肝脏能量代谢与手术后多器官衰竭的关系

测定１６９例外科大手术后病人的动脉血酮体比率（ＡＫＢＲ），并与术后临床过程进行比较。根据术后ＡＫＢＲ变化将病人分为３组：Ａ组１０２例，术后ＡＫＢＲ一直保持在０．７以上；Ｂ组６１例，术后ＡＫＢＲ曾一度降至０．４～０．７，但３～５天后逐渐回升到０．７以上；Ｃ组６例，术后ＡＫＢＲ逐渐下降到０．４以下。术后Ａ组中仅２例发生单个器官衰竭（占２．０％）；Ｂ组中２０例共发生２６个器官衰竭（占３２．８％），但随着ＡＫＢＲ的回升并发症亦缓解；而Ｃ组６例病人共发生３４个器官衰竭，且均死于多器官衰竭。由此表明，ＡＫＢＲ可作为评价肝脏能量代谢的可靠指标，肝脏能量代谢障碍在术后多器官衰竭的发生中起着关键性作用。     

肝脏能量代谢与手术后多器官衰竭的关系

作者对１６９例经历了外科大手术后的患者进行了动脉血酮体比率（ＫＢＲ）的观测，并与术后临床过程进行了比较分析。根据术后ＫＢＲ变化将全部患者分为三组：Ａ组１０２例，术后ＫＢＲ一直保持于０．７以上；Ｂ组６１例，术后ＫＢＲ曾一度降至０．４～０．７；Ｃ组６例，术后ＫＢＰ逐渐下降到０．４以下。术后Ａ组２例发生器官衰竭（２．０％）；Ｂ组２０例发生２６个器官衰竭（３２．８％）．但随ＫＢＲ的回升并发症亦缓解；而Ｃ组６例患者均死于多器官衰竭。作者认为ＫＢＲ是评价肝脏能量代谢的可靠指标，同时证明肝脏能量代射障碍在多器官衰竭的发生中起到了关键性的作用。     

肝脏能量代谢与手术后多器官衰竭的关系

作者对１６９例经历了外科大手术后的患者进行了动脉血酮体比率的观测，并与术后临床过程进行了比较分析。根据术后ＫＢＲ变化将全部患者为三组：Ａ组１０２例，术后ＫＢＲ一直保持于０。７以上；Ｂ组６１例，术后ＫＢＲ曾一度降至０．４－０．７；Ｃ组６例，术后ＫＢＲ逐渐下降到０．４以下，术后Ａ组２例发生官衰竭（２．０％）；Ｂ组２０例发生２６个器官衰竭（３２．８％），但随ＫＢＲ是评价肝脏能量代谢的可靠指标，同时证明肝     

胆道阻塞解除后肝功能指标的临床观察与评价

对１１例黄疸持续时间＞１个月的梗阻性黄疸患者做了术前及术后１、３、７ｄ肝吲哚氰绿（ＩＣＧ）排泄试验．并做了血清胆红素、甘氨结合胆酸、ＡＫＰ、ＧＰＴ、总蛋白、Ａ／Ｇ等肝功能指标测定．结果：术前血清胆红素均值达正常３０倍（３０４±９２ｍｇ·Ｌ－１）．甘氨结合胆酸达４０倍．ＡＫＰ为４倍．吲哚氰绿血浆１５ｍｉｎ滞留率（ＩＣＧＲ１５）为５．６倍．吲哚氰绿清除率（ＩＣＧｋｍ）为正常１／４。术后血清胆红素等下降迅速．术后１Ｗｋ胆红素较术前已平均下降了５０％；胆酸下降７５％．ＡＫＰ下降５５％；而ＩＣＧ滞留率和清除率恢复缓慢（ＩＣＧＲ１５下降１６％，ＩＣＧｋｍ上升０．０１８）．这种恢复速度的不同导致ＩＣＧ测定值和其它检测指标的曲线分离。ＧＰＴ、总蛋白、Ａ／Ｇ在手术前后无明显变化，表明ＧＰＴ、总蛋白、Ａ／Ｇ在反映胆道阻塞时肝细胞功能损伤及再通手术后肝功能恢复方面敏感性低，而胆红素、胆酸等值的迅速下降则更多的反映胆道通畅情况．而不是肝功能的恢复程度。动物实验研究显示胆道阻塞引起的肝细胞损害在胆道再通后恢复缓慢．因此ＩＣＧＲ１５和ＩＣＧｋｍ的改变似能更好地反映肝细胞功能的恢复状况。     

自体LAK细胞和rIL－2治疗晚期肾癌的实验与临床研究

应用自体ＬＡＫ细胞和重组白细胞介素－２（ｒＩＬ－２）治疗２０例晚期肾癌患者。自患者周围血分离到的单个核细胞（ＰＢＭＣ）体外经ｒＩＬ－２短期培养，其ＮＫ、ＬＡＫ活性明显增强并于第５、７天达高峰。当这些ＬＡＫ细胞与ｒＩＬ－２过继回输给同一患者后，病人周围血ＮＫ、ＬＡＫ活性明显增加（Ｐ＜０．０ｌ），ＮＫ比率、ＩＬ－２受体表达明显增加（Ｐ＜０．０５），提示对肾癌患者的免疫调节作用。本组病人获部分缓解（ＰＲ）ｌ例，轻度缓解（ＭＲ）３例，平均缓解期５个月。毒副作用主要表现为发热、寒战，病人能耐受，表明ＬＡＫ／ｒＩＬ－２疗法是安全的方法。     

检测AKBR和Ⅳ—C在肝癌患者手术治疗中的应用研究

目的 探讨测定动脉血酮体比和血清四型胶原在肝癌患者手术及预后评估中的意义。方法 在手术前后对２０例行部分肝切除的原发性肝癌患者连续测定ＡＫＢＲ和血清Ⅳ－Ｃ并与术后并发症情况做对比。结果 按术后ＡＫＢＲ分成三组,Ａ组,始终≥０．７;Ｂ组（７例）,波动在０．４和０．７之间,Ｃ组（３例）;降在０．４之下。各组并发症发生率依闪为２０％,４２．９％和１００％。按术后Ⅳ－Ｃ分为两组：〈２００μｇ／Ｌ的Ⅰ组中Ａ     

酮咯酸和哌替啶用于胸科术后镇痛的比较

３０例择期开胸患者随机分为两组，Ｋ组（酮咯酸３０ｍｇ）１５例，Ｐ组（哌替陡５０ｍｇ）１５例。术后当晚刀口疼痛时肌注给药。应用 ＶＡＳ法测痛，Ｋ组镇痛优良率 ７３， ７％，Ｐ组镇痛优良率 ８０． ０％，经 Ｘ２检验无统计学意义（Ｐ＞０．０５）。用药前和用药后１、４、７小时心率（ＨＲ）、血压（ＳＢＰ／ＤＢＰ）变化，两组内和组间比较均无显著性差异（Ｐ＞０．０５）。用药前和用药后１、７小时呼吸频率（ＲＲ）和动脉血气（ＡＢＧ）变化，两组内和组间比较亦无显著性差异（Ｐ＞０．０５）、用药期间未发现明显的不良反应。结果表明，酮咯酸用于胸科术后镇痛，疗效满意，对循环和呼吸功能影响轻微，巨无呼吸抑制之顾虑。//     

精氨酸增强梗阻性黄疸细胞免疫功能及其降低感染的临床疗效观察

研究非精氨酸（Ａ组）３７例（含１４例ＡＯＳＣ）和精氨酸组（Ｂ组）２９例（含１１例ＡＯＳＣ）细胞免疫变化和围手术期感染性并发症。结果显示：无论手术前，还是手术后Ｂ组ＣＤ３＾＋、ＣＤ４＾＋显著高于Ａ组（Ｐ〈０．０１），而Ｂ组ＳＩＬ－２Ｒ显著低于Ａ组（Ｐ〈０．０１）。在ＡＯＳＣ术后，Ｂ组体温、ＷＢＣ计数明显低于Ａ组（Ｐ〈０．０１），Ａ组术后感染性并发症非常显著高于Ｂ组（Ｐ〈０．０１）。研究表明精氨酸有显     

ERCP及ES对腹腔镜胆囊切除术的辅助作用

将８８６例腹腔镜胆囊切除术（ＬＣ）的病人分为两组。院内组４０７例，在ＬＣ前选出其中１１６例可疑胆总管结石者进行ＥＲＣＰ检查，将检出的３例胆道蛔虫病人先行内镜胆管取出（ＥＲＢＡ）。７例胆总管结石病人先行内镜括约肌切开（ＥＳ）取石。然后再行ＬＣ。术后仅２例胆管残石（０．５％）。院外组因没有条件行ＥＲＣＰ，ＬＣ术后经证实的胆管残石发生率为３．３％（１６／４７９），明显高于院内组（Ｐ＜０．０１）。对于两组共１８例胆管残石病人，１４例通过ＥＳ取出残石．证明ＥＲＣＰ及ＥＳ与ＬＣ相结合，更能充分发挥微创外科的积极作用。     

心胸手术对乙型肝炎表面抗原阳性患者肝功能影响分析

为探讨心胸手术对乙型肝炎表面抗原（ＨＢｓＡｇ）阳性患者肝功能的影响，选择６０例手术患者，其中ＨＢ－ｓＡｇ阳性３０例（病例组），ＨＢｓＡｇ阴性３０例（对照组），于手术前后分别测定肝功能指标进行对比分析。结果显示：ＨＢｓＡｇ阳性患者谷丙转氨酶（ＧＰＴ）术后高于术前（Ｐ＜０．０１）；谷丙／谷草转氨酶比值（ＧＯＴ／ＧＰＴ）术后低于术前（Ｐ＜０．０５）；其中大三阳（ＨＢｓＡｇ、ＨＢｅＡｇ和抗－ＨＢｃＡｇ阳性）患者ＧＰＴ术后高于术前（Ｐ＜０．０５）。结论：心胸手术对ＨＢ－ｓＡｇ阳性患者肝功能有不同程度的损害作用，但并非手术绝对禁忌症。     

Thrombotic and nonthrombotic hepatic artery complications in adults and children following primary liver transplantation with long-term follow-up in 1000 consecutive patients.

Arterial complications have a major impact on survival after liver transplantation (LTx). The aim of this study was to examine arterial complications in adults and children after LTx. A total of 1000 consecutive primary LTx patients [mean age 40.5 years: 600 males, 400 females, 834 adults; 166 children (age <18 years)] were studied. Forty-two patients (4.2%; 31 adults, 11 children) developed hepatic artery thrombosis (HAT). Thrombosis in children occurred significantly early (mean 5.4 days) compared with adults (mean 418.7 days, P = 0.0001). Nonthrombotic complications occurred in 30 patients (29 adults, one child). Overall, 13-year patient survival after HAT was 43.2% (72.7% children, 32.9% adults). For nonthrombotic complications, 54.3% of adults died and 69.4% grafts were lost. An overall incidence of 4.2% thrombotic and 3.2% nonthrombotic complications was observed. Rate of HAT was higher in children, but survival was better compared with adults.     

肝蒂联合右肝静脉阻断在巨块型肝癌切除中的应用

目的评估肝蒂联合右肝静脉阻断在巨块型肝癌切除中的作用和意义。方法对2003年2月至2006年8月中南大学湘雅二医院肝胆外科收治的138例位于右半肝及中央型的巨大肝癌行肝蒂联合右肝静脉阻断,观察肝脏血流阻断时间、手术时间、术中出血量、术后肝功能的变化及术后并发症。结果135例在肝外游离出右肝静脉并加以阻断,3例以小的心耳钳沿腔静脉方向纵行夹住右肝静脉阻断出肝血流。所有病例右侧均顺利阻断肝蒂。肝脏血流阻断时间平均为(18±6)min,手术时间平均为(180±45)min,术中出血400~1200mL,56例术中未输血。术后无一例发生肝功能衰竭。术后膈下感染2例,胆漏4例,经引流自愈。结论在巨块型肝癌切除中,肝蒂联合右肝静脉阻断技术可以有效地减少术中出血,降低术后肝功能衰竭的发生率。     

腹腔镜胆囊切除术中不同气腹压力对人体肝脏功能的影响

目的 观察腹腔镜肿囊切除术中不同气腹压力对人体肝脏功能的影响。方法 将97例病人分为低气腹压组和高气腹压组,比较两组间术后肝功能的变化。结果 与低气腹压组比较,高气腹压组天门冬氨酸转氨酶（AST）、丙氨酸转氨酶（ALT）、总胆红素（TBil）、间接胆红素（IBil）升高明显,且恢复较晚,而两组血清吲哚氰绿滞留试验（ICGR15）和动脉血酮体比值（AKBR）变化则差异不大。结论 对于术前肝功能正常的病人,不同气腹压力对人体肝脏功能产生不同的影响,其中尤以对血清转氨酶和血清胆红素的影响较为突出,而对肝脏的储备功能和能量代谢状态无明显影响。     

HEPATIC RESECTION

In the four years between the beginning of 1979 and the end of 1982, 23 hepatic resections have been carried out for tumours, trauma, biliary access, cystic disease of the liver and spontaneous rupture. There have been four deaths amongst these 23 patients. The 23 resections were performed on 68 patients referred for possible surgery on their hepatic lesions. Right-sided hepatic resections and resections carried out under emergency circumstances were found to carry a significantly higher risk than all other resections. Of the various organ imaging methods available for assessment of hepatic tumours, CT scanning seems to be the most powerful. Liver surgery is probably best done in a limited number of units prepared to implement appropriate protocols of investigation and surgical management.     

Evaluation of hepatic reserve for surgical treatment in portal hypertension

Based on a hepatic hemodynamic study, estimated by hepatic catheterization technique in 233 patients of portal hypertension, a classification of hepatic reserve is proposed. Surgical treatments for preventing esophageal variceal bleeding which does not decrease portal pressure may safely be applied to the patients whose effective hepatic blood flow of over 300 ml/min/M², intrahepatic shunting rate below 40 per cent, IGC disapperance rate of over 0.04 min⁻¹, or BSP 30 minute retention rate of below 35 per cent.     

格拉斯哥预后评分对原发性肝癌预后预测价值的初步探讨

目的：探讨术前格拉斯哥预后评分（Glasgow prognostic score,GPS）与原发性肝癌患者肝功能状态及预后的关系。方法97例原发性肝癌患者,根据 GPS 评分不同将患者分为 GPS 0分组、GPS 1分组、GPS 2分组,比较组间患者肝功能状态、肿瘤生物学进展情况以及总体生存时间之间的差异。结果GPS 0分组52例（53．6％）,GPS 1分组31例（32．0％）,GPS 2分组14例（14．4％）。组间患者的年龄及性别构成无显著性差异（P 均＞0．05）,组间患者转氨酶、胆红素及AFP 相比,差异有统计学意义（P 均＜0．05）,GPS 评分较高组患者转氨酶、胆红素及 AFP 水平较高;且 GPS 评分较高组患者肿瘤临床病理分期较晚,肝功能 Child-Pugh 分级较差,瘤体更大,多发肿瘤及肿瘤血管侵犯、肝外转移等情况更为多见,上述指标的组间比较差异有统计学意义（P 均＜0．05）。生存分析结果显示,GPS 0分组与 GPS 1分组患者的总体生存时间相比,GPS 0分组患者的生存时间更长,组间差异有统计学意义（P ＝0．013）。结论GPS 评分可能与原发性肝癌患者的肿瘤生物学进展情况、肝功能状态及总体生存情况相关,高 GPS 评分多预示患者进展至病程晚期,肝功能状态较差,预后不良。     

Survival and recurrences after hepatic resection or radiofrequency for hepatocellular carcinoma in cirrhotic patients: A multivariate analysis

Hepatic resection is still considered the treatment of choice for hepatocellular carcinoma in patients with liver cirrhosis. Radiofrequency ablation is a new emerging modality. The aim of this study was to compare two homogeneous groups of patients who underwent either surgical resection or laparoscopic radiofrequency, analyzing the factors predicting survival and intrahepatic recurrences with use of a multivariate analysis. From February 1997 to April 2003, 98 patients were enrolled in this prospective study. Inclusion criteria were a single nodule of less than 5 cm, Child A-B class of liver function, and no previous treatment: 40 patients were in the surgical group and 58 patients were in the radiofrequency group. The two groups were homogeneous as far as preoperative characteristics were concerned. Operative mortality was zero, and the rates of operative morbidity were similar. Actuarial survival at 4 years was not significantly different (61% after resection and 45% after radiofrequency). There was a significant higher incidence of intrahepatic recurrences after radiofrequency than after resection (53% versus 30%; P = 0.018). This was mainly due to local recurrences, whereas those appearing in other liver segments were similar in both groups. A multivariate analysis showed that the significant factors predictive of an intrahepatic recurrence were the level of α-fetoprotein, the etiology of cirrhosis, and the type of the treatment. On the other hand, multivariate analysis of the survival showed that only the level of α-fetoprotein was an independent predictor of survival. The results of our study showed a significant lower incidence of intrahepatic recurrences after resection compared with after radiofrequency. This seems not to significantly influence the overall survival, probably because of a prompt and effective treatment of the recurrences themselves. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation).     

大鼠肝硬变和肝癌发生中肝组织病理和甲胎蛋白的变化

目的 探讨大鼠肝硬变和肝癌发生中肝组织病理和甲胎蛋白变化的意义.方法 选取雄性Wistar大鼠,分别采用DENA、四氧化碳和橄榄油诱导建立肝癌和肝硬变模型,于诱导前和诱导后2周、4周、8周、14周、18周和21周分别获取肝、脾组织和外周静脉血,HE染色进行肝脾组织病理学检查,ELISA法测定外周血清AFP水平.结果 大鼠肝硬变诱发过程中18周后出现肝假小叶,淤血性脾肿大;大鼠肝癌诱发过程中14周病理性核分裂,核仁变大、数量增多,肝癌结节形成,脾脏充血性改变.大鼠肝硬变诱发过程中外周血AFP在4周开始升高,14周与对照组比较差异显著(P<0.05);大鼠肝癌诱发过程中外周血AFP在2周开始升高,8周时与对照组比较差异显著(P<0.05);肝癌大鼠外周血AFP表达水平在8周时显著高于肝硬变大鼠(P<0.05).结论 不同诱导因素下大鼠肝脏病理变化出现时间和损害程度不尽相同,DENA对肝脏损害程度较四氯化碳对肝脏损害重;肝细胞受到病毒、细茵、毒素、化学毒物等损害时,动态监测外周血AFP水平,对评估肝细胞损伤程度和癌变具有双重生物学意义.     

A good model of hepatic failure after excessive hepatectomy in mice

AIMS: This study was intended to establish in mice: 1) a safety limit for the extent of hepatectomy and 2) the extent of hepatectomy invariably causing fatal hepatic failure, to facilitate gene expression analysis. MATERIALS AND METHODS: In 70%-hepatectomy, the left lateral and median lobes were removed, and in 90%-hepatectomy, all lobes except the caudate were resected. One-week survival rates, serum concentrations of aspartate aminotransferase, alanine aminotransferase and total bilirubin were measured. Histological examinations were performed using hematoxylin and eosin staining, and immunohistochemical tests were done with antibody against Ki-67 antigen. RESULTS: All of the 70%-hepatectomized mice were alive at 1 week, but the 90%-hepatectomized mice all died within 24 h after hepatectomy. Serum aminotransferase and total bilirubin levels were significantly higher in the 90%-hepatectomized mice than in the 70%-hepatectomized mice. Liver histology revealed more prominent vacuolar degeneration in the former. Ki67-positive hepatocytes appeared and proliferated immediately after 70%-hepatectomy, but few were observed in the 70%-hepatectomized mice. CONCLUSION: We established 90%-hepatectomy as the safety limit for murine hepatectomy and as a model for liver regeneration, and 90%-hepatectomy as a "fatal hepatic failure level."     

A case of inflammatory pseudotumor of the liver hilum successfully treated with aggressive hepatectomy

Inflammatory pseudotumor (IPT) of the liver is a rare, benign tumor. When the tumor involves the hepatic hilum, however, the clinical course of the patient becomes problematic because of obstructive jaundice and portal hypertension. Complete removal of the tumor sometimes is difficult when the hepatic hilum is extensively involved, and liver transplantation becomes necessary for such an unresectable tumor. This report concerns a 7-year-old boy who presented with obstructive jaundice and portal hypertension owing to an inflammatory pseudotumor of the hepatic hilum and was treated successfully with aggressive hepatectomy, vascular reconstructions of both the portal vein and the hepatic artery, and biliary reconstruction. The patient was discharged after 39 days of hospitalization. Eight months later, portal vein obstruction was detected and treated successfully with percutaneous transhepatic balloon dilatation of the obstructed site. The liver has continued to function well for 11 months after the tumor resection.