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。     

Liver infarction after laparoscopic cholecystectomy injury to the right hepatic artery and portal vein

A 66-year-old woman presented with fever and right upper quadrant pain 5 weeks after laparoscopic cholecystectomy. Angiogram revealed occlusion of the right hepatic artery and right portal vein which necessitated a right hepatic lobectomy. To our knowledge this has not been previously reported. The patient recovered uneventfully.     

Current role of portal vein embolization/hepatic artery chemoembolization

This article has reviewed indications, methods, and results of PVE and TACE for hepatobiliary tumors. PVE is applied mainly to increase the safety of major hepatic resection in patients with hilar cholangiocarcinoma, HCC, or metastatic liver tumors. Hepatic arterial embolization causes selective ischemia of the liver tumor and enhances the cytotoxicity of the chemotherapeutic agent administered concomitantly. A survival benefit of TACE in patients with unresectable or recurrent HCC has been demonstrated. The significance of preoperative TACE is still controversial. TACE is routinely performed before PVE in HCC patients.     

Combined hepatic artery and segmental portal vein occlusion in antiphospholipid syndrome

Antiphospholipid syndrome can have various clinical presentations, two of the most common being arterial and venous thrombosis. It is, however, unusual for them to occur in combination. We report here a case of combined hepatic artery and segmental portal venous occlusion in a 32-year-old patient who was shown to have a lupus anticoagulant. There have been no previous reports of thrombosis occurring simultaneously in the coeliac axis and the portal vein. Computerised tomography, Doppler ultrasound scanning and selective visceral angiography were used to demonstrate the anatomical lesions. The patient was treated medically with unfractionated heparin leading to a favourable clinical outcome. The diagnosis and management of this case is discussed with reference to the current literature on visceral thrombosis and antiphospholipid antibody syndrome.     

Direct vascular implantation of liver for hepatic regeneration after interruption of the portal vein and hepatic artery

This paper reports an experiment in which nine dogs were subjected to extended partial hepatectomy in addition to interruption of the portal vein and hepatic arterial system. The lobe of the liver which sustained the dog was supplied solely by blood from an extrahepatic vascular source previously implanted directly into the liver parenchyma. It is hoped that the ability of a small segment of liver to regenerate, under these conditions, might prove clinically useful in some patients with tumors of the liver, gallbladder, or extrabiliary system who, by present criteria, are considered inoperable.     

Simultaneous hepatic artery and portal vein thrombosis after living donor liver transplantation

Simultaneous hepatic artery and portal vein thrombosis rarely occurs after liver transplantation. The etiology is unknown. Of 213 patients (72 children and 141 adults) that underwent living donor liver transplantation (LDLT) from January 1996 to March 2003, 4 (2%) developed simultaneous thrombosis at 3 hours to 7 days (median, 4 days) after the operation. Emergent thrombectomy was performed in three patients; the remaining patient was registered in the Japan organ transplant network. All of the patients died due to hepatic failure (range, 18 hours to 6 days after the diagnosis; median, 2 days). Portal vein, hepatic artery, and hepatic vein velocity in the liver graft were measured every 12 hours by Doppler ultrasonography for 2 weeks after liver transplantation. These parameters were stable until just before the simultaneous thrombosis. These findings indicate that protocol Doppler ultrasonography can diagnose, but not predict, this fatal complication.     

彩色Doppler超声检测门静脉和肝动脉在肝硬化门静脉高压症诊断中的作用

目的通过回顾性探讨门静脉和肝动脉的彩色 Doppler 超声检查参数在诊断肝硬化门静脉高压症的敏感性和特异性,并提出在中国人群中上述参数的正常参考值。方法自2001年7月到2004年3月,选取普外科门诊的可疑肝硬化病人和部分正常人群共110例,共有99例完全符合人选标准和检测标准。99例病人全部经肝穿刺活检或手术中取肝组织活检为金标准分为正常组和硬化组,分别测量正常组和硬化组的门静脉流速(PVV)、肝动脉搏动指数(HA-PI)和肝血管指数(LVI),以及上述指标在诊断肝硬化和门静脉高压症的敏感性和特异性,并根据 ROC 曲线推算出上述指标的正常参考值。结果硬化组的 PW 明显低于正常组的 PVV,(11.0±2.5)cm/s vs(16.9±2.9)cm/s,(P<0.001),硬化组的 HA-PI 明显高于正常组的 HA-PI,(1.2±0.2)vs(0.9±0.2),(P<0.001),硬化组的肝脏 LVI 明显低于正常组的 LVI,(9.1±0.6)vs(19.1±1.9),(P<0.001)。PVV为14 cm/s 时诊断肝硬化门静脉高压症的敏感性为91.7%,特异性为91.7%。HA-PI 为1.1时诊断肝硬化门静脉高压症的敏感性为82.6%,特异性为83.3%。LVI 为10时诊断肝硬化门静脉高压症的敏感性为93.8%,特异性为93.8%。结论肝硬化门静脉高压症时门静脉和肝动脉的血流动力学有明显的改变,这种改变反映到彩色 Doppler 超声检查参数以 LVI 诊断的敏感性和特异性最高。     

Comparison of hepatic artery and portal vein reperfusion during orthotopic liver transplantation.

BACKGROUND: During orthotopic liver transplantation (OLT), it is standard procedure to reperfuse the liver via the portal vein (PV) despite having a lower oxygen content and perfusion pressure than the hepatic artery (HA). There are no published studies that describe graft function and outcome when the HA is used for reperfusion. We report a retrospective comparison of graft outcome after HA or PV reperfusion when the piggyback technique was used. METHODS: We identified 26 patients who had undergone OLT with HA reperfusion and 26 patients reperfused via the PV. Demographics, primary diagnosis, surgeon, warm and cold ischemic times, and blood product use were recorded. In each patient, whole blood lactate concentration, prothrombin time (PT), and alanine aminotransferase (ALT) were measured at defined time points during and after surgery as indices of graft lactate metabolism, synthetic function, and reperfusion injury, respectively. Thirty-day and 1-year outcome data were recorded. Data were compared between the HA and PV groups. RESULTS: Demographics, blood product use, primary diagnosis, cold ischemic time, and surgeon were similar between the groups. Warm ischemic time was longer in the HA group (mean [SD] HA 51.2 [14.7], PV 40 [9.1] min, P=0.002). Blood lactate concentrations were similar at all time points. There was no difference in 24-hr postoperative PT between the groups (median [InterQuartile (IQ) range] HA 17.5 [16-28.3], PV 19 [16-24] sec, P=0.85). Peak postoperative ALT values were comparable (median [IQ range] HA 1031 [668-1701], PV 1107 [754-1824] IU/ml, P=0.78). There were no statistically significant differences in 30-day or 1-year mortality, but more early deaths occurred in the HA group. Using our data, we calculated that a prospective randomized trial would need approximately 300 patients to be sure that mortality was the same with both techniques. CONCLUSION: We have demonstrated no clinically or statistically significant differences in indices of graft function, reperfusion injury, or outcome between primary HA or PV reperfusion.     

原发性肝癌肝动脉和门静脉血液动力学变化的临床研究

应用彩色多普勒血流声像仪对４０例原发性肝癌病人的肝固有动脉和门静脉血流进行宣测定，并与１６例肝硬变病人和２０例正常人对比。结果发现：原发性肝癌病人肝固有动脉的血流速度、血流量显著高于正常人和肝硬变病人；门静脉血流量，与肝硬变病人相似，明显高于正常人，但门静脉血流速度低于正常人；肝固有动脉与门静脉供血比例高达１：１．４９，大于正常人和肝硬化病人。     

Anatomic relationship between the internal jugular vein and the carotid artery in preschool children--an ultrasonographic study

Background:  Central venous cannulation in young children is technically difficult and may lead to potentially serious complications especially when performed blindly or using anatomical landmarks only.
Aim:  The aim of this study was to determine the anatomical relationship of the internal jugular vein (IJV) and the common carotid artery (CA) in preschool children using ultrasound.
Methods:  Forty five children aged 60 months and under were included prospectively and divided into three groups: group 1: <6 months, group 2: 7–18 months and group 3: 19–60 months. With the head in neutral position the location of the left and right IJV was noted as anterior (A), anterolateral (AL), lateral (L) or medial (M) in relation to the CA at the level of the cricoid cartilage. Depths of IJV and CA as well as time taken to locate the vessels were recorded.
Results:  The IJV was more commonly found in the AL position in all groups. The mean depth was 0.96 cm in group 1, 0.95 cm in group 2 and 3. Mean duration for localization of the vessels was 4.2 s in group 1, 4 s in group 2 and 4.3 s in group 3. The differences between the groups were not significant.
Conclusion:  This study demonstrates that the IJV cover the CA in the majority of young children. Depth of the IJV is rarely more than 1 cm deep to the skin. Ultrasound location of the IJV and CA is easy and does not necessarily delay the procedure. The findings of this study support the use of ultrasound guidance for CVC in children.     

Regional infusion for colorectal hepatic metastases. A randomized trial comparing the hepatic artery with the portal vein

To evaluate which site of infusion maximizes tumor response to regional hepatic chemotherapy, 25 patients were randomized preoperatively to receive chemotherapy administration via hepatic artery or portal vein catheters. Of the 25 patients, five did not have catheters placed due to extrahepatic disease, and one patient did not receive infusion chemotherapy. Continuous floxuridine infusion was given at a dosage of 0.3 mg/kg/d, alternating with saline solution every two weeks. The mean percentage of hepatic tumor replacement (36% vs 41%), mean serum alkaline phosphatase level (218 vs 179 IU/mL), and mean plasma carcinoembryonic antigen level (689 vs 563 ng/mL) were similar in both groups. Four (50%) of eight hepatic artery patients responded to treatment compared with 0/11 portal vein patients. Ten of 11 portal vein patients showed progressive tumor growth; nine of these patients were crossed over to arterial infusion. Three (33%) of these nine patients had an objective tumor response with the hepatic arterial infusion. This prospective, randomized clinical trial demonstrates significantly improved tumor response after hepatic arterial infusion compared with portal vein infusion.     

Easypump在肝动脉、门静脉持续灌注化疗应用的体会

目前,在临床上发现的肝癌多为中晚期,尽管部分病人可采取手术治疗,但由于肝癌容易侵犯血管和多源性起源的特性而造成复发率极高,术后5年复发率常达90％以上。因此,治疗肝癌必需采取综合性治疗,其中化疗对控制肿瘤细胞的复发占重要地位。由于化疗药物引起的不良反应,往往给病人带来极度的痛苦和不适,而产生恐惧感,甚至因不能持续而终止化疗。针对这一情况,我科从2000年12月～