加速康复外科优化重型肝炎肝移植围手术期管理临床实践的专家共识

为了更好地将加速康复外科(ERAS)的理念用于优化重型肝炎肝移植围手术期管理,达到减少并发症、促进患者快速康复的目的,中国医师协会器官移植分会移植免疫学组、中华医学会外科学分会手术学组、广东省医师协会器官移植医师分会组织专家制订了《加速康复外科优化重型肝炎肝移植围手术期管理临床实践的专家共识》。该共识从ERAS优化重型肝炎肝移植术前、术中、术后治疗策略3个方面,总结各移植中心的临床经验,提出相应的专家共识,希望为临床优化重型肝炎肝移植围手术期管理提供参考方案。     

儿童肝移植术后感染诊治专家共识

近年来,随着外科技术逐渐成熟,儿童肝移植在我国发展迅速,一些经验丰富的移植中心,儿童肝移植术后生存率已达到国际先进水平。然而,术后感染仍是影响移植物存活率及受者生存率的主要原因。为进一步提高儿童肝移植术后感染的诊治水平,中国研究型医院学会加速康复外科专业委员会组织多个学科的相关专家,总结国内外儿童肝移植术后感染的研究进...     

成人肝移植受者围术期凝血功能管理专家共识(2021版)

肝移植是终末期肝病的有效治疗方法。肝移植受者术前凝血功能障碍可增加围术期出血、血管并发症及再次手术的风险。因此,应重视肝移植受者围术期凝血功能的管理。目前,各移植中心关于肝移植受者围术期凝血功能的管理尚缺乏统一的标准。为此,中华医学会器官移植学分会围手术期管理学组组织相关专家,遵照循证医学原则,结合相关文献、专家经验和各移植中心的研究结果,深入论证,拟定了《成人肝移植受者围手术期凝血功能管理专家共识》。本共识旨在对成人肝移植受者围术期凝血功能障碍的诊治提出建议,以期形成多学科诊疗模式下的成人肝移植受者围术期凝血功能管理体系,优化凝血功能管理,减少因凝血功能障碍引起的并发症,提高肝移植术后生存率,提升诊疗效率。     

中国儿童肝移植麻醉技术操作规范(2019版)

儿童肝移植作为一项复杂的系统性工程,其成功离不开肝移植外科、麻醉科、ICU、儿科和肝病科等多个科室专家所组成的多学科团队。儿童肝移植麻醉管理有其特殊性,充分的术前评估、严密的术中监测和精细化的麻醉管理以及麻醉医师与其他多学科团队成员间充分的沟通与合作是确保手术成功的关键。为进一步规范儿童肝移植麻醉与围手术期管理,中华医学会器官移植学分会组织移植外科和麻醉专家,总结国内外相关研究最新进展,并结合国际指南和临床实践,从儿童肝移植麻醉前评估与准备、麻醉方法与用药、围手术期麻醉监测和管理以及麻醉恢复与术后管理等方面,制订《中国儿童肝移植麻醉技术操作规范(2019版)》。     

儿童肝移植术后生长发育的临床研究

目的探讨儿童肝移植术后的生长发育状况。方法选择2006年9月至2014年5月于北京友谊医院及天津市第一中心医院接受肝移植术的70例患儿为研究对象,分别计算每例患儿移植时和术后6个月、1年、2年、3年、4年和5年的身高Z评分(ZH)、体重Z评分(ZW)。分析患儿ZH、Zw评分在各个时间点的变化趋势,并将其各个时间点的ZH和ZW评分与2005年中国九省/市儿童体格发育调查数据制定的生长标准均数0(标准均数)进行比较;按照移植时ZH、ZW评分将患儿分别分为Z≥-2组和Z-2组,比较各组患儿ZH、ZW评分的变化趋势。结果肝移植时患儿ZH和ZW评分均数分别为-1.63±1.35和-1.53±1.52。接受肝移植术后,ZH、Zw评分逐渐提高。患儿的ZH和ZW评分在移植时和术后6个月的平均水平均明显低于标准均数(均为P0.01),其余术后时间段ZH和ZW评分与标准均数比较,差异无统计学意义(均为P0.05)。ZH评分-2组和≥-2组患儿的ZH评分在移植时、术后6个月、术后1年比较,差异有统计学意义(均为P0.05)。ZW评分-2组和≥-2组患儿的ZW评分在移植时、术后6个月、术后1年、术后2年比较,差异均有统计学意义(均为P0.05)。结论儿童肝移植患儿在术后生长发育逐渐恢复,术后1年出现明显快速增长。     

儿童肝移植术后病原菌感染的危险因素分析

目的探讨儿童肝移植术后3个月内病原菌感染的危险因素。方法回顾上海交通大学医学院附属仁济医院2006年10月至2014年12月收治的328例儿童肝移植临床资料,探讨影响儿童肝移植术后感染的危险因素。结果对于所有接受肝移植的患儿中122例术后3个月内发生细菌和/或真菌感染的感染率为37.2%;术前患儿低体重和高PELD评分是所有接受儿童肝移植共同的感染危险因素;术前住院时间大于7天、术后是否发生胆漏和多次手术是儿童肝移植术后感染的独立危险因素。结论应通过加强营养支持干预、精细手术操作、多学科密切合作及完整系统的术后随访管理多方面努力降低儿童活体肝移植术后降低细菌和真菌感染的发生率。     

25例儿童肝移植病例回顾及分析

目的 探讨单中心儿童肝移植手术方式、围术期管理对患者临床结局的影响.方法 纳入青岛大学附属医院器官移植中心自2016年1月—2021年1月25例儿童肝移植患者临床资料,观察患者的一般结果、术后外科并发症以及预后.结果 本组25例患儿中,3例患儿术后2个月内死亡,门静脉狭窄2例,肝功能延迟恢复1例,术后2个月生存率为86...     

儿童小体积供肝肝移植治疗成人急性肝衰竭1例附文献复习

目的总结儿童小体积供肝肝移植治疗成人急性肝衰竭的临床经验。方法回顾性分析1例低龄儿童小体积供肝肝移植治疗成人急性肝衰竭病例的临床资料并进行文献复习。结果供体为4.5岁儿童,脑死亡器官捐献供肝质量为544.6 g,受体体质量52 kg,移植物受体体质量比为1.05%。手术采用经典原位肝移植术。术后艰难康复,相继并发脑水肿、应激性消化道大出血、急性肾损伤、小肝综合征、肺不张、肺部感染、真菌感染、腹腔感染、胸腔积液等并发症。经对症综合治疗后,移植肝功能逐渐恢复正常,2~3周再生至移植成人标准肝体积大小,住院102 d后康复出院。术后10个月随访受体肝功能正常,生活质量良好。结论儿童小体积供肝可以成功应用于成人受体,但需要根据供肝情况选择合适的受体、手术方式及围手术期精细管理。     

儿童活体肝移植链式管理模式的构建及实施

目的 探讨儿童活体肝移植链式管理模式的临床实践效果。方法 采取历史对照研究设计，选取移植中心2020年3月至2021年3月行原位肝移植术的患儿28例为对照组，实施常规护理；2021年5月至2022年2月行原位肝移植术的患儿30例为干预组，依托多学科团队实施链式管理，包括跨科间大循环及科内小循环双链式闭环管理。结果 与对照组比较，干预组大小循环交接环节遗漏率显著降低，术前疫苗接种率、围术期疼痛控制率及照护者满意度显著提高（均P＜0.05）。结论 链式管理模式的实施能够改善科室间及科内大小循环的交接遗漏问题，普及患儿术前疫苗接种，解决患儿围术期疼痛问题，提升患儿照护者的满意度，保障患儿围术期护理安全。     

肝移植综合技术的改进与体会

目的:总结本移植中心肝移植综合技术提高的经验.方法:回顾性分析我院两个阶段[1999～2004年和2005～2007年(后期)]因良性终末期肝病行肝移植术病人的生存率.结果:后期的肝移植病人术后1个月、3个月和1年生存率分别为91.9%、85.5%和80.0%,明显高于前期的71.8%、66.7%和64.1%.术后围手术期死亡的病人较多,而术后中远期的生存率变化不大,本中心最长的生存病例已达102个月.结论:肝移植术式的改良、移植肝预先用血浆进行灌注、术后肠内营养的应用及免疫抑制剂的减量或个体化应用是提高肝移植术后生存率的原因.     

Organ Transplantation in the Madrid Autonomous Region

The Madrid Autonomous Region, a Spanish area with 6,200,000 inhabitants, has 7 hospitals authorized for organ transplantation, with 25 active programs for carrying out various transplantations: 18 for adults and 7 for children. Most of these hospitals are reference transplant centers for other Spanish regions. Between 715 and 760 transplantations are performed annually, which represents between 19% and 22% of Spanish activity. During 2007, 395 kidney, 220 liver, 55 heart, and 35 lung transplantations were performed, as well as 23 isolated or combination transplantations of other abdominal organs (pancreatic, intestinal, or multivisceral). Kidney, liver, heart, and children's intestinal transplant activity in 2007 represented 37%, 63%, 80%, and 100%, respectively, of all pediatric national activity. The Madrid Autonomous Region has a donation rate of 34.2 donors per million inhabitants. Of these, 30% are from non–heart-beating donors (NHBD), Maastrich criteria category 1 or 2. Various hospitals perform kidney, liver, and lung transplantations with these organs, representing 11% of the lung transplantations carried out in recent years, with this being a pioneer procedure worldwide. Despite the important transplant activity, we are working to increase donations, to improve organ donor detection and management protocols, as well as to reach a consensus on criteria to decrease the nonviability rates of potential transplant organs.     

小儿肝移植术后行非移植手术麻醉的回顾性分析

目的:回顾性分析小儿肝移植术后行非移植手术的麻醉经过与预后,为此类患儿的围手术期麻醉管理提供借鉴。方法:病例资料来源于2017年1月至2020年3月在上海儿童医学中心接受肝移植术后行非移植手术的全部患儿,共计25例。根据手术特点将患儿分为两组：移植并发症相关手术组（R组,15例）和非移植并发症相关手术组（N组,10例）...     

Recipient-Based Approach to Tailoring Immunosuppression in Liver Transplantation

Improvements in the field of transplant immunosuppression (IS) have led to significant advances in long-term survival of liver transplant recipients. Despite this progress, survival rates vary depending on recipient, donor and/or perioperative factors. Tailoring IS based on recipient factors is of growing interest among health care providers involved in the care of organ transplant recipients. To date there is no consensus document addressing individualized IS therapy for liver transplant recipients. This review will discuss the information available on the effect of the various IS drugs on recipient-based factors such as age, ethnicity, and liver disease etiology.     

Lebendspende-Lebertransplantation beim Kind

Liver transplantation is the first-line therapy for children with acute and chronic hepatic failure, metabolic liver diseases and liver tumors. As most of the children with end-stage liver disease are very small in stature the resources of compatible organs of deceased donors are limited. Living liver donation was able to nearly eliminate waiting list mortality with excellent patient and graft survival. As 80% of the pediatric recipients have a body weight <25 kg donation of the left lateral lobe (segments II+III) is sufficient in most of the cases. According to a standardization of the surgical procedures as well as the preoperative, intraoperative and postoperative management donation of the left lateral lobe advanced to a procedure with very low donor morbidity and mortality rates. The complexity of hepatic disease patterns in pediatric patients which often affect other organ systems demand a close cooperation with an experienced pediatric team. Pediatric living donor liver transplantation requires high expertise in liver surgery and split liver transplantation and should therefore only be performed in transplant centers meeting these high qualifications.     

Extracorporeal membrane oxygenation for perioperative support in neonatal and pediatric cardiac transplantation

Currently there is a lack of consensus on guidelines in the clinical application of extracorporeal membrane oxygenation (ECMO) in neonatal and pediatric cardiac transplantation patients. In this context, given the limited data presently available through the Extracorporeal Life Support Organization (ELSO) Registry, we conducted a preliminary survey to specifically evaluate the practice of using ECMO as a bridge to cardiac transplantation or as posttransplantation therapy for failure to wean from cardiopulmonary bypass or graft failure. We received responses to our questionnaire from 95 of 118 (81%) centers located in the U.S.A. and abroad. Of the 95 centers that responded, 36 were performing neonatal/pediatric cardiac transplants, with 29 centers reporting the concomitant use of ECMO to support cardiac transplant patients. There was wide variability in the responses from the 29 centers to a selected list of relative ECMO contraindications. However, only 7 centers had specific ECMO entry criteria for cardiac transplant patients. Fifteen of the 29 centers provided relevant data on cardiac transplant patients including the proportions of neonatal (11 of 37) and pediatric (63 of 217) patients requiring ECMO; neonatal (2 of 5) and pediatric (16 of 27) patients surviving to transplant; and neonatal (1 of 5) and pediatric (12 of 27) patients surviving to hospital discharge. These findings confirm the important role of ECMO in providing perioperative support in neonatal and pediatric cardiac transplantation patients. However, the lack of consensus among centers contributes to uncertainty in the decision making process to offer ECMO and to utilize ECMO effectively in this high risk population. We recommend that institution-specific information be collected, either using the ELSO Registry (or by a similar multicentric database) to develop specific guidelines for ECMO applications in cardiac transplant patients, and to carefully monitor and follow up EMCO treated patients to further evaluate the efficacy of this limited resource.     

Graft survival in pediatric liver transplantation

BACKGROUND/PURPOSE: Liver transplantation is standard therapy for children with a variety of liver diseases. The current shortage of organ donors has led to aggressive use of reduced or split grafts and living-related donors to provide timely liver transplants to these children. The purpose of this study is to examine the impact of these techniques on graft survival in children currently treated with liver transplantation. METHODS: Data were obtained on all patients less than 21 years of age treated with isolated liver transplants performed after January 1, 1996 in an integrated statewide pediatric liver transplant program, which encompasses 2 high-volume centers. Nonparametric tests of association and life table analysis were used to analyze these data (SAS v 6.12). RESULTS: One hundred twenty-three children received 147 grafts (62 at the University of Florida, 85 at the University of Miami). Fifty-two (36%) children were less than 1 year of age at time of transplant, and 80 (55%) were less than 2 years of age. Patient survival rate was identical in the 2 centers (1-year actuarial survival rate, 88.4% and 87.1%). Twenty-five (17%) grafts were reduced, 28 (19%) were split, 6 were from living donors (4%), and 88 (60%) were whole organs. One-year graft survival rate was 80% for whole grafts, 71.6% for reduced grafts, and 64.3% for split grafts (P =.06). Children who received whole organs (mean age, 6.1 years) were older than those who received segmental grafts (mean age, 2.5 years; P <.01). Multifactorial analysis suggested that patient age, gender, and use of the graft for retransplant did not influence graft survival, nor did the type of graft used influence patient survival. CONCLUSIONS: The survival rate of children after liver transplantation is excellent independent of graft type. Use of current techniques to split grafts between 2 recipients is associated with an increased graft loss and need for retransplantation. Improvement in graft survival of these organs could reduce the morbidity and cost of liver transplantation significantly in children.     

Coronary events in patients undergoing orthotopic liver transplantation: perioperative evaluation and management

Patients with advanced liver disease have a high prevalence of cardiac risk factors. The stress of liver transplant surgery predisposes these patients to major cardiac events, such as myocardial infarction or ventricular arrhythmias in addition to heart failure exacerbation. Liver transplant patients who experience coronary events in the perioperative period have a decreased five‐yr survival rate. Cardiovascular risk stratification prior to liver transplant can be accomplished by dobutamine stress echocardiography, stress myocardial perfusion imaging, cardiac computed tomography, and coronary angiography. Pre‐liver transplant management of cardiovascular pathology includes cardiovascular intervention like percutaneous coronary intervention, coronary bypass graft surgery, or medical management. Thorough screening and optimal management of underlying cardiovascular pathology and cardiovascular risk factors should decrease the incidence of new cardiac events in liver transplant recipients.     

Splenic Artery Aneurysm Management in the Cirrhotic Patient Listed for Liver Transplantation: A Systematic Review

BackgroundSplenic artery aneurysms (SAA), although rare in the general population, occur more commonly in liver transplant candidates owing to cirrhosis-induced portal hypertension. In this population, particularly in the perioperative period, SAAs are at heightened risks of rupture with potentially fatal consequences. There is no consensus regarding optimal management of asymptomatic SAA diagnosed before liver transplantation.Materials and MethodsWe performed a systematic review of the literature to investigate the management options and outcomes of asymptomatic SAAs in liver transplant candidates. The EMBASE and MEDLINE electronic databases were used to identify articles.ResultsEleven articles met the criteria for analysis and included 159 patients with SAAs, among whom 121 had asymptomatic aneurysms diagnosed pre transplant and subsequently underwent liver transplantation. The majority of SAAs were located distally or intrahilar (80%) and more than half of the patients had multiple SAAs. In 121 patients diagnosed pre transplant, 37 patients had treatment instigated (28 treated surgically and 8 treated radiologically). Post-transplant rupture was noted in 2 patients treated surgically (2/28) with no fatality. No rupture was observed in the radiologically treated group, although 1 patient died of splenic abscess and sepsis after embolization. In 86 untreated patients, 4 cases of post-transplant rupture were recorded (2/4 resulted in fatality).ConclusionAsymptomatic SAAs are at risks of rupture post transplant and treatment should be considered, regardless of aneurysm size. Both surgical and radiological treatments offer adequate control, and choice of treatment is dependent on location and number of SAA present.     

Intraoperative blood loss in orthotopic liver transplantation: The predictive factors

Liver transplantation has been associated with massive blood loss and considerable transfusion requirements. Bleeding in orthotopic liver transplantation is multifactorial. Technical difficulties inherent to this complex surgical procedure and pre operative derangements of the primary and secondary coagulation system are thought to be the principal causes of perioperative hemorrhage. Intraoperative practices such as massive fluid resuscitation and resulting hypothermia and hypocalcemia secondary to citrate toxicity further aggravate the preexisting coagulopathy and worsen the perioperative bleeding. Excessive blood loss and transfusion during orthotopic liver transplant are correlated with diminished graft survival and increased septic episodes and prolonged ICU stay. With improvements in surgical skills, anesthetic technique, graft preservation, use of intraoperative cell savers and overall perioperative management, orthotopic liver transplant is now associated with decreased intra operative blood losses. The purpose of this review is to discuss the risk factors predictive of increased intra operative bleeding in patients undergoing orthotopic liver transplant.