含肝中静脉的成人间右半肝活体肝移植

目的探讨成人间含肝中静脉右半肝活体肝移植的可行性及临床效果。方法回顾性分析我院2007年2~11月完成的30例含肝中静脉的成人活体右半肝移植的资料,观察临床效果。结果右半肝供肝重量为540~1 058 g(中位数708 g),供者残肝体积均大于全肝体积的30%。供、受者围手术期无死亡。供者发生并发症4例(13.3%),受者发生并发症7例(23.3%),均治愈。术后对供、受者随访2~8月(中位数5月),随访期间供者无死亡,1例(3.3%)受者术后4月死于曲霉菌感染。结论含肝中静脉的成人间活体右半肝移植供者是安全的,受者临床效果满意。     

活体右半肝移植肝中静脉取舍选择与供受者的安全性

目的 根据术前CT评估供体残余肝脏比例(RLV%)和评估移植物重量与受者体重比(GRWR),参考肝中静脉解剖情况等因素制定术前肝中静脉(MHV)切取分配方案,研究这种分配方案对活体肝移植供、受体安全的影响,并为今后临床工作提供参考.方法 同一外科小组连续73例活体右半肝肝移植病例按术前肝中静脉分配方案,切取肝中静脉28例,不切取肝中静脉45例.对供受者性别、年龄、体重、手术时间及失血量等基本资料,移植物重量、无肝期、供肝冷保存时间、围术期供受者存活率、小肝综合征发生率以及供受者术后肝功能恢复情况等移植物相关资料进行比较.结果 两组供者术中均未输注血制品,术后均无死亡及小肝综合征发生病例.1例受体术后6 d出现移植肝急性肝坏死转尸体肝移植后痊愈,1例发生小肝综合征保守治疗后痊愈,受者围手术期死亡1例(术后30 d),死亡原因为全身播散性感染并发呼吸功能衰竭旭肝功能已恢复正常.切取MHV组与不切取MHV组之间受者年龄、供体体重小于受体病例所占比例、实际GRWR、移植物重量、移植物冷保存时间、受体术后ALT最高值问差异有统计学意义.结论 这种以术前CT评估供者残肝比例和评估GRWR为分类标准,重点参考MHV解剖因素的MHV取舍方案对供、受者均是安全的.     

副肝右静脉的应用解剖

目的 为活体肝移植(living donor liver transplantation,LDLT)提供副肝右静脉(accessory right hepatic vein,aRHv)的解剖学资料.方法 选取50例无病变成人尸体肝脏标本,解剖aRHV和肝右静脉(right hepatic vein,RHV),观测统计aRHV的出现率、数量、管径、开口部位、引流范围及与RHV的关系.结果 aRHV出现率为96.0%,其中,直径≥13.00mm和直径≥5.00 mm的出现率分别为60.0%和32.0%;aRHV汇入下腔静脉(IVC)肝后段上、中、下份,分别为6.4%、17.0%和76.6%,其管径分别为(4.33±1.10)mm、(5.76±2.52)mm、(4.83±1.34)mm;汇入IVC肝后段下份的aRHV,其开口部位46.8%(22/47)位于8:00～9:00点位之间;引流Ⅵ段、Ⅶ段的aRHV,管径分别为(6.30±2.20)mm和(4.49±1.22)mm;aRHV直径与RHV管径呈负相关(P=0.022,r=-0.410).结论 aRHV出现率较高,以开口于IVC肝后段下份右后侧者居多,汇人IVC肝后段中份的aRHV管径最粗;较细小的aRHV主要引流肝Ⅶ段,而较粗大的aRHV则引流肝Ⅵ段或Ⅵ段和Ⅶ段;当RHV较小时,其出现较粗大aRHV的可能性较大,反之则小,LDLT术前掌握aRHV的解剖特点,有助于制定合理的手术方案.     

应用尸体静脉移植物重建成人右半肝活体肝移植肝静脉

目的:探讨尸体静脉移植物在成人间右半肝活体肝移植肝静脉重建中的应用价值。方法:对我院器官移植研究所2007年6月至2008年1月收治的9例成人间右半肝活体肝移植病例,采用在4℃UW液中保存7 d 以内的尸体静脉移植物重建供肝Ⅴ、Ⅷ段肝静脉粗大属支以及右肝下静脉,回顾分析相关资料,总结处理经验。结果:利用尸体静脉移植物重建肝Ⅴ、Ⅷ段肝静脉以及右肝下静脉流出道的例数占同期实施的成人间活体肝移植的81.8%(9/11),其中架桥重建1支肝静脉6例,架桥重建2支肝静脉2例,架桥重建3支肝静脉1例。9例患者中,1例患者术后14 d死于肾功能衰竭和肺部感染,超声检查血流通畅,未发现架桥静脉血栓,余8例患者术后随访9～15个月,架桥肝静脉累计通畅率为:3个月72.7%(8/11)、6个月54.5%(6/11) 和9个月36.5%(4/11),移植肝脏再生均衡,右肝端面Ⅴ或Ⅷ段无明显充血和肝萎缩坏死,肝功能正常。结论:采用在4℃ UW液中保存7 d以内的尸体静脉移植物重建肝Ⅴ、Ⅷ段肝静脉粗大属支以及右肝下静脉是一种简单、安全和有效的成人间右半肝活体肝移植肝静脉重建方法。     

Early experiences on living donor liver transplantation in China: multicenter report

Background Because of the lack of brain death laws in China, the proportion of cadaveric organ donation is low. Many patients with end-stage liver disease die waiting for a suitable donor. Living donor liver transplantation （LDLT） would reduce the current discrepancy between the number of patients on the transplant waiting list and the number of available organ donors. We describe the early experience of LDLT in the mainland of China based on data from five liver transplant centers. Methods Between January 2001 and October 2003, 45 patients with end-stage liver disease received LDLT at five centers in China. The indication and timing, surgical techniques and complications, nonsurgical issues including rejection, infection, and advantages of LDLT in the series were reviewed. Actuarial patient and graft survival rates were calculated by using the Kaplan-Meier product-limit estimate. Statistical analysis was completed by using SPSS 10.0. Results All LDLT recipients were cirrhotic patients, except for one man with fulminant hepatic failure. Among the 45 cases of LDLT, 35 （77.8%） were performed in one center （the First Affiliated Hospital of Nanjing Medical University）. The overall 1 and 3 year survival rate of the recipients was 93.1% and 92.0%, respectively. Of the 45 LDLT donors, there were 3 cases of biliary leakage, 2 subphrenic collections, 1 fat liquefaction around the incision and 1 biliary peritonitis after T tube removal. All donors recovered completely. Conclusions LDLT provides an excellent approach to addressing the problem of donor shortage in China even though the operation is complicated, uncompromising and difficult with respect to the safety of the donors and receptors. Despite early technical hurdles having been overcome, perfection of technique is still necessarily. At present, LDLT is a good choice for the patients with irreversible liver disease.     

犬活体肝移植的应用解剖学研究

目的 观察家犬肝脏的解剖学特点,为犬活体肝脏移植实验研究奠定基础.方法 健康本地家犬12例,活体和离体进行肝脏解剖学观测.结果 家犬肝脏重量、体积与体重成正相关,根据体重(kg)可较准确估计肝脏重量(g)和体积(cm3),回归方程式分别为:①Y =231.73+ 16.67X,R2=0.87,②Y=56.52+0.91X,R2=0.94;家犬肝脏分为七叶,其中左外侧叶、左中叶和乳状突各占全肝比例分别为(30.02±1.07)％、(15.05±0.59)％和(2.84±0.14)％.结论 犬与人肝脏管道系统大致相近,变异较少见,是建立大动物活体肝移植模型较理想的动物之一.     

Treatment of hepatic venous stenosis by transfemoral venous balloon dilation following living donor liver transplantation: a case report

Hepatic venous stenosis may be a cause of graft failure in living donor liver transplantation (LDLT). Balloon dilation and metallic frame approaches have been used successfully to treat hepatic venous stenosis. Here, we report the effect of transfemoral venous balloon dilation for treating a child with hepatic venous stenosis after LDLT.     

术中超声在活体肝移植术中的应用价值

目的探讨术中超声(IOUS)监测在活体肝移植术(LDLT)中的应用价值。方法在活体肝移植手术过程中,运用IOUS技术(灰阶超声和彩色多普勒血流显像)检查26例供体和受体的肝脏实质及血管状况,观察肝内异常回声的大小、轮廓和血供,纪录肝静脉的解剖信息。手术结束前,对所有重新吻合的血管进行灰阶超声和彩色多普勒血流显像检查。结果经IOUS检查,术中明确1例供体肝内实质性占位;确认13例供肝肝中静脉及5例术前CT发现的直径0.5cm以上的供体副肝静脉;为1例改变术前确定的手术方式提供依据;诊断1例受体肝动脉狭窄。结论在LDLT术中运用IOUS可有效评估移植供、受体肝脏实质和血管解剖状况,对选择最佳肝脏切面具有指导作用,并可为改变手术方式提供一定的参考依据。     

Current status of adult-to-adult living donor liver transplantation: surgical techniques and innovations

In response to critical organ shortage, transplant surgeons have utilized living donors in an attempt to decrease the mortality rate associated with waiting on the liver transplant list. Although the surgical techniques were first utilized clinically 15 years ago, the application of living donor liver transplantation （LDLT） has been somewhat limited by the steep learning curve associated with developing a program. Clinical success with LDLT in children was realized early, but the application of the techniques to adult patients has only occurred more recently. This procedure is now widely applied to adult recipients, with many technical improvements.     

腹腔镜下切取活体供肝技术的实验研究

目的探讨腹腔镜活体供肝切取的技术及可行性。方法运用腹腔镜系统对猪（n=3）进行左肝切取，操作参照人活体肝移植供体要求进行，观察手术过程中供体生命征，总腹腔镜操作时间、左肝管道系统分离时间、肝组织分离时间、供肝温缺血时间及术中出血量，并测量供肝质量参数。结果（1）手术过程中血压、呼吸、心率、血气参数稳定，均较顺利取出活体供肝，出血量较少。（2）切取的供肝左肝动脉长约1．6—1．8cm，左肝门静脉长约0．8—1．0cm，左肝管约0．6—0．8cm，左肝静脉约0．2—0．3cm。经左肝动脉及门静脉灌注良好，温缺血时间为5min；5min；4min。结论从技术层面而言，腹腔镜下猪活体取肝是可行的。     

凝血弹性图在活体肝移植术中应用的研究

目的对成人活体肝移植术中使用凝血弹性图进行凝血功能监测,探讨手术各阶段凝血紊乱的诱因及相应治疗方法。方法 33例行活体肝移植手术患者,于手术开始时(T_1)、无肝期再灌注前5min(T_2)、新肝期再灌注后5min(T_3)及再灌注后60min(T_4)进行肝素酶修正及自然全血凝血弹性图检测。结果 T_1及T_2肝素酶修正组与自然全血组凝血弹性图数值差异无统计学意义(P>0.05)。T_3时自然全血组与肝素酶修正组数据均显示低凝状态且肝素或肝素样物质为主要原因。T_4后肝素造成的凝血异常逐步改善,但较之T_1仍处于低凝状态。结论凝血弹性图对凝血状况的连续监测可以快速准确判断活体肝移植术中不同阶段凝血异常的原因,指导临床针对性治疗,并可评价治疗效果。     

肝移植术后早期死亡的危险因素分析

目的:从肝移植患者术前、术中和术后早期的各项指标中筛选肝移植术后早期（术后至出院）死亡的高危因素,为提高肝移植术后生存率奠定基础。方法：回顾性分析长征医院2001年5月至2005年9月间307例肝移植患者围手术期临床资料,单因素分析术后早期死亡的可能危险因素,对有价值的指标进行多因素Logistic回归分析,筛选确切的高危因素。结果：4例患者因资料不全剔除,303例参与此次回顾性分析。单因素分析结果提示性别、Child分级、肝性脑病、肝肾综合征、早期拔管时间、白细胞计数、术前血红蛋白（Hb）、血尿素氮、血肌酐、凝血酶原时间、血钠、血钾、腹水量、手术时间、术中尿量、大量输血、术中输碳酸氢钠量、吸空气时动脉氧分压（PaO2）、胆红素、术前终末期肝病模型（MELD）评分等20项因子是术后早期死亡危险因素。多因素Logistic回归分析结果显示,女性、低血钠、手术时间长、大量输血（>7 500 ml）、术前高MELD分值等5项因子是肝移植术后早期死亡的独立危险因素。结论：女性、低血钠、手术时间长、大量输血者、术前高MELD评分的患者肝移植术后早期病死率较高,临床应根据患者具体情况采取针对性的措施。     

活体右半肝移植时肝内胆道的解剖变异及临床意义

目的 根据肝内胆道分支的模式描述其解剖变异，并确定每种变异的发生率及临床意义。方法 55例活体肝移植供者，均采用术中胆道造影，根据其右前段和右后段胆道的分支模式，对肝内胆道解剖变异进行分类，并与手术结果相比较。结果 肝内胆道解剖为Ⅰ型的有37例(67.3％)，Ⅱ型的有7例(12.7％)，Ⅲ型有10例(18.2％)，Ⅳ型有1例(1.8％)，Ⅴ型有0例(0％)。Ⅰ型中35例见单一胆道开口形成单一吻合口，2例形成2个胆道开口，经成形后形成1个吻合口；Ⅱ型中5例见2个胆道开口，其中4例形成2个吻合口，1例两个开口成形后形成1个吻合口，2例形成1个胆道开口，1个吻合口；Ⅲ型中9例见2个开口，其中3例经成形后形成1个吻合口；1例见3个开口(包括1支尾状叶胆道开口)，成形后形成2个吻合口。Ⅳ型1例，2个胆道开口，2个胆道吻合口。所有病例都完成活体右半肝切取术。结论 32.7％的病例肝内胆道分支模式是不典型的。最常见的两种变异是Ⅲ型(18.2％)和Ⅱ型(12.7％)。Ⅰ型多能形成单一胆道开口和单一吻合口，最适合活体右半肝移植，其他胆道变异类型常形成多个胆道吻合口，使手术操作相对复杂。术中肝内胆道解剖变异不是活体右半肝移植的手术禁忌证。     

生长抑素对成人活体肝移植围术期肝功能的影响及其可能机制的研究

Background The aim of this study was to investigate the possible effect of somatostatin on the liver function of recipients undergoing living donor liver transplantation.Methods Forty recipients were randomized into group A （n=20） and group B （n=20）. Recipients in group A received no somatostatin whereas somatostatin was administrated for recipients in group B perioperatively. Liver function, the plasma concentration of endothelin-1 and nitric oxide, the intragraft expressions of endothelin-1 and inducible nitric oxide syntheses at 2 hours after declamping of the portal vein were compared between the two groups.Results Compared to group A, alanine transaminase values in group B were significantly reduced at 2 hours after portal vein declamping, at the end of the operation and postoperation day 1 （P 〈0.05）, whereas aspartate aminotransferase values in group B decreased at 30 minutes after portal vein clamping, at 2 hours after portal vein declamping and at the end of the operation （P 〈0.05）. Total bilirubin values in group B were reduced significantly at 2 hours after portal vein declamping and at the end of the operation when compared to group A （P 〈0.05）. Intragraft expression of endothelin-1 was significantly downregulated at 2 hours after declamping of the portal vein accompanied with a reduction of plasma concentration of endothelin-1 in the peripheral blood （P 〈0.05）.Conclusions Somatostatin had a protective effect on liver function during the early phase after declamping of portal vein for recipients undergoing living donor liver transplantation, and the possible mechanism might be partially attributed to the downregulation of endothelin-1.     

彩色多普勒超声在活体供肝肝移植中的应用价值

目的探讨彩色多普勒超声（CDFI）在活体供肝肝移植（LDLT）术前、术中及术后的应用价值。方法回顾性总结和分析了6例LDLT术前、术中及术后的CDFI检查结果。结果术前超声发现1例供者肝动脉过细,1例肝静脉属支过粗;术中超声未发现明显异常;术后受者超声发现l例桥血管栓塞。结论CDFI在LDLT整个肝移植过程中观察血供具有重要价值。     

Outcomes of adult-to-adult living donor liver transplantation: a single center experience

Background Since January 2002, adult-to-adult living donor liver transplantation （AALDLT） has gained increasing popularity in China in response to the shortage of cadaveric donor livers. This study presents a detailed analysis of the outcomes of AALDLT in a single center.
Methods A total of 70 patients underwent AALDLT at our center between January 2002 and January 2007. Among these, 67 patients received a right lobe graft without the middle hepatic vein and 3 patients received dual grafts. Three-dimensional volumetric computed tomography, magnetic resonance imaging with angiography and cholangiography were performed preoperatively. Recipient operation time, intraoperative transfusion requirement, length of intensive care unit stay, length of hospital stay, liver function tests, coagulation tests and surgical outcomes were routinely investigated throughout this study.
Results All donors survived the procedure with an overall complication rate of 15.3%. Overall recipient 1-year survival and complication rates were 87.1% and 34.2%, respectively. Among the 70 cases, average graft recipient weight ratio was 0.94% （0.72%-1.43%） and average graft volume/standard liver volume ratio was 46.42% （31.74%-71.68%）. All residual liver volumes exceeded 35%. Liver function and coagulation recovered rapidly within the first 7 days after transplantation.
Conclusions AALDLT is a safe procedure for the donors and an effective therapy for patients with end-stage liver disease. Patient selection and timely decision-making for transplantation are essential in achieving good outcomes. With accumulation of experience in surgery and clinical management, timely feedback and proper modification, we foresee better outcomes in the future.     

肝移植术后心脏死亡捐献肾行肾移植手术2例并文献复习

目的:加深针对扩大标准供肾的心脏死亡器官捐献(donation after cardiac death, DCD) 肾移植手术供肾质量术前评估以及术中术后管理的认识。方法:2 例供肾均来自于中南大学湘雅二医院器官移植中心同一例行肝移植手术术后5 年的供者。供者因移植肝功能恶化, 依次出现肝昏迷、脑死亡、肝肾综合征和心脏死亡。供肾评分系统(deceaseddonor score, DDS) 以及“零点”双肾肾穿刺活检被用以评估供肾功能, 综合评估后2 例受者接受了肾移植手术。结果:术后随访6 个月, 2 例受者移植肾功能基本正常。2 例受者出现肺部感染, 在给予相应治疗后出院, 未出现急性排斥反应。结论:采用肝移植术后供者DCD 肾移植手术, 术前需对供肾做出详细评估;手术后短期效果满意, 有助于扩大供体池, 远期效果有待进一步观察。     

活体肝脏移植的发展

活体肝脏移植是在尸体肝脏资源面临严重短缺的情况下发展起来的,在某些亚洲国家和地区由于传统观念的影响以及尚未接受脑死亡法,活体肝脏移植几乎是供肝的唯一来源.活体肝脏移植供肝者的选择和评价涉及特殊法律与伦理问题,活体供肝者的安全是第一位的,是活体肝脏移植能否为公众接受的关键.对肝脏解剖生理学的研究表明,成年人供出右半肝后剩下的左半肝完全可以行使正常的肝脏功能,供肝者术后发生死亡是极个别事件,而接受活体肝脏移植的受肝者近远期结果接近甚至优于尸体肝脏移植.我国大陆成人间活体肝脏移植已出现蓬勃发展的局面,移植数量迅速增加,供体的安全性进一步提高,有望在短期内发展成肝脏移植的重要形式.     

粪便细菌移植对肝性脑病大鼠肝功能及血氨的影响

目的 建立大鼠肝性脑病及FMT细菌模型,确定粪便细菌移植对肝性脑病大鼠肝功能及血氨的影响,初步了解粪便细菌移植(fecal microbiota transplantation,FMT)的临床意义.方法 选择32只SD大鼠,采用CCL4+酒精的方法建立大鼠肝性脑病模型及肠道埋管,分为4组(A组:正常对照组;B组:肝性脑病模型组;C组:益生菌组;D组:FMT组),对C组进行益生菌移植,200 μL/d(200 μL益生菌溶液中含益生菌2.7×109),持续2周;对D组进行FMT移植,200 μL/d(200 μL粪便细菌溶液中含粪便细菌2.7×109),持续2周.记录大鼠一般生存情况及大便情况,对移植前后体重进行比较,测定移植前、后肝功能(ALT、AST、ALB、TB及DB)和门静脉及尾静脉血氨.结果 所有实验大鼠均未出现死亡;粪便细菌移植后肝性脑病大鼠体重移植前明显增加[D组移植前(225.18±14.81)g,移植后2周(266.83 ±33.40)g,P＜0.05];移植后大鼠肝功能较前明显好转[移植后2周ALT:D组与B组分别为(610.49±4.98) U/L和(990.07±4.80) U/L,P＜0.05;AST:D组与B组分别为(72.46±4.42)U/L和(101.58±2.19)U/L,P＜0.05;ALB:D组与B组比较ALB明显上升,分别为(24.48 ±0.12) g/L和(17.53 ±0.53) g/L,P＜0.05;TB:D组为(13.45±0.77) μmol/L,B组为(27.20±0.77) μmol/L,P＜0.05;DB:D组为(10.04±0.09) μmol/L,B组为(16.04±0.51) μmol/L,P＜0.05];门静脉及尾静脉血氨较移植前明显降低[D组门静脉及尾静脉血氨分别为(26.26 ±0.30) μmol/L和(23.10 ±0.35) μmol/L,B组分别为(36.28±1.32) μmol/L和(32.90±0.35) μmol/L,P＜0.05].结论 对大鼠进行人体粪便细菌移植是可行的;粪便细菌移植可改善肝性脑病大鼠的肝功能,降低血氨.