大鼠肝动脉永久性或间歇阻断后侧枝循环的观察

永久性肝动脉结扎（ＰＨＡＬ）后侧枝循环的建立．是ＰＨＡＬ治疗肝癌效果不持久的原因之一．如何防止或减少侧枝循环的形成．是肝癌缺血治疗的重要环节之一。通过大鼠选择性腹腔动脉造影（ＳＣＡ）的方法．观察ＰＨＡＬ和肝动脉反复暂时阻断（ＲＴＢＨＡ）后侧枝形成的情况。ＰＨＡＬ后２ｗｋＳＣＡ即可见侧枝循环．随着时间延长．侧枝愈加明显丰富，其主要来源是肠系膜上动脉、腹腔动脉和大网膜。ＲＴＢＨＡ后２ｗｋ，ＳＣＡ未显示侧枝形成。实验结果表明肝动脉的间歇阻断可以防止侧枝循环的建立。这为ＲＴＢＨＡ的临床运用提供了实验依据。     

缝扎肝右静脉后肝动脉与门静脉血流改变的实验研究

目的：探讨结扎主肝静脉对肝动脉与门静脉血流动力学的影响。方法：小型猪共12头，剖腹后，电磁血流计测量结扎前后肝动脉、门静脉血流，大网膜静脉置管测量结扎前及结扎后30min、1、3、5、7、14、21、28、56d的自由门静脉压力(FPP)，56d后再次开腹测量肝动脉、门静脉血流。结果：FPP术后均升高，以术后7d内明显，6头超过35cmH2O，且其中3头小猪出现上消化道出血；肝动脉血流速早期增加，56d降至略高于术前水平；门静脉血流速早期减少，未检测到逆向血流，术后56d，门静脉血流速恢复为略低于术前水平。结论：结扎一条主肝静脉不会引起结扎肝叶的萎缩坏死，可能会导致上消化道出血。     

Hepatic arterial buffer response fails to restore hepatic oxygenation after temporary liver dearterialization in canines

BACKGROUND: Hepatic artery thrombosis is a rare but extremely troublesome condition after liver transplantation. Recently, urgent arterial revascularization has been used as rescue therapy, leading to improved graft and patient survivals. Hepatic artery ligation produces a progressive reduction in portal vein blood flow. Theoretically, a hyperemic response may be expected following hepatic artery reperfusion (hepatic artery buffer response, HABR). In this study, we tested the hypothesis that HABR can maintain adequate liver oxygenation after temporary liver dearterialization. METHODS: Seven dogs (19.7 +/- 1.2 kg) subjected to 60 minutes of hepatic artery occlusion were observed for 120 minutes thereafter. Systemic hemodynamics was evaluated through Swan-Ganz and arterial catheters, and splanchnic perfusion by portal vein and hepatic artery blood flows (PVBF and HABF) via an ultrasonic flowprobe. Liver enzymes (ALT and LDH) and systemic and hepatic oxygen delivery (DO2hepat) were calculated using standard formulae. RESULTS: Hepatic artery occlusion induced a progressive reduction in PVBF and DO2hepat. A complete restoration of HABF after hepatic artery declamping was observed; however, the DO2hepat (33.3 +/- 5.9 to 16.5 +/- 5.9 mL/min) did not return to the baseline levels. CONCLUSION: Temporary hepatic artery occlusion induced a progressive decrease in portal vein blood flow during ischemia, an effect that continued during the reperfusion period. The hepatic artery blood flow was promptly restored after declamping. However, HABR was not able to restore hepatic oxygen delivery to baseline levels during the reperfusion period.     

反复暂时性肝动脉阻断作为晚期肝癌的序贯治疗—附25例报告

本文报告反复暂时性肝动脉阻断结合腹腔或肝动脉内化疗治疗２５例晚期不可切除肝恶性肿瘤的结果。２５例中１０例用肝动脉间歇阻断加腹腔５─氟尿嘧啶化疗,５例加经肝动脉导管灌注５─氟尿嘧啶化疗,１０例加经肝动脉大剂量顺铂“双路”化疗。治疗后５例肿瘤明显缩小,肿瘤直径小于原５０％。５例中３例为大剂量顺铂“双路”治疗,其中１例成功施行肿瘤序贯切除。全组治疗后平均存活时间为１１．３个月,最长存活５６个月,２例迄今仍存活。     

The effect of temporary hepatic artery or portal vein occlusion in obstructive jaundice.

Hepatic hemodynamics before vascular occlusion and the effect of transient hepatic artery or portal vein occlusion on the liver were investigated in normal dogs and dogs with experimentally induced obstructive jaundice by measurement of hepatic tissue blood flow (HTBF), index of hemoglobin concentration (IHb), oxygen saturation (ISO2), serum glutamic pyruvic transaminase (SGPT) concentration, and malonaldehyde (MDA) concentration in liver tissue. Livers with obstructive jaundice had increased blood flow and a lower hemoglobin concentration compared with normal livers at baseline before vascular occlusion. Percentage change of ISO2 from baseline was higher than percentage change of HTBF after reperfusion in both normal and obstructive jaundiced liver, although they were decreased to almost similar proportions during vascular occlusion. MDA concentration in obstructive jaundice after reperfusion following vascular occlusion was higher than in normal liver. Furthermore, MDA concentration after reperfusion following hepatic artery occlusion was increased compared with after reperfusion following portal venous occlusion in obstructive jaundice. There was no evidence of massive liver necrosis which was newly developed by transient vascular occlusion. These results represent the pathological condition in the liver before transient vascular occlusion and after reperfusion in obstructive jaundice.     

Continuous transcatheter arterial thrombolysis for early hepatic artery thrombosis after liver transplantation

Early hepatic artery thrombosis (HAT) after orthotopic liver transplantation remains a significant cause of graft loss and patient death. The most effective treatment approach is still controversial. The purpose of this study was to assess the effect of continuous transcatheter arterial thrombolysis in the treatment of early HAT. Routine posttransplant color Doppler imaging (CDI) was performed to monitor hepatic artery blood flow. HAT was confirmed by arterial angiography in suspected cases. HAT was identified in 8 patients (8/287, 2.8%) which occurred on days 2 to 19 (mean, 5.2 days) after liver transplantation. Patients with HAT were treated with continuous transcatheter arterial thrombolysis using urokinase. Successful revascularization through thrombolysis was obtained in all eight cases. One patient died of a pulmonary infection at 2 months after liver transplantation. Another patient underwent retransplantation because of resistant allograft rejection and recurrence of HAT 6 months after the first operation, but died from multiple system organ failure 2 months later. The other six patients remained in good health during the follow-up period of 3 to 27 months. Our results demonstrate that CDI is an effective method to monitor the occurrence of early HAT after liver transplantation. Furthermore, continuous transcatheter arterial thrombolysis with urokinase could be a rational therapeutic approach to rescue the allograft following early HAT diagnosis confirmed by arterial angiography.     

Preoperative hepatic and regional arterial chemotherapy in the prevention of liver metastasis after colorectal cancer surgery

OBJECTIVE: To investigate whether preoperative hepatic and regional arterial chemotherapy is able to prevent liver metastasis and improve overall survival in patients receiving curative colorectal cancer resection. METHODS: Patients with stage II or stage III colorectal cancer (CRC) were randomly assigned to receive preoperative hepatic and regional arterial chemotherapy (PHRAC group, n = 110) or surgery alone (control group, n = 112). The primary endpoint was disease-free survival, whereas the secondary endpoints included liver metastasis-free survival and overall survival. RESULTS: There were no significant differences in overall morbidity between PHRAC and Control groups. During the follow-up period (median, 36 months), the median liver metastasis time for patients with stage III CRC was significantly longer in the PHRAC group (16 +/- 3 months vs. 8 +/- 1 months, P = 0.01). In stage III patients, there was also significant difference between the 2 groups with regard to the incidence of liver metastasis (20.6% vs. 28.3%, P = 0.03), 3-year disease-free survival (74.6% vs. 58.1%, P = 0.0096), 3-year overall survival (87.7% vs. 75.7%, P = 0.020), and the median survival time (40.1 +/- 4.6 months vs. 36.3 +/- 3.2 months, P = 0.03). In the PHRAC arm, the risk ratio of recurrence was 0.61 (95% CI, 0.51-0.79, P = 0.0002), of death was 0.51 (95% CI, 0.32-0.67; P = 0.009), and of liver metastasis was 0.73 (95% CI, 0.52-0.86; P = 0.02). In contrast, PHRAC seemed to be no benefit for stage II patients. Toxicities, such as hepatic toxicity and leukocyte decreasing, were mild and could be cured with medicine. CONCLUSIONS: Preoperative hepatic and regional arterial chemotherapy, in combination with surgical resection, could be able to reduce and delay the occurrence of liver metastasis and therefore improve survival rate in patients with stage III colorectal cancer.     

结直肠癌术前经肝动脉联合区域动脉灌注化疗的安全性评价

目的 评价术前肝动脉联合区域动脉灌注化疗预防结直肠癌根治术后肝转移的安全性.方法 2001-2007年收治的Ⅱ期和Ⅲ期结直肠癌患者随机分成术前肝动脉联合区域动脉灌注化疗组(介入组,n=256)和对照组(n=253).对两组围手术期的血常规、肝功能、免疫指标、并发症情况等进行评价.结果 介入组介入术后7天(手术前)Ⅲ级肝功能异常、白细胞减少、贫血和血小板减少发生率分别为3.1%(8/256)、5.5%(14/256)、7.4%(19/256)、6.6%(17/256),无Ⅳ级毒副反应,全组均顺利接受手术.介入组和对照组手术后并发症发生率分别为9.8%(25/256)及8.3%(21/253)(X2=1.86,P＞0.05).截至2007年10月,所有患者均接受了随访,平均随访时间42±14个月.介入组和对照组Ⅲ期患者5年总生存率分别为81.0%:60.4%(X2=5.15,P＜0.05)、5年肝转移率分别为18.9%(28/148):27.3%(41/150)(X2=5.41,P＜0.05),Ⅱ期患者肝功能异常、白细胞减少、贫血和血小板减少和免疫指标、并发症情况等两组无差异.结论 术前肝动脉联合区域动脉灌注化疗对结直肠癌手术影响较小,不增加术后并发症的发生,而且可显著降低Ⅲ期结直肠癌术后肝转移发生率,延长患者生存期.     

Effects of repeated temporary clipping of the middle cerebral artery on pial arterial diameter, regional cerebral blood flow, and brain structure in cats

Temporary clipping of the major arterial trunk is an important maneuver to control excessive unexpected bleeding in neurosurgical operations; however, repeated temporary clipping can give rise to severe neurological deficits after surgery. The present study was performed to confirm and explain these clinical findings. Initially, a single 20-minute or 1-hour occlusion of the middle cerebral artery was performed in each of 5 cats. Pial arterial diameter was determined by video imaging, regional cerebral blood flow was measured by autoradiography, and cerebral edema and infarction were observed. In the 20-minute occlusion group, no abnormal changes were found 5 hours after recirculation. In the 1-hour occlusion group, pial arteries were dilated by 45%, and regional cerebral blood flow increased to more than twice the resting cortical values. The extent of cerebral edema was 41.2 +/- 7.5% (SE) and infarction was 34.5 +/- 9.5% (SE) of the hemisphere. In the second experiment, three 20-minute occlusions of the middle cerebral artery in a 1-hour interval were performed in 20 cats. In 10 of them, thiopental (40 mg/kg) was used to protect the brain. In the group without barbiturate treatment, pial arteries were dilated by 40% at the end of experiment, regional cerebral blood flow decreased to about 70% compared with single 20-minute occlusion, cerebral edema was 19.5 +/- 8.1% (SE), and infarction was 8.1 +/- 3.7% (SE) of the hemisphere. In the treated group, these were only trivial changes. The effect of repeated clipping may cumulatively cause brain damage, and barbiturates should be used whenever repeated clipping is necessary.     

Influence of systematic echodoppler arterial survey on hepatic artery thrombosis after liver transplantation in adults

Abstract Hepatic artery thrombosis after liver transplantation remains a major problem which may lead to graft loss and retransplantation. Hepatic artery diseases were compared in two matched groups of liver grafted patients. In Group I (67 patients), echodoppler examinations of the graft hepatic artery were carried out after clinical or biological abnormalities became evident. In Group II (85 patients), echodoppler examinations were systematically made during the follow-up at 2 weeks, 1, 3, 6, and 12 months after liver transplantation. In cases of an abnormal echodoppler examination, arteriography was carried out in order to confirm hepatic artery stenosis and to perform endoluminal angioplasty. In Group I, echodoppler examinations revealed no arterial blood flow in three cases and reduction of hepatic blood flow in two cases. Hepatic artery thromboses were always confirmed by angiography, in the latter two cases, a collateral arterial revascularization of the graft was developed. In this group, two retransplantations, one choledocojejunostomy, and four percutaneous radiological biliary drainages were necessary. In Group II, echodoppler results showing a resistive index below 0.5 and a systolic acceleration time above 0.08 s involved 13 arteriographies. Ten stenoses were diagnosed without any biological abnormalities. Nine endoluminal angioplasties were made without any complication. There was no recurrence of stenosis. One pseudoaneurysm of the femoral artery was cured by compression. The early and non-aggressive detection of hepatic artery stenoses after liver transplantation by echodoppler allows treatment by angioplasty in order to prevent hepatic artery thrombosis and reduce retransplantation.     

经导管肝动脉α-氰基丙烯酸正丁酯胶栓塞治疗肝内出血

目的探讨以α-氰基丙烯酸正丁酯胶(NBCA)作为栓塞剂经导管肝动脉栓塞治疗肝内出血的价值。方法收集接受经导管肝动脉栓塞治疗的肝动脉出血患者7例,均使用NBCA作为栓塞剂,评价技术成功率、临床有效率及相关并发症。结果造影显示假性动脉瘤6例,对比剂外溢1例。对7例患者均成功施行经导管肝动脉栓塞术,术后即刻造影假性动脉瘤和对比剂外溢征象消失,技术成功率100%;NBCA及超液化碘油混合剂用量为(0.76±0.24)ml;术后患者腹痛症状缓解,血红蛋白浓度升高,临床有效率100%。未发生手术相关并发症,随访1个月无再出血病例。结论采用NBCA胶行经导管肝动脉栓塞治疗肝内出血安全有效,具有重要临床应用价值。     

选择性肝左、右动脉阻断联合控制性低中心静脉压在肝叶切除手术的应用临床研究

目的观察选择性肝左、右动脉阻断联合控制性低中心静脉压术中出血量的影响。方法择期全麻下行肝叶切除术患者24例。分为两组：低中心静脉压组（LCVP组）和选择性肝左、右动脉阻断联合控制性低中心静脉压组（S组）。二组患者均为12例。两组患者在肝实质完全离断过程中CVP控制在0～0．49kPa水平。测量两组患者术中出血量。结果选择性肝左、右动脉阻断联合控制性低中心静脉压组和LCVP组术中出血量分别为（313±167）ml和（474±222）ml（P〈0．05）。结论选择性肝左、右动脉阻断联合控制性低中心静脉压较单存低中心静脉压可减少肝叶切除手术术中出血量。