我国肝移植事业在一代又一代医学前辈锲而不舍的努力下,于 20 世纪 90 年代末取得重大突破,在随后的 20 多年中得到蓬勃发展[1-2].在完成早期的学习曲线和经验累积后,我国部分肝移植中心开始涉足更为复杂的儿童肝移植领域,但是由于多种原因,早期儿童肝移植发展较为缓慢,直到近10 年才出现"井喷式"爆发[2].儿童肝移植效果也得到显著改善,5 年生存率提高至83.6％[3],在大型儿童肝移植中心甚至可超过 90％[4],达到国际先进水平[5-6].手术数量的增加和手术质量的改善,为我国儿童肝移植临床基础研究走向世界前列奠定了基础,但与发达国家相比,我们在多学科合作、术后长期随访管理以及临床科研数据库建设等方面仍有不同程度的差距,需要逐步积累经验.

Objective:To explore the reconstruction strategy and technical selection of S3 hepatic vein with middle hepatic vein confluence in pediatric liver transplantation(LT)using living donor left lateral segment to lower the risk of vascular complications caused by variant grafts.Methods:From January 2015 to June 2021, retrospective analysis is performed for 840 consecutive cases of pediatric living donor LT using left lateral segment(LLS).There are 32 cases of S3 hepatic vein with middle hepatic vein confluence with an overall incidence of 3.81%.Individualized reconstruction strategies are implemented according to the specific conditions of variation and different interposition vessels available: group I unification venoplasty technique with interposition vein graft is employed for reconstructing HV from grafts, prolonged S3 is formed into a single opening with S2 and then anastomosed with recipient(21 cases); group Ⅱ dual HV reconstructions were performed(11 cases); venoplasty of recipients'LHV, MHV and inferior vena cava(IVC)is performed for creating a large orifice for anastomosis with S2 HV from graft and S3 is anastomosed with stump of recipient right HV directly or interposed blood vessels.Clinical features and prognosis of two groups, the incidence, treatment and prognosis of HVOO and the incidence of HVOO between variant and non-variant groups were compared.Results:The median follow-up time of variant group(32 cases)is 23.8 month with an incidence of HVOO at 15.6%.During the same period, the non-variant group incidence of HVOO is 4.5%.There is inter-group statistical difference( P=0.014).The only statistical difference between groups Ⅰ and Ⅱ is ultrasonic blood flow velocity of S3 HV at 14 POD [(39.15±16.37)vs(20.05±8.52)cm/s, P=0.001].HVOO occurred in 7 cases and 6 cases respectively in groupⅠ and group Ⅱ.There is no statistical difference( P=0.310).There are no intractable vascular complications.Long-term vascular patency of allogeneic and autologous interposition vein is satisfactory and there is no graft failure or mortality related to HVOO. Conclusions:Selecting strategies and techniques for reconstructing S3 hepatic vein with middle hepatic vein confluence at our center are reasonable, safe and effective.And the overall treatment efficacy is satisfactory.Reasonable selection of multidimensional reconstruction methods and accurate application of various technologies are conducive to improving patient prognosis.

Objective:To explore the relationship between serum lactate level and early prognosis after liver transplantation (LT) in children.Methods:Between January 1, 2018 and December 31, 2020, 675 pediatric LT recipients were recruited. Clinical data were retrospectively reviewed, early postoperative serum lactate level and clearance rate recorded and receiver operating characteristic (ROC) curve plotted for determining optimal cut-off values. The inter-group differences in early postoperative complications and patient/graft survival rates were compared.Results:According to ROC, blood lactate levels >1.99 mmol/L at 12 h postoperatively were associated with early postoperative graft loss (AUC 0.73, 95% CI: 0.62-0.84, P=0.01). Age and weight of recipients in high-level group were 7.17(5.70-10.40) month and 7.00(6.00-8.60) kg and both were significantly lower than those in low-level group [7.80(6.21-13.58) month and 7.20(6.45-9.00) kg]. The inter-group differences were statistically significant ( P=0.017, P=0.034). Blood plasma transfusion volume, red blood cell transfusion volume, portal vein pressure pre-closure, postoperative intensive care unit (ICU) stay, ventilator use time, early allograft dysfunction rate, early postoperative pulmonary infection rate and recipient mortality rate in high-level group were 400 (200-400) ml, 2.00 (2.00-4.00) U, (15.71±4.44) mmHg, 2.50(2.00-3.00) day, 3.81(2.47-8.50) hour, 22.95%(42/185), 16.76%(31/185) and 6.49%(12/185) respectively. The above values were significantly higher than those in low-level group 200(100-400) ml, 2.00 (2.00-3.00) U, (14.69±4.68) mmHg, 2.00(2.00-3.00) day, 3.53(2.34-6.12) hour, 14.69%(72/490), 11.02%(54/490) and 1.43%(7/490) respectively. The inter-group differences were statistically significant ( P<0.001, P=0.014, P=0.015, P=0.037, P=0.043, P=0.011, P=0.045 & P<0.001). The incidence of early postoperative acute cellular rejection was significantly lower in high-level group than that in low-level group [11.89%(22/185) vs 22.86%(112/490)]. The inter-group difference was statistically significant ( P=0.01). The 1/3-month cumulative survival rates of patient/graft were 94.6%, 94.1% and 92.4%, 91.4% in high-level group versus 99.2%, 98.6% and 99.0%, 98.4% in low-level group. There were significant inter-group differences ( P=0, P<0.000 1). With a rising level of lactate at 12 h postoperatively, risk of early graft loss and early recipient mortality spiked markedly ( P<0.05). Conclusions:Serum lactate level post-operation is a valid predictor of early prognosis after LT in children.

目的 探讨急性脑梗死(ACI)继发肺部感染患者病原菌学及相关危险因素.方法 对2019年1月-2022年3月天津市第一中心医院收治219例ACI患者的临床资料进行回顾性分析,根据所选患者是否发生肺部感染将其分为未感染组(161例)及感染组(58例).统计肺部感染患者病原菌学特点,比较两组临床资料,并采用多因素Logistic回归分析法分析ACI继发肺部感染的危险因素.结果 从58例肺部感染患者共分离出64株病原菌,其中革兰阴性菌的占比最高(76.56％).感染组年龄大于未感染组,住院时间＞14 d、有吸烟史、肺部疾病史、合并基础疾病、有侵入性操作、低蛋白血症、吞咽功能障碍、入院时美国国立卫生院神经功能缺损(NIHSS)评分＞14分的患者占比大于未感染组(P＜0.05).多因素Logistic回归分析结果显示,ACI继发肺部感染的独立危险因素包括有吸烟史、肺部疾病史、年龄大、有侵入性操作、吞咽功能障碍、入院时NIHSS评分＞14分(P＜0.05).结论 ACI继发肺部感染与有侵入性操作、吞咽功能障碍、入院时NIHSS评分＞14分等因素有关,其感染病原菌主要为革兰阴性菌,为减少肺部感染的发生,临床可据此给予患者针对性的治疗及干预措施.

目的 探讨实时三维经食管超声心动图(RT-3DTEE)及心脏血管造影(CCTA)在左心耳封堵术中对封堵器型号选择的应用价值.方法 选取北部战区总医院自2020年5月至2021年3月收治的行左心耳封堵术的非瓣膜性房颤患者39例为研究对象.术前应用RT-3DTEE和CCTA观察左心耳的大小、形态、立体结构,并明确有无血栓;术中应用RT-3DTEE和心脏造影(CA)测量左心耳锚定区最大直径(LZD).将RT-3DTEE、CA、CCTA这3种方式所测LZD与封堵器直径进行相关性和一致性分析.结果 39例患者均成功植入Watchman封堵器,封堵器直径为(23.87±3.17)mm.CCTA所测LZD最大[(25.83±3.35)mm],大于RT-3DTEE的(24.06±2.98)mm和CA的(23.45±3.23)mm,但3种方法所测LZD之间差异无统计学意义(P>0.05).3种方法中,RT-3DTEE所测LZD与封堵器直径相关性最优(r=0.93,P<0.001),优于CCTA(r=0.81,P<0.001)和CA(r=0.89,P<0.001).Bland-Altman一致性分析显示所有数据点均在95％一致性界限内,RT-3DTEE所测LZD与封堵器直径之间一致性最优.结论 RT-3DTEE联合CCTA在左心耳封堵术中能够获得更多关于左心耳解剖结构的信息,可为封堵器型号的选择提供可靠、准确的临床建议.

Objective:To study the impact of donor left hepatic vein classification and the reconstruction methods on hepatic venous outflow obstruction (HVOO) after pediatric living-donor liver transplantation using left lateral liver segments.Methods:A retrospective study was performed on the clinical data of 653 children recipients who underwent living-donor liver transplantation with left lateral liver segments from January 2014 to December 2020 at Tianjin First Central Hospital. There were 309 males and 344 females, aged 7.0 (6.0, 10.0) months, with an age range of 3-121 months. Based on the left hepatic vein on preoperative donor enhancement CT as well as the intraoperative reconstruction methods, the recipients were divided into 3 groups: type Ⅰ group ( n=514), anastomosis using a single opening was performed directly between the donor and the recipient; type Ⅱ group ( n=118), angioplasty was performed on two adjacent recipient venous orifices before anastomosis, and type Ⅲ group ( n=21), an interposition vessel was anastomosed to two widely spaced openings or the two veins were anastomosed separately. The preoperative general status of the patient, postoperative HVOO incidences, and graft and recipient survival rates were compared among the three groups. The patients were followed up by outpatient reexamination or telephone. Results:Graft to recipient weight ratio in the type Ⅲ group was smaller than that in the type Ⅰ group and the type Ⅱ group ( P<0.05). For all the 653 patients, the incidence of postoperative HVOO was 4.59% (30/653), with the incidences of HVOO in the 3 groups of patients were 4.1% for the type Ⅰ group (21/514), 5.1% for the type Ⅱ group (6/118), and 14.3% for the type Ⅲ group (3/21), respectively. There was no significant difference among the groups ( P>0.05). The recipient cumulative survival rates at 1 and 3 years after surgery in the type I group were 97.8% and 97.0%, and the corresponding rates in the type Ⅱ group were 96.5% and 94.2%, and in the type Ⅲ group were 94.1% and 86.9%, respectively. There was a significant difference between the type Ⅰ and type Ⅲ groups ( P=0.048). The graft cumulative survival rates at 1 and 3 years in the type Ⅰ group were 97.4% and 96.9%, and the corresponding rates in the type Ⅱ group were 94.9% and 92.5%, and in the type Ⅲ group were 94.1% and 86.9%, respectively. The difference in the postoperative graft cumulative survival rates between the type Ⅰ group and type Ⅱ group was significant ( P=0.044). Conclusions:The anatomy of the left hepatic vein supplying the left lateral liver segment was highly variable, and the majority of the variations could be reconstructed. A reasonable reconstructive method could reduce the incidence of postoperative HVOO and improved the outcomes of the graft.

Objective: To explore the use of multi-mode preoperative rehabilitation strategy in patients with ulcerative colitis（UC） undergoing preoperative stoma resection. Methods: A total of 120 UC patients who underwent preoperative stoma resection after IPAA were enrolled in this study. The patients receiving multi-mode preoperative rehabilitation interventions at home were assigned to the experimental group（n = 60）, and those receiving routine treatment and nursing after IPAA as the control group（n = 60）. Postoperative ventilation time, postoperative hospitalization days, 6-minute walking distance at admission, 1 week and 4 weeks after surgery, and prealbumin and albumin indexes at admission, 3 days and 7 days after surgery were compared between the two groups. Results: The 6-minute walking distances in the experimental group were significantly higher than those in the control group at admission, 1 and 4 weeks postoperation（P ＜ 0.05）. The serum levels of pre-albumin and albumin in the experimental group at 1 day preoperation, 3 days postoperation and discharges were higher than those in the control group（P ＜ 0.05）.The hospitalization days were markedly reduced as compared with the control group（P ＜ 0.05）. Conclusion: Multimode pre-rehabilitation interventions at home could contribute to enhancing the recovery of intestinal function after surgery, and reducing surgical stress and hospitalization days in the patients with UC.

Objective:To investigate the effects of different donor types on the prognosis of pediatric liver transplant recipients with low-body-weight (≤6 kg).Methods:The clinical data of low-body-weight pediatric liver transplant recipients from the Department of Pediatric Organ Transplantation, Tianjin First Central Hospital from January 2013 to June 2021 were retrospectively analyzed.The recipients were divided into living donor group, split donor group and whole liver group according to the donor type.The basic information of donors and grafts, preoperative and intraoperative information of recipients, major postoperative complications and survival rates of recipients and grafts were compared.Results:A total of 244 recipients were enrolled in this study, including 183 cases in the living donor group, 18 cases in the split donor group and 43 cases in the whole liver group.There were no statistical differences in the preoperative data of the three groups, including gender, age, body weight, blood type matching, primary disease, Child-pugh grading, and pediatric end-stage liver disease score (PELD). The incidence of hepatic artery thrombosis (HAT) in the three groups was 2.2%, 16.7% and 25.6%, respectively, the difference was statistically significant between the living donor group and the split donor group ( P=0.017) as well as the whole liver group ( P<0.001). There was no significant difference between the latter two groups ( P=0.525). The median follow-up time was 37, 31 and 47 months, respectively.The 1-year and 3-year cumulative graft survival rates were 92.9%, 91.3%, 83.3% and 83.3% 76.7%, 76.7% ( P=0.016), respectively.There was statistical difference between the living donor group and the whole liver group ( P=0.004), and no statistical difference between the split donor group and the living donor group ( P=0.212) as well as the whole liver group ( P=0.610). The 1-year and 3-year cumulative recipient survival rates in the three groups were 92.9%, 91.3%, 94.4% and 94.4%, 86.0%, 86.0%, respectively, and there was no statistical difference among the three groups ( P=0.463). Multivariate analysis suggested that donor age and anhepatic phase were independent risk factors for HAT.Cold ischemia time, volume of intraoperative blood transfusion and HAT were independent risk factors for early graft loss (within 3 months). The volume of intraoperative blood transfusion and the duration of anhepatic phase were independent risk factors for recipient death. Conclusions:Living donor liver transplantation is more effective than whole liver transplantation for children with low body weight (≤6 kg). Due to the small sample size and the early exploration stage of split liver transplantation in children, the efficacy of split liver transplantation remains to be explored in clinical practice.

Objective:To explore the correlation between the percentage of eosinophils in peripheral blood and the occurrence of acute rejection and evaluate the predictive value of the percentage of eosinophils in blood for early rejection in children after liver transplantation (LT).Methods:From January 2019 to December 2020, clinical data were retrospectively reviewed for children undergoing LT.They were divided into two groups of acute rejection and non-rejection based upon the pathological findings of liver biopsy within 6 months.The mean percentage of early postoperative eosinophil was compared between two groups.With a contour graph, repeated measurement ANOVA was performed for determining the correlation with the occurrence of acute rejection.And receiver operating characteristic (ROC) curve was plotted for determining the critical mean percentage of eosinophil during an early stage of rejection.Results:A total of 396 children undergoing LT were recruited.The postoperative incidence of early acute rejection was 17.93%(71/396). After stratification by age (0~1y/1-6y/>6y), the mean percentage of eosinophil during an early postoperative period was significantly correlated with the occurrence of rejection within 6 months in children aged 0~1 years, but not in children of other ages.The results of repeated measurement indicated that the mean percentage of eosinophil in acute rejection group was significantly higher than that in non-rejection group among children aged 0~1 ( F=25.38, P<0.001). ROC curve of the mean percentage of eosinophil predicting the rejection reaction at 1~7 days showed that its area under curve (AUC) was 0.743 (95% CI: 0.668-0.817) with a sensitivity of 65%, a specificity of 74%, a critical value of 3.23%, a positive predictive value of 31.18% and a negative predictive value of 91.05%. Conclusion:Among pediatric LT recipients, the mean percentage of eosinophil at Day 1-7 has certain predictive value for the occurrence of acute rejection after LT in children aged 0~1 years.With high specificity and negative predictive value, it may be utilized as an indicator of early risk screening.

Objective:To explore the feasibility of withdrawing immunosuppression after pediatric liver transplantation (LT) and to explore the related influencing factors of immune tolerance.Methods:Clinical data were retrospectively reviewed for 14 children undergoing LT and withdrawing immunosuppressant postoperatively from January 2013 to January 2017. There were 8 boys and 6 girls with a body mass index (BMI) of (20.32±4.65) kg/m 2. The age of recipients at the time of transplantation ranged from 0.58 to 0.71 years and the median age was 0.58 years. The recruiting age ranged from 2.65 to 4.52 years and the median age was 3.75 years. And the interval from transplantation to inclusion was (3.08±1.10) years. Among donors, there were 6 males and 8 females with an age range of (22.84±13.93) years. In 14 cases, liver transplant was performed for patients with biliary atresia, including living donor liver transplantation (n=10) and cadaveric liver transplantation (n= 4) . Among participants in immunosuppressant withdrawing, 4 cases had immunosuppressant removed for post transplant lymphoproliferative disorder (PTLD) . All of them received immunotherapy post-LT. Children aged >6 years received a triple regimen of steroid + tacrolimus (FK506) + montecoculphate while those aged ≤6 years had a double regimen of hormone + FK506. In 10 cases, immunosuppressant was withdrawn according to the withdrawal plan. Four PTLD children received immunosuppressive tapering alone according to pathological type and clinical symptoms. Periodic liver function tests and programmed liver biopsies were performed at the beginning of the study, 1 year and 2 years. Hematoxylin eosin (HE) staining was performed for evaluating acute liver rejection and fibrosis by Banff standard and Ishak scoring system. Results:Among them, 5/14 children successfully stopped immunosuppressive to achieve immune tolerance. Nine children became immune intolerant and 3 had normal liver function during follow-ups. However, the pathological results of programmed liver biopsy hinted at rejection. The remaining 6 cases showed abnormal liver function during follow-ups and liver function normalized after resuming immunosuppressive therapy. As compared with immune intolerants, age at the time of transplantation was smaller for immune tolerants. The median age of transplantation was 0.58 (0.50~0.58) years. The age of immune intolerants during transplantation was 0.67 (0.58~ 2.04) years and the difference was statistically significant ( P=0.012, Z= -2.51 ) . The level of direct bilirubin (DBIL) in immune tolerants was lower than that in immune intolerants. The median value of DBIL was 2.47(2.23~2.53) μmol/L in immune tolerants and 2.63(2.52~2.99) μmol/L in immune intolerants and the difference was statistically significant ( P=0.004, Z= -2.87) . Conclusions:The proportion of immune tolerance after pediatric liver transplantation remains high and age and DBIL level affect immune tolerance.

Objective:To explore the risk factors of biliary complications(BCS)after pediatric living donor liver transplantation(LDLT).Methods:From January 2016 to December 2020, retrospective review of clinical data was performed for 681 children aged <18 years undergoing LDLT.There were 324 boys and 357 girls with a median age of 7.4 months and a median weight of 7.0 kg.Among 61 BCS patients(9.0%), there were biliary stricture(n=34, 5.0%), bile leakage(n=21, 3.1%)and bile leakage combined with biliary stricture(n=6, 0.9%). According to the absence or presence of BCS after LT, the recipients were divided into two groups of BCS(n=61)and non-BCS(n=620). The incidence and risk factors of BCS were analyzed.T-test, Wilcoxon rank sum test, Chi square or Fisher exact test was employed for univariate statistical analysis and Logistic regression for multivariate statistical analysis.Results:The median follow-up period was 35.5 months.Univariate analysis revealed statistically significant inter-group differences( P=0.005, 0.046, 0.009, 0.011, 0.024, 0.023, 0.004, 0.038, 0.002, 0.029, 0.023, 0.002, 0.011)in donor age[(31.4±5.7)vs.(34.3±7.5)years], time of anhepatic phase[43(37.0, 53.0)vs.47(38.8, 56.0)min], time from portal vein opening to hepatic artery opening[35(30.0, 41.0)vs. 38(30.8, 47.8)min], type of perfusion fluid, number of donor bile ducts, intestinal loop length[40(30.0, 40.0)vs.40(25.0, 40.0)cm], mode of biliary reconstruction, whether or not placing a support tube, incidence of hepatic artery thrombosis[1.6%(10/620)vs.9.8%(6/61)], incidence of abdominal infection[4.5%(28/620)vs.11.5%(7/61)], incidence of cytomegalovirus(CMV)infection[55.3%(343/620)vs.70.5%(43/61)], incidence of portal vein thrombosis[1.1%(7/620)vs.8.2%(5/61)]and incidence of pulmonary infection[19.0%(118/620)vs.32.8%(20/61)]. Multivariate analysis indicated that independent risk factors of BCS included donor age( P=0.023), number of donor bile ducts( P=0.017), time from portal vein opening to hepatic artery opening( P=0.010), hepatic artery thrombosis( P=0.004), abdominal infection( P=0.019), CMV infection( P=0.022), portal vein thrombosis( P=0.003), pulmonary infection( P=0.021)and short intestinal loop length( P=0.012). Conclusions:Biliary complications are common after pediatric LDLT.Independent risk factors are donor age, number of donor bile ducts, time from portal vein opening to hepatic artery opening, hepatic artery thrombosis, abdominal infection, CMV infection, portal vein thrombosis, pulmonary infection and short length of intestinal loop.

术后胃瘫综合征(postsurgical gastroparesis syn-drome,PGS)是一种以胃排空障碍为主的胃动力紊乱综合征,是发生于胃大部切除,胰十二指肠切除、胃癌根治等手术后的以无胃流出道梗阻、胃肠动力紊乱所致的非机械性胃排空延迟,发生率为0.47％～28.00％[1-2],常发生在手术后3～5 d拔出胃管开始进食或改半流质饮食后,轻者表现为自觉恶心、腹胀及上腹部压迫感、肠鸣音减弱,重者出现重度胃潴留、呕吐大量胃液、胆汁返流、肠鸣音消失、食管运动障碍[3],严重影响术后恢复,术后早期肠内营养(early enteral nutrition,EEN)被多项指南[41推荐,EEN联合消化液回输可有助于减少消化液丢失、纠正电解质紊乱.

Objective:To evaluate the efficacy of basiliximab plus single steroid induced immunotherapy during donor-recipient ABO-compatible pediatric liver transplantation(LT).Methods:From January 1, 2019 to January 19, 2020, a total of 150 children of donor-recipient ABO-compatible LT were randomly divided into basiliximab group(basiliximab plus single steroid induction and postoperative immunosuppression with tacrolimus alone)and steroid group(conventional dose of steroid induction plus postoperative immunosuppression with tacrolimus and steroid). Clinical characteristics, survival rate of recipients and liver allografts, rejection rate and infection rate were observed.Results:The median follow-up time was 9.2(0.7~15.5)months.No significant inter-group differences existed in survival rate of recipients/grafts or the incidence of acute rejection, early postoperative pulmonary infection, cytomegalovirus and Epstein Barr virus infection. However, in 56 living donor LT, acute rejection(6cases, 10.7%)occurred in basiliximab group versus(12cases, 25.5%)in steroid group. During living donor LT, the incidence of acute rejection declined markedly in bsiliximab group as compared with steroid group( P=0.043). Conclusions:Both safe and effective for donor-recipient ABO-compatible pediatric LT, basiliximab plus single steroid induced immunotherapy can significantly lower the occurrences of acute rejection during living donor LT.

目的 探讨肝移植治疗儿童胆道闭锁(biliary atresia,BA)合并肝脏恶性肿瘤的临床疗效及预后.方法 2015年1月1日—2019年12月31日期间天津市第一中心医院儿童器官移植科的儿童肝移植患者中,有4例原发疾病为胆道闭锁合并肝恶性肿瘤,回顾性分析这4例患者的临床资料.结果 4例患者中BA合并肝母细胞瘤(hepatoblastoma,HB)3例,BA合并肝细胞癌(hepatocellular carcinoma,HCC)1例,所纳入的患者术前均诊断BA,其中1例术前诊断为BA合并HB,其余3例为肝移植术后病理诊断为BA合并HB或HCC.4例患者肝移植术后均顺利恢复,术后中位随访时间为25.5个月,4例患者全部存活,随访期内均未发现肿瘤复发.结论 肝移植是BA合并肝脏恶性肿瘤的有效治疗方式,对于低风险患者,移植术后未行辅助化疗的近期疗效确切,远期疗效尚需进一步研究.

Objective:To explore the efficacy of reduced left lateral segment graft during pediatric living donor liver transplantation.Methods:From January 2014 to December 2019, 67 children aged under 1 year underwent living donor liver transplantation with reduced left lateral segment graft (RLLS group). Clinical data were analyzed retrospectively and compared with those of left lateral segmentgraft living donor liver transplantation (LLS group). The differences in basic profiles, postoperative complications and postoperative patient/graft survival rate were compared.They were divided into two groups according to whether graft/recipient weight ratio (GRWR) was more than 4%.And major postoperative complications and graft/recipient survival rates were compared.Results:Age, height and weight of recipients were significantly lower in RLLS group than those in control group ( P<0.05). However, donor weight, donor body mass index (BMI), estimated graft volume and proportion of fatty liver from donor were significantly higher than those in control group ( P<0.05). Operative duration, intraoperative blood loss and erythrocyte transfusion were significantly higher than those in control group ( P<0.05). No significant inter-group differences existed in average postoperative hospital stay, intensive care unit (ICU) stay duration or postoperative ventilator use time ( P>0.05); no significant inter-group difference existed in the incidence of such major surgical complications as hepatic artery thrombosis, portal vein stenosis and bile duct complications ( P>0.05). The 1/3-year cumulative survival rates of postoperative patients and grafts were 92.5%, 91.2% and 92.5%, 91.2% in RLLS group and 96.3%, 95.3% and 95.9%, 95.1% in LLS group respectively.There was no significant inter-group difference ( P<0.05). The rate of postoperative hepatic vein stenosis was significantly higher in GRWR>4% group than that in control group ( P<0.05). Conclusions:Due to a rapid progress of technology, living donor liver transplantation has achieved satisfactory outcomes in children with reduced left lateral segment graft.Whether or not performing reduction surgery should be judged comprehensively according to the matching of donors and recipients and blood flow of liver during operations.And GRWR>4% is not an implementation criterion.

Objective:To summarize the clinical characteristics of de novo non-alcoholic fatty liver disease(NAFLD)in pediatric recipients in early stage post liver transplantation(LT)to enhance our understanding of this rare complication.Methods:The clinical data of 8 recipients who underwent liver transplantation in the children's organ transplantation Department of Tianjin first central hospital from January 2014 to December 2019 and developed NAFLD within 3 months after operation were retrospectively analyzed. Taking liver biopsy as the standard for the diagnosis of NAFLD, the clinical and histological characteristics of early NAFLD after transplantation were summarized and analyzed.The median time from LT to NAFLD was 1.55(0.63, 2.93)months and the median follow-up period 23.60(8.74, 32.58)months.Results:NAFLD was all pathologically confirmed by liver biopsy. Seven cases had abnormal liver function and 1 case of steatosis was detected by ultrasound pre-biopsy. There were acute cellular rejection(2 cases)and drug-induced graft injury(1 case). The median period of recovery for graft function was 32.0(12.0, 34.0)days. Macrovesicular graft steatosis predominated.Conclusions:Occurring earlier in children after LT, NAFLD is frequently accompanied by abnormal graft function. Liver biopsy is required for making a definite diagnosis. Abnormal graft function persists a long time. However, prognosis is generally decent.

目的 探索巴利昔单抗在小于2岁的ABO血型不相容儿童肝脏移植中的应用效果及其安全性.方法 采用随机对照研究的方法,前瞻性收集2019年1月至2020年8月期间笔者所在医院的44例符合纳入标准的患儿,随机分为试验组与对照组,试验组术中及术后第4天使用巴利昔单抗免疫诱导,对照组不使用诱导治疗.比较2组肝移植受者肝移植术后并发症发生情况、术后3个月的供体特异性抗体(DSA)发生率以及随访期间的肝肾功能变化、生长发育情况和患儿存活情况.结果 共44例患儿纳入本研究,其中试验组19例,对照组25例.2组患儿肝移植术后他克莫司使用剂量和他克莫司谷值浓度、血肌酐、血胱抑素、身高和体质量的变化趋势差别不大;肝移植术后的主要并发症,包括肺感染、巨细胞病毒血症、EBV病毒血症及肝移植术后3个月内血流感染发生率比较差异均无统计学意义(P＞0.05),但试验组的急性细胞性排斥发生率低于对照组(P=0.04).术后3个月时,试验组患儿的DSA阳性率(0,0/19)低于对照组(20.0％,5/25),差异有统计学意义(P=0.04).所有患儿的术后中位随访时间为16.6个月(3.8～25.4个月).随访期间对照组死亡2例,试验组和对照组的生存情况比较差异无统计学意义(P=0.24).结论 巴利昔单抗可安全应用于小于2岁的ABO血型不相容儿童的肝移植,不增加术后感染风险,且术后早期急性细胞性排斥反应发生率及术后3个月的DSA发生率均较低.

目的 比较拉米呋定与乙肝疫苗方案预防乙型肝炎核心抗体(hepatitis B core antibody,HBcAb)阳性供肝儿童肝移植术后新发乙型肝炎病毒(hepatitis B virus,HBV)感染效果.方法 对天津市第一中心医院自2013年5月—2019年6月251例接受HBcAb阳性供肝儿童肝移植的资料进行回顾性分析,依据采用预防方案的不同分为拉米呋定组和乙肝疫苗组,对两组患儿的新发乙肝病毒感染情况以及临床资料进行比较分析.结果 拉米呋定组45例和乙肝疫苗组206例,两组在供受者的临床特征方面无显著差异,两组的新发乙肝病毒感染例数分别为5例(11.1％)和10例(4.9％),发生率无显著统计意义(P=0.075),停用拉米呋定与新发乙肝存在关系.结论 单用拉米呋定和乙肝疫苗均是有效预防HBcAb阳性供肝术后新发乙肝的方案,停用拉米呋定会增加新发乙肝的风险.

目的:明确寻常型银屑病相关复发因素,建立科学有效的自我管理模式.方法:收集2017年3月至2018年12月皮肤科门诊就诊的寻常型银屑病复诊患者,填写调查问卷,通过Logistic回归法分析相关影响因素,根据影响因素制定个体化健康教育处方.将复诊的患者随机分为对照组和干预组,分别实施常规健康教育和个体化健康教育处方的临床干预,3个月后比较有效率,6个月后比较复发率.结果:共计213例银屑病复诊患者完成调查问卷,其中177例为复发患者,呼吸道感染、吸烟、紧张焦虑、睡眠障碍、寒冷、干燥、中断治疗与复发相关性大.98例(干预组54例,对照组44例)银屑病复发患者参与随机干预试验,干预组有效率和复发率分别为87.03％和11.1％,对照组分别为88.63％和36.4％,其中复发率差异有统计学意义(P<0.05).结论:银屑病患者复发与自我管理能力密切相关,个体化健康教育处方有助于提高银屑病患者的疗效,降低复发率.

目的:研究儿童肝移植术后5年发生纤维化的临床相关危险因素。方法:2013年1月至2016年12月天津市第一中心医院共完成儿童肝移植498例，其中94例于术后4～6年行肝穿刺活检。根据术后肝活检的结果将受者分为纤维化组和非纤维化组，采用单因素分析及多因素Logistic回归分析儿童肝移植术后肝纤维化临床危险因素。根据筛选出的独立危险因素建立Logistic回归模型，得到联合预测因子的预测值。绘制联合预测因子的受试者工作特征曲线(ROC)，评价其预测纤维化发生的准确性。结果:94例儿童受者中有54例(57.5%)出现肝纤维化。单因素分析显示，两组受者在冷缺血时间( Z＝-2.094)、热缺血时间( Z＝-2.421)、药物性肝损伤( χ2＝7.389)、胆道狭窄( χ2＝4.560)、肝动脉血栓、排斥反应( χ2＝6.955)上差异有统计学意义(均 P<0.05)。多因素Logistic回归分析显示冷缺血时间(OR＝1.003, 95%CI：1.000～1.006)、药物性肝损伤(OR＝6.493, 95%CI：1.615～26.101)、胆道狭窄(OR＝6.451，95%CI：1.205～33.295)和排斥反应(OR＝2.735，95%CI：1.057～7.077)是肝移植术后发生肝纤维化的独立危险因素。联合预测因子的ROC曲线下面积(AUC)为0.786(95%CI：0.691～0.881)，临界值为0.311，灵敏度为90.70%，特异度为60.00%，且联合预测因子的诊断价值与其他独立危险因素单独诊断的价值差异有统计学意义( P<0.05)。 结论:儿童肝移植术后5年肝纤维化的发生率为57.5%，冷缺血时间、胆道狭窄、排斥反应和药物性肝损伤是儿童肝移植术后5年发生纤维化的独立危险因素。联合预测因子对儿童肝移植术后肝纤维化的发生具有较高的预测价值。