 4.573，95%CI 1.418～14.749，P=0.011）是发生多重耐药菌感染的独立危险因素（P＜0.05）。结论 多重耐药菌感染严重威胁肝移植患者的预后，缩短术后ICU留置时间、保护肾功能对于早期预防肝移植术后多重耐药菌感染尤为重。     

肝移植围手术期的危险因素与术后肺部并发症的关系分析

目的探讨肝移植围手术期的危险因素与术后肺部并发症的关系。方法回顾性分析我院2003年4月至2007年3月行肝移植手术的终末期肝病患者107例,单因素兼多因素Logistic回归分析患者术前、术中和术后的一些因素与肝移植术后肺部并发症情况的相关性。结果本研究所有患者的肺部并发症发生率为60．8％。术前Neld评分≥25分（P=0．041）,术中输液总量〉10L（P=0．026）,输血液制品总量〉4L（P=0．033）是术后发生肺部并发症的危险因素,而术后前3d至少有2d的液体平衡≤-300ml（P=0．021）是保护因素。结论肝移植术前改善基础状况,术中控制输液量、减少输血液制品量,术后尽早实现液体出人量的负平衡可减少术后肺部并发症的发生率。