同种异体原位肝移植的肝动脉重建

目的 总结同种异体原位肝移植术中肝动脉吻合的经验。方法 回顾悸分析20例原位肝移植术中影响肝动脉吻合的因素和处理技巧。结果 16例行供、受者肝固有动脉端端吻合，3例供者肝总动脉与受者肝固有动脉吻合，1例供者肝总动脉与受者脾动脉吻合；术后彩色多普勒超声监测显示肝动脉血流通畅，均未发现有血栓形成或肝动脉狭窄，全部病例未发生胆道并发症，现存活15例。结论 合理选择吻合用血管是避免术后发生血栓形成和动脉狭窄的关键。     

The second generation of Carolina Rinse,solution II,improves graft survival following orthotopic liver transplantation in the rat by preventing reperfusion injury

Carolina Rinse solution was designed to minimize reperfusion injury following orthotopic liver transplantation. Carolina Rinse blocks reperfusion-induced endothelial cell killing, diminishes postoperative enzyme release and improves survival dramatically. Adenosine and mildly acidotic pH were identified as key components. Here we report results with a simplified formulation, Carolina Rinse H, which contains extracellular inorganic ions similar to Ringer's solution, adenosine, as well as antioxidants and radical scavengers (allopurinol, glutathione and desferrioxamine). In this study, 44 rat livers were explanted and stored for 12 h in University of Wisconsin (UW) cold storage solution (non-survival conditions). Control livers were rinsed with 15 ml cold Ringer's solution just prior to completion of implantation surgery. In this control group, average 30-day survival was poor (8%). However, survival was increased to around 60% when grafts were rinsed with Carolina Rinse II. Survival was not improved significantly by rinsing the graft with Ringer's solution containing antioxidants and radical scavengers with adenosine omitted (about 30%). Peak SGOT values of nearly 3000 U/l, measured 1–3 days postoperatively in the Ringer's rinse control group, were decreased 4- to 5-fold both by Carolina Rinse II and by Ringer's solution containing antioxidants. On the other hand, the addition of adenosine to Ringer's solution improved survival (around 60%) but did not decrease the postoperative elevation of serum enzymes significantly. Thus, it appears that adenosine was necessary for optimal survival whereas antioxidants and radical scavengers were needed to prevent injury to the transplanted graft. These data were consistent with the hypothesis that at least two mechanisms, one involving the liver and a second one non-hepatic, are responsible for post-transplant patho-physiology. Carolina Rinse II also reduced the postoperative elevation in serum enzymes 2- to 3-fold in livers stored under survival conditions (e. g., for 8 h in UW solution). This study demonstrated convincingly that a very simple rinse solution, Carolina Rinse II, improved survival significantly and minimized graft injury following orthotopic liver transplantation.     

自制肝脏保存液在大鼠原位肝移植模型中的应用

目的研制一种新型的专用于肝脏保存的溶液,以期达到价廉、专用、损伤小并能长时间保存的目标。方法自制肝脏保存液;建立大鼠原位肝移植模型;使用自制肝脏保存液(A组)、UW液(B组)和HC-A液(C组)保存大鼠肝脏2、8、24h后行大鼠原位肝移植,于移植后6 h比较各项肝脏功能。结果对于ALT、AST、HA,自制肝脏保存液组及其亚组与UW液组同步升高(P>0.05),与HC-A液组比较,前者的含量均低,差异有统计学意义(P<0.05)。对于LDH、STB,自制肝脏保存液组及其亚组与HC-A液组同步升高(P>0.05),与UW液组比较,前者的含量均高(P<0.05)。结论经大鼠原位肝移植模型证实,自制肝脏保存液与UW液在保护肝脏功能方面作用相当,优于HC-A液。     

Methyl palmitate prevents Kupffer cell activation and improves survival after orthotopic liver transplantation in the rat

Abstract. The purpose of this study was to determine whetherprevention of Kupffercell activation following orthotopic liver transplantation improves postoperative survival. First, particle phagocytosis by Kupffer cells was monitored continuously from the uptake of colloidal carbon by the perfused liver. Unstored livers took up carbon at rates of around 150 mg/g per hour, whereas storage for 24 h in Euro-Collins solution nearly doubled values to about 290 mg/g per hour. Treatment of rats with methyl palmitate, an inhibitor of phagocytosis by Kupffer cells, reduced carbon uptake to about one-third to one-half of control values in unstored and stored livers, respectively. Oxygen uptake, which was increased about 25% in stored and unstored livers by infusion of colloidal carbon, was only increased 5%-10% in both groups following treatment with methyl palmitate, suggesting that Kupffer cell activation was prevented by methyl palmitate. In livers transplanted after storage for 6 h in Euro-Collins solution (nonsurvival conditions), control rats survived only about 12 h, while treatment with methyl palmitate increased survival time significantly - more than threefold - to about 40 h. These data are consistent with the hypothesis that activation of Kupffer cells following cold ischemic storage and reperfusion is an early event involved in liver graft failure.     

Methyl palmitate prevents Kupffer cell activation and improves survival after orthotopic liver transplantation in the rat

The purpose of this study was to determine whether prevention of Kupffer cell activation following orthotopic liver transplantation improves postoperative survival. First, particle phagocytosis by Kupffer cells was monitored continuously from the uptake of colloidal carbon by the perfused liver. Unstored livers took up carbon at rates of around 150 mg/g per hour, whereas storage for 24 h in Euro-Collins solution nearly doubled values to about 290 mg/g per hour. Treatment of rats with methyl palmitate, an inhibitor of phagocytosis by Kupffer cells, reduced carbon uptake to about one-third to one-half of control values in unstored and stored livers, respectively. Oxygen uptake, which was increased about 25% in stored and unstored livers by infusion of colloidal carbon, was only increased 5%–10% in both groups following treatment with methyl palmitate, suggesting that Kupffer cell activation was prevented by methyl palmitate. In livers transplanted after storage for 6 h in Euro-Collins solution (nonsurvival conditions), control rats survived only about 12 h, while treatment with methyl palmitate increased survival time significantly — more than threefold — to about 40 h. These data are consistent with the hypothesis that activation of Kupffer cells following cold ischemic storage and reperfusion is an early event involved in liver graft failure. Present address: Department of Trauma Surgery, University of Saarland, W-6650 Homburg/S., Federal Republic of Germany     

应用钛环血管吻合器建立大鼠原位肝移植模型

目的 探讨应用钛环血管吻合器建立大鼠原位肝移植(OLT)模型的可能性.方法 采用雄性SD大鼠80只,分为钛环钉法(TS)组和三袖套法(TC)组,行OLT各20次.结果 TS组与TC组比较,手术时间、无肝期、手术成功率及1周存活率差异均不显著.TS组修肝准备时间较TC组短,分别为(19.55±3.9)min和(23.35±5.9)min,两组比较,P＜0.05.吻合血管的阻塞率TS组低于TC组(5%和35%),P＜0.05.结论 应用钛环钉行大鼠OLT操作简便,在肉眼或额镜下可操作,是建立大鼠OLT的可行方法,并为临床肝移植应用钛环钉吻合供肝各血管来缩短无肝期和减少血管并发症提供了依据.     

The importance of orthotopic liver transplantation in acute hepatic failure

Selection of patients with acute hepatic failure for liver transplantation remains difficult, and there is no definite proof of a survival effect. We therefore did a retrospective study in 75 consecutive patients referred over a 12-year period. In two-thirds we identified a cause, mostly viruses or drugs. Patients were grouped by the Clichy and King's College criteria. In 20 there was no indication for transplantation. Of the 5 with autoimmune hepatitis, 3 died, significantly differing from the other 15 ( P = 0.009). The remaining 55 met our criteria, except 1. All 9 patients with absolute contraindications died. Of the 46 enlisted, 7 died without transplantation. One-year survival after transplantation was 69%, compared with 58% by "intention to treat." For patients enlisted, transplantation reduced mortality by 78% ( P = 0.069). The Clichy and King's College criteria reliably predict survival without transplantation, except in autoimmune hepatitis. Our study strongly suggests that transplantation improves survival.     

原位肝移植肝动脉重建的外科技巧

目的 探讨肝脏移植肝动脉重建的外科技巧和影响肝动脉重建效果的因素.方法 对2004-2005年施行的368例同种原位肝移植病人的临床资料进行分析总结.结果 368例肝移植病人中与动脉相关的并发症共22例,发生率为5.9%(22/368);围手术期发生的15例动脉相关并发症中,12例为动脉血栓形成,3例为误伤右副肝动脉而继发的大面积肝坏死;术后远期发生的7例动脉相关并发症中,动脉血栓形成3例和动脉广泛狭窄4例.所有22例动脉相关的并发症中,接受再次肝脏移植者13例.因肝动脉并发症导致病人死亡11例,占该组肝移植病人死亡的30.5%(11/36).结论 保护供体肝动脉的完整性、正确选择受体动脉的吻合部位、显微外科血管重建技术的应用以及预防或及时纠正血液高凝状态等是提高肝动脉重建质量,降低肝动脉并发症发生率的重要因素.     

原位肝移植肝动脉并发症的预防和治疗

目的 总结分析原位肝移植肝动脉重建及其并发症的防治经验,提高肝移植疗效和受体存活率。方法 总结1995年5月至2005年4月实施的122例肝移植临床资料,肝动脉重建采用供者腹腔动脉干Carrell’s袖片或肝总动脉-脾动脉汇合部与受者肝左-右动脉汇合部袖片吻合21（16．76％）,与受者胃十二指肠-肝固有动脉汇合部吻合87例（71．76％）,采用髂动脉-腹主动脉搭桥14例（11．48％）。术后根据凝血酶原时间（PT）,应用普通肝素或低分子肝素预防性抗凝。术中、术后应用多普勒超声监测肝动脉血供。结果 术后肝动脉血栓形成（HAT）3例,肝动脉狭窄（HAS）2例。1例HAT于术后19d死于多器官功能衰竭,另4例通过放射介入治疗治愈。其余病例随访2～62个月,未见肝动脉血栓形成（HAT）和肝动脉狭窄（HAS）。本组肝动脉并发症发生率为4．10％。结论 正确地选择肝动脉重建吻合的部位和术后有效的抗凝治疗可减少HAT和HAS的发生,多普勒超声监测能早期发现HAT和HAS,挽救移植物,避免再移植。     

肝性脊髓病肝脏移植术后的疗效观察

目的 为进一步探讨肝脏移植术对肝性脊髓病疗效观察。方法 对我院2例肝性脊髓病病人行原位肝移植术后进行临床资料回顾分析，随访时间最长2年5个月。结果 肝移植术后病人的临床症状、体征及生活质量均获得明显改善，四肢肌力得到有效恢复。结论 肝脏移植对肝性脊髓病是一种新的、从病因上治疗的有效方法。     

Carolina rinse solution--a new strategy to increase survival time after orthotopic liver transplantation in the rat

Recently, we described a new solution, Carolina rinse, that prevents nonparenchymal cell injury in vitro after reperfusion of livers stored in University of Wisconsin cold solution (Currin RT, Toole JG, Thurman RG, Lemasters JJ. Transplantation 1990; 50: 1076). The present study was designed to examine the effect of Carolina rinse on graft survival in vivo. Unlike UW cold storage solution, which is high in potassium, Carolina rinse contains extracellular inorganic ions at levels similar to blood, a calcium channel blocker and a radical scavenger. Carolina rinse also contains fructose and mildly acidotic pH to reduce hypoxic cell death. Livers from Lewis rats were explanted, stored in UW cold storage solution under nonsurvival conditions, and rinsed with either 15 ml of Ringer's, UW solution, Carolina rinse, or Carolina rinse saturated with nitrogen prior to completion of implantation surgery. In the Ringer's rinse group, only 4% of recipients survived 30 days postoperatively. In this group, SGOT levels reached maximal values of about 5000 U/L. Survival was also poor (25%) when grafts were rinsed with UW solution. In the Carolina rinse group, however, 9 of 16 rats (56%) survived indefinitely, and maximal postoperative SGOT levels were reduced 3-fold. Liver injury indexed histologically was also decreased about 3-fold by Carolina rinse compared with the control group rinsed with Ringer's solution. Carolina rinse diminished postoperative sinusoidal endothelial cell damage assessed by electron microscopy and reduced carbon particle phagocytosis due to Kupffer cells significantly. Moreover, Carolina rinse diminished graft swelling and improved postoperative hepatic microcirculation compared with the Ringer's rinse group. Taken together, these results indicate that Carolina rinse is a superior alternative to Ringer's solution in vivo to protect liver grafts from reperfusion injury when removing high-potassium-containing cold storage solutions clinically prior to implantation.     

大鼠肝移植后树突状细胞的迁移变化

目的：研究大鼠肝移植后树突状细胞（DC）的迁移情况。方法：制作Wistar大鼠到SD大鼠的肝移植模型（实验组），并设Wistar大鼠间肝移植作为对照（对照组）。分别于术后第3、5、7天处死受者，切取移植肝组织及腹腔淋巴结，进行组织学观察，并以免疫组织化学染色观察移植肝组织和淋巴结中S-100^＋DC的动态变化，以及CD25^＋T淋巴细胞在淋巴结的活化增殖。结果：肝组织病理学检查显示，实验组移植后第5天即出现轻至中度急性排斥反应，至第7天发展成中至重度排斥反应，受者存活时间（9．7±1．4）d。免疫组织化学染色显示，术后第3天实验组移植肝组织中DC数量明显增多，于第5天达到高峰，第7天则出现下降，明显高于对照组，差异有统计学意义（P〈0．05）。从第3天开始，淋巴结中DC数量明显增多，第5、7天持续上升，与对照组相比，差异有统计学意义（P〈0．05）。移植术后第3天，实验组淋巴结中CD25^＋T淋巴细胞明显增多，呈现明显的T淋巴细胞活化增殖反应。结论：同种异体肝移植后，DC对抗原的摄取和递呈加速，产生对T淋巴细胞强烈而持久的刺激，最终激活T淋巴细胞，导致排斥反应的发生。     

Hepatic reperfusion injury following orthotopic liver transplantation in the rat

At 24 hr following orthotopic transplantation, rat liver grafts were perfused in situ for 7 min with trypan blue, a vital dye that provides information on hepatic microcirculation and stains nuclei of nonviable cells. Spotty and uneven dye distribution was observed indicating that hepatic microcirculation was disturbed 24 hr following transplantation surgery. Under these conditions, 15-20% of the hepatocytes were nonviable as assessed from trypan blue staining and frank necrosis. In contrast, perfusion of livers from untransplanted rats or liver explants exposed to cold ischemia for 60 min were judged normal by the criteria of uniform distribution of dye in the organ and absence of necrosis and nuclear dye uptake. Thus the observed damage was associated with reintroduction of blood and can therefore be classified as a reperfusion injury. The altered microcirculation and cell death following the operation was reduced markedly by perfusion of the cold, ischemic explant with nitrogen-saturated but not with oxygen-saturated buffer for 5 min prior to the implantation operation. Protection was even greater if the perfusion medium contained verapamil (20 micrograms/ml), a Ca++ channel blocker. We conclude that reperfusion of the stored liver causes an oxygen-dependent alteration in hepatic microcirculation that leads to hypoxia and scattered hepatocellular necrosis in the implanted graft. Brief perfusion of the hypoxic implant under anaerobic conditions may remove substrates involved in oxygen radical generation and prevent reperfusion injury upon introduction of oxygen into the graft via the blood. Taken together, these results suggest that removal of Euro-Collins' solution under anaerobic conditions may be beneficial clinically in preventing injury of surgical explants.     

Protocol for the technique of orthotopic liver transplantation in the rat

Orthotopic rat liver transplantation (OLT) has been generally accepted as an excellent model for the analysis of pathological, physiological, and immunological aspects related to organ transplantation. However, many researchers require a long training period to achieve a high success rate using this major surgical procedure on small animals. We therefore developed a protocol for learning rat OLT. It is recommended, initially, that the heterotopic heart transplantation (HHT) model be used to master the cuff technique, since this technique is similar to that in OLT and leads to an understanding of another organ transplantation technique. For beginners who advance beyond the HHT step to OLT but cannot finish the anhepatic phase within 30 min, we recommend the use of portosystemic-shunted rats as recipients. These animals have had their spleens transposed subcutaneously more than 3 weeks before use. The use of these modifications and this training program makes it possible to master the techniques and to achieve a high success rate with a short training period. © 1993 Wiley-Liss Inc.     

同种异体原位肝移植的复杂肝动脉重建经验总结

目的  总结同种异体原位肝移植术中复杂肝动脉重建的相关经验。方法  回顾性分析2015年1月至2019年3月期间行复杂肝动脉重建的7例肝移植受者资料。其中4例经典肝移植,3例背驮式肝移植。观察受者术中的一般情况,包括无肝期、术中出血量、肝动脉吻合时间、手术时间; 观察受者预后情况及并发症发生情况。结果  2例供者变异右肝动脉重建血管,分别用供者腹腔干或肝总动脉与受者肝总动脉吻合; 2例用髂动脉搭桥,然后供者肝动脉与受者腹主动脉吻合; 1例供者肠系膜上动脉与受者肝总动脉端端吻合; 1例供者腹腔干与受者脾动脉吻合; 仅1例因肝动脉吻合后出现急性肝动脉血栓,需再次行肝移植。6例肝移植受者均顺利完成手术,无围手术期死亡,无肝期49~77 min,术中出血量300~1 500 mL,肝动脉吻合时间23~56 min,手术时间5.3~11.1 h。术后住院时间23~56 d,均未出现肝动脉血栓、狭窄。所有受者术后2周内肝功能基本恢复正常,无严重外科并发症发生,移植肝均获得良好的功能。结论  正确辨别肝动脉有否变异,选择适宜的方式处理供、受者肝动脉并重建新肝动脉血供,是肝移植术中的关键步骤。     

原位肝移植肝动脉并发症的防治

目的 探讨原位肝移植肝动脉并发症的预防及治疗。方法 回顾性分析1999年2月至2001年2月完成的22例原位肝移植，其中4例行体外静脉转流下的原位肝移植术，17例行背驮式原位肝移植，1例为活体供肝部分肝移植。11例供肝的肝固有动脉与受者的肝固有动脉吻合，4例供者脾动脉与受者肝总动脉吻合，3例供者腹腔动脉与受者肝总动脉吻合，2例应用供者髂动脉在供者肝固有动脉与受者腹主动脉间架桥吻合，1例供者肝右动脉与受者肝固有动脉吻合，1例供者肝固有动脉与受者异位肝右动脉吻合。术后以多普勒超声扫描监测肝动脉血流。结果 1例术后5d时发生肝动脉血栓形成，以尿酶介入溶栓后出现吻合口出血，再次手术行肝动脉吻合。21例无肝动脉并发症发生。15例随访1－20个月，多普勒超声扫描提示肝动脉血流、形态正常，胆道造影未见肝外胆管狭窄，血清学检查提示肝功能状态良好。结论 原位肝移植预防肝动脉并发症的关键在于血管吻合时操作精细，实现血管内膜对内膜的无张力吻合。     

Organ survival after primary dysfunction of liver grafts in clinical orthotopic liver transplantation

Abstract In a retrospective analysis of 632 orthototopic liver transplant procedures performed between 1982 and 1997, the incidence of primary dysfunction (PDF) of the liver and its influence on organ survival were studied. Graft function during the first 3 postoperative days was categorized into four groups: (1) good (GOT max < 1000 U/l, spontaneous PT > 50 %, bile production > 100 ml/day); (2) fair (GOT 1000‐2500 U/l, clotting factor support < 2 days, bile < 100 ml/day); (3) poor (GOT > 2500 U/l, clotting factor support > 2 days, bile < 20 ml/day); (4) primary non‐function (PNF; retransplantation required within 7 days). The aim of this study was to evaluate graft survival comparing organs with PDF (poor function) and PNF vs organs with initial good or fair function. After a median follow‐ up of 45 months, initially good and fair function of liver grafts resulted in a significantly better long‐term graft survival compared with grafts with initially poor function or primary non‐function (if re‐transplanted) (P < 0.01). The Cox model revealed primary function as a highly significant factor in the prediction of long‐term graft survival (P < 0.0001). We conclude that these results confirm the hypothesis that primary graft function is of major importance for the long‐term survival of liver transplants. Patients with a poor primary function have the worst survival prognosis, which leads to the interpretation that these patients may be candidates for early retransplantation.     

提高原位肝移植术后长期生存率的临床研究

目的 探讨提高原位肝移植术后长期生存率的临床措施。方法 回顾性分析我科3年多来所施行的72例原位肝移植病人术后生存情况、并发症发生的种类及数量，以及诊治处理方法，以探讨成功及失败原因。结果 72例肝移植病人中，原发病为良性疾病50例(其中终末期乙肝肝硬化34例)；恶性疾病22例(其中HCC19例)。术后发生并发症54例次，含因凝血功能紊乱致术后腹腔内继发性出血4例，术前腹水感染未能控制，致术后腹水严重感染2例，激素用量过大致应激性溃疡出血、穿孔1例，胆瘘6例，肺部感染21例，肠道真菌感染5例。全组无原发性肝无功能及血管并发症，随访2～41个月，无远期胆道并发症及慢排发生。住院期死亡6例，随访期死亡6例，目前生存60例，总生存率为83．33％，存活超过1年者32例，最长已3年5个月。结论 ①术中技术的改进及新技术的应用；②采用个体化的免疫抑制方案；③加强术后感染预防与治疗；④加强乙肝复发的预防和治疗；⑤预防肿瘤复发的系列措施，是提高肝移植术后生存率的关键。