移植物体重比对左外叶小儿活体肝移植术后短期肝功能的影响

目的 探讨移植物体重比(Graft recipient body weight ratio,GRBW)对小儿活体左外叶肝移植术后短期肝功能恢复的影响.方法 2006年6月至2009年3月共施行活体肝移植25例,其中17例左外叶活体肝移植患儿作为研究对象.分别于术后1～7 d测量患儿肝脏功能,采用SPSS15.0统计软件分析了解GRBW与术后短期肝功能恢复的相关性.结果 ①肝移植术后肝功能恢复良好(P<0.000 1);②GRBW与术后谷丙转氨酶(ALT)变化呈正相关(P<0.05)、与AST变化呈负相关(P<0.05).结论 左外叶小儿活体肝移植GRBW对于术后肝功能恢复意义重大,移植术中应充分保证足够的GRBW比值.     

CT三维重建及肝脏体积测定在小儿肝脏肿瘤手术中的应用

目的探讨螺旋CT三维成像及肝脏体积测定在小儿巨大肝脏肿瘤和位于肝门部位肝脏肿瘤手术治疗中的价值。方法2002年1月至2009年1月本院诊治巨大和位于肝门部位的小儿肝脏肿瘤25例,均使用螺旋CT增强扫描,并在CT工作站行肝动脉、门静脉及肝静脉的三维影像重建,测量全肝体积,预测切除肝脏体积,并计算残余肝脏体积及残余肝脏体积与标准化肝脏体积之比。结果25例经CT三维重建后均获得清晰的肿瘤瘤体及与血管毗邻关系的图像。其中手术患儿21例,未手术患儿4例。21例手术患儿中,行右半肝切除6例,左半肝切除5例,右三叶切除5例,左二三叶切除1例,肝中叶切除4例,手术患儿术后平均残余肝脏体积为182．55cm^3,最小残余肝脏体积为62．26m^3,平均残余肝脏体积与标准化肝脏体积之比（平均残余肝脏体积比）为44．69％,最小残余肝脏体积比为20．16％,所有患儿同手术期均未发生严重肝功能衰竭。结论通过CT三维重建的画面,可以旋转地动态观察肝脏血管的走行、位置及与肿瘤的关系,并可计算出术后残余肝脏体积及残余肝脏体积与标准化肝脏体积之比,为判断手术的可行性、手术方案的选择与制定及评估术后残余肝脏功能提供了很大的帮助。     

犬部分肝移植模型的实验研究

目的建立犬部分肝移植的动物模型。方法杂交犬124只随机分两组：供体组62只和受体组62只；供体组又随机分为活体供肝组12只和尸体供肝组50只；活体供肝组行标准左半肝切取术。尸体供肝组行原位肝脏灌注后，切取肝脏，然后去除右叶、方叶和尾状叶，保留门静脉、肝动脉和胆管于左叶待用。受体组行“H”型分流术和背驼式左半肝原位植入术。结果活体供肝组12例：术中死亡2例，术后存活10例。供肝的热缺血时间几乎为零，冷缺血时间平均29．5min。尸体供肝组50例：供肝的冷缺血时间平均47．5min。受体组犬62例：受体犬手术时间平均5．6h，无肝期时间平均45min。术中死亡5例，其中创面出血3例，下腔静脉吻合口出血2例。术后存活57例。57例肝脏血管重建后即可有胆汁从肝管中渗出。结论犬是理想的部分肝移植动物模型，“H”型分流可有效维持受体无肝期血循环稳定，免除了门腔转流的操作。为临床开展亲体和小儿部分肝移植提供了技术训练和经验的参考。     

小儿尸体肝移植探讨

目的　本研究探讨尸体肝移植治疗小儿终末期肝病的方法和疗效。方法　我院分别于2 0 0 2年 4月～ 2 0 0 2年 12月对 5例患儿 (先天性胆道闭锁 4例 ,肝脏血管内皮肉瘤 1例 )进行肝移植术 ,患儿年龄 6个月～ 5岁。减体积肝移植 3例 ,取左半肝和左外侧叶为移植物。割离式肝移植 2例 ,分别取左外后叶和右后叶为移植物。受体行保留下腔静脉的全肝切除术 ,然后将供肝进行原位移植。结果　 5例患儿移植肝重 2 6 0～ 5 6 5 g ,占受体体重1.94 %～ 5 .4 6 % ,4例术后已经健康存活 7～ 15个月 ,1例于术后第 5d死于心功能衰竭。结论　尸体肝移植是治疗小儿终末期肝病的有效方法 ,严格的围手术期管理特别是精确的手术技术是小儿肝移植成功的关键。     

小儿肝移植临床应用进展

小儿肝移植现已成为治疗儿童终末期肝病的一种有效方法。与成人肝移植相比小儿肝移植有其自身的特点 :①手术适应证不同 ,小儿多为先天性终末性肝病 ;②供体来源相对缺少以及等待器官时的高死亡率 ,术前危险性高 ;③已形成减体积、原位劈肝以及亲属活体供肝移植等特殊手术方式以适应小儿的体型特点和扩大供体来源 ;④术后并发症多与特定的手术方式相关 ,并且术后易形成免疫抑制性并发症 ;⑤原发病对小儿受体的远期存活影响较小 ,远期预后相对较好。一、小儿肝移植的适应证小儿肝移植的适应证主要为良性终末性肝病 :①先天性肝脏及胆道畸形 :…     

64层CT在儿童门静脉海绵样变性手术治疗中的价值

目的 探讨64层CT在门静脉海绵样变性术前病情判断及手术方式选择中的作用.方法 情况,与患儿手术治疗方式对比分析.结果 12例患儿中5例食管胃底静脉曲张,行胃底及食管下段血管断流术和脾切除术,4例仅行脾切除术,3例病变累及肝内门静脉行活体肝移植.自发性脾/胃-肾静脉分流8例,腹膜后Retzius静脉丛(RV)开放4例,术中保留.术后1例肝移植出现门静脉血栓死亡,其余无明显并发症.结论 64层螺旋CT血管成像可清楚显示门静脉及分支,侧支循环建立情况,有助于术前手术方案选择.     

小儿活体亲属原位肝移植5年随访

按中国传统习俗,死后必须整体埋葬,虽经各种卫生宣教及群体的呼吁,在香港尸体供肝仍然短缺,所以开展小儿活体亲属肝移植(LROLT).1993年5月及8月间,首次成功地进行了2例LROLT.为增加尸体供肝,大多数小儿可采用减体积性异体肝移植.     

小儿肝移植技术的新进展

经过几代外科医生及相关学科专家的共同努力,目前小儿肝移植技术趋于成熟,本文就小儿肝移植技术的进展,综述如下。1移植肝重量的计算肝脏是人体最重要的代谢和免疫器官,移植肝的重量与患儿的预后密切相关,如果供肝体积过小不足以满足机体代谢需要时,就会导致术后肝功能不全,甚至导致移植后早期肝无功能。动物实验结果表明,门静脉血流通过相对较小的移植肝脏会对肝组织造成严重的灌注损伤,进而导致肝功能衰竭[1];反之如果移植肝体积过大,会导致腹腔压力增高,呼吸困难,心脏和肾脏血液回流障碍,特别是移植肝体积过大导致的血流灌注不良是门静脉…     

肝移植治疗尿素循环障碍导致的高氨血症四例

目的 探讨肝移植治疗尿素循环障碍所致高氨血症的临床疗效和预后.方法 回顾性分析2001年6月至2014年5月北京友谊医院和天津市第一中心医院收治的4例因尿素循环障碍行肝移植患儿的术前特点、肝移植手术情况及术后随访的资料.结果 4例患儿均因间断发作呕吐、意识障碍、性格行为改变等前来就诊,均通过基因检测及血、尿氨基酸分析确诊为鸟氨酸氨甲酰基转移酶缺陷所致高氨血症.首次发病年龄1.5 ～3.0岁,均为女性,分别于53.9、40.6、40.3、22.8个月时接受肝移植手术;例1和例2的供体为成人尸体供肝的左外侧叶,例3的供体为活体供肝的左外侧叶,例4的供体为儿童尸体供肝全肝;4例患儿术后肝功能逐渐恢复,血氨正常且恢复正常饮食,于术后25～ 30 d出院.术后定期随访,迄今已随访162.2、124.2、12.0和4.8个月,均健康存活,生长发育正常.结论 肝脏移植是治疗尿素循环障碍导致高氨血症的重要手段,移植术后患儿可获得长期生存.     

活体肝移植治疗肝豆状核变性5例

目的 探讨活体肝移植治疗小儿肝豆状核变性的临床疗效。方法 采用亲体部分肝移植术及术后监测临床生命体征、血生化指标,抗感染、免疫抑制、营养支持等综合方法,治疗肝豆状核变性5例。结果 供体术后顺利康复;患儿术后健康存活,至今分别为3(3例)、2、1年。肝脏功能、血铜蓝蛋白已恢复正常,正常饮食,均无复发。结论 活体肝移植可纠正小儿肝豆状核变性的肝脏病变及原有的代谢缺陷,提高患儿生活质量,挽救其生命,是治疗小儿肝豆状核变性终末期肝病的一种有效方法。     

Usage of 64-detector-row spiral computed tomography volumetry in preoperative volume prediction in living donor liver transplantation in children

Purpose  

To investigate the correlation between the graft volume calculated by 64-detector-row spiral computed tomography (CT) and the graft weight measured during the living donor liver transplantation (LDLT) operation, and try to get an equation to help determine the possible weight of graft before operation.     

Clinical applications of computerized tomography 3-D reconstruction imaging for diagnosis and surgery in children with large liver tumors or tumors at the hepatic hilum

The present study assessed the benefits of 3-D reconstruction of spiral computerized tomography (CT) scans for the diagnosis of and surgical guidance to large liver tumors or tumors at the hepatic hilum. We retrospectively analyzed the cases of 18 children with large liver tumors or with tumors at the hepatic hilum treated in past 5 years. The ages ranged from 45 days to 14 years. Ten cases were examined using the three-dimensional reconstruction using 64 slice spiral CT and eight patients underwent conventional CT or conventional enhanced CT scanning. In 16 cases, the volume of tissue removed exceeded one-third the entire volume of the liver (considered “large” tumors). The largest tumor removed weighed 4.8 kg. In two cases, the excised tissue represented less than one-third of the total liver volume, but in these cases the location of the tumor was considered “complex” due to the proximity to major hepatic vessels. Seven tumors were located in the right lobe, three in the left lateral segment, three in medial segment, three extended beyond the right lobe and two extended beyond the left lateral segment. Pathological diagnoses included hepatoblastoma (n = 9), hepatocellular carcinoma (n = 2), mesenchymal hamartoma (n = 4), teratoma (n = 1) and adenoma (n = 2). The 3-D reconstructed images could be rotated to view the image from several sides, were semitransparent and allowed for the measurement of tumor size and determination of spatial relation to blood vessels. All 18 children had curative resections as indicated by “tumor-free” microscopic margins. No major intra- or postoperative complications were encountered. Three-dimensional CT imaging can provide high quality images of the tumors and location of the tumor relative to vital hepatic blood vessels. This technique offers a kind of comparatively accurate method compared with traditional imaging techniques, it could help the surgeon identify the tumor borders accurately and devise a comparative safe surgical strategy. With its help the surgeon could identify vital hepatic blood vessels before operation, so they can avoid massive hemorrhaging and avoid massive hemorrhaging during operation. This technique should be more widely applied in the resection of large or complex liver tumors.     

Hepatic venous reconstruction using the superficial femoral vein in a right‐lobe living donor liver transplant patient with interrupted inferior vena cava

Anatomical abnormalities in patients with BA often include polysplenia, preduodenal portal vein, interrupted retrohepatic IVC, cardiac abnormalities, and situs inversus. In LDLT patients who had congenital vascular anomalies, additional surgical modifications for the reconstruction of hepatic venous branches are sometimes necessary to prevent venous parenchymal congestion. We report a 12‐yr‐old female with post‐Kasai BA with interrupted retrohepatic IVC who underwent right‐lobe LDLT because the left liver graft volume was insufficient. The donor right liver graft had three major hepatic branches, including the RHV, IRHV, and MHV tributary (V8). We performed hepatic venous reconstruction by creating a large, wide triple orifice consisting of the RHV and two SFVs, which were anastomosed to the V8 and IRHV using the donor's SFV as an interposition graft. In conclusion, the reconstruction of venous orifices for right‐lobe LDLT patients with the absent retrohepatic IVC is can be carried out using an SFV graft derived from the living donor or the recipient.     

Comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging for volumetric and helical modes on 320-detector CT and helical mode on 64-detector CT

Background

Advanced multidetector CT systems facilitate volumetric image acquisition, which offers theoretic dose savings over helical acquisition with shorter scan times.

Objective

Compare effective dose (ED), scan duration and image noise using 320- and 64-detector CT scanners in various acquisition modes for clinical chest, abdomen and pelvis protocols.

Materials and methods

ED and scan durations were determined for 64-detector helical, 160-detector helical and volume modes under chest, abdomen and pelvis protocols on 320-detector CT with adaptive collimation and 64-detector helical mode on 64-detector CT without adaptive collimation in a phantom representing a 5-year-old child. Noise was measured as standard deviation of Hounsfield units.

Results

Compared to 64-detector helical CT, all acquisition modes on 320-detector CT resulted in lower ED and scan durations. Dose savings were greater for chest (27–46%) than abdomen/pelvis (18–28%) and chest/abdomen/pelvis imaging (8–14%). Noise was similar across scanning modes, although some protocols on 320-detector CT produced slightly higher noise.

Conclusion

Dose savings can be achieved for chest, abdomen/pelvis and chest/abdomen/pelvis examinations on 320-detector CT compared to helical acquisition on 64-detector CT, with shorter scan durations. Although noise differences between some modes reached statistical significance, this is of doubtful diagnostic significance and will be studied further in a clinical setting.     

临时性门腔静脉架桥联合流出道改良重建在部分供肝肝移植中应用的实验研究

目的 通过动物肝移植实验,探索门腔静脉架桥和改良肝静脉出口重建这一联合方法的可行性及价值.方法 选择20～25 kg和10～15 kg健康杂交犬各12只,组成供体组和受体组,并随机配对.供体手术取左外侧叶及左中央叶为供肝,然后完全阻断门静脉.受体犬先预置门腔静脉之间端侧吻合架桥的分流通道,切肝门静脉阻断时开放,供肝植入...     

The reduced left lateral segment in pediatric liver transplantation: an alternative to the monosegment graft

Abstract:  Tailoring graft size to small paediatric recipients is a challenge. We have developed a reduced left lateral segment as an alternative to monosegment transplantation for small size recipients. Since November 2000, 89 children have been transplanted with 100 deceased donor liver grafts in our unit. Our median patient and graft survival is 89% and 88% respectively. Four of these cases were performed using a new technique of creating a small donor graft by reducing the left lateral segment. The median weight of the reduced liver graft was 264 g (range: 165–390 g). The median blood transfusion requirement was 101 mL/kg body weight (range 69–167 mL/kg). The median values of peak ALT were 1473 IU/L, INR 2.2 and bilirubin 293 μmol/L in the first two wk following surgery. One neonatal recipient died five days after transplantation from a massive intracranial haemorrhage despite satisfactory graft function. Another recipient with excellent graft function died 10 months later from primary pulmonary hypertension and secondary cardiac failure. Hepatic artery thrombosis occurred in one patient with successful revascularization but he was retransplanted three months later for chronic rejection. No biliary or venous outflow complications occurred in this group. This technique of reduced left lateral segment liver transplantation is an alternative to the monosegment graft and allows small recipients to be successfully transplanted with few technical complications related to graft preparation.     

小儿肝移植13例经验回顾

目的 总结小儿肝脏移植13例的经验及教训.方法 从2001年9月至2007年8月对13例终末期肝病患儿实施了肝移植术,其中先天性胆道闭锁7例,先大性肝纤维化3例,肝豆状核变性1例,Caroli病1例.肝脏血管内皮肉瘤1例,年龄5个月至12岁.供体及受体在门诊进行367个月随访并收集数据,对受体存活期与手术方式、术者经验、患儿年龄及原发病、家庭经济状况、父母教育背景等因素的关系进行分析.结果 本组13例患儿全部顺利完成肝移植手术.不同手术方式的结果 :亲体肝移植4例,供体随访6～59个月,均无并发症,健康生活;4例受体,1例于手术后15个月死于急性坏死性肠炎.另外3例无并发症健康生活,其中1例手术后25个月免疫耐受.尸体肝移植9例,目前存活4例,已死亡4例;另外1例手术后14个月因慢性排斥反应行二次肝脏移植手术.不同手术时间的结果 :2001年1月至2003年1I)月间手术6例.已死亡5例,2年生存率为33.3%;2004年4月至2007年4月间开展手术7例,已死亡1例.存活6例,2年牛存率为57.1%.结论肝移植是治疗小儿终末期肝病的有效方法 ,随着经验的积累,手术并发症和病死率有大幅度降低的趋势.医生和护理人员的经验,患儿的病情,家庭的经济实力,家庭主要成员的心理承受力、挽救孩子生命的动机、坚定程度和毅力,医护人员和家长的密切配合是影响肝移植预后的因素.     

Bowel obstruction due to diaphragmatic hernia in an elder child after pediatric liver transplantation

A 10-yr-old boy with end-stage liver cirrhosis due to Wilson's disease received a living donor liver transplantation (LDLT) at our institution. The donor was his father and the graft was a left lateral segment. The liver transplantation procedure and the postoperative course were uneventful. Two months after the procedure, he developed a first episode of bowel obstruction that was treated with conservative therapy. During a second episode of bowel obstruction, he also presented respiratory distress. A plain chest X-ray revealed the presence of small intestine loops in the right thoracic cavity and bowel obstruction due to diaphragmatic hernia was diagnosed. Repair of the diaphragmatic hernia was performed and the patient has been doing well after the surgery. Diaphragmatic hernia after LDLT is rare but should be recognized as a possible complication when a left lobe or a left lateral segment graft is used.