一种新的大鼠原位肝移植肝上下腔静脉吻合法

大鼠原位肝移植术经过许多学者改进 ,其术式基本固定 ,即 :门静脉和肝下下腔静脉应用袖套管 (cuff管 )吻合 ,胆总管应用内支架管 (stent管 )吻合 ,肝上下腔静脉采用连续缝合或亦用cuff管技术吻合。然而 ,成功的肝上下腔静脉吻合仍是肝移植中最困难的操作。本文采用静脉段内覆的stent管处理肝上下腔静脉 ,操作简单 ,费时少 ,报道如下。1.材料 :(1)健康雄性Wistar大鼠 2 8只 (中国科学院上海实验动物中心提供 ) ,体重 2 5 0～ 30 0 g ;(2 )以聚乙烯管制作的stent管 (外径 3.5mm ,内径 3.2mm ,长 3.5mm )若干。stent管推进器的制备 :取与stent…     

肝上腔静脉成形术联合肝后腔静脉扩展术在肝移植中的应用:首次115例经验报道

目的：本文介绍原位肝移植中腔静脉成形术的方法并评估其结果。方法：1994年11月至2000年9月，我们对连续115例原位肝移植9包括6例左外侧叶及2例右叶移植）病人采用了腔静脉成形术。在起初的4年里，53例（66．3％）移植病人需行股－腋静脉体外转流，而以后的2年内该比例降至8例（22．9）％。无一例病人需中转为背驮式或经典术式。结果：中位手术时间4.5h，中位热缺血时间25min，中位输血量6U浓缩红细胞。上述结果在首次移植及再次移植间无差异。本组无与腔静脉成形技术相关的围手术期死亡。包括活体原位肝移植在内，均未观察到肝静脉流比道梗阻。没有病人因急性肾功能衰竭而需术后血透。病人留置于ICU的中位天数2d，中位住院天数为10d。结论：腔静脉成形术无需解剖肝后腔静脉，肝静脉或肝短静脉，肝下腔静脉也得以保留，并因此更有利于肝切除术维持稳定的血流动力学，在再次移植中优势更为明显。大开口的三角形腔静脉吻合容易操作，能在较三时间内完成供肝植入，且易与吻合血管口径的匹配，并可避免流出道阻塞。操作时间的缩短头了静脉体外转流的可能。我们认为腔静脉成形技术能适用于所有病人，且相应手术的并发症少。     

无肝期阻断下腔静脉对背驮式肝移植的影响

目的 探讨背驮式肝移植无肝期血流阻断方式的不同引起的再灌注损伤差异及无肝期时间的长短对机体的影响。方法 通过大鼠无肝期下腔静脉血流的阻断来建立相关模型,以血液指标的改变做为指标,结合光镜检查结果,了解机体损伤差异。结果 无肝期的延长及下腔静脉阻断可以加剧机体损伤。结论 背驮式肝移植无肝期可以短时间阻断或部分阻断下腔静脉。     

急性高容量血液稀释下肝下下腔静脉阻断对血流动力学的影响

目的观察琥珀酰明胶行急性高容量血液稀释(AHHD)对Pringle法联合肝下下腔静脉阻断行肝部分切除患者血液动力学的影响。方法选择ASAI～Ⅱ级择期行肝切除术的患者20例,麻醉诱导后20～30 min内输入琥珀酰明胶(20 ml/kg体重),行第一肝门联合肝下下腔静脉阻断,联合阻断和开放过程根据HR、MAP和CVP调节异氟醚吸入浓度和复方氯化钠输入速率,必要时用血管活性药物。记录AHHD、阻断和开放三个过程不同时间点的HR、MAP和CVP的变化。结果与AHHD前比较,MAP在AHHD完成即刻[(84±10)mm Hg]和AHHD后10 min[(85±9) mm Hg]均有明显升高(P＜0．05)；CV P在AHHD 10 min[(9．7±2．0)cm H_2O]、HHD完成即刻[(12．6±2．3)cm H_2O]和AHHD后10 min[(12．4±1．9)cm H_2O]均有显著性升高(P＜0．05,P＜0．01．P＜0．01)。与联合阻断前比较,MAP在阻断后5min[(69±10)mm Hg]、10min[(72±11)mm Hg]下降显著(P＜0．05)；CVP在阻断后1min[(7．2±2．4)cm．H_2O]、5 min[(4．8±2．8)cm H_2O]和10min[(5．0±2．3)cm H_2O]均明显下降(P＜0．05,P＜0．01,P＜0．01)；与阻断开放前比较,MAP在阻断开放后5min[(79±12)mm Hg]、10min[(78±10)mm Hg]上升显著(P＜0．05)；CVP在阻断开放后1min[(9．8±2．4)cm H_2O]、5min[(11．2±2．8)cm H_2O]和10min[(11．5±2．5)cm H_2O]均明显上升(P＜0．05,P＜0．01,P＜0．01)。在整个手术过程中HR的变化差异无统计学意义。结论术前急性高容量血液稀释,阻断过程中必要时再辅以小剂量血管收缩药,可安全地用于Pringle法联合肝下下腔静脉阻断行肝部分切除术。     

大鼠原位肝移植解剖重建研究进展

大鼠肝移植模型的构建,为解决临床肝移植术后并发症及围手术期治疗等问题提供了理想的动物模型。随着对大鼠肝移植模型建立的深入研究,逐渐形成了经典的“二袖套”法。然而,在移植手术过程中,手术视野差、血管扭转、胆道损伤和无肝期较长等问题仍是传统方法无法避免的。目前国内外大鼠肝移植模型改进方式主要围绕肝上下腔静脉、门静脉、肝下下腔静脉和胆管这4个重要解剖结构的重建展开。为此,本文就肝上下腔静脉、门静脉、肝下下腔静脉和胆管重建领域的最新进展进行整理总结,以便为大鼠肝移植模型的构建提供参考,促进肝移植技术的进一步发展。     

去甲肾上腺素用于肝移植术新肝期的血流动力学影响

目的：观察去甲肾上腺索治疗肝移植术中新肝期的高血流动力效应。方法：10例肝硬化施行肝移植患者，分为治疗．且和对照组．每组5例。治疗组在新肝期之初，给予去甲肾上腺素溶液持续静脉泵注治疗，直至术毕．观察并记录有创血流动力学指标的变化。结果：治疗组的MAP和外周血管阻力(SVR)均明显高于对照组，但均未超出正常范围；心输出量(CO)、HR、肺血管阻力(PVR)和尿量在两组均未见显着性变化。结论：在肝移植新肝期应用适宜剂量的去甲肾上腺素持续静脉泵注，对“高排低阻”血流动力学状态具有治疗作用．效果明显。     

基于受体肝内下腔静脉吻合的新辅助性部分肝移植动物模型的建立

探讨辅助性原位部分肝移植(APOLT)存在的原肝和移植肝之间的门静脉血流竞争问题,需要建立理想的大动物模型。既往不少模型需完全阻断肝上下腔静脉,借助离心泵维持循环稳定,手术复杂、操作费时,难以在普通动     

脾切除对活体肝移植术后肝脏血流动力学的影响

目的 研究活体肝移植联合脾脏切除术后患者肝脏血流动力学变化情况.方法 回顾性分析2006年8月至2009年3月开展的66例活体肝移植手术患者的病例资料,肝移植时行脾切除者共22例(脾切除组),年龄(45±11)岁,按1∶2的比例随机抽取同期具有可比性的肝移植时未行脾切除的44例患者作为对照组,年龄(44±10)岁,对比分析移植术后两组间患者肝脏血流动力学变化.结果 术前、术后1 d保留脾脏组和脾切除组门静脉血流速度分别为(12±2)cm/s和(11±3)cm/s、(35±18)cm/s和(32±17)cm/s,两组术后门静脉血流速度均显著大于术前水平(P＜0.05),术后1周两组肝右静脉血流速度分别为(44±18)cm/s和(31±15)cm/s,术后保留脾脏组肝右静脉血流速度明显大于脾切除组(P＜0.05),术后2周两组肝动脉血流速度分别为(18±8)cm/s和(26±7)cm/s,肝动脉阻力系数分别为0.66±0.13和0.57±0.12,1周后脾切除组肝动脉血流速度明显大于保留脾脏组(P＜0.05),而肝动脉阻力系数明显小于后者(P＜0.05).结论 活体肝移植联合脾切除术后肝脏的血流动力学情况优于单纯活体肝移植术式.

Abstract：

Objective To investigate the changes of hepatic hemodynamics in patients with splenectomy plus living donor liver transplantation (LDLT). Methods The data of 66 patients received LDLT from August 2006 to March 2009 were analyzed retrospectively:22 cases received splenectomy with LDLT (splenectomy group) and aged (45±11) years. Forty-four comparable cases received LDLT only in the mean time were selected as control group and aged (44±10) years. Comparative analysis was performed between the two groups with respect to the changes of hepatic hemodynamics after transplantation.Results Blood velocity in portal vein in control group and splenectomy group at 1 day before and after the transplantation were (12 ±2) cm/s vs. (11+3) cm/s, (35±18) cm/s vs. (32 ± 17) cm/s, respectively. Postoperative blood velocity in portal vein in both groups increased significantly than the preoperative level ( P ＜ 0.05).Blood flow velocity in right hepatic vein in both groups at 1 week after the treatment were (44±18)cm/s and (31±15) cm/s(P＜0.05), respectively. Blood flow velocity in hepatic artery in both groups 2 weeks after the operation were (18±8) cm/s vs. (26±7) cm/s(P＜0.05) and resistance coefficient of hepatic artery were 0.66±0.13 vs. 0.57±0.12 (P＜0.05), respectively. Conclusion Hepatic hemodynamics in patients received LDLT plus splenectomy is superior to that in patients received LDLT only.     

全肝血流阻断下的肝后段下腔静脉修补术

1概述肝后段下腔静脉（RHIVC）损伤,常伴有肝静脉损伤,统称为肝后或肝旁或近肝静脉损伤[1,2],易引起致命性的大出血（常在2000ml以上）,是最危险的腹部损伤之一。因其位置隐蔽,显露困难,很难处理,易致死亡。即使在大的创伤中心,其病死率也高达60％～100％（平均83％）。RHIVC损伤在300例腹部刀伤中约有1例,在全部下腔静脉（IVC）损伤中约占1／4。一般将其并在严重肝外伤中,按最近修订的AAST（MoorsEE等）肝损伤分级法[3],该损伤属肝损伤V级。伤后均需紧急处理,以前曾主张作肝周或肝后留置纱布填塞止血,但由于此法再出…     

肝上下腔静脉合并肝脏损伤的救治探讨

肝上下腔静脉合并肝脏损伤多由腹部贯通伤或钝性损伤引起，因出血凶猛，手术暴露困难，死亡率极高，达６０％～８０％［１，２］，以医源性损伤多见［３］。本院２０００年１月至２００１年１０月，收治２例肝上下腔静脉合并肝脏损伤的病人，就其救治体会探讨如下。临床资料例１，男性，３１岁，因右上腹部被钝器撞伤伴腹痛１小时而入院。入院时查体：心率９２次／分，脉搏细弱，血压１２／８Kpa，四肢湿冷，痛苦面容，左侧呼吸音弱，全腹压痛、反跳痛、肌紧张，移动性浊音阳性，门诊B超示肝、脾破裂，腹腔内出血，左侧胸腔积液。在抗休克…     

Replacement of the retrohepatic vena cava in segmental liver transplantation

Reduced grafts represent an important technical development in paediatric liver transplantation. The use of a left lateral segment graft has required preservation of the native inferior vena cava to “piggy-back” the graft onto it. We report four children who underwent left lateral segment transplantation with caval replacement using the donor iliac vein because the native retrohepatic inferior vena cava was small, friable or difficult to preserve. There were no caval or hepatic vein complications post-transplant and the donor iliac vein proved to be a satisfactory interpositional graft. The technique offers the advantages of a wider retrohepatic cava avoiding venous outflow or caval obstruction, provides good tissue to suture and is well suited for the triangulation technique of the left hepatic vein. Received: 24 January 1997 Received after revision: 20 June 1997 Accepted: 30 June 1997     

大鼠原位肝移植不同术式的探讨

采用“套管法”改进后的“缝合法”行大鼠原位肝移植８０例“套管法”吻合肝上腔静脉平均为８．６分钟，手术成功率９０％，一周存活率１０％。“缝合法”吻合肝上腔静脉平均为１０分钟，手术成功率９３．３％，一周存活率８３．３％，结果提示，“套管法”存活率低，缺乏实验应用价值，而改进的的“缝合法”既简化了手术，又缩短了手术时间和无肝期。     

经腹腔心包路径肝上下腔静脉与右心房吻合肝移植治疗布-加综合征合并肝癌1例附手术视频

目的  总结经腹腔心包路径供肝肝上下腔静脉与受者右心房吻合肝移植治疗布-加综合征（BCS）合并肝癌的相关经验。 方法  回顾性分析1例经腹腔心包路径肝上下腔静脉与右心房吻合肝移植治疗BCS合并肝癌病例的临床资料。 结果  患者的肝静脉和肝上下腔静脉局部闭塞,在心脏不停跳情况下,采用经腹腔心包路径完成肝上下腔静脉与右心房吻合肝移植,此外,由于受者肝动脉病变,采用受者脾动脉切断,远端结扎,近端反转与供肝肝总动脉吻合,完成肝动脉重建,手术过程顺利。术后1周左右移植肝肝功能逐步恢复正常,无重大并发症发生。患者术后25 d出院,随访8个月余无BCS复发征象。 结论  经腹腔心包路径肝上下腔静脉与右心房吻合肝移植治疗BCS是安全可行的,对于合并肝癌的患者预后较好。     

Magnetic ring anastomosis of suprahepatic vena cava: novel technique for liver transplantation in rat

To improve the technique of suprahepatic vena cava (SHVC) reconstruction in rat OLT, novel magnetic rings were designed and manufactured to facilitate reconstruction of SHVC and shorten the anhepatic time. One‐hundred and twenty adult male Wistar rats were randomly divided into two groups: rings group (n = 30), using magnetic rings for SHVC reconstruction; suture group (n = 30), 7/0 prolene suture was used for SHVC running anastomosis as control. Cuff techniques were used for portal vein and infrahepatic vena cava reconstruction as Kamada and Calne described. The bile duct was reconnected with a stent. The hepatic re‐arterialization was omitted. In the rings group, the SHVC reconstruction took 0.91 ± 0.24 (mean ± SD) min; the anhepatic phase and the recipient operation time were 5.63 ± 0.65 min and 36.02 ± 8.02 min, respectively. In suture group, the anastomotic time of SHVC was 10.40 ± 2.11 min; the anhepatic phase and the recipient operation time were 17.76 ± 2.51 and 49.38 ± 12.06 min, respectively, and there was statistically significant difference between the two groups. The ALT levels reached peak at 24 h post‐OLT (186.2 ± 32.5 IU/l) and restored to normal level at 96 h gradually. In the rings group, 29 of 30 rats survived at day 7 and 28 of 30 rats survived at day 30. In contrast, only 25 of 30 recipients in suture group remained alive at day 7 and 22 of 30 remained alive at day 30 (P < 0.05). Better anastomotic healing was founded in rings group by pathology and scanning electron microscope. The magnetic rings technique provides a novel, simple method for SHVC reconstruction of OLT in rat. It significantly shortens anhepatic phase, while the success rate of the operation is satisfactory.     

原位肝移植术后下腔静脉狭窄的原因及防治

目的 探讨肝移植术后下腔静脉狭窄的原因和防治方法。方法 本组共施行原位肝移植术8例,通过彩超及下腔静脉造影检查证实术后发生下腔静脉狭窄2例。结果 在2例下腔静脉狭窄中,1例经球囊扩张及支架置入术而治愈;另1例病人拒绝手术自动出院。结论 肝移植术后下腔静脉狭窄的重要因素是吻合技术不当,肝脏体积过大,血肿形成,腹水生成,癌肿复发。球囊扩张、支架置入是有效的治疗手段。     

肝移植中肝脏左旋显露手法对血流动力学的影响

目的:通过观察肝移植中切肝阶段采用肝脏左旋显露手法时下腔静脉压力及其他循环指标的变化,探讨该术式的安全性和有效性。方法:选择择期行原位肝移植的手术病人18例,分别记录进腹后左侧旋转肝脏时的下腔静脉压、中心静脉压、平均动脉压等循环指标;测定病人术前至术后肾功能指标。结果:18例肝移植均顺利进行,所有病人术后愈合良好,无明显术后并发症。病人心率和下腔静脉压在肝脏旋转后显著升高(P<0.01)。肾灌注压则在旋肝后显著降低(P0.05),但旋转后2阶段(第2次左旋)出现了显著变化(P0.05)。结论:无论是经典式还是背驮式肝移植术,术中采用肝脏左旋显露手法是一种安全、有效的显露右半肝及肝后下腔静脉的方法。该法可避免传统手法对肝后下腔静脉的机械性损伤,不会引起术中全身血流动力学剧烈波动,对术后肾功能具有保护作用。     

Superior vena cava obstruction and liver transplantation in a child

We report a case of superior vena cava obstruction in a child, which was probably secondary to long-term central venous cannulation. The obstruction was asymptomatic preoperatively, but became evident during liver transplantation, and complicated the intraoperative management. There is one other case report of this occurring in an adult in similar circumstances, and we believe that ours is the first report of such a presentation in the paediatric age group.     

Liver transplantation in a patient with complex anomaly of the inferior vena cava

Background

After the introduction of noninvasive imaging exams, congenital anomalies of the inferior vena cava (IVC) have become more commonly recognized. We report the first successful orthotopic liver transplantation (OLT) performed in an asymptomatic adult with complex IVC anomaly: duplication of the infrarenal IVC, azygos continuation of the IVC, agenesia of the hepatic portion of the IVC and presence of several anomalous veins communicating the common iliac vein and the IVC of one side with the contralateral side.

Methods

This complex anomaly was diagnosed with a venous abdominal angio CT.

Results

At liver transplantation, the short suprahepatic portion of the IVC was identified and clamped. The right, middle, and left hepatic veins were sectioned and joined in a single, wide cuff, using venoplasty. This single orifice was anastomosed to the suprahepatic IVC of the new liver. No venovenous bypass was employed. The patient had an uneventful postoperative course. A post transplantation venous abdominal angio CT showed normal blood flow at the anastomosis of the hepatic veins of the receptor and the IVC of the new liver.

Conclusions

This report is important to alert liver transplant teams of the possibility of complex IVC in asymptomatic adult individuals. Identification of these anatomical anomalies is vital to reduce the risk of serious hemorrhage and other operative complications during OLT.     

Compressive stenosis of the inferior vena cava due to localized ascites after living-donor liver transplantation

A 54-year-old woman was admitted to our hospital following the diagnosis of decompensated liver cirrhosis with hepatitis C. She underwent living-donor liver transplantation, performed using the left hepatic lobe with the middle hepatic vein donated by her husband. After the transplantation, the patient suffered from massive ascites with liver dysfunction. Computed tomography demonstrated stenosis of the suprahepatic inferior vena cava (IVC) with focal collection of fluid. A second laparotomy was performed 19 days after the transplantation. When the encapsulated localized ascites on both sides of the IVC was opened, the ascites was flushed away. Subsequently, the grafted liver was easily mobilized and it was placed in the natural position without any tension, and the pressure gradient of the IVC was improved. Herein, we report a very rare case of compression stenosis of the IVC resulting in Budd-Chiari syndrome caused by localized encapsulated ascites.     

肝硬化鼠肝移植后早期全身和内脏血流动力学的变化

目的 观察正常鼠肝移植及及肝硬化鼠肝移植术早期全身和内脏血流动力学的变化。方法 实验动物随机分为正常鼠（NL,10只）、肝硬化鼠（IHPH,10只）、正常鼠肝移植（NL－OLT,9只）、肝硬化鼠肝移植（IHPH－OLT,16只）组。分别采用放射性微球法行血流动力学研究。结果 NLOLT鼠绝大多数血流动力学参数与NL鼠比较差异无显著意义。IHPH及IHPH－OLT 3d,7d组心输量和内脏血流量和内脏血流量增加,平均动脉压、周围血管总阻力和内脏血管阻力降低。内脏血流动力学紊乱较全身明显。结论 肝硬化鼠肝移植后的血流动力学紊乱可能与移植前已存在的病理生理因素有关。