门静脉回流技术在胰肾联合移植动物实验中的应用

目的研究门静脉回流技术在胰肾联合移植动物实验中的应用。方法 24只杂交长白猪随机分为体循环回流组(SVD)和门静脉回流组(PVD),每组内随机分为供、受体,经供体猪腹主动脉原位灌注,大块联合切取供体胰、节段十二指肠、左肾、脾脏。修剪移植肾脏、胰腺和十二指肠,左肾静脉与肠系膜上静脉吻合后．PVD组采用移植物门静脉与受体肠系膜上静脉吻合,SVD组采用移植物门静脉与下腔静脉吻合。各组腹主动脉与受体腹主动脉吻合,十二指肠内置人T型管、输尿管内置人脑室引流管自腹壁引出待Ⅱ期手术吻合。结果 SVD组和PVD组手术均很成功,供肾、胰植入受体后立即恢复良好的血液循环,并且迅速恢复功能,平均存活期分别为12d和14d。结论门静脉回流技术是可行的。     

用供体腹主动脉行肝动脉重建小型猪肝移植模型的可行性研究

目的 探讨用供体腹主动脉行肝动脉重建小型猪肝移植模型的可行性.方法 取广西巴马小型猪10头(供、受体各5头),在取供体时,切取与腹腔动脉相连的一段腹主动脉,在供肝植入时用该段腹主动脉与受体腹主动脉吻合进行肝动脉重建,以获得植入肝理想的入肝血流.结果 5例受体巴马小型猪肝血流再通后在胆管吻合前均见金黄色胆汁流出,受体猪术后24 h均存活,手术获得成功.结论 在巴马小型猪的肝移植术中使用供体腹主动脉进行肝动脉重建是可行的,研究结果 为使用供体腹主动脉进行肝动脉重建的肝移植动物实验研究提供了重要基础.     

门静脉回流的胰肾联合移植大鼠模型制备

目的探索建立大鼠胰肾联合移植（SPK）模型的手术技巧。方法以雄性健康近交封闭群SD大鼠作为供体，Wistar大鼠作为受体，行整块胰肾十二指肠移植。采用供体腹主动脉和受体腹主动脉端侧吻合，供体门静脉和受体肠系膜上静脉端侧吻合，供体肾静脉和受体肾静脉袖套式吻合，供体输尿管膀胱瓣与受体膀胱吻合，最后将十二指肠近端结扎，远端腹壁造瘘。结果共正式实验40例，手术成功率为85％。供体肾、胰植入受体后立即恢复良好的血液循环，移植后24h血糖、肌酐降为正常，术后移植胰腺具有内分泌功能。结论此模型切实可行，手术成功率高，术后并发症少，可用于SPK基础方面的研究。     

Improved technique of vascular anastomosis for small intestinal transplantation in rats

AIM To establish a new improved vascular anastomotic technique to simplify the surgical technique and increase the survivsl rate of small intestinal transplantation in rats. METHODS The graft removed en bloc consisted of entire small intestine, portal vein and aortic segment with superior mesenteric artery. The graft was perfused in situ and the gut lumen was irrigated during the operation.Heterotopic small bowel transplantation was performed by microvascular end-to-side anastomosis between the donor aortic segment with superior mesenteric artery and the recipient abdominal aorta, and by the formation of a "Cuff" anastomosis between the donor portal vein and the recipient left renal vein. Both ends of the grafts were exteriorized as stomas. RESULTS A total of 189 intestinal transplantations were performed in rats, 33 of which were involved in the formal experimental group, with a survival rate of 84.8%. The average time for the donor surgery was 80min ±10min; for graft repair 10min ± 3min; and for recipient surgery 95min ± 15min. The average time for the arterial anastomosis and the vein anastomosis was 18min ± 5min and imin,respectively. The warm ischemic time and cold ischemic time were 22min ± 5min and less than 60min, respectively. The whole operation was completed by a single surgeon, the operative time being about 3 hours. CONCLUSION The vascular anastomosis used in this study could simplify surgical technique,reduce the operative time and elevate the survival rate of small intestinal transplantation in rats.     

Establishment of a new pig model for auxiliary partial orthotopic liver transplantation

AIM: To establish a new pig model for auxiliary partial orthotopic liver transplantation (APOLT). METHODS: The liver of the donor was removed from its body. The left lobe of the liver was resected in vivo and the right lobe was used as a graft. After the left lateral lobe of the recipient was resected, end-to-side anastomoses of suprahepatic inferior vena cava and portal vein were performed between the donor and recipient livers, respectively. End-to-end anastomoses were made between hepatic artery of graft and splenic artery of the host. Outside drainage was placed in donor common bile duct. RESULTS: Models of APOLT were established in 5 pigs with a success rate of 80%. Color ultrasound examination showed an increase of blood flow of graft on 5th d compared to the first day after operation. When animals were killed on the 5th d after operation, thrombosis of hepatic vein (HV) and portal vein (PV) were not found. Histopathological examination of liver samples revealed evidence of damage with mild steatosis and sporadic necrotic hepatocytes and focal hepatic lobules structure disorganized in graft. Infiltration of inflammatory cells was mild in portal or central vein area. Hematologic laboratory values and blood chemical findings revealed that compared with group A (before transplantation), mean arterial pressure (MAP), central venous pressure (CVP), buffer base (BB), standard bicarbonate (SB) and K+ in group B (after portal vein was clamped) decreased (P<0.01). After reperfusion of the graft, MAP, CVP and K+ restored gradually. CONCLUSION: Significant decrease of congestion in portal vein and shortened blocking time were obtained because of the application of in vitro veno-venous bypass during complete vascular clamping. This new procedure, with such advantages as simple vessel processing, quality anastomosis, less postoperative hemorrhage and higher success rate, effectively prevents ischemia reperfusion injury of the host liver and deserves to be spread.     

First case of cadaveric liver transplantation in Japan

The first case of liver transplantation from a brain-dead donor in Japan is described. The recipient was a 43-year-old man with familial amyloid polyneuropathy who manifested various neuropathic symptoms and autonomic dysfunction at the time of transplantation. The graft had three arteries, for which a single trunk was created at the back table. A side-to-side cavacaval anastomosis was performed as an outflow reconstruction. To avoid portal congestion, a temporary shunt between the right posterior branch of the portal vein and the vena cava was constructed, instead of a venovenous bypass. The graft preservation time was 7.2 h and the operation time was 12.2 h. Although sufficient blood flow in the hepatic artery, portal vein, and hepatic vein was confirmed intra- and postoperatively, using Doppler ultrasound, transient graft dysfunction was observed immediately after surgery, but there was spontaneous improvement. The patient was discharged 100 days after transplantation.     

Modified techniques of heterotopic total small intestinal transplantation in rats

AIM：To establish a successful model of heterotopic total small inestinal transplantation(SIT)in rats in order to reduce the complications and increase the survival rats.METHODS:A total of 196Wistar rats underwent heterotopicSITwith microsurgical technique.Technical modifications included shortening fasting time and supplying energy before surgery,administering optimal volume of crystalloid fluid to the donor and recipient during surgical procedures,reducing mechanical and ischemic injuries to donor intestine,revascularizing small intestinal graft with a combination of conventional aorta to aorta anastomosis and a cuffed portal vein to left renal vein anastomosis which resulted in an acceptably short warm ischemic time,and also an adequate blood supply and drainage of the graft.RESULTS:The average time for the donor surgery was 86min&#177;20min,the mean operative time for the recipient was 115min&#177;20min and warm ischemia time was shortened to 40min&#177;5min,There was a shorter revascularizing time of the graft,the abdominal aorta(AA)to AA anastomosis being21min&#177;10min,and the cuffed portal vein(PV)to the renal vein anastomosis being 5min&#177;5min,The one-week survival rate of 98rats withSITwas88.78%(87/98),without thrombosis and stenosis of anastomosis,The longest survival time of recipient rats was more than389days after SIT,the rats were maintaining normal weight,with perfect intestinal function and intact intestinal histology.CONCLUSION:These modified techniques for SITwould remarkably reduce the complications and improve survival rate in rats,which provided a potentially mor consistent and practical model for experimental and clinical studies.     

静脉移植物在成人间活体肝移植中应用的研究

目的研究移植血管在成人间活体右半肝移植（LDLT）中的应用。方法对26例成人间LDLT患者，用大隐静脉重建肝Ⅴ、Ⅷ段肝中静脉粗大属支，及右肝下静脉，用大隐静脉补片修补供体门静脉损伤．狭窄以及肝动脉搭桥。结果利用大隐静咏重建Ⅴ、Ⅷ段肝中静脉粗大属支和右肝下静脉流出道20例，其总的重建率76．9％（20／26），其中重建一支静脉15例，重建两支静脉5例。重建引流的模式和病例数如下：Ⅴ53例，Ⅴ82例，Ⅴ5和Ⅴ83例，V5和右肝下静脉1例，Ⅴ8和右肝下静脉1例，右肝下静脉10例。肝动脉搭桥率11．5％（3／26），肝动脉和腹主动脉间大隐静脉搭桥2例，肝动脉与肝动脉间夫隐静脉搭桥1例。供体门静脉补片1例。所有病例术中和术后随访2～48月，超声检查均未发现血栓，血流通畅。结论自体大隐静脉在LDLT术中重建Ⅴ5、Ⅴ8及右肝下静脉流出道和肝动脉搭桥，能有效预防小肝综合征和动脉并发症。     

Portal vein arterialization technique for liver transplantation patients

Liver transplantations were performed on two patients with hepatic failure caused by liver cirrhosis. Hard obsolete thrombi and portal venous sclerosis were observed in the major portal veins of both patients. The arteria colica media of one recipient and the portal vein of the donor were anastomosed end-to-end. The hepatic artery of the first donor was anastomosed end-to end with the gastroduodenal artery of the first recipient; meanwhile, the portal vein of the second donor was simultaneously anastomosed end- to-end with the common hepatic artery of the second recipient. The blood flow of the portal vein, the perfusion of the donor liver and liver function were satisfactory after surgery. Portal vein arterialization might be an effective treatment for patients whose portal vein reconstruction was difficult.     

复制大鼠异位心脏移植模型100例的体会

目的 :总结复制大鼠腹腔异位心脏移植模型的体会。方法 :健康远交系Wistar大鼠为供体 ,SD大鼠为受体 ,各 10 0只。供心的升主动脉及主肺动脉分别与受体的腹主动脉和下腔静脉做端侧吻合 ,将供心移植于受体的腹腔内。结果 :共建立 10 0例大鼠异位心脏移植模型 ,供心缺血时间 (30± 5 )min ,手术成功率 91%。结论 :手术成功的关键 :1.麻醉剂量合适 ;2 .注意供心的保护 ,缩短供心缺血时间 ;3.提高血管吻合质量 ,避免吻合口出血及血流不通畅 ;4 .术后保温 ,纠正酸中毒     

对肝功能衰竭的猪行异位部分肝移植的效果评价

目的 探讨在猪急性缺血性肝功能衰竭时行辅助性异位部分肝移植的作用。 方法在缩窄门静脉8 5％以上的同时,对结扎及不结扎肝动脉的家猪体内配对开展辅助性异位部分肝移植,监测受体存活情况、肝功能、肝脏血流情况、病理及供肝胆汁分泌情况。 结果 在缩窄门静脉85％以上并结扎肝动脉的受体肝脏体积缩小,病理提示大片肝细胞坏死,在缩窄门静脉85％以上而未结扎肝动脉的受体肝脏色泽正常,病理肝细胞无明显异常;植入肝体积增大,病理提示肝细胞存活良好并有分裂增生。 结论 受体肝动脉结扎、门静脉缩窄可以造成急性肝功能衰竭模型;辅助性异位部分肝移植能纠正肝功能衰竭;保留受体肝脏动脉血供、减少门静脉血供对受体肝脏功能无严重影响。     

Macrochimerism of donor type CD56+ CD3+ T cells in donor specific transfusion via portal vein following living related donor liver transplantation

Antigens given orally or through the portal vein are known to be less immunogenic and to induce immunologic unresponsiveness. The mechanisms responsible for graft enhancement are still unclear. Moreover, in actuality, it is difficult to perform transfer of donor antigens via the portal vein in clinical transplantation. We investigated the effect of transfer of donor blood via the portal vein intra- and post-operatively in living related donor liver transplantation for recurrent multiple hepatocellular carcinoma. A 62-year-old female, who suffered from recurrent multiple hepatocellular carcinoma with hepatitis C virus, underwent living related donor liver transplantation with the right lobe of her daughter. Eleven hepatocellular carcinomas were recognized in the resected specimen. Donor blood was administered via the portal vein using a catheter inserted in the middle colic vein intra- and postoperatively. Mononuclear cells were obtained by operative liver biopsy or postoperative biopsy using fine needle aspiration biopsy, and from peripheral blood. They were analyzed by two or three color-flow cytometry using several antibodies. The differentiation between donor and recipient was estimated by means of anti-HLA antibodies of donor and recipient. The postoperative course was uneventful. She did not suffer from acute cellular rejection and was discharged on day 30 the after operation. CD56+ CD3+ T cells in the liver increased notably from 20% to 50% after transplantation. One half of the CD56+ CD3+ T cells in the liver graft were of the donor type (donor anti-HLA A2 antibody) on day 8 after surgery. Donor type CD56+ CD3+ T cells occupied 17.4% of the total CD56+ CD3+ T cells even on day 42 after the operation. Stimulation index by mixed lymphocyte reaction continued at a low level (< 2) from day 1 after the operation. Steroids were discontinued after 40 postoperative days. FK506 was also reduced to 0.5 mg/day 4 months after the operation. There was no recurrence of hepatocellular carcinoma and hepatitis C virus for two years after the operation. Macrochimerism of donor type CD56+ CD3+ T cells in a graft might be induced by the transfer of donor blood via the portal vein and may play an important role in transplantation tolerance. Inoculation of donor blood via the portal vein may also be very useful for rapid reduction of immunosuppression.     

8a Liver transplantation: newer surgical approaches

The standard procedure for orthotopic liver transplantation remains transplantation of the whole organ together with resection of the vena cava and the use of venovenous bypass. In cases of severe mismatch of the donor and recipient vena cava, the piggyback technique, if necessary with vena cava plasty, is preferable. Furthermore, in all cases where venovenous bypass cannot be performed, the piggyback or other technique preserving the vena cava should be performed. In paediatric patients, reduced/size liver transplantation may be indicated because of the shortage of small livers. In the hands of experienced surgeons, the results of reduced-size liver transplantation in paediatric patients are similar to those of whole organ transplantation. Further innovative procedures to overcome the problem of organ shortage include split-liver and living related transplantation in children. Distinct advantages of living related transplantation can be seen in a well-functioning graft, lack of preservation injury, elective operation and optimal graft-size matching. The immunological advantage that has been claimed could not be demonstrated so far, and will need to be examined in the long-term follow-up. However, there remains a distinct disadvantage for living related transplantation with regard to the surgical technique. Pre-operative portal venous thrombosis should be carefully assessed, but is not a contraindication to liver transplantation if the confluence of the superior mesenteric vein and splenic vein is patent. Arterial reconstruction at the confluence of two arteries (hepatic and gastroduodenal or splenic artery) seems to be preferable to an end-to-end anastomosis because of improved inflow into the graft and a reduced risk of arterial stenosis and thrombosis. Where the common hepatic arteries are small, with reduced or reversed flow, and in patients with coeliac trunk stenosis, we recommend a direct approach to the suprarenal or infrarenal aorta. Bile duct anastomosis may preferably be performed with a side-to-side technique, to reduce early and late biliary complications.     

Rat liver transplantation without preservation of ＂phrenic ring＂ using double cuff method

AIM： To develop a double cuff rnebhod for rat liver transplantation without preservation of “phrenic ring“ to shorten the portal vein clamping time.METHODS: “Phrenic ring“ was completely excluded from the donor liver, and end to end anastomosis of suprahepatic inferior vena cava was performed.RESULTS: The portal vein clumping time was shortened to 10.6 min, the successful rate was 83.1%.CONCLUSION: This method can simplify the operation and shorten the portal vein clumping time.     

Techniques for overcoming atretic changes of the portal vein in living donor liver transplantation

BackgroundSpontaneous diversion of the portal flow through collateral vessels into the systemic circulation is frequently observed in liver transplant recipients with severe portal hypertension. This induces main portal vein atretic change and modifies flow into the collateral even after donor graft implantation. These atretic changes make liver transplantation challenging. In this article we described several methods for overcoming this challenge by appropriate surgical techniques.MethodsThree anastomotic techniques for living donor liver transplantation were performed in patients with atretic changes in the portal vein.ResultsThe three techniques were (1) venoplasty to widen the diameter by using the recipient's portal vein, and the diameter of the recipient's portal vein was enlarged using their own portal vein stump patch; (2) conduit with cryopreserved vessels, and we dissected around the superior mesenteric vein and splenic vein junction and a conduit was built using the cryopreserved vessels; and (3) left gastric varix to portal vein anastomosis, if the recipients had large gastric varix and variceal wall was sufficiently thick for anastomosis.ConclusionsSelection of optimal methods for portal vein anastomosis is essential in patients with atrophic change on the portal vein. If these methods are used aptly, they can be considered as favorable methods for overcoming each situation.     

Laser Doppler velocimetry measurement of canine mucosal circulation response to bronchial artery reperfusion after lung transplantation.

Left lung transplantation accompanied by reestablishment of the circulation of the bronchial arteries by simultaneous transplantation of part of the aorta was performed on seven dogs. Mucosal circulation of the bronchi at the anastomosis was evaluated using laser Doppler velocimetry (LDV). Since the donor lung must maintain blood supply through the bronchial arteries, the donor aorta from its ascending portion to the descending portion below the outlet for the last bronchial artery was retained with the lung graft. The distal end of the left brachiocephalic artery was sutured to the side of the recipient aorta when the blood supply to the bronchial arteries was to be restored. The LDV values before reperfusion of the bronchial arteries were 20 to 65% (mean: 42.8%) of the preoperative value. Since the LDV values increased to 36 to 125% (mean: 79.9%) of the control, blood flow to the bronchial mucosa increased evidently. Four out of seven dogs died one to two days after the operation due to bleeding and operative stress. One dog was sacrificed on the 4th postoperative day and another on the 16th. The last dog died 40 days after surgery. The unfavorable course of the LDV values in these three dogs suggest that the method used does not ensure an adequate blood supply to the bronchial arteries in the long term.     

Modifications in combined liver-small bowel transplantation in pigs

AIM: To inlToduce combined liver-small bowel transplantation in pigs.METHODS: Eighteen transplantations in 36 large white pigs were performed. Three modifications in combined liver-small bowel transplantation model were applied: Veno-venous bypass was not used. Preservation of the donor duodenum and head of pancreas in continuity with the combined graft to avoid biliary reconstruction. The splenic vein of donor was anastomosed end-to-end with the portal vein of recipients by the formation of a “cuff”.RESULTS: Without immunosuppressive therapy, 72-hour survival rate of the transplanted animals was 72 % (13/18).Five of 18 pigs operated died of respiratory failure (3 cases) and bleeding during hepatectomy (2 cases). The longest survival time of animals was 6 days.CONCLUSION: Our surgical modifications are feasible and reliable, which have made the transplantation in pigs simpler and less aggressive, and thus these can be used for preclinical study.     

Technical dilemma in living-donor or split-liver transplant

In partial liver transplantation for adults criteria for the extent of reconstruction of middle hepatic vein tributaries have not been clarified. After hepatic venous and portal anastomoses in living-donor liver transplantation using left liver graft without middle hepatic vein, color Doppler ultrasonography was applied to check venous and portal blood flow. Color Doppler ultrasonography demonstrated absent hepatic venous flow and reversed portal venous flow in the congested area of the left paramedian sector which had been drained by the divided branch of the middle hepatic vein. The area was darkly discolored before arterial reperfusion and under clamping of the artery. Reconstruction of the venous branch was added after arterial anastomosis. Color Doppler ultrasonography revealed restored normal venous outflow and portal inflow after venous reconstruction. Postoperative course of the recipient was uneventful with rapid recovery of liver function. We propose that middle hepatic vein tributaries should be reconstructed if color Doppler ultrasonography demonstrates absent venous flow and reversed portal flow, and if the liver volume excluding the discolored area under occlusion of the hepatic artery is estimated to be insufficient for postoperative metabolic demand.     

Use of an interpositional venous graft posterior to the pancreas for LDLT patients with portal vein thrombosis

Portal vein thrombosis is a risk factor in patients who require liver transplantation, because it is often difficult to treat portal vein thrombosis, especially when it involves the confluence of the superior mesenteric vein and splenic vein. Since some transplant centers that perform living-donor liver transplantation do not have cryopreserved cadaveric vein grafts available and do not use graft veins that are long enough for a jump graft, it is difficult to reconstruct the portal vein with interpositional vein grafts in patients with portal vein thrombosis. We describe the treatment of portal vein thrombosis with an interpositional vascular graft posterior to the pancreas in a living-donor liver transplantation patient without using a jump graft. This method provided a shorter rout between the donor and recipient portal vein than a jump graft. Our experience suggests that this solution can be helpful in treating portal vein thrombosis.     

Modified technique for combined liver-small bowel transplantation in pigs

AIM: As the conventional combined liver-small bowel transplantation is complicated with many postoperative complications, the aim of this study was to describe a modified technique for the combined liver-small bowel transplantation with preservation of the duodenum, partial head of pancreas and hepatic biliary system in pigs. METHODS: Composite liver/small bowel allotransplantations were undertaken in 30 long-white pigs. The graft included liver, about 3 to 4 m proximal jejunum, duodenum and partial pancreatic head. Vessels reconstructions included subhepatic vena cava-vena cava anastomosis, aorta-aorta anastomosis and portal-splenic vein anastomosis. RESULTS: Without immunosuppressive treatment, the median survival time of the animals was 6 days (2 to 12 days), and about 76.9 % (20/26) of the animals survived for more than 4 days after operation. CONCLUSION: The modified technique is feasible and safe for the composite liver/small bowel transplantation with duodenum and pancreas preserved in pigs. And also this technique can simplify the operation and decrease possible postoperative complications.