肝胰十二指肠器官簇移植外科技术

2004年9月1例原发性肝癌合并胰头转移的患者在我院接受肝胰十二指肠器官簇移植，整块切除全肝、胆囊、十二指肠、胰腺、脾脏、胃大部和部分上段空肠，进行了血管和消化道重建。移植后胰腺功能正常，未应用胰岛素维持。术后第4d肠道功能恢复，术后1周肝功能恢复正常；术后16d时因腹腔内出血行剖腹探查血肿清除术，同时对感染伤口进行减张缝合，愈合良好；术后2月时出现不全性肠梗阻症状，保守治疗后好转。患者目前已存活5个月，肝脏和胰腺功能均正常，痊愈出院。肝胰十二指肠器官簇移植术的成功为上腹部晚期恶性肿瘤患者提供了延长生命的机会，同时为晚期肝病伴有胰腺功能不良患者的彻底治愈探索出新的手术方式。     

保留胰腺的肝胰十二指肠器官簇移植治疗终末期肝病合并糖尿病

肝硬化患者大多有糖代谢障碍表现,高达30%的肝硬化最终合并糖尿病,肝移植后由于免疫抑制剂的应用使原有糖尿病进一步加重。研究表明,糖尿病患者肝移植术后的长期存活率较无糖尿病患者显著降低。因此,对于合并有糖尿病的终末期肝病患者同时进行肝胰联合移植是十分必要的。     

肝胰十二指肠器官簇移植术后的免疫抑制治疗

目的探讨肝胰十二指肠器官簇移植术后的免疫抑制治疗的合理用药方案。方法收集本中心共实施的10例肝胰十二指肠器官簇移植手术病例,其中5例为上腹部肿瘤伴腹腔多发转移病灶患者接受了肝脏、胰腺及上消化道全切除术后行器官簇移植,5例乙型肝炎后肝硬化失代偿期合并2型糖尿病患者予以单纯肝切除术后行器官簇移植。10例患者均采用巴利昔单抗＋他克莫司＋激素＋霉酚酸酯四联免疫抑制方案,对患者的临床资料进行回顾性分析。结果10例患者手术顺利,术后肝脏、胰腺及十二指肠功能恢复良好。5例肿瘤患者最长存活326d,3例死于多器官功能衰竭,2例死于肿瘤复发。5例肝硬化合并糖尿病患者除1例于术后4周死于移植物抗宿主病（GVHD）外,其余4例均存活,最长生存时间已超过21个月。随访期内及至患者死亡,10例患者均未发生排斥反应。结论采用巴利昔单抗＋他克莫司＋激素＋霉酚酸酯四联免疫抑制方案可以有效预防肝胰十二指肠器官簇移植术后排斥反应的发生。     

1例肝移植术后再行肝胰十二指肠器官簇移植的手术配合

对1例肝移植术后肝癌复发并腹腔内广泛侵犯的患者再行上腹部器官簇移植术，手术过程顺利，术后恢复良好。提出特殊情况下上腹部器官簇移植的手术配合要点：充分的术前准备、密切的术中配合、严格无菌操作、及时准确应用各类药物和恰当的输液输血，是该手术成功的关键。     

肝胰十二指肠器官簇移植(附一例报道)

目的探讨肝胰十二指肠联合移植术治疗1例原发性肝癌合并胰头转移的疗效。方法2004年9月,对1例原发性肝癌合并胰头转移的患者行病肝、全胰腺十二指肠、远端胃及脾脏切除后,进行肝胰十二指肠原位器官簇移植。结果移植术后胰腺功能恢复正常,未应用胰岛素维持;术后1周肝功能恢复正常。患者目前已存活5个月,肝脏和胰腺功能均正常,未发生排斥反应,未见肿瘤复发迹象,一般情况好。结论肝胰十二指肠器官簇移植为上腹部晚期恶性肿瘤患者提供了延长生命的机会,同时更为晚期肝病伴有胰腺功能不良患者的彻底治愈探索出新的手术术式。     

1例肝移植术后再行肝胰十二指肠器官簇移植的手术配合

对1例肝移植术后肝癌复发并腹腔内广泛侵犯的患者再行上腹部器官簇移植术,手术过程顺利,术后恢复良好.提出特殊情况下上腹部器官簇移植的手术配合要点:充分的术前准备、密切的术中配合、严格无菌操作、及时准确应用各类药物和恰当的输液输血,是该手术成功的关键.     

保留受者胰腺的肝胰十二指肠器官簇移植一例报告

目的探讨保留受者胰腺的肝胰十二指肠器官簇移植术的方法和疗效。方法2006年9月28日为1例肝移植术后发生胆道并发症合并1型糖尿病的患者实施了肝胰十二指肠器官簇移植，术中采用保留受者胰腺的方法。结果术后1周时，受者肝脏功能基本恢复正常；术后第2天即停用胰岛素静脉泵，移植胰腺功能恢复正常。术后第1天胰尾部出现胰瘘，但引流通畅，未予以其他特殊处理，术后第4天胰瘘自行愈合；术后第4天胃肠功能恢复正常；术后第5天，受者即可自行下床活动。受者现已存活12个月，肝脏和胰腺功能均正常。结论保留受者胰腺的方法不仅简化了器官簇移植术的操作，而且使术中和术后并发症明显减少，从而为需行肝胰十二指肠器官簇移植的良性病受者探索出了一种更为简捷安全的新手术方法。     

腹部器官簇移植的临床应用进展

腹部器官簇移植是指腹腔内3个以上在解剖和功能上相互关联的脏器群体移植，如肝、胰、十二指肠移植等，具有器官功能替代全面和保持移植器官间正常解剖生理结构的特点。腹部器官簇移植涉及多个腹部器官的疾病，如严重脏器创伤、短肠综合征后期伴发的肝功能衰竭和侵犯多脏器的恶性肿瘤等，因多个脏器的损伤、病变或被迫切除，普通外科手术和单器官移植术等治疗方法均不能根治，而器官簇移植由于可以解决多个器官的功能替代问题而成为治疗上述疾病的有效方法。可以说，器官簇移植代表了器官移植领域中的先进技术，其手术技术要求高、围手术期治疗复杂，肠瘘和感染等术后并发症发生率较高，因此虽然临床意义重大，但同时也面临巨大挑战和困难。     

老年胰十二指肠切除术术后并发症分析

目的 分析5年来实施的52例老年胰十二指肠切除术术后并发症.方法 52例老年患者实施胰十二指肠切除术,男性32例,女性20例,年龄65～76岁,中位年龄70.5岁.术后病理证实为Vater's壶腹癌及十二指肠乳头癌24例,胰腺癌16例,胆管癌12例.结果 全组病死4例(7.7%).主要并发症包括上消化道出血4例(7.7%),腹腔内出血4例(7.7%),多脏器功能衰竭(MOF)3例(5.8%),急性呼吸窘迫综合征(ARDS)2例(3.8%),胰瘘3例(5.8%),胆瘘5例(9.6%),胃瘫6例(11.5%),精神障碍8例(15.4%).结论 MOF是老年患者胰十二指肠切除术术后主要致死并发症,胃瘫和精神障碍发病率高于中青年组.

Abstract：

Objective To analyze the postoperative complications in aged patients receiving pancreaticoduodenectomy. Methods Pancreaticoduodenectomy was employed for the treatment of 52 aged patients. Of the 52 patients with a mean age of 70.5(65-76), 32 were male and 20 female. Postoperative pathological examination confirmed that 24 patients suffered from Vater,s ampullary and duodenal cancers, 16 from pancreatic carcinoma and 12 from cholangiocarcinoma. Results The mortality was 7.7%. Severe complications included bleeding (upper gastrointestinal tract or abdominal cavity),MOF, ARDS, postsurgical gastroparasis syndrome(PGS), mental disorder, pancreaticogastrostomy leak and biliary-enteric anastomotic leak et al. Conclusion MOF is the main lethal complication. Incidence of PGS and mental disorder is high.     

腹部器官簇移植治疗终末期肝病合并胰岛素依赖的2型糖尿病五例

目的 总结了改良的腹部器官簇移植(MCT)治疗终末期肝病合并胰岛素依赖的2型糖尿病(T2DM)患者的经验.方法 回顾性分析了单中心连续实施的5例MCT的资料.5例全部为男性,原发病为乙型肝炎后肝硬化合并T2DM 3例,乙型肝炎后肝硬化合并T2DM 1例,原发性肝癌(HCC)合并T2DM 1例.受者切除患肝后,原位植入包括肝脏、胰腺、部分十二指肠的器官簇,器官簇来源于同一个供者.胆道和胰腺外引流采用供者十二指肠与受者上段空肠Roux-en-Y吻合或者侧侧吻合方式.术后采用巴利昔单抗诱导,他克莫司(Tac)+吗替麦考酚酯(MMF)+皮质激素联合应用预防排斥反应,之后过渡至单用Tac维持治疗.结果 5例手术均顺利,患者于术后早期(8～27 d)完全脱离胰岛素治疗,并且血糖水平维持正常.其中3例术前C肽水平严重降低,术后早期明显升高,并维持于正常水平.1例术后发生移植物抗宿主病,并死亡,其他4例顺利恢复,术后分别随访22、15、5和4个月,均存活,并已恢复正常生活,移植物功能正常,血糖水平正常.结论 腹部器官簇移植是治疗终末期肝病合并胰岛素依赖的2型糖尿病的有效手段.

Abstract：

Objective Modified upper abdominal cluster transplantation (MCT), which was inspired by the classical cluster transplant technique, has been proven more effective and feasible in the treatment of patients with end stage liver diseases associated with insulin-dependent diabetes mellitus (DM) than orthotopic liver transplantation (OLT) alone. In this study, we summarized our experience with MCT in 5 consecutive patients suffering from end stage liver diseases associated with insulin-dependent type 2 DM in our single center.Methods Five patients with hepatitis B-related chronic liver cirrhosis and insulin dependent type 2 DM received MCT in our single center. The biliary and exocrine pancreatic drainage reconstructions were achieved by a Roux-en-Y duodenojejunostomy or a side-to-side duodenojejunostomy. A quadruple immunosuppressive regimen based on tacrolimus including Basiliximab induction, mycophenolate mofetil (MMF) and steroids was used in the early stage post-transplant, and then converted to tacrolimus monotherapy.Results All of the patients experienced an uneventful post-operative recovery. They were rendered independent from insulin therapy shortly after transplantation. The fasting glucose and glycosylated hemoglobin levels were within normal range. In addition, the fasting C-peptide value was increased from much lower than the normal range pre-transplant to within normal range post-transplant and maintained stable since then. However, the third patient suffered from graft verse host disease (GVHD) 20 days post-operatively and died from severe infection on the post-operative 47 days. The other 4 patients had returned to work and a normal lifestyle over 22, 15, 5 and 4 months of follow-up.Conclusion MCT is an effective method in treating patients suffering from end stage liver diseases combined with insulin-dependent type 2 DM. Whether a cluster graft would increase the risk of GVHD needs further investigation.     

肝移植围手术期糖尿病防治的初步研究

目的研究肝移植围手术期糖尿病对患者的影响及防治措施。方法回顾性分析131例肝移植患者临床资料，观察患者围手术期糖尿病的发生及对术后并发症的影响，探讨移植术后新发糖尿病与原发疾病、术后免疫抑制药物等因素的关系。结果移植术后新发糖尿病发生率为19．3％（21／109），与糖尿病家族史和术后使用大剂量激素有关，与非糖尿病患者相比，围手术期糖尿病患者急性排斥反应、细菌感染、高血压等并发症的发生率显著升高（P〈0．05），术前及术后早期（2周内）将血糖降至正常可减少感染的发生。结论围手术期出现糖尿病会增加肝移植患者术后并发症的发生率，应该有效控制血糖以减少感染并发症的发生，同时肝移植术后早期应避免使用大剂量激素.     

原位肝移植治疗终末期自身免疫性肝病

目的 评价肝移植治疗终末期自身免疫性肝病的疗效并总结临床经验.方法 回顾性分析2003年9月至2009年7月间因终末期自身免疫性肝病接受肝移植手术的11例患者的临床资料,其中8例为原发性胆汁性肝硬化,2例为自身免疫性肝炎,1例为原发性硬化性胆管炎.平均年龄为(44.2±8.7)岁.手术方式均采用附加腔静脉整形的改良背驮式肝移植术.术后免疫抑制治疗采用他克莫司或环孢素A联合激素的二联免疫抑制方案,部分患者使用骁悉和熊去氧胆酸.结果 本组11例患者中2例原发性胆汁性肝硬化患者死亡,其中1例于术后第5天死于肺部感染和多器官功能衰竭,另1例于术后964 d死于脓毒症和移植肝失功.5例患者术后1个月内出现急性排斥反应,加强免疫抑制治疗后痊愈.9例患者生存良好并存活至今,随访期7～62个月,中位随访时间为38个月.受体1年存活率为91%,3年存活率为82%,最长存活期5年.随访期间未发现复发病例.结论 肝移植是治疗终末期自身免疫性肝病的惟一有效手段,手术时机的正确把握和有效的免疫抑制治疗是减少肝移植术后并发症的关键.

Abstract：

Objective To evaluate the effect of liver transplantation for end-stage autoimmune liver disease (ESALD) and summarize the clinical experience of liver transplantation in the treatment of ESALD.Methods The clinical data of 11 ESALD cases who underwent liver transplantation from September 2003 to July 2009 were analyzed retrospectively. There were 2 males and 9 females ( median age, 44. 2 ± 8. 7years). The indication of liver transplantation was end stage of primary biliary cirrhrosis (8 cases),autoimmune hepatitis (2 cases), and primary sclerosing cholangitis ( 1 case). In all cases, modified piggyback liver transplantation with venacavaplasty was carried out. Postoperatively all patients were treated with immunosuppressive agents including tacrolimus (or cyclosporine A) and prednisone, some patients were treated additionally with mycophenolate mofetil and ursodeoxycholic acid. Results Postoperatively 2patients of primary biliary cirrhosis died, one of lung infection and multiple organ failure on the 5th postoperative day, the other dying of sepsis and graft dysfunction on the 964th postoperative day. Five cases suffered from episodes of acute cellular rejection within 1 month after transplantation and was successfully reversed by strengthened immunosuppressive therapy. Nine patients recovered satisfactorily and with excellent life quality until now. Patients were followed up from 7 months to 62 months with the median follow-up time of 38 months. The recipient survival rate at 1 year and 3 years was 91% and 82% ,respectively. One patient has now survived for 5 years. No recurrent ALD case was found during follow up.Conclusions Orthotopic liver transplantation is an exclusive treatment for ESALD. Optimum operation timing and effective immunosuppressive treatment are very important for decreasing occurrence of complications.     

胰肾联合移植治疗肝移植后糖尿病合并肾功能衰竭二例

目的 总结肝移植后再行胰肾联合移植治疗糖尿病合并肾功能衰竭的临床处理经验.方法 2例肝移植受者术前合并有2型糖尿病,分别于肝移植后7年余和4年余发生肾功能衰竭,遂行胰肾联合移植,2例的移植肝功能均正常.采取腹部器官联合快速切取技术整块切取双肾、全胰及十二指肠节段,先行肾移植,再行胰腺移植,供肾移植于左侧髂窝,供胰移植于右侧髂窝,供者的十二指肠与受者的空肠侧侧吻合,供者的十二指肠内置管,通过受者的空肠引流出体外.例1采用抗白细胞介素受体单克隆抗体诱导的四联免疫抑制方案预防排斥反应;例2术中给予抗胸腺细胞球蛋白和甲泼尼龙,术后继续使用2d,采用他克莫司+吗替麦考酚酯+皮质激素预防排斥反应.结果 2例手术过程顺利,术后移植胰腺功能正常,血糖均于术后10d左右恢复正常,无需胰岛素治疗,移植肾功能1周时恢复正常,第2例1周后血清肌酐渐进性升高,经验性抗排斥反应治疗效果不明显,移植肾活组织检查未见明显排斥反应征象,遂将他克莫司替换为西罗莫司,之后受者的肾功能逐渐恢复正常.目前2例受者已分别随访36个月及9个月,移植肝、肾及胰腺功能均正常.结论 肝移植后合并糖尿病、肾功能衰竭时可考虑行胰肾联合移植,但术后免疫反应复杂,需严密监测移植物功能.     

肝移植术后肺部并发症分析

目的 评估原位肝移植患者术前肺功能情况及其在预测肝移植术后肺部并发症(postoperative pulmonary complications,PPC)中的作用.方法 2008年8月至2009年6月天津市第一中心医院完成71例原位肝移植手术,分析患者术前肺功能状况及其与术后肺部并发症的关系.结果 71例患者中肝移植术前肺功能异常者65例,肺弥散功能减低65例(91.5%),限制性通气功能减低30例(42.2%),小气道功能减低28例(39.4%),阻塞性通气功能减低21例(29.6%).移植术后肺部并发症的发生率为56.3%,肺部并发症包括:肺不张,肺炎,急性呼吸衰竭.限制性和阻塞性通气功能减低组肺部并发症的发生率与正常组相比差异有统计学意义(x2=6.703,P=0.010;x2=4.768,P=0.029),中、重度的弥散功能减低组肺部并发症的发生率与轻度和正常组相比差异有统计学意义(x2=8.478,P=0.004).结论 肝移植患者术前肺功能异常是常见的,通气功能减低(VCmax＜80%或FEV1.0＜80%)及中、重度肺弥散功能减低(TLCOSB＜60%)可作为预测术后肺部发生并发症的一个指标.

Abstract：

Objective To probe the correlation between preoperative pulmonary dysfunction and postoperative pulmonary complications in patients of orthotopic liver transplantation. Methods From August 2008 to June 2009, 71 orthotopic liver transplantation patients were studied. Preoperative pulmonary function and its relationship with postoperative pulmonary complications were analyzed.Results Preoperatively 65 out of 71 patients had abnormal lung functions, suffering from pulmonary diffusing capacity reduction (65 cases, 91.5% ), followed by reduction of restrictive ventilation function (30 cases, 42. 2% ), small airway function reduction ( 28 cases, 39.4% ), and obstructive ventilatory function reduction (21 cases, 29. 6% ). The incidence of postoperative pulmonary complications was 56. 3% including: pulmonary atelectasis, pneumonia, acute respiratory failure. The incidence of posttransplantation pulmonary complications in patients with pulmonary restrictive or obstructive ventilation function reduction was higher than in normal group (x2 = 6.703, P= 0.010; x2 = 4.768, P = 0.029), and there was significant difference in pulmonary complication rate between groups of moderate and severe diffusing capacity reduction and mild reduction and normal range (x2 = 8.478, P = 0.004 ).Conclusions Preoperative pulmonary function abnormality in patients before liver transplantation such as pulmonary ventilatory function reduction (VCmax ＜ 80% or FEV1.0 ＜ 80% ) and moderate to severe pulmonary diffusing capacity reduction (TLCOSB ＜ 60% ) predicts higher incidence of postoperative pulmonary complications.     

终末期肝病模型评分较高的良性终末期肝病患者肝移植疗效评价

目的 探讨终末期肝病模型(MELD)评分较高的良性终末期肝病患者的肝移植疗效.方法 回顾分析80例良性终末期肝病肝移植患者的资料,根据MELD评分的不同将患者分成两组,MELD评分≥30分的23例为高MELD评分组,MELD评分＜30分的57例为低MELD评分组.分别比较两组患者手术时间、术中无肝期、术中血液制品输入量、术后重症监护病房(ICU)治疗时间和受者1年存活率,同时比较死亡患者和存活患者的临床资料,寻找导致术后死亡的危险因素.结果 高MELD评分组的手术时间、术中血液制品输入量、ICU治疗时间以及术后3个月内的死亡率明显高于低MELD评分组,差异有统计学意义(P＜0.05),而术中无肝期和患者1年存活率,两组间的差异无统计学意义(P＞0.05).死亡者和存活者相比较,MELD评分的差异无统计学意义(P＞0.05),而术前机械通气、血清钠水平、持续性肝性脑病(重型)等方面的差异有统计学意义(P＜0.05).结论 对于良性终末期肝病患者,单纯依靠MELD评分不足以准确判断患者肝移植术后的生存状态,高MELD评分者也可获得较好的肝移植结果,术前严重的低钠血症、重度肝性脑病以及机械通气是除MELD评分以外影响患者术后生存状况的危险因素.     

肝脏穿刺活检在肝移植术后的应用

目的 通过对肝移植术后肝脏穿刺活检资料的分析,探讨移植术后各种并发症的病理组织学表现,指导肝移植术后并发症的诊治.方法 回顾性分析198例肝移植术后患者249例次诊断性肝脏穿刺活检组织病理资料和治疗效果.苏木精-伊红染色法分析其病理学形态改变,排斥反应采用Banff排斥反应病理标准、RAI评分分级.结果 所有病理活检资料中,急性排斥反应发病率为最高,共71例次(28.5％),胆道并发症39例次(15.7％)、肝炎病毒感染及复发28例次(11.2％)、药物性损害34例次(13.7％)、再灌注损伤35例次(14.1％)、巨细胞病毒感染14例次(5.6％)、肿瘤复发7例次(2.8％)、慢性排斥反应16例次(6.4％)、原发性移植物无功能2例次(0.8％)、难以确定3例次(1.2％).结论 移植肝行穿刺活检术能很好的明确肝功能异常的病因,进而指导临床进行精确、有效的治疗,建议各移植中心将肝脏穿刺列为肝移植术后的常规检查,定期活检,更好的保护移植物的生存状态.     

大鼠肝脏胰腺十二指肠整块联合异位移植

为探索肝胰十二指肠整块联合移植术式的可行性，在国内首先建立了大鼠ＳＨＰＤ模型，并评价了术后大鼠生存以及移植物功能状况。结果表明大鼠异位ＳＨＰＤ切实可行，手术成功率高，术后１周存活率达７５％，能长期存活，术后行相关检查，表明移植物血管通畅，供肝和供胰有功能。     

Short‐term outcomes of en bloc combined heart and liver transplantation in the failing Fontan

Patients with failing Fontan physiology and liver cirrhosis are being considered for combined heart and liver transplantation. We performed a retrospective review of our experience with en bloc combined heart and liver transplantation in Fontan patients > 10 years old from 2006 to 18 per Institutional Review Board approval. Six females and 3 males (median age 20.7, range 14.2‐41.3 years) underwent en bloc combined heart and liver transplantation. Indications for heart transplant included ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, and/or lymphatic abnormalities. Indication for liver transplant included portal hypertension and cirrhosis. Median Fontan/single ventricular end‐diastolic pressure was 18/12 mm Hg, respectively. Median Model for End‐Stage Liver Disease excluding International Normalized Ratio score was 10 (7‐26), eight patients had a varices, ascites, splenomegaly, thrombocytopenia score of ≥ 2, and all patients had cirrhosis. Median cardiopulmonary bypass and donor ischemic times were 262 (178‐307) and 287 (227‐396) minutes, respectively. Median intensive care and hospital stay were 19 (5‐96) and 29 (13‐197) days, respectively. Survival was 100%, and rejection was 0% at 30 days and 1 year post‐transplant. En bloc combined heart and liver transplantation is an acceptable treatment in the failing Fontan patient with liver cirrhosis.     

膀胱引流式胰、肾联合移植长期存活患者代谢性酸中毒的转归

目的 总结膀胱引流式胰，肾联合移植术后长期存活患者代谢性酸中毒的演变规律及处理经验。方法 对2例膀胱引流式胰，肾联合移植术后长期存活（5年，8年）患者进行随访。观察其临床表现，血液气体分析及碳酸氢钠的给药方式，剂量和疗效。结果 2例患者术后均发生代谢性酸中毒，需长期给予碳酸氢钠替代治疗。结论 膀胱引流式胰，肾联合移植术后的代谢性酸中毒很难自行代偿纠正。一定程度上影响了患者的生活质量。