供体肝切取方法及其选择

总结了在美国参加４１例供肝切取的手术经验。４１例供体年龄２岁－７６岁，平均４１．３岁，全部为同一供体行多器官切取。在供肝切取前的预分离手术中３８便采用标准法，另３例先用标准法，因术中血压下降而改为快速灌注法完成预分离术。切取的４１个供肝，移植后无一生原发性移植物功能衰竭。认为预分离手术以标准法为佳，但目前在我国宜首选快速灌注法。     

肝移植供体手术的实际和供肝切取技术

本文阐述了肝移植供体手术中常见的问题和对策．详细介绍了快速灌洗后切取供肝的新技术。认为快速灌洗后切取供肝的技术可最大限度地缩短供肝的热缺血时间，有效地提高供肝的灌洗质量和供体器官的利用率。     

快速供肝切取与修整的外科技巧

目的总结肝脏移植供肝的快速切取和修整经验。方法分析2004年共186例快速供肝的切取和修整的资料。快速切取技术采用原位腹主动脉、肠系膜上静脉灌注附加下腔静脉引流，快速切取供肝，4℃UW液中保存和修整肝脏。结果供肝热缺血时间为3～10min，平均4．5min；冷缺血时间平均为3-16h，平均7h。供肝的修整时间为26～90min，平均46min。供肝修整时发现肝动脉解剖变异20例。结论快速供肝切取法要求术者技术娴熟、动作迅速和准确，可最大限度地减少供肝热缺血时间。快速切取法能保证供肝的质量和确保供肝切取的成功。     

肝移植供体切取中变异肝动脉的保护

目的 探讨在肝移植供体切取过程中如何避免损伤变异肝动脉。资料与方法 分析123例供肝切取资料，统计变异肝动脉发生率。结果 肝动脉解剖变异32例（26．02％），其中仅肝右动脉（RHA）变异11例（8．94％），仅肝左动脉（LHA）变异10例（8．13％），左右肝动脉均变异3例（2．44％），肝总动脉（CHA）起于肠系膜上动脉7例（5．69％），其它少见类型1例（0．81％），为肝固有动脉（PHA）来源于胃左动脉。结论 肝动脉解剖复杂，熟悉肝动脉解剖变异可减少供肝切取过程中的肝动脉损伤。     

活体肝移植的供肝切取技术

为缓解肝移植中的尸体供肝不足问题，探讨活体供肝的供肝切除方法。供者男４例，女４例，年龄１９－４６岁，平均３３．１岁。其中５例切取肝脏Ⅱ，Ⅲ段，３例切取Ⅱ，Ⅲ，Ⅳ段术中用Ｂ型超垢波引导确定切肝界线，应用超声切割器切开肝实质，切肝过程不阻断肝脏血流，术中用自体血回输装置收集出血并再利用。     

肝移植中供肝切取的体会

我院移植外科 1994年 5月至 1998年 11月为 6例肝硬化患者实施了原位肝移植手术并获得成功。我们设计的供肝切取 ,修整 ,保存方法 ,在实际应用中取得满意的效果 ,为 6例肝移植手术的成功提供了可靠的保证。一、供肝切取与灌注1.切口 :取腹部正中及双肋缘下十字切口。纵切口过脐 ,肋缘下切口达腋中线。为节省时间切口可由术者和助手同时完成。2 .门静脉插管灌注 :术者直接于肝十二指肠韧带处暴露门静脉 ,在助手帮助下完成门静脉插管灌注。注意在解剖门静脉时 ,术者以左手经网膜孔将肝十二指肠韧带翻转即可显露门静脉 ,尽量不要横断肝十二指肠…     

供肝的切取与保存

肝脏组织对缺血缺氧较敏感 ,长时间热缺血保存不当将导致肝脏细胞水肿、死亡。良好的供肝质量依赖于完善的切取手术与保存技术 ,不仅决定供肝的使用情况 ,同时对移植器官功能恢复 ,早期、晚期生存率均有一定的影响。一、供肝切取技术腹部多器官联合迅速切取是解决移植器官短缺的主要方法。多器官联合快速切取法使器官功能恢复迅速 ,很少出现器官功能延迟或原发性无功能。胆道并发症少 ,最大限度地缩短了供体器官的热缺血时间 ,获得高质量的移植物。目前在我国尚无法较长时间维持供体循环稳定的情况下 ,多器官联合快速切取是器官切取的最佳技…     

临床活体肝部分移植供肝切取术

自１９８９年７月Ｓｔｒｏｎｇ等〔１〕成功开展首例活体肝移植以来，这一手术有了迅猛的发展，至今总例数已近１０００例。由于该术式供肝来自健康人，对供体手术的安全性有极其严格的要求，初期曾有人预言，供肝切取术至少有１％～２％的死亡率，但几年来事实表明，至今...     

肝移植供肝切取技术及供肝的选择

作在法国参加23例供肝切取手术,对供肝的灌注,切取,修剪,保存等方面进行了观察。本组行全肝肝移植20例,劈离式肝移植2例,减体积肝移植1例,供肝全部存活,肝移植后供肝的质量与供体死亡前肝脏本身的质量,供体血液动力学情况,复苏情况,供肝切取技术,保存技术（保存液,时间,温度）以及受体高质量的血管吻合等因素有关,其中任何一步出现差错,将都严重影响供肝的功能。     

原位肝移植供肝切取与修整技术的探讨

我院自 1999年 7月～ 2 0 0 1年 10月为 2 8例患者施行了原位肝移植术。我们体会在肝移植术全过程中 ,供肝的切取、保存、修整技术对于移植术后移植肝的存活、功能的恢复及术中术后并发症的发生有至关重要的影响。现结合 2 8例原位肝移植术的供肝切取及修整技术报告如下。一、临床资料2 8例供体均为男性脑死亡患者 ,年龄 2 3～ 4 0岁 ,采用经腹主动脉灌注 0～4℃肾保存液 (高渗枸橼酸盐嘌呤液 ,上海市血液中心生产 ) 2 0 0 0ｍｌ,经门静脉灌注 0～ 4℃ＵＷ液 2 0 0 0ｍｌ,肝脏离体后继续灌注ＵＷ液 2 0 0 0ｍｌ的肝肾联合快速切取法。供肝的…     

CADAVERIC LIVER PROCUREMENT USING AORTIC PERFUSION ONLY

Background : To test the effectiveness of a simpler surgical technique for cadaveric liver procurement for liver transplantation, a prospective randomized study was carried out between August 1994 and December 1995, to compare aortic perfusion only (APO) for flush-preservation of the liver with the conventional combined aortic and portal perfusion (APP) technique. Methods : Forty multiple organ donors were enrolled with 20 in each arm of the trial. Donor parameters (age, bodyweight, liver function tests), surgeons performing the operations, the involvement of other procurement teams and the total ischaemic times were similar in the two groups. The liver recipients had a wide range of native liver pathology but were of similar age, sex and bodyweight in the two groups. Results : The mean procurement operation times for the APO and APP groups were 126.7 ± 38.6 and 137.8 ± 55.9 min, respectively (P= ns). The perfusion took longer to complete in the APO group (10.2 ± 1.7 vs 7.2 ± 1.4 min (APP), P < 0.001). The liver temperature fell to its lowest level (12.5 ± 3.4°C (APO) vs 11 ± 3°C (APP), P= ns) in a similar time (11.9 ±3.8 min (APO) vs 9.3 ± 3.4 mins (APP), P= ns). There was no graft primary non-function or graft arterial injury in either group. There was no significant difference between the APO and APP initial graft outcomes. The 3-month patient survival rate was identical in the two groups (95%); 81% of renal grafts from the APO donors functioned well from the time of transplantation as did 76% of those from APP donors. Conclusions : It is concluded that the APO procurement technique produces equivalent results to those achieved with the APP method. The simplicity of the APO technique makes it the preferred technique.     

供肝获取术中供肝质量和灌注情况的快速判断

目的探讨在供肝获取术中快速判断供肝质量和灌注情况的方法。方法对83例供肝获取术中供肝质量和灌注情况的快速判断进行总结。结果83例供体中,有16例在获取术中发现供肝质量有异常(其中7例放弃获取,9例用于移植),有1例在获取术中判断供肝质量为正常,移植术前肝组织活检病理发现血吸虫虫卵。在76例获取的供肝中．有3例术中发现灌注不足。所有用于受体的供肝均在门静脉开放后3—15分钟内可见金黄色胆汁分泌。结论在现阶段我国多为无心跳供体和快速多器官联合获取法广泛使用的情况下。供肝获取术中供肝质量和灌注情况的快速判断尤为重要。     

原位肝移植11例报告

目的探讨受体肝脏获取和原位肝移植的方法。方法获取11例供体肝脏,检查肝质量,观察肝植入后功能;对11例患者施行原位肝移植,总结手术情况及相关并发症,统计成功率和生存情况。结果成功获取供体肝脏,植入受体后发挥良好功能;11例肝移植全部成功,患者存活良好。结论供体肝脏功能良好,肝移植的成功率和受术者的生存情况都令人满意。     

A COMPARISON OF FLUSHING SOLUTIONS FOR LIVER PROCUREMENT USING AN ISOLATED PERFUSED PORCINE MODEL

There is no agreement on the best technique of in situ flushing of livers prior to storage. In order to study this, porcine livers were stored in the University of Wisconsin (UW) solution for 18h and then assessed using an isolated perfused porcine model. Livers flushed in situ with UW solution were compared to livers flushed with a non-preservation solution (Hartmann's solution). No statistically significant differences could be found in bile production (18.7 ± 4.4 vs 17.9 ± 3.8 mL/1000g per 2h), aspartate amino-transferase (AST) levels in the perfusate after 2h of isolated perfusion (687 ± 101 vs 724 ± 114U/L), potassium levels in the perfusate after 2h on the circuit (5.4 ± 1.5 vs 5.5 ± 2.3mmol/L), weight gain (15.2 ± 3.7 vs 17.1 ± 4.0%) or platelet sequestration (41.6 ± 11.7 vs 37.4 ± 9.8%) between livers flushed with UW solution as opposed to those flushed with Hartmann's solution, respectively. Of overriding importance was the solution in which the liver was stored, reconfirming the superiority of UW solution over an extracellular solution for preservation. If extrapolated to the clinical situation, these findings would have substantial cost-saving implications.     

ENDOTOXIN LEVELS IN ADULT LIVER DONORS

This study was undertaken to determine the levels of endotoxin in a group of adult donors whose livers were procured for transplantation. In the group of 25 adults, endotoxin levels were found to be significantly elevated in the systemic venous blood when compared to control levels. Portal venous endotoxin levels were also elevated following hepatic hilar dissection and after cannulation of the portal vein prior to removing the donor liver.     

大鼠小体积肝移植后肝再生障碍的实验研究

目的探讨部分肝移植后肝再生状况和小体积移植物发生肝再生障碍的可能机制。方法实验分为大鼠全肝移植组（OLT）、50%部分肝移植组（50%PLT）和30%部分肝移植组（30%PLT）。分析各组术后肝功能的变化,通过免疫组化观察移植肝标本Cyclin D1和PCNA的表达,并对移植肝组织结构进行电镜观察。结果各组ALT和AST于术后24hr达到峰值,且30%PLT组上升显著。Cyclin D1和PCNA的免疫组化表达中,50%PLT组表达明显上调,而30%PLT组表达则明显抑制。电镜观察发现30%PLT组术后微观结构改变显著。结论 30%PLT组术后肝细胞增殖再生受到明显抑制,推测与肝细胞微环境的恶化和叠加的缺血再灌注损伤有关。     

THE NEW AGE OF LIVER TRANSPLANTATION

The advent of cyclosporin A for immunosuppression (IS) in liver transplantation (LTx) in the early 1980s heralded a new age for LTx, resulting in widespread application, rapidly expanding indications, relaxation of restrictions in donor selection and advances in the preservation of liver grafts and management of LTx operations. Liver transplantation, together with the transplantation of other organs (kidney, pancreas, heart, heart-lung, intestine), became possible. In Australia, around 125 LTx (22% in children) are performed each year. Indications are: primary sclerosing cholangitis; primary biliary cirrhosis; auto-immune hepatitis; chronic viral hepatitis; biliary atresia; metabolic disorders; fulminant hepatic failure (FHF); alcoholic cirrhosis; and malignancy (cancer, CA). Since 1965, 810 patients underwent LTx and 70 (9%) re-Tx. Patient survivals at 1, 5 and 9 years post-Tx are 80, 74 and 66%, respectively. Patients with primary diseases that recur in the LTx (hepatitis B and CA) do less well following LTx, with 5-y-ear survival rates of 55 and 40%. respectively). Recent developments include: increasing the availability of donor organs by the use of living donors, ‘split’ cadaveric donor (CD) grafts, ‘marginal’ and non-heart-beating CD grafts and xenografts; expanding the indications for LTx; development of effective liver support systems for patients with FHF; the treatment of diabetics with liver failure with islet Tx (at the time of LTx); more effective immunosuppression; and methods to diminish recurrent disease in LTx. Some understanding of the unique ‘tolerogenic’ capabilities of the liver has come with the recognition of ‘two-way microchimerism’. The satisfactory 5–9 year outcomes for patients underline the cost-effectiveness of LTx.     

Long-Term Quality of Life Issues Among Adult-to-Pediatric Living Liver Donors: A Qualitative Exploration

Use of live donors as a source of transplantable livers has expanded to include adult recipients. Follow-up reports concerning living donor experiences are short-term and primarily focus on medical outcomes. We present our quality of life findings from a purposive sampling of a cohort of adult-to-pediatric live liver donors, 3-10 years after donation. In-depth interviews conducted among 15 live donors revealed the spectrum of complexity and impact that donation had on the donors. Virtually all donors (14/15) reported that they never really made a decision to donate; rather, agreeing to donate was an automatic leap. Overall, 10 out of the 15 donors related a sense that they were considered nonpatients by the medical team and family members in two primary areas: post operative treatment of pain (6/15) and long-term follow-up care (9/15) with five donors reporting concerns in both areas. Overall, family relationships were believed to have been strengthened by the donation process. Most donors experienced some degree of financial strain with three donors maintaining unrewarding employment to continue healthcare insurance. The majority of donors reported that return to normalcy took a significant amount of time even though no serious medical consequences were experienced. These observations serve to highlight some of the long-term quality of life issues that persist beyond the medical consequences of live donation.     

同种异体原位肝移植10例报告

目的 探讨原位肝移植的适应证、手术技术及手术期期处理特点。方法 对１例肝尾叶癌，２例先天性弥漫性肝内胆管囊性扩张症及７例晚期肝硬变进行了原位肝移植，对其中１便１１岁女孩进行了减体积肝移植（ＲＳＬＴ）。供肝均取２０－４０岁脑死亡的健康人。８例供、受者ＡＢＯ血型相同，２例供者为Ｏ型，受者为Ａ型。供肝采用单独肝脏切取法，以ＵＷ液进行门静脉和腹主动脉灌注。病肝采用经典式原位肝移植切肝法，在生物泵转流下切除     

再次肝移植12例报告

目的总结再次肝移植的临床经验。方法回顾我所再次肝移植病人的临床资料,并结合文献进行讨论。结果12例患者接受了再次肝移植,再次肝移植率为4．17％,再次移植的原因分别为：3例肝动脉栓塞,9例胆道并发症,其中6例同时伴有慢性排异。术后8例恢复顺利出院,最长存活15个月,最短存活5个月;4例死亡。结论再次肝移植能有效挽救移植肝失功能患者的生命,手术指征的掌握,手术时机的选择,手术技巧的提高和围手术期的正确处理是指提高再次肝移植成功率的关键。