大鼠肝门部整块切除术后门静脉动脉化重建肝血流的实验模型

目的 子解用门静脉动脉化重建肝血流的可行性。方法 建立门静脉动脉化重建肝脏血流的梗阻性黄疸大鼠实验模型,观察肝脏的结构和功能改变。结果 大鼠胆总管结扎５d后,胆红素（ＢＩＬ）、转氨酶（ＡＬＴ、ＡＳＴ）和碱性磷酸酶（ＡＬＰ）显著增高（与对照组相比,Ｐ＜０.０１）,胆总管结扎５d后的大鼠行胆管再通＋门静脉动脉化手术后１周。ＢＩＬ即可恢复正常（与对照组相比,Ｐ＞０.０５）,ALT、AST和ALP明显下降,但差异仍有显著意义（Ｐ＜０.０５）,手术后１个月即可完全恢复正常（与对照组相比,Ｐ＞０.０５）,肝脏结构亦可顺利恢复。结论 门静脉动脉化重建肝血流在临床上有一定的可行性和应用前景。     

肝门区肿瘤切除中肝脏血流阻断方法的探讨

目的 探讨肝脏血流阻断技术在肝门区肿瘤切除中的合理应用.方法 回顾性分析2005年1月至2008年3月采用第一肝门阻断法(Pringle法)和常温下全肝血流阻断技术(NHVE)相结合切除16例肝门区肿瘤的临床资料,分析肿瘤和肝门区血管的毗邻关系、阻断次数、阻断时间、术中出血量、输血量、术后并发症等指标.结果 本组16例患者采用Pringle法与NHVE相结合技术切除肿瘤,Pringle法平均阻断(3.8±1.6)次,平均阻断时间(46.6±28.8)min;NHVE平均阻断(1.6±0.4)次,平均阻断时间(23.5±8.2)min;术中出血量平均(1250±320)ml,输血量平均(860±245)ml;术中修补下腔静脉损伤4例,肝静脉损伤2例,门静脉主干损伤2例;术后均有肝脏酶学指标、胆线素不同程度的升高,经保肝等治疗后恢复正常,未发牛肝功能衰竭等严重并发症.结论 Pringle法与NHVE技术分步结合使用可减少全肝血流阻断时间、增加肝门区肿瘤切除的安全性.     

Experimental study on the interruption of hepatic blood flow in obstructive jaundice, with special reference to the causes of death and prolonged jaundice after biliary decompression

The purpose of this investigation was to elucidate the influence of interruption of the hepatic blood flow on survival and on prolonged jaundice after biliary decompression in dogs with obstructive jaundice. There were three experimental groups. Two or three weeks after inducing obstructive jaundice by ligation of the common bile duct with cholecystectomy, the hepatic artery (group A), portal vein (group B) or both (group C) were interrupted for various intervals, with antibiotics administration. Biliary decompression was simultaneously performed with choledochoduodenostomy. The one week survival rate after the interruption of hepatic blood flow was more than 60% at 2 and 1 hours in group A, 20 and 10 minutes in group B, 10 and 5 minutes in group C at two and three weeks after biliary obstruction, respectively. Necrosis more than 50% of the liver was observed in early death cases. Edema and stasis in the bile canaliculi were markedly observed histologically in survivors in groups A and C, accompanied with significant elevations of serum T. Bil and GPT. The changes were greater in cases with longer periods of jaundice. In obstructive jaundice, hepatic artery occlusion causes hepatic necrosis, in spite of antibiotics administration, and may induce prolonged jaundice after biliary decompression. As an indicator of the prognosis, the serum total bile acid value was useful.     

Changes in the hepatic perfusion index during the development of experimental hepatic tumours

A model of microscopic liver tumour has been developed in the Fisher rat by intraportal injection of 1.6 x 10(7) Walker 256 carcinosarcoma cells. Rats were studied at 2, 4 and 6 days after the inoculation of live Walker cells. A control group received dead Walker cells. No tumour was visible in control groups at 2, 4 and 6 days after inoculation. Similarly in rats injected with live cells no tumour was visible at 2 days after inoculation but at 4 and 6 days the percentage hepatic replacement was (mean +/- s.d.) 7.0 +/- 2.3 and 27.9 +/- 6.80 respectively. The hepatic perfusion index was significantly raised at 4 and 6 days after inoculation of live cells compared with control animals and those receiving viable cells after 2 days inoculation. Portal flow and portal venous inflow were significantly reduced when the hepatic perfusion index increased but hepatic arterial flow did not alter. Changes in the hepatic haemodynamics were accompanied by increases in the portal and splanchnic vascular resistance and an increase in the amount of arteriovenous shunting through the liver. These findings confirm studies that the hepatic perfusion index is useful in the detection of occult liver metastases but that the change is not a consequence of an increase in the hepatic arterial flow.     

The effects of intravenously infused catecholamines on hepatic blood flow in conscious dogs with experimental obstructive jaundice

This study was conducted to examine how the effects of dopamine and dobutamine on hepatic blood flow were influenced by obstructive jaundice in a conscious canine model. Prior to biliary obstruction, portal venous blood flow (PVF) increased in response to the infusion of either dopamine or dobutamine: dopamine infused at 8 g/kg per min produced an increase of 19±0% in PVF, while dobutamine infused at 16 g/kg per min produced an increase of 30±2%. Although hepatic arterial blood flow (HAF) decreased dose-dependently in response to the infusion of dopamine, no significant change was observed in HAF in response to any dose of dobutamine. Obstructive jaundice attenuated or completely abolished the PVF-increasing effect of dopamine, whereas it did not significantly alter the effect of dobutamine on hepatic blood flow. In dogs with obstructive jaundice, dopamine at 16 g/kg per min produced a decrease of 17±3% in PVF. These findings suggest that dobutamine is more effective than dopamine for increasing hepatic blood flow in patients with obstructive jaundice.     

Portal blood flow, effective hepatic blood flow, and outcome after partial portal decompression

What a great time to practice Surgery! Things we only dreamed about 20 years ago are finding their way into clinical care and greater advances are around the corner. As practicing surgeons, we have prospered by being raised on the shoulders of giants in Surgery that trained and inspired us. Dr. David B. Skinner was such a giant.     

蛋白激酶C在阻塞性黄疸肝损伤中的作用及果糖防治机制的研究

目的探讨阻塞性黄疸肝损害的调控机制。方法采用胶原酶原位肝灌注法获取大鼠肝细胞，行原代培养。(1)用蛋白激酶C(protein kinase C，PKC)激动剂PMA、拮抗剂Chelerythrine作用于肝细胞，再用50μmol／L甘氨鹅脱氧胆酸钠(glycochenodeoxycholate，GCDC)作用后行FCM及TUNEL检测肝细胞凋亡情况；(2)使用不同浓度果糖(Fructose)作用于肝细胞，100μmol／L的GCDC作用后行FCM及TUNEL检测；(3)结扎大鼠胆总管，有和无果糖喂养后3d、7d、14d、21d处死大鼠，分别用TUNEL技术及SAN2法检测阻塞性黄疸大鼠肝脏组织细胞凋亡状态及PKC蛋白的表达。结果(1)随PMA浓度的增加，肝细胞的凋亡明显增加，随Chelerythrine的增加，肝细胞的凋亡明显减少；(2)经果糖作用后，100μmol／L的GCDC致肝细胞的凋亡率明显减少，且随果糖作用浓度的增加肝细胞凋亡率减少；(3)大鼠胆总管结扎后，无果糖作用时，随结扎时间的延长，细胞凋亡指数(AI)增加，结扎14d后AI达高峰，PKC蛋白表达越强，AI就越高。有果糖作用时，PKC蛋白在14d、21d表达较无果糖作用时明显减少，凋亡指数较无果糖作用时均明显减少。结论蛋白激酶C信号通道参与了阻塞性黄疸肝细胞凋亡的调节，并在阻塞性黄疸肝损害的发生和发展中起重要作用。果糖通过抑制PKC的表达在阻塞性黄疸肝损伤中起保护作用。     

Histological changes in the brain due to experimental obstructive jaundice

Histopathological changes and energy charge of the canine brain under the experimental obstructive jaundice were investigated. The common bile duct was ligated in group A (n = 25), and biliary decompression was carried out in group B after the duration of the obstructive jaundice, (n = 11). The results were as follows. 1) Simple atrophy, pyknosis, neuronophagia, and ghost cell were observed in nerve cells. 2) The changes of nerve cells appeared after 7 days of the obstructive jaundice at the basal ganglia, putamen and red nucleus. After 13 days of the obstructive jaundice, they spread widely to the thalamus, cerebral cortex and substantia nigra. 3) According to decreasing ratio of serum bilirubin concentration, B group was classified into 4 groups. Poorly decompressed groups III and IV showed severe histological changes than fairy decompressed groups I and II. 4) Energy charge of the substantia nigra after 7 days of the obstructive jaundice decreased to 0.65 comparing with 0.77 of control group. The results indicate that obstructive jaundice should be decompressed as early as possible.     

自制肝钳血流控制在肝切除术中的应用

目的探讨自制肝钳在肝切除术中对血流控制的作用。方法回顾性分析我院2004年3月-2007年5月应用自制肝钳行血流控制实施肝切除术45例的临床资料。结果术中平均出血量（526±297）ml,平均手术时间（176．07±41．20）min。术中血压、血氧饱和度平稳,术后肝功能恢复好。全组无一例发生肝功能衰竭。结论自制肝钳能满足大多数肝切除术的血流控制要求,操作简便、安全可靠,值得在临床推广应用。     

Effective hepatic blood flow and hepatic bioenergy status in murine peritonitis

To assess the effects of sepsis on effective hepatic blood flow (EHBF) and hepatic tissue bioenergy status 250-350 g rats underwent either sham laparotomy or cecal ligation and perforation (CLP). At 5-, 10-, and 20-hr intervals cardiac output (CO), EHBF, and tissue adenine nucleotide levels were measured. CLP rats showed a hyperdynamic response to sepsis at 20 hr, with CO increased by 25% over sham rats. At all time intervals studied EHBF was decreased and at 20 hr it was maximally decreased by 35%. Hepatic energy charge (HEC) was calculated from tissue adenine nucleotide measurements. HEC was not statistically different in sham and CLP rats at 5 hr and was 11 and 9% reduced from sham levels in CLP rats at 10 and 20 hr, respectively. Thus, EHBF is decreased very early in sepsis; before any changes in hepatic bioenergy status are noted. In this hyperdynamic model of sepsis EHBF is decreased early and decreases progressively with time which may contribute to the significant decrease in HEC that is demonstrated.     

Changes of hepatic blood flow and intrahepatic microvascular bed in rats with chronic biliary obstruction]

The effective hepatic blood flow (EHBF) and intrahepatic microvascular bed (IMB) of rats were studied with hydrogen clearance and India ink perfusion 1, 2, 3 weeks after common bile duct ligation (CBDL). The EHBF decreased significantly in all 3 CBDL groups, compared to control (P < 0.0001). There was no significant difference among CBDL groups (P > 0.05). In a given group no significant difference was noted between the blood flow of the left lateral lobe and that of the middle lobe. The IMB was destroyed severely in all CBDL groups. It was concluded that when chronic biliary obstruction developed the EHBF decreased significantly because of shrinkage of IMB resulting from extensive fibrosis of the liver, and necrosis of liver cells.     

Changes in graft flow pattern from the descending aorta due to intraaortic balloon pump

During surgery for lung cancer in a patient who had undergone coronary artery bypass grafting through the descending aorta by left thoracotomy, we measured graft bypass blood flow from the descending aorta under intraaortic balloon pump (IABP) assistance. Under IABP assistance, the diastolic waveform changed to a spiky pattern with a sharp drop in blood flow of approximately 16% compared to that without IABP assistance. We report changes in graft flow pattern during IABP assistance when the graft is placed from the descending aorta.