肝移植患者术中凝血功能的变化及影响因素

目的:探讨不同肝移植术式术中凝血功能变化的规律及相关的影响因素.方法:将2006-06/2007-05我院15例亲体肝移植患者及29例原位肝移植患者,分为肝癌组,肝硬化和急性肝衰组.综合评估患者术前状态,于患者术前及术中(无肝前期、无肝期、再灌注期30 min、再灌注期1 h)检测凝血酶原时间(PT)、活化的部分凝血酶原时间(APTT)、国际标准化比值(INR)、纤维蛋白原(FIB)、血小板计数(PLT)、血红蛋白量(HB)、白蛋白(ALB)及CO_2结合力(TCO_2),观察不同肝移植术式术中各组患者凝血功能及酸碱失衡的变化规律及特点,分析术前和术中可能存在的影响因素及与凝血功能的相关性.结果:肝硬化患者组术前凝血状态介于肝癌组与急性肝衰组之间.术前PLT明显减少,与其他两组相比差异显著(P<0.05).无肝期各项指标进一步恶化.再灌注30 min PT,APTT,INR值达到峰值,FIB水平于无肝期达到最低点(亲体移植:0.68±0.17 g/L vs 0.93±0.37 g/L,0.77±0.19 g/L,0.83±0.27 g/L,0.72±0.31 g/L;原位肝移植:0.65±0.14 g/L vs 0.89±0.10 g/L,0.71±0.26 g/L,0.69±0.16 g/L,0.70±0.23 g/L,P<0.05).肝癌组各指标术前基本正常,术中变化幅度均较前两组小(P<0.05).急性肝衰组患者术前PT、APTT、INR延长最为显著,凝血状态最差(P<0.05),但术中恢复较快.除无肝期外,FIB较其他两组明显减少(P<0.05).应用Pearson相关分析术中出血量与围手术期因素的相关关系,发现MELD评分与术中出血量具有相关性(r=0.619,P<0.05).与原位肝移植相比,亲体肝移植术中凝血功能及代谢紊乱的变化较大,尤以无肝前期及无肝期恶化明显.再灌注后各项凝血指标恢复迅速(P<0.05).结论:应根据具体情况个性化治疗肝移植患者.     

肝移植术中凝血功能的监测及处理

2001～2004年,我们对23例肝移植手术患者手术期间的凝血及血小板功能进行了监测。现报告如下。     

原位肝移植术中凝血弹性图与凝血时间的相关性

凝血弹性图(TEG)能及时、准确、动态地反映肝移植术中不同时期的凝血状况，指导血制品的输注及各种治疗药物(如鱼精蛋白、6—氨基己酸等)的应用。本研究试图探讨19例肝移植术中TEG的变化以及与激活的全血凝块形成时间(ACT)的相关性。     

活体肝移植术患者围术期凝血功能变化

目的探讨活体肝移植术围术期患者凝血功能变化规律和影响因素。方法 24例肝移植受者于静吸复合全麻下行活体部分肝移植术。分别于麻醉后术前（T0）、手术60 min（T1）、无肝期30 min（T2）、新肝期15 min（T3）、新肝期120 min（T4）、术毕（T5）、术后24 h（T6）采集中心静脉血检测PT、APTT、TT、血小板计数（PLT）、纤维蛋白原浓度（FIB）、D-二聚体、血清钙离子浓度（Ca2＋）,同时应用Sonoclot凝血和血小板功能分析仪测定激活全血凝固时间（ACT）、凝血速率（CR）和血小板功能（PF）。结果 PT、ACT于T2～T5时,APTT、TT、D-二聚体于T3～T5时均显著升高（P〈0.05或P〈0.01）;FIB、CR、PF、Ca2＋于T2～T5时、PLT于T4～T5时均明显下降（P〈0.05或P〈0.01）。结论活体肝移植术从无肝期开始出现凝血功能紊乱,新肝初期加重,术后24 h逐渐恢复至术前水平。凝血因子消耗、纤溶亢进、血小板功能下降是凝血功能障碍的主要因素。     

急诊肝移植围手术期凝血功能的调整

回顾分析7例急诊肝移植患者围手术期凝血功能的调整方法，旨在提高急诊肝移植围手术期的管理水平，现报道如下。     

原位肝移植围手术期凝血功能分析95例

目的:探讨原位肝移植围手术期凝血功能的变化规律以及各凝血指标对于原位肝移植围手术期凝血功能测定的敏感性.方法:2004-01/2006-11于我院行同种异体肝移植术患者95例.分别测定肝移植术前、术中(无肝前期、无肝期及新肝期)及术后24、72h的凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)、纤维蛋白原(Fib)、血小板计数(PLT),并描记Sonoclot曲线.用SPSS10.0进行自身配对样本T检验统计学分析.结果:随肝移植手术进行,凝血功能逐渐恶化:PT、APTT逐渐延长,PLT、Fib逐渐减少.至新肝期逐渐达到高峰,以后除PLT外均逐渐好转,术后72 h基本恢复至术前水平.Sonoclot曲线体现:激活全血凝固时间(ACT)逐渐延长,凝结速率(CR)逐渐下降,新肝期为最显著,之后逐渐好转.围手术期血小板功能(PF)无明显差异( P>0.05).结论:Sonoclot凝血及血小板功能分析仪的应用对于肝移植术中凝血功能变化的监测及对症处理具有非常重要的作用.     

肝移植术中成分输血管理体会

肝移植是治疗晚期肝病惟一有效的方法。晚期肝病患者多存在代谢和凝血功能紊乱，加之手术创伤大、持续时间长，故术中出血量大。2002年1月-2008年12月，我院成功实施了100例同种异体原位肝移植术，现介绍术中成分输血的体会。     

肝移植术中凝血弹性图应用的研究

目的异体原位非转流肝移植术中使用凝血弹性图进行凝血功能监测,探讨新肝期再灌注后凝血紊乱的诱因及相应治疗方法。方法 153例终末期肝病行非转流肝移植手术患者,于切皮时、再灌注前5 min、再灌注后5 min及给予鱼精蛋白后10 min检测肝素酶修正及自然全血凝血弹性图。结果切皮时及再灌注前5 min肝素酶修正组与自然全血组凝血弹性图数值差别无统计学意义。再灌注后,自然全血标本在60 min内均未形成有效的凝血图形,46例标本反应为无凝血形成。肝素酶修正组数据与灌注前比较,凝血时间（K）值显著延长,Alpha角度（Angle）与最大幅度（MA）值明显降低。静脉给予不同剂量鱼精蛋白后自然全血标本的有效凝血图形恢复,各组数值有显著性差异。肝素酶修正组各记录数值接近再灌注前水平。结论异体原位非转流肝移植术中的凝血异常由多种原因造成,凝血弹性图对凝血状况的连续监测可以快速准确判断凝血异常的原因,指导临床针对性治疗,并可评价治疗效果。新肝期再灌注后凝血紊乱多由供肝外源性肝素或肝素样物质释放入血引起,给予适当剂量鱼精蛋白可以拮抗肝素活性,改善凝血状况。肝素酶修正凝血弹性图可及时监测到这种变化。     

肝脏疾病的凝血功能障碍与内毒素血症

肝病时内毒素血症与凝血功能异常的发生率均较高。内毒素血症对凝血功能障碍究竟有何影响,两者之间的关系如何,这是值得探讨的问题。本文着重介绍两者的发病机理及其相关性,以便为治疗提供理论依据。     

肝移植围手术期并发症的处理

目的探讨肝移植围手术期并发症的发生规律及处理方法。方法回顾性分析44例肝移植病例的并发症及处理。结果32例发生肺部细菌性感染(72％),其中13例合并真菌感染(29．5％)．死亡2例(15．3％);急性肾功能不全(ARF)9例(20．4％),7例须连续肾脏替代(CRRT)治疗,死亡3例(33．3％);大量胸腔积液14例(31．8％),无死亡;急性排斥反应5例(11．3％),无死亡;腹腔内出血5例(11．3％)．死亡2例(40％);胸腔内出血2例(4．5％),无死亡;T管脱出2例(4．5％)．死亡1例(50％)。结论肝移植围手术期死亡主要与并发症有关．早期诊断与处理并发症,是提高肝移植存活率的重要措施。     

原位肝移植患者围手术期成分输血探讨

目的:探讨原位肝移植围手术期成分输血疗效及手术前血液成分的准备,总结成分输血经验,降低用血量,减少输血反应。方法:44例肝移植患者来自不同的地区,其中1例来自韩国的患者,1例蒙古族患者;2例行肝肾联合移植的患者。部分受体与供体之间有血缘关系,ABO、RH血型相合。将44例肝移植患者按照病情诊断,分为肝硬化组18例(40.1%),男13例、女5例;肝恶性肿瘤组26例(59.1%),男24例、女2例。根据患者手术中、手术后的不同出血情况,给予不同的血液成分治疗,所用红细胞悬液均进行白细胞过滤。结果:肝硬化组成分用血量大于肝恶性肿瘤组(肝癌)。不同病情的肝移植患者需要的血液成分差异很大。讨论:术前明确患者的诊断及病程,探讨患者围手术期的出血量,提供安全、合理、有效的成分输血治疗,应用白细胞过滤技术,减少输血反应,降低输血总量是保障原位肝移植手术取得成功的关键环节。     

Intraoperative management and early post-operative outcomes of patients with coronary artery disease who underwent orthotopic liver transplantation

Background: Coronary artery disease (CAD) is frequently observed in aging end-stage liver disease (ESLD) patients who require orthotopic liver transplantation (OLT). This situation is challenging for both the pa- tients and the medical staff. Methods: We retrospectively studied the case records of 26 ESLD patients with CAD who underwent OLT with total clamping of the inferior vena cava between 2014 and 2018. We analyzed the details of the pre-operative evaluation, intraoperative anesthetic management and post-operative prognosis of these patients. Results: All patients tolerated the anhepatic stage well. Post-reperfusion syndrome (PRS) was observed in 13 patients (50%) and 2 of them were severe but corrected well. ST-segment depression was frequently observed during the anhepatic stage and reperfusion stage. No mortality due to cardiac-related events occurred among the patients during hospitalization. OLT with the modi ed piggyback technique could successfully be performed in ESLD patients with mild and moderate CAD. Conclusions: A thorough evaluation and optimization of recipients, strict monitoring and optimized man-agement of circulation, knowledge of the complicated changes during OLT procedures, and strategies to ameliorate post-reperfusion syndrome favorite the outcomes.     

Outcomes of liver transplantation for end-stage biliary disease: A comparative study with end-stage liver disease

AIM: To evaluate the outcomes of patients with endstage biliary disease(ESBD) who underwent liver transplantation, to define the concept of ESBD, the criteria for patient selection and the optimal operation for decision-making.METHODS: Between June 2002 and June 2014, 43 patients with ESBD from two Chinese organ transplantation centres were evaluated for liver transplantation. The causes of liver disease were primary biliary cirrhosis(n = 8), cholelithiasis(n = 8), congenital biliary atresia(n = 2), graft-related cholangiopathy(n = 18), Caroli's disease(n = 2), iatrogenic bile duct injury(n = 2), primary sclerosing cholangitis(n = 1), intrahepatic bile duct paucity(n = 1) and Alagille's syndrome(n = 1). The patients with ESBD were compared with an end-stage liver disease(ESLD) case control group during the same period, and the potential prognostic values of multiple demographic and clinical variables were assessed. The examined variables included recipient age, sex, pre-transplant clinical status, pre-transplant laboratory values, operation condition and postoperative complications, as well as patient and allograft survival rates. Survival analysis was performed using Kaplan-Meier curves, and the rates were compared using log-rank tests. All variables identified by univariate analysis with P values 0.100 were subjected to multivariate analysis. A Cox proportional hazard regression model was used to determine the effect of the study variables on outcomes in the study group.RESULTS: Patients in the ESBD group had lower model for end-stage liver disease(MELD)/paediatric end-stage liver disease(PELD) scores and a higher frequency of previous abdominal surgery compared to patients in the ESLD group(19.2 ± 6.6 vs 22.0 ± 6.5, P = 0.023 and 1.8 ± 1.3 vs 0.1 ± 0.2, P = 0.000). Moreover, theoperation time and the time spent in intensive care were significantly higher in the ESBD group than in the ESLD group(527.4 ± 98.8 vs 443.0 ± 101.0, P = 0.000, and 12.74 ± 6.6 vs 10.0 ± 7.5, P = 0.000). The patient survival rate in the ESBD group was not significantly different from that of the ESBD group at 1, 3 and 5 years(ESBD: 90.7%, 88.4%, 79.4% vs ESLD: 84.9%, 80.92%, 79.0%, χ2 = 0.194, P = 0.660). The graftsurvival rates were also similar between the two groups at 1, 3 and 5 years(ESBD: 90.7%, 85.2%, 72.7% vs ESLD: 84.9%, 81.0%, 77.5%, χ2 = 0.003, P = 0.958). Univariate analysis identified MELD/PELD score(HR = 1.213, 95%CI: 1.081-1.362, P = 0.001) and bleeding volume(HR = 0.103, 95%CI: 0.020-0.538, P = 0.007) as significant factors affecting the outcomes of patients in the ESBD group. However, multivariate analysis revealed that MELD/PELD score(HR = 1.132, 95%CI: 1.005-1.275, P = 0.041) was the only negative factor that was associated with short survival time.CONCLUSION: MELD/PELD criteria do not adequately measure the clinical characteristics and staging of ESBD. The allocation system based on MELD/PELD criteria should be re-evaluated for patients with ESBD.     

同种异体原位肝移植14例次治疗经验

目的：总结终末期肝病患者同种异体肝移植手术的临床经验,介绍肝移植供体获取和受体手术的方法和术后处理方案。方法：对13例患者行14次手术(再次肝移植1例),其中乙肝肝硬化并肝癌7例,终末期乙肝肝硬化1例,丙肝肝硬化并“意外癌”1例,重症肝炎肝衰4例(1例为肝移植术后10个月,因乙肝复发,重型肝炎行二次肝移植术)。手术行改良背驮式5例,经典非转流术式9例次,其中1例行减体积肝移植(左肝外叶切除)。结果：手术移植物成活率100％,无原发性移植肝无功能和功能延迟恢复发生。手术成功率：良性终末期肝病和肝癌100％(9／9),重症肝炎为60％(3／5),总成功率为85．7％(12／14)。远期存活8例,存活1年以上5例。结论肝移植是治疗由各种急、慢性肝病导致的终末期肝功能衰竭和肝癌的有效方法。良性终末期肝病和早期肝癌的手术效果良好,明显优于重症肝炎和晚期肝癌。选择适当的手术时机,合理的手术方式,良好的供体质量,术中麻醉管理和术后早期ICU的围手术期管理,术后免疫抑制剂的应用,术后并发症处理是保证手术成功的重要条件。乙肝和肝癌等移植后易复发疾病的控制,对于提高肝移植术后患者的长期存活率非常重要。     

肝后腔静脉成形术行原位肝移植103例

目的:探讨肝移植新术式肝后腔静脉成形术在人原位肝移植中的应用价值.方法:应用改良肝移植新术式肝后腔静脉成形术行原位肝移植103例,观察其手术所用时间、无肝期、术中出血量及并发症等.结果:本组无1例发生围手术期死亡.肝后腔静脉成形术手术所用时间及无肝期(6.8±0.8 h,52.6±14.5 min)显著短于同期报告资料经典式肝移植(7.4±0.6 h,86.5±7.1 min)以及改良背驮式肝移植(7.9±0.6 h,78.4±7.94 min).术中出血量(2960±1120 mL)也显著少于改良背驮式(4662±913 mL)和经典式肝移植(4441±1072 mL).肝后腔静脉成形术术后肾功能不全发生率为29.1%(30/103),与经典式肝移植相近,比改良背驮式高,但均能在术后3-4 wk内恢复正常.结论:肝移植新术式肝后腔静脉成形术能简化病肝切除和新肝植入的手术操作,缩短手术时间,减少术中出血,值得临床进一步推广应用.     

Gut perforation after orthotopic liver transplantation in adults

AIM： To describe cases of gut perforation after orthotopic liver transplantation.
METHODS： Data were colleted from our center database and medical records. Six of 187 patients （3.2%）who underwent orthotopic liver transplantation from January to December 2005 developed gut perforation.All patients were male with an average age of 46 years.Modified piggyback liver transplantation was performed at the Organ Transplantation Center, First Affiliated Hospital, Sun Yat-Sen University.RESULTS： Previous operation, steroid therapy, and prolonged portal venous cross clamp time, poor nutritional status and iatrogenic injury were found to be its ecological factors. The patients with gut perforation were found to have fever, increased leukocytes, mild abdominal pain and tenderness. The median portal venous clamp time was 63 min （range 45-72 min）,median cold ischaemia time was 11.3 h （range 7-15 h）.Median intraoperative blood loss was 500 mL （range 100-1200 mL） and median operation time was 8.8 h （range 6-12 h）. None of the six patients developed acute cellular rejection. White cell count was above 18 × 10^9/L in five patients （neutrophilic leukocytes were above 90%） and 1.5 × 10^9/L in one patient. Bacterial culture in drainage liquid revealed enterococci in five patients. Of the 6 patients undergoing orthotopic liver transplantation, 3 survived and 3 died after modified piggyback liver transplantation.
CONCLUSION： Gut perforation occurs after orthotopic liver transplantation in adults. A careful and minimal dissection during OLT, longer retention of the stomach tube, and reducing the portal clamp time and steroid dose should be taken into consideration. If gut perforation is not prevented, then early diagnosis,preferably through detection of enterococci may ensure better survival.