原位肝移植供肝撕裂伤的处理

目的 探讨原位肝移植供肝获取过程中发生撕裂伤的处理方式.方法 对2018年2月至2021年1月清华大学附属北京清华长庚医院297例原位肝移植手术中供肝撕裂伤的情况进行回顾性分析.对供肝撕裂伤进行分级分度:包膜撕裂<2 cm为A级,≥2 cm但<5 cm为B级,≥5 cm为C级;无明显肝实质裂伤即肝实裂深度<1 mm为I...     

原位肝移植中移植肝早期功能的评价

目的通过测定原位肝移植中一些血清学指标来评价肝移植术后早期移植肝的功能状况。方法随机选取瑞金医院肝移植中心原位肝移植患者20例。分别在麻醉开始后（S）、无肝期开始即刻（A1）、无肝期结束前即刻（A2）、门静脉血流开放即刻（R0）、门静脉血流开放60min（R1）、门静脉血流开放3h（R3）、门静脉血流开放6h（R6）、门静脉血流开放12h（R12）、门静脉血流开放24h（R24）时间点抽取外周血，测定血清ALT、AST、LDH、GMP-140、vWF和HA。结果ALT、LDH在再灌注后即刻（R0）、AST在R6即达到峰值（P〈0．05），以后逐渐下降，但仍维持较高水平。LDH与ALT呈高度正相关（R=0．948，P〈0．001），LDH与AST呈中度正相关（R=0．646，P〈0．001）。GMP-140再灌注后开始升高，R3、R6、R12点达到峰值（P〈0．001），以后逐渐下降，但仍维持高水平。血管性血友病因子（von Willebrand factor，vWF）在再灌注后R6、R12、R24点高于正常。HA在再灌注后均高于正常。结论AST和ALT仍然是原位肝移植术后早期反映移植肝功能状况的可靠指标；LDH与ALT及AST存在良好相关性；GMP-140、vWF和HA的升高反映了肝窦内皮细胞（SEC）的损伤程度，但能否准确反映早期移植肝功能状况则有待进一步证实。     

大鼠肝移植小移植物模型的研究

目的 建立大鼠肝移植小移植物模型，探讨移植物体积对受体生存的影响。方法 48只雄性SD大鼠随机分为4组：70％肝切除组(A组)、全肝移植组(B组)、中等移植物组(C组)、小移植物组(D组)。观察各组大鼠生存率。于术后不同时间点，采取外周静脉血检测肝功能；行肝组织常规组织学及透射电镜检测。结果 D组第3天生存率为56％，显著低于A、B、C组(P＜0．01)；各时间点D组各生化指标均显著高于其他3组(P＜0．01)；A、C和D组肝脏组织学以肝细胞再生的表现为主，B组以淋巴细胞浸润为主。D组术后第3天光镜下和透射电镜检查可见分裂肝细胞；第21天移植肝体积已达正常水平。结论 大鼠肝移植小移植物模型供肝量应超过全肝重量的45％。影响小移植物成活的主要因素是缺血—再灌注损伤和手术技术。     

A survival-based scoring-system for initial graft function following orthotopic liver transplantation

Initial graft function following orthotopic liver transplantation is a major determinant of postoperative survival and morbidity. Despite several efforts to provide scoring-systems for initial graft function, there is still a lack of a generally accepted classification scheme. The previously published systems assessed initial graft function based on the first postoperative days or weeks using liver-related laboratory parameters. It was shown that in most cases the scoring-systems did not correlate with patient survival. We intended to refine the definition of initial graft function in order to provide a survival based classification system. In a retrospective analysis of 761 patients following primary liver transplantation, a new scoring-system for early postoperative graft function was developed. Statistically significant differences in long term survival were calculated for ALAT, ASAT, bile production and prothrombin activity on days 1, 3, 7, 14. Points were then assigned according to the degree of survival: improved survival=1 point, poor survival=2 points. Patients were split into three groups corresponding to initially good, moderate and poor function. Applying this score, early and late patient survival rates and incidence of initial non-function were statistically significantly different. This was in contrast to the Gonzalez and the Ploeg-Maring classification scales, which are based on arbitrarily chosen cutoff levels. Retransplantation rates and postoperative morbidity were comparable both for the new and the older systems. We can conclude that the presented refined scoring-system for initial graft function provides a significant correlation to patient survival and initial non-function. We recommend the refined system for future studies.     

肝移植术后免疫抑制剂的替换应用

目的 探讨和总结肝脏移植术后免疫抑制剂的替换应用情况和经验。方法 回顾性分析我院1993年4月－2001年7月施行的67例肝脏移植，对48例早期肝移植患者中发生的免疫抑制剂替换应用情况进行总结。结果 48例患者中，21例（43．8％）因术后出现排斥反应或严重毒副作用而替换为其它免疫抑制方案。环孢素A（CsA 硫唑嘌呤（Aza)＋激素方案组（31例）中，15例（48．4％）进行替换；CsA 霉酚酸酯（MMF）＋激素组（14例）中，6例（43％）进行替换。发生排斥反应者常规应用激素冲击治疗，同时替换免疫抑制剂，将CsA替换为他克莫司（FK506）或提高CsA剂量，可获得有效控制；出现药物性肝损害者应及时减少CsA用量或成FK506，其肝功能多能改善；出现肾功能损害者应减少CsA用量并改联用MMF，或替换成FK506后可有效挽救肾功能；白细胞减少或严重感染者，应停用Aza或MMF，或将CsA改为FK506后可有效挽救肾功能；白细胞减少或严重感染者，应停用Aza或MMF，或将CsA改为FK506；神经系统病变经更换免疫抑制剂可以好转。结论 合理应用免疫抑制剂是提高肝移植成功率的关键之一；治疗中应视具体情况及时、果断、合理地转换免疫抑制剂，可以有效控制排斥反应、毒副作用及相关并发症，提高移植肝的存活率。     

原位肝移植后初期肝功能不良危险因素分析

目的分析原位肝移植后导致初期肝功能不良(IPGF)发生的危险因素.资料与方法分析36次原位肝移植.肝移植术后72 h内ALT和(或)AST>1500 IU/L作为IPGF组,<1500 IU/L作为非IPGF组.受体肝移植前分析指标为年龄、原发疾病、Child分级;供肝分析指标为热缺血时间、冷保存时间、冷保存末期肝活检;手术分析指标为受体手术时间、无肝期时间.结果供肝热缺血时间IPGF组显著高于非IPGF组(P=0.04),IPGF组受体肝功能Child C者、供肝冷保存时间均高于非IPGF组,但未达到显著性差异,其余因素两组无差异(P>0.05).结论供肝热缺血时间是引起IPGF的危险因素,肝移植前肝功能Child C级、供肝冷保存时间可能是潜在危险因素.     

Perioperative use of continuous renal replacement therapy for orthotopic liver transplantation

Purpose

We present a retrospective study describing the perioperative use of continuous renal replacement therapy (CRRT) for orthotopic liver transplantation (OLT).

Materials and Methods

We retrospectively reviewed the clinical course of patients who underwent OLT with the perioperative use of CRRT. The following variables were recorded: Gender, age, indication for transplantation, time when CRRT was initiated, postoperative need for CRRT, and the patient and organ (liver, kidneys) outcome up to 1 year after transplantation.

Results

Among 105 patients who underwent OLT from 2006 to 2010; we used CRRT in 12 cases (11.4%) perioperatively, including 9 (8.3%) patients intraoperatively. Perioperative CRRT was employed for volume, electrolyte, and/or pH management. All patients who underwent CRRT perioperatively were alive at 1 month, 10 (83.3%), at 3 and 6 months and 9 (75%) at 1 year after OLT. Only 1 surviving patient (8.3%) required renal replacement therapy at 1 month after surgery. Renal replacement therapy was not required in any surviving patient up to 12 months posttransplantation.

Conclusion

Perioperative and especially intraoperative use of CRRT therapy can potentially improve the outcomes of patients undergoing OLT.     

Simplified technique for auxiliary orthotopic liver transplantation using a whole graft

Background

Acute liver failure is associated with a high mortality rate and the main purposes of treatment are to prevent cerebral edema and infections, which often are responsible for patient death. The orthotopic liver transplantation is the gold standard treatment and improves the 1-year survival.

Aim

To describe an alternative technique to auxiliary liver transplant on acute liver failure.

Method

Was performed whole auxiliary liver transplantation as an alternative technique for a partial auxiliary liver transplantation using a whole liver graft from a child removing the native right liver performed a right hepatectomy. The patient met the O´Grady´s criteria and the rational to indicate an auxiliary orthotopic liver transplantation was the acute classification without hemodynamic instability or renal failure in a patient with deterioration in consciousness.

Results

The procedure improved liver function and decreased intracranial hypertension in the postoperative period.

Conclusion

This technique can overcome some postoperative complications that are associated with partial grafts. As far as is known, this is the first case of auxiliary orthotopic liver transplantation in Brazil.     

小体积肝移植和辅助性原位小体积肝移植治疗猪急性肝功能衰竭的近期疗效观察

目的观察小体积肝移植和辅助性原位小体积肝移植治疗猪急性肝功能衰竭的近期疗效。方法急性肝功能衰竭猪随机分为3组接受肝移植治疗:A组行全肝移植(n=5);B组行小体积肝移植(n=5);C组行辅助性原位小体积肝移植(n=5)。各组动物开腹后即刻、切脾后即刻和再灌注后30 min分别监测门静脉压力,并观察术后生化指标变化、病理改变和1周生存率。结果A、B和C三组的移植肝重量与受体体重之比分别为(2．44±0．30)％、(0．76±0．02)％和(0．75±0．03)％。再灌注后30 min,B组移植肝门静脉压力显著高于其它两组(A:B:C=13．3:17．5:12．2 cmH2O, P<0．01),C组原肝门静脉压力显著高于移植肝门静脉压力(14．3:12．2 cmH2O,P<0．05)。A组和C组术后第2天起血清天冬氨酸转氨酶、总胆红素、凝血酶原时间、乳酸和血氨水平明显下降,术后第7天基本恢复至正常水平。B组术后上述生化指标一直维持在较高的水平,术后第2～4天明显高于其它两组(P<0．01)。A组、B组和C组1周生存率分别为100％、20％和80％,B组明显低于其它两组(P<0．05)。结论辅助性原位小体积肝移植治疗急性肝功能衰竭近期疗效优于小体积肝移植,术中不必干预原肝门静脉。     

The effect of perfusion speed on graft reperfusion injury after rat orthotopic liver transplantation

Objective

The objective of this study was to investigate the effects of various perfusion speeds on reperfusion injury of grafts after liver transplantation.

Methods

Liver transplantation was performed from Sprague-Dawley (SD) to SD rats. Recipients were divided into 4 groups according to perfusion speed: 50 mL/h for group A, 100 mL/h for group B, 150 mL/h for group C, and 200 mL/h for group D. Peripheral blood was collected from the caudal vein. All survivors were humanely killed at 24 hours posttransplantation. The morphological changes in grafts were evaluated using light microscopy, serum tumor necrosis factor-α (TNF-α), and endothelial nitric oxide synthase (eNOS) proteins as well as their messenger RNA (mRNA)-intragraft levels.

Results

The pathohistological damage of grafts in the 150 mL/h and 200 mL/h groups were compared with the 50 mL/h and 100 mL/h groups. TNF-α in serum was increased at 6 hours, reaching a peak at 12 hours posttransplantation. The TNF-α levels in the 50 mL/h and 100 mL/h groups were significantly lower than the 150 mL/h and 200 mL/h groups; the 50 mL/h group was greater than the 100 mL/h group as well as the 200 mL/h group was greater than the 150 mL/h group. The expressions of eNOS protein and mRNA intragraft in the 150 mL/h and 200 mL/h groups were significantly reduced compared with the 50 mL/h and 100 mL/h groups, and the 50 mL/h group was decreased when compared with the 100 mL/h group. There was no significant difference between the 150 mL/h group and the 200 mL/h group.

Conclusion

The optimal perfusion speed for harvesting rat liver graft is 100 mL/h. High-speed perfusion may impair sinusoid endothelial cells and low-speed perfusion may extend the warm ischemia time and increase microthrombus formation.