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目的 总结甲状腺功能亢进（甲亢）性心脏病的围手术期处理经验。方法 回顾性分析７６例甲亢性心脏师的围手术期药物治疗方法。结果 全部病人均顺利度过围期,无围手术期死亡,无甲亢危象及心脏功能障碍发生,经抗甲状腺药物及甲瘃腺次全切除术的治疗,７６％（５８／７６）的病人围手术期内甲亢性心脏病获得治愈。结果 甲亢性心脏病并非手术的禁下,经抗甲状腺药物治疗及恰当术前准备,心脏病多能得到有效控制并;安全度过手术期     

原发性肾病综合征甲状腺功能的变化及临床意义

甲状腺与肾脏作为人体重要的内分泌器官，二者相互关系密切，研究证实甲状腺激素（thyroid hormone，TH）对肾脏的生长发育起促进作用，并为维持肾脏功能所必须，同时肾脏病变所致TH的变化也是显著的。近年来原发性肾病综合征（primary nephrotic syndrome，PNS）逐年增多，其伴发甲状腺代谢异常的现象也越来越受到人们的关注，临床观察发现持续大量蛋白尿的PNS患者甲状腺功能改变，     

甲亢围手术期T3,T4与皮质醇变化的临床研究

甲亢围手术期Ｔ３、Ｔ４与皮质醇变化的临床研究川北医学院附属医院（南充市，６３７０００）任少平王崇树郑惠玲吴成秀张涛盛涛甲状腺机能亢进症（简称甲亢）术后发生的甲状腺危象具有相当高的病死率，其发生原因仍不完全明了。为探讨危象的发生机制，我们从１９９１年起...     

消化道肿瘤术前漏诊甲状腺功能亢进的临床分析

恶性肿瘤合并甲状腺功能亢进（甲亢）围手术期易发生各种并发症，特别是甲亢危象，可危及患者生命^[1]。因此，围手术期处理极为重要。但合并甲亢的恶性肿瘤患者在临床上极易漏诊。10年来我院术前漏诊17例合并甲亢的恶性肿瘤患者，经围手术期积极治疗，取得一定疗效，现报告如下。     

肾病综合征伴甲状腺激素水平异常患者临床病理分析

目的检测肾病综合征（nephroticsyndrome,NS）患者的甲状腺激素（TH）水平,探讨NS伴TH异常者的临床特点及病理分布。方法选择符合NS诊断标准且既往无甲状腺相关疾病史的患者143例,所有患者均测定TH并进行肾活检,分析总结其临床特点、病理类型分布及与足细胞病的相关性等。结果①143例NS患者中,TH水平正常者34例（TH正常组）,TH水平异常者109例（TH异常组）,其中非甲状腺疾病综合征96例,自身免疫性甲状腺疾病13例,桥本氏甲状腺炎11例,甲状腺功能减退症1例,Graves甲状腺功能亢进1例。②TH正常组24h尿蛋白定量明显低于TH异常组,白蛋白水平明显高于TH异常组,总胆固醇水平明显低于TH异常组。③TH异常组中,白蛋白水平与血清游离三碘甲状腺原氨酸（FT3）、血清游离甲状腺素（FT4）水平呈正相关（r=0．551、0．642,P〈0．01）,与促甲状腺激素（TSH）水平呈负相关（r=-0．251,P〈0．01）。总胆固醇水平与FT4呈负相关（r=-0．427,P〈0．01）、与TSH（r=0．289,P〈0．01）呈正相关,与FT3无相关性。④109例NS并TH水平异常患者肾活检病理显示,系膜增生性肾炎43例,膜性肾病40例,IgA肾病9例,膜增生性肾小球肾炎4例,局灶节段硬化性肾小球肾炎11例,微小病变肾病2例。表现为足细胞病者56例、非足细胞病53例,两者间TH水平差异无统计学意义（P〉0．05）。结论①NS患者临床易合并TH异常,表现以非甲状腺疾病综合征为主,自身免疫性甲状腺疾病次之。②NS合并TH异常者比正常者临床表现更突出。③NS合并TH异常者病理以系膜增生性肾炎、膜性肾病多见。其表现为足细胞病者与非足细胞病者病例数相当。     

胃十二指肠溃疡穿孔合并甲状腺功能亢进围手术期处理17例分析

目的 总结胃十二指肠溃疡穿孔合并甲状腺功能亢进（甲亢）的治疗经验。 方法 回顾性分析2003年1月至2008年12月天津市南开医院外科收治17例胃十二指肠溃疡穿孔合并甲亢病人的临床资料。 结果 15例术前诊断合并甲亢的病人,围手术期进行了预防甲状腺危象的处理,无一例发作甲状腺危象;2例漏诊甲亢诊断的病人术后均发生了甲状腺危象,其中1例死亡。 结论 胃十二指肠溃疡穿孔合并甲亢增加了围手术期风险。术前准备充分、术式简单有效、术后预防性治疗可以避免甲状腺危象的发生。     

甲状腺手术的围手术期护理体会

目的总结甲状腺手术围手术期护理体会,提升护理质量。方法对64例接受甲状腺手术的患者实施充分术前准备、术中密切配合、术后严密观察等围手术期精心护理措施,回顾性分析患者的临床资料。结果通过围手术期精心护理,64例患者均顺利康复出院,未发生与护理相关的并发症。患者对护理的满意度为100%。结论对接受甲状腺手术的患者进行精心围手术期护理措施,有助于降低术后并发症发生率,提升护理质量和患者满意度,促进患者康复。     

当归对阻塞性黄疸患者淋巴细胞IL-2活性和IL-2R表达的影响

目的探讨围手术期当归对阻塞性黄疸患者细胞免疫功能的调节作用。方法用当归注射液围手术期对患者进行治疗（共14d）,观察其外周血淋巴细胞IL-2的活性及IL-2R表达的变化。结果阻塞性黄疸患者血淋巴细胞IL-2活性及IL-2R表达阳性率与正常人相比均明显下降（P〈0.01）。给予当归治疗后,发现术前其IL-2活性及IL-2R表达阳性率均明显升高（P〈0.01）,术后其IL-2活性及IL-2R表达阳性率与术前相比虽略有下降,但与用药前相比仍有明显升高（P〈0.01）。结论围手术期应用当归具有改善阻塞性黄疸患者细胞免疫功能状态的临床实用价值。     

垂体腺瘤病人围术期生长素和泌乳素的变化

垂体腺瘤病人围术期生长素和泌乳素的变化张云馨１滕述１孙振荣２王恩真１１北京天坛医院麻醉科（１０００５０）２北京天坛医院神经外科为探寻垂体腺瘤病人围术期生长素（ＧＨ）、泌乳素（ＰＲＬ）的变化规律与垂体功能正常的手术病人有何不同，我们进行了临床对比观察，...     

巨大甲状腺肿的围手术期处理

目的探讨巨大甲状腺肿的围手术期处理办法，减少并发症的发生。方法回顾性分析我院近5年对巨大甲状腺肿76例的围手术期处理。结果喉返神经损伤4例（4／76），占5．26％，所有患者术后生命体征均平稳，元气管塌陷（萎陷）窒息、呼吸困难。无死亡病例。手术时间平均（1．8±0．5）h，术中平均出血量约（150±80）ml。平均切除甲状腺组织的重量为（362±42）g。平均住院时间（9±4）d。服碘前、后腺体缩小差异有统计学意义。结论正确积极地进行围手术期处理，可以明显减少并发症的发生，增加手术成功率，对患者明显有益。     

“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.     

重型肝炎肝移植的围手术期处理

目的 总结重型肝炎病人肝移植围手术期若干问题的处理经验.方法 对中山大学附属第三医院肝移植中心2004年6月至2006年6月完成的218例重型肝炎肝移植病例资料进行回顾性分析.结果 218例重型肝炎肝移植围手术期成活率92.7%(202/218),其中急性重型肝炎肝移植为90.4%(57/63),慢性重型肝炎肝移植为93.5%(145/155).术后常见的并发症分别为感染(74.7%)、肝移植相关性脑病(65.6%)和.肾功能不全(14.7%).结论 重型肝炎肝移植的围手术期死亡率高.重视围手术期的处理足提高重型肝炎肝移植成功率的关键.     

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??Death data of patients with hepatocellular carcinoma after liver resection in the perioperative period of liver transplantation: an analysis of 10 cases ZHANG Tong, FU Bin-sheng, LI Hua, et al. Liver Transplantation Center??the Third Affiliated Hospital??Sun Yat-sen University; Organ Transplantation Research Center of Guangdong; Organ Transplantation Research Institution of Sun Yat-sen University??Guangzhou 510630, China
Corresponding author: CHEN Gui-hua??E-mail:chgh1955@263.net
Abstract Objective To analyze death data of patients with hepatocellular carcinoma after liver resection in the perioperative period of liver transplantation(LT) so as to summary the clinical experience. Methods The clinical data of 81 liver transplant recipients with hepatocellular carcinoma after liver resection from October 2003 to October 2008 in the Third Affiliated Hospital of Sun Yat-sen University were analyzed retrospectively. The death data of 10 patients in the perioperative period of LT were analyzed. Results The overall mortality of liver transplant recipients with hepatocellular carcinoma after liver resection was 12.3% (10/81). The mortality of patients with hepatocellular carcinoma after liver resection for primary LT??≤30d??was 12.7% (9/71). The mortality of patients with hepatocellular carcinoma after repeated liver resection for LT??≤30d??was 10%(1/10). The mortality of patients for salvage LT ??≤30d??was 10%??4/40??. The mortality of patients beyond salvage LT ??≤30d??was 16.1%??5/31??. Pulmonary infection (6/10) and intraoperative massive abdominal bleeding (5/10) were major causes of death in the perioperative period of liver transplantation. The surgical related mortality in the perioperative period of liver transplantation was 5/10. The volume of five patients with intraoperative massive abdominal bleeding was more than 10 000 mL. Conclusion The mortality of liver transplant recipients with hepatocellular carcinoma after liver resection remains higher. Pulmonary infection and intraoperative massive abdominal bleeding are the main death causes for patients who underwent liver transplantation after liver resection for HCC.     

The ins and outs of microRNAs as biomarkers in liver disease and transplantation

Ongoing research is being conducted in the field of transplantation to discover novel, noninvasive biomarkers for assessment of graft quality before transplantation and monitoring of graft injury after transplantation. MicroRNAs (miRNAs) are among the most promising in this field. MiRNAs are small noncoding RNAs that function as important regulators of gene expression in response to cellular stress and disease. An advantage that makes miRNAs attractive candidates for biomarker research is their fast release from cells in response to stress and injury, which can occur via different routes. In the context of liver transplantation (LT), noninvasive measurement and stability of extracellular miRNAs in blood, bile, and graft perfusates has been linked to cell‐type specific injury and early graft outcome following LT. Furthermore, specific intrahepatic miRNA expression patterns have been associated with graft survival and recurrent disease, like hepatitis C virus‐related fibrosis and hepatocellular carcinoma. Therefore, miRNAs with strong predictive value and high sensitivity and specificity might be successfully applied to assess hepatic injury and to diagnose (recurrent) liver disease before, during and after LT. In this review, the current features and future prospects of miRNAs as biomarkers in and out of the liver are discussed.     

治疗性高碳酸血症对大鼠移植肝脏缺血再灌注损伤的影响

目的 探讨治疗性高碳酸血症对大鼠移植肝脏缺血再灌注损伤的影响.方法 清洁级雄性Wistar大鼠32只,6周龄,体重220～280 g,采用完全随机设计的方法两两配对实施肝脏原位移植16只.采用随机数字表法,将受体鼠随机分为2组(n=8):肝移植组(LT组)和治疗性高碳酸血症组(TH组).LT组再灌注即刻吸入50％ O2-50％N2混合气体2 h;TH组再灌注即刻吸入O2-N2-CO2混合气体lh,调节气体浓度和呼吸频率,维持FiO2 50％、PaCO2 80～ 100 mm Hg,而后继续吸入50％O2-50％N2混合气体lh.再灌注期间记录MAP、PaO2和PaCO2.再灌注2h时,取动脉血样,测定血清ALT、AST、TNF-α、IL-1和IL-6的水平;取肝组织,测定NF-κB活性,计算凋亡指数,观察肝组织病理学结果.结果 与LT组比较,TH组血清ALT、AST、TNF-α、IL-1和IL-6水平、肝组织NF-κB活性和凋亡指数降低,MAP、PaO2和PaCO2升高(P＜0.05).TH组肝组织病理学损伤较LT组减轻.结论 治疗性高碳酸血症可减轻大鼠移植肝脏缺血再灌注损伤,机制与抑制炎性反应和细胞凋亡有关.     

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。     

Inducing Hepatitis C Virus Resistance After Pig Liver Transplantation—A Proof of Concept of Liver Graft Modification Using Warm Ex Vivo Perfusion

Normothermic ex vivo liver perfusion (NEVLP) offers the potential to optimize graft function prior to liver transplantation (LT). Hepatitis C virus (HCV) is dependent on the presence of miRNA(microRNA)‐122. Miravirsen, a locked‐nucleic acid oligonucleotide, sequesters miR‐122 and inhibits HCV replication. The aim of this study was to assess the efficacy of delivering miravirsen during NEVLP to inhibit miR‐122 function in a pig LT model. Pig livers were treated with miravirsen during NEVLP or cold storage (CS). Miravirsen absorption, miR‐122 sequestration, and miR‐122 target gene derepression were determined before and after LT. The effect of miravirsen treatment on HCV infection of hepatoma cells was also assessed. NEVLP improved miravirsen uptake versus CS. Significant miR‐122 sequestration and miR‐122 target gene derepression were seen with NEVLP but not with CS. In vitro data confirmed miravirsen suppression of HCV replication after established infection and prevented HCV infection with pretreatment of cells, analogous to the pretreatment of grafts in the transplant setting. In conclusion, miravirsen delivery during NEVLP is a potential strategy to prevent HCV reinfection after LT. This is the first large‐animal study to provide “proof of concept” for using NEVLP to modify and optimize liver grafts for transplantation.     

Cardiac diseases among liver transplant candidates

Improvements in early survival after liver transplant (LT) have allowed for the selection of LT candidates with multiple comorbidities. Cardiovascular disease is a major contributor to post‐LT complications. We performed a literature search to identify the causes of cardiac disease in the LT population and to describe techniques for diagnosis and perioperative management. As no definite guidelines for preoperative assessment (except for pulmonary heart disease) are currently available, we recommend an algorithm for preoperative cardiac work‐up.     

Living related liver transplantation for biliary atresia with portopulmonary hypertension: case report

Portopulmonary hypertension is a complication of end-stage liver disease that adversely affects the outcome of liver transplantation (LT). We report a case of living related LT who developed severe pulmonary hypertension during and after LT. This 16-year-old girl suffered from biliary atresia, having undergone a portoenterostomy at 60 days of age, at the time of discovery of liver cirrhosis. She had been admitted to a local hospital several times for episodes of esophageal variceal bleeding. Neither dyspnea nor cyanosis was discerned until LT. Although pulmonary hypertension (PH) was disclosed by echocardiogram upon preoperative evaluation, we did not consider this a contraindication for LT, because the PH was mild. She underwent living LT from her father (graft volume/recipient body weight ratio: 0.99%). After induction of anesthesia for LT, a pulmonary flotation catheterization showed severe PH (>40 mm Hg). The pulmonary artery pressure continued to be elevated during surgery, although it was possible that her severe scoliosis affected the data. Hyperbilirubinemia was observed after LT, despite good liver function tests. On postoperative day 12, a portal vein thrombosis was detected requiring emergency thrombectomy and splenectomy. Her general condition worsened after the second surgery. She died due to cardiopulmonary failure. Autopsy showed marked hypertrophy of the right ventricle with intimal thickening in the pulmonary artery. In this case, the underestimated PH might have resulted in the unfortunate outcome. Before LT, PH should be carefully evaluated by measures including invasive assessment.     

Neutrophil gelatinase‐associated lipocalin associated with irreversibility of pre‐liver transplant kidney dysfunction

Kidney outcomes in early post‐liver transplantation (LT) are crucial for long‐term prognosis, but difficult to predict. Among 203 adult LT patients, we studied the value of plasma neutrophil gelatinase‐associated lipocalin (NGAL) measured pre‐LT for predicting acute kidney injury (AKI), kidney‐replacement therapy within three months, and kidney dysfunction at three months post‐LT. Glomerular filtration rate (GFR) was estimated by creatinine‐based and cystatin C‐based equations. Highest NGAL levels were among patients on pre‐LT kidney‐replacement therapy, whereas NGAL exceeded 200 μg/L in only three (2%) patients with pre‐LT GFR >60 mL/min. Pre‐LT NGAL >260 μg/L predicted GFR <60 mL/min at three months post‐LT (OR 17.8, 95% CI 2.1–153) independently of 19 other variables reflecting recipient characteristics, liver and kidney function, perioperative hemodynamic stress, and immunosuppression. Of 81 patients with pre‐LT GFR <60 mL/min, 48% had GFR <60 mL/min at three months, and an NGAL level >260 μg/L predicted this outcome with 90% specificity and 46% sensitivity. NGAL failed to predict post‐LT AKI or need for temporary kidney‐replacement therapy. In conclusion, NGAL independently predicted irreversibility of pre‐LT kidney dysfunction and could thus help in optimizing patient care and in the decision to perform combined liver–kidney transplantation. Pre‐LT NGAL was not useful in patients with preserved pre‐LT kidney function or in predicting post‐LT AKI.