器官捐赠与分配

美国移植器官捐赠和分配的法律、制度相对齐全，较充分地体现了公平、公正、最大限度利用宝贵的供体资源的原则，值得我国借鉴。     

腹部多器官的快速整体切取与胰腺修整方法的改进

笔者对供体腹部多器官整体切取及胰腺修整技术进行了改进。采用单腹主动脉灌注腹部器官，并在胰腺血管构建中重建胃十二指肠动脉。整体切取的器官移植后功能完好，无严重并发症出现。提示单腹主动脉灌注技术可以保证腹部多器官切取及联合应用的要求，胃十二指肠动脉的重建有利于胰腺血运的保证。     

腹腔器官联合快速切取的临床研究

我科进行了原位灌洗联合切取肝肾和胰、十二指肠和肾的临床研究，并利用同一供者成功地为３人进行了器官移植手术，即１例同种异体原位肝脏移植与２例肾脏移植。按此方法所取器官移植结果：５２例肾脏移植通血后１￣１０分钟之内均有尿液泌出，肝移植通血后１５分钟即有金黄色胆汁泌出。此法可避免因血管变异所造成的切取损伤，降低器官的废弃率，缩短了热缺血时间，提高移植器官功能，此法适合我国国情。     

胰肾联合移植的供体切取与修整7例

目的　总结胰肾一期联合移植手术的供体切取和修整方法。方法　采用原位灌注联合切取和体外修整的方法完成7例尸 体供胰、十二指肠和肾的联合切取与修整。结果　7例获取器官的热缺血时间平均3分30秒,联合切取器官时间14分20秒,灌 注液平均用量1050mL。用切取、修整的胰、肾完成了3例胰肾联合移植和9例肾移植,均迅速恢复功能,未出现严重外科并发 症。3例胰肾联合移植术后均完全停用胰岛素,正常饮食,胰肾功能正常存活已分别达34个月、25个月和21个月。结论　供体 切取和修整的质量是胰肾联合移植成功的关键之一,此原位灌注联合切取和体外修整的方法可提供保证。     

美国器官捐献和移植管理体系简介

美国是世界上器官移植开展最早和数量最多的国家,1968年就出台了《联邦遗体捐献法》,1984年又出台了《国家器官移植法》,有较为完善的法律体系,成立了国家层面的器官捐献移植协调管理机构和分布在各州和地区的58个器官获取组织,建立了覆盖全国的网络,形成了有效的经济运行机制,能有效地开展工作,较好地解决了移植器官短缺的问题。这些实践对中国目前开展的器官捐献工作有重要的借鉴和参考意义。     

腹部实质器官的切取与保存

供体器官的质量在某种程度上取决于器官切取手术与保存技术，完美的供体手术技术，不但可以减少原发性供体功能衰竭的发生，还可放宽供体选择指征，最大限度地解决供体器官短缺的现状，挽救更多濒临死亡的病人。在脑死亡法尚未通过的国家，或者在供体生命指标不易维持的情...     

上腹部器官簇移植供体器官的切取及修整

目的 探讨上腹部多器官移植中器官簇的切取、修整、血管整形方法及移植效果.方法 5例供体器官簇的获取均采用腹部多器官联合切取,腹主动脉、肠系膜上静脉、胆道及十二指肠同时灌注降温.供体器官簇的肠系膜上动脉和腹腔干分别与取自供体的髂内、外动脉预先行端端吻合,再通过髂总动脉与受体腹主动脉单口端侧吻合（动脉“搭桥”）.受体行上腹部肝、胆、胰、脾、十二指肠、全胃、空肠上段及大小网膜切除,接受肝、胰、十二指肠器官簇移植.结果 5例患者移植术后器官簇存活及功能均良好,肝胰功能均在术后1周左右恢复正常.其中2例患者分别于术后第2天、第3天出现十二指肠空肠吻合口瘘,经再次手术后治愈.目前,除1例患者于术后3个月肿瘤复发、肺转移,死于全身衰竭外;其余4例患者移植物功能良好,现均已存活达6个月.结论 获取质量良好的上腹部器官簇及适当的血管整形,是保证移植效果的前提;上腹部器官簇移植是治疗上腹多脏器恶性肿瘤的有效治疗方法.     

胰肾联合移植中供体切取和修整的技巧

目的:总结胰肾一期联合移植中供体胰十二指肠及肾脏切取及修整的经验。方法:回顾性分析19例胰肾联合移植术中供体胰十二指肠及肾脏切取的方法与移植物的修整技巧。结果:无1例发生移植物损伤。联合移植术后9 d之内18例完全停用外源性胰岛素,空腹血糖正常，尿糖≤（+）。术后2～4 d，血肌酐和尿素氮降至正常。3例出现移植肾脏急性排斥反应，2例发生移植胰腺急性排斥反应，给予甲泼尼龙冲击治疗后恢复正常。1例术后因移植物加速排斥反应，术后11 d切除移植胰、肾。结论:胰肾联合移植手术中，供体胰十二指肠及肾脏的切取及修整是手术成功的重要因素之一。     

胎胰器官整体培养方法探索

因胰组织碎片普通培养不太理想，本文报告用人胎胰和新生鼠胰分别进行了整胰高氧摆动培养和胰组织碎片普通培养的比较研究，结果表明整胰高氧摆动培养的胰岛素分泌量、胰岛释放功能及胰岛细胞形态学的检查等均比胰组织碎片的普通培养好。而且经高氧培养的胰腺组织其免疫原性也明显降低。     

Improving pancreas graft utilization through importation

Background

We analyze our outcomes utilizing imported allografts as a strategy to shorten wait list time for pancreas transplantation.

Methods

This is an observational retrospective cohort of 26 recipients who received either a locally procured (n = 16) or an imported pancreas graft (n = 10) at our center between January 2014 and May 2017. Wait list times of this cohort were compared to UNOS Region 9 (New York State and Western Vermont). Hospital financial data were also reviewed to analyze the cost‐effectiveness of this strategy.

Results

Imported pancreas grafts had significantly increased cold ischemia times (CIT) and peak lipase (PL) levels compared to locally procured grafts (CIT 827 vs 497 minutes; P = .001, PL 563 vs 157 u/L; P = .023, respectively). There were no differences in graft or patient survival. The median wait time was significantly lower for simultaneous kidney‐pancreas transplants at our center (518 days, n = 21) compared to Region 9 (1001 days, n = 65) P = .038. Despite financial concerns, the cost of transport for imported grafts was offset by lower standard acquisition costs.

Conclusions

Imported pancreas grafts may be a cost‐effective strategy to increase organ utilization and shorten wait times in regions with longer waiting times.     

Retrieval of the pancreas allograft for whole‐organ transplantation

Proper pancreas retrieval during multi‐organ recovery is one of the cornerstones of technically successful whole‐organ pancreas transplantation. With evolving surgical approaches for organ retrieval and implantation, it has become standard to procure the pancreas in conjunction with other abdominal organs without compromising either vasculature, graft quality, or transplant outcomes. This review summarizes the major steps required for proper whole‐organ retrieval of the pancreas allograft with suggestions and tips whenever alternative approaches are available.     

供肝获取和灌洗方式对移植术后早期肝功能的影响

目的 探讨不同的供肝获取和灌洗方式对移植术后早期肝功能的影响.方法 对442例肝移植的临床资料进行回顾性分析.442例均为尸体供者,供肝切取术中采用腹主动脉和脾静脉插管对供肝进行原位灌洗,灌洗液为4℃UW液或4℃UW液联合高渗枸橼酸盐嘌呤溶液(HC-A液),获取的供肝均保存于UW液中.按照供肝获取方式、灌洗液的种类、灌洗液静脉引流途径及胆道冲洗方法的不同将病例分为5组.肝移植术后1周,测定受者血清总胆红素(TBil)、直接胆红素(DB)、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、碱性磷酸酶(ALP)、γ-谷氨酰转移酶(γ-GT)及前白蛋白(PA)等肝功能指标,以及活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白(Fb)及国际标准化比值(INR)等凝血功能指标.结果 肝、肾分别切取者的供肝获取手术耗时(17.6±2.5)min,联合切取者为(15.9±2.3)min,二者间的差异有统计学意义(P＜0.05).联合切取者中,灌洗液经颈静脉引流者的γ-GT、AST、PT和INR明显低于经肝下下腔静脉引流者(前一项P＜0.01,后三项P＜0.05),而Fb明显高于经肝下下腔静脉引流者(P＜0.05);采用UW液和HC-A液联合灌洗者,其γ-GT、ALT、AST,DB和TT均明显低于单用UW液灌洗者(前三项P＜0.05,后二项P＜0.01),而Fb明显高于单用UW液灌洗者(P＜0.01).结论 联合切取法有利于缩短器官获取时问;采用UW液和HC-A液联合灌洗及灌洗液经颈静脉引流更有利于术后早期肝功能的恢复.     

Deceased donor uterus retrieval: A novel technique and workflow

Uterus transplantation has proven successful when performed with a living donor. Subsequently, interest in the novel field of reproductive transplantation is growing. The procedure is still considered experimental, with fewer than 25 cases performed worldwide, and the techniques of both uterus procurement and transplantation are still developing. We detail a new approach to deceased donor uterus procurement. In contrast to reported techniques and our own initial experience, in which the deceased donor uterus was procured post cross‐clamp and after other organs were procured, our approach now is to perform the uterus procurement prior to the procurement of other organs in a multiorgan donor and hence prior to cross‐clamp. We describe our practical experience in developing and implementing the logistical workflow for deceased donor uterus procurement in a deceased multiorgan donor setting.     

Effects of pre-transplant dialysis modality on early outcome of kidney transplantation from donation after cardiac death

Objective To compare the influence of hemodialysis (HD) and peritoneal dialysis (PD) on early outcome of patients underwent kidney transplantation from donation after cardiac death (DCD). Methods Patients admitted in the First People's Hospital of Foshan with DCD kidney transplant from January 1st, 2011 to June 30th, 2016 were analyzed retrospectively. Recipients were grouped into HD group (n=61) and PD group (n=28) according to their pre-transplant dialysis modality. Their short-term outcomes after DCD kidney transplant were compared, including recovery of renal function, short-term complications and laboratory data. Results Patients had longer dialysis duration and lower hemoglobin, serum albumin and phosphorus in PD group than those in HD group (all P＜0.05), but no significant difference shown in age, gender, body mass index, primary disease, blood pressure, and hepatitis B infection (all P＞0.05). HD patients with 6.00(4.00, 11.00) d recovery time of renal function, 18.00(17.00, 21.50) d hospital time, had 24.59% the delayed graft function (DGF), 3.28% acute rejection and 16.39% infection during hospitalization. While for PD patients the recovery time of renal function was 4.00(3.75, 7.00) d; hospital time was 19.00(15.00, 21.75) d; the incidence rate of DGF was 14.29%; acute rejection was 3.57%; and infection during hospitalization reached 17.86%. Above indexes were not significantly different between HD and PD groups (all P＞0.05). Repeated measure ments showed that, compared with those before transplant surgery, after 1 month, 3 months and 6 months HD and PD groups had decreased creatinine and phosphorus, and increased hemoglobinserum albumin and calcium; Serum albumin and calcium were different between the two groups (P＜0.001, P=0.040), whereas creatinine, hemoglobin and phosphorus did not show difference (all P＜0.05). After transplantation the trends of creatinine, hemoglobin, calcium and phosphorus were not different between the two groups (P values were 0.295, 0.310, 0.501 and 0.063, respectively). Conclusions No significant difference of the recovery regarding renal function, anemia, nutrition status and mineral metabolites was found between pre-transplant HD and PD modality in patients who underwent DCD kidney transplantations.     

Initial Blood Washout During Organ Procurement Determines Liver Injury and Function After Preservation and Reperfusion

Organ procurement is the first step toward effective liver preservation and comprises a thorough washout of blood components from the microvasculature. To study the efficacy of optimal blood washout of the liver, three groups were compared including low-pressure perfusion with UW-CSS (12 mmHg, group A), which is the routine method in clinical practice, high-pressure perfusion with UW-CSS (100 mmHg, group B) and low-pressure perfusion with modified UW solution (12 mmHg, group C). After procurement all livers were preserved in original UW-CSS for 0, 24 or 48 h, followed by reperfusion in oxygenated Williams Medium E for 24 h at 37 degrees C. Histology results of livers procured in group A, showed good hepatocyte viability but also remaining erythrocytes. However, injury parameters were high and ATP concentrations were low. No functional differences were found. Group B, high pressure, and group C, modified UW-CSS, both showed better results. High-pressure washout is preferable since the warm ischemia time during procurement is short. We propose to use high-pressure UW-CSS perfusion for the initial blood washout of the donor liver instead of the usually used low-pressure washout.     

Combined pancreatic and kidney transplantation: en bloc retrieval and transplantation - a new surgical technique

Abstract We designed and performed on two patients a new surgical procedure of en bloc kidney and pancreatic transplantation. The liver, pancreas and kidneys were removed en bloc in the donor. On the bench, the liver and the left kidney were separated from the bloc, leaving the pancreas and the right kidney for combined kidney and pancreatic transplantation, The portal vein was divided near to the emergence of the splenic vein. The coeliac axis was taken with an aortic patch. The left renal vein was cut at its entrance to the inferior vena cava (IVC) and the left renal artery was taken with an aortic patch. Reconstruction of the pancreatic vessels was performed with a double anastomosis: the portal vein was anastomosed to the hole in the IVC resulting from the section of the left renal vein and the splenic artery was anastomosed to the hole in the aorta resulting from the section of the left renal artery. The proximal ends of the aorta and IVC were closed with running sutures. In the recipient, the iliac vessels on the right side were dissected. Anastomosis of the distal part of the aorta and the IVC was performed with the right iliac vessels. Duodenocystostomy and reimplantation of the ureter were done according to the usual techniques. This new surgical technique allowed an easy vascular reconstruction of the pancreatic vessels. In the recipient, only one side was used for renal and pancreatic transplantation. Moreover, the length of the transplant procedure was significantly reduced.     

Short segment aortic endarterectomy--a technique to aid cannulation in donors with severe aorto-iliac disease

Cannulation of the abdominal aorta in older donors with advanced atherosclerotic disease is challenging and may lead to dissection or plaque embolization. We describe a different technique, short segment aortic endarterectomy, which can be a useful alternative during organ procurement. It permits safer cannulation and securing of atherosclerotic infrarenal aortas, thereby allowing us to flush and safely use organs that otherwise would have been discarded.     

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目的 对供者肝脏等器官的联合获取、修整和保存方法进行研究。方法 采用原位腹主动脉和门静脉插管、低温灌注，快速多器官联合获取、低温保存技术及体外修整获得可供移植的肝移植物。结果 获取122例供者的移植物，平均热缺血时间为4min30s，平均获取时间为20min，平均冷缺血时间为10h。均采用4℃的HCA液(高渗枸橼酸盐腺嘌呤溶液)和UW液灌注和保存。118例修整成适用于临床用的肝的移植物，76例供肝在移植前留取了病理活检标本，病理检查提示供肝结构正常。移植术后，无原发性肝无功能发生。结论 该方法适合于供者肝脏等器官的快速联合获取、修整和保存。