Glisson肝蒂解剖法联合背侧入路在腹腔镜肝脏S7切除中的应用

目的探讨Glisson肝蒂解剖法联合背侧入路行腹腔镜肝脏S7切除的安全性和可行性。方法回顾分析2018年11月至2019年6月在南京大学医学院附属鼓楼医院完成的3例腹腔镜下肝脏S7切除术患者的临床资料,记录患者的手术时间、术中出血量、术后住院时间和手术并发症。结果全组3例均成功完成了Glisson肝蒂解剖法联合背侧入路行肝脏S7切除,无中转开腹手术。手术时间为160~430 min,平均(310±112)min;术中出血量为100~1000 ml,平均(433±403)ml,其中1例术后第3天出现胆漏,余病例未发生胆漏、出血、感染等并发症。术后病理均与术前一致。结论Glisson肝蒂解剖法联合背侧入路行腹腔镜肝脏S7切除安全、有效,是一种值得推广的原位肝切除手术入路。

全内脏反位供者供肝移植一例

全内脏反位是一种罕见的先天性解剖异常,表现为右位心、正常腹部器官镜像和其他先天性异常,又称镜面人,发生率约0.01%[1]。患有这种疾病的潜在供者通常因解剖学问题而未能成功捐献。迄今为止,虽然镜面人作为受者行肝移植成功案例较多[2-3],但是镜面人作为供者捐献肝脏成功行肝移植罕有报道。2018年3月,南京大学医学院附属鼓楼医院移植外科成功实施1例全内脏反位供者供肝移植,取得良好效果,现报道如下。

环状聚四氟乙烯人工血管重建肝静脉流出道在右半肝活体肝移植中的应用价值

目的探讨环状聚四氟乙烯人工血管重建肝静脉流出道在右半肝活体肝移植中的应用价值。方法采用回顾性描述性研究方法。收集2015年6月至2018年8月南京大学医学院附属鼓楼医院收治的4例和南京医科大学第一附属医院收治的17例行右半肝活体肝移植供者和对应21例受者的临床病理资料;21例供者中,男10例,女11例;中位年龄为46岁,年龄范围为35~57岁;中位体质量为64 kg,体质量范围为56~72 kg。21例受者中,男16例,女5例;中位年龄为42岁,年龄范围为21~68岁;中位体质量为63 kg,体质量范围为47~77 kg。观察指标:(1)手术及术后情况。(2)随访情况。采用门诊或电话方式进行随访,了解受者术后移植肝功能、肝癌复发、人工血管并发症、人工血管通畅性、生存等情况。随访时间截至2020年8月。受者需终生定期随访。正态分布的计量资料以x±s表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。采用Kaplan-Meier法计算通畅率和生存率并绘制通畅率曲线和生存曲线。结果(1)手术及术后情况:21例供者手术时间为(367±72)min,供肝质量为(557±68)g,供肝质量与受者体质量比为0.89%±0.16%,住院时间为(10±2)d。21例供者术后未出现需再次手术或有创处理并发症,1例轻度胆瘘,术后留置腹腔引流管1周拔除。21例受者均顺利完成经典原位肝移植。供肝静脉流出道重建时间为(24±4)min,供肝植入时间为(326±66)min,无肝期为(42±6)min。重建肝中静脉V518支,直径为(6.1±1.3)mm,V815支,直径为(7.2±1.2)mm,肝右后下静脉10支,直径为(6.3±1.3)mm。受者术后入住重症监护室时间为(1.5±0.9)d,总住院时间为(22.6±6.7)d。21例受者中,10例术后发生并发症,其中5例术后1周发生肝功能异常(丙氨酸氨基转移酶、天冬氨酸氨基转移酶均>1000 IU/L,胆红素轻度升高),同时伴腹腔积液增加;行增强CT检查结果示供肝右前叶淤血,肝中静脉V5或V8分支血栓形成,经保肝、抗凝、输注白蛋白等对症治疗后肝功能均恢复正常,腹腔积液减少。2例术后1个月下腔静脉血栓形成,反复出现胸腔积液,行腔静脉造影检查,考虑人工血管血栓形成(其中1例腔静脉旁侧支循环形成,予以球囊扩张并置入腔静脉支架),术后继续口服华法林抗凝治疗后恢复正常。1例胆瘘(腹腔引流液培养出肺炎克雷伯杆菌),1例腹腔感染,1例肺部感染,均经抗感染对症治疗后恢复正常。21例受者无严重并发症和围术期死亡。(2)随访情况:21例受者均获得随访,随访时间为10~57个月,中位随访时间为38个月。21例受者术后6个月均未出现移植肝无功能,其中2例肝癌复发。术后2年6例受者死亡(肝癌复发3例、急性大出血2例、肝衰竭1例),无因人工血管引起的严重并发症死亡。21例受者术后1个月、3个月、6个月、1年、2年肝静脉流出道通畅率分别为88.4%、88.4%、82.4%、68.0%、42.1%。21例受者术后6个月、1年、2年总体生存率分别为100.0%、94.4%、71.4%。结论环状聚四氟乙烯人工血管重建肝静脉流出道应用于右半肝活体肝移植安全、可行。

Biological features of intrahepatic CD4^(+)CD25^(+)T cells in the naturally tolerance of rat liver transplantation

The biological features of intrahepatic CD4^(+)CD25^(+)T regulatory cells in the naturally tolerance of rat liver transplantation were explored.Orthotopic liver transplan-tation was performed in two allogeneic rat strain combina-tions,one with fatal immunosuppression despite a complete major histocompatibility complex mismatch.The subjects were divided into three groups according to different donors and recipients[Tolerance group:LEW-to-DA;Rejection group:DA-to-LEW;Syngegnic group(control group):DA-to-DA].The proportion of intrahepatic CD4^(+)CD25^(+)T cells from three groups was determined by flow cytometry(FCM)in different time.The intrahepaitc CD4^(+)CD25^(+)T cells were isolated by magnetic activated cell sorting(MACS)method and identified by FCM.The Foxp3 mRNA was detected by reverse transcriptase polymerase chain reaction(RT-PCR).And their suppression on the proliferation of CD4^(+)CD25^(-)T effector cells was analyzed by cell proliferation assay in vitro.Beginning immediately after transplantation,the proportion of Treg cells increased over time in both allogeneic groups but was significantly greater in the Rejection group.The pro-portion of Treg cells declined after day 5,and such reduction was more dramatic in the Rejection group than in the Tole-rance group.Animals in the Tolerance group showed a second increase in the proportion after day 14.Intrahepatic CD4^(+)CD25^(+)T cells isolated from spontaneous tolerance models inhibited the proliferation of mixed lymphocyte reaction.The purity of CD4^(+)CD25^(+)Tcells sorted by MACS was 86%–93%.The CD4^(+)CD25^(+)T cells could specifically express the Foxp3 gene compared with CD4^(+)CD25^(-)T cells.In vitro,the spleen cells from LEW rats can irritate the proliferation of CD4^(+)CD25^(+)T cells more obviously than the syngegnic spleen cells.CD4^(+)CD25^(+)Tr cells could suppress the proliferation of CD4^(+)CD25^(-)T cells,but the inhibition was reversed by exo-genous IL-2(200 U/mL).The CD4^(+)CD25^(+)T regulatory cells specifically express the Foxp3 gene,which may play animpor-tant role in the induction of liver transplantation tolerance by suppressing the reaction of effective T cells.

Emergency adult living donor right lobe liver transplantation for fulminant hepatic failure

Fulminant hepatitis is fatal in most cases and timely liver transplantation is the only effective treatment.This study evaluates the survival outcomes of patients who underwent living-donor liver transplantation(LDLT)using right lobe liver grafts for fulminant liver failure due to hepatitis B infection.Nine cases of adult right lobe LDLT were performed in our department from September 2002 to August 2005 and the clinical and following-up data were reviewed.According to the pre-transplant Child-Pugh-Turcotte classification,the nine patients were classified as grade C.The model for end-stage liver disease(MELD)score of these patients ranged from 16 to 42.The principal complications before transplantation included abnormal renal function,hepatic coma of different degrees and alimentary tract hemorrhage.The main complications after transplantation included pulmonary infection in two cases,acute renal failure in three cases and transplantation-related encephalopathy in one case.No primary failure of vascular or biliary complications occurred.The one-year survival rate was 55.6%.There were no serious complications or deaths in donors.In general,it is extremely difficult to treat fulminant hepatitis by conservative regimen,particularly,in cases with rapid progression.Emergency adult living-donor liver transplantation is an effective treatment for fulminant hepatitis patients and is relatively safe for donors.