活体肝移植不同供肝切取方式对残肝再生的影响

目的 探讨活体肝移植不同方式供肝切取术后供者康复及肝脏再生情况.方法 回顾性分析2006年5月至2011年5月13例活体肝移植供者临床资料.对不同方式供肝切取手术方法、供者术后肝功能指标变化及残肝再生情况进行比较.结果 供者手术分为不包含肝中静脉右半肝切除8例,包含肝中静脉右半肝切除2例,左半肝切除3例.供者肝功能及凝血指标均于术后两周恢复正常,术后未见严重并发症,随访情况良好,无供者死亡.术前CT估算供肝体积与术中实际切取供肝重量呈正相关(r＝0.838,P＜0.01).术后复查CT测残肝体积示:右半肝供者残肝较左半肝供者残肝再生速度快,不带肝中静脉右半肝供者较带肝中静脉右半肝供者残肝再生速度略高,但供者肝脏功能恢复无明显差异.结论 不同术式活体肝移植供者在规范化围手术期处理、精细手术操作后肝功能均能得到较好的康复,而供肝切取术后残肝再生速度则受切取比例、残肝供血情况、细胞因子调控等多因素影响.     

活体肝移植的供肝处理技巧

目的 探讨活体肝移植术供肝的选择，切取和修整，方法 1997至2001年期间，第四军医大学西京医院共完成活体肝移植术3例。其中2例是儿童活体肝移植术，另1例是成人辅助性原位活体肝移植术，供肝切取均为左外叶，供者术中作必要的肝周韧带游离和肝门解剖，超声刀切取供肝，不阻断肝脏血流。结果 供者手术时间为5-6.5h，失血量为200-400ml，无并发症发生。目前所有的供者肝功能均正常。恢复正常的工作和生活。结论 左肝外叶切除对供者是非常安全的。一般无手术并发症发生。     

婴幼儿亲属活体部分供肝肝移植中的供、受者安全性分析

目的 探讨婴幼儿亲属活体部分供肝肝移植中的供、受者的安全性.方法 2006年9月至2009年11月,行婴幼儿亲属活体部分供肝肝移植者8例,受者原发病均为先天性胆道闭锁.供者术前常规行三维CT观察和计算全肝及肝叶(段)体积及形状,磁共振胰胆管造影术(MRCP)了解胆道情况.根据婴幼儿受者腹腔容积切取合适肝叶(段)行肝移植术.受者术后给予抗排斥反应和预防感染等治疗;供者术后给予保肝和抑酸治疗.分析供、受者术前、术中及术后情况.结果 8对供、受者手术均获成功.6例供肝为左外侧叶,1例为S3肝段,1例为减体积S3肝段,供肝重量为(235.9±53.6)g(148～302 g),供肝重量与受者体重比(GW/RW)为(2.65±0.48)%(2.11%～3.36%).对供、受者随访3～40个月(中位数18个月),8例供者均存活,发生并发症2例(25%).8例受者中,死亡1例(12.5%),其他受者发生并发症13例次.结论 术前对供、受者行精确评估,切取合适供肝行肝移植术,术中精细操作,术后精心治疗可最大程度保证供、受者的安全.     

成人间活体肝移植94例报告

目的 探讨成人间活体肝移植供者评估、手术方式的选择及术后并发症分析.方法 收集2007年1月至2010年8月同一外科组施行的94例成人间活体肝移植的临床资料.受者年龄18 ～76岁,供者年龄19 ～60岁.94例活体肝移植手术方案包括:左半肝供肝移植2例,右半肝供肝移植92例,44例切取肝中静脉例,48例不切取肝中静脉.分析供受者术前评估、术后并发症及存活情况.结果 所有供者均恢复良好出院,供者并发症发生率为7.4％.随访截止于2011年5月31日,中位随访时间为37个月,死亡8例.供者1年存活率为95.7％,移植物存活率为94.7％.1例发生小肝综合征;1例因急性肝坏死行再次肝移植;24例(25.5％)经胆道造影或磁共振胰胆管成像检查发现胆道吻合口狭窄,但其中9例(9.6％)表现为肝功能异常.结论 活体肝移植是治疗终末期肝病的有效方法,精确的术前评估、合理手术方式选择,采用左半肝或右半肝供肝、含或不含肝中静脉的活体肝移植,在成人间活体肝移植中均能有效的保证供受者安全.     

腹腔镜辅助活体供者右半肝切取临床应用(附视频)

目的探讨腹腔镜辅助技术在活体肝移植供者右半肝切取中的应用。方法从2011年7月4日至11月1日,四川大学华西医院已完成7例腹腔镜辅助活体肝移植供者右半肝切取(不包括肝中静脉)手术,总结手术方法及其要点。结果 7例供者均未中途转为开放手术。腹腔镜辅助活体供肝切取平均手术时间(6.04±0.36)h,术中平均出血量(150±40)mL。1例供者围手术期出现右侧肋缘下穿刺孔肌肉出血,术后8h予以手术止血成功。余6例供者未发生Clavien-Dindo外科并发症分级二级以上并发症。供者住院费用无明显增加。未观察到腹腔镜辅助手术对移植物的不良影响。结论腹腔镜辅助部分供肝切取明显减少了供者手术创伤,缩短了供者住院时间,值得在活体肝移植供者手术中推广。     

腹腔镜活体肝移植供肝切取技术要点及评价(附12例报告)

目的探讨腹腔镜活体肝移植供肝切取手术的技术要点和应用前景。方法回顾性分析2015年9月至2016年10月四川大学华西医院肝脏肝移植外科12例腹腔镜下活体肝移植供肝切取术病人资料。分析12例供者及相应12例受者的手术及预后情况。结果 12例供者中,切取不包括肝中静脉的右半肝6例,左外叶3例,不包括肝中静脉的左半肝3例。术中失血量400(100~600 mL)。供者住院时间7(4~10 d)。所有供者术后均无并发症发生及围手术期死亡。12例受者术前移植物受体体重比(GRWR)为0.94%(0.54%~3.70%)。手术时间625(405~720 min)。术中失血量750(200~3000)mL。术后住院时间20(7~40)d。1例受者病人术后第7天发生消化道出血,保守治疗后出血停止。1例受者病人术后出现肺部感染,保守治疗后无效于术后第8天因呼吸衰竭死亡。其余受者病人术后顺利出院。结论随着技术的不断发展和器械的不断改进,腹腔镜活体肝移植供肝切取将有广阔的应用前景。     

亲属活体供肝移植治疗儿童终末期肝病六例

目的 探讨亲属活体供肝移植(LDLT)治疗儿童终末期肝病的效果,并总结治疗经验.方法 2005年9月至2007年1月对6例终末期肝病患儿进行了LDLT.6例患者中,原发病为肝内外胆管弥漫性囊性扩张症Ⅳ型伴肝硬化1例、肝豆状核变性2例、门静脉海绵样变性3例;供者为患儿的母亲3例、父亲2例及舅父1例,分别切取供者的右半肝1例和左半肝5例作为供肝;在切除受者全部病肝和保留下腔静脉后,对受者施行部分供肝的原位肝移植.术后依据供、受者的临床表现、血液学指标和影像学检查,对活体供肝移植的治疗效果进行评价.结果 术后对供、受者随访了6～21个月.6例供者均健康存活,未发生并发症.6例受者中,1例于术后第4天死于门静脉血栓形成,1例于术后5个月时死于肝内静脉血栓形成,其余4例均长期健康存活.结论 亲属活体供肝移植是治疗儿童终末期肝病的有效方法.术前进行仔细的供、受者选择和完善的影像学检查,术中应用精确的手术技术,术后给予严格的管理是儿童LDLT成功的关键.     

成人间活体供肝移植中供肝的肝中静脉分配

目的 探讨成人间活体供肝移植中切取供者右半供肝(含或不含肝中静脉)的安全性及临床效果.方法 2007年6月至2008年9月,单小组实施成人间活体供肝切取手术78例;76例行右半供肝移植,其中供肝含肝中静脉30例(含肝中静脉组),不含肝中静脉46例(不含肝中静脉组).对两组供者的基本资料、手术相关资料以及术后肝功能恢复情况进行了评估和比较.结果 CT计算供者残留肝脏体积比为29.40%～50.99%;供肝重量与受者体重的比例(GRWR)为0.74%～1.76%.两组供者(含与不含肝中静脉组)在年龄、体重身高指数(BMI)、手术时间、术中失血量和输注红细胞量、拔除引流管时间、住院时间以及供者存活率方面比较,差异均无统计学意义;含肝中静脉组供者体重小于受者体重所占的比例(75.0%)明显高于不含肝中静脉组(40.0%),差异有统计学意义(P<0.05);含肝中静脉组切取的供肝重量、实际GRWR以及供肝冷保存时间明显低于不含肝中静脉组(P<0.05);两组供者术后肝功能恢复情况比较.差异无统计学意义.结论 供者经过严格的术前评估,切取含或不含肝中静脉的右半供肝均是安全的,临床效果满意.     

多渠道扩大供肝来源——第18届国际肝移植学会年会概述

第18届国际肝移植学会年会于2012年5月16—19日在美国旧金山举行.世界各国的肝移植领域专家与学者就器官移植领域的多个问题进行了深入探讨,本文主要就扩大供肝来源这一议题作简单回顾. 一、安全开展活体肝移植 来自首尔国立大学医学院的SUH指出,由于肝脏脂肪变性非常常见,活体肝移植时肝脏脂肪变性程度的评估非常重要.一项回顾性研究分析了捐献右肝的263例供者结果显示,47例(17.9％)为肝脏脂肪变性≥5％,其中4例(1.5％)肝脏脂肪变性者≥30％中,1例严重非酒精性脂肪肝变性患者(供者)死亡.因此,遵循供者安全是活体肝移植中的最高原则,应将严重非酒精性脂肪性肝炎患者列为供者禁忌[1].另一项研究将供肝切取时肝脏脂肪变性程度分为＜5％组和5～30％组[2].在移植后1年内,两组移植物体积无显著差异,提示轻度脂肪肝不是供肝切取的主要危险因素,肝脏再生能力不会受损.为了更好的匹配供肝重量/受者体重,切取右肝往往作为首选,有研究显示,残肝体积＜35％者和＞35％者的各项并发症发生情况并无显著差异,无供者死亡事件,故研究认为,右肝切除的供者的残肝体积可以＜35％[3].     

全频超声乳化吸引刀在活体肝移植供肝切取中的应用

目的评价全频超声乳化吸引刀在活体肝移植供肝切取中的应用价值。方法62例活体肝移植的供体行右叶切除术。静脉复合麻醉,常规行双侧肋缘下"人"字形切口,游离右侧肝脏,确定切肝线,不阻断入肝血流,采用全频超声乳化吸引刀切离肝脏组织,至右半肝仅留有右肝静脉、门静脉右干和右肝动脉连结。全身肝素化后,依次阻断并切断右肝动脉、门静脉右干、右肝静脉,动脉远端不结扎,移去切取的肝脏进行灌注及修整。结果62例供者手术均顺利,供体手术时间(279±29)min,失血量(210±55)ml,无1例输血,术后住院时间(12.5±3.4)d,住院费用(28822±2846)元。所有供体全部存活。术后发生肝脏断面胆漏者2例,经充分引流1周后治愈;1例供体术后伤口脂肪液化,经换药后治愈。结论在活体肝移植中应用全频超声乳化吸引刀切取供肝,可降低失血及胆漏的发生率,可最大限度地保护供肝和残肝功能,是肝脏横断技术的重大进步。     

Multiple necrotic nodules of the liver simulating liver metastasis

A 70-year-old man was referred to our hospital due to anemia and elevated serum tumor marker levels. He had advanced colon cancer, and hepatic lesions were found incidentally. On ultrasonography (US) and computed tomography (CT), the hepatic lesions had a maximum diameter of 20 mm and were located in Couinaud's segments V, VI, VII, and VIII, which suggested liver metastasis. On early- and late-phase CT during hepatic arteriography (CTHA), all of the lesions had rim enhancement. On early-phase CT during arterioportography (CTAP), all of the lesions were seen as nodules with an irregular perfusion defect, and on late-phase CTAP, all the lesions gradually became iso-dense, and their shape and size changed. Based on the CTAP findings, these lesions were thought to be fibrotic tumors. Partial resection of the liver (including the lesions in Couinaud's segments V and VIII) was done. Histological examination revealed that the lesions were necrotic nodules. Thus, CT angiography (CTHA and CTAP) was useful for identifying necrotic nodules, because their appearance on this modality is different from that of liver metastases.     

Bridging a patient with acute liver failure to liver transplantation by the AMC-bioartificial liver

Recently a phase I clinical trial has been started in Italy to bridge patients with acute liver failure (ALF) to orthotopic liver transplantation (OLT) by the AMC-bioartificial liver (AMC-BAL). The AMC-BAL is charged with 10 x 10(9) viable primary porcine hepatocytes isolated from a specified pathogen-free (SPF) pig. Here we report a patient with ALF due to acute HBV infection. This patient was treated for 35 h by two AMC-BAL treatments and was bridged to OLT. There was improvement of biochemical and clinical parameters during the treatment. No severe adverse events were observed during treatment and follow-up of 15 months after hospital discharge. Possible porcine endogenous retrovirus (PERV) activity could not be detected in the patient's blood or blood cells up to 12 months after treatment.     

Drugs and the liver

The liver is a major organ with multiple functions. A number of drugs are metabolized by the liver during phase 1 and 2 reactions which include complex processes involving cytochrome P450 enzymes. Genetic and acquired variability in cytochrome P450 activity may have profound effects on pharmacokinetics. Additionally, drugs can also modify how the liver functions and cause dysfunction or even failure of the organ both by a direct effect on the liver or by alteration in liver blood flow. It is important to recognize the signs and symptoms of liver failure in patients and identify possible causes including drug interactions. Furthermore, once a patient has been recognized to be suffering with liver dysfunction or failure drug choice and dosing regime will need to be rationalized.Paracetamol overdose can have severe and life threatening consequences for patients due to its effect on liver function. It is the leading cause of acute liver failure in the UK,¹ Correct and early management is crucial and will be discussed within this article.     

Anatomy of the liver

This article highlights the clinically and surgically relevant aspects of the anatomy of the liver. The liver is the largest organ in the human body. It can be divided functionally into eight hepatic segments, each with their own blood supply and bile outflow. Anatomically, however, it is divided into the right, left, caudate, and quadrate lobes. The porta hepatis, effectively the hilum of the liver, receives the hepatic artery, hepatic portal vein, right and left hepatic ducts, as well as lymphatic and autonomic nerves.     

Drugs and the liver

The liver is a major organ with multiple functions. A number of drugs are metabolized by the liver during phase 1 and 2 reactions which include complex processes involving cytochrome P450 enzymes. Genetic and acquired variability in cytochrome P450 activity may have profound effects on pharmacokinetics. Additionally, drugs can also modify how the liver functions and cause dysfunction or even failure of the organ both by a direct effect on the liver or by alteration in liver blood flow. It is important to recognize the signs and symptoms of liver failure in patients and identify possible causes including drug interactions. Furthermore, once a patient has been recognized to be suffering with liver dysfunction or failure drug choice and dosing regime will need to be rationalized.Paracetamol overdose can have severe and life-threatening consequences for patients due to its effect on liver function. It is the leading cause of acute liver failure in the UK,¹ Correct and early management is crucial and will be discussed within this article.     

Drugs and the liver

The liver is a major organ with multiple functions. A number of drugs are metabolized by the liver during phase 1 and 2 reactions which include complex processes involving cytochrome P450 enzymes. Genetic and acquired variability in cytochrome P450 activity may have profound effects on pharmacokinetics. Additionally, drugs can also modify how the liver functions and cause dysfunction or even failure of the organ both by a direct effect on the liver or by alteration in liver blood flow. It is important to recognize the signs and symptoms of liver failure in patients and identify possible causes including drug interactions. Furthermore, once a patient has been recognized to be suffering with liver dysfunction or failure, drug choice and dosing regime will need to be rationalized. Paracetamol overdose can have severe and life-threatening consequences for patients due to its effect on liver function. It is the leading cause of acute liver failure in the UK. Correct and early management is crucial and will be discussed within this article.     

Anatomy of the liver

The liver is the largest organ in the body. Its gross anatomical divisions comprise the right, left, caudate and quadrate lobes, which do not correspond with its functional division into eight hepatic segments, each with their own blood supply and biliary drainage. The porta hepatis transmits the hepatic artery, portal vein and right and left hepatic ducts (the portal triad), together with lymphatic and autonomic nerves. The venous drainage of the liver, directly into the inferior vena cava, comprises the right, left and middle hepatic veins, together with the small accessory hepatic veins.