腹腔镜活体供肝切除术应用于儿童肝移植

目的　本研究前 ,我们已经做过了 5 0余例腹腔镜切除术 ,无一例死亡 ,其中包括 2 0例肝左叶切除 ,在此腹腔镜并非用于获取左叶供肝。腹腔镜供肝切除需要肝切除、肝脏移植、腹腔镜外科各方面的专业知识以及腹腔镜和肝脏外科最新的技术设备。尽管我们已经完成了很多例复杂的成人肝切除术 ,但腹腔镜用于较大的肝脏移植物 (例如成人受体的右肝叶 )的获取 ,目前在技术上尚不可行。从一活体供体上获取一个肝移植物非同于传统的肝切除术 ,因为不能应用血管夹闭技术 ,被切除部分的血管蒂必须保留。开腹的活体供肝切除术也需要这些操作过程 ,而这些操…     

活体肝移植中轻度脂肪变性供肝的应用

背景：在活体肝移植中使用脂肪变性供肝不但影响供者的安全,同时也影响受者的生存。 目的：评价活体肝移植中使用轻度脂肪变性供肝时供者的安全性及受者预后情况。 方法：回顾性分析104例成人间右半肝活体肝移植的资料,根据移植过程中供肝活检病理标本的脂肪变性程度将所有病例分成4个组。比较各组移植供受者移植后2周的肝体积增生率,分析104例成人间活体右半肝肝移植受者移植后死亡情况及原因。 结果与结论：4组病例在供受者移植后肝功能的恢复和受者后移植预后无明显差别,没有肝功能延迟恢复和原发无功发生。轻度大泡性脂肪肝者只要残肝足够可以成为合适的活体肝移植供者。使用轻度大泡性脂肪肝并不增加受者病死率和移植物失功。     

活体肝移植右半肝内肝静脉的应用解剖

目的:为活体肝移植提供右半肝内肝静脉的解剖学资料.方法:采用50例无病变成人尸体肝标本进行解剖剥离,对肝右静脉(RHV)及属支、副肝右静脉(aRHV)和肝中静脉(MHV)右半肝属支等进行观测.结果:RHV分型中A型、B型分别为74.0%和26.0%.RHV主干属支汇合形式可分为3种,其中90.0%为树状,8.0%呈2支型,2.0%呈3支型.RHV主要属支共(5.88±2.26)支,Ⅴ段、Ⅵ段、Ⅶ段、Ⅷ段主要属支直径分别为(4.05±1.06)mm、(3.96±0.86)mm、(4.64±1.57)mm、(4.46±1.30)mm,长度分别为(21.51±11.24)mm、(28.94±15.90)mm、(30.14±14.41)mm和(23.03±11.14)mm;Ⅴ、Ⅷ段静脉血液同时汇入RHV和MHV者分别占66.0%、88.0%,Ⅴ段静脉血仅通过MHV回流者占34.0%.直径≥3.00mm的aRHV的出现率为60.0%.结论:RHV引流范围同时受MHV和aRHV影响,主要属支数目不恒定,其右叶上段属支管径较下段粗,右后叶属支较前叶属支长.右叶部分活体肝移植术前应充分掌握右半肝内肝静脉的解剖学资料,以利于制定合理的手术方案.     

成人活体肝移植中小体积供肝问题及处理

得益于前期成功经验及技术的改进,采用右半肝作为移植物的成人间活体肝移植术取得了良好的手术效果.但在将小体积供肝( GBWR ＜0.8)运用于成人间右半供肝活体肝移植术时,小肝综合征仍是导致术后患者死亡、移植失败的重要危险因素.本文旨在通过回顾历史、分析现状、综述文献并结合临床经验,对小体积供肝的安全性进行综述性分析,对于部分经过选择的一般状况良好的受体,植入小体积供肝(0.8 ＞GBWR ＞0.6)可取得良好移植效果.     

活体肝移植肝左静脉的应用解剖

目的:观测肝左静脉的解剖结构,为活体肝移植供肝切取和供肝肝左静脉与受体静脉吻合提供解剖学基础.方法:通过50例成人无病变肝脏剥离解剖,对肝左静脉进行形态学观测,采集相关数据并进行统计分析.结果:肝左静脉(LHV)与肝中静脉(MHV)共干和非共干者分别为80.00%(40/50)和20.00%(10/50);共干血管长度及其近端直径是(5.09±2.78)mm和(12.02±1.91)mm,非共干LHV与MHV开口间距离为(2.00±1.15)mm;LHV肝外段长度为(9.89±4.86)mm;LHV主干(96.00%,48/50)居镰状韧带左侧,成(35.31±16.79)°角;LHV主干长度及其近端直径为(39.1±15.16)mm、(8.44±1.28)mm;LHV的引流段变化较大,依据属支的多少可分5型.结论:LHV多与MHV共干注入IVC,LHV肝外段和外科干长度以及LHV的投影个体差异甚大,活体肝移植前掌握供肝LHV主干及其属支的解剖,有助于设计合理的手术方案.     

活体肝移植肝中静脉的临床解剖研究

目的:为活体肝移植(LDLT)提供有关肝中静脉(MHV)的解剖学资料.方法:通过50例成人无病变肝标本剥离解剖,对MHV主干进行形态学观测,采集相关数据并进行统计分析.结果:MHV与肝左静脉(LHV)共干者为80.0%(40/50),单独开口者为20.0%(10/50),其中前者77.5%(31/40),后者90.0%(9/10)开口于IVC肝后段上份1:00点位;MHV依主干支数可分为三型;MHV主干、肝外段、外科干长分别为(68.3±15.4)mm,(6.9±2.8)mm,(8.1±6.2)mm;主干汇入IVC处(近端)、中点(1/2处)及起始端内径分别为(8.7±1.5)mm,(7.3±1.4)mm.(6.4±1.5)mm;MHV与IVC的夹角为(50.0±9.8)°;MHV主干上壁距IVC汇入口1～4 cm处及起始处至肝膈面的深度分别为(14.9±6.4)mm,(26.4±6.9)mm,(35.3±9.2)mm,(38.8±5.0) mm,(34.5±5.2)mm;MHV主干走行与传统定位肝中裂的"标志线"并非完全一致.结论:MHV汇入IVC的形式以MHV与LHV共干者居多;MHV单独汇入IVC者其开口部位较共干者有相对呈向前的趋势;MHV主干在肝膈面的投影多位于"标志线"的右侧.     

活体肝移植肝右静脉的临床解剖研究

目的:为活体肝移植(LDLT)提供有关肝右静脉(RHV)的形态学资料.方法:利用50例无病变成人尸体肝脏进行剥离解剖,对RHV和副肝静脉进行观察,测量RHV主干及相关数据并进行统计分析.结果:RHV 80.0%(40/50)开口于下腔静脉(IVC)肝后段上份10:00处,其肝外段长(5.8±3.5)mm,外科干长(7.0±5.5)mm,主干长(68.3±30.2)mm,汇入IVC处内径为(10.7±2.4)mm;主干在距IVC 1 cm、2 cm、3 cm、4cm及主干汇合起始处上壁距肝膈面的距离分别为(10.8±5.3)mm、(22.7±7.0)mm、(32.8±8.2)mm、(40.1±7.3)mm、(33.5±9.8)mm;RHV与IVC的夹角为(40.5±9.4)°;根据RHV的引流范围及有无直径≥5.0 mm的副肝右静脉将RHV分为两型,各型再分为两个亚型.直径≥3.0mm和≥5.0mm的副肝右静脉出现率分别为60.0%(30/50)、32.0%(16/50).结论:RHV解剖变异较大,其引流范围受副肝右静脉和肝中静脉的影响,LDLT术前应掌握其结构特点,制定合理的手术方案.     

左外叶下段活体肝移植肝裂的应用解剖

目的；为左外叶下段活体肝脏移植直术提供肝裂的应用解剖学资料。方法：在３０例成人尸肝上观察肝左叶间裂和左外叶段间介和铸型后部分界之间的关系。结果：肝左叶间裂以状韧带为外部分界标志，与内部真正的分界不完全一致，该裂中部向左右偏移可分别达１～２ｃｍ。左外叶段间裂膈面分界９０％偏 上、／４～２／５部，脏面８０％偏前（下）１／３～１／２部，其中５０％偏差２／５～１／２部，左外叶下段膈面较脏面大。结论：左外叶     

肝移植后肝功能的异常

背景：肝移植后导致肝功能异常原因复杂,早期弄清引起肝功能异常的原因对治疗至关重要。 目的：较全面的了解肝移植后可以导致肝功能异常的原因,以便应用于临床诊治。 方法：应用计算机检索CNKI和FMJS数据库,采用医学主题词检索,检索词为“肝移植;肝功能异常;转氨酶异常;胆红素升高;原因”或“liver transplantation; abnormal liver function; transaminase abnormalities; bilirubin increased, and causes”,时间范围为1991年1月至2012年7月,共检索到98篇文章,选择文章主要内容与肝移植后肝功能异常直接相关的、发表在权威杂志上的文章共35篇进行综述。 结果与结论：肝移植后导致肝功能异常的原因众多,临床表现复杂。最常见的原因依次是急性排斥反应、胆道并发症及病毒感染。肝移植后早期,尤其是1个月内出现肝功能异常,需警惕小体积综合征和原发性移植物无功的发生。各种原因引起的肝功能异常,转氨酶及胆红素升高的程度不尽相同。急性排斥反应、自身免疫性肝炎、病毒感染、门静脉及肝静脉狭窄、缺血-再灌注损伤等转氨酶升高较胆红素升高显著;慢性排斥反应、胆道并发症、肝动脉狭窄、原发性胆汁性肝硬化、原发性硬化性胆管炎等早期以梗阻酶碱性磷酸酶、谷氨酰转移酶、总胆红素、直接胆红素升高为主;肿瘤导致的肝功能异常视肿瘤大小、压迫部位不同,可表现出以转氨酶升高为主或以胆红素升高为主。此外,各种原因多有其特殊病史,仔细询问病史有助于早期诊断。临床工作中,应重视尽量详尽的采集病史,根据转氨酶和胆红素升高的具体情况,首先考虑引起肝功能异常的常见原因,经临床证实排除后再考虑其他相对不常见原因,并结合实验室检查、影像学检查及肝脏穿刺病理活检,尽早明确病因及治疗。     

HBV感染对肝移植术后巨细胞病毒感染的影响

目的 探讨肝移植患者移植术前后HBV感染对移植术后巨细胞病毒(CMV)感染及其肝功能的影响.方法 回顾性分析我院近两年来113例肝移植患者临床资料,排除术后1月内死亡、血型不符、失访和并发其他噬肝病毒感染患者,共有102例患者纳入.根据肝移植术前是否感染HBV将患者分为HBV感染组和对照组(非HBV感染);对于感染组患者,又根据移植术后HBV是否复发分为术后复发组和非复发组,采用免疫组化方法 检测CMV被膜抗原pp65水平,时间分辨法检测乙肝病毒抗原和抗体水平,常规方法 检测肝转氨酶水平.结果 HBV感染组(n=83)和对照组(n=19)中,术后pp65阳性率分别为84.3%(70/83)和57.9%(11/19)(P=0.024);HBV感染组中,HBV复发组和非复发组中pp65阳性率分别为90.9%(10/11)和83.3%(60/72)(P=0.843),各组间肝转氨酶水平差异无统计学意义(P0.05).结论 肝移植术前HBV感染可以增加术后CMV病毒血症风险,而肝移植后HBV复发并不增加CMV病毒血症风险;同时,与单一HBV或CMV感染而言,两种病毒联合感染并不明显引起肝转氨酶水平的升高.     

Regulation of hepatic blood flow in patients with liver cirrhosis and after liver transplantation

We studied liver blood flow at rest and its regulatory changes after exercise and food intake in ten patients with advanced liver cirrhosis and in 14 patients more than 10 months after orthotopic liver transplantation. The results were compared with those obtained in ten healthy volunteers. Sorbitol steady state infusion was employed to measure functional liver blood flow (FLBF). Thirty minutes of half-maximal muscular work, performed on a supine position ergometer and consumption of a standard meal were used as stimuli to study regulatory changes in hepatic perfusion. Results: FLBF at rest was reduced in end stage cirrhosis (mean 1257±105 ml/min in cirrhosis vs. 1707±76 ml/min in controls; P<0.01). After liver transplantation FLBF at rest was normalized (mean 1922±169 ml/min) in patients with stable graft function. Muscular exercise led to a reduction in FLBF, which in the transplanted patients was the same range as in normal controls (−26.7±3.7%; −24.7±0.7, respectively), but was reduced in cirrhosis (−19.1±2.1%; P<0.05). After ingestion of a standard meal FLBF increased substantially in normal controls (+40.2±2.3%), while in patients with cirrhosis this increase was rather small (+10.1±1.9%; P<0.001). After transplantation the food-induced increase in FLBF(+20.5±3.6%) was larger than in cirrhosis (P<0.05) but remained smaller than in the controls (P<0.01). We conclude that in cirrhosis FLBF is reduced and adaptive changes after exercise or food intake are impaired. After transplantation FLBF is normalized, but blood flow regulation, especially after food intake remains abnormal.     

Unusually rapid development of a HBsAG-positive liver cirrhosis after liver transplantation

Summary We report the case of a 44-year-old man who was transplanted in 1986 for hepatocellular carcinoma in a HBsAG-positive liver cirrhosis. The patient had no severe complications postoperatively. He received passive immunization for the prevention of hepatitis B reinfection during the first 6 months after liver grafting. Twelve months after the transplantation the new liver was reinfected with hepatitis B virus. Without any clinical or laboratory signs of severe hepatitis, the patient developed a histologically proven complete liver cirrhosis within 8 months after reinfection of the graft. The reasons for this might have been, first, a deleterious course of the infection under immunosuppressive therapy, and, second, the additional influence of a postoperatively acquired CMV infection or the combined toxic influence of cyclosporin A and its metabolites on the acute inflammation in the liver.Abbreviations ALT Alanine aminotransferase (EC No 2.6.1.2) - AST Aspartate aminotransferase (EC No 2.6.1.1) - CMV Cytomegalo virus - EBV Ebstein-Barr virus - ELISA Enzyme linked immunosorbentassay - HBV Hepatitis B virus - HLA Human leukocyte antigen - HSV Herpes simplex virus     

肝移植术后妊娠围生期处理

目的探讨肝移植术后妊娠围生期处理。方法分析我院1例肝移植术后妊娠并成功分娩患者围生期免疫抑制剂使用情况及成功分娩情况,并复习相关文献。结果本例患者行同种异体原位肝移植术后1年8月妊娠,孕期调整免疫抑制剂剂量,移植物功能良好,并成功分娩。结论育龄妇女肝移植术后通过调整免疫抑制剂剂量,监测移植物功能及定期产前检查,防治并发症,可以正常妊娠及分娩。     

肝移植后早期胃肠功能对预后的影响

背景：肝移植患者常合并胃肠功能恢复延迟,可能一定程度影响患者预后。 目的：回顾性分析肝移植后胃肠功能完全恢复时间,探讨其与肝移植患者预后的关系。 方法：收集2006年1月至2011年10月某省两所三级甲等医院符合纳入标准的254例肝移植后患者的病历资料,对肝移植患者后胃肠功能完全恢复时间进行描述性分析。根据恢复时间不同分为< 7 d组、7-14 d组和> 14 d组,对比观察各组患者肝移植后并发症发生率、移植后住院天数及住院费用等。 结果与结论：254例患者肝移植后胃肠功能完全恢复时间< 7 d者142例,7-14 d者90例,>14 d者22例。< 7 d组患者的感染性并发症(肺部、腹腔、切口)、肝移植后2周血清总胆红素水平、住院时间及住院费用最低,7-14 d组次之,>14 d组最高,差异均有显著性意义(P < 0.05);< 7 d组肝移植后2周血清白蛋白水平最高,7-14 d组次之,而>14 d组最低,差异有显著性意义(P < 0.05)。而肝移植后肾功能不全、急性排斥反应等并发症发生率差异无显著性意义(P > 0.05)。结果表明,肝移植后胃肠功能恢复延迟发生概率较高,其延迟患者肝移植后感染相关并发症发生机会升高、住院时间延长、住院费用增加。     

Hepatic reinnervation following orthotopic liver transplantation in man.

We have studied changes in the pattern of intrinsic hepatic innervation in sequential liver biopsies from 16 patients who underwent orthotopic liver transplantation. Seventy-one needle biopsies were used, including specimens obtained at the time of transplantation (time zero) and up to 4 years post-transplantation; five transplant hepatectomy tissue blocks removed 3-32 months after transplantation were also assessed. Paraffin sections were immunostained with anti-PGP 9.5 and anti-S-100 to identify nerve fibres. All 'time zero' biopsies contained portal nerves and all but two showed staining of parenchymal fibres. After 1 week, no subsequent biopsies contained parenchymal fibres. The disappearance of portal fibres was less rapid and showed greater variability between patients, but they had all disappeared by 6 weeks and there was no positive staining between 6 and 60 weeks. Thereafter, a minority of biopsies showed innervation of a few small portal tracts. Samples from the porta hepatis, hepatectomy specimens, and needle biopsies containing large tracts showed persistence of major nerve trunks at all stages. Abnormally large nerve bundles were seen in some of these areas. The pattern of nerve staining showed no obvious relationship to the intensity of rejection changes. Our results suggest that there is a limited, delayed capacity for regeneration of portal, but not parenchymal, fibres in the transplanted human liver. The physiological significance of this long-term parenchymal denervation in transplanted livers remains to be determined.     

CD28 gene polymorphisms and acute cellular rejection after liver transplantation

The co-stimulatory molecule CD28 plays an important role in T-cell-mediated immune response like acute cellular liver transplant rejection. The aim of the retrospective case- control study was to examine whether the single nucleotide polymorphisms (SNPs) rs3116487, rs3116494, and rs3116496 of the CD28 gene are associated with acute cellular liver transplant rejection. The mentioned SNPs were genotyped in 147 liver transplant recipients without acute cellular rejection and 144 liver transplant recipients with acute cellular rejection by real-time endpoint genotyping. The genotype and allele frequencies of the SNPs did not show any significant differences between both groups. Haplotype analyzes of the SNPs also showed no association. Our data suggest that the analyzed SNPs are not major contributors to the susceptibility of acute cellular liver transplant rejection.     

冷缺血损伤后大鼠肝脏移植后肝脏再生的分子机制

目的： 研究不同冷缺血损伤条件下，大鼠肝脏移植后肝脏再生的分子机制。方法: 建立大鼠原位肝移植模型。实验分为: 冷缺血1 h、8 h和16 h组。观察各组的生存率，并在术后90 min、1、2、4和7 d收集标本，观察白介素-6(IL-6)、肿瘤坏死因子（TNF-α）、信号转导激活蛋白3 (STAT3)等表达情况。免疫组化检测细胞周期素D1的表达和肝细胞摄取溴脱氧尿核苷情况。比较实验各组肝脏移植后TNF-α和IL-6的表达水平。分析实验各组移植术后48 h 溴脱氧尿核苷染色阳性的肝细胞数。结果: 冷缺血1 h、8 h和16 h后肝脏移植物的存活率均为100％（>14 d）。移植术后90 min，与冷缺血1 h组相比，冷缺血8 h和16 h组大鼠移植肝内TNF-α等因子表达明显增加（P<0.05）。移植术后90 min，与冷缺血1 h和8 h组相比，16 h组IL-6的表达亦明显增强（P<0.05）。冷缺血8 h和16 h组STAT3活性明显增强。冷缺血8 h组细胞周期素D1在胞浆和细胞核内均有表达。冷缺血16 h组细胞周期素D1仅在核内表达。肝细胞复制活跃。与冷缺血1 h和8 h组相比，冷缺血16 h组术后48 h溴脱氧尿核苷染色阳性的肝细胞计数也明显增多（P<0.05）。结论: 大鼠肝脏移植物经受16 h冷缺血损伤后仍然能够启动，完成肝脏再生，修复组织损伤。大鼠肝脏移植后的肝脏再生可能通过TNF-α/IL-6／STAT3/cyclin D1/DNA合成的途径调节。     

Liver transplantation for acute-on-chronic liver failure from erythropoietic protoporphyria

Erythropoietic protoporphyria (EPP) is an inherited disorder of the heme metabolic pathway that is characterized by accumulation of protoporphyrin in the blood, erythrocytes, and tissues, and cutaneous manifestations of photosensitivity, all resulting from abnormalities in ferrochelatase (FECH) activity due to mutations in the FECH gene. Protoporphyrin is excreted by the liver, and excess protoporphyrin leads to cholelithiasis with obstructive episodes and chronic liver disease, finally progressing to liver cirrhosis. Patients with end-stage EPP-associated liver disease require liver transplantation. We describe here a 31-year-old male patient with EPP who experienced acute-on-chronic liver failure and underwent deceased-donor liver transplantation. Surgical and postoperative care included specific shielding from exposure to ultraviolet radiation to prevent photosensitivity-associated adverse effects. The patient recovered uneventfully and was doing well 24 months after transplantation. Future prevention and treatment of liver disease are discussed in detail.     

左外叶活体肝移植肝静脉的临床应用解剖

目的 :观察肝左叶静脉解剖结构 ,模拟左外叶活体肝移植肝静脉切取方法。方法 :解剖正常人肝脏标本 30具 ,观察肝脏铸型标本 30具 ,测量肝左静脉长度、管径及属支分布情况。结果 :肝左静脉主要由左外叶上段静脉支和下段静脉支汇合并延续而成 ,主要接收或不接收较有意义的属支有左后上缘静脉支和左叶间裂静脉支。结论 :肝左外叶静脉血管解剖变异较多 ,活体取肝前应仔细研究其结构特点 ,设计合理的切取模式 ;移植前肝静脉需行必要的整形 ,以便与受体静脉进行吻合。少数情况下肝左外叶活体移植为禁忌证。