心脏停搏供体肝移植中灌洗的初步研究

目的 探讨在大鼠心脏停搏供体肝移植中，不同的灌洗速度与压力对供肝质量的影响。方法 雄性SD大鼠，按供肝获前供体大鼠经历心脏停搏时间0、15，30min，和2种灌洗速度A(8ml/min）、B（2ml/min）随机共分为6组，即0－A、15－A、30－A、0－B、15－B和30－B。灌洗液采用4℃乳酸林格氏液，经腹主动脉共灌洗10ml。每组各行8对大鼠原位肝移植，观察灌洗压力、冷灌洗后的肝脏病理、要后肝功能变化和1周存活率。结果 随着供肝经历的心脏停搏时间的延长，高速率灌洗对供肝造成的存活率分别为75％（6／8）、12．5％（1／8）、0％（0／8）、100％（8／8）、75％（6／8）和62．5％（5／8）。结论 缓慢低压灌洗可以减轻对心脏停搏供体移植在灌洗这一环节的损伤，提高此类肝移植术后的存活率。     

心脏停搏供体大鼠供肝热缺血对原位肝移植物的影响

目的:探讨来自心脏停搏供体大鼠肝移植供肝热缺血再灌注损伤对移植物的影响.方法:实验分为4组:对照组(C)和移植组,移植组根据供肝获取前经历供体心脏停搏时间的不同分为3组:热缺血0 min(W0组)、热缺血15min(W15组)和热缺血30 min(W30组),其后用建立大鼠动脉化原位肝移植模型,每组均为24只大鼠,分别测定术后3、7、14和30 d移植肝组织学、肝功能和细胞增殖核抗原Ki-67蛋白的变化,每个时间点各取6只大鼠处死.结果:随着供肝热缺血时间的延长,移植肝损伤加重,并且恢复过程也延长.移植组和对照组术后第3、7、14和30天血清ALT、AST均无显著性改变.肝移植术后早期肝细胞Ki-67表达水平随供肝热缺血时间的延长而增高,术后14 d恢复正常.各组的肝细胞Ki-67表达均与血清ALT、AST无关.结论:肝移植过程中供肝热缺血主要损伤肝细胞,并随着供肝热缺血时间的延长移植肝细胞损伤加重,肝细胞功能恢复早于其形态学恢复.     

肝窦内皮细胞在心跳停搏供肝热缺血中的表现

肝窦内皮细胞（sinusoid endothe-lial　cell,SEC）不仅作为抗原提呈细胞参加移植肝免疫排斥反应,其损伤后还可导致供肝微循环紊乱,并最终引起原发性移植肝无功能（primary graft non-function,PGF）的发生。我们从免疫组织化学和细胞超微结构等方面对心跳停搏供肝（non-heart-beating donor,NHBD）热缺血中SEC的表现进行研究。     

血液心脏停搏后不良反应少于晶体停搏

已有不少小样本随机对照试验比较了血液或晶体停搏液在心脏手术中的心肌保护作用。由于血液的成分比晶体停搏液更接近于正常生理状态，因此在心脏手术中可带来显著的临床益处。为明确血液是否能降低术后不良反应，加拿大多伦多Surmybrook和女子学院Guru等检索了MEDLINE、EMBASE和Cochrane对照试验登记数据库，对相关数据进行荟萃分析，并将分析结果在Circulation[2006，114（1 Suppl）：I331]上发表。     

心脏停搏技术的研究进展

外科手术中的心脏停搏可选择通过诱导心脏去极化、超极化、极化或影响钙机制来实施完成。心脏高 K+ 去极化停搏技术被认为是心脏停搏技术中的金标准 ,可提供良好的心肌保护 ,但术后仍伴随不同程度的附加心肌损伤。诱导心脏超极化、极化或影响钙机制等心脏停搏技术的研究近年来逐渐增多 ,但在临床常规应用之前尚需长期研究。     

如何确定扩展的供肝标准？

1．引言 在肝移植供体器官的供应和接受移植受体数量的需求之间全球性的巨大不平衡不断地促进人们去最大程度的利用现有供体资源．增加供体的数量和发现新的供体资源。直到最近，尸体供肝移植仍然很大程度上受到供体需要是诊断脑死亡但仍有持续心脏活性标准的限制。在脑死亡（DBD）之后捐赠的供体仍然占到全美肝移植肝源的人约95％。摄近几年．已经有关于活体右半肝捐赠的报道。这种成人对成人的活体供体移植将一个健康供体置丁严重的并发症和死亡的风险中，并且这种肝移植的数量对全部可获得的肝脏供体数量并没有大的影响。     

迷走神经介导性心脏停搏的临床分析

目的:探讨迷走神经与心脏停搏的关系及其临床意义。方法:描记24小时动态心电图(Holter),同时进行心率变异性分析,食管心脏电生理检查(TEAP)及阿托品试验。结果:Holter显示:13例心脏停搏患者中,8例为窦性停掉,5例为二度Ⅱ型房室传导阻滞所致的心室停搏。TEAP参数显示窦房结及房室结功能不良,静脉注射阿托品2mg后,重复作TEAP,所有参数均恢复至正常范围(P<0.01)。结论:迷走神经张力增高可致心脏停搏,正确认识迷走神经介导性心脏停搏有着重要的临床意义。     

食管心房调搏治疗房室折返性心动过速合并心脏停搏

患者男、45岁,突发心悸16小时入院。有发作性心动过速史20余年,近一年发作较频,曾于(13与15个)月前因阵发性室上性心动过速(下称室上速)伴反复心脏停搏两次住院,发作最长达20多小时。三次住院均观察到在室上速发作中常间以心脏停搏,每次持续约6—10s(图1见35页)。感胸闷,但无抽搐或意识丧失。此次入院前两周内未服过任何抗心律失常药物。自称平日心率偏慢,约50—60/min,发作时心率最快可超过200/min。无心肌炎病史。     

超速抑制继发心脏停搏

一、定义 超速抑制后继发心脏停搏是指快速激动传人心脏各级起搏点，直接引起心脏各起搏点的超速抑制而出现短暂的或暂时性的全心停搏，轻者患者发生头晕目眩，重者因循环停顿可出现心源性晕厥。     

无心跳供体心脏移植热缺血时限的实验研究

目的探讨未经药物预处理的无心跳供体心脏移植成功的热缺血时限。方法实验犬30只,供体和受体组各5只,对照组：心脏以0℃组氨酸-色氨酸-酮戊二酸溶液（histidine—tryptophan—ketogluarate solution,HTK）500ml主动脉根部灌注,心脏停跳后切取供心,置于0℃HTK液中保存2h;热缺血16min组：心脏缺氧停跳后热缺血16min．用0℃ HTK液500ml灌注冲洗冠状动脉,切取供心．置于0ccHTK液中保存2h;热缺血18min组：心脏缺氧停跳后热缺血18min,灌注及保存方法同热缺血16min组。以标准心脏移植方法行原位移植,监测供体心脏移植前后的血流动力学指标、心脏质量,测定心肌酶等指标,电镜观察心肌组织超微结构改变。结果心脏移植实验中对照组及热缺血16min组均可成功复跳、脱离体外循环辅助,血流动力学指标差异无统计学意义（P〉0．05）。热缺血18min组仅有2例可以脱机,与对照组及热缺血16min组相比,左心室舒张末期压升高、-dp／dtmax下降较明显．与对照组差异有统计学意义（P〈0．05）,但与16min组比较,差异无统计学意义（P〉0．05）,心脏质量及心肌酶明显升高（P〈O．05）,电镜观察超微结构破坏明显。结论常温热缺血16min的供心有可能被成功用于心脏移植。     

活体肝移植中非标准供肝的可用性分析

目的 了解活体肝移植非标准供肝受体的并发症及生存率,分析活体肝移植中非标准供肝的可用性.方法 四川大学华西医院肝移植中心2001年1月-2007年12月完成成人间活体肝移植并资料齐全的患者92例.比较不同供体年龄、性别配型、供肝脂肪变程度、移植物质量与受体体质量比(GRWR)、肝中静脉重建情况,患者术后6个月的生存率及并发症发生率.根据不同资料分别采用单因素方差分析、X2检验或Cpx回归分析.结果 使用脂肪变性≥30%供肝的4例受体术后都出现了不明原因的肝功能衰竭,均在观察时间内死亡,而脂肪变性＜30%的受体中,术后6个月生存率为91.7%.虽然GRWR＜0.8%的受体生存率(86.9%)与GRWR≥0.8%的受体生存率(87.8%)比较,差异无统计学意义(X2=0.022,P＞0.05),但小供肝组流出道的重建情况与其生存率相关(X2=10.612,P＜0.01).供体年龄是否≥50岁和供、受体性别是否配型等对术后6个月并发症及生存率的影响差异均无统计学意义(P＞0.05).Cox回归分析结果显示,供肝脂肪变性≥30%对生存率有较大的影响.结论 供肝脂肪变性程度是影响受体术后并发症及生存率的重要因素.而以往认为的GRWR＜0.8%现已不是绝对的禁忌标准,但必须保证小供肝受体流出道通畅.供体年龄≥50岁、交叉性别供肝对受体术后并发症及生存率无影响.     

Analyzing predictors of graft survival in patients undergoing liver transplantation with donors aged 70 years and over

AIM To increase the number of available grafts.METHODS This is a single-center comparative analysis performed between April 1986 and May 2016. Two hundred and twelve liver transplantation(LT) were performed with donors ≥ 70 years old(study group). Then, we selected the first cases that were performed with donors 70 years old immediately after the ones that were performed with donors ≥ 70 years old(control group).RESULTS Graft and patient survivals were similar between both groups without increasing the risk of complications, especially primary non-function, vascular complications and biliary complications. We identified 5 risk factors as independent predictors of graft survival: recipient hepatitis C virus(HCV)-positivity [hazard ratio(HR) = 2.35; 95% confidence interval(CI): 1.55-3.56; P = 0.00]; recipient age(HR = 1.04; 95%CI: 1.02-1.06; P = 0.00); donor age X model for end-stage liver disease(D-MELD)(HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); donor value of serum glutamic-pyruvic transaminase(HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); and donor value of serum sodium(HR = 0.96; 95%CI: 0.94-0.99; P = 0.00). After combining D-MELD and recipient age we obtained a new scoring system that we called DR-MELD(donor age X recipient age X MELD). Graft survival significantly decreased in patients with a DR-MELD score ≥ 75000, especially in HCV patients(77% vs 63% at 5 years in HCV-negative patients, P = 0.00; and 61% vs 25% at 5 years in HCV-positive patients; P = 0.00). CONCLUSION A DR-MELD ≥ 75000 must be avoided in order to obtain the best results in LT with donors ≥ 70 years old.     

Donor safety and remnant liver volume in living donor liver transplantation

AIM:To evaluate the relationship between donor safety and remnant liver volume in right lobe living donor liver transplantation(LDLT).METHODS:From July 2001 to January 2009,our liver transplant centers carried out 197 LDLTs.The clinical data from 151 cases of adult right lobe living donors(not including the middle hepatic vein) were analyzed.The conditions of the three groups of donors were well matched in terms of the studied parameters.The donors' preoperative data,intraoperative and postoperative data were calculated for the three groups:Group 1 remnant liver volume(RLV) 35%,group 2 RLV 36%-40%,and group 3 RLV 40%.Comparisons included the different remnant liver volumes on postoperative liver function recovery and the impact of systemic conditions.Correlations between remnant liver volume and post-operative complications were also analyzed.RESULTS:The donors' anthroposomatology data,op-eration time,and preoperative donor blood test indicators were calculated for the three groups.No significant differences were observed between the donors' gender,age,height,weight,and operation time.According to the Chengdu standard liver volume formula,the total liver volume of group 1 was 1072.88 ± 131.06 mL,group 2 was 1043.84 ± 97.11 mL,and group 3 was 1065.33 ± 136.02 mL.The three groups showed no statistically significant differences.When the volume of the remnant liver was less than 35% of the total liver volume,the volume of the remnant had a significant effect on the recovery of liver function and intensive care unit time.In addition,the occurrence of complications was closely related to the remnant liver volume.When the volume of the remnant liver was more than 35% of the total liver volume,the remnant volume change had no significant effect on donor recovery.CONCLUSION:To ensure donor safety,the remnant liver volume should be greater than the standard liver volume(35%) in right lobe living donor liver transplantation.     

供肝脂肪变性与肝移植术后糖尿病发病风险的关系

目的探讨肝移植术后糖尿病（PTDM）发病的危险因素以及供肝脂肪变性对PTDM发病风险的影响。方法回顾性分析2001年4月至2008年12月438例接受肝移植患者的术前、术后的临床资料。采用2006年中华医学会肝脏病学分会制定的非酒精性脂肪性肝病（NAFLD）诊疗指南的组织病理评分标准判定供肝脂肪变性程度，肝功能状态判定采用Child—Pugh评分系统。根据术后空腹血糖将患者分为非PTDM组（n=298，男250例，女48例，平均年龄48岁）与PTDM组（n=140，男120例，女20例，平均年龄50岁）。对PTDM可能的危险因素，包括年龄、性别、空腹血糖、体质指数、术前肝功能、供肝脂肪变性、术后抗排异药种类、白细胞介素-2受体拮抗剂（IL-2RA）应用等进行单因素分析。在单因素分析基础上进行logistic多元回归分析。结果非PTDM组供肝脂肪变性者占34．6％（103／298），PTDM组供肝脂肪变性者占44．3％（62／140），2组无显著差别（X^2=3．83，P=0．05）。单因素分析提示术前空腹血糖（F=23．38，P〈0．05）、术前肝功能、IL-2RA、免疫抑制剂类型与PTDM显著相关（X^2值分别为7．69、8．30、0．02，均P〈0．05），而供肝脂肪变性与PTDM相关性处于临界水平（X^2=3．83，P=0．05）。logistic多元回归分析提示术前空腹血糖异常（OR=1．853，P〈0．01）、供肝脂肪变性（OR=1．80，P〈0．05）可提高PTDM患病风险，而使用IL．2RA（OR=0．43，P〈0．01）可降低PTDM患病风险。结论供肝脂肪变性、术前空腹血糖异常为PTDM的危险因素，而IL-2RA应用则可降低PTDM发生风险，术前肝功能异常可能增加PTDM的发生风险，免疫抑制剂与PTDM的关系有待进一步研究。     

成人活体肝移植治疗终末期肝病

目的探讨成人活体肝移植治疗终末期肝病的方法及技术要点。方法回顾性分析2000年9月至2005年6月的成人活体肝移植患者12例。其中,左半肝(Ⅱ、Ⅲ、Ⅳ段,包括肝中静脉)移植3例;右半肝(Ⅴ、Ⅵ、Ⅶ、Ⅷ段)不包括肝中静脉移植8例,包括肝中静脉1例。结果 12例供体无因手术死亡者。手术时间(6．20±1．40)h;术中出血量300-1 200 ml;1例术后并发胆瘘,1例切口脂肪液化;随访 6-12个月,无远期并发症发生,术后3-6个月恢复工作。受体手术时间5-11 h;采用改良方法重建移植肝流出道、显微外科技术重建肝动脉、端端吻合重建胆道;术中出血800-7000 ml;移植物冷缺血时间(1．90±0．50)h;无肝期时间(1．63±0．43)h;移植肝重量与受体体重比为1．20％±0．26％。1例受体术后并发腹腔内局限性胆瘘,1例病死,11例长期生存。结论成人活体肝移植是解决供肝短缺、治疗终末期肝病的有效方法,同时能相对保证供体的安全。     

Quality of life and psychological outcome of donors after living donor liver transplantation

AIM: To investigate the health related quality of life (HRQoL) and psychological outcome of donors after living donor liver transplantation. METHODS: Participants were 92 consecutive liver transplant donors who underwent hepatectomy with- out middle hepatic vein at West China Hospital of Sichuan University between January 2007 and Sep- tember 2010. HRQoL was measured using the Chinese version of the Medical Outcomes Study Short Form-36 (SF-36), and psychological symptoms were measured using the Symptom Checklist-90-Revised (SCL-90-R). Data collected from donors were compared to previ- ously published data from the general population. Clin- ical and demographic data were collected from medical records and questionnaires.RESULTS: The general health score of the SF-36 was significantly lower in females (59.78 ± 12.25) than in males (75.83 ± 22.09). Donors more than 40 years old scored higher in social functioning (85.71 ± 14.59) and mental health (82.61 ± 20.00) than those younger than 40 (75.00 ± 12.13, 68.89 ± 12.98; social func- tioning and mental health, respectively). Donors who had surgery more than two years prior to the study scored highest in physical functioning (P = 0.001) and bodily pain (P = 0.042) while those less than one year from surgery scored lowest. The health of the liver recipient significantly influenced the general health (P = 0.042), social functioning (P = 0.010), and role- emotional (P = 0.028) of donors. Donors with full-time employment scored highest in role-physical (P = 0.005), vitality (P = 0.001), social functioning (P = 0.016), mental health (P 0.001), the physical component summary scale (P 0.001), and the mental compo- nent summary scale (MCS) (P 0.001). Psychological measures indicated that donors were healthier than the general population in obsessive-compulsive behav- ior, interpersonal sensitivity, phobic anxiety, and para- noid ideation. The MCS of the SF-36 was significantly correlated with most symptom scores of the SCL-90-R. CONCLUSION: HRQoL and psychological outcome were favorable in living liver transplant donors after donation. Specifically, gender, age, time since opera- tion, recipient health condition, and employment after donation, influenced postoperative quality of life.     

Strategies to optimize the use of marginal donors in liver transplantation

Liver transplantation is the treatment of choice for end stage liver disease, but availability of liver grafts is still the main limitation to its wider use. Extended criteria donors(ECD) are considered not ideal for several reasons but their use has dramatically grown in the last decades in order to augment the donor liver pool. Due to improvement in surgical and medical strategies, results using grafts from these donors have become acceptable in terms of survival and complications; nevertheless a big debate still exists regarding their selection, discharge criteria and allocation policies. Many studies analyzed the use of these grafts from many points of view producing different or contradictory results so that accepted guidelines do not exist and the use of these grafts is still related to non-standardized policies changing from center to center. The aim of this review is to analyze every step of the donationtransplantation process emphasizing all those strategies, both clinical and experimental, that can optimize results using ECD.     

Preservation of non-heart-beating donor livers in extracorporeal liver perfusion and histidine-trytophan-ketoglutarate solution

AIM： To compare the preservation of non-heart- beating donor （NHBD） livers in cold histidine-trytophan- ketoglutarate （HTK） solution and extracorporeal liver perfusion （ECLP）. METHODS： Livers harvested from health pigs were stored for 10 h in cold HTK solution （group A, n = 4） or perfused with oxygenated autologous blood at body temperature （group B, n = 4）. Both groups were then tested on the circuit for 4 h. Bile production, hemodynamic parameters, hepatocyte markers and reperfusion injury of extracorporeal livers were tested in each group. Liver tissues from each group were examined at the end of reperfusion. RESULTS： At 1, 2, 3 and 4 h after reperfusion, bile production, hemodynamic parameters, hepatocyte markers and reperfusion injury of livers in group A were statistically different from those in group B （P 〈 0.05 or P 〈 0.01）. CONCLUSION： ECLP is better than HTK solution to preserve NHBD livers. ECLP can assess the graft viabilitybefore liver transplantation.     

Day-of-surgery rejection of donors in living donor liver transplantation

AIM: To study diagnostic laparoscopy as a tool for excluding donors on the day of surgery in living donor liver transplantation (LDLT).METHODS: This study analyzed prospectively collected data from all potential donors for LDLT. All of the donors were subjected to a three-step donor evaluation protocol at our institution. Step one consisted of a clinical and social evaluation, including a liver profile, hepatitis markers, a renal profile, a complete blood count, and an abdominal ultrasound with Doppler. Step two involved tests to exclude liver diseases and to evaluate the donor’s serological status. This step also included a radiological evaluation of the biliary anatomy and liver vascular anatomy using magnetic resonance cholan-giopanc reatography and a computed tomography (CT) angiogram, respectively. A CT volumetric study was used to calculate the volume of the liver parenchyma. Step three included an ultrasound-guided liver biopsy. Between November 2002 and May 2009, sixty-nine potential living donors were assessed by open exploration prior to harvesting the planned part of the liver. Between the end of May 2009 and October 2010, 30 potential living donors were assessed laparoscopically to determine whether to proceed with the abdominal incision to harvest part of the liver for donation. RESULTS: Ninety-nine living donor liver transplants were attempted at our center between November 2002 and October 2010. Twelve of these procedures were aborted on the day of surgery (12.1%) due to donor findings, and eighty-seven were completed (87.9%). These 87 liver transplants were divided into the following groups: Group A, which included 65 transplants that were performed between November 2002 and May 2009, and Group B, which included 22 transplants that were performed between the end of May 2009 and October 2010. The demographic data for the two groups of donors were found to match; moreover, no significant difference was observed between the two groups of donors with respect to hospital stay, nar-cotic and non-narcotic analgesia requirements or the incidence of complications. Regarding the recipients, our study clearly revealed that there was no significant difference in either the incidence of different complications or the incidence of retransplantation between the two groups. Day-of-surgery donor assessment for LDLT procedures at our center has passed through two eras,open and laparoscopic. In the first era, sixty-nine LDLT procedures were attempted between November 2002 and May 2009. Upon open exploration of the donors on the day of surgery, sixty-five donors were found to have livers with a grossly normal appearance. Four donors out of 69 (5.7%) were rejected on the day of surgery because their livers were grossly fatty and pale. In the laparoscopic era, thirty LDLT procedures were attempted between the end of May 2009 and October 2010. After the laparoscopic assessment on the day of surgery, twenty-two transplantation procedures were completed (73.4%), and eight were aborted (26.6%). Our data showed that the levels of steatosis in the rejected donors were in the acceptable range. Moreover, the results of the liver biopsies of rejected donors were comparable between the group A and group B donors. The laparoscopic assessment of donors presents many advantages relative to the assessment of donors through open exploration; in particular, the laparo-scopic assessment causes less pain, requires a shorter hospital stay and leads to far superior cosmetic results. CONCLUSION: The laparoscopic assessment of donors in LDLT is a safe and acceptable procedure that avoids unnecessary large abdominal incisions and increases the chance of achieving donor safety.