肝移植术后肝动脉狭窄患者胆管并发症的治疗

目的 探讨原位肝移植术（OLT）后肝动脉狭窄（HAS）患者胆管并发症的发生率及肝动脉介入治疗对胆管并发症的预防和治疗作用.方法 回顾分析本中心2003年10月至2006年3月22例OLT后HAS患者胆管并发症的发生情况,并分析HAS的介入治疗对胆管并发症的预防和治疗作用.结果 22例OLT术后HAS患者,3例于术后近期行再次肝移植术,1例死于严重感染.其余18例HAS患者中,GGT和ALP升高发生率为100%,胆管狭窄（BS）的发生率为61.1%（11/18）,胆漏的发生率为5.6%（1/18）.12例患者接受肝动脉介入治疗后,6（50%）例发生BS,经胆道介入治疗后,0例治愈,6（100%）例好转;2例患者未行肝动脉介入治疗,1例发生BS,经保守治疗治愈;4例患者在出现BS后诊断HAS,均接受肝动脉和胆道介入治疗,0例治愈,3（3/4）例好转,1（1/4）例无效.结论 OLT后合并HAS患者的胆管并发症发生率较高,肝动脉介入治疗对HAS患者胆管并发症的预防和治疗作用不理想.     

原位肝移植术后腹腔内出血的原因和处理

目的 探讨肝移植术后腹腔内出血的原因和处理方法.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例同种原位肝移植(orthotopic liver transplantation,OLT)患者的临床资料.总结原位肝移植术后腹腔内出血的诊治经过.结果 638例肝移植患者共发生术后腹腔内出血53例,发生率为8.3%(53/638).53例患者分别根据出血的原因、部位和严重程度采取相应的止血措施,其中对31例考虑为凝血功能障碍所致创面或肝周渗血而仅行非手术治疗,另22例为外科因素所致的术后活动性腹腔内出血,在应用止血药物、输血和积极扩充血容量等抗休克治疗无效后则中转二次探查止血手术.53例腹腔内出血患者死亡12例,死亡原因主要是严重感染和多器官功能衰竭;其余41例治愈且无并发症发生.与腹腔内出血相关的病死率为22.6%(12/53).结论 OLT术后可能出现不同部位的腹腔内出血,死亡率较高;临床上须掌握术后腹腔内出血的常见原因,一旦发生则应及时做出正确的治疗选择以改善预后.     

原位肝移植术后并发曲霉菌感染的诊断和治疗

目的 探讨原位肝移植术后并发曲霉菌感染的诊断和治疗措施. 方法对2000年1月至2006年12月中山大学附属第一医院施行的776例同种原位肝移植患者的临床资料进行回顾性分析,总结原位肝移植术后发生曲霉菌感染的诊治经过.结果 本组患者发生曲霉菌感染13例,感染发生率为1.68%(13/776);其中肺部感染7例,肝脏感染2例,颅内感染1例,多器官感染3例.两性霉素B脂质体是治疗肝移植术后曲霉菌感染的主要药物,对早期病例疗效满意.因曲霉菌感染死亡7例,病死率为53.8%(7/13).结论 防治肝移植术后曲霉菌感染的关键是做好早期诊断,及时治疗.抗真菌治疗应该清除病灶、调整免疫抑制剂及选用敏感抗真菌药物;抗真菌药物的使用应该早期、足量、全程用药.     

肝移植术后腹腔出血的原因与防治

目的探讨原位肝移植(OLT)术后腹腔出血的原因和有效的防治措施。方法回顾性分析和总结1999年2月至2004年6月OLT术后13例腹腔出血患者的临床资料。结果腹腔出血发生率为7.2%(13/181),病死率为15.4%(2/13)。出血发生在OLT术后24h内7例(53.8%),7d内9例(69.2%),7d后4例(30.8%)。出血部位包括供肝活检部位渗血3例、腹壁出血3例、肝动脉吻合口出血2例、胆总管吻合口出血2例、腹腔渗血2例和下腔静脉壁的分支出血1例。结论OLT术后近期腹腔出血的主要原因是凝血功能紊乱和术中止血不妥;腹腔感染或胆漏引起血管破裂是致使后期腹腔出血的主要原因。纠正凝血功能紊乱,精细的手术操作和控制腹腔感染或胆漏可有效的预防OLT术后的腹腔出血。     

原位肝移植术后消化道出血的病因与治疗

目的 探讨原位肝移植术后消化道出血的病因与治疗.方法 回顾性分析16例肝移植术后消化道出血患者的临床资料,总结其病因与治疗经验.结果 16例患者发生消化道出血的时间在肝移植术后2 d～4.5年.经检查发现患者的出血原因主要为食道静脉曲张破裂出血4例,急性胃黏膜病变出血3例,门脉高压性胃病出血3例,十二指肠球部多发性溃疡出血2例,十二指肠降段黏膜下小动脉出血、十二指肠乳头肌切开后出血、胆道出血及不明原因出血各1例.有2例经止血治疗无效而死亡,1例在肝移植围手术期死于多器官功能衰竭,1例死于急性心肌梗死,2例死于晚期肿瘤,其他患者经过积极止血治疗后好转,并长期存活.结论 肝移植术后消化道出血的病因主要为食道静脉曲张破裂出血、急性胃黏膜病变、门脉高压性胃病及消化性溃疡等.采用及时的止血治疗,必要时行剖腹探查手术止血是治疗成功的关键.     

肝硬变肝功能衰竭患者行肝移植时

目的探讨肝功能衰竭患者行同种原位肝移植（OLT）时术前准备的原则和方案。方法回顾性比较分析7例因肝硬变肝功能衰竭行OLT和3例因非硬变性肝病行OLT术前凝血功能、一般状况、内环境状况、术中出血量与术后过程的关系。结果7例肝硬变患者血小板计数均下降,凝血功能差,而3例因非硬变性肝病者血小板下降不明显;7例肝硬变患者术前均进行了利尿和保肝支持治疗,而3例因非硬变性肝病者除2例进行了保肝支持、输少量全血和人白蛋白外,未输注凝血因子和血浆,也未进行利尿治疗。术中7例肝硬变患者平均出血8455ml,除补充相应量的血以外,还平均输注人白蛋白88.5g和血浆957.1ml,但术毕血白蛋白仅26.1g/L,术后48h内内环境紊乱较明显,术后1个月内5例发生真菌感染,3例发生腹腔内出血,而3例非硬变肝病患者平均出血2660ml,术中仅输很少人白蛋白,术毕血白蛋白30.7g/L,内环境紊乱不明显,术后1月内无感染和腹腔内出血发生。结论肝硬变肝功能衰竭患者行肝移植术前完全纠正凝血功能障碍、低蛋白血症、贫血和内环境紊乱是保证手术和术后顺利的重要因素。     

肝硬变肝功能衰竭患者行肝移植时术前准备的重要性

目的 探讨肝功能衰竭患者行同种原位肝移植（OLT）时术前准备的原则和方案。方法 回顾性比较分析7例因肝硬变肝功能衰竭行OLT和3例因非硬变性肝病行OLT术前凝血功能、一般状况、内环境状况、术中出血量与术后过程的关系。结果 7例肝硬变患者血小板计数均下降，凝血功能差，而例因非硬变性肝病者血小板下降不明显；7例肝硬变患者术前均进行了利尿和保肝支持治疗，而例因非硬变性肝病者除2例进行了保肝支持、输少量全血和人白蛋白外，未输注凝血因子和血浆，也未进行利尿治疗。术中7例肝硬变患者平均出血8455ml，除补充相应量的血以外，还平均输注人白蛋白88.5g和血浆957.1ml，但术比血白蛋白仅26.1g/L，术后48h内内环境紊乱较明显，术后1个月内5例发生真菌感染，3例发生腹腔内出血，而3例非硬变直病患者平均出血2660ml，术中仅输少人白蛋白，术毕血白蛋白30.7g/L，内环境紊乱不明显，术后1月内无感染和腹腔内出血发生。结论 肝硬变肝功能衰竭患者行肝移植术前完全纠正凝血功能障碍、低蛋白血症、贫血和内环境紊乱是保证手术和术后顺利的重要因素。     

原位肝移植术后静脉流出道梗阻的原因和处理

目的 探讨原位肝移植术后静脉流出道梗阻的原因和处理方法.方法 对2000年1月至2006年12月收治的776例同种原位肝移植患者的临床资料进行回顾性分析.总结原位肝移植术后静脉流出道梗阻的诊治经验.结果 776例肝移植患者中共发生术后静脉流出道梗阻10例,发生率为1.29%.其中肝上下腔静脉吻合口狭窄6例,肝后段下腔静脉狭窄2例,肝静脉流出道梗阻2例.10例均进行了下腔静脉造影而明确诊断,8例患者在下腔静脉造影的同时施行了气囊扩张或放置血管内支架术,2例介入治疗效果不佳而中转再次肝移植术;该组因术后静脉流出道梗阻而死亡3例,与静脉流出道梗阻相关的病死率为30%(3/10).结论 原位肝移植术后静脉流出道梗阻的发生与腔静脉的吻合技术,腔静脉吻合方式以及供肝体积与受者肝床不匹配有关;术后尽早发现流出道梗阻的存在,并及时做出正确的治疗选择如介入治疗或再次肝移植等是改善该并发症预后的关键.     

重症肝炎行原位肝移植术及肝肾联合移植术的疗效比较

目的 总结重症肝炎患者行原位肝移植或肝肾联合移植的结果,探讨肝肾联合移植的手术适应证.方法 分析52例重症肝炎患者单纯行原位肝移植(orthotopic liver transplantation,OLT)和肝肾联合移植(combined liver-kidney transplantation,CLKT)两组患者死亡率、术后肾功能不全的发生率、ICU天数、住院天数等.结果 CLKT组患者术前肾功能明显差于OLT组,术后发生严重感染的患者明显多于OLT组.但OLT组中28例(70％)患者术后早期发生肾功能不良,其中11例需血液透析;而CLKT组患者中需血液透析仅2例,两组比较差异有统计学意义(P＜0.01).CLKT组患者在围手术期2例(16.7％)死亡.OLT组围手术期死亡16例(40％),其中死于急性肾衰9例,两组死亡率比较差异有统计学意义(P＜0.01).结论 重症肝炎患者若术前肾功能较差,术后易并发严重感染,肝移植后急性肾衰的发病率和死亡率较高,可考虑行CLKT术.     

肝癌肝移植术后肿瘤复发的治疗策略

目的比较肝癌肝移植术后肝内复发的患者分别实施肿瘤切除术、经导管肝动脉灌注化疗栓塞术（TACE）、射频消融术（RFA）、再次原位肝移植术（re—OLT）的临床疗效。方法回顾性分析我中心2004年1月至2009年6月凶肝癌行肝移植手术术后肝内复发的患者53例。其中肿瘤切除术3例,TACE22例,RFA18例,re—OLT10例,观察术前一般情况、术后生存时间、术后并发症、肿瘤进展情况、治疗费用等情况。重点对比分析TACE、RFA、re—OLT三种治疗方法的疗效。结果肿瘤切除术3例,随访4～12个月,均无手术并发症,未见肝脏及远处复发或转移,一般情况良好。TACE组、RFA组与re—OLT组的平均生存时间、累积生存率、各部位进展情况的差异无统计学意义;RFA组的并发症,特别是胆道并发症发生率比TACE组及re—OLT组低;3组的治疗费用的差异有统计学意义,RFA〈TACE〈re—OLT。结论TACE、RFA及re—OLT治疗方法对肝癌肝移植术后肝内复发的治疗效果相近。RFA的并发症及治疗费用明显少于TACE及re—OLT,可作为肝癌肝移植术后肝内复发的首选治疗方案。     

Gastrointestinal complications after cardiac surgery

BACKGROUND: Gastrointestinal complications after cardiac surgery are often difficult to diagnose, and are associated with high morbidity and mortality rates. The aim of this study was to determine risk factors for these complications. METHOD: Between 1996 and 2001 data were collected prospectively from 6119 patients who underwent 6186 cardiac surgical procedures. Data from patients who experienced major gastrointestinal complications were analysed retrospectively by univariate and multivariate analysis. RESULTS: Fifty major gastrointestinal complications were identified in 47 patients (incidence 0.8 per cent). Thirteen of these patients died within 30 days. The most common complication was upper gastrointestinal bleeding (16 patients). Intestinal ischaemia was the most lethal complication (eight of ten patients died). Abdominal surgical operations were performed in 12 patients. Multivariate analysis identified nine variables that independently predicted major gastrointestinal complications: age over 80 years, active smoker, need for preoperative inotropic support, New York Heart Association class III-IV, cardiopulmonary bypass time more than 150 min, postoperative atrial fibrillation, postoperative heart failure, reoperation for bleeding and postoperative vascular complications. CONCLUSION: Nine risk factors for the development of major gastrointestinal complications after cardiac surgery were identified. Gastrointestinal complications were often lethal but did not independently predict death within 30 days.     

心血管手术后消化道出血临床分析

目的分析心血管手术后消化道出血的临床特点。方法对1735例2003年1月～2007年12月问本科心血管手术患者的临床资料进行回顾性分析,总结术后消化道出血的特点,以及高危因素、病变类型、诊断方法及预后。结果共有13例（0．75％）患者出现术后消化道出血,经积极内科治疗,7例患者出血控制,2例纤维胃镜患处局部钳夹治疗成功,1例行介入治疗封堵成功,1例在内科治疗24h无效后经手术治愈,另2例因出血凶猛,致循环衰竭死亡。结论心脏术后消化道出血发生率低但死亡率高,体外循环时间、机械通气、低心排综合征是其高危因素。早期明确诊断和积极干预是决定病情转归的关键。     

Recombinant activated factor VII in critical bleeding after orthotopic liver transplantation

Critical bleeding throughout the intraoperative phase of orthotopic liver transplantation (OLT) strongly increases patient mortality and intensive care unit (ICU) stay. The aim of this study was to report our experience on the use of recombinant activated factor VII (rFVIIa) in postoperative critical bleeding after OLT. In 7 patients with persistent severe bleeding after application of a standard transfusion protocol, we administered a 90 microg/kg bolus of rFVIIa and if necessary eventually repeated it after 3 hours. We recorded the blood loss and the need for transfusions before and after the rFVIIa therapy. Blood losses and need for platelets significantly decreased after rFVIIa administration; a nonsignificant decrease in red blood cells and fresh frozen plasma transfusions also occurred. In 6 patients treatment with rFVIIa was effective; only 1 patient died because of hemorrhagic shock and no thromboses were detected among the treated patients. Awaiting stronger evidence from randomized controlled trials, we suggest that in some challenging cases of massive bleeding rFVIIa should be considered a useful option to control bleeding.     

GASTROINTESTINAL COMPLICATIONS FOLLOWING RENAL TRANSPLANTATION

Gastrointestinal complications occur'red in 19 of 290 recipients (6.6%) of the 325 cadaveric renal allografts undertaken between September 1969 and December 1978. The mortality was 42.1%. Upper gastrointestinal complications, principally haemorrhage, occurred in 12 patients (4.1%), 11 of whom were males, usually within four months of transplantation, and often associated with acute rejection and its treatment. Surgery was required in five patients. The overall mortality was 16.7%. Colonic complications occurred in five patients (1.7%), four of whom died, the absence of specific signs having led to a significant delay in diagnosis. One patient died from abdominal vascular disease, and one from carcinoma of the gallbladder. To decrease the high morbidity and mortality, both medical and appropriate surgical prophylaxis for peptic ulceration and diverticular disease are necessary, as is an awareness of the transplant recipient's propensity to develop a gastrointestinal complication at any time, up to years after transplantation. Early recognition and treatment of such complications are essential.     

Gastrointestinal complications following renal transplantation.

Gastrointestinal complications occurred in 19 of 290 recipients (6.6%) of the 325 cadaveric renal allografts undertaken between September 1969 and December 1978. The mortality was 42.1%. Upper gastrointestinal complications, principally haemorrhage, occurred in 12 patients (4.1%), 11 of whom were males, usually within four months of transplantation, and often associated with acute rejection and its treatment. Surgery was required in five patients. The overall mortality was 16.7%. Colonic complications occurred in five patients (1.7%), four of whom died, the absence of specific signs having led to a significant delay in diagnosis. One patient died from abdominal vascular disease, and one from carcinoma of the gallbladder. To decrease the high morbidity and mortality, both medical and appropriate surgical prophylaxis for peptic ulceration and diverticular disease are necessary, as is an awareness of the transplant recipient's propensity to develop a gastrointestinal complication at any time, up to years after transplantation. Early recognition and treatment of such complications are essential.     

胰十二指肠切除术后晚期出血的诊断与治疗

目的总结胰十二指肠切除术后晚期出血的诊断与治疗经验。方法回顾性分析2002年1月至2013年2月新疆医科大学第一附属医院收治的246例行胰十二指肠切除术患者的临床资料。胰头及壶腹部恶性肿瘤行标准胰十二指肠切除术或联合脏器切除,良性肿瘤及十二指肠乳头肿瘤行保留幽门的胰十二指肠切除术。消化道吻合采用胰肠或胰胃吻合两种方式。患者术后出血时间〉5d定义为晚期出血。消化道出血为消化道出血组,腹腔出血为腹腔出血组。按出血程度分为轻度和重度出血。采取保守治疗和手术治疗（包括介入和开腹手术治疗）两种方法治疗晚期出血。计数资料组间比较采用Fisher确切概率法。结果246例患者中行标准胰十二指肠切除术224例,行保留幽门的胰十二指肠切除术10例,行胰十二指肠切除联合门静脉切除或置换术9例,行胰十二指肠切除联合肠系膜上静脉置换术1例,行胰十二指肠切除联合肝方叶切除术1例,行胰十二指肠切除联合左半肝切除术1例。246例患者中行改良胰肠端侧吻合127例,行胰胃套入吻合53例,行传统胰肠端端套人吻合39例,行胰管空肠黏膜对黏膜吻合27例。患者围手术期死亡15例,病死率为6．10％（15／246）。术后29例患者发生晚期出血,出血发生率为11．79％（29／246）。其中消化道出血14例,腹腔出血15例。29例出血患者中轻度出血9例（消化道出血5例、腹腔出血4例）;重度出血20例（消化道出血9例、腹腔出血11例）。17例患者术后发生先兆出血,其中消化道出血5例、腹腔出血12例。29例患者均经常规保守治疗,消化道出血组患者保守治疗成功率为8／14,腹腔出血组为2／15,两组比较,差异有统计学意义（P〈0．05）。保守治疗失败患者均中转手术治疗。20例重度出血患者中行手术治疗19例,1例经保守治疗成功。9例轻度出血患者全部行保守治疗,1例因肺部感染死亡,其余均获治愈。29例术后晚期出血患者中死亡10例,病死率为34．5％（10／29）。消化道出血组患者病死率为2／14,腹腔出血组为8／15,两组比较,差异无统计学意义（P〉0．05）。结论胰十二指肠切除术后晚期出血常有先兆出血征象,出血程度多为重度。消化道出血经保守治疗多可治愈,腹腔出血需积极手术治疗。     

Incidence of gastrointestinal complications in cardiopulmonary bypass patients

Gastrointestinal complications after cardiac surgery are associated with a high mortality rate. Because of the absence of early specific clinical signs, diagnosis is often delayed. The present study seeks to determine predictive risk factors for subsequent gastrointestinal complications after cardiosurgical procedures. Within a 1-year period, a total of 1116 patients who had undergone open heart surgery with cardiopulmonary bypass were prospectively studied for gastrointestinal complications. To determine predictive factors, all case histories of the patients were analyzed. Of the 1116 patients, 23 (2.1%) had gastrointestinal complications during the postoperative period, 10 of whom had to undergo subsequent abdominal surgery. Of these 23 patients, 20 died. Early gastrointestinal complications, which occurred mostly on postoperative days 6 or 7, consisted of bowel ischemia or hepatic failure. Late complications were gastrointestinal bleeding, pseudomembranous colitis, cholecystitis, and septic rupture of a spleen. The relative risk for abdominal complications after cardiopulmonary bypass was highly increased in association with (1) a cardiac index less than 2.0 l/min-1/(m2)-1, (2) postoperative onset of atrial fibrillation, (3) emergency surgery, (4) need for vasopressors, (5) need for intraaortic balloon counterpulsation, and (6) need for early redo thoracotomy due to surgical complications. All patients with necrotic bowel disease had elevated serum lactate levels. Furthermore, cardiopulmonary bypass and aortic clamping times were significantly prolonged in patients who developed gastrointestinal complications. A number of predictive factors contribute to the development of gastrointestinal complications after cardiopulmonary bypass surgery. Knowledge of these factors may lead to earlier identification of patients at increased risk and may allow more efficient and earlier interventions to reduce mortality.     

Pulmonary complications of orthotopic liver transplantation

Pulmonary complications following orthotopic liver transplantation (OLT) were prospectively evaluated in 18 individuals transplanted at the New England Deaconess Hospital. Of sixteen patients who survived the immediate postoperative period, 12 (75%) sustained a pulmonary complication. Of these complications, 64% were noninfectious--whereas 22% were infectious, and 14% probably infectious. Six of eight documented infections were caused by viruses of the herpes group. In four cases of viral pneumonitis other pulmonary pathogens were isolated (fungi-3, protozoan-1, bacteria-1). Unlike noninfectious complications, pulmonary infections were associated with a fatal outcome in five of six patients who died after OLT. Pulmonary complications are frequent and serious occurrences after OLT, and contribute to both the morbidity and mortality of this procedure. Compared with pulmonary complications seen after transplantation of other organs, OLT was associated with a higher proportion of noninfectious complications but a similar spectrum of pulmonary infections.