改良背驮式原位肝移植术13例报告

目的:探讨改良背驮式原位肝移植术的优缺点。方法:分析13例改良背驮式原位肝移植术的术中资料、术后并发症。结果:术前肝功能均属Child B～C级。采用快速病肝切除技术,使病肝切除术时间缩短为30～60分钟,总手术时间缩短为4～6小时,术中出血量减少为1400～4600ml。采用供肝下腔静脉和受体下腔静脉侧侧吻合术,术后未发生肝血液流出道狭窄及梗阻。本组供肝冷缺血时间4～14小时,术后肝功能恢复至正常时间3～14天。其中7天内恢复正常7例。住院时间3～4周。无围手术期死亡。术后肺部感染3例,经合理治疗痊愈,两例发生排斥反应。经早期诊断和治疗,1周后排斥反应控制。结论:采用改良背驮式原住肝移植术具有简便、手术时间短、出血少、并发症少等优点,能提高肝移植手术安全性。     

非转流经典原位肝移植术中肾功能的变化

选择26例行经典式非转流原位肝移植患者,采用气管内插管静吸复合麻醉,经右颈内静脉和右股静脉穿刺置入中心静脉导管.于开腹前(T0)、无肝期前5 min(T1)、新肝期前5 min(T2)、新肝期15 min(T3)、新肝期30 min(T4)分别经右颈内静脉、右股静脉导管测量上、下腔静脉压力,并抽血测定肾功能,同时记录无肝期尿量.发现与T0比较,T2时上腔静脉压力下降而下腔静脉压力升高;血清肌酐(Cr)自无肝期明显上升,新肝开放后继续维持较高水平.认为Cr自无肝期开始显著上升,结合尿量和阻断远端下腔静脉压力变化,提示存在肾功能影响.     

猪暂时性门腔分流背驮式肝移植模型的建立

目的:探讨猪背驮式肝移植手术的改进方式,提高猪肝移植的生存率.方法:对照组用方法1行猪背驮式肝移植:用彭式解剖分离器"刮吸法"保留下腔静脉,切除受体肝.实验组用方法2,暂时性门腔分流猪背驮式肝移植.在方法1的"刮吸法"保留下腔静脉,切除受体肝的基拙上加暂时性门腔分流.冷缺血时间、无肝期、手术时间、失血量、生存期等观察指...     

重型肝炎

前列腺素El脂微球载体制剂治疗慢性重症肝炎疗效观察，MARS人工肝治疗慢性重型肝炎肝肾综合征疗效观察与护理，肝移植术后胆道系统并发症的原因分析及护理，背驮式原位肝移植及其并发症预防，猪原位肝移植术体外静脉．静脉转流方法的探讨，肝脏移植围手术期凝血功能动态变化及治疗处理，SWH液对大鼠肝脏能量代谢的影响，小型猪原位肝移植的外科技巧及术中管理。     

肝移植患者术中凝血功能的变化及影响因素

目的:探讨不同肝移植术式术中凝血功能变化的规律及相关的影响因素.方法:将2006-06/2007-05我院15例亲体肝移植患者及29例原位肝移植患者,分为肝癌组,肝硬化和急性肝衰组.综合评估患者术前状态,于患者术前及术中(无肝前期、无肝期、再灌注期30 min、再灌注期1 h)检测凝血酶原时间(PT)、活化的部分凝血酶原时间(APTT)、国际标准化比值(INR)、纤维蛋白原(FIB)、血小板计数(PLT)、血红蛋白量(HB)、白蛋白(ALB)及CO_2结合力(TCO_2),观察不同肝移植术式术中各组患者凝血功能及酸碱失衡的变化规律及特点,分析术前和术中可能存在的影响因素及与凝血功能的相关性.结果:肝硬化患者组术前凝血状态介于肝癌组与急性肝衰组之间.术前PLT明显减少,与其他两组相比差异显著(P<0.05).无肝期各项指标进一步恶化.再灌注30 min PT,APTT,INR值达到峰值,FIB水平于无肝期达到最低点(亲体移植:0.68±0.17 g/L vs 0.93±0.37 g/L,0.77±0.19 g/L,0.83±0.27 g/L,0.72±0.31 g/L;原位肝移植:0.65±0.14 g/L vs 0.89±0.10 g/L,0.71±0.26 g/L,0.69±0.16 g/L,0.70±0.23 g/L,P<0.05).肝癌组各指标术前基本正常,术中变化幅度均较前两组小(P<0.05).急性肝衰组患者术前PT、APTT、INR延长最为显著,凝血状态最差(P<0.05),但术中恢复较快.除无肝期外,FIB较其他两组明显减少(P<0.05).应用Pearson相关分析术中出血量与围手术期因素的相关关系,发现MELD评分与术中出血量具有相关性(r=0.619,P<0.05).与原位肝移植相比,亲体肝移植术中凝血功能及代谢紊乱的变化较大,尤以无肝前期及无肝期恶化明显.再灌注后各项凝血指标恢复迅速(P<0.05).结论:应根据具体情况个性化治疗肝移植患者.     

重建肝动脉大鼠肝移植模型的建立

目前最流行的大鼠原位肝移植方法是“二袖套”法,即肝上下腔静脉（SVC）缝合加肝下下腔静脉（IVC）及门静脉（PV）袖套吻合。上述方法虽不重建肝动脉,但术后大鼠均可获得存活。但研究发现,重建大鼠肝动脉则可显著降低术后胆道并发症,提高术后长期生存率。为此,我们在改进“二袖套”法大鼠肝移植基础上建立了重建肝动脉大鼠肝移植模型,旨在下一步进行肝移植方面的基础研究。     

建立大鼠原位肝移植模型的手术技巧

目的采用"二袖套法"建立稳定的大鼠原位肝移植模型,为临床试验提供依据,并探讨手术技巧。方法在Kamada的"二袖套法"基础上进一步改进,供体经腹主动脉行肝脏冷灌注,用缝合法吻合肝上下腔静脉,用袖套法吻合门静脉与肝下腔静脉,胆道采用支架法重建。对200只SD大鼠进行原位肝移植,记录各项操作时间以及术后存活率、并发症情况,专人对数据统计分析。结果共对200只大鼠采用改良的"二袖套法"行原位肝移植。手术成功率为90.00%(180/200)。部分大鼠死亡原因包括出血、肝下腔静脉血栓、肝上下腔静脉回流不畅、袖套扭转、脱落、胆瘘、胆道梗阻、肝功能衰竭以及肝脓肿。结论能熟练进行显微外科操作,并且手术精确是缩短操作过程以及减少术后并发症发生的前提。而受体大鼠的术后存活情况又与无肝期时间密切相关。     

十七次猪原位肝移植的体会

目的为临床肝移植作技术准备.方法用香猪行猪原位肝移植手术共17次.结果供体放血猪的肝热缺血时间为5min±2.8min,冷缺血时间为196min±70.1min.受体手术时间为172min±18.3min,无肝期为45.3min±10.2min;受体猪用滚柱式动力泵加储血器行门静脉-左颈外静脉体外转流,转流量为570ml/min±231ml/min,转流时间为34min±8.3min.17头猪中术中死亡7头,术后存活不足24h7头,超过24h3头,最长存活30天.结论良好的外科技术和维持无肝期循环稳定是原位肝移植手术成功的关键.     

改良双袖套法大鼠原位肝移植500例

目的:改进大鼠肝移植的方法,缩短无肝期,提高手术成功率,总结大鼠原位肝移植经验.方法:正式实验分组:(1)预输注供者凋亡的脾细胞正常大鼠肝移植研究组(分4小组);(2)同期输注供者凋亡的脾细胞对正常大鼠肝移植研究组(分4小组);(3)术后输注供者凋亡的脾细胞正常大鼠肝移植研究组(分4小组);(4)预输注供者凋亡的脾细胞对肝硬化大鼠肝移植研究组(分4小组);(5)预输注供者凋亡的血液淋巴细胞对正常大鼠肝移植研究组(分3小组),每小组各10只大鼠.观察手术时间以及大鼠肝移植2 d和1 wk存活率.结果:在正式实验大鼠肝移植中,供体手术时间30±5 min.供肝热缺血时间2±0.5 min,袖套准备及肝脏修整时间10±2 min,受体手术时间51±10 min;无肝期16±4 min.冷缺血时间61±5 min.正式实验大鼠肝移植2 d存活率96.8%(184/190),1 wk存活率95.3%(181/190).结论:改进显露方法及肝上下腔静脉吻合方法后,手术简化,同时并发症减少,生存率提高.     

肝脏移植概述

肝脏移植是治疗终末期肝病的根本方法,其适应证包括良性终末期肝病、肿瘤性疾病和先天性、代谢性肝病。肝脏移植术式包括经典原位肝移植、背驮式肝移植和腔静脉成形式肝移植等。术后要防治并发症,控制排异反应,乙型肝炎患者要控制乙型肝炎,肝癌患者要防止肿瘤复发。     

Islet-after-failed-pancreas and pancreas-after-failed islet transplantation: Two complementary rescue strategies to control diabetes

For selected patients with type 1 diabetes, β-cell replacement is the treatment of choice, either by islet transplantation (ITX) or whole pancreas transplantation (PTX). When either modality fails, current practice is to consider retransplantation, or return to exogenous insulin. We investigate outcomes with PTX after failed ITX (PAI), and ITX after failed PTX (IAP). All patients receiving PAI or IAP at a single institution were identified. Donor and recipient variables were documented, including transplant outcomes analyzed for insulin requirement and metabolic control. Five subjects were listed for PAI, and 2 received transplants. Of the 4 listed for IAP, 3 have received transplants. The mean waitlist time was 4.5 ± 4.1 y for PAI and 0.35 ±0 .4 y for IAP (p = 0.08). Metabolic control was excellent after PAI, with 2/2 insulin-independent. After IAP, 1/2 achieved insulin independence and good metabolic control after 2 islet infusions. The third could not receive 2^nd infusion and presented c-peptide levels < 0.1 nmol/L. Both strategies are feasible. The outcomes after PAI in our center must be offset by much longer waitlist time due to the sensitization status of these patients. Data from multicentre experience will allow more robust comparative outcomes to be made, the current observations being restricted to a limited patient set.     

Islet-after-failed-pancreas and pancreas-after-failed islet transplantation: Two complementary rescue strategies to control diabetes

For selected patients with type 1 diabetes, β-cell replacement is the treatment of choice, either by islet transplantation (ITX) or whole pancreas transplantation (PTX). When either modality fails, current practice is to consider retransplantation, or return to exogenous insulin. We investigate outcomes with PTX after failed ITX (PAI), and ITX after failed PTX (IAP). All patients receiving PAI or IAP at a single institution were identified. Donor and recipient variables were documented, including transplant outcomes analyzed for insulin requirement and metabolic control. Five subjects were listed for PAI, and 2 received transplants. Of the 4 listed for IAP, 3 have received transplants. The mean waitlist time was 4.5 ± 4.1 y for PAI and 0.35 ±0 .4 y for IAP (p = 0.08). Metabolic control was excellent after PAI, with 2/2 insulin-independent. After IAP, 1/2 achieved insulin independence and good metabolic control after 2 islet infusions. The third could not receive 2^nd infusion and presented c-peptide levels < 0.1 nmol/L. Both strategies are feasible. The outcomes after PAI in our center must be offset by much longer waitlist time due to the sensitization status of these patients. Data from multicentre experience will allow more robust comparative outcomes to be made, the current observations being restricted to a limited patient set.     

Non-composite combined liver and intestinal allotransplantation

Introduction Small bowel transplantation has been the optimal choice for patients with irreversible intestinal failure. Advances in total parenteral nutrition (TPN) have allowed patients with short bowel syndrome to survive, but the long-term effects are often complicated by intestinal failure. As a result, many candidates for intestinal transplantation have concomitant cholestatic liver damage. Thus, simultaneous liver and intestinal transplantation is required.[1-5] Herein we present a cas…     

Heart-lung transplantation

Heart-lung transplantation itself is not a particularly difficult operation technically. It is the setting in which this procedure is performed which is difficult. The three issues of importance in a successful outcome are appropriate harvest of the heart-lung bloc from the donor, careful explant of the heart and lungs of the recipient, and finally the implant of the heart-lung bloc into the recipient. None of this requires extraordinary technical skill, but does require careful coordination and planning as well as adhering to some fundamental principles. One of the major pitfalls encountered is bleeding related to the explant procedure. Another is graft failure related to harvest and/or the implant procedure. The third is injury to either the phrenic nerve(s) or the left recurrent laryngeal nerve related to the explant procedure. Heart-lung transplantation is a major investment in resources of all sorts including financial, personnel, as well as the organs themselves. It is absolutely imperative that this procedure be performed only by experienced surgeons in centers with established expertise.