供肝获取和灌洗方式对移植术后早期肝功能的影响

目的 探讨不同的供肝获取和灌洗方式对移植术后早期肝功能的影响.方法 对442例肝移植的临床资料进行回顾性分析.442例均为尸体供者,供肝切取术中采用腹主动脉和脾静脉插管对供肝进行原位灌洗,灌洗液为4℃UW液或4℃UW液联合高渗枸橼酸盐嘌呤溶液(HC-A液),获取的供肝均保存于UW液中.按照供肝获取方式、灌洗液的种类、灌洗液静脉引流途径及胆道冲洗方法的不同将病例分为5组.肝移植术后1周,测定受者血清总胆红素(TBil)、直接胆红素(DB)、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、碱性磷酸酶(ALP)、γ-谷氨酰转移酶(γ-GT)及前白蛋白(PA)等肝功能指标,以及活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白(Fb)及国际标准化比值(INR)等凝血功能指标.结果 肝、肾分别切取者的供肝获取手术耗时(17.6±2.5)min,联合切取者为(15.9±2.3)min,二者间的差异有统计学意义(P＜0.05).联合切取者中,灌洗液经颈静脉引流者的γ-GT、AST、PT和INR明显低于经肝下下腔静脉引流者(前一项P＜0.01,后三项P＜0.05),而Fb明显高于经肝下下腔静脉引流者(P＜0.05);采用UW液和HC-A液联合灌洗者,其γ-GT、ALT、AST,DB和TT均明显低于单用UW液灌洗者(前三项P＜0.05,后二项P＜0.01),而Fb明显高于单用UW液灌洗者(P＜0.01).结论 联合切取法有利于缩短器官获取时问;采用UW液和HC-A液联合灌洗及灌洗液经颈静脉引流更有利于术后早期肝功能的恢复.     

尿胰蛋白酶抑制剂对肝脏保存再灌注中肝窦内皮细胞损伤的保护作用

目的　探讨尿胰蛋白酶抑制剂 (UTI)对肝脏低温保存再灌注中窦内皮细胞损伤的保护作用。方法　应用离体大鼠肝脏保存再灌注模型 ,测定保存 12 h、2 4 h,再灌注 30 min流出液中内皮素 (ET)、丙氨酸转氨酶 (AL T)、天冬氨酸转氨酶(AST)、乳酸脱氢酶 (L DH)的活性、透明脂酸 (HA)的摄取量以及肝组织中髓过氧化物酶 (MPO)水平 ,光镜下观察肝窦内皮细胞的形态学改变 ,比较分析 U TI(10 0 U/ m l)对上述指标的影响。结果　对照组肝脏保存再灌注流出液中 ET含量明显升高 (P<0 .0 5 ) ,HA摄取明显降低 (P<0 .0 5 ) ,并伴随 AL T、AST、L DH、MPO水平显著增高和肝窦内皮细胞形态学的异常改变 ;保存液中加入 UTI后 ,上述指标异常变化均明显减轻 ,其差异具有显著性 (P<0 .0 5 )。结论　 UTI对离体大鼠肝脏窦内皮细胞的保存再灌注损伤有保护作用     

感染肝吸虫的肝脏作为移植供肝的可行性(附14例报告)

目的 探讨感染肝吸虫的肝脏作为移植供肝的可行性.方法 14例肝功能衰竭患者接受感染肝吸虫的供肝移植.均为尸体供肝,供者生前均未诊断肝吸虫病,肝功能正常.供肝均采用快速切取技术获取,用UW液灌洗、保存,供肝热缺血时间为(4.0±2.1)min,冷缺血时间为(582±167)min.肝脏保存之后在供肝胆管中发现肝吸虫成虫,由此确定供肝感染肝吸虫.14例患者均接受经典原位肝移植术,常规留置T管.术后2～4d开始给予吡喹酮,每天3次,每次25mg/kg,2d 为一个疗程.采用他克莫司、霉酚酸酯和肾上腺皮质激素联用预防排斥反应.观察患者生存状况、早期肝功能恢复情况以及胆管并发症发生率.术后第7天和3个月留取胆汁,涂片找肝吸虫虫卵.结果 移植前1例供肝存在小叶间胆管轻度增生,1例为轻度大泡性脂肪肝(5%),其余供肝组织均正常.术后随访时间中位数为31个月,移植物1年和3年存活率分别为85.7%和78.6%.所有患者术后早期肝功能均迅速改善,无移植物原发无功能或功能恢复延迟出现.术后发生胆管并发症2例(14.3%,2/14),1例为肝内胆管狭窄(术后3个月),另1例为胆总管结石(术后2年).术后全部患者的胆汁中均未发现肝吸虫虫卵.结论 感染肝吸虫的肝脏可以作为移植供肝,但此类供肝的选择标准尚待探讨.     

Celsior液和UW液保存供肝的前瞻性随机对照研究

目的比较Celsior液和UW液保存供肝的效果。方法随机选取拟行肝移植的患者60例，平均分为两组，一组接受以Celsior液灌洗和冷保存的供肝（Celsior液组）移植，另一组接受以UW液灌洗和冷保存的供肝（UW液组）移植，两组在患者年龄、性别构成、肝功能分级以及原发病、肝移植术式等方面的差异无统计学意义。比较两组供肝组织学变化、术后早期肝功能恢复情况及术后3个月内缺血性胆道狭窄的发生率。结果Celsior液组供肝冷缺血时间为（8．83±1．53）h，UW液组为（9．08±1．85）h，差异无统计学意义（P〉0．05）。两组术后早期血清丙氨酸转氨酶、天冬氨酸转氨酶、γ-谷氨酰转移酶、胆红素总量、出血时间及胆汁量的差异无统计学意义（P〉0．05），术后3个月内，Celsior液组缺血性胆道狭窄发生率为6．7％（2／30），UW液组为13．3％（4／30），差异无统计学意义（P〉0．05）。两组移植肝的组织学改变相似。结论在冷缺血时间一致的情况下，Celsior液保存供肝的效果与UW液相同。     

不行体外静脉转流原位肝移植治疗肝豆状核变性一例

我院于 2 0 0 1年 9月为一名肝豆状核变性患者成功施行了不经体外静脉转流的经典式同种异体原位肝移植 ,目前患者存活 1 2个月。现报告如下。一、资料与方法1 .受者情况 :男性 ,2 0岁 ,体重 53ｋｇ ,临床诊断为肝豆状核变性 ,于 2 0 0 1年 9月 2 9日在全身麻醉下行原位肝移植术。术中见病肝呈重度结节样硬变 ,无腹水 ,血管无变异。2 .供肝切取 :供肝取自于一体重 50ｋｇ、2 2岁之男性尸体 ,与受者同为Ｂ型血。供肝切取采用快速多器官联合切取技术 ,肠系膜上静脉和腹主动脉插管 ,以ＵＷ液灌洗 ,灌洗液总量约为 2 0 0 0ｍｌ,离体后经门静脉灌…     

原位肝移植治疗肝门部胆管癌二例报告

目的 探讨肝门部胆管癌是否为肝移植的适应证。方法 为２例让部胆管癌的患者施行了同种原位肝移植术。供肝切取采用腹腔器官联合快速切取法,灌洗液及保存液为ＵＷ液。无肝期采用Ｂｉｏ－Ｍｅｄｉｕｃｕｓ转流泵行体外静脉转流。术后免疫抑制治疗,例１采用环孢素Ａ、泼尼松和硫唑嘌呤三联用药,例２采用霉酚酸酯代替硫唑嘌呤。结果 移植后肝功能恢复正常,黄疸减退、但例１术后４天因血液浓缩而出现脑栓塞,肺内感染,术后１２天     

活体肝移植供肝腹腔镜切取术的实验研究

目的:探讨腹腔镜活体供肝切取的技术及可行性。方法:运用腹腔镜对猪(n=2)进行左肝切取,操作参照人活体肝移植供体要求进行,观察手术过程中供体生命体征,总腹腔镜操作时间、左肝管道系统分离时间、肝组织分离时间、供肝温缺血时间及术中出血量,并测量供肝质量参数。结果:(1)手术过程中动物血压、呼吸、心率、血气参数稳定,较顺利地取出活体供肝,出血量较少;(2)切取的供肝左肝动脉长约1.8 cm及1.6 cm,左肝门静脉长约1.0 cm及0.8 cm,左肝管约0.8 cm及0.6 cm,左肝静脉约0.3 cm及0.2 cm。经左肝动脉及门静脉灌注良好,温缺血时间为5m in及4m in。结论:从技术层面而言,腹腔镜下猪活体取肝是可行的。     

肝再生时前列腺素E_2调控枯否细胞的白介素6生成

实验观察了肝切除后前列腺素E_2(PGE_2)与枯否细胞(KC)生成白介素6的关系。取S-D雄鼠分成70％肝切除和探查对照两大组,每组各再分成高精氨酸和低精氨酸RPMI-1640组织培养基(以下分别简称HA和LA培养基)两小组。分别在术后2、5、7和14天杀死动物,取出肝脏,用Hank平衡盐液(HBSS)灌洗,在铜筛中研碎至HBSS中,经沉淀、孵育等步骤取得肝细胞和非实质细胞,用HA或LA孵育肝细胞4小时,提取KC,其纯度>95％,活力>90％。     

同种异体原位肝移植一例报告

为一肝脏巨大平滑肌肉瘤患者进行原位肝移植术。供者为一２５岁的男性脑死亡者。供肝用４℃ＵＷ液自腹主动脉灌注，快速切取肝脏，热缺血时间为８分钟。受者用＂Ｙ＂形管建立左侧股静脉、门静脉和左侧腋静脉的体外循环后切除病肝，供肝的肝上下腔静脉、肝下下腔静脉和门静脉与受者的相应血管行端端吻合。术后并发腹腔内出血、急性肾功能衰竭、肺部感染和黄疸等，于术后４７天死于脑溢血。该例移植肝功能良好，未出现排斥反应。应用ＵＷ液灌洗和保存肝脏，快速切取肝脏，能提高供肝质量。术后早期应测定血中环孢素Ａ的浓度，慎用广谱抗生素。     

二种不同成份灌洗液肺保存效果的对比

目的 比较2种不同成份肺灌洗液的肺保存效果.方法 将犬分成2组,一组供肺采用改良的Euro-Collins液(含高钾,钾浓度108mmol/L)灌洗,另一组用低钾葡萄糖液(LPG液,钾浓度4 mmol/L)灌洗.4℃保存6小时后行异体左肺移植,保留受体的右肺.术后10分钟～72小时定时阻断右肺动脉血流,采股动脉血作血液气体分析,并作病理检查.结果 改良的Euro-Collins液和LPG液灌洗的肺移植后即刻受体动脉血氧分压(PaO2)分别为(17.3±6.2)kPa和(19.7±7.0)kPa.CO2分压(PaCO2)分别为(5.28±1.17)kPa和(4.8±0.7)kPa,两组比较,P>0.05,移植后72小时的PaO2分别为(14.6±6.1)kPa和(18.4±7.6)kPa,PaCO2分别为(4.2±0.9)kPa和(4.6±0.7)kPa,两组比较,P>0.05.移植肺组织光镜和电镜观察发现,灌洗后即刻及保存6小时的组织学改变主要表现为肺泡上皮及毛细血管上皮细胞肿胀、肥大、变性,移植后72小时可见肺泡内有渗出、淋巴细胞浸润及血管壁增厚,2个组的病理改变相似.结论 含高钾的改良Euro-Collins液及含低钾的LPG液肺保存效果相似,灌洗液中的K+浓度并非影响移植肺功能的关键因素.     

胸腰椎骨折椎弓根内固定断裂与植骨融合方式的相关性分析

[目的]探讨胸腰椎骨折椎弓根螺钉内固定系统内固定术后,椎弓根螺钉断裂与植骨融合方式之间的关系,以探讨胸腰椎骨折植骨融合的最佳方式。[方法]回顾性研究1995年5月~2005年12月本院脊柱外科收治的胸腰椎骨折病人197例,其中A组单纯内固定(不植骨)患者14例,B组“H”形椎板植骨21例,C组横突间植骨67例,D组椎间、椎内联合横突间植骨95例。[结果]术后随访6~32个月,内固定断裂12例,其中A组4例,B组3例,C组5例,D组0例,4组中D组内固定断裂率显著低于其他3组(P<0.05)。[结论]椎间、椎体内联合横突间植骨重建脊柱三柱的稳定性,符合人体生物力学原理,能有效降低内固定断裂的发生。     

On the measurement of the functional properties of the CFTR

A number of methods are currently employed to assess the functional properties of CFTR channels and their response to pharmacological potentiators, correction of the defective CFTR trafficking, and vectorial introduction of new proteins. Here we review the most common methods used to assess CFTR channel function. The suitability of each technique to various experimental conditions is discussed.     

Preservation of the pylorus and resection of the head of the pancreas

The historical evolution of the pylorus-preservation resection of the head of the pancreas is traced from the first resections early in this century to relative standardization of the operation, to a lowering of the operative mortality, and to an interest in improving nutritional status after resection. There are many theoretical advantages for the function of the upper gastrointestinal tract after pylorus and gastric preservation, such as maintenance of gastric capacitance and equilibration of osmotic pressure in gastric digestants, foodstuff digestion and absorption, and bowel motility. After the pylorus-preserving resection, gastric emptying is normal, pyloric function to prevent duodenal reflux is often normal, and gastric acids and serum levels of duodenal hormones are at normal levels, whereas after standard pancreatoduodenectomy, all of these are often abnormal. No prospective blinded studies have been published comparing nutritional values after the two operative procedures, but evidence is presented of a satisfactory result with regard to gastric capacitance, body weight gain, and lack of postgastrectomy symptoms. An undoubted advantage of the pylorus-preserving feature is a simplification of the operation. These gains are achieved without increase in operative mortality, without increase in the incidence of jejunal ulcer, and without theoretical or actual decrease in value of the procedure as a cancer operation, except in patients with duodenal carcinoma proximal to the ampulla of Vater.     

下颌全牙弓后移量及最后界的测量

目的：研究下颌牙弓的有效后移量及找寻下颌牙弓移动的后界。方法：选取涉及拔除下颌第三磨牙或下颌第三磨牙缺失的病例18例（男6例,女12例）。采用种植支抗牵引下牙弓向远中,治疗完成时所有病例均明确到达下颌牙弓后界,即下颌第二磨牙远中到达下颌升支前缘软组织交界处。应用治疗前后的曲断片测量下颌第二磨牙远中到升支前缘的距离。结果：下颌第二磨牙后移量为（3.49±1.21）mm;治疗后磨牙后间隙的长度为（4.43±0.97）mm。结论：下颌牙弓可确定性地实现整体后移;最大后移量由磨牙后间隙的长度决定;其最后界止于下颌第二磨牙远中与下颌升支前缘软组织交界处。     

The Measurement of the Inclination Angle of the Hamate and Analysis of the Inclination Angle for the Rotation Deformity of the Little Finger in the Fixation of the Carpometacarpal Joint

ObjectiveComplex base fractures of the fifth metacarpal bone and dislocation of the fifth carpometacarpal joint are more prone to internal rotation deformity of the little finger sequence after fixation with a transarticular plate. In the past, we have neglected that there is actually a certain angle of external rotation in the hamate surface of transarticular fixation. This study measured the inclination angle of the hamate surface relative to the fifth metacarpal surface for clinical reference.MethodsIn a prospective single‐center study, we investigated the tilt angle of 60 normal hamates. The study included thin‐layer computed tomography (CT) data from 60 patients from the orthopaedic clinic and inpatient unit from January 2017 to March 2020, including 34 men and 26 women who were 15~59 years old, average 35 years old. The CT data of 60 cases in Dicom format of the hand was input into Mimics and 3‐Matics software for three‐dimensional (3D) reconstruction and measuring the angle α between hamate surface and the fifth metacarpal surface. According to the possible placement of the transarticular plate on the fifth metacarpal surface, we measured the angle β between the hamate surface 1 and the fifth metacarpal surface and the angle γ between the hamate surface 2 and the fifth metacarpal surface.ResultsThe average angle between the hamate surface and the fifth metacarpal surface was 11.66°. The hamate surfaces 1 and 2 have an external rotation angle of 7.30° and 7.51° on average with respect to the fifth metacarpal surface, respectively. There is no statistically significant difference in the angles between the two groups (P > 0.05).ConclusionsThe horizontal angle of the dorsal side of the hamate is different from the back of the fifth metacarpal surface, and the hamate has a certain external rotation angle with respect to the fifth metacarpal surface. No matter how the transarticular plate is placed, the plate always has a certain external rotation angle relative to the fifth metacarpal surface. When the fixation is across the fifth carpometacarpal joint, if the plate does not twist and shape, it will inevitably cause internal rotation of the fifth metacarpal, resulting in internal rotation deformity of the little finger sequence.     

静脉输注甘露醇开放血脑屏障对抗生素透过血脑屏障的影响

目的　通过快速静脉输注甘露醇可逆性开放血脑屏障 (BBB) ,探知此方法能否增加抗生素透过BBB的量 ,在何时达到最高峰 ,其通透量增加后临床上有无不良反应。方法　采用自身配伍设计 ,共 6个样本组。对照组仅使用抗生素 ;其余 5组分别在使用甘露醇前 60、3 0min ,同时使用甘露醇后 3 0、60min使用抗生素 ,各组皆取使用抗生素后 1h的脑脊液测其抗生素浓度。抗生素选用头孢三嗪。结果　测量值经过q检验 ,经 2 0 %甘露醇处理前后的CSF中的头孢三嗪浓度差异有非常显著性。全组患者经临床观察未出现神经系统的不良反应。结论　经静脉快速输注2 0 %甘露醇后可以使透过BBB的水溶性抗生素的量增加 ,两者使用的顺序是在抗生素使用 3 0min内即给予甘露醇快速滴注。该方法不会增加低神经毒性抗生素在中枢神经系统的不良反应。     

Preservation of the pylorus in resection of the head of the pancreas

Whipple's pancreatoduodenectomy was the standard operation for diseases of the head of the pancreas for more than 40 years, but the results were vitiated in part by poor gastrointestinal function and malnutrition. Reintroduced in 1978, pylorus-preserving proximal pancreatoduodenectomy (PPPP) has had an increasing impact on pancreatic surgery as its benefits have been recognized: improved nutritional status, decreased incidence of postgastrectomy syndromes, and a technically easier operation. Postoperative mortality rates and 5-year survival rates are comparable with those of the classic Whipple procedure. PPPP is indicated for most patients with chronic pancreatitis of the pancreatic head. It is also appropriate for patients with periampullary cancer and for those with pancreatic cancer arising from the lower part of ‘the head and the uncinate process. More than 650 patients have now undergone PPPP: 31% for chronic pancreatitis and 66% for periampullary and pancreatic cancers. We assess the indications for PPPP, outline the operation, and review the results.