摘要目的 探讨逆灌注条件下门静脉、肝动脉不同复流顺序对肝移植患者缺血/再灌注损伤和术后早期肝功能恢复的影响.方法 回顾性分析联勤保障部队第900医院2009年1月至2013年6月97例经典原位肝移植患者资料.依据不同复流顺序分为:R-IPR组(门静脉先复流,35例),R-IAR组(肝动脉先复流,30例),R-SAPR组(门静脉肝动脉同时复流,32例).术前1天,术后1、3、5、7天监测肝功能、凝血功能等相关指标,用透射电镜观察复流后2h肝内胆管上皮细胞及肝细胞超微结构,图像分析系统计量分析线粒体形态.结果 R-IPR组、R-SAPR组及R-IAR组胆管二次热缺血时间(WIT Ⅱ)呈依次下降趋势,差异有统计学意义(P＜0.05).术后1d,R-IAR组丙氨酸氨基转移酶[(471.3±86.7) U/L比(562.2± 150.4) U/L比(553.2±153.1) U/L]、γ谷氨酰转肽酶[81.3±25.9)U/L比(115.8±39.3) U/L比(110.8±42.7) U/L]和总胆红素[(91.4±42.6) μmol/L比(124.9±49.4) μmol/L比(129.0±45.8)μmol/L]均低于R-IPR组与R-SAPR组,差异有统计学意义(P＜0.05).且R-IAR组、R-SAPR组、R-IPR组胆管细胞线粒体肿胀程度依次加重,R-IAR组线粒体平均面积、周长较其他两组减小,差异有统计学意义(P＜0.05).结论 经典原位肝移植在逆灌注条件下,先开放肝动脉可促进肝移植术后早期肝脏功能恢复,并且由于胆道WIT Ⅱ缩短,还减轻了胆道系统的缺血/再灌注损伤.

abstractsObjective To study the influence of sequential and contemporaneous revascularizations of portal vein and hepatic artery during liver transplantation with retrograde reperfusion on the ultra-structural changes in intrahepatic cholangiocytes of the graft with liver ischernia reperfusion injury,and the recovery of short-term liver function after operation.Methods The clinical data of 97 patients who underwent orthotopic liver transplantation (OLT) using retrograde reperfusion via the vena cava (IVC) in our hospital from January,2009 to June,2013 were retrospectively analyzed.Using to the different sequences of revascularization,97 digible patients were divided into three groups:group R-IPR:the initial arterial revascularization group (35 patients);group R-IAR:the initial portal revascularization group (30 patients);group R-SAPR:simultaneous reperfusion group (32 patients).Liver function,coagulation function and other related parameters were continuously monitored for the transplant recipients at the following time points:1 day before operation,2 hours after reperfusion and on postoperative Day 1,2,5 and 7.The ultra-structure of intrahepatic bile duct epithelial cells at 2 hours after reperfusion were studied by transmission electron microscopy and morphometric analysis of mitochondria was performed by the computer image analysis system.Results The levels of ALT,GGT and TB in group R-IAR were significantly lower than those in group R-IPR and group R-SAPR (P＜0.05).There were no significant differences among the three groups in other parameters that reflected liver function at any time point (P＞0.05).In group R-IAR and group R-IPR,mitochondrial swelling of bile duct epithelial cells was more severe than that in group R-SAPR.There were significant differences among the three groups in the mitochondrial average area and the average perimeter (P＜0.05).Mild swelling of mitochondria in hepatic cells was observed in group R-IAR and group R-IPR.There was no significant difference in the mitochondrial average area and average perimeter between the two groups (P＞0.05).Mitochondrial swelling of hepatic cells was most severe in group R-SAPR.There were significant differences in the average area and average perimeter of hepatic cell mitochondria between group R-SAPR and the other two groups (P＜0.05).Conclusion During liver transplantation with retrograde reperfusion,initial arterial revascularization reduced the short-term levels of transaminases,improved early liver function after operation and protected the intrahepatic bile duct against the second ischemia reperfusion injury.