原位肝移植术后并发症的诊断和治疗

目的 总结7例原位肝移植术后并发症的诊治经验。方法 从1999年12月～2000年11月共施行原位肝移植7例。结果 全组存活5例,死亡2例。术后并发症包括:颅内出血、腹腔内出血、肺感染、胸腔积液、ARDS、急性排斥反应、高胆红素血症、下腔静脉狭窄等。结论 肝移植术后并发症较多;术中正确的手术操作,彻底细致的止血,术后凝血功能的调控,感染及肾功能不全的预防,高胆红素血症的对症处理,免疫抑制剂的合理使用等措施能有效地减少肝移植术后并发症的发生。     

肝肾胰联合移植的围手术期处理

目的总结肝胰肾联合移植围手术期处理的经验。方法报告肝、胰、肾一期联合移植治疗1例乙型肝炎后肝硬化、肝功能不全合并慢性肾功能不全伴慢性胰腺炎导致胰岛素依赖型糖尿病患者的临床特点及治疗体会。对患者围手术期处理及相关资料进行回顾性分析。结果采用胰液空肠内引流及原位背驮式同期尸体肝、胰、肾联合移植。手术顺利，移植肝脏及胰腺功能1周内逐渐恢复，肾功能延迟恢复。术后第16天因移植肾血流下降，切除移植肾脏，于原移植部位行第2次肾移植，肾功能逐渐恢复正常。至2005年11月随访10个月，患者未发生排斥反应及明显感染，移植肝、胰、肾功能均正常，一般情况良好。结论肝胰肾联合移植技术安全，术后因各脏器对功能恢复所需内环境各不相同，矛盾较多，围手术期处理对患者的长期存活至关重要。     

Erythropoietin-resistant anaemia in a predialysis patient with Klinefelter syndrome

A diabetic predialysis patient who had significantly reduced sensitivity to erythropoietin therapy was admitted to Tsukuba University Hospital. Many factors that might have been the cause of the erythropoietin resistance were examined, and a diagnosis of refractory anaemia was made based on a bone marrow aspiration biopsy. A cytogenetic abnormality (47, XXY) was also detected in the bone marrow biopsy specimen, and hence the patient was also diagnosed with Klinefelter syndrome. It was suspected that the sex chromosome abnormality influenced glucose intolerance, renal insufficiency, and erythropoietin resistance due to myelodysplastic changes in the bone marrow.     

血缘性活体肝部分移植术一例报告

目的介绍１例血缘性活体肝部分移植术的临床体会。方法受体为１０岁女童,诊断为先天性弥漫性肝内胆管囊性扩张症、复发性胆管炎、肝硬变,供体为患儿的父亲,手术方式为切取供体肝脏的左外侧叶,并原位移植给患儿。术后进行了严格的监护治疗和随访。结果供体手术历时４００分钟,出血４１０ｍｌ,切取肝脏３００ｇ,术后顺利恢复。受体手术历时６５２分钟,出血１６６５ｍｌ,无肝期８０分钟,移植肝脏热缺血时间为０,冷缺血时间１３７分钟。采用环孢霉素Ａ、硫唑嘌呤及皮质激素行免疫抑制治疗,术后第１１天出现急性排斥反应,经激素冲击治疗而愈。现患者已健康生存７个月余,肝功能正常。结论在现有外科技术条件下,活体肝部分移植术是可行的。良好的术后管理是确保肝移植术成功的关键。     

Recent observations on osteomyelitis in sickle-cell disease

Summary Patients with sickle-cell haemoglobinopathy are more susceptible to osteomyelitis than normal people. The commonest causative organism in such cases has been widely reported as the salmonella species. Our findings in a prospective study of 21 consecutive patients with osteomyelitis in sickle-cell haemoglobinopathy show that the staphylococcus species is the most likely causative organism.

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Résumé Les sujets porteurs d'une hémoglobinopathie avec hématies falciformes sont plus fréquemment atteints d'ostéomyélite que les sujets normaux. On a beaucoup insisté sur le fait que les germes le plus souvent en cause dans ces cas seraient des salmonelles. Nos constations, dans une étude prospective portant sur 21 cas d'ostéomyélite sur hémoglobinopathie drépanocytaire, démontrent que les staphylocoques sont les agents pathogènes les plus habituels.

     

小鼠原位肝移植模型的建立

目的 建立稳定的小鼠原位肝移植模型。方法 采用对端吻合重建肝上下腔静脉，“双袖套法”重建门静脉和肝下下腔静脉。支架法重建胆管。结果 共施行50例小鼠原位肝移植，术后24h存活率92％（46／50），1周存活率84％（42／50），2周存活率80％（40／50）。结论 本实验中小鼠原位肝移植存活率较高，稳定可靠，易于标准化，是一种研究移植免疫的理想的动物模型。     

人体原位肝移植一例报告

报告１例人体同种异体原位肝移植手术及术后经过。受者为晚期肝硬化合并门静脉高压症的患者。采用同血型供肝，４℃ＵＷ液行肝脏冷灌注和保存，冷缺血时间１５小时。移植术中无肝期采用体外静脉转流技术，血流动力学变化和肾功能影响甚微。术后无外科手术并发症发生。应用二联免疫抑制治疗方案，中、西医结合有效地控制和逆转了急性排斥反应。受者存活８６天。     

中叶供肝肝移植的可行性动物实验研究

目的：探索肝中叶作为独立供肝进行移植的可行性,以进一步拓宽供肝来源。
方法：普通级健康犬分成供体组（n=12,20~25 kg）和受体组（n=12,10~15 kg）,供受体随机配对。供体手术将位于中央区的方叶、右中叶在体内劈离,原位灌注后保留其专属的门静脉中支、肝中动脉和中肝管,得到独立的中央区供肝并称重。受体手术先建立临时性门腔分流,供肝背驮式植入,流出口和腔静脉壁端侧吻合,供肝门静脉中支和受体门静脉主干行端端吻合后恢复新肝血流,重建动脉和胆管。术后观察受体腹腔及胆汁引流,每日检测肝功能,死亡后行尸检,移植物取标本行病理检查。
结果：犬肝被深陷的叶间裂分隔成7叶,各叶间由较少的肝桥连接,方叶和右中叶由门静脉中支、中肝动脉营养血回流至肝中静脉,胆汁引流至中肝管。供体组体内劈离技术全部得以完成,手术时间（215.0±67.7）min,失血量（229.3±66.5）mL。比较GRWR,中央区供肝[（1.3±0.3）%]和假设的左侧区供肝的[（2.1±0.4）%]及右侧区供肝的[（0.9±0.1）%]之间差异均有统计学意义（均P<0.01）。受体组手术时间（327.6±75.3）min,无肝期（33.6±7.5）min,失血量（415.5±79.8）mL。12个供肝均成功植入,冷缺血时间为（41.9±12.1）min,（8.3±3.6）min后排泌胆汁。受体肝功能指标在术后第1天发生明显变化,随后逐渐恢复,中位存活时间92.5（18~272）h,未发现有因吻合口出血、血栓等外科技术性并发症而死亡受体。
结论：犬动物模型证实肝中央区可以劈离出来作为一个独立的供肝器官,为将来拓宽供肝来源提供了另外一种思路。     

肝硬化或肝移植术后腹外疝的外科治疗：附35例报告

目的:探讨肝硬化或肝移植术后合并腹外疝行疝修补术的疗效。方法:回顾性分析2006年1月—2016年12月中山大学附属第一医院行择期疝修补术治疗的35例肝硬化或肝移植术后合并腹外疝患者临床资料,其中腹股沟疝18例,腹壁切口疝10例,脐疝5例,脐疝合并切口疝1例,腹白线疝1例。分析患者术后并发症发生率与疝复发情况及相关临床指标。结果:35例患者中,男27例,女8例;平均年龄(59.0±9.42)岁;术前16例(45.7%)凝血酶原时间延长,16例(45.7%)低蛋白血症,24例(68.5%)腹水;术前肝功能Child-pughA级16例(45.7%),B级18例(51.4%),C级1例(2.8%);术前ASAⅡ级11例(31.4%),Ⅲ级20例(57.1%),IV级4例(11.4%)。所有患者均完成手术,围术期无死亡病例。腹股沟疝平均手术时间(97.0±18.7)min,术中出血量平均(30.0±5.0)mL。切口疝平均手术时间(125±33.5)min,术中出血量平均(100.5±23.5)mL。脐疝平均手术时间(106.0±45.1)min,术中出血量平均(40.5±20.5)mL。术后中位住院时间8(1～63)d。术后总体并发症发生率为22.8%,其中血清肿2例(5.7%)、血肿4例(11.4%)、切口感染1例(2.9%)、手术部位感染2例(5.7%)。术后随访率65.7%,中位随访25个月。术后2例手术区域不适感(8.7%),无慢性疼痛病例,4例复发(17.4%),其中腹股沟疝和切口疝各2例(8.7%)。结论:肝硬化或肝移植术后合并腹外疝患者行择期疝修补术是安全有效的,但术后并发症和复发率较高。     

Successful outcome of liver transplantation in a patient with hepatitis C and common variable immune deficiency

A 43-year-old man with common variable immune deficiency underwent liver transplantation for cirrhosis caused by hepatitis C virus (HCV). HCV had been acquired from a contaminated batch of immunoglobulin. He developed cirrhosis within 3 years of infection with the virus, then liver failure requiring liver transplantation. The immediate post-transplant course was uncomplicated. Five months after transplantation he developed liver failure, and the histological appearances were those of severe cholestatic hepatitis. Withdrawal of immunosuppression resulted in recovery from liver failure. Clearance of the HCV from serum was also observed and has been sustained during follow-up (despite the subsequent reintroduction of low-dose immunosuppression). The patient is alive and well more than 5 years after transplantation. His post-transplant course has been remarkable for the aggressive recurrence then clearance of the HCV.     

大鼠心脏停搏供体肝移植供肝活性的研究

目的　比较不同类型的大鼠心脏停搏供体 (NHBD)肝移植中供肝的活性 ,探讨肝移植应用NHBD供肝的可行性。方法　应用氧气极谱法测定线粒体呼吸控制率 (RCR ) ;应用荧光法测定线粒体质子ATP酶活性 ;动脉血气分析 ;肝功检查 ;测定血清细胞因子白细胞介素 (IL) 1β ,IL 6和肿瘤坏死因子 (TNF) α作为应激标志物指标 ;肝组织形态学检测。结果　线粒体质子ATP酶活性与热缺血时间 (WIT)呈负相关 ;在KCL3 0组RCR值、ATP酶活性和PaO2 测定值显著高于OC3 0组 (P <0 .0 5 ) ;在心脏停搏 3 0min时 ,血清ALT及LDH值两组都显著增高 ,KCL60组ALT和LDH明显增高组间差异有统计学意义 (P <0 .0 5 )。结论　肝移植应用NHBD供肝是可行的 ,心跳缓慢停止的NHBD模型供肝活性明显优于心脏骤停NHBD。     

The validity of the MEGX test in correlation with histology after orthotopic rat liver transplantation

Abstract Lidocaine metabolism (MEGX test) as an indicator for liver function in the assessment of different degrees of liver disease and as a predictor for liver outcome after transplantation is well established. Since reduced liver function is associated with an alteration in parenchymal and non-parenchymal cells, we evaluated whether MEGX values correlate with histology in an in vivo model of orthotopic rat liver transplantation (ORLT) to assess histological damage without taking biopsy specimens. Livers from syngeneic Lewis rats were transplanted with rearterialization after 15–30 h of cold storage in UW solution and rinsing with Carolina Rinse Solution prior to implantation. Forty-eight hours after transplantation, the MEGX test was performed and metabolites were measured with a commercial kit as described elsewhere. Biopsy specimens were taken and graded three degrees of damage (mild, moderate, and severe) in a double blind fashion by a pathologist. MEGX values were assigned to the histological results. Statistical analyses were done with a Mann-Whitney test ( n = 58) for mean values. The mean MEGX values attributed to histologies with a mild, moderate, severe degree of damage were 159.96, 78.46 and 44.42 ng/ml, respectively. When the histological groups were compared with the mean MEGX values, mild vs moderate, mild vs severe and moderate vs severe were significant ( P - 0.0001). In conclusion, MEGX values correlate significantly with histological grading in a linear fashion after ORLT. The MEGX test may be of clinical value because it reflects the histological pattern of livers and may reduce the necessity to take biopsy specimens before and after transplantation.     

人体原位肝移植13例报告

目的 总结临床肝移植的经验。方法 对１１例原位肝移植与２例肝、肾联合移植的临床资料进行回顾性分析。结果 全组死亡５例,存活８例,直接死亡原因为脑出血（３例）、原发性移植肝无功能（１例）和急性排斥反应（１例）。术后服用拉米呋啶的７例均未见乙型肝炎复发。术后发生急性肾功能衰竭、排斥反应、脑血管意外、感染及肝上、肝下下腔静脉吻合口扭曲梗阻等技术或非技术因素所致的并发症。结论 开展肝移植的初期应严格掌握适     

大鼠原位肝移植胆道外引流模型的建立

目的 建立一个稳定的大鼠原位肝移植胆道外引流模型,为研究移植术后胆汁中的成分,细胞学及免疫学指标提供可能。方法 在Ｋａｍａｄａ方法的基础上,加以技术改进,肝上下腔静脉采用端端吻合法,门静脉及肝下下腔静脉采取袖套法吻合,胆总管内置引流管引至大鼠颈背部,外接引流袋。结果 共施行大鼠原位肝移植７５次,２４ｈ动物存活率这９３．３％,１周动物存活为８６．６％,结论 该模型是研究肝移植术后胆汁成分,胆汁细胞学     

辅助减体肝、肠联合移植术一例

目的 研究辅助减体肝、肠联合移植的手术技术和免疫抑制方案。方法 从一成年供者获取整块肝，肠，脾，肾后，将减体肝脏和十二指肠，空肠，部分回肠植入一无小肠的患者体内。术前和术后使用环孢素Ａ（ＣｓＡ），甲泼尼龙（ＭＰ），环磷酰胺（ＣＴＸ）免疫抑制治疗，给予抗凝和肠外营养支和术后使用环孢素Ａ（ＣｓＡ），甲泼尼龙（ＭＰ），环磷酰胺（ＣＴＸ）免疫抑制治疗，给予抗凝和肠外营养支持疗法（ＴＰＮ）。结果 临床观察和     

大鼠小肠-辅助性肝脏联合移植的实验研究

目的　研究小肠—辅助性肝脏联合移植的可行性以及移植后的肝脏增生。方法　供、受者均为Lewis大鼠 ,分为移植组和对照组。移植组 :切取供者小肠和 6 0 %肝脏 ;切除受者小肠 ;然后将移植物植入受者。移植物血液供应通过连自移植物的腹主动脉和受者腹主动脉端 侧吻合 ,静脉回流通过移植物的肝下下腔静脉和受者左、右肾静脉之间的下腔静脉端 侧吻合。对照组 :单行剖腹探查 ;观察 1 8个月后处死。分别测量两组的肝脏重量 ,检测肝功能、肝脏和小肠的组织学改变。结果　移植组受者自身肝脏未见增生 ,移植肝脏明显增生 ;受者的肝脏 /体重比明显升高。移植组和对照组体重、肝脏功能检查、肝脏和小肠的组织学差异不显著。移植组受者自身肝脏、移植肝脏及对照组肝脏肝细胞的凋亡指数差异无显著性。移植组受者自身肝脏肝细胞增殖指数较移植肝脏及对照组肝脏肝细胞的增殖指数明显降低。结论　小肠—辅助性肝脏联合移植是可行的 ;辅助性肝移植可以提高肝脏 /体重比。     

经颈静脉肝内门体分流术(TIPSS)与肝移植

目的 经颈静脉肝内门体分流术（TIPSS）正逐渐成为控制食管曲张静脉破裂出血和肝移植之间的桥梁。目前国内没有有关TIPSS对原位肝移植手术影响的报道。方法 回顾性研究接受术前TIPSS治疗的肝移植病人，即评价TIPSS作为肝移植桥梁的有效性和是否影响移植手术。结果 匹兹堡移植中心5例术前接受TIPSS的肝移植病人。行TIPSS与肝移植间隔时间为9．6（0．2－24．7）个月，3例病人在肝移植前能有效地控制出血。4例病人的支架位于肝实质内，并不影响手术；1例部分突出于肝外门静脉，术中需要移去支架。术后随访时间平均4.2(2-7)个月，无门静脉血栓形成。手术时间和术中输血量无显著性差异。结论 TIPSS是一种有效的桥梁，并没有增加移植术后并发症发生率和死亡率；鉴于有潜在的手术风险，支架最好放置在肝实质内，但肝外支架并不构成移植手术的反指征。     

心脏死亡器官捐献原位肝移植的初步经验:附单中心4例报告

目的:小结近期开展的心脏死亡器官捐献(DCD)肝移植的临床经验。方法:回顾性分析2011年9月—2012年2月4例接受DCD原位肝移植术的终末期肝病患者的临床资料。结果:全组肝移植病例均获成功,无肝功能延迟恢复;无胆漏、急性排斥反应、应激性溃疡出血、肾功能损害、爆发性肝炎等并发症。1例患者术后伤口感染及肝脏VII,VIII段部分坏死、右膈下积血,经加强抗感染、换药及穿刺引流后治愈。结论:DCD供肝原位肝移植效果良好,是解决我国肝移植面临的肝源短缺的一个极有潜力的办法,DCD肝移植的顺利开展尚有待广泛宣传及多部门、多学科通力合作。     

Successful tracheal transplantation with fresh allografts in a rabbit model

Abstract. Purpose: Immunogenicity and the restoration of blood supply to the donor graft remains a clinical challenge in tracheal allotransplantation. We conducted a study on 20 rabbits of a genetically similar strain to eliminate the risk of rejection caused by immunogenicity. Methods: We examined the histomorphological changes related to revascularization and the immunogenic reaction of the fresh allografts after tracheal transplantation. Histomorphological assessment was conducted by investigating the anastomotic sites, graft necrosis, and epithelization. Cellular changes, including the infiltration of granulocytes, histiocytes, and fibroblast proliferation related to a granulation tissue-like reaction, were also assessed, with lymphocyte infiltration which is an indicator of graft rejection. All of these characteristics, apart from epithelization, were graded semiquantitatively as none (0), mild (1), moderate (2), and severe (3). Epithelization was graded as 0, indicating no epithelization; 1, ≤20%; 2, ≤40%; 3, ≤60%; 4, ≤80; 5, complete epithelization of the entire graft. Results: Morphologic integrity of the trachea was completely retained in 16 (80%) animals. The overall rating score of epithelization was 3.6 ± 1.0, while those of the granulation tissue-like reaction and lymphocyte infiltration were 4.8 ± 0.6 and 1.5 ± 0.7, respectively. Conclusion: These findings demonstrate that tracheal allotransplantation is possible with fresh allografts in genetically similar strains of rabbits. Received: March 1, 2001 / Accepted: November 20, 2001     

The association of pre-operative anaemia with survival after orthotopic liver transplantation

Anaemia is common in patients with end-stage liver disease. Pre-operative anaemia is associated with greater mortality after major surgery. We analysed the association of pre-operative anaemia (World Health Organization classification) with survival and complications after orthotopic liver transplantation using Cox and logistic regression models. We included patients undergoing their first orthotopic liver transplantation between 2004 and 2016. Out of 599 included patients, 455 (76%) were anaemic before transplantation. Pre-operative anaemia was not associated with the survival of 485/599 (81%) patients to 1 year after liver transplantation, OR (95%CI) 1.04 (0.64–1.68), p = 0.88. Pre-operative anaemia was associated with higher rates of intra-operative blood transfusions and acute postoperative kidney injury on multivariable analysis, OR (95%CI) 1.70 (0.82–2.59) and 1.72 (1.11–2.67), respectively, p < 0.001 for both. Postoperative renal replacement therapy was associated with pre-operative anaemia on univariate analysis, OR (95%CI) 1.87 (1.11–3.15), p = 0.018.