终末肺气肿同期行单肺移植和对侧肺减容术的围术期护理

对肺移植患者围手术期实施全程、系统的护理。认为良好的围手术期护理是肺移植成功的关键因素之一。通过该例肺移植术积累了该类手术的护理经验,为进一步开展肺移植工作打下基础。     

同种异体犬单肺移植供肺采取及保护

目的　通过犬肺进行肺动脉灌注 ,掌握手术方法、供肺的修剪及保存 ,为人体肺移植供肺打下基础。方法　杂种犬及毕格犬 7只 ,静脉复合及支气管插管麻醉后经胸正中切口 ,肺动脉内灌注 Euro- Collins(EC)溶液后切除心肺块 ,置入 EC液中修剪及保存。结果　供肺均顺利获得 ,供肺采取手术时间 30～ 40 min,平均 35± 0 .42min;冷缺血时间 2 0～ 6 0 min,平均 44± 0 .2 5 min;肺动脉灌注时间 6～ 30 min,平均 19± 0 .71min。结论　掌握了犬肺移植供肺切取的全过程 ,对手术、肺动脉灌注的方法等有新的认识 ,为人体肺移植供肺打下了良好的基础。     

一氧化氮与肺移植

20年来，随着肺移植技术及围手术期管理的改进，肺移植已成为治疗许多终末期肺部疾病唯患一的有效方法。肺移植所涉及的病理生理过程相当复杂，其中许多机制尚未明了，所以相对于其它脏器移植而言，其死亡率仍然很高。由于供肺来源严重短缺；再次手术机会少，所以提高首次手术疗效尤为重要。因此在肺移植中，采用多种手段的综合治疗是必要的。     

二肽基肽酶4抑制剂作用于肺缺血再灌注损伤的研究进展

肺缺血再灌注损伤(LIRI)是肺移植、体外循环术后常见并发症, 是影响移植成功率的重要因素, 但其具体发病机制目前尚未被完全阐明。寻找防治LIRI的靶点和药物, 对提高"边缘性供肺"利用率和肺移植患者的远期生存率具有重要的临床意义。二肽基肽酶4(DPP4)抑制剂是一类口服降糖药, 既往研究显示DPP4抑制剂具有多种药理活性, 包括抗炎、抗纤维化、免疫调节等多种胰腺外功能。最近的研究显示DPP4抑制剂可能通过抑制炎症反应、减轻氧化应激、调控血糖水平和激活自噬等多种机制减轻LIRI。本文就DPP4抑制剂在LIRI中的临床及临床前应用和作用机制进行综述。     

肺移植供体的选择和处理

肺移植已经成为治疗许多终末期肺部疾病的有效方法,移植给患者的肺即“供肺”,来自肺外原因死亡的病人。由于常温下肺不能长时间保存,供肺必须从仍有心跳,即有血液灌注的供体上采取,用低温保护液灌注保存,也就是要使供肺没有或只有很短的“热缺血”时间,然后在数小时内完成移植。器官移植适应证的扩大使需要移植的患者成倍的增加,西方国家都已经确立“脑死亡”法,当病人进入不可逆昏迷、确定脑死亡后,就在人工维持呼吸及循环的情况下,摘取脏器供移植使用,这样的器官有良好的活力和较正常的生理功能,移植效果好。我国至今尚未制…     

肺移植治疗肺纤维化10例临床分析

目的 探讨肺移植治疗肺纤维化的手术适应证、围手术期的处理及疗效.方法 2002年9月至2005年12月无锡市胸科医院采用肺移植治疗肺纤维化10例,包括特发性肺间质纤维化9例、术前长期依赖呼吸机（150 d）的重症肺炎后肺纤维化1例.手术方式均为单肺移植,其中2例在体外循环下进行,有1例为左侧供肺植入右胸腔.结果 术后1例于137 d死于重症肺部感染合并急性呼吸窘迫综合征,其余9例患者痊愈出院,平均术后住院时间为44 d.随访中1例术后9个月死于肺部感染,1例术后25个月溺水意外死亡,其余7例均健在,且肺功能有极大的改善.结论 单肺移植是治疗特发性肺间质纤维化的有效方法.     

右肺移植同期左肺减容术治疗终末期肺气肿的报告

目的　探讨人体单肺移植同期行对侧肺减容术(LVRS)在治疗慢性阻塞性肺气肿(COPD)中的治疗效果及经验。方法　供体:脑死亡患者,使用改良的4℃LPD肺保护液,顺行灌注后再逆行灌注,肺膨胀状态下取下整体肺块无菌冷保护下送受体手术室,解剖修整后取右肺供移植用。受体:终末期双侧COPD ,右侧重于左侧,切除右全肺,适当保留右主支气管、右肺动脉及右肺静脉心房袖供吻合,将供体右肺移植于受体右胸腔内,再作左肺上叶减容术,减容达左肺2 5 %。结果　手术经过顺利,移植肺成活,无急性排异反应。左肺减容侧因术后胸腔内活动性渗血再次开胸。患者肺功能恢复满意,已长期存活。结论　使用改良LPD液顺灌及逆灌供肺对保护其功能及减轻排异反应有明显的效果,气管套叠式吻合及吻合口周围使用生物蛋白胶对减轻支气管吻合口并发症有益。单肺移植同时进行另一侧肺减容对患者术后肺功能的改善有明显作用。     

单肺移植治疗艾森曼格综合征(附1例报告)

目的总结单肺移植治疗艾森曼格综合征围手术期处理的经验教训。方法对1例52岁的房间隔缺损合并艾森曼格综合征女性患者在全麻体外循环下行同种异体右全肺移植术,同时行房间隔缺损修补术。供体为32岁男性,术前未作HLA配型,供肺保护采用4C改良低钾右旋糖酐液（LPD）灌洗,4CUW液保存。术后给予三联免疫抑制剂。结果术后心肺功能恢复良好。但术后12h发生超急性排斥反应,术后第5天导致急性肝肾功能衰竭,用人工透析维持。第9天出现口腔感染和泌尿系感染,给予口腔护理及氯霉素膀胱冲洗,第12天因全身感染死亡。结论术前供肺保护和手术技巧是单肺移植治疗艾森曼格综合征手术成功的关键;抗排斥和抗感染是手术后处理的重要环节。     

肺移植8例临床经验总结

目的探讨肺移植治疗终末期肺良性疾病的效果,并对我院肺移植的经验进行总结。方法回顾分析2017年6月至2018年5月安徽省立医院完成的8例肺移植病例的临床资料,受者年龄为20-63岁,中位年龄36岁;男性6例,女性2例;单肺3例,双肺5例。原发病为慢性阻塞性肺病2例,肺纤维化1例,肺淋巴管肌瘤病1例,α-糜蛋白酶缺乏症1例,矽肺1例,支气管扩张症1例,呼吸道化学性烧伤1例。对所有受者的并发症发生情况、死亡情况及随访情况进行分析。结果没有围手术期死亡病例。术后早期胸腔出血二次手术止血1例。支气管胸膜瘘2例,经保守治疗2月后好转。1例术后2月出现急性肾衰。5例出现移植后气道狭窄。3例术后出现肺部感染,其中2例合并支气管胸膜瘘。1例术后10月因心衰死亡。结论肺移植是治疗终末期肺良性疾病的有效方法,恰当的病例选择、良好的供肺选择及保护、有效的术后管理是肺移植成功的关键。     

肺移植的围术期管理

围术期管理是肺移植术中的重要环节,直接关系到手术的成败。恰当的围术期监测和处理,可以避免并发症的发生或减小并发症的影响,使肺移植患者安全度过围术期,以获长期存活。     

Effect of sevoflurane on tissue permeability of lung ischemia-reperfusion injury in rats

Objective:To investigate the effect of sevoflurane on tissue permeability of lung ischemiareperfusion injury(LIRI)in rats.Methods:A total of 45 wistar rats were randomly divided into3 groupsⅠ,Ⅱ,Ⅲ.Modified Eppinger method was adopted to establish the rat lung ischemiareperfusion injury model.GroupⅠserved as the control group,groupⅡas ischemia reperfusion group,groupⅢas sevoflurane ischemia-reperfusion group.Blood gas index,lung permeability index(LPI)change,lung tissue pathology change and lung water content were observed and compared between groups of rats at different time points.Results:During ischemia reperfusion,all rats kept balance of the MAP during different time points,SPO_2 of groupⅡandⅢdecreased significantly thanⅠgroup(P0.05);after reperfusion lung permeability index in GroupⅡandⅢwas higher than the control group significantly(P0.05),120 min after reperfusion LPI change and iujury of groupⅢwas significantly lower thanⅡgroup(P0.05);interstitial and alveolar cavity effusion in of groupⅢwere lower than that of groupⅡ.Conclusions:Sevoflurane pretreatment can reduce the lung tissue permeability,and LIRI plays a protective role in LIRI.     

无心跳供体肺移植的研究进展

综述了无心跳供体(non-heart-beating-donor,NHBD)肺移植方面的研究进展,包括NHBD供肺可耐受的缺血时间、针对NHBD供肺的抗凝和溶栓的研究、不同通气模式和吸入药物的影响、供肺保存期间所采取的干预措施如尸体内原位表面冷却以及在保存液中添加各种药物的效果和作用机制等.使用NHBD供肺有望成为缓解供肺短缺的主要解决途径.     

保护性有氧肺膨胀与移植肺保护形态学的研究

目的探讨实验性过度肺膨胀对供体肺脏保护的有害影响及肺移植中的保护性肺膨胀。方法杂种犬16只,随机分为对照组和实验组,建立肺过度膨胀动物模型。监测体循环动脉压及中心静脉压,实验组过度肺膨胀,对照组正常肺膨胀均为6h。通过光学显微镜和电子显微镜观察肺组织的病理形态学改变。结果①实验组体循环动脉压和中心静脉压与对照组比较差异无显著性(P>0.05);②病理和超微结构改变:实验组过度膨胀性肺损伤的程度明显大于正常肺膨胀的对照组。结论①超出呼吸生理极限的肺过度膨胀可导致不可逆性肺损伤;②灌注期间应保持供肺的充分膨胀,但不宜过度膨胀,以防止肺泡上皮和肺毛细血管内皮细胞受到不可逆性损伤;③供肺保存过程中应处于保护性肺膨胀状态,即正常膨胀的状态更加符合生理。     

Advanced considerations in organ donors

The rising need for lung transplantation over recent years has not paralleled the availability of suitable lung allografts. The number of lung transplantations performed each year in the United States remains limited by an inadequate supply of suitable donors as well as low donor utilization rates. While several methods have been proposed for increasing the donor pool, there is considerable disparity between acceptance and utilization of these practices among transplant centers. In this review article, we explore various approaches for enhancing donor selection and expanding the donor pool. We discuss the use of “extended criteria” donors including high risk groups such as drug overdose donors, and we examine the role of techniques in donor assessment and selection such as the use of computed tomography for accurate size matching. We review topics in donor management such as the establishment of specialized donor care facilities and the implementation of lung-focused resuscitation protocols, and we discuss advancements in donor procurement such as the utilization of local procurement teams. We also review barriers to donation, such as variability in organ procurement organization (OPO) consent practices, as well as patient-specific factors such as religious or cultural beliefs. Addressing these aspects of donor evaluation, management, and accessibility is essential in maximizing the number of lungs available for transplantation within the existing donor pool.     

Selection and management of the lung donor

This article reviews recent developments in the selection, assessment, and management of the potential lung donor that aim to increase donor organ use. The scarcity of suitable donor organs results in long waiting times and significant mortality for those patients awaiting transplant. Strategies to expand the donor pool can substantially improve donor lung use rates. Although further long-term studies are required to confirm that long-term outcomes are not being compromised, the available evidence suggests that the traditional factors defining a lung as marginal or extended do not actually compromise outcomes within the framework of current donor management strategies.     

Strategies to increase limited donor resources.

A number of strategies have been advocated to increase the number of lung donors including: 1) improvement in donor resuscitation; 2) better methods of lung preservation; 3) extension of the lung donor selection criteria; 4) development of a living-related lung donor programme; and 5) utilisation of nonheart beating donors. Other strategies such as the split-lung technique and techniques of lung reduction to accommodate large lungs into a small-size recipient have also been used successfully. In this article, each of these strategies have been reviewed and some recommendations are suggested based on the authors' own experience and that of the literature.     

一氧化碳吸入对大鼠供体肺组织细胞凋亡的影响

目的观察吸入低浓度一氧化碳（CO）对大鼠供体肺组织细胞凋亡的影响。方法建立大鼠肺移植离体肺灌注试验模型，SD大鼠24只，按照有无CO吸入分为空白对照组、CO吸入组，每组均取6对分别作为肺移植的供体鼠和受体鼠。再灌注后一小时切取供体肺组织，在光镜和电镜下比较肺组织细胞学改变，用末端脱氧核苷酸转移酶介导的dUTP缺口末端标记（TUNEL）法比较肺组织细胞凋亡的变化。结果CO吸人组肺组织细胞损伤较对照组明显减轻，凋亡细胞数量明显减少。结论吸入一氧化碳可以明显抑制大鼠供体肺组织细胞的凋亡，减轻供体肺移植术后的缺血再灌注损伤。     

Cardiorespiratory function and pathological findings in heart-lung block reimplanted after hypothermic preservation

A good result from the heart-lung transplantation depends on the quality of the preservation of cardiopulmonary transplants. To determine the functional and pathological status of the heart-lung block after preservation for several hours, we performed 10 heterologous heart-lung transplantations in Beagle dogs (weight 13.5 kg) under extracorporeal circulation. Weight and length compatibility between donor and receiver was ensured. Measurements of hemodynamics, lung mechanics and blood gases were performed in the donor and in the receiver before the transplantation, and in the receiver after heart-lung reimplantation. Histological studies were carried out by biopsy on the heart and on the lung of the donor before removal, at the beginning of the preservation at low temperature, after 3 h of ischemia in cold, and every hour after recirculation in the heart-lung block. Myocardial preservation was conducted with cold cardioplegia at 4 degrees C (Ringer lactate solution with high potassium). Lung preservation was achieved by injecting a Euro-Collins solution at 4 degrees C, with addition of dog plasma, into the pulmonary artery; during the whole ischemic phase, the lung parenchyma was maintained at 0 degrees C, and inflated at a 10 cm H2O pressure. After transplantation, we observed that cardiac output was low in all cases, with normal or subnormal pulmonary arterial pressure. Dynamic lung compliance was very low immediately after transplantation, and increased when restarting the circulation, but deteriorated again after several hours. At the same time alveolo-arterial O2 pressure difference and arterio-alveolar CO2 pressure difference progressively increased, due to the extensive gas exchange impairment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lung transplantation from donors after circulatory death using portable ex vivo lung perfusion

BACKGROUND:

Donation after circulatory death is a novel method of increasing the number of donor lungs available for transplantation. Using organs from donors after circulatory death has the potential to increase the number of transplants performed.

METHODS:

Three bilateral lung transplants from donors after circulatory death were performed over a six-month period. Following organ retrieval, all sets of lungs were placed on a portable ex vivo lung perfusion device for evaluation and preservation.

RESULTS:

Lung function remained stable during portable ex vivo perfusion, with improvement in partial pressure of oxygen/fraction of inspired oxygen ratios. Mechanical ventilation was discontinued within 48 h for each recipient and no patient stayed in the intensive care unit longer than eight days. There was no postgraft dysfunction at 72 h in two of the three recipients. Ninety-day mortality for all recipients was 0% and all maintain excellent forced expiratory volume in 1 s and forced vital capacity values post-transplantation.

CONCLUSION:

The authors report excellent results with their initial experience using donors after circulatory death after portable ex vivo lung perfusion. It is hoped this will allow for the most efficient use of available donor lungs, leading to more transplants and fewer deaths for potential recipients on wait lists.     

The new allocation era and policy

Since the Department of Health and Human Services (DHHS) issued the Final Rule in 1998 as a guideline for organ transplantation and allocation policies, the lung allocation system has undergone two major changes. The first change came with the implementation of the lung allocation score (LAS) instead of waiting time as the primary determinant for donor lung allocation. The LAS model helped allocate donor lungs based on medical urgency and likelihood of post-transplant success. The LAS has been successful in prioritizing the sickest candidates and reducing waitlist mortality in line with the Final Rule mandates. However, the LAS model did not address geographic variability in donor lung supply and demand, leading to disparities in waiting list survival based on a patient’s listing location, which was inconsistent with the Final Rule. In an urgent response to a lawsuit filed by a patient demanding broader geographic access to lungs in November 2017, the second major change in lung allocation occurred when the primary allocation unit for donor lungs expanded from the local donation service area (DSA) to a 250-nautical mile radius around the donor hospital. The Organ Procurement and Transplantation Network has since undergone a review of the current organ allocation systems and has approved a continuous organ distribution framework to guide the creation of a new organ allocation system without rigid geographic borders. In this review, we will describe the history of lung allocation, the changes to the allocation system and their consequences, and the potential future of lung allocation policy in the U.S.