供肝切取与保存技术中几个关键环节的探讨

目的 探讨提高和完善供肝切取与保存技术，提高器官利用率，减少肝移植术后近、远期并发症的发生。方法 1995年5月至2005年6月我院实施了122例原位肝移植，采用腹腔器官联合快速切取技术进行了165例供肝和供肾联合切取，先行经肠系膜上静脉至门静脉插管，随即行腹主动脉插管，UW液原位灌洗。灌洗开始后优先处理胆道，用UW液经胆总管冲洗胆道。整块切取肝脏、双侧肾脏。回手术室进一步修剪，对变异的肝动脉（25例，20．5％）整形使之变为单支。结果 165例供肝热缺血时间120～310s，冷缺血时间260～840min。移植肝通血20～30min后均有金黄色胆汁分泌。术后均未发生原发性无功能和器官功能延迟。结论 对于脑死亡的供者器官切取采取原位灌洗，整块切取及体外修整，可最大限度地缩短热缺血时间，有效避免变异血管损伤，进而提高供者器官的利用率。确切的胆道冲洗对避免肝内外胆管自溶和术后胆道狭窄非常重要。良好的供肝切取与保存是移植成功的保证，可有效地减少手术并发症，进而取得良好的疗效。     

肝移植中供肝切取的体会

我院移植外科 1994年 5月至 1998年 11月为 6例肝硬化患者实施了原位肝移植手术并获得成功。我们设计的供肝切取 ,修整 ,保存方法 ,在实际应用中取得满意的效果 ,为 6例肝移植手术的成功提供了可靠的保证。一、供肝切取与灌注1.切口 :取腹部正中及双肋缘下十字切口。纵切口过脐 ,肋缘下切口达腋中线。为节省时间切口可由术者和助手同时完成。2 .门静脉插管灌注 :术者直接于肝十二指肠韧带处暴露门静脉 ,在助手帮助下完成门静脉插管灌注。注意在解剖门静脉时 ,术者以左手经网膜孔将肝十二指肠韧带翻转即可显露门静脉 ,尽量不要横断肝十二指肠…     

供肝切取与保存技术中几个关键环节的探讨

目的探讨提高和完善供肝切取与保存技术,提高器官利用率,减少肝移植术后近、远期并发症的发生。方法1995年5月至2005年6月我院实施了122例原位肝移植,采用腹腔器官联合快速切取技术进行了165例供肝和供肾联合切取,先行经肠系膜上静脉至门静脉插管,随即行腹主动脉插管,UW液原位灌洗。灌洗开始后优先处理胆道,用UW液经胆总管冲洗胆道。整块切取肝脏、双侧肾脏。回手术室进一步修剪,对变异的肝动脉(25例,20.5%)整形使之变为单支。结果165例供肝热缺血时间120~310 s,冷缺血时间260~840 min。移植肝通血20~30 min后均有金黄色胆汁分泌。术后均未发生原发性无功能和器官功能延迟。结论对于脑死亡的供者器官切取采取原位灌洗,整块切取及体外修整,可最大限度地缩短热缺血时间,有效避免变异血管损伤,进而提高供者器官的利用率。确切的胆道冲洗对避免肝内外胆管自溶和术后胆道狭窄非常重要。良好的供肝切取与保存是移植成功的保证,可有效地减少手术并发症,进而取得良好的疗效。     

肝移植供肝切取技术及供肝的选择

作在法国参加23例供肝切取手术,对供肝的灌注,切取,修剪,保存等方面进行了观察。本组行全肝肝移植20例,劈离式肝移植2例,减体积肝移植1例,供肝全部存活,肝移植后供肝的质量与供体死亡前肝脏本身的质量,供体血液动力学情况,复苏情况,供肝切取技术,保存技术（保存液,时间,温度）以及受体高质量的血管吻合等因素有关,其中任何一步出现差错,将都严重影响供肝的功能。     

快速供肝切取与修整的外科技巧

目的总结肝脏移植供肝的快速切取和修整经验。方法分析2004年共186例快速供肝的切取和修整的资料。快速切取技术采用原位腹主动脉、肠系膜上静脉灌注附加下腔静脉引流，快速切取供肝，4℃UW液中保存和修整肝脏。结果供肝热缺血时间为3～10min，平均4．5min；冷缺血时间平均为3-16h，平均7h。供肝的修整时间为26～90min，平均46min。供肝修整时发现肝动脉解剖变异20例。结论快速供肝切取法要求术者技术娴熟、动作迅速和准确，可最大限度地减少供肝热缺血时间。快速切取法能保证供肝的质量和确保供肝切取的成功。     

临床活体肝部分移植供肝切取术

自１９８９年７月Ｓｔｒｏｎｇ等〔１〕成功开展首例活体肝移植以来，这一手术有了迅猛的发展，至今总例数已近１０００例。由于该术式供肝来自健康人，对供体手术的安全性有极其严格的要求，初期曾有人预言，供肝切取术至少有１％～２％的死亡率，但几年来事实表明，至今...     

原位肝移植供肝切取与修整技术的探讨

我院自 1999年 7月～ 2 0 0 1年 10月为 2 8例患者施行了原位肝移植术。我们体会在肝移植术全过程中 ,供肝的切取、保存、修整技术对于移植术后移植肝的存活、功能的恢复及术中术后并发症的发生有至关重要的影响。现结合 2 8例原位肝移植术的供肝切取及修整技术报告如下。一、临床资料2 8例供体均为男性脑死亡患者 ,年龄 2 3～ 4 0岁 ,采用经腹主动脉灌注 0～4℃肾保存液 (高渗枸橼酸盐嘌呤液 ,上海市血液中心生产 ) 2 0 0 0ｍｌ,经门静脉灌注 0～ 4℃ＵＷ液 2 0 0 0ｍｌ,肝脏离体后继续灌注ＵＷ液 2 0 0 0ｍｌ的肝肾联合快速切取法。供肝的…     

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。     

活体肝移植的供肝切取手术40例临床分析

目的：探讨活体肝移植的供肝切取技术,方法：在1993年9月至1999年6月期间,香港大学玛丽医院共作活体肝移植40例,供肝切取包括：左外侧叶14例,左半有6例,右半肝20例,术中首先行肝门解剖,肝叶游离,然后用超声刀切取供肝、术中不阻断肝血流。切取肝左外侧叶和左半肝时切面分别靠近镰状韧带的右侧和中肝静脉的右侧,切取右半肝的切面靠近中肝静脉的左则。结果：切取供体手术时间为7．2-15.5h平均11．0h,供体手术的平均失血量为723ml(200ml-2600ml）。7例供体发生了术后并发症,包括切口感染,切口疝,右肺上叶不张,右膈下积液,粘连性肠梗阻,术后高胆红素血症及胆管狭窄各1例,经治疗后均痊愈。目前所有的从体肝功能均正常,完全恢复体力,恢复原来的工作,结论：极度仔细及精良的供肝切取技术是安全的,在尸肝缺乏时活体肝脏切取技术可为肝移植提供优质的供肝。     

活体右半肝供肝切取的经验

目的对活体右半肝供肝切取手术经验进行总结。方法回顾性分析我中心单一外科小组2007年8月至2008年12月期间连续实施右半肝切取的76例供者资料。术前综合考虑移植物大小、残肝比例、有无脂肪肝、肝中静脉类型及受体术前门静脉高压情况,以确定是否带肝中静脉。术中以缺血线确定肝切平面,以术中B超了解肝中静脉的走向及分支,肝切线在肝中静脉左或右侧紧贴肝中静脉。行术中胆道造影,了解胆道结构及变异。记录手术时间,术中失血量,术后住院时间,术后住院期间总胆红素、国际标准化比值(INR)和ALT水平变化情况以及术后各种并发症发生情况。结果 76例供体均顺利完成手术,手术时间(8.3±1.3)h,术中失血量(325±127)ml,术中均未输血。总胆红素、INR和ALT水平于术后第12天恢复正常。本组供体术后住院期间最常见并发症是伤口感染(共5例),胆汁郁积4例,断面漏胆4例;11例患者于术后4～7d出现不同程度的胃排空障碍;均经相应处理后好转。术后住院9～21d,中位时间14d。结论充分的术前评估以及精准的术中操作能够保证供肝的顺利切取并有利于供体的术后恢复。     

肝移植中转基因技术应用的研究进展

1转基因技术在供肝缺血再灌注损伤中的作用 缺血再灌注损伤是供肝早期功能损害甚至失活的一个重要原因。将表达过氧化物岐化酶的基因转入供肝，清除氧自由基，可以减轻缺血再灌注损伤。用腺病毒载体，使小鼠供肝表达线粒体过氧化物酶，可明显减轻肝细胞缺血再灌注损伤。这与抑制氧化还原反应，激活NFkb和AP1转录因子有关。Amersi等将血红素加氧酶-1（HO-1）转入遗传性肥胖的Zucker大鼠，能减轻冷保存供肝缺血再灌注损伤，存活率由对照组的40％提高到80％。     

不同冷保存时间的热缺血供肝在肝移植中的疗效

目的 探讨不同冷保存时间的热缺血供肝在肝移植中的疗效.方法 回顾性分析2006年1月至2007年12月中山大学附属第一医院收治的154例肝移植受者采用热缺血时间≤10 min的无心跳供者肝脏进行肝移植的疗效.根据冷保存时间将患者分为3组:<8 h为Ⅰ组,58例;8～12 h为Ⅱ组,62例;>12 h为Ⅲ组,34例.采用方差分析、t检验和X~2检验分析3组肝移植术后ALT峰值、并发症、移植肝存活和受者生存情况的差异.结果 3组受者术后均未发生原发性移植肝无功能.随访时间8～32个月,Ⅰ组受者的ALT峰值、感染发生率、胆道并发症发生率、移植肝存活率和生存率分别为(482±357)U/L、12%(7/58)、12%(7/58)、86%(50/58)和88%(51/58),Ⅲ组受者分别为(1274±608)U/L、29%(10/34)、26%(9/34)、68%(23/34)和71%(24/34),两组比较差异有统计学意义(t=5.X~2=4.28,6.77,4.51,4.28,P<0.05);而Ⅱ组受者仅ALT峰值达到(953±424)U/L,与Ⅰ组比较差异有统计学意义(t=4.76,P<0.05).结论 热缺血时间≤10 min的供肝能够耐受12 h的冷保存损伤,超过此时限,移植术后胆道并发症和感染的发生率显著升高,移植肝存活率和受者生存率显著降低.     

Comparison of UW solution and Euro-Collins solutions for cold preservation of human liver grafts

University of Wisconsin solution, a new organ preservation medium, is reported to extend the period of cold storage. In order to evaluate the efficacy of UW solution in human liver preservation we compared 58 donor liver grafts preserved in Euro-Collins (EC) solution. All livers were harvested in a similar manner. Donor and recipient characteristics in the two groups were comparable. The mean preservation time of the UW solution was 11.5 +/- 4.2 hr (range 3-20 hr), significantly longer than the EC mean preservation time of 4.9 +/- 1.6 hr (2-9.6 hr) (P = 0.0001). Evaluation of mean postoperative liver function tests and coagulation factors on days 1-7 showed no statistical difference between the two groups. There was one primary graft nonfunction in the EC group and none with the UW organs. Hepatic artery thrombosis was similar in each group. The incidence of early retransplantation was similar. Three-month graft survival was 81% in the UW group vs. 73% in the EC group. Patient survival at three months was 87% with the UW organs and 84% with the EC organs. We conclude that cold storage of liver grafts in the UW solution has allowed for significantly longer preservation, permitting transplantation to be performed under semielective conditions and procurement of organs from much further distances. Grafts stored in UW solution perform as well as those stored in Euro-Collins, with no significant difference in liver function abnormalities postoperatively.     

Predictive value of liver tissue flow in assessment of the viability of liver grafts after extended preservation in pigs

The crucial damage in cold storage of liver allografts is to the hepatic sinusoidal lining (microcirculation). Using different solutions, we studied whether determinations of graft tissue flow were valuable in estimating the viability of liver grafts. Twenty-three pairs of female pigs underwent orthotopic liver transplantation and were assigned to five groups according to the cold preservation time or solutions used: in group I the liver grafts were stored in Euro-Collins solution (EC) for 4 h (n = 3), in group II the grafts were stored in EC for 12 h (n = 5), in group HI the donor was pretreated with azathioprine (AZA), 1 mg/kg per day, orally (PO) for 3 days before harvesting and the graft was implanted after 12 h cold storage with EC (n = 6), in group IV the graft was stored in modified University of Wisconsin solution (mUW) for 4 h (n = 3), and in group V the graft was stored in mUW for 24 h (n = 6). Liver tissue blood flow (LTBF) was measured, using a laser doppler device, at 60 min after recirculation of the graft. In the case of EC preservation, LTBF (ml/100 g of liver tissue per min) correlated well with 4-day survival: 21.2 ± 3.0 ml/100 g of tissue per min mean ± SD, in group I (3/3, 100%); 10.0 ± 2.8 ml/100 g of tissue per min in group II (0/5, 0%); and 19.1 ± 3.4 m1/100 g of tissue per min in group III (5/6, 83.3%) (P < 0.05, group II vs I and III). All grafts with LTBF of more than 15 ml/100 g tissue per min functioned well. However, changes in microcirculation of the mUW-stored livers did not correlate with early function of the graft: 23.0 ± 2.3 m1/100 g of tissue per min in group IV (4-day survival; 3 of 3, 100%) and 23.5 ± 9.1 m1/100 g of tissue per min in group V (0 of 6, 0%). This was accompanied by graft dehydration during storage and an increased number of erythrocytes in the hepatic sinusoids post-recirculation. We concluded that assessment of liver tissue flow by LDF was very helpful and easy to apply in predicting liver graft failure in the case of preservation with Euro-Collins solution. However, LTBF should be carefully evaluated as a marker of liver graft viability when the liver graft is preserved with mUW.     

Influence of preservation solution on the isolation and culture of human hepatocytes from liver grafts

A major problem for the isolation and transplantation of hepatocytes is the lack of resources for obtaining viable hepatocytes. Improving this situation would enhance hepatic cell transplantation programs. Our objective was to evaluate the influence of the preservation solutions used during organ retrieval on the quality of hepatocytes isolated from liver tissue. We compared the results of the collagenase perfusion technique for isolation of hepatocytes in human livers flushed with University of Wisconsin (UW) and Celsior preservation solutions. Yield (number of viable cells per gram of tissue), cellular viability, efficiency of cells to attach to culture plates and form a monolayer, and drug metabolizing competence of the hepatocytes were measured. Successful isolation was achieved in 63% of the procedures using the UW solution and 100% of the procedures using the Celsior solution. In the UW group, significantly lower cell viability (38 +/- 41% vs. 79 +/- 14%, p < 0.05), yield of cells (4.0 +/- 5.2 x 10(6) vs. 8.2 +/- 5.6 x 10(6) cells/g, p < 0.05), and protein content at 24 h of culture (0.6 +/- 0.6 vs. 1.2 +/- 0.3 mg protein per plate, p < 0.05) than in Celsior solution were found. However, similar values of P450 activities were found in both groups. The more successful isolation, better yield, and higher cell viability obtained from human liver grafts preserved in Celsior solution, in comparison to UW solution, suggest Celsior solution as the most appropriate for preserving cadaveric hepatic tissue to be used for hepatocyte harvesting.