肝脏移植中脂肪肝供肝的研究进展

目前，肝脏移植作为治疗终末期肝病惟一有效的方法被广泛接受并取得了长足的进展。但供体短缺也越来越成为制约肝移植发展的主要问题。利用脂肪肝(fatty liver，FL)扩大供肝的来源，是移植界一直努力尝试的课题。然而，由于FL作为供肝与移植术后原发性移植肝无功能(primary nonfunction，PNF)及移植肝功能低下的发生明显相关，致使许多供肝在获得后又被抛弃。因此，研究FL作为供肝的可行性，提高移植后的肝功能，避免PNF的发生，是近几年研究的热点之一。     

脂肪沉着供肝在肝脏移植中的应用

目的探讨供肝脂肪浸润程度与肝脏移植病人预后的关系。方法天津市第一中心医院2002年1～12月间供体采用UW液灌注的首次肝脏移植病人71例，根据供肝脂肪浸润程度分为四组，比较各组问术后谷丙转氨酶（ALT）、谷草转氨酶（AST）水平、ICU时间及1年移植物存活率等各项指标。结果轻度脂肪肝组与无脂肪肝组的术后ALT、AST、ICU时间、1年移植物存活率均无显著性差异，中度脂肪肝组的术后ALT、AST、ICU时间均高于轻度及无脂肪肝组，但1年移植物存活率一致，三组均无移植物原发无功（PNF）发生。重度脂肪肝组只有2例，故未作统计学分析，其中1例发生PNF，于术后第2天行再次移植手术。结论轻、中度脂肪肝均可应用于l临床肝移植，对病人预后无影响；重度脂肪肝PNF发生率较高，不宜应用。     

应用次优供肝的肝脏移植：供肝切取技术的影响

D＇Amico F，Vitale A，GringeriE等纳入15例患者采用随机对照试验，检验了供肝切取技术对于次优供体肝脏移植术后结局的影响。他们比较了改良双重灌注（MDP）技术（压脉器夹闭脾静脉和肠系膜静脉的流入血流，经腹主动脉和门静脉冷灌注）和单纯腹主动脉灌注（SAP）技术。该研究表明，当应用MDP技术切除供肝的时候，     

边缘性供肝的研究进展

供肝短缺已成为限制肝移植广泛应用的主要因素.如何扩大供体来源成为目前研究焦点之一.边缘性供肝用于移植有助于改善这一临床困境.然而,边缘性供肝存在术后原发性移植肝无功能、功能低下、迟发型移植物失活及疾病传染等风险.研究边缘性供肝危险因素及预防策略有助于推动肝脏移植的发展.本文总结了近年来边缘性供肝的研究进展.结合本中心的经验,提出边缘性供肝应用于临床有助于改善供体短缺的现状,并强调缺血再灌注损伤是边缘性供肝的核心问题及未来主要研究方向.     

劈离式肝脏移植8例

供肝短缺是肝移植手术的制约因素,虽然活体部分供肝、边缘供体增加了供体池,但都存在一定风险,数量也极其有限。劈离式肝脏移植（splitting liver transplantation,SLT）可一定程度上缓解供受者间的矛盾,尤其儿童供肝短缺问题。     

肝移植中应用边缘供肝的相关研究新进展

供肝短缺是当今制约临床肝移植发展的主要问题。临床上经常遇到脂肪肝供体、高龄供体、乙肝表面抗原阳性供体、冷缺血时限较长等边缘供肝（marginal donor）问题。我们就近年来国外有关边缘供肝在临床肝移植的应用及效果的最新进展做一综述。总体上说边缘供肝可以扩大供肝来源且疗效确切。     

活体肝部分移植术供肝的处理

目的 探讨活体肝移植术供肝的处理方法。方法 以日本京都大学经治的９例活体肝部分移植供者为对象,对供肝的灌洗时机、方法和供肝的修整及保存等方面进行观察。结果 ９例供肝顺利切取,肝切除量平均占全肝的２０％￣２９％,受肝者存活良好。结论 供肝的灌洗时机、方法和供肝的修整及保存都是活体体肝部分移植术中应重视的问题。     

HBcAb阳性移植供肝用于乙型肝炎病毒相关性肝病患者的研究进展

随着肝移植技术的迅速发展,供肝短缺已经成为制约临床肝移植的瓶颈,因此拓展供肝来源成为目前肝移植临床的重点.我国为乙型肝炎大国,如果能够利用乙型肝炎病毒相关联供肝,不但增加供体数量,还能增加患者的生存希望并挽救更多生命.据国外文献报道,采用抗-HBc阳性肝脏不会影响移植物或患者的存活率,但是供体的可靠性值得关注.随着对边缘供肝的研究,将抗-HBc阳性供肝移植给乙型肝炎病毒相关性肝病患者,并且术后应用单一拉米夫定预防治疗,对移植后降低乙型肝炎复发的感染十分重要.抗-HBc阳性供肝应用于乙型肝炎病毒相关性肝病患者为将来拓展供肝标准、基因治疗等前端技术在肝移植中的应用拓展思路.我们采用抗-HBc阳性供肝用于乙型肝炎病毒相关性肝病患者的新进展及术后预防乙型肝炎复发的措施进行综述.     

减体肝脏移植

自从1963年Starzl施行了第一例临床原位肝移植以来．迄今全世界大约已完成50，000余例肝脏移植手术，阻碍肝移植发展的重要因素之一是供体的缺乏．随着对肝段解剖概念的更新．肝脏外科技术的进步及移植科学的发展，临床减体肝脏移植(Reduced-size hepatic transplantation RSHT)应运而生。     

肝脏移植中的肝动脉并发症及其对策

中国的肝脏移植事业在过去10年中取得不菲成绩，在21世纪依然保持蓬勃发展的势头。作为目前治疗肝脏终末期疾病的唯一有效手段，肝脏移植围手术期死亡率已降至5％以下，受体术后1年生存率已超过80％。然而，与国际水准相比，在术后并发症防治方面尚未形成系统化的认识，有待进一步总结经验，从     

大鼠边缘性体积供肝肝移植模型的实验研究

目的通过建立不同体积供肝的大鼠肝移植模型,探索边缘性体积供肝大小的适宜范围,为研究小肝综合征的发病机理及防治措施提供一种易于复制的小动物模型。方法将192只大鼠随机分为全肝移植组、半肝移植组、小体积供肝移植组及超小体积供肝移植组,每组48只,分别建立全肝、半肝、小体积供肝和超小体积供肝的大鼠肝移植模型。移植术后,4组各抽取24只大鼠用于观察存活率;抽取12只大鼠于移植术前,移植术后5、15、30、45及60min测定门静脉压力;另12只大鼠于术后24h测定谷丙转氨酶（ALT）水平。结果全肝移植组的7d累积生存率为100％（24／24）,半肝移植组为87．5％（21／24）,小体积供肝移植组为37．5％（9／24）,超小体积供肝移植组均于术后48h内死亡。全肝移植组术中开放门静脉后,60min内其门静脉压力稳定;半肝移植组大鼠在开放门静脉后,其门脉压力虽有小幅升高,但仍保持相对稳定;而小体积供肝移植组和超小体积供肝移植组开放门静脉后,其门静脉压力均显著升高,15min时均达到高峰,之后该2组的门静脉压力开始回落,至45～60min时逐渐稳定。供肝的体积大小与开放门静脉后5（r=-0．942）、15（r=-0．947）、30（r=-0．900）、45（r=-0．825）和60min（r=-0．705）时的门静脉压力均呈负相关关系（P〈0．001）。肝移植术后24h,全肝移植组和半肝移植组ALT水平均低于小体积供肝移植组及超小体积供肝移植组（P〈0．05）,且小体积供肝移植组ALT水平低于超小体积供肝移植组（P〈0．05）。供肝体积的大小与大鼠移植术后的ALT水平呈负相关关系（r=-0．685,P〈0．001）。结论大鼠部分肝移植模型中,供肝与受体标准肝脏体积比（Gv／sLV）的安全界限为50％,GV／SLV为30％～35％的供肝可视为边缘性体积供肝,小于30％的供肝可视为超小体积供肝。     

Long‐Term Outcomes of Pediatric Living Donor Liver Transplantation in Japan: An Analysis of More Than 2200 Cases Listed in the Registry of the Japanese Liver Transplantation Society

The Japanese Liver Transplantation Society (JLTS) was established in 1980 in order to characterize and follow trends in patient characteristics and graft survival among all liver transplant patients in Japan. This study analyzed the comprehensive factors that may influence the outcomes of pediatric patients who undergo living donor liver transplantation (LDLT) by evaluating the largest cohort in the world. Between November 1989 and December 2010, 2224 pediatric patients underwent LDLT in Japan. There were 998 male (44.9%) and 1226 female donors (55.1%) without donor mortalities related to transplant surgery. There were 946 male (42.5%) and 1278 female (57.5%) recipients with a median age of 4.0 years (range: 13 days to 17.9 years). Cholestatic liver disease was the leading indication for LDLT (n = 1649; 76.2%), followed by metabolic disorders (n = 194; 8.7%), acute liver failure (n = 192; 8.6%) and neoplastic liver disease (n = 66; 3.0%). The 1‐, 5‐, 10‐ and 20‐year patient survival rates were 88.3%, 85.4%, 82.8% and 79.6%, respectively. Blood‐type incompatibility, recipient age, etiology of liver disease and transplant era were found to be significant predictors of overall survival. We are able to achieve satisfactory long‐term pediatric patient survival outcomes in the JLTS series without compromising the living donors.     

活体肝移植小肝综合征的研究进展

目的 探讨在活体肝移植中小肝综合征发生的原因、预防及治疗方法.方法 复习国内、外近几年活体肝移植术后有关小肝综合征的相关报道.结果 供体年龄、脂肪肝程度、受体术前疾病状态(MELD评分)、术后高门静脉灌注、流出道不畅及移植物大小和质量对活体肝移植术后小肝综合征的发生起着重要作用,术前选择最佳的供体,术中的脾脏切除或脾动脉结扎或对门静脉限流,保证流出道的绝对通畅,术后及早发现并积极治疗能显著减少小肝综合征的发生.结论 小肝综合征的危险因素是可以预测的,积极的应对措施可以用于小肝综合征的预防与治疗.     

Intraoperative ‘No Go’ Donor Hepatectomies in Living Donor Liver Transplantation

Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT is employed worldwide, there is little data on rates and causes of ‘no go’ hepatectomies—patients brought to the operating room for possible donor hepatectomy whose procedure was aborted. We performed a single‐center, retrospective review of all patients brought to the operating room for donor hepatectomy between October 2000 and November 2008. Of 257 right lobe donors, the donor operation was aborted in 12 cases (4.7%). The main reasons for stopping the operation were aberrant ductal or vascular anatomy (seven cases), unsuitable liver quality (three cases) or unexpected intraoperative events (two cases). Over the median period of follow‐up of 23 months, there were no long‐term complications of patients with aborted donor procedures. This report focuses exclusively on an important issue: the frequency and causes of no go decisions at a single large volume North American LDLT center. The rate of no go donor hepatectomies should be as low as possible without compromising donor safety—however, even with rigorous preoperative evaluation the rate of donor abortions will be significant. The default surgical position should always be to abort the donor operation if there is an unexpected finding that places the donor at increased risk.     

Selective Use of Older Adults in Right Lobe Living Donor Liver Transplantation

Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor liver transplantation (RLDLT) due to concerns about possible increased morbidity in donors and poorer outcomes in recipients. Since 2000, 130 adult RLDLTs have been performed at our institution. Recipients were divided into those who received a right lobe graft from a donor ≤age 44 (n = 89, 68%; median age 30) and those who received a liver graft from a donor age >44 (n = 41, 32%; mean age 52). The two donor and recipient populations had similar demographic and operative profiles. With a median follow-up of 29 months, the severity and number of complications in older donors were similar to those in younger donors. No living donor died. Older donor allografts had initial allograft dysfunction compared to younger donors. Complication rates were similar among recipients in both groups but there was a higher bile duct stricture rate with older donor grafts (27% vs. 12%; p = 0.04). One-year recipient graft survival was 86% for older donors and 85% for younger donors (p = 0.95). Early experience with the use of selected older adults (>44 years) for RLDLT is encouraging, but may be associated with a higher rate of biliary complications in the recipient.     

异位辅助性分肝移植供肝切取与植入体会

目的　为临床辅助性肝移植的开展,探索供肝切取及植入方法。　方法　猪异位辅助性部分肝移植13例,供肝切取按预分离方法分为A、B两组,A组标准法5例,B组快速灌注法8例。　结果　A组供肝质量优良为100%,B组供肝质量优良占88%。辅肝移植手术时间为122±28min,腔静脉和门静脉吻合时间为40±12min。　结论　如条件允许应首选标准法预分离,血流动力学不稳定时,可行快速灌注法预分离。     

Living Donor Liver Transplantation with Left Liver Graft

Small-for-size syndrome in LDLT is associated with graft exposure to excessive portal perfusion. Prevention of graft overperfusion in LDLT can be achieved through intraoperative modulation of portal graft inflow. We report a successful LDLT utilising the left lobe with a GV/SLV of only 20%. A 43 year-old patient underwent to LDLT at our institution. During the anhepatic phase a porto-systemic shunt utilizing an interposition vein graft anastomosed between the right portal branch and the right hepatic vein was performed. After graft reperfusion splenectomy was also performed. Portal vein pressure, portal vein flow and hepatic artery flow were recorded. A decrease of portal vein pressure and flow was achieved, and the shunt was left in place. The recipient post-operative course was characterized by good graft function. Small-for-size syndrome by graft overperfusion can be successfully prevented by utilizing inflow modulation of the transplanted graft. This strategy can permit the use of left lobe in adult-to-adult living donor liver transplantation.     

成人活体部分肝移植的临床抉择

目的 探讨成人活体部分肝移植中供肝移植物大小与术式的临床抉择。方法 采用文献回顾的方法对活体部分肝移植中供体的评估、供肝大小的判断与选择、切取术式，以及供体安全性等加以综述。结果 供肝移植物大小是影响供体安全性与受体预后的关键因索，临床有带肝中静脉的左半肝移植、含左侧尾叶的扩大左半肝移植、右半肝移植以及带肝中静脉的扩大右半肝移植可供选择，以使供肝与受体标准肝大小之比(GW／ESLW)≥30％，供肝与受体体重之比(GW／BW)≥0.8％。结论 根据GW／ESLW以及GW／BW预测值．结合肝脏解剖特点．选择合理的供肝切除术是具有重要的临床意义。     

成人原位活体部分肝移植4例报告

目的 :报道成人活体部分肝移植的临床经验。方法 :回顾性研究 4例临床资料。结果 :所有病人年龄均大于 18岁 ;2例施行左半肝移植术 ,2例施行右半肝移植术。供体平均手术时间大约 7h ,平均失血量为 40 0ml,无一发生术后并发症。受体平均手术时间是 6 .8h ,移植肝重量介于 34 0 g～ 870g ,移植肝重量与体重的比例介于 0 .80 %～ 0 .91%;1例发生肝动脉部分栓塞 ,3个月后因胆道并发症而再次行原位移植 ,无近期手术死亡率。结论 :无论左半肝还是右半肝移植术 ,均能达到较好疗效 ,为成年病人的肝移植提供了新的供肝来源和选择。     

活体肝移植供体的评估和随访

目的:探讨活体肝移植中供体的评估及随访策略。方法:对30例活体供肝者的临床资料进行回顾分析。结果:供体的总剔除率为28.6%(12/42),病毒性肝炎是最重要的剔除原因(6/12)。供肝重量与受体体重之比(graft鄄recipientweightratio,GRWR)均数为(1.39±0.45)%。所有供体均顺利康复。供体肝功能一般在5～7d内均恢复正常。供体随访时间为1个月～8年,随访时间超过6个月者23例,康复时间为(6±1.5)个月。供肝者残留肝恢复正常体积的时间为6～14个月。术后(8±1.0)个月,86.7%(26/30)的供体恢复术前工作或劳动;30%(9/30)的供体出现过一过性症状,如腹部不适、疼痛等,其中22.2%(2/9)的供体主诉疼痛较严重,需要就医。随访显示,供体均因献肝而赢得社会、朋友的尊重。结论:活体肝移植不仅安全可行,且献肝可能对供、受体的感情、心理、家庭及社交产生良好的、积极的影响。