附加腔静脉成形的背驮式原位肝植术

目的 探讨腔静脉成形术在背驮式原位肝移植中的应用价值及在防止移植肝流出道阻塞并发症中的作用。方法 ３例终末期肝病病人选为肝移植受者。供肝的下腔静脉及受体的肝后下腔静脉（包括肝静脉）均作了成形术,在单独股－腋静脉转流术下行改良背驮式肝移植术。结果 ３例病人术中均较平稳,手术时间和无肝期缩短,出血量减少,术后肝功能恢复快,恢复顺利,无并发症发生。结论 腔静脉成形术可防止背工肝移植肝静脉流出道阻塞,术中     

腔静脉成型术在背驮式肝移植术中的应用

目的推荐和总结在实施背驮式肝移植术中采用腔静脉成型术，以期减少术后肝脏流出道梗阻并发症的发生。方法总结2002年1月至2003年4月所实施的23例背驮式肝移植病人，术中实施受体肝静脉成型后，在腔静脉前壁做等腰三角形成型，与供体肝后腔静脉后壁的等腰三角形成型后对口吻合，以减少肝脏流出道梗阻的经验。结果22例病人术中过程顺利，术后恢复良好，无一例发生肝脏流出道梗阻。1例由于术中切肝时误将受体肝后腔静脉横断而改行原位肝移植，术后恢复良好，未发生流出道梗阻。结论在背驮式肝移植术中采用腔静脉成型技术，可以明显降低肝脏流出道梗阻并发症的发生。同时具有简化切肝过程，降低吻合难度，强化移植肝的稳定性，无肝期短的优点。当供受体之间大小存在明显差异时，或实施儿童的减体积性肝移植时该技术具有明显优势。强调用此法切肝时切忌误伤受体肝后腔静脉。     

背驮式肝移植中肝静脉流出道阻塞的预防

目的　探讨腔静脉成形术在背驮式肝移植中的应用价值及防止移植肝流出道阻塞中的作用。方法　 3位终末期肝病病人的供肝下腔静脉及受体肝后下腔静脉 (包括肝静脉 )均作了成形术 ,在单独股—腋静脉转流术下行改良背驮式肝移植。结果　 3例病人术中均非常平稳 ,手术时间、无肝期缩短 ,出血量减少 ,术后肝功能恢复快 ,康复顺利 ,无并发症发生。结论　腔静脉成形术可防止背驮式肝移植肝静脉流出道阻塞 ,术中对受体血流动力学干扰小 ,缩短无肝期 ,减少并发症发生     

背驮式原位肝移植术

标准的原位肝移植手术，受体的肾静脉以上至横隔以下的腔静脉段，作为肝切除的一部分而被切除。有时，由于静脉侧支循环的建立，该段腔静脉后的分离和随后的止血都极困难。所以，1989年Tzakis等报道了一种保留下腔静脉全长的原位肝移植手术，称为背驮式原位肝移植术（PiggybackorthotopicLiverTransplantation）。此后，学者们对这种术式又进行了某些改良，使得这一技术更趋完善。有人认为，背驮式手术技术是肝移植的最重要发展项目之一。我院于1996年5月至今，已分别对成人和儿童3例患者成功地施行了背驮式原位肝移植术。1手术方法我院3…     

腔静脉成形背驮式肝移植治疗原发性肝癌

目的　探讨腔静脉成形背驮式肝移植治疗原发性肝癌的效果。方法　对32 例乙型肝炎肝硬化、原发性肝癌患者施行腔静脉成形背驮式肝移植,其临床分期,Ⅱa期1 例,Ⅱb期22 例,Ⅲ期9例。术中证实门静脉癌栓11例,胆管癌栓3例,下腔静脉和/或肝静脉癌栓6 例;对于瘤体较大者,术中行射频处理,Ⅲ期患者术中均进行12、8、9、16、13、14 组淋巴结清扫;对于瘤体较大及术后甲胎蛋白处于高水平者进行化疗;术后采用他克莫司及泼尼松预防排斥反应。结果　手术历时(8.5±2.1)h,无肝期(60±25)min,失血量(800±450)ml;术后存活时间超过6个月者30 例(93.8 %),超过12个月者26例(81.3 %),超过18个月者18例(56.3 %),存活时间最长者26个月;Ⅱa、Ⅱb期患者术后无瘤时间平均为11.5个月,存活时间为15 个月;Ⅲ期患者存活8~15 个月;围手术期无患者死亡,未发生与腔静脉成形术相关的流出道梗阻,无因术后出血需手术探查及肾功能衰竭病例。结论　腔静脉成形背驮式肝移植可作为乙型肝炎肝硬化、原发性肝癌的有效治疗手段。     

背驮式原位肝移植术治疗Caroli''s病

目的 总结背驮式原位肝移植技术治疗Caroli's病的经验。方法 回顾性分析2例Caroli's病病人行背驮式原位肝移植手术的临床资料。结果 2例Caroli's病病人背驮式原位肝移植手术获得成功，手术效果好，已分别存活17及18个月，已恢复工作和正常生活，结论 背驮式原位肝移植是目前治疗弥漫的伴反复胆管炎的Caroli's病的有效方法。     

背驮式肝移植术中暂时性门腔静脉分流12例

2003年2月至2004年2月,法国冈城大学医疗中心肝胆外科实施的32例背驮式肝移植中,共有12例术中采用暂时性门腔静脉分流,现将此12例的手术操作及相关情况报告如下。资料与方法12例患者中,男性4例,女性8例,年龄33～67岁,平均56岁。施行肝移植并行辅助门腔静脉分流的原因:8例为肝功能失代偿合并严重门静脉高压症伴广泛侧支循环形成,2     

无肝期阻断下腔静脉对背驮式肝移植的影响

目的 探讨背驮式肝移植无肝期血流阻断方式的不同引起的再灌注损伤差异及无肝期时间的长短对机体的影响。方法 通过大鼠无肝期下腔静脉血流的阻断来建立相关模型,以血液指标的改变做为指标,结合光镜检查结果,了解机体损伤差异。结果 无肝期的延长及下腔静脉阻断可以加剧机体损伤。结论 背驮式肝移植无肝期可以短时间阻断或部分阻断下腔静脉。     

91例肝移植手术方式分析

目的:探讨经典原位肝移植术、改良背驮式肝移植术和原位肝移植腔静脉成形术在临床应用中的利弊。方法:对2001年10月至2003年8月实施的91例肝移植术式进行总结,其中经典原位肝移植术24例(A组),改良背驮式肝移植术43例和改良背驮加术中门鄄腔静脉端侧吻合转流8例(B组),原位肝移植腔静脉成形术16例(C组);91例肝移植手术均未应用体外静脉转流技术。结果:原位肝移植腔静脉成形术的手术时间、无肝期最短(P<0.05),且术中输血量较改良背驮式肝移植术和经典原位肝移植术少(P<0.05)。3组术后ICU留置天数无显著差异(P=0.542)。结论:经典原位肝移植术、改良背驮式肝移植术和原位肝移植腔静脉成形术是肝移植的基本术式;从趋势上看,改良背驮式肝移植术将成为主流术式;对某一个具体病例选择何种术式需根据病情及术中情况决定。     

背驮式原位肝移植流出道梗阻的原因分析及处理(附6例临床报告)

目的探讨背驮式肝移植流出道梗阻的原因及处理方法。方法回顾性分析我中心2002年1月至2003年9月实施的329例肝移植病例，其中经典非转流152例，经典转流31例，改良背驮式146例。6例出现明确的流出道梗阻，对这一并发症的临床表现及处理进行分析。结果这6例病人中，2例表现为急性Budd—Chiari综合征，其中1例剖腹探查，纠正吻合口扭转。另1例因同时伴有严重的肝功能障碍，急诊行二次肝移植；1例CT表现为左外侧叶淤血，未做特殊处理；另外3例手术关腹时血压、中心静脉压下降，右肝后加垫后缓解。结论背驮式肝移植流出道梗阻的发生与腔静脉吻合方式及供肝与受体是否匹配有关；术前详细地评估供受体条件并选择术式，术中及时发现并发症的存在并处理，可减少这一并发症带来的不良后果。     

再次背驮式肝移植并肾移植治疗肝移植术后慢性排斥并肾功能不全(附一例报告)

目的 探讨用原位背驮式肝移植并肾移植术治疗先天性多囊病肝移植术后慢性排斥并肾功能不全。方法 供肝取自同血型脑死亡供体;顺利切除原病肝,行原位再次背驮式新肝植入及右髂窝肾移植。结果 再次背驮式肝移植并肾移植手术成功,供肝,供肾功能良好,术后１８ｄ死于曲霉菌性腹膜炎所致的多器官功能衰竭。结论 背驮式技术适用于再次肝移植;肝移植术后慢性排斥反应并肾功能不全是联合肝肾移植的适应证。     

Novel technique for suprahepatic vena cava reconstruction in rat orthotopic liver transplantation

In previous studies, the suture technique and the cuff method were applied to anastomoses of the suprahepatic vena cava (SHVC) in rat orthotopic liver transplantation. However, the anastomosis of SHVC is difficult during transplantation because of the short length of the SHVC. Here, we developed a novel method for anastomoses of SHVC, using a veno-lined stent technique. The veno-lined stent for SHVC anastomosis was prepared after the donor operation. The special veno-lined stent was a 4.0-mm-long polythene tube in which a venous segment from the donor was lined. During the recipient operation, the donor SHVC was anastomosed end-to-end to the recipient SHVC, using the veno-lined stent. Anastomoses of the portal vein and infrahepatic vena cava were performed using a cuff technique. Continuity of the bile duct was established using a stent. The hepatic artery was ligated, and the graft was not arterialized. As controls, the unlined stent, the suture technique, and the cuff method were also used for SHVC anastomoses, respectively, as three control groups with the identical procedures above. In total, 30 orthotopic liver isografts were performed using the veno-lined stent technique. The survival rate was 90% (27/30) after 1 week and 70% (21/30) after 2 months, with normal hepatocellular function. The SHVC anastomosis using a veno-lined stent took 10 +/- 2 (mean +/- SD) min. The anhepatic phase, recipient operative time, and complete operation time were about 14 +/- 2 min, 40 +/- 5 min, and 120 +/- 10 min, respectively. However, in the nonlined stent control group, a total of 20 orthotopic liver isografts used the nonlined stent for SHVC anastomoses, and all failed because of venous thrombosis in SHVC; none survived over 1 week. In the suture technique control group, 40 orthotopic liver isografts were performed using a suture technique for SHVC anastomoses. The results showed no significant difference with those of the veno-lined stent method. But in the cuff method control group, of all 20 orthotopic liver isografts performed using the cuff method for SHVC anastomoses, 10 failed because of failed ligation on the anastomostic site. The survival rates at 1 week and 2 months postoperatively were significantly different from those of the veno-lined stent method. The veno-lined stent technique provides a novel, simple, and reliable method for SHVC anastomoses. It avoids bleeding during suture and the ligation difficulties found with the cuff method. The operation's success rate is satisfactory. This model is successful, and could be applied in various experimental studies.     

Replacement of the retrohepatic vena cava in segmental liver transplantation

Reduced grafts represent an important technical development in paediatric liver transplantation. The use of a left lateral segment graft has required preservation of the native inferior vena cava to “piggy-back” the graft onto it. We report four children who underwent left lateral segment transplantation with caval replacement using the donor iliac vein because the native retrohepatic inferior vena cava was small, friable or difficult to preserve. There were no caval or hepatic vein complications post-transplant and the donor iliac vein proved to be a satisfactory interpositional graft. The technique offers the advantages of a wider retrohepatic cava avoiding venous outflow or caval obstruction, provides good tissue to suture and is well suited for the triangulation technique of the left hepatic vein. Received: 24 January 1997 Received after revision: 20 June 1997 Accepted: 30 June 1997     

Magnetic ring anastomosis of suprahepatic vena cava: novel technique for liver transplantation in rat

To improve the technique of suprahepatic vena cava (SHVC) reconstruction in rat OLT, novel magnetic rings were designed and manufactured to facilitate reconstruction of SHVC and shorten the anhepatic time. One‐hundred and twenty adult male Wistar rats were randomly divided into two groups: rings group (n = 30), using magnetic rings for SHVC reconstruction; suture group (n = 30), 7/0 prolene suture was used for SHVC running anastomosis as control. Cuff techniques were used for portal vein and infrahepatic vena cava reconstruction as Kamada and Calne described. The bile duct was reconnected with a stent. The hepatic re‐arterialization was omitted. In the rings group, the SHVC reconstruction took 0.91 ± 0.24 (mean ± SD) min; the anhepatic phase and the recipient operation time were 5.63 ± 0.65 min and 36.02 ± 8.02 min, respectively. In suture group, the anastomotic time of SHVC was 10.40 ± 2.11 min; the anhepatic phase and the recipient operation time were 17.76 ± 2.51 and 49.38 ± 12.06 min, respectively, and there was statistically significant difference between the two groups. The ALT levels reached peak at 24 h post‐OLT (186.2 ± 32.5 IU/l) and restored to normal level at 96 h gradually. In the rings group, 29 of 30 rats survived at day 7 and 28 of 30 rats survived at day 30. In contrast, only 25 of 30 recipients in suture group remained alive at day 7 and 22 of 30 remained alive at day 30 (P < 0.05). Better anastomotic healing was founded in rings group by pathology and scanning electron microscope. The magnetic rings technique provides a novel, simple method for SHVC reconstruction of OLT in rat. It significantly shortens anhepatic phase, while the success rate of the operation is satisfactory.     

乌司他丁对腔静脉成形肝移植术肾功能的保护作用

目的观察腔静脉成形肝移植术患者肾功能的变化与乌司他丁对肾功能的保护作用。方法71例腔静脉成形肝移植术患者,随机给予乌司他丁30万IU或等量生理盐水,持续静脉输注1h,新肝期再重复一次。根据腔静脉平均阻断时间分成≤62min组,其中用乌司他丁23例(U1组)、生理盐水18例(C1组);>62min组,其中用乌司他丁13例(U2组)、生理盐水17例(C2组)。监测血流动力学、血气、生化指标、肾功能指标、凝血功能、体温、尿量及出血量等。结果下腔静脉阻断(IVC)时间为(62.3±11.2)min。与术前相比,所有患者术后24h血尿素氮(BUN)明显升高(P<0.01),血肌酐(Cr)在新肝期1h、术毕、术后24h均明显升高(P<0.01)。术后24hBUN、CrU1组明显低于C1组(P<0.01),U2组亦明显低于C2组(P<0.01)。而U1与U2组、C1与C2组BUN、Cr差异无统计学意义。结论腔静脉成形术肝移植术对肾功能有明显损伤,术中使用乌司他丁对肾脏有一定程度的保护作用。     

Standardized quick en bloc technique for procurement of cadaveric liver grafts for pediatric liver transplantation

This paper describes a quick procedure for cadaveric liver graft retrieval during multiple organ harvesting. The technique is based on minimal preliminary dissection, absence of in situ direct portal perfusion, and en bloc removal of the liver and pancreas, with an aortic patch encompassing the coeliac trunk and superior mesenteric artery. The results of 110 pediatric liver transplantations with 109 organs harvested using this technique are reported. There were no graft harvesting injuries. The liver graft primary nonfunction rate was 4.5% (5/110). The 3-month retransplantation rate was 10%. The actual patient survival rates were 93% at 3 months and 90% at 1 year; actual graft survival rates were 85.5% and 78%, respectively. The technique described was at least as safe as conventional procedures. A major advantage of the procedure is its flexibility, which allows for the easily combined procurement of other organs (whole pancreas and intestine).     

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目的 总结背驮式肝移植时病肝切除及肝流出道重建的经验。方法 回顾性分析1999年1月至2002年10月行67例背驮式肝移植时病肝切除及肝流出道重建的方法改进及效果。结果 肝移植病例围手术期死亡7例，手术死亡率为10.45％。2例存活超过3年，8例存活超过2年，19例存活超过1年。结论 病肝切除及肝流出道重建方法的改进有利于提高背驮式肝移植的成功率、减少技术性并发症。     

背驮式肝移植可视化仿真手术的研究

目的 研究三维可视化仿真手术技术在背驮式肝移植中的应用价值.方法 利用2例胆总管结石患者的肝脏64排CT扫描数据,对CT图像进行分割,三维重建.重建出的肝脏及其管道模型分别以STL格式导入FreeForm Modeling System进行修饰和平滑.利用系统的力反馈设备,进行背驮式肝移植手术的仿真研究.结果 重建的肝脏模型形态逼真,立体感强;手术模拟过程真实、形象,且有"力"的感受.结论 可视化的肝脏重建模型立体、逼真,有利于肝移植手术方案的合理设计,降低手术风险及减少手术并发症;虚拟肝移植手术有利于医务人员的培训和学习.     

改良二袖套法大鼠原位肝移植180例

目的改进二袖套法大鼠原位肝移植方法,建立稳定的大鼠肝移植模型。方法采用改良Kamada二袖套法进行大鼠原位肝移植180例,观察手术成功率、手术时间、免疫病理改变和术中、术后并发症等。结果总手术成功率85.6%,供者手术时间(40.0±3.8)min,修肝时间(14.3±2.1)min,受者手术时间(48.0±4.2)min,无肝期(22.0±2.3)min。SD-Wistar大鼠肝移植后出现免疫排斥病理改变。常见并发症有麻醉意外、气胸、失血性休克、下腔静脉空气栓塞、血栓形成或胆道梗阻等。结论改良Kamada二袖套法可提高手术成功率,减少并发症。SD-Wistar大鼠肝移植为高排斥组合,可作为肝移植免疫耐受研究的模型。