尸体腹部多器官联合切取(TAE)技术的改进及临床应用

目的 :探讨尸体多器官联合切取的最佳方法。方法 :1998～ 2 0 0 2年采用改进后的多器官联合切取技术进行了 65例次多器官联合切取术 ,主要改进点有 :①采用纱布填塞导尿管内腔用以灌注腹主动脉 ;②气囊注水 ,堵塞腹主动脉上段 ;③回血由下腔静脉肾静脉开口以下引入 3升袋内 ;④优先灌注腹主动脉而后灌注肝门静脉 ;⑤体内整块切取肝、胰、脾、肾、十二指肠等器官。结果 :建立腹主动脉灌注的时间为(1.0± 0 .3 )min ,建立肝门静脉灌注的时间为 (1.0± 0 .7)min ,腹腔多器官联合切取时间为 (10 .0± 3 .0 )min ,热缺血时间 (2 .0± 1.2 )min。本院行肝移植 4例 ,肝肾联合移植 2例 ,供外院行肝移植 12例 ,所有肝移植病人肝功能在 3周内恢复正常 ;胰肾联合移植 1例 ,术后 2周脱离胰岛素和透析治疗 ;肾移植 12 7例 ,术后肾功能恢复时间 (4 .82± 3 .73 )d ,急性肾小管坏死 4例 (3 .2 % )。结论 :优先灌注腹主动脉优于优先灌注肝门静脉 ;改进后的尸体腹部多器官联合切取技术能快速优质切取供器官 ,适于临床推广使用。     

胰、十二指肠及肾联合移植的解剖学基础及临床应用

目的：探讨胰肾联合移植的供体器官切取及移植手术方法。方法：2001年10月施行1例胰液肠腔引流式胰、十二指肠及肾联合移植，手术分3个步骤：①供体腹部多器官(包括胰、肝脏、肾脏)联合原位灌洗、整块切取；②供胰、供肾的修整；③供胰和供肾的植入。监测术后胰腺、肾的功能恢复。结果：联合整块切取腹部多器官成功，热缺血时间在3min之内。施行1例胰液肠腔引流式胰、十二指肠及肾联合移植，术后移植肾功能在术后第3d肌酐、尿素氮恢复正常；第5d停用胰岛素，移植胰内外分泌功能正常。随访1年，人／移植物存活良好。结论：胰、十二指肠及肾联合移植是治疗胰岛素依赖型糖尿病并发尿毒症的有效方法，供体腹部多器官联合原位灌洗、整块切取的方法可有效缩短器官的热缺血时间，减少损伤和提高供体器官的利用率。     

肝肾胰十二指肠联合切取及修整的技术改进

目的:探讨肝肾胰十二指肠联合切取及修整的技术改进。方法:采用原位灌注联合切取和体外修整的方法完成6例尸体供肝肾胰十二指肠联合切取及修整。结果:6例获取器官的热缺血时间为(3.0±1.5)min,冷缺血时间为(7.0±3.0)h。修整时动脉重建方式既保证了肝脏血供又改善了胰腺十二指肠血供。同时为6例乙肝肝硬化病人实施原位肝移植,术后病人恢复顺利;为6例I型糖尿病合并尿毒症病人实施胰液膀胱引流式胰十二指肠及肾一期联合移植术,手术顺利,术后病人移植胰腺和肾脏功能恢复良好;为6例慢性肾功能衰竭(尿毒症)病人实施肾移植术,术后病人恢复顺利。结论:肝肾胰十二指肠联合切取和修整的质量是器官移植成功的关键之一,采用原位灌注联合切取和保留胰腺的胃十二指肠动脉是可靠的。     

胸腹部多器官联合切取技术方法探讨

目的　探讨胸腹部多器官联合切取的技术方法及其对获取的器官质量的影响。 方法 采取胸部U型切口联合腹部大“十”切口,分别建立胸部器官和腹部器官原位灌注,在灌注的同时进行多器官游离和切取。 结果　2003年至今采用此方法行胸、腹腔多器官联合切取术8次,获得供心、肝、胰各8个,供肺8对及供肾16个。热缺血时间为(2±1.2)min,器官切取时间约(20±3)min。未出现任何影响器官质量和功能的手术意外损伤。临床行心脏移植6例、心肺联合移植2例、双肺移植3例、单肺移植5例、肝移植6例、肝肾联合移植2例、胰肾联合移植3例、肾移植11例,所有移植器官均在术后立即发挥功能。 结论　采用胸腹部多器官联合切取的技术方法能够快速优质的获取胸部和腹部供器官,缩短热缺血时间,减少手术损伤,提高供器官的质量和数量。     

供胰的切取保存及修整技术

目的：探讨胰肾联合移植术的供体器官切取、保存及修整的技术方法。方法：1998年5月～2003年9月共联合整块切取腹部多器官86例次，期间施行2例改良式胰液空肠引流胰十二指肠及肾一期联合移植术，结合我院联合整块切取腹部多器官的经验，及胰肾联合移植临床开展情况对供胰的切取与修整技术进行总结。结果：联合整块切取腹部多器官86例均成功，热缺血时间在3min之内。施行2例改良式胰液空肠引流胰十二指肠及肾一期联合移植术，术后移植胰、肾功能均恢复正常，无其它外科并发症。结论：掌握正确的供胰切取、保存及修整方法是保证移植成功的关键因素，主要包括供胰切取的速度与质量以及修整过程中的一些注意点，以尽量缩短热缺血时间，减少损伤。     

肝肾联合移植的解剖学基础及临床应用

目的：探讨肝肾联合移植的供体器官切取及移植手术方法。方法：1998年5月-2001年7月共联合切除供肝、供肾30例次,施行1例肝移植及1例肝肾联合移植,手术方法主要有3个步骤：供体肝脏、肾脏联合原位灌洗、整块切取;病肝的切除;供肝和供肾联合植入。结果：供体肝肾联合切取30例均成功,热缺血时间在5-10min之内。1例肝移植及1例肝肾联合移植获得成功。结论：肝肾联合移植是唯一能挽救肝、肾同时衰竭的病人生命的有效方法,供体肝脏、肾脏联合原位灌洗、整块切取的方法可有效缩短热缺血时间,提高供肝、肾的质量以及供体器官利用率。     

全胰移植的解剖学基础

只要知道肝动脉在解剖上的变异就可以联合切取肝和胰。在具有单一的肝中动脉的个体中，可将胰与腹腔干以及肠系膜上动脉一同切取；肝与全部的肝动脉一起切取。在具有肝左动脉的情况下，肝应当与腹腔干、肝左动脉和肝中动脉一起切取；胰与肠系膜上动脉一起切取。只要确认胰背动脉来自脾动脉，脾动脉将被移植到肠系膜上动脉上。在具有肝右动脉的个体中，肝与肝中动脉，肝右动脉以及肠系膜上动脉一起切取；胰将与腹腔干、肝总动脉、胃十二指肠动脉和脾动脉一起切取。     

胰肾联合移植前供胰评估标准的临床分析

文题释义： 脑死亡器官捐献供者：包括脑干在内全脑功能完全、不可逆转地停止后进行器官捐献。各种原因致供者脑死亡而身体器官功能可用于器官移植,这一类供者是器官移植供者的主要来源之一。 胰肾联合移植术：是同期进行胰腺和肾脏移植,将供肾置于腹膜外,胰腺置于腹腔,是糖尿病合并终末期肾病患者的有效治疗方法,不仅能治愈糖尿病、终末期肾病,而且能延缓甚至逆转糖尿病相关并发症。 背景：胰肾联合移植是治疗终末期糖尿病肾病的主要方法,供胰的质量直接关系到受者的手术安全及长期存活,但是国内目前对于胰肾联合移植供胰评估标准并无统一规范。 目的：总结分析63例脑死亡器官捐献供者供胰的评估标准。方法：回顾性分析2016年9月至2018年11月广州医科大学附属第二医院完成脑死亡器官捐献潜在供胰的评估、获取及胰肾联合移植的临床资料。供胰和供肾来源于器官获取组织主导的公民器官捐献,脑死亡供者根据《中国脑死亡判定标准(成人)》进行判定。通过胰肾联合移植供胰评估的主要标准、次要标准和禁忌证,对供者进行严格评估和筛选。结果与结论：对168例供者进行严格评估,共成功完成63例胰肾联合移植供胰的评估、获取和手术,供胰的冷缺血时间为145-320 min。手术方法均采用改良的同侧胰肾联合移植术。63例患者手术过程顺利,1例受者术后需口服降糖药,1例受者恢复胰岛素使用,余受者血糖正常,均成功摆脱降糖药和胰岛素,取得了良好的手术效果。结果表明,采用作者所在移植中心胰肾联合移植前供胰评估标准,可以简单有效地进行供胰评估,提高了供胰利用率,并取得了良好的手术效果。 ORCID: 0000-0003-2967-2233(刘路浩) 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

肝移植供肝切取与修整技术

目的：总结临床肝移植供肝切取与修整技术。方法：采用原位腹主动脉、门静脉双路灌注及肝。肾联合快速切取法切取供肝及。肾40例次，并施行同种异体肝移植40例，其中3例行肝。肾联合移植。结果：全组供肝平均热缺血时间为4min，切取时间为25min，保存时间为6h。全组移植肝均于恢复血流10min内有金黄色胆汁泌出，1周左右肝功能恢复正常。结论：我院开展的供肝、肾的切取与修整技术在临床实际应用中取得满意的效果，为移植手术的成功提供了可靠的保证。     

大鼠肝、肾、胰器官簇移植的解剖基础研究

目的：为大鼠肝、肾、胰器官簇移植的开展提供解剖学基础。方法：35只大鼠显微镜下解剖观察肝肾、胰主要血管、胆管、胰管、输尿管的分布及其形态规律。结果：35只大鼠腹主动脉、肝上下腔静脉、肝下下腔静脉直径分别为（2．2±0．4）mm、（8．8±0．6）mm、（7．8±0．6）mm；肝、肾、胰血管细小（〈0．3mm．1．0±0．2mm，〈0．2mm）；肝动脉、胰腺血管有变异（分别为6／35、6／35）；采用腹主动脉、下腔静脉可以完成器官簇的移植手术。结论：肝、肾、胰器官簇移植在解剖学上比单一器官移植更简单，为大鼠肝、肾、胰器官簇移植手术模型建立提供了解剖学基础。     

中国传统文化和观念对器官捐献意愿的影响分析

背景：中国需要接受器官移植的患者数量还以每年超过10%的增量扩大,由于缺乏公民自愿捐献,中国较世界其他国家面临着更为严峻的供体短缺问题。导致目前中国器官供体短缺的具体原因是什么？中国公民究竟如何看待遗体器官捐献,他们对遗体器官捐献的态度如何？是哪些因素影响了中国公民遗体器官捐献行为的实施？目的：了解中国传统观念对中国公民逝世后器官捐献意愿的影响程度。方法：采用随机整群抽样法,选取来自不同社会阶层的900名接受问卷调查者为研究对象,应用自制的公众对人体器官捐献的认知、态度和行为调查表进行问卷调查。结果与结论：①有55.16%的民众认为进行器官捐献的主要目的是想帮助他人,有24.22%的民众认为进行器官捐献的主要目的是一种社会公德的体现,11.94%的民众认为进行器官捐献其实是自己生命的延续。②有70.00%的民众认为捐献的器官应该用于器官移植事业,以便挽救更多患者的生命,其平均得分为 2.53 分;而建议将捐献器官应用于医学教学用和病理解剖用的比较接近,平均得分依次为 1.72 和 1.75。③有65.01%的民众支持采取心肺死亡的标准来判断人死亡,24.33%的民众支持采取脑死亡的标准判断人死亡,还有10.66%的民众认为不清楚采取什么方式。④有50.52%的民众认为影响器官捐献的主要因素是中国传统文化和观念的影响,其次是捐献程序和家属感情。调查结果发现,中国传统文化和观念是影响民众进行器官捐献的主要因素,大部分民众认为以心肺死亡的标准来判断人死亡为最佳方法,认为捐献器官的主要目的是想帮助别人,捐献的器官应首先应用于器官移植,以便挽救更多的生命。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

Autologous Is Superior to Allogeneic Hematopoietic Cell Transplantation for Acute Promyelocytic Leukemia in Second Complete Remission

To identify favored choice of transplantation in patients with acute promyelocytic leukemia (APL) in second complete remission, we studied 294 patients with APL in second complete remission (CR2) receiving allogeneic (n = 232) or autologous (n = 62) hematopoietic cell transplantation (HCT) reported to the Center for International Blood and Marrow Transplantation Research (CIBMTR) from 1995 to 2006, including 155 with pre-HCT PML/RAR∝ status (49% of allogeneic and 66% of autologous). Patient characteristics and transplantation characteristics, including treatment-related mortality, overall survival (OS), and disease-free survival, were collected and analyzed for both univariate and multivariate outcomes. With median follow-up of 115 (allogeneic) and 72 months (autologous), 5-year disease-free survival (DFS) favored autologous with 63% (49% to 75%), compared with allogeneic at 50% (44% to 57%) (P = .10). OS was 75% (63% to 85%) versus 54% (48% to 61%) (P = .002), for autologous and allogeneic transplantation, respectively. Multivariate analysis showed significantly worse DFS after allogeneic HCT (hazard ratio [HR], 1.88; 95% confidence interval [CI], 1.16 to 3.06; P = .011) and age > 40 years (HR, 2.30; 95% CI, 1.44 to 3.67; P = .0005). OS was significantly worse after allogeneic HCT (HR, 2.66; 95% CI, 1.52 to 4.65; P = .0006); age > 40 (HR, 3.29; 95% CI, 1.95 to 5.54; P < .001), and first complete remission < 12 months (HR, 1.56; 95% CI, 1.07 to 2.26; P = .021). Positive pre-HCT PML-RAR∝ status in 17 of 114 allogeneic and 6 of 41 receiving autologous transplantation did not influence relapse, treatment failure, or survival in either group. The survival advantage for autografting was attributable to increased treatment-related mortality (TRM) in the allogeneic group of 30% compared to 2% in the autologous group, in addition to the added mortality associated with GVHD. We conclude that autologous HCT yields superior OS for APL in CR2. Long-term DFS in autologous recipients, even with minimal residual disease–positive grafts, remains an important subject for further study.     

Second toe-to-hand transplantation: A surgical option for hand amputations

Background:

The toe to hand transplantation is a method of reconstruction on the unique or multiple amputations of the fingers. It can be used the whole toe or with certain modifications as a wrap-around flap from the big toe or fingertip. It is a widely accepted option for the thumb.

Methods:

It is a series of patients with amputation of one or more fingers of the hand were operated with second toe to hand transplantation. The survival was evaluated and the sensory recovery by 2-point discrimination.

Results:

We practiced 12 transplants, 8 thumb, and 4 in other fingers. Ten were adults and two children. All transplants survived. Two patients required tenolysis flexor. The sensibility was recovered with good 2-point discrimination of 8 mm.

Discussion:

In the more proximal finger amputations, a second toe is the most appropriate, with lower morbidity of the donor site. The rates of success are between 95 to 100%. We had a success rate of 100%. The resulting defect is in the foot is minimum when the second toe was used. The decision to use one of these techniques depends on the decision and transplant surgeon training. We always used the second toe for transfers to the hand, considering that it will be thinner than the original thumb; our patients had no complaint about the appearance.

Conclusion:

Toe-to-hand transplantation is a good technique, providing a very good aesthetic appearance and allowing the recovery of sensitivity. The defect that is created in the foot does not produce significant aesthetic and functional alterations.     

胎儿肾移植的解剖学要点

在以胎肾为供体的肾移植应用解剖学研究的基础上,我们先后为11例患者进行了大月龄胎儿肾整块移植术,成功9例.对于手术至关重要的低温灌洗途径的选择、供体血管的解剖及与受体血管的吻合方式和部位等解剖学技术逐步进行了改进和完善,介绍了供肾体外血循环的建立和观察方法,提出了保护肾上极动脉的初步意见。     

Non-adherence with drug treatment after heart or lung transplantation in adults: A systematic review

Objective

Heart or lung transplantation is a complex intervention requiring medication adherence. The objective of this systematic review is to estimate the prevalence of non-adherence (NA) with post-transplantation medication in heart or lung recipients and to assess its clinical impact. We examined in the selected studies if the authors considered the patient's perspective in their evaluations.

Methods

The electronic database MEDLINE, EMBASE and The Cochrane Central Register were searched. Only studies that reported the number of non-adhere subjects were eligible. The different methods of measurement, the ways in which authors defined NA and if authors had integrated patient's perspective in their secondary objectives were also assessed.

Results

The range frequency of NA was 1-42.9% for all drugs. Non-adherent patients tend to experience worse outcomes compared to adherent patients. The patient's perception of drug side-effects is the most reported patient-related factor for impairing adherence.

Conclusion

NA after heart or lung transplantation is an important issue and concerns not only immunosuppressant treatments. The main striking point of the selected studies is the lack of patient perspective and the omission of patients-healthcare providers’ relationship.

Practice implications

Future research must focus on patients’ motivation for the medication-taking behaviour.     

西罗莫司在肾移植中的应用：理论与技术

背景：钙调磷酸酶抑制剂可以有效的减少急性排斥反应发生率和改善肾移植近期疗效,但因其肾毒性而无法改善移植肾的远期存活率。无肾毒性的免疫抑制剂西罗莫司的出现,为避免使用钙调磷酸酶抑制剂提供了可能。目的：对目肾移植后初期使用西罗莫司(不使用钙调磷酸酶抑制剂类药物)和肾移植后由钙调磷酸酶抑制剂类药物向西罗莫司转换两种使用西罗莫司的治疗方案进行综述。方法：以“肾移植,西罗莫司”为中文关键词,以“kidney transplantation,sirolimus”为英文关键词,采用计算机检索2000年1月至2013年9月CNKI数据库和1996年1月至2013年9月PubMed数据库相关文章,选择肾移植后初期使用西罗莫司和肾移植后由钙调磷酸酶抑制剂类药物向西罗莫司转换的相关文章进行分析。结果与结论：西罗莫司同钙调磷酸酶抑制剂类药物相比,具有无肾毒性、抗肿瘤、降低巨细胞病毒感染率等优势;但并非所有的患者均适合使用西罗莫司,严格的患者筛选是取得满意临床效果的重要前提。制定合适的治疗方案,密切监测药物浓度,注意预防和治疗相关并发症都是成功使用西罗莫司过程中不容忽视的重要因素。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

Anatomic bases for liver transplantation

Summary This study gathers the anatomic implications for a good liver transplantation. During hepatic removal a left hepatic a.exists in 20% of cases; a right hepatic artery originating from the superior mesenteric a. (SMA) can be the only arterial supply in 9% of cases; the whole lesser omentum has to be removed and the SMA from 6 cm to its origin. The SMA must be freed from the celiac ganglia and its ostium removed with the celiac trunk in an aortic patch cut on the anterior side in order to avoid the renal ostia. During total hepatectomy, dissection of the portal triad is often difficult because of portal hypertension dilating accessory portal veins (parabiliary arcade) and pedicular lymphatics. Nerve plexuses are thick in front of the hepatic artery or behind the portal triad. Transection of triangular ligaments leads to the retrohepatic inferior vena cava (IVC) that must be freed from its posterior tributaries (right suprarenal vein and inferior phrenic veins flowing either into the IVC or into the hepatic veins). One big problem during hepatic replacement is the biliary anastomosis which must be well irrigated. In the recipient, dissection up to the hilum preserves hepatic and pancreatico-duodenal pedicles. The biliary tract of the graft must be cut low, behind the pancreas, and several centimeters of the gastroduodenal artery must be preserved to save hepatic and gastroduodenal pedicles.

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Bases anatomiques de la transplantation hépatique

Résumé Ce travail rassemble les notions anatomiques nécessaires au bon déroulement d'une transplantation hépatique. Le prélèvement du greffon doit enlever tout le petit omentum contenant une éventuelle a. hépatique gauche née de l'a. gastrique gauche (20%) et emporter l'a. mésentérique supérieure jusqu'à 6 cm de son origine pour ne pas oublier une a. hépatique droite née de cette dernière: son ostium est pris avec le tronc clique dans un patch aortique découpé sur la face antérieure. Lors de l'hépatectomie totale, la dissection du pédicule hépatique est rendue délicate par l'hypertension portale qui dilate les veines portes diets accessoires (arcade parabiliaire) et les lymphatiques pédiculaires. Les plexus nerveux sont riches devant l'artère hépatique et derrière le pédicule. La section des ligaments triangulaires droit et gauche amène à la veine cave inférieure (VCI) rétro-hépatique qu'il faut libérer de ses afférences postérieures (en particulier la veine surrénale principale droite toujours haut située et les veines phréniques inférieures qui s'abouchent soit dans la VCI soit dans les veines hépatiques du carrefour). Lors du remplacement, l'anastomose biliaire doit être vascularisée. Chez le receveur la dissection jusqu'au hile permet de conserver les pédicules. La voie biliaire du greffon doit être coupée bas derrière le pancréas et les premiers centimètres de l'artère gastro-duodénale conservés pour préserver les pédicules hépatique et pancréaticoduodénal.

     

Factors influencing the occurrence of active cytomegalovirus (CMV) infections after organ transplantation.

In this study, several factors influencing the occurrence of active CMV infection after organ transplantation (Tx) are analysed. For this purpose, 105 heart, kidney and lung transplant recipients who were CMV-positive or had a CMV-positive donor, were closely monitored for active CMV infection by antigenaemia, cultures, CMV serology and lymphocyte proliferation (LP) to CMV. Univariate and multivariate regression analysis were performed. As pretransplant risk factors the HLA-type and numbers of HLA mismatches between recipients and their donors, and the CMV serology of the recipient and donor were analysed. A new finding was that recipients of donors positive for HLA-B7 were especially at risk for developing active CMV infection (P = 0.03) and CMV disease (P = 0.03). This was not due to increased rejection treatment in these patients. Post-transplant risk factors for development of active CMV infection were absence of detectable cellular immunity to CMV (lymphocyte proliferation) after Tx (P < 0.01) and rejection treatment with OKT3 or ATG (P = 0.05). High levels of IgG anti-CMV did not prevent occurrence of active CMV infection or CMV disease in the CMV+ recipients.     

Comparison of potentiality to induce graft-versus-host reaction with small bowel, pancreas/spleen, and liver transplantation in the rat.

Although small bowel transplantation (SBT), or pancreas-spleen transplantation (PST) often lead to lethal graft-versus-host reaction (GVHR) in experimental animals, fatal GVHR is rare after clinical liver transplantation. This study describes a modified model of SBT and PST in the rat using cuff techniques applied to the renal artery and vein of the recipient. The ability of LEW (RT1(1)) or BN (RT1n) lymphocytes accompanying intestinal, splenic, or hepatic grafts to induce lethal GVHR in (LEW x BN) F1 hybrid recipients was compared. SBT and PST experiments showed that lethal GVHR always occurred in LEW-into-F1 combination, but was much less frequent in BN-into-F1 SBT. In mixed lymphocyte reaction (MLR), LEW mesenteric or splenic T cells showed significantly higher proliferative responses against BN stimulators than did BN mesenteric or splenic T cells against LEW. Adoptive cell transfer experiments using mesenteric or splenic cells also showed that LEW cells were higher responders than BN. In contrast with SBT and PST results, a lethal GVHR was not induced after liver or pancreas grafting alone in either parent-to-F1 combination. In MLR, hepatic T cells from either parent failed to elicit a proliferative response against allostimulators. These results indicate that the occurrence of lethal GVHR is dependent upon the reactivity of parental lymphocytes against allo-antigenicity of F1 hybrids and also upon the lymphoid tissue transplanted. The lack of alloreactivity of hepatic T cells accounts for the absence of lethal GVHR after liver grafting.