胆道并发症发生率的高低往往代表了一个肝移植中心的整体技术水平。欧美成熟的肝移植中心胆道并发症发生率为7%~10%，1年生存率达到90%。来自中国肝移植登记注册网（CTLR）的资料： 香港玛丽医院2006年统计了香港公民在大陆进行肝移植的148例患者，在长期随访中发现，有48%的受体发生了胆道并发症，1年生存率只有59%； 说明目前肝移植胆道并发症的防治仍然是亟待解决的难题。究其原因，还是对胆管微循环保护的研究不够深入和并发症发生的防治体系不够完善，笔者就此谈几点体会。1胆管微循环保护的理论人体肝脏胆管及血管铸型模型的研究显示，胆管为动脉单一供血，肝固有动脉和胃十二指肠动脉终末支分出3点、9点动脉滋养肝外胆管，并构成肝门部胆管周围血管丛(peribiliary vascular plexus,PVP)，胆管的动脉系统与门静脉之间无明显的交通血管，门静脉在胆管的血液供应中作用有限 (图1)。在动脉损伤时胆管很难从别的途径获得充分的血液供应，从而造成胆管的缺血性损伤。碳素墨汁灌注透明法显示，肝门部每个肝叶胆管及其分叉部均有肝固有动脉的较大分支支配，肝动脉的分支与胆管壁微血管之间呈垂直的连接方式。胆管厚切片透明后可清楚地显示出PVP的平面结构: 外层微血管直径较粗，内层微血管象链条一样排列，中层微血管连接在内、外层之间[３](图2)。动脉血流从外层较粗大血管流入位于胆管黏膜下的内层微血管，它是胆管动脉的终末分支,由内层微血管滋养的胆管上皮细胞层是胆管最易受损的部位(Achilles heel)。所以，肝移植中胆管动脉灌洗非常重要，应尽可能选用能够进入胆管黏膜内层血管网的低黏滞度灌注液。笔者研究证实了HCA液结合UW液灌注快速获取无心跳供体（NHBD）的肝脏，其保存效果优于单用UW液、Celsior液或HTK液，采用价廉低黏滞度HCA液联合UW液灌注，既能防止胆管PVP微血栓形成，又能充分发挥UW液对肝细胞和胆管细胞的保护作用.............................
Objective To compare single cell suspension of neural stem cells (NSCs) with neurospheres transplantation for spinal cord injury (SCI) so as to explore the therapeutic effectiveness of two NSCs transplantation methods for SCI. Methods The NSCs were isolated from the spinal cord of adult Sprague Dawley (SD) rats, purified and cultured. At passage 3, the cells were identified by Hoechst33342, Nestin staining, and gl ial fibrillary acidic protein staining for differentiated cells. Sixty adult SD rats (weighing 230-250 g) were made the SCI models at T10 level with modified Allen method and randomlydivided into 3 groups (20 rats in each). The injury sites were treated by injecting 5 μL sal ine (group A), 5 μL single cellssuspensions of NSCs at passage 3 (group B), and 5 μL neurospheres cell suspensions at passage 3 (group C). At preoperation and 3, 7, 14, 21, and 28 days after operation, the locomotor functions of each group were assessed using the Basso, Beattie, and Bresnahan (BBB) rating scale. HE staining was applied to observe the morphology of spinal cord. Subsequently immunofluorescence staining was used to observe microtubule-associated protein 2 (MAP-2). Results The cells cultured were NSCs by morphological observation and immunofluorescence staining. After 3 days of modeling surgery, BBB score significantly decreased when compared with preoperative score, and there was no significant difference among 3 groups at 3 and 7 days (P gt; 0.05). BBB score increased in different degrees with time; at 14, 21, and 28 days, BBB score of groups B and C was better than that of group A, and group C was better than group B, showing significant differences (P lt; 0.05). HE staining showed that spinal cord structure of group C was more clear than that of groups A and B, and had less scar. There was no significant difference in the number of MAP-2 positive cells among 3 groups at 3 and 7 days (P gt; 0.05). At 14, 21, and 28 days, the number of MAP-2 positive cells of groups B and C was significantly more than that of group A, and group C was more than group B, showing significant differences (P lt; 0.05). Conclusion Transplantation of neurospheres suspension compared with single cell can significantly promote NSCsto differentiate into neurons and is conducive to recover the lower extremity function after SCI.
Objective To summary the clinical effect of a special method of vascular reconstruction in pancreaticoduodenectomy (PD) combined with portal vein (PV) and superior mesenteric vein (SMV)/spleen vein(SV) confluence resection in the treatment of pancreatic head cancer with PV and SMV/SV confluence were both invaded by tumor. Methods Retrospectively summarized the clinical data of 1 pancreatic head cancer patient who got treatment at Shanghai General Hospital in March 2017, whose PV and SMV/SV confluence were both invaded by tumor. According to the preoperative CT judgement, the degree of tumor and vascular infiltration was determined as type of Loyer E, the invasion part was located on the right wall of the SMV/SV confluence, and the depth of infiltration did not exceed the lowest point of the SMV/SV confluence junction. This patient underwent PD combined with the invasion of the PV and the right part of SMV/SV confluence resection, with the left part of SMV/SV confluence was retained, and then vascular graft was used for the anastomosis between the PV and the SMV/SV confluence. Results The patient’s operative time was 380 min, and the blood loss was 200 mL. The blocking time of PV, SMV, and SV was 35, 30, and 30 min, respectively, without postoperative pancreatic fistula, biliary leakage, incision infection, pulmonary infection, vascular graft infection, blood clots, liver failure, and other complications. The patient recovered and discharged from hospital on postoperative twelfth day. In postoperative 1-month, the patient reviewed on abdomen CT angiography (CTA), showing the vascular graft unobstructed. In postoperative 3-, 6-, 9-, and 12-month, there was no obvious discomfort, and chest and abdominal CT found no tumor recurrence and metastasis in postoperative 12-months, as well as liver function was normal. Conclusions For pancreatic head cancer with PV and SMV/SV confluence are both invaded by tumor, PD combined with the invasion of the PV and the right part of SMV/SV confluence resection, then the left part of SMV/SV confluence and PV are anastomosed by vascular graft, this is a special method of vascular reconstruction. It can reduce SV to reconstruct the anastomosis separately, shorten PV blocking time and the liver ischemia time, so it is very important in the rapid recovery of the liver function.
Objective To explore the effectiveness of anterolateral thigh bridge flap with free skin graft wrapping vascular bridge in repairing complex calf soft tissue defects. Methods The clinical data of 11 patients with complex calf soft tissue defects between April 2018 and October 2021 were retrospectively analyzed, including 9 males and 2 females, aged 11-60 years, with a median age of 39 years. There were 8 cases of calf soft tissue defect caused by traffic accident, and 3 cases of calf skin infection caused by chronic osteomyelitis. The skin and soft tissue defects ranged from 10 cm×8 cm to 35 cm×10 cm after thorough debridement and accompanied with bone and tendon exposure. There was only one main vessel in calf of 9 cases and no blood vessel that could be anastomosed with the flap vessel could be found in the recipient site of 2 cases. The anterolateral thigh skin flap (the flap size ranged from 12 cm×10 cm to 37 cm×12 cm) was taken to repair the soft tissue defect. The donor site of the flap was treated with direct suture (8 cases) or partial suture followed by skin grafting (3 cases), and the vascular bridge was wrapped with medium-thickness skin graft. Results The flaps of 11 patients survived completely without necrosis, infection, and vascular crisis. The blood supply of the vascular bridge was unobstructed and the pulse was good. The color of the medium-thickness skin graft were ruddy. All 11 patients were followed up 2-40 months, with an average of 19.4 months. The flaps healed well with the surrounding tissues without obvious exudation and color difference. The flaps had normal color and temperature, good blood supply, and soft texture. The shape of the flap and calf contour were satisfactory and the function of the limb recovered well. The donor area of thigh flap healed by first intention without obvious scar formation. The donor area of skin healed well with a longitudinal oblong scar only and the appearance was satisfactory. ConclusionThe anterolateral thigh bridge flap transplantation with free skin wrapping vascular bridge is an effective method for the treatment of complex calf soft tissue defects.
Objective To investigate the effectiveness of Flow-through bridge anterolateral thigh flap transplantation in the treatment of complex calf soft tissue defects. Methods The clinical data of the patients with complicated calf soft tissue defects, who were treated with Flow-through bridge anterolateral thigh flap (study group, 23 cases) or bridge anterolateral thigh flap (control group, 23 cases) between January 2008 and January 2022, were retrospectively analyzed. All complex calf soft tissue defects in the two groups were caused by trauma or osteomyelitis, and there was only one major blood vessel in the calf or no blood vessel anastomosed with the grafted skin flap. There was no significant difference between the two groups in general data such as gender, age, etiology, size of leg soft tissue defect, and time from injury to operation (P>0.05). The lower extremity functional scale (LEFS) was used to evaluate the sufferred lower extremity function of the both groups after operation, and the peripheral blood circulation score of the healthy side was evaluated according to the Chinese Medical Association Hand Surgery Society’s functional evaluation standard for replantation of amputated limbs. Weber’s quantitative method was used to detect static 2-point discrimination (S2PD) to evaluate peripheral sensation of the healthy side, and the popliteal artery flow velocity, toenail capillary filling time, foot temperature, toe blood oxygen saturation of the healthy side, and the incidence of complications were compared between the two groups. Results No vascular or nerve injury occurred during operation. All flaps survived, and 1 case of partial flap necrosis occurred in both groups, which healed after free skin grafting. All patients were followed up 6 months to 8 years, with a median time of 26 months. The function of the sufferred limb of the two groups recovered satisfactorily, the blood supply of the flap was good, the texture was soft, and the appearance was fair. The incision in the donor site healed well with a linear scar, and the color of the skin graft area was similar. Only a rectangular scar could be seen in the skin donor area where have a satisfactory appearance. The blood supply of the distal limb of the healthy limb was good, and there was no obvious abnormality in color and skin temperature, and the blood supply of the limb was normal during activity. The popliteal artery flow velocity in the study group was significantly faster than that in the control group at 1 month after the pedicle was cut, and the foot temperature, toe blood oxygen saturation, S2PD, toenail capillary filling time, and peripheral blood circulation score were significantly better than those in the control group (P<0.05). There were 8 cases of cold feet and 2 cases of numbness on the healthy side in the control group, while only 3 cases of cold feet occurred in the study group. The incidence of complications in the study group (13.04%) was significantly lower than that in the control group (43.47%) (χ2=3.860, P=0.049). There was no significant difference in LEFS score between the two groups at 6 months after operation (P>0.05). ConclusionFlow-through bridge anterolateral thigh flap can reduce postoperative complications of healthy feet and reduce the impact of surgery on blood supply and sensation of healthy feet. It is an effective method for repairing complex calf soft tissue defects.