用袖套式血管吻合法建立大鼠肝、肠联合移植模型

目的 建立肝、肠联合移植手术模型。方法 用Ｗｉｓｔａｒ大鼠行同种异体肝、肠联合移植。先行肝移植,再行小肠移植。肝脏为原位移植,供肠异位移植于左肾处（切除左肾）。门静脉、肝下下腔静脉和肠系膜上静脉采用袖套式吻合法分别与受者的门静脉、肝下下腔静脉和左肾静脉吻合,回肠末端在左下腹造瘘。结果 手术成功率为６２．５％,动物平均存活时间１１．２ｄ。组织学检查发现移植肝和小肠发生排斥反应。结论 用袖套式血管吻合     

门静脉回流式肠道引流的同侧胰肾联合移植术四例

目的 改进门静脉回流式肠道引流的胰肾同侧联合移植术的动脉重建方法.方法 供者采用肝胰肾脾联合切取法,并切取供者髂血管备用.修整供者器官时,将肝总动脉与胃十二指肠动脉端端吻合,以重建胰十二指肠动脉弓;将髂总静脉与门静脉端端吻合,以延长门静脉1～2 cm;将髂外动脉与肠系膜上动脉和腹腔干共同的腹主动脉袖片行端端吻合,备用.胰腺移植时,将供者延长后的门静脉与受者肠系膜上静脉行端侧吻合,将供者髂总动脉及髂内动脉经末端同肠系膜打孔穿出后,供者髂总动脉与受者髂外动脉行端侧吻合,供者髂内动脉用血管夹暂时夹闭,准备与供肾动脉吻合.供者十二指肠与受者空肠用吻合器行侧侧吻合.肾移植时,将供肾静脉与受者髂外静脉行端侧吻合,肾动脉与夹闭备用的供者髂内动脉行端端吻合,开放肾血流后,将移植肾经切口置于右下腹部侧腹膜外同定,并在腹膜外吻合输尿管与膀胱.结果 除1例术后第50天时因腹腔感染导致多器官功能衰竭而死亡外,其他3例术后均恢复顺利.术后对3例存活患者随访了24～27个月,患者移植物功能良好,完全停用胰岛素,血清肌酐为72.5～119.7μmol/L.结论 门静脉回流式肠道引流的胰肾同侧联合移植术较传统术式操作简单,而十二指肠动脉弓的重建改善了胰腺及十二指肠的血液供应.术中利用供者髂总动脉搭桥,将供肾动脉吻合到供者髂内动脉的术式可以减少在受者严重钙化的周围血管上的操作次数,同时为患者保留了左侧髂动脉.     

二例成人间双活体供肝移植的手术重建技巧

目的探讨成人间双活体供肝移植的手术重建技巧。方法2例成人患者,1例原发病为乙型肝炎后肝硬化、巨块型肝癌,接受其2位姐姐的左半肝移植,移植物与受者体重比(GR/WR)为1.5%,移植于原肝位置左侧的左半肝,其肝左静脉、门静脉分别于受者的肝左静脉、门静脉左支端端吻合,胆肠吻合方式重建供肝胆道;移植至右侧的左半肝,沿矢状位旋转180°,其肝左静脉、门静脉分别与受者的肝右静脉、门静脉右支端端吻合,左肝管与受者的肝总管端端吻合。另1例原发病为乙型肝炎后肝硬化,接受其母亲的右半肝移植,但由于供肝存在大泡状空泡变性,且供、受者的体重差较大,为能满足患者的生理需要,故该例同时行尸体左半肝移植,GR/WR为1.2%,右半肝的肝右动脉、肝右静脉分别于受者的同名血管端端吻合,其门静脉与受者的门静脉右支端端吻合,右肝管与受者的肝总管端端吻合;左半肝的肝左静脉、门静脉及肝动脉分别与受者的肝左静脉、门静脉左支及脾动脉端端吻合,胆肠Roux-en-Y吻合方式重建供肝胆道。结果除母亲供者术后3d出现短暂乳糜漏,经对症治疗11d后痊愈外,供者无其它并发症发生。2例患者术后恢复良好,未发生排斥反应及全身感染,现已随访10个月以上,肝功能正常,均恢复正常工作和生活。结论成人间双活体供肝移植可为受者提供更大的肝脏,又可减少供者的风险,但手术操作复杂,需要对供、受者的条件进行充分评估后施行。     

短肠综合征合并高位肠瘘患者施行亲属活体小肠移植一例

目的总结短肠综合征合并高位肠瘘患者施行亲属活体小肠移植的经验和体会。方法为1例因肠系膜上动脉栓塞而切除空肠、大部分回肠及右半结肠的患者施行亲属活体小肠移植,供者为患者之子,移植回肠长度为150 cm,供肠热缺血时间1 min,冷缺血时间65 min。受者切除肠瘘,供肠动、静脉分别与受者的腹主动脉和下腔静脉行端侧吻合,供肠的近端与受者的空肠残端行端端吻合,远端侧壁与结肠残端行侧端吻合,移植小肠末端造口,作为观查窗。术后使用他克莫司、霉酚酸酯和甲泼尼龙预防排斥反应,并给予抗感染、抗凝以及胃肠外为主、肠内营养为辅的支持治疗。结果术后移植小肠功能接近正常,能胜任一般的体力劳动。术后110 d,患者因情绪变化突发心脏意外,抢救无效死亡。结论合并肠瘘的短肠综合征并非小肠移植禁忌证,术前充分准备和术后细致观察及管理是成功的关键。     

非整块肝脏和小肠联合移植的外科技术(附一例报告)

目的　介绍国内首例非整块肝脏和小肠联合移植的外科技术。方法　采用在体灌注、整块切取的方法获取肝脏和小肠,供者器官采用 UW液保存。将供者肝脏、小肠联合植入短肠综合征合并胆汁淤积的男性受者体内,供肝采用改良背驮式肝移植术;供肠的动脉、静脉分别与受者的肾下腹主动脉和下腔静脉吻合。结果　至术后2个月时,移植小肠和肝脏均无排斥反应,肠黏膜结构正常,对肠内营养耐受良好;CT示移植肝形态正常,复查肝功能完全恢复正常。结论　选择性应用非整块肝脏和小肠联合移植术是安全有效的,特别适合需要接受肝脏、小肠联合移植的成年患者。     

袖套式血管吻合法建立肝肠联合移植的实验研究

目的 建立一种新肝肠联合移植手术模型,探讨移植肝脏对移植小肠的保护作用.方法Wistar大鼠同种异体肝肠联合移植,供体手术时门静脉和肠系模上动脉进行双重冷灌注,用冷新霉素液冲洗小肠肠腔并清洁.受体手术的先进行肝脏移植,再进行小肠移植,门静脉、肝下下腔静脉袖套式吻合,肠系膜上动脉在显微镜下与左肾动脉油套式吻合,供体肠系膜上静脉袖套式与受体左肾静脉吻合,回肠下端在左下腹部造□,完成肝肠联合移植.结果 手术成功率为62.5%(15/24),手术平均存活为11.2天.手术后组织学发现:移植肝脏和小肠发生排斥反应.结论(1)袖套式血管吻合技术在大鼠身上建立的肝肠联合移植模型是可行的.(2)肝肠联合移植后移植的肝脏不能起到保护移植小肠的作用.     

三袖套血管吻合法行大鼠异位小肠移植

目的改进大鼠小肠移植血管吻合术式,以缩短移植肠缺血时间,简化手术操作,提高手术成功率。方法动脉吻合采用供者带肠系膜上动脉的腹主动脉段两端与受者的腹主动脉袖套吻合,静脉吻合采用供者的门静脉与受者的左肾静脉袖套吻合,即三袖套吻合法。结果共进行70次手术,成功65次,手术成功率92.9%;整个手术用时2～3h,其中动脉吻合用时(5±2)min,静脉吻合用时(2±1)min,动静脉吻合用时(8±2)min。结论三袖套血管吻合法可简化大鼠小肠移植手术,缩短手术时间。     

小鼠异位小肠移植模型的建立

目的 探讨稳定的小鼠异位小肠移植模型制作方法,为小肠移植排斥反应的研究提供良好的实验工具.方法 选用C57BL/6小鼠作供体和BALB/c小鼠作受体进行同种异基因型异位节段性小肠移植.采用小肠供体的门静脉与受体下腔静脉端侧吻合,供体带主动脉片的肠系膜上动脉与受体腹主动脉端侧吻合,供体近端肠管结扎,远端与受体空肠端侧吻合的方式建立异位小肠移植.术后禁食3天,不禁饮,每天分两次经皮下分别给予5%葡萄糖生理盐水2 mL,术后不使用抗生素和免疫抑制剂.小鼠存活超过5 d视为手术成功.结果 共行小肠节段性移植30例,术后5 d存活率达70%(21/30).供体手术时间(41±5.5)min,热缺血时间约0.5 min,供体肠段肠系膜上动脉组织片修整时间约为3 min,供体冷保存时间为(30±7.5)min,受体手术时间(90±7.5)min,其中腹主动脉及下腔静脉阻断时间为(40±3.0)min,静脉吻合时间(10±2.0)min,动脉吻合时间(15±2.5)min,成活小鼠受体手术平均出血量约0.2 mL.手术失败的9例小鼠的死亡原因为动脉吻合口部位狭窄及吻合口处血栓形成(6例),吻合口出血导致出血性休克(2例)和术后腹腔内感染(1例).结论 良好的供体肠段的获取、高质量的血管吻合和肠道吻合及供、受体补液是提高小鼠小肠移植手术成功率的关键.     

大鼠小肠移植模型的改进

目的：在传统小肠移植模型基础上改进操作方法并试图建立一个操作简便、并发症少、稳定的大鼠小肠移植模型.方法：显微镜下切取供肠的范围包括近端空肠、门静脉及其带肠系膜上动脉的腹主动脉袖.动脉吻合采用供体带肠系膜上动脉的腹主动脉袖与受体的腹主动脉端侧吻合,静脉吻合采用供体的门静脉用袖套法与左肾静脉端端吻合,移植肠两端造瘘.结果：正式实验100次,手术成功率91%.供体手术控制在50 min以内,受体手术控制在80 min以内,手术时间约为150 min.结论：完全在显微镜下建立大鼠小肠移植模型并将手术方法加以改进能在手术视野清晰、术中操作定位准确、局部创伤小的基础上使手术时间缩短,并发症更少,存活率更高.     

大鼠异位节段小肠移植模型建立技术的改进

目的：建立大鼠异位节段小肠移植模型。方法：对40例（80只）Wistar大鼠施行异位小肠移植,供受体术前抗生素灌胃,改变供受体术式,减少受体手术时间、手术损伤及供肠缺血时间;采用腹主动脉-肠系膜上动脉吻合以及左肾静脉-门静脉单套管吻合,血管吻合方法采用单纯间断吻合,重建供肠血管;移植小肠双造口,静脉补液通路采用股静脉。结果：肠缺血时间≤35min,吻合口无狭窄,40例大鼠接受小肠移植,建模成功35例。结论：改进小肠移植技术中的多个细节后,降低了大鼠小肠移植术的难度。     

Lung and heart-lung transplantation

This report is a brief summary on current events related to lung and heart-lung transplantation. Eleven patients have undergone transplantation of the heart and both lungs at Stanford University. The ages ranged from 22–45, the average age being about 36 years, and included were four females and seven males. The diagnosis was primary pulmonary hypertension in three and Eisenmenger syndrome-congenital heart disease with pulmonary hypertension-in eight. Eight patients are living and well, two to more than 24 months after transplantation of the heart and both lungs. All these patients were discharged and are fully rehabilitated, which is an important consideration. There have been three operative deaths, one was secondary to two previous operations that made our operation much too long, another was secondary to the use of intravenous cyclosporine, and the third was related to the poor maintenance of the donor lung. Three of the eleven patients were catheterized following the transplant from six months to a year after transplantation, and the pulmonary artery pressure and pulmonary vascular resistance were absolutely normal in all three of these individuals. Of course the plan is to go ahead with further catheter studies at yearly intervals in all of the patients. The last patient underwent transplantation in January, 1983. I think no matter how effective or how ingenious the medical staff is with artificial organs, it will be a long time before these early results of transplantation of the heart and both lungs can be matched by any types of artificial organ implants. Supported in part by a grant (HL 13108) from the National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, and from the Dr. Ralph and Marian Falk Foundation for Medical Research Gist of a Lecture given at the Japan Surgical Society, April 7, 1983.     

Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation represents an important treatment option for patients with intestinal failure. Early attempts were hindered by technical and immunological complications. However, significant developments in immunosuppressive therapy have led to marked improvements in outcomes in recent years. The main indications for intestinal transplantation are life-threatening complications or unacceptable quality of life on total parenteral nutrition (TPN), or following evisceration for extensive intra-abdominal tumours. In suitable patients, in the absence of significant liver disease, an isolated intestinal graft is appropriate. A combined liver and intestinal transplant is indicated in patients with significant liver disease, almost always as a result of long-term TPN. Pathology affecting the foregut may require more extensive grafts including the stomach, duodenum and pancreas. Multivisceral transplantation is technically demanding. The transplant recipient has frequently undergone multiple previous laparotomies and may present with multiple stomata, fistulae, collections, distortion of intra-abdominal anatomy and significant contraction of the abdominal cavity. The most important early complications are acute rejection and sepsis, which frequently occur together. In the long-term, chronic rejection and malignancy are the leading causes of graft loss and mortality and immunosuppression related renal impairment a major source of morbidity. It is hoped that ongoing improvements in intestinal and multivisceral transplantation may eventually justify its use as a primary alternative to long-term TPN.     

Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation represents an important treatment option for patients with intestinal failure. Early attempts were hindered by technical and immunological complications. However, significant developments in immunosuppressive therapy have led to marked improvements in outcomes in recent years. The main indications for intestinal transplantation are life-threatening complications or unacceptable quality of life on total parenteral nutrition (TPN), or following evisceration for extensive intra-abdominal tumours. In suitable patients, in the absence of significant liver disease, an isolated intestinal graft is appropriate. A combined liver and intestinal transplant is indicated in patients with significant liver disease, almost always as a result of long-term TPN. Pathology affecting the foregut may require more extensive grafts, including the stomach, duodenum and pancreas. Multivisceral transplantation is technically demanding. The transplant recipient has frequently undergone multiple previous laparotomies and may present with multiple stomata, fistulae, collections, distortion of intra-abdominal anatomy and significant contraction of the abdominal cavity. The most important early complications are acute rejection and sepsis, which frequently occur together. In the long term, chronic rejection and malignancy are the leading causes of graft loss and mortality and immunosuppression related renal impairment a major source of morbidity. It is hoped that ongoing improvements in intestinal and multivisceral transplantation may eventually justify its use as a primary alternative to long-term TPN.     

Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation represents an important treatment option for patients with intestinal failure. Early attempts were hindered by technical and immunological complications. However, significant developments in immunosuppressive therapy have led to marked improvements in outcomes in recent years. The main indications for intestinal transplantation are life-threatening complications or unacceptable quality of life on total parenteral nutrition (TPN), or following evisceration for extensive intra-abdominal tumours. In suitable patients, in the absence of significant liver disease, an isolated intestinal graft is appropriate. A combined liver and intestinal transplant is indicated in patients with significant liver disease, almost always as a result of long-term TPN. Pathology affecting the foregut may require more extensive grafts including the stomach, duodenum and pancreas. Multivisceral transplantation is technically demanding. The transplant recipient has frequently undergone multiple previous laparotomies and may present with multiple stomata, fistulae, collections, distortion of intra-abdominal anatomy and significant contraction of the abdominal cavity. The most important early complications are acute rejection and sepsis, which frequently occur together. In the long-term, chronic rejection and malignancy are the leading causes of graft loss and mortality. It is hoped that ongoing improvements in intestinal and multivisceral transplantation may eventually justify its use as a primary alternative to long-term TPN.     

Present status and future perspectives of intestinal transplantation.

Intestinal transplantation (ITx) is the only definitive therapy for irreversible intestinal failure. Owing to the limited short- and long-term graft survival over the years, ITx has been a complementary treatment to home parenteral nutrition. However, the development of intestinal and multivisceral transplantation has been significant over the past 15-20 years owing to the progress in immunosuppressive therapy, refinement of surgical techniques, post-transplant care, intestinal immunology, and immunological as well as anti-infectious monitoring. The improvement of patient- and graft survival over the last few years together with data on the cost effectiveness of ITx, following 2 years after transplantation, may require a redefinition of the indication for ITx.     

临床肝肾移植三例体会

目的　探讨肝肾序贯移植和同期联合移植的手术难点及围手术期处理要点。方法　对2例肾移植术后发生药物性肝损害的病例实施肝移植 ,并对 1例巨大多囊肝、多囊肾的病例实施肝肾联合移植。结果　 2例肾移植术后实施肝移植的病例 ,其中 1例因术后肾功能衰竭导致多器官功能衰竭死亡 ;另 1例术后肝、肾功能良好 ,现已存活 1年。肝肾联合移植病例术中采用肝后腔静脉直接阻断法 ,使重达 10kg的巨大病肝得以顺利切除 ,并采用腔静脉成型术完成改良背驮式肝移植。术后免疫方案采用人源化单克隆抗体达利珠单抗免疫诱导下的以FK5 0 6、霉酚酸酯 (MMF)和激素的三联用药 ,肝、肾功能恢复良好 ,现为术后 6个月。结论　序贯性肝肾移植在术前应该准确评估移植肾功能 ,如果移植肾功能不良 ,应果断选择实施肝肾联合移植。肝后下腔静脉直接阻断法在实施巨大病肝切除时具有较大优势。肝肾联合移植术中及术后建议采用达利珠单抗免疫诱导下的免疫三联用药。     

Renal Comorbidity After Solid Organ and Stem Cell Transplantation

After transplantation of solid organs or hematopoietic stem cells, a significant acute decrease in renal function occurs in the majority of patients. Depending on the degree of kidney injury, a large number of patients develop chronic kidney disease (CKD) and some develop end‐stage renal disease requiring renal replacement therapy. The incidence varies depending on the transplanted organ, but important risk factors for the development of CKD are preexisting renal disease, hepatitis C, diabetes, hypertension, age, sex, posttransplant acute kidney injury and thrombotic microangiopathy. This review article focuses on the risk factors of posttransplant chronic kidney disease after organ transplantation, considering the current literature and integrates the incidence and the associated mortality rates of acute and chronic kidney disease. Furthermore, we introduce the RECAST (RE nal C omorbidity A fter S olid organ and hematopoietic stem cell T ransplantation) registry.     

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目的 报告国内首例同种异体肝小肠联合移植，并就肝肠联合移植适应证、排斥诊断与治疗、感染防治、肠功能恢复与营养支持进行讨论。方法 供肠长380cm，供肠肠系膜上动脉、门静脉分别与受体腹主动脉、下腔静脉端侧吻合；供肝行改良背驮式肝移植。术后免疫抑制剂采用FK506 激素 骁悉 赛尼哌方案。排斥监测采用内镜指导下肠粘膜活检病理学检查及临床观察。并采取措施防治感染和促进移植肠功能的恢复。结果病人恢复顺利，移植肠和移植肝功能良好，未发生排斥反应，术后3个月时已摆脱全肠外营养，依靠肠内营养维持营养状态。结论 肝小肠联合移植对肠衰竭合并全肠外营养所致肝功能损害病人，是可行、有效的治疗方法。