Reducing biliary complications in adult-to-adult living donor liver transplantation using right lobe graft: experience of 124 cases

The aim of this paper is to summarize our experience of using right lobe liver grafts to reduce biliary complications in adult-to-adult (A-A) living donor liver transplantation (LDLT). From January 2002 to October 2007, 124 adult patients underwent living donor liver transplantation using right lobe grafts at the West China Hospital, Sichuan University Medical School, China. There was no death in all donors. Biliary reconstruction for 178 hepatic duct orifices from 124 donor grafts was performed which included 106 reconstructions of duct-to-duct anastomoses and 72 cholangiojejunostomy. Nine recipients had biliary complications including six bile leakages (four from the anastomotic site and two from the cut surface of the liver graft) and three biliary strictures. With the improved techniques for biliary reconstruction, we have achieved good results in 124 recipients of A-A LDLT. We ascribe our success to the introduction of microsurgical techniques and the use of fixed operators which help in decreasing the biliary complications of LDLT.     

改进小体积肝移植供肝大鼠模型建立方法的实验研究

目的探讨改进切肝技术,以建立更可靠的小体积肝移植供肝大鼠模型。方法以Kamada的“二袖套法”为基础,建立30％小体积肝移植中叶供肝大鼠模型。实验分两组：Ⅰ组（28只）,常规方法切肝,以中叶作供肝;Ⅱ组（36只）,改进为左叶和右叶的切肝方法,余方法步骤同Ⅰ组。观察两组手术并发症和7d生存率。结果Ⅱ组肝后下腔静脉狭窄的发生率明显低于Ⅰ组（P〈0．05）,其他并发症发生率两组间无明显差异（P〉0．05）。术后7d生存率Ⅱ组（60％,21／36）高于Ⅰ组（33％,9／28）,但差异未显示有统计学意义（Χ^2=0．272,P〉0．05）。结论采用中叶供肝、改进切肝技术,可以建立更稳定可靠的部分体积肝移植供肝大鼠模型。     

活体肝移植肝动脉重建技术与并发症

目的 探讨活体肝移植中肝动脉重建的显微外科技术，以降低肝动脉栓塞的发生率，提高患移植后的生存率。方法 本组24例，其中右半肝活体肝移植6例，左半肝移植16例，左外叶2例；采用显微外科技术行肝动脉吻合。吻合的方式是端端吻合。结果11例肝动脉直径＜2mm，重建肝动脉时间为24～88min。行单支动脉吻合20例，两支动脉吻合4例；2例患术后出现肝动脉血栓形成，均须行再次肝移植后恢复。本组肝动脉血栓的发生率为8．3％。结论 显微外科技术重建肝动脉可减少肝移植术后肝动脉栓塞的发生。     

活体右半肝供者肝脏血管和胆道解剖变异分析

目的:探讨活体肝移植右半肝供者血管、胆道解剖学特点。方法:依据门静脉分型、肝静脉解剖分型、胆道分型及肝动脉解剖分型,观察90例右半肝活体肝移植供者的肝静脉、门静脉、肝动脉及胆道的解剖学特点。结果:正常门静脉的比例为94.4%(85/90),三叉型门静脉的比例为5.6%(5/90);肝动脉变异率较高;正常胆道的比例为66.7%(60/90),三叉型胆道占20%(18/90),3型胆道的比例为12.2%(11/90),4型胆道占1.1%(1/90);肝中静脉和肝左静脉共干的比例为70.0%(63/90),大于5mm的肝右下静脉出现概率为26.6%(24/90),左内叶上段静脉汇入肝左静脉的比例为68.8%(62/90),共同汇入肝左静脉和肝中静脉的比例为21.1%(19/90),汇入肝中静脉的比例为10.0%(9/90)。结论:肝脏血管和胆道的解剖变异很常见,准确的术前评估对于活体肝移植至关重要。     

不同灌注方式对大鼠小体积肝移植生存率的影响

目的 探讨不同的灌注方式对大鼠小体积肝移植生存率的影响。方法 将 156 只 SD 大鼠随机分为经门静脉灌注组（GroupⅠ）和经腹主动脉灌注组（GroupⅡ）, 每组 78 只, 供、 受体各 39 只。GroupⅠ与 GroupⅡ在获取供肝后, 切除肝脏的左叶和中叶, 剩余约 30%体积进行移植, 术中记录供体和受体的体质量、 移植肝质量、 温缺血时间、供体手术时间、 冷缺血时间、 无肝期、 肝下下腔静脉阻断时间及受体手术时间相关指标, 比较 2 组大鼠术后 6 h、 1 d、 3 d 和 7 d 的血清丙氨酸转氨酶（ALT）和天冬氨酸转氨酶（AST）水平、 病理 HE 染色及 7 d 生存率。结果 2 组术中血清 ALT、 AST 均逐渐下降, 但是 GroupⅠ下降缓慢, 术后 24 h 高于 GroupⅡ（P＜0.05）。HE 染色提示 GroupⅠ术后早期肝组织显微结构损伤大, GroupⅠ的 7 d 中位生存期低于 GroupⅡ （Log-rank χ2=4.050, P=0.044）。结论 使用经腹主动脉灌注的方法建立大鼠小体积肝移植模型具有肝脏损伤小、 生存率高的优势。     

肝脏拖出在特殊部位肝外伤手术中的应用

目的总结肝脏拖出在8例特殊部位肝外伤手术中应用的经验。方法应用肝脏拖出实施第VII段或第VIII段、尾状叶等特殊部位肝外伤手术共8例,行间歇性肝门阻断。其中2例行挫裂伤下腔静脉壁修补,1例在第三肝门肝短静脉逐个结扎后,拖出翻转行尾状叶切除门静脉后壁裂伤修补。术中肝门阻断时间（55±21）min,出血量（2140±750）ml,手术时间（75±42）min。结果全组无手术死亡,手术过程顺利,术中暴露病变清晰,效果满意。结论应用肝脏拖出术,能解决特殊部位肝外伤的术野显露问题,从而为该部位外伤的处理提供良好的视野和空间。     

儿童活体和尸体肝移植的临床效果比较

目的 分析和评价儿童活体和尸体肝移植的效果。 方法 回顾性分析 320 例终末期肝病儿童肝移植的预后及影响因素。 根据肝移植手术方式的不同, 将 320 例受者分为活体肝移植组（活体组）252 例和尸体肝移植组（尸肝组）68 例。 活体组所有供者均为 3 代以内的直系亲属; 尸肝组所有供者均为心脏死亡或脑死亡供者。 比较两 组受者术后存活情况和并发症情况。 结果 活体组受者 1、2、3 年的总体存活率分别为 95.1%、93.5%和 93.5%, 尸肝组分别为 92.3%、92.3%和 82.4%, 两组间比较差异无统计学意义（Log-rank χ2=0.69, P=0.41）。 随访期间, 活体组死亡14 例（5.56%）, 其中 8 例死于呼吸系统并发症, 3 例死于多器官功能衰竭, 3 例死于移植肝功能衰竭; 尸肝组死亡 5 例（7.35%）, 其中 1 例死于呼吸系统并发症, 2 例死于多器官功能衰竭, 1 例死于腹腔出血, 1 例死于其他原因。 两组门静脉血栓（PVT）、流出道梗阻、胆道并发症、肺部感染差异无统计学意义（均 P＞ 0.05）, 活体组肝动脉血栓（HAT）比例低于尸肝组（1.98% vs. 10.29%, χ2=10.245, P < 0.01）。 结论 活体肝移植作为治疗终末期肝病的有效手段, 疗效较好。     

隆突支气管肺动脉切除重建治疗中心型肺癌

目的回顾性总结隆突支气管肺动脉切除重建治疗中心型肺癌的经验。方法应用隆突支气管肺动脉切除治疗中心型肺癌60例,其中右上叶袖状切除重建29例,右全肺半隆突切除1例,右全肺隆突切除3例,右上叶袖状合并隆突切除3例,右中叶及下叶背段袖状切除重建5例,左上叶袖状切除19例,同时行肺动脉切除成形18例。结果全组无手术死亡。随访1～5年,生存1年57例(95.0%),3年29例(48.3%),5年19例(31.7%)。结论本方法可扩大中心型肺癌的手术指征,符合肺癌手术“两个最大限度”的原则。     

腹腔镜胆囊床剥离的风险防范

目的 探讨腹腔镜胆囊切除术中胆囊床剥离的危险因素与防范措施.方法 对接受腹腔镜胆囊切除术中用传统胆囊床剥离方法 完成的490例患者资料进行回顾性分析,同期随机选取500例采用改良腹腔镜胆囊床剥离方法 的患者进行前瞻性研究.结果 传统方法 完成的490例患者中,发生肝中静脉床面属支损伤大出血3例,胆囊动脉后支床面分支出血2例,术后诊断胆囊床胆漏5例,变异右肝门静脉损伤2例,变异右肝管损伤1例.改良胆囊床剥离法完成的500例患者中,无一例发生严重手术并发症,同时解剖观察显示胆囊床胆囊动脉后支床面分支占39.6%(198/500),肝中静脉床面属支占11.2 96(56/500),其分布以胆囊床面右侧居多,床面扩张的迷走胆管占2.2%(11/500),变异裸露右肝管占0.6%(3/500),右肝门静脉分支占0.4%(2/500).结论 在腹腔镜胆囊切除术中行胆囊床剥离时存在潜在的手术风险.术中遇意外性损伤,应及时中转开腹.改良腹腔镜胆囊床剥离法有助于防范胆囊床剥离的手术风险.     

232例肝淤血声像图分析

目的探讨肝淤血二维及彩色多普勒超声表现，为临床治疗右心衰疗效评价提供理论依据。方法回顾232例肝淤血患者的声像图进行分析。结果232例淤血性肝脏患者中97例为早期淤血性肝脏，占41．8％。声像图表现为肝脏各径线测值均增大，左肝厚度≥6．0cm，右肝最大斜径≥14cm，肝实质回声稍有减弱，肝静脉内径增宽1．0cm左右。135例有淤血性肝硬化，占58.2％。其中100例为75岁以上患者，占74．1％。声像图表现肝脏测值相应减小，右肝减小明显，肝表面比较光滑或偶有细结节状突起，肝实质回声增强增多，肝静脉各支显著增宽、扩张。232例患者中，合并腹水患者49例，占21．1％，合并胸水患者55例，占23．7％，合并胸、腹水患者45例，占19．4％，同时合并有胸水、腹水及心包积液患者25例，占10．8％。结论超声对淤血性肝脏病变的诊断符合率较高，且能与其他肝脏弥漫性病变相鉴别，对临床治疗方案选择及疗效评价有实用意义。     

Variations of the hepatic and cystic arteries among Ethiopians

The anatomy of the hepatic and cystic arteries were investigated in 110 postmortem and cadaveric subjects. The right hepatic artery took origin from the proper hepatic artery (66.3%), the common hepatic artery (18.2%), the superior mesenteric artery (8.2%) or the celiac trunk (7.3%). Ten cases of accessory right hepatic artery originating from the superior mesenteric artery (7 cases), gastroduodenal artery (2 cases) or the left hepatic artery (1 case) were observed. The origin of the left hepatic artery included the proper hepatic artery (71.8%), the common hepatic artery (16.4%), the celiac trunk (10.9%) and the splenic artery (0.9%). The 14 cases of accessory left hepatic arteries originated from the common hepatic artery (5 cases), right hepatic artery (3 cases), gastroduodenal artery (2 cases) or the celiac trunk (4 cases). An extrahepatic branch to the quadrate lobe of the liver, also known as the middle hepatic artery, was observed in 47.3% arising mainly from the right or left hepatic arteries (20% each), the superior mesenteric artery (2.7%) and from the gastroduodenal artery (4.6%). The cystic artery mainly arose from the right hepatic artery (75.5%) but also took origin from the middle hepatic artery (12.7%), gastroduodenal artery (7.3%) or the left hepatic artery (4.5%). When the cystic artery is to the left of the common hepatic artery at its origin (39.1%), it crossed from left to right anterior to the common hepatic duct (28.2%) or posterior to the duct (10.9%). Irrespective of its relationship with the common hepatic duct, the cystic artery passed in the triangle of Calot in 89 cases. There were 11 accessory cystic arteries arising from the right hepatic (6 cases), the middle hepatic (3 cases) or the left hepatic arteries (2 cases). Arterial variations seen in the present study were significantly higher (p < 0.05) than that reported in the literature. This was mainly due to the variations seen in origin of the right hepatic artery in the female subjects which was significantly higher (p < 0.05) than in the male subjects. The significance of this finding needs further investigation.     

A perivascular system releasing sirolimus prevented intimal hyperplasia in a rabbit model in a medium-term study

The main complication of aortocoronary reconstruction with vein grafts is restenosis in the course of time. The aim was to assess the effect of a periadventitial polyester mesh releasing sirolimus on intimal hyperplasia of autologous grafts. We implanted v. jugularis ext. into a. carotis communis in rabbits. The vein graft was either intact, or was wrapped with a pure polyester mesh, or with a sirolimus-releasing mesh. Three and six weeks after surgery, the veins were subjected to standard histological staining and the thicknesses of the tunica intima, the media and the intima-media complex were measured. Wrapping the vein with a mesh releasing sirolimus or with a pure mesh decreased the thickness of the intima in comparison with a vein graft by 73 ± 11% or 73 ± 8% after 3 weeks, and by 73 ± 9% or 59 ± 12% after 6 weeks, respectively. Sirolimus-releasing meshes reduced the thickness of the media by 65 ± 9% and 20 ± 12% after 3 and 6 weeks. The thickness of the intima-media complex in grafts with sirolimus-releasing meshes decreased by 60 ± 6% and 30 ± 13% in comparison with pure PES meshes, after 3 and 6 weeks, respectively. A periadventitial polyester mesh releasing sirolimus has the potential to become an effective device in preventing vein graft restenosis.     

重症肝挫裂伤纱布条填塞的止血作用

作者报道闭合性肝挫伤４０例，轻症２０例，重症１７例，肝静脉或肝后静脉破裂３例。在２０例严重病例中，用纱布填塞作为辅助止血或临时止血７例，其中基层医院纱布填塞临时止血转院１例，肝内血肿大网膜填塞外加纱布垫填塞止血２例，挫裂伤肝叶切除止血后，在覆盖的大网膜上用阴道纱布填塞止血３例，肝右静脉破裂纱垫填塞临时止血１例，都达到止血目的，认为这是一种有效的临时止血措施。     

大鼠同种带瓣主动脉移植模型的建立和改进

目的 为了简化手术步骤，方便操作，提高手术成功率。方法 采用wistar大鼠(200～250g)为供体，sD大鼠(200～250g)为受体，行同种带瓣主动脉腹主动脉补片式异位移植36例。供体经修剪保留两个主动脉瓣叶及相应宽度瓣下附着心肌(0．5mm)和主动脉壁(5mm)，三定点连续缝合法移植于左肾静脉下方腹主动脉前壁。结果 手术成功率为94．4％。结论 实验结果提示：与腹主动脉间置式移植相比，本手法操作简单，成功率高，可满足类似实验要求。     

药物性慢性肝损害40例分析

目的提高临床对引起慢性肝病药物的认识。方法回顾性分析确诊的40例慢性药物性肝病的临床资料。结果药物诱发慢性肝炎18例，慢性肝内胆汁淤积7例，肝硬化3例，脂肪肝6例，肝脏腺瘤3例，肝静脉血栓形成2例，肝肉芽肿1例；40例中治愈35例(87．5％)，好转4例(10．0％)，死亡1例(2．5％)。常见诱导慢性肝病的药物有抗结核药、化疗药、镇静安眠抗惊厥药、非甾体类抗炎药、抗雌激素、降脂药等。结论诱导慢性肝病的药物应引起临床上的重视。     

螺旋CT肝脏血管成像质量影响因素探讨

目的探讨多层螺旋CT（MSCTA）肝脏血管成像的显影参数及图像质量影响因素。方法分析80例健康者和90例肝硬化患者的肝脏血管成像技术参数，分别测量腹主动脉（AA）、门静脉（PV）、肝实质（L）的CT值，比较不同注射速率下AA、PV、L、PV—L的峰值、达峰值时间、域值、延迟时间及图象质量。结果不同注射速率（2．5ml／s、3．5ml／8、4．5ml／s）下各时间点：AA最大峰值[（223．9±16．7）Hu、（273．3±12．7）Hu、（301．3±14．6）Hu]高于PV—L[（65．1±9．5）Hu、（83．7±17．9）Hu、（96．5±15．6）Hu]（均P〈0．01）；AA达峰值时间[（46．6±3．8）s、（36．2±6．5）s、（31．4±5．8）s]低于PV-L[（56．6±4．2）s、（49．6±5．0）s、（41．6±5．8）s]（均P〈0．05）；在MSCTA图像上，注射速率4．5ml／s组显示（肝动脉：A级15例、B级4例、C级1例、D级0例，门静脉：A级15例、B级4例、C级1例）明显高于2．5ml／8组（肝动脉：A级4例、B级5例、C级10例、D级3例，门静脉：A级2例、B级12例、C级6例）（均P〈0．01）；肝硬化组的最佳预设阔值180～220Hu高于正常组150～180Hu（P〈0．05）。结论注射速率可影响MSCTA肝脏血管成像质量，健康者和肝硬化患者的MSCTA技术参数不同。     

多层螺旋CT在诊断小肝癌中的应用

目的探讨多层螺旋cT诊断小肝癌的应用价值。方法分析56例确诊为小肝癌患者的多层螺旋cT资料。结果病灶位于肝右叶36例,肝左叶19例,肝尾叶1例,共发现78个病灶。单发癌结节44例,多发癌结节12例,结节直径0．5-3．0cm。CT平扫检出率为61．5％,增强扫描动脉期、门脉期和延迟期检出率分别为87．2％、80．8％和74．4％。结论多层螺旋cT三期增强扫描小肝癌有典型特征表现且检出率高,为临床诊断治疗提供了更丰富、准确的依据,具有重要的临床价值。     

超声显示右肺癌手术前后肝短静脉数量变化

目的证实起临床作用的肝短静脉数量可人为地增加。方法应用超声记录右肺癌患者手术前后肝短静脉的数量、内径、血流速度等的变化,观察手术前后肝脏位置及肝脏与下腔静脉间距的变化,所得资料行自身对照统计学分析。结果右肺癌患者手术后肝短静脉的人均数量明显增加(P<0.01)、平均内径和血流无明显差别(P>0.05),肝脏与下腔静脉的间距增大(P<0.05)、肝右后叶下缘明显上移。结论人为增大肝脏与下腔静脉间距可增加发挥临床作用的肝短静脉数量。     

Identification of tolerant recipients following liver transplantation

The need to administer livelong immunosuppressive medication (IS) to transplant recipients to prevent graft rejection often results in severe side effects like infections, malignancies, renal failure and cardiovascular complications. This constitutes one of the major drawbacks of clinical organ transplantation. Therefore, a means to establish medication-independent graft acceptance (tolerance) would be a major breakthrough in the field. Transplantation tolerance can be readily generated in experimental animal models, but so far most efforts to purposely induce this phenomenon in the clinic have failed. Liver transplantation is a unique clinical setting in that up to 20% of recipients can spontaneously withdraw IS without rejecting their grafts and are considered as operationally tolerant. This clinical observation is probably the most extreme manifestation of the well-documented intrinsic tolerogenic properties of the liver. The high rate of spontaneous operational tolerance following liver transplantation and the relative resistance of liver allografts to the effects of cytopathic alloimmune responses make liver transplantation the most suitable clinical transplantation model to test IS withdrawal strategies and tolerance promoting therapies. Liver transplantation constitutes therefore a unique setting to learn the mechanisms underlying allograft tolerance in humans.     

Drug-induced liver graft toxicity caused by cytochrome P450 poor metabolism

Aims

The drug-metabolizing capacity of transplanted liver highly influences drug efficacy or toxicity, particularly in the early postoperative period. The aim of our study was to predict therapeutic failures or severe adverse drug reactions by phenotyping for cytochrome P450 (P450) polymorphism resulting in reduced or no activity of the key drug-metabolizing enzymes.

Methods

A validated analytical system with metabolomic tools has been developed for estimation of the drug-metabolizing capacity of transplanted liver, which allows the prediction of potential poor metabolizer phenotypes of donors and facilitates improvement of the individual recipient therapy.

Results

Of the 109 liver donors in Hungary, the frequency of poor metabolizers was found to be 0.92%, 5.5% and 8.3% for CYP2C9, CYP2C19 and CYP2D6, respectively. In the present study, two liver grafts transplanted in paediatric recipients were reported to be poor metabolizer phenotypes. The liver grafts presented normal function in the early postoperative days; 2 weeks after transplantation, however, increasing liver enzymes were detected. Histological investigation of a liver biopsy suggested drug toxicity. The test of drug metabolizing status showed one of the liver grafts to be a CYP2C9 poor metabolizer, and the other was found to be a CYP2C19 poor metabolizer. Rationalization of the medication resulted in the recovery of both the grafts and the recipients within 1 week.

Conclusions

Prospective investigation of the P450 status may lead to the optimization of drug choice and/or dose for a more effective therapy, avoid serious adverse effects, and decrease medical costs. Phenotyping donor livers and tailored medication can contribute to the improvement of graft and recipient survival.

What is already known about this subject

• The activity of drug-metabolizing enzymes, primarily cytochrome P450 enzymes, can determine a patient''s response to a drug.
• Therapeutic failure or drug toxicity in the postoperative period after liver transplantation is influenced by the drug metabolizing capacity of the graft.
• Dose adjustment or selection of an alternative drug, which is not a substrate for the polymorphic enzyme may prevent the development of side-effects in recipients of poor metabolizer liver grafts.

What this study adds

• A validated analytical system with metabolomic tools has been developed to estimate the drug-metabolizing capacity of transplanted liver, which allows the prediction of potential poor metabolizer phenotypes of donors and facilitates the improvement of individual recipient therapy.
• In the test of drug-metabolizing status, one of the liver grafts was found to be a CYP2C9 poor metabolizer, while the other was a CYP2C19 poor metabolizer.
• Rationalization of the medication resulted in the recovery of both the grafts and the recipients within 1 week.