Objective: To investigate the clinical evaluation effects of Corona Virus Disease 2019 (COVID-19) risk assessment scale on preoperative and surgical risk of liver transplantation during the COVID-19 outbreak

ObjectiveTo discuss the preservation solution (PS) contamination and initial experience of liver transplantation from organ donation by citizens after death and initial experience.MethodsThe 78 liver transplant recipients in a hospital in Guangzhou from March 2016 to October 2017 were divided into two groups based on the finding of the culture of PS. The positive group received the sequential therapy of antibiotics with ertapenem and imipenem for one week. The negative group stopped using imipenem. The situation of PS contamination and infection after liver transplantation and prognosis during the follow-up 3 months of the recipients were analyzed.ResultsAmong the 78 recipients, 32 PSs culture were positive (41.03%), and 33 strains of pathogens were isolated. The most common pathogenic bacteria were gram-negative bacilli (9 strains, 27.27%) and coagulase–negative staphylococci (9 strains, 27.27%). The infection rates after liver transplantation in culture positive group and culture negative group were 31.25% and 13.04%, respectively (χ2=3.837, P=0.048）. The most frequent infection sites were lower respiratory tract (5 cases, 31.25%), abdominal cavity (5 cases, 31.25%) and surgical incision (4 cases, 25.00%). There was no significant difference of postoperative infection rate among patients with different CTP, MELD and surgical methods (P>0.05). One case (1.28%) was infected with the same pathogenic bacteria as PS contamination 3 weeks after liver transplantation, and died of multiple organ failure. There was no significant difference of the acute rejection rate (1, 3.13% and 2, 4.35%) and mortality (2, 6.25% and 5, 10.87%) between the two groups (P>0.05).ConclusionContamination of the PS is frequent in liver transplantation, which is the risk factor for postoperative infection of recipients. Early targeted antimicrobial treatment against pathogens cultured from PS is positive in reducing the contamination-associated infection rate after liver transplantation.

Although studies have shown that detection of peripheral circulating tumor cells (CTCs) is an important tool for monitoring prognosis and therapeutic response in patients with cancer, few studies have analyzed their role in patients with hepatocellular carcinoma (HCC) following liver transplantation (LTx). The present study examined whether CTC levels were associated with HCC recurrence in patients with HCC after LTx. This prospective study included 47 patients who received LTx between October 2014 and May 2016 and who underwent analysis for peripheral CTCs at least twice using the CanPatrol system. Baseline Edmondson stage, T stage, accumulated tumor diameter, microvascular cancer embolus, and alpha-fetoprotein (AFP) levels were greater in patients with recurrence (all p<0.05). In addition, 70.2% of patients with HCC were CTC-positive. Although the proportion of CTC subtypes changes following LTx and over the follow-up period with increased epithelial and interstitial CTC levels, no significant associations were observed between change in total CTCs or CTC subtype and HCC recurrence (all p>0.05). In conclusion, baseline Edmondson stage, T stage, accumulated tumor diameter, microvascular cancer embolus, and AFP levels may be predictive of HCC recurrence following LTx; however, CTC levels and subtypes were not. Further large, multicenter studies are necessary to confirm these results.

Objective To summarize the development of China donation after cardiac death (DCD), influence factors of DCD potential donors and application of extracorporeal membrane oxygenation (ECMO) in DCD.Methods The clinical data of DCD donors in Guangzhou General Hospital of Guangzhou Military of PLA Organ Procurement Organization (OPO) during January 2010 and December 2015 was analyzed retrospectively, mainly focusing on the indexes like the total number of DCD, average growth rate per annum, donation rate per million population (PMP), discard of DCD donor liver, proportion of C-Ⅰ, C-Ⅱ and C-Ⅲ, influence factors of organ donation in DCD potential donors and the ECMO application in DCD.The data of DCD of China and Guangdong province during the same period was also summerized.Chi-square test and Man-Whitney U test was used to compare the proportion of C-Ⅰ between our hospital and China and average growth rate per annum between our hospital and Guangdong province, respectively.P<0.5 was deemed statiatically significant.Results There were 241 DCD donors during January 2010 and December 2015 in our hospital, with C-Ⅰ, C-Ⅱ and C-Ⅲ accounting for 29.9% (72/241) , 26.6% (64/241) and 43.5% (105/241), respectively.The proportion of C-Ⅰ(29.9%) in our hospital was higher than national average (13%) (χ2=55.381, P<0.05).234 donor livers were obtained from 241 DCD donors, 26 of the livers were discarded and the liver discard rate was 11.1% (26/234).The main reasons for discard were overlength of cold/warm ischemia time, liver cirrhosis, poor perfusion, abnormal liver function and contusion.There was no statistical significance for average growth rate per annum of DCD between our hospital (67.78%) and Guangdong province (104.50%) (U=11.0, P>0.05).The donation rate per million population of our hospital and Guangdong province was increased from 0.407 PMP and 0.144 PMP to 3.948 PMP and 4.145 PMP, respectively.The donation conversion rate was 31.0% (241/778) within the scope of the OPO of our hospital.The influence factors for poor conversion rate were mainly because of family and social factors, the condition of donors and doctor-patient relationship.One hundred and forty-five DCD donors were implemented organ donation supported by ECMO during the same period, with C-Ⅰ, C-Ⅱ and C-Ⅲ accounting for 58.3% (42/72), 62.5% (40/64) and 60.0% (63/105).Conclusion Enhancing the attention and acceptance of organ donation in public, and reasonable application of organ preservation technology will help to promote the development of DCD liver transplantation.

Objective To explore the efficiency of the ABC-HOME in the rapid identification and assessment of potential donors.Methods We developed a submit system and a rapid assessment method of ABC-HOME for potential donors at 2013.They were on trial in service area hospitals of Guangzou General Hospital Organ Procurement Organization (GHOPO) from February,2015.We reviewed medical records of potential donors occurring in the intensive unit at 2014,from February to December 2015 and 2016,respectively.We examined data on the number of potential donors,actual donors and beds of ICU,and calculated the number of potential donors and actual donors per bed per year.The reasons for donation failure were analyzed.Results 19,38 and 50 organ donations were realized in 243,474 and 513 potential donors in 2014,from February 2015 to December 2015 and 2016,respectively.The growth rate of organ donation and the number of actual donors per bed per year was 95.0%,8.2% and 0.45,0.89 and 0.96,respectively.The conversion rate in these potential donors was 8.92% from February 2015 to December 2016.The reasons for donation failure included the family and social factors,doctor-patient relationship and communication factor and illness condition of donors' factors.Conclusion ABC-HOME is a convenient assessment method for potential donors,which can help to promote the identification of potential donors and to increase the number of potential donor information.

Objective To summarize the experiences and protocol of extracorporeal membrane oxygenation (ECMO) technique in donors with brain death and unexpected cardiac arrest.Method We described here the organ donation of one case of brain death complicated with hemodynamic instability and cardiac arrest,and the corresponding recovery of the receptor liver.A 50-year old female developed brain death due to brain aneurysmal hemorrhage.He was given two kinds of high-dose vasopressor,but hemodynarnic instability was not improved.After ECMO support,the hemodynamics turned to stable,but unexpected cardiac arrest happened.The total operating time of ECMO was 5 h,including 4 h after cardiac arrest.The liver was transplanted into a 65-year old female with hepatocellular carcinoma (diagnosed by Hangzhou Criteria) by classic orthotopic liver transplantation with end-to-end anastomosis.Result One liver and two kidneys were obtained successfully,and all the receptors recovered uneventfully.The post-operative ALT and AST levels reached the peak at 169 U/L and 365 U/L respectively,and returned to normal two weeks later.Conclusion ECMO can be used to support brain death complicated with hemodynamic instability and unexpected cardiac arrest.It can save precious time for organ donation,and preserve the function of liver and kidney as well.

总结了1例肝移植术后并发消化道胸腔瘘患者的护理.护理要点包括:急性呼吸衰竭期呼吸机辅助呼吸及胸腔闭式引流的管理,胸腔镜下胸腔探查术及胸腔持续冲洗的护理,消化道瘘的评估,剖腹探查、空肠部分切除、端端吻合术的围术期护理,“三阶段热量递减方案”营养支持的护理,以及应用免疫抑制剂和抗菌药物的观察和护理.患者救治成功,康复出院,随访6个月,状况良好.

Objective To investigate the application and clinical value of donation after citizens death (DCD) in salvage liver transplantation (SLT).Method The clinical data of 12 recipients who underwent SLT from DCD of 12 donors at the Guangzhou General Hospital of Guangzhou Military Area from October 2010 to December 2013 were retrospectively analyzed.Of the donors,there was one case of type of China-Ⅰ,2 cases of the type of China-Ⅱ and 9 cases of the type of China-Ⅲ.Extracorporeal membrane oxygenation (ECMO) was applied to donation after brain and cardiac death to avoid warm ischemia.Of the recipients,6 met the Milan criteria,3 UCSF(The University of California,San Francisco) criteria and 3 Hangzhou criteria respectively.Orthotopic liver transplantation was performed on recipients.Eleven recipients received end-to-end anastomosis of the bile duct and followed up regularly.Result Liver transplantation was successfully performed on all recipients.No mortality during operation,no recovering delay and non-function of the transplanted liver occurred.Postoperative complications occurred in 4 cases,2 patients died,and 2 patients recovered and discharged after the second surgery.Ten recipients had a long-term survival.Two cases of hepatocellular carcinoma (HCC) recurrence were still alive after active treatment.The longest survival time was 42 months.All of them had no long-term complications such as biliary stricture.Conclusion The role and status of SLT in the treatment of HCC has become increasingly,and there will be more and more use of DCD donor in SLT.To ensure the DCD donors safely and effectively applied in SLT,we should grasp the characteristics of SLT,choose the appropriate DCD donor according to recipients,and rationally use the ECMO to protect the graft quality.

Objective To evaluate the clinical value of minimally invasive methods for non-anastomotic biliary stricture (NABS) after orthotopic liver transplantation.Methods The clinical data of 403 patients who underwent liver transplantation during recent 10 years in Liver Transplantation Center at General Hospital of Guangzhou Military Commanmol were analyzed retrospectively,and 13 patients with NABS were selected.The outcomes of 3 types of NABS patients treated by endoscopic retrograde cholangiopancreatography(ERCP) or percutaneous transhepatic cholangial drainage(PTCD) were compared and the indication for re-transplantation was identified.Results PTCD treatments of 4 patients were proved ineffective.The shortterm curative rate of minimally invasive treatments was 8/13.Five patients eventually required surgical treatments (re-transplantation in 4,Roux-en-Y anastomosis in 1).According to cholangiography results,NABS were divided into 3 types,namely hepatic bile duct strictures (n =4,type Ⅰ),multiple extra-hepatic and intrahepatic biliary strictures (n =7,type Ⅱ),intrahepatic biliary strictures (n =2,type Ⅲ).The success rates of minimally invasive treatment in 3 types of NABS were 3/4,4/7 and 1/2,respectively.Nearly half of type Ⅱ and type Ⅲ patients needed re-transplantation,which was more likely for those patients with hepatic artery stenosis (2/3).Conclusion NABS treated with minimally invasive methods are preferred.Based on the appearance of biliary stricture,type Ⅰ patients had the best prognosis.For those type Ⅱ and type Ⅲ patients who failed minimally invasive treatment,especially combined with hepatic arterial stenosis,surgical treatment should be timely,so as not to lose a chance for re-transplantation.

Objective To summarize the procedure and method of extracorporeal membrane oxygenation (ECMO) support donation after brain death followed by cardiac death (DBCD).Method The clinical data,the selected standard and the organ procurement procedure of 39 DBCD cases were retrospectively analyzed from January 2009 to December 2012 in our liver transplantation center,including 30 males and 9 females with the mean age and mean BMI of 28.1 ± 10.2 and 21.3 ± 2.5 respectively.The primary diseases included head trauma (29 cases),intracranial bleeding (8 cases),and anoxia (2 cases).The mean DRI was 1.27 ± 0.28.ECMO was introduced in all the donors.Result The mean length of ECMO time was 161 77 min.The initial,balance and reperfusion value of ECMO volume was 3.14 ± 0.24,1.76 ± 0.58 and 3.10 ± 0.48 L/min respectively.All the donors had no warm ischemia time.The TBIL and ALT showed no significant difference in all the donors when estimated,before the ECMO started and before the organ procurement,but the Cr was increased and urine output decreased significantly.All the donated organs included 38 livers,and 78 kidneys.Thirty-seven cases of liver transplantation and 64 cases of kidney transplantation were performed finally.One liver out of the 38 cases was unused due to the positive HbsAg,and 14 kidneys unused due to renal insufficiency and kidney stones.Condusion There is no dispute in the ethics Committee and all the donor's family members about the usage of ECMO.The ECMO support DBCD could well control the warm ischemia,and obtain satisfactory curative effect of transplantation.

The donated organ after cardiac death would undergo warn ischemia injury inevitably,and the incidences of primary non-function of donated organs,transplanted organ loss and ischemic-type biliary lesions were increased.It is a paramount research dilemma to devise how to avert,lessen and recover the warm ischemia organs after donation of cardiac death (DCD).Since February 2009,the Liver Transplantation Center of Guangzhou General Hospital of Guangzhou Military Command of PLA has applied the extracorporeal membrane oxygenation (ECMO) to protect the organs of DCD.The mechanism of recovering the donors from warm ishemia by ECMO has good prospects in the field of international organ donation,and it is an important method to solve the problem of donor shortage in China.Spreading the application range of ECMO in DCD and establishing the standard procedures and techniques in China is of great importance.

Objective To summarize the clinical experiences in liver transplantation from donation after cardiac death donors. Methods The clinical data of 20 recipients who underwent liver transplantation from donation after cardiac death of 20 donors at the Guangzhou General Hospital of Guangzhou Military Area from July 2006 to May 2011 were retrospectively analyzed.Extracorporeal membrane oxygenation (ECMO) was applied to donors with brain and cardiac death to avoid warm ischemia.Donors in type Ⅲ according to the Maastricht classification did not receive ECMO.Liver grafts were obtained 5 minutes after the stop of heartbeat of the donors.Orthotopic liver transplantation was performed on recipients.Seventeen recipients received end-to-end bile duct anastomosis and 3 received cholangioenterostomy.All the recipients were followed up regularly.The survival curve was drawn by Kaplan-Meier method.Results Of the 20 donors,2 ( 10％ ) were in the type of Maastricht Ⅲ and 18 (90％) were donation after brain and cardiac death donors.Liver transplantation was successfully performed on all recipients,and the mean operation time,duration of anhepatic phase,mean volume of blood loss and duration of postoperative intensive care unit stay were (6.2 ± 2.7 ) hours,( 54 ± 13 ) minutes,( 2305 ± 1311 ) ml and (44 ±35) hours,respectively.There was no mortality during operation,and no recovering delay and non-function of the transplanted liver occurred.One recipient died of sepsis and 1 died of pulmonary infection at 1 month after operation,the other 18 recipients all survived.The longest survival time was 58 months.Conclusions Donation after cardiac death is the main source of liver grafts in China currently,and donation after brain and cardiac death is the main type.Establishment of rational flow-sheets of the donation after cardiac death and liver transplantation,rational application of ECMO for protecting the liver grafts are helpful for the work of organ donation after brain and cardiac death.

Objective To summarize and further investigate the initial experience of organ procurement process for organ donation after cardiac death(DCD).Methods The clinical data,the selected standard,and the organ procurement process of 28 cases of DCD from July 2009 to January 2012 in the liver transplantation center of Guangzhou General Hospital were reviewed and analyzed.Results Twenty-eight cases of DCD all had donated organs successfully.Among these cases,there were 3 cases(10.7%)of the Maastricht Ⅲ,and one case(3.6%)of the Maastricht Ⅳ,and 24 cases(85.7%)of the organ donation after brain death plus cardiac death(DBCD).Three cases of the Maastricht Ⅲ were practiced the organ procurement process of DCD.One case of the Maastricht Ⅳ was practiced the organ procurement process of DBCD without the extracorporeal membrane oxygenation(ECMO).Twenty-four cases of DBCD were practiced the organ procurement process of DBCD with the ECMO.The donator warm ischemic time was zero min in DBCD,18 min in Maastricht Ⅳ,and mean 25 min(22-28 min)in Maastricht Ⅲ.All the donated organs included 28 livers,40 kidneys,and 2 hearts.And all these organs had been practiced the liver transplantation,the kidney transplantation,and the heart transplantation.Conclusions The organ procurement process for organ DCD includes the DCD process and the DBCD process in China,and the later includes the organ procurement process with the ECMO and without the ECMO.The ECMO could well control the warm ischemia for protecting the donors just without ethics dispute.So,the using of the ECMO for the organ DCD of citizen in China has a very important contribution.

<正>内科综合治疗和人工肝支持是治疗肝衰竭的主要方法,但由于缺乏特效药物和手段,目前肝衰竭病死率仍较高,生存率不足50%。肝移植是治疗肝衰竭最有效的方法,临床疗效获得广泛认可。然而由于供肝匮乏以及严格的技术准入制度,肝移植治

Objective To summarize the early clinical experience of the extracorporeal membrane oxygenation (ECMO) for protecting the liver donation after cardiac death (DCD).Methods Review and analysis the clinical data of 17 cases of liver transplantation with the donors from Chinese citizen after cardiac death from July 2009 to May 2011 in our liver transplantation center,and comprehend the primary diseases and the relevant index of the donors,the flow-sheet of donation and obtain of the organs from the donation after cardiac death,and the apply methods of extracorporeal membrane oxygenation during those processes.Results All 17 cases had been diagnosed as brain death before,and waited for cardiac death,so all were clearly the donation of brain death plus cardiac death(DBCD).During the processes waiting for cardiac death,extracorporeal membrane oxygenation were introducted in every case,and the using time were 51-380 (mean 187)min.The donation after brain death plus cardiac death (DBCD) were all harvested liver donors and were transplanted to 17 receivers respectively.In our center,there was no operational death in liver transplantation in this series.The post-operation liver function recovered satisfactory,without transplant liver non-function or recovering delay.One case died of the pulmonary infection one month later after operation,and the other 16 cases all survived and were followed up to now.The longest survival time was 29 months.Conclusion The donation after brain death plus cardiac death (DBCD) was the special donation type for citizen in China.The extracorporeal membrane oxygenation (ECMO) could well control the warm ischemia for protecting the liver donor just without ethics dispute.So,the using of the extracorporeal membrane oxygenation (ECMO) for the liver donation after cardiac death(DCD)of citizen in our China have very important contribution.

<正>原发性肝癌(HCC)作为肝移植的一种适应征已被广泛认可,肝移植既能最大限度根治性切除肿瘤又能解决相关终末期肝病,具有独特的优势。来自中国肝移植注册系统(CLTR)的数据表明,截至2009年12月31日,我国大陆地区已登记的肝移植手术总例数为16190例,其中肝癌肝移植7151例,占总体移植例数的44.2%。移植后肿瘤复发是影响肝癌肝移植疗效的关键,而免疫抑制的合理使用是影响肿瘤复发的重要因素。肝移植术后长期使用免疫抑制剂使机体免疫力下降,对肿瘤监视和抑

Objective To investigate the effect of the surgical techniques and details around biliary reconstruction process on the biliary complications in liver transplantation. Methods From August 2003 to December 2006 and January 2007 to March 2010 two time periods, group A 74 cases and group B 131 cases each, all 205 cases of liver transplantation fulfilled in Guangzhou General Hospital of PLA were implemented biliary reconstruction with same methods. Some different surgical techniques and details and the rates of the biliary duct complication were compared statistically. Results The death rates of group A and group B had no difference statistically. But the biliary complication incidence of group A and group B had was 11.0% and 5.3% respectively. The warm ischemia time of group B was shorter than that of group A significantly. There were some differences between two groups, such as the perfusion of the biliary duct, the conservation of blood supply of biliary endings for both donor and recipient, careful bile duct exploration in receptor, and minor tension between the anastomosis of the bile duct. Conclusion With short warm ischemia time, adequate perfusion of bile duct of the liver donor, conservation of blood supply of biliary endings for both donor and recipient, careful bile duct exploration in receptor and minor tension between the anastomosis of the bile duct are all important factors for improving the quality of biliary reconstruction and reducing biliary complications.

Objective To investigate the application of conglutinant pancreaticoenterostomy in pancreaticoduodenectomy. Methods 66 patients were divided into two groups according to the different types of anastomosis. One group received conglutinant pancreaticoenterostomy with biomedical fibrin glue and the other received traditional invaginated pancreaticoenterostomy. The intraoperative anastomotic time and amount of bleeding and the postsurgical complications and duration of hospital stay were compared between the two groups. Results The anastomotic time was obviously shortened in conglutinant pancreaticoenterostomy than in traditional invaginated pancreaticoenterostomy. No pancreatic fistula occurred after conglutinant pancreaticoenterostomy,but two patients developed fistula after the other procedure. There were no significant differences in other data between the two groups. Conclusions Conglutinant pancreaticoenterostomy is a simple,safe,and effective surgical procedure.

目的探讨医用生物蛋白胶在胰肠吻合中的应用。方法对胰十二指肠切除术患者根据吻合方式分两组,每组33例,一组采用传统套入式胰肠吻合,另一组采用医用生物胶粘合吻合技术进行胰肠吻合,分别对胰肠吻合时间、出血量、术后并发症、术后住院时间等分析比较。结果粘合式胰肠吻合在术中吻合时间比套入式吻合明显缩短,术后无胰瘘发生,而传统套入式胰肠吻合发生2例胰瘘。其余方面两组间无明显差别。结论粘合式胰肠吻合技术是一种安全简便、实用的方法。

Objective To study the effect of the surgical techniques and key points for reconstructing the biliary tract on incidence rate of biliary complication in orthotopic liver transplantation.Methods One hundred and sixty-seven cases of liver transplantation during two phases from August 2003 to December 2006 and January 2007 to July 2009 in General Hospital of Guangzhou Military Command of PLA were classified into group A (74 cases) and group B(93 cases) respectively.The clinical data of the two groups were collected and compared,including the procurement of the liver graft,the operation technique and procedures of reconstructing the biliary duct,the complications of the biliary duct after operation and the prognosis of patients.Results The warm ischemia time of group B was shorter than that of group A.There was no significant difference in the reconstruction way of the biliary duct between the two groups(P0.05).The routine procedures were performed in group B as following:except for the irrigation of the gallbladder with cold physiologic saline,the bile common duct was also intubated to sufficiently irrigate the intra-hepatic bile duct.The hepatic artery was infused with physiological saline solution with heparin and lidocaine during liver graft trimming.Before reconstruction of the biliary duct,the inferior segment of the bile common duct was irrigated with saline using urethral catheter,then explored and dredged with the fiber choledochoscope.The blood supply of the bile duct of the graft should be protected during procurement.Two key points should be kept in mind to determine the length of the recipient and the donor bile duct.First,the donor bile duct should be short as far as possible.Second,the anastomosis should have micro-tension.The mortality in group A and group B were 5% and 6%,and the morbility of biliary complications were 11% and 6%(P0.05).Conclusion Sufficient perfusion of donor biliary duct,adequate blood supply of both donor and recipient biliary duct,shortening warm ischemia time,careful exploration of recipient bile duct and maintaining micro-tension of bile-duct anastomosis are key points to reduce the incidence of biliary complications.