Objective Small-for-size syndrome (SFSS) is a common and serious problem after living donor liver transplantation (LDLT) of small grafts.To prevent SFSS by selecting large enough graft,enlarging outflow tract,and controlling the portal vein pressure and flow during LDLT.Methods 113 adult LDLT recipients were reviewed from Dec.1,2007 to Nov.30,2009.Enlarging the portal outflow tract by the incision of the anterior rim of the orifice of the right hepatic vein (RHV),modificating graft inflow,and selecting large enough graft were done to prevent SFSS.The relationship between the patients' GRWR,portal vein flow,portal vein pressure and the occurrence of SFSS was analyzed.Results All patients received the outflow orifice modification.The portal vein pressure and the portal vein flow were decreased after spleen artery ligation.No SFSS ocurred.Conclusion Selecting large enough liver graft,and enlarging portal vein inflow and outflow were safe for the LDLT recipients,and can effectively prevent SFSS.

ObjectiveTo summary clinical character of de novo hepatitis B virus infection after liver transplantation,and explore the strategy of prevention and treatment.MethodsThe clinical data of recipients undergoing liver transplantation and the recipients who developed de novo hepatitis B virus infection after liver transplantation between Jan. 2000 to Dec. 2010 were retrospectively analyzed.Results365 patients who underwent liver transplantation were negative for serum HBsAg before liver transplantation.Among them,11patients were diagnosed as having de novo hepatitis B virus infection after liver transplantation,with the morbidity being 3.0 ％(11/365).Most recipients did not have any clinical presentation.They were just found HBsAg positive during the follow-up period.The liver functions were normal.All 11patients received anti-virus therapy after they were found having positive HBsAg and replicated HBV-DNA.One patient whose primary disease was hepatitis C combined with primary hepatic carcinoma was treated with pegylated interferon,thereafter,he was found having YMDD-mutation of HBV-DNA,and he was treated with entecavir.The rest 10 patients received anti-virus treatment with nucleoside analog.The 10 recipients were injected with hepatitis B immunoglobin during operation.After anti-HBV therapy,one patient died from acute liver failure because of inefficient treatment,and one patient died from tumor recurrence.The remaining nine patients survived:HBeAg of one patient became negative,and HBV-DNA replications of the four patients became negative (＜1×105 copies/L).The liver function of the patients who survived was normal.ConclusionFor recipients who were HBsAg negative before liver transplantation,when they received liver transplantation,,they should be given strict screening of blood product for transfusion.The liver transplantation patient who is HBsAg negative in serum before liver transplantation,and whose donor is HBcAb positive in serum and/or HBV-DNA positive in serum,should be treated with HBIG and/or nucleoside analog during operation or after operation,as we said above is a ideal strategy to prevent de novo hepatitis B virus infection after liver transplantation.The prognosis of de novo hepatitis B virus infection after liver transplantation is mild.

ObjectiveTo study the role of middle hepatic vein (MHV) on the early function and regeneration of the donor remnant liver in living donor liver transplantation (LDLT).Methods Between August 2007 and August 2008,66 LDLT were performed,36 without MHV (group A),and 30 with MHV (group B) in the donor liver.The donor operation time,intraoperative blood loss,postoperative hospital stay,serum bilirubin,international normalized ratio (INR),alanine aminotransferase (ALT) and albumin were analyzed.We measured the volume of remnant liver with CT scan at 2 weeks after operation,and compared the function and regeneration of the remnant liver between the two groups. Results At 2 weeks after operation,there was no significant difference (P=0.16) in the volume of remnant liver between group A (959.3±195.2 ml) and group B (883.7±155.5 ml).There was also no difference (P=0.62) in the regeneration rate of segment IV between group A (78.2 ％ ± 29.1 ％) and group B (82.7 ％ ± 40.4％).The serum bilirubin,INR and ALT in group B was significantly higher than group A immediately after liver transplantation,but there was no difference at 1 week after transplantation.ConclusionExtended right hepatectomy with MHV was safe,and did not significantly impact early liver function and regeneration in the donor.

Objective To analyze the curative effects and survival results of combined liver kidney transplantation (CLKT).Methods From 2002 to 2011,the clinical data of 36 Chinese patients who underwent CLKT were retrospectively analyzed in our centre.The age of recipients was 47.4 ±13.1 years.Four patients had undergone liver transplantation and 7 patients kidney transplantations before CLKT, respectively. The complications and the survival were analyzed. Results The survival patients were followed up for 47.9 months (29.1 - 115.7).The cumulative 1-,3 and 5-year patient survival rate was 88.7％,85.4％ and 81.4％; The 1,3- and 5-year survival rate of liver graft was 79.8％,76.3％ and 72.3％; The 1-,3- and 5 year survival rate of kidney graft was 85.7％,82.4％ and 78.2％.Three patients underwent liver re-transplantation due to severe biliary complications,and one patient kidney re-transplantation due to renal allograft dysfunction.Conclusion CLKT is a effective treatment for end-stage liver disease with renal insufficiency and achieves excellent results.

Objective To summary therapeutic method for delayed portal vein thrombosis after liver transplantation. Methods In 3100 cases undergoing cadaveric whole liver transplantation in a single center, there were 12 cases of delayed portal vein thrombosis after liver transplantation.Average occurring time was 29. 8 months after liver transplantation. Among these 12 patients, 2 cases were complicated with severe biliary complication (intrahepatic stricture) , 2 cases presented with liver failure of transplanted liver, and one case had portal vein compression by hepatic hilum tumor under the image examination, who received liver re-transplantation; two patients presented upper gastrointestinal bleeding, and they experienced endoscopic ligation and sclerotherapy respectively; the rest five patients without any clinical presentation were subjected to anticoagulation and antiplatelet therapy. Results Among 12 cases, 8 patients survived by the time of follow-up, including two patients undergoing re-transplantation; one patient lost follow-up. The liver function tests of the patients who survived were all normal. Conclusion The individualized therapeutic methods should be adopted for the patients with delayed portal vein thrombosis after liver transplantation.

ObjectiveTo investigate the effect of living donor right liver graft transplantation (LDLT) with middle hepatic vein (MHV) on the early congestion and regeneration of the donor remnant liver.MethodsBetween August 2008 and August 2009,28 LDLT were performed with 11 LDLT without MHV (group A) and 17 LDLT with MHV (group B).The donor operative time,intraoperative blood loss,postoperative hospital stay,bilirubin,INR,and ALT level were recorded in detail.We measured the volume of remnant liver by means of CT scan 2 weeks after operation and compare the degree of congestion and regeneration of the remnant liver between the two groups.ResultsThere were 10 cases in group B and 0 cases in group A suffering from congestion at segment Ⅳ,and the difference was significant(P =0.006).In group B,6 cases in type Ⅰ and 4 cases in type Ⅱ developed congestion at segment Ⅳ,and the difference was significant(P=0.035).Two weeks post operation,the volume of segment Ⅳ in group B was smaller than in group A(P=0.005).The regeneration rate of segment Ⅳ in group B was smaller than in group A (P =0.007),on the contrary,the regeneration rate of segment Ⅰ - Ⅲ in group B was larger than in group A( P =0.008 ).But the regeneration rate of remnant liver was the same in both groups (P =0.63 ).ConclusionsThe right lobe hemihepatectomy with MHV does not damage the early liver function of the donor significantly.The segment Ⅳ of the remnant liver suffered from congestion and impeded the regeneration,but was compensated by the regeneration of segments Ⅰ - Ⅲ.

Objective To investigate the experience of treating Budd-Chiari syndrome through orthotopic liver transplantation.Methods The clinical data of LTx performed on 9 patients with Budd-Chiari syndrome from December 2003 to April 2010 were retrospectively analyzed. We summarize the preoperative image and surgical experience,and observe the occurrence of postoperative complications and survival. Results Budd-Chiari syndrome was diagnosed in 9 patients by the preoperative abdominal CT enhancement and vascular reconstruction,and cavity venography was done to observe obstruction and sub-type of CAVA vein.All 9 patients were subjected to cadaveric liver transplantation.Eight cases accepted classic non bypass type,and one accepted living related right lobe liver transplantation. Postoperative triple immunosuppressive regimen included tacrolimus,mycophenolate mofetil,and hormone.The average follow-up periods for all these 9 patients were 32.8 months (13 to 61 months). One patient died from the tumor recurrence at 35th month after the operation.Two patients received re-transplantation for the lost of the graft.One recipient received the donor liver with medium steatosis,and the re-transplantation was performed on the12th day after the first transplantation due to the primary non function of the graft.The other one received the secondary liver transplantation at 6th month after the first transplantation due to the biliary complication and died from the liver tumor recurrence. Among all the 9 cases,seizure disorder (1 case),dysfunction of duodenal papillary muscle (1 case) and small-for-size syndrome (one case) occurred after the operation.Pulmonary infection occurred in 4 cases:3 cases due to the bacterial infection and 1 due to the fungal infection. Neither outflow obstruction nor the recurrence of the Budd-Chiari syndrome occurred in this study.The 1- and 2-year survival rate after the operation was both 100％,and 3-year survival rate post-transplantation was 88.9％ (8/9).Conclusion Liver transplantation can be the ideal treatment to the Budd-Chiari syndrome based on the definite clinical diagnosis,accurate imaging evaluation and eligible modus operandi.

Objective To summarize the experience of reconstruction of Ⅴ and Ⅷ hepatic veins in right lobe (without middle hepatic vein) living donor liver transplantation. Methods The clinical data of 55 cases of living donor liver transplantation of right lobe without middle hepatic vein were analyzed, and Ⅴ and Ⅷ hepatic veins were reconstructed. All donors underwent evaluation on the basis of vascular anatomy, GRWR and graft volume/ESLV. Fifty-one grafts underwent reconstruction of Ⅴ and Ⅷ hepatic veins with cold-storage cadaveric iliac veins. Great saphenous vein, varicose umbilical veins, recipient intrahepatic portal veins and recipient intrahepatic veins were used respectively in the remaining 4 cases. Results One recipient died of obstruction of out-flow on the postoperative day 43. One recipient was converted to cadaver donor liver transplantation at the 7th day after operation, because of acute liver function failure. The remaining 53 cases recovered successfully. Conclusion Reconstruction of Ⅴ and Ⅷ hepatic veins with proper materials in right lobe (without middle hepatic vein) living donor liver transplantation is feasible, and the effect is satisfactory.

Objective To identify the changes of anti-HBs titers of patients with hepatitis B virus (HBV)-related diseases in the early stage (within the first week) post-liver transplantation (LT) and analyze their influencing factors.Method A total of 26 patients were enrolled in this study.They were all positive for HBsAg pre-LT and received the prophylaxis of lamivudine in combination with intravenous hepatitis B immunoglobulin (HBIG) in the first week post-LT.The titers of anti-HBs were detected daily in blood and drainage fluid every day in the first week post-LT.If the anti-HBs titers were greater than 1000 IU/L,blood and drainage were diluted,then detected again.Result The titers of anti-HBs in HBV-DNA negative groups,low HBsAg groups,and HBeAg negative groups were higher than those in the HBV-DNA positive groups,high HBsAg groups and HBeAg positive groups in the first five days post-LT.The median titer of anti-HBs in drainage fluid was 181.60 IU/L (0.00-968.50 IU/L).And the titer of anti-HBs in drainage fluid was correlated with anti-HBs titers in blood at the same time (r =0.927,P =0.000).The amount of anit-HBs calculated in drainage fluid was very high,but it fluctuated in a wide range (0.00-908.55 IU).Conclusion In the early stage post-LT,patients in high risk groups should receive higher doses of HBIG to maintain safe levels of anti-HBs,while the lower doses of HBIG are enough to the patients in low risk groups.Furthermore,the anti-HBs titers in blood aren't affected by the anti-HBs loss in drainage fluid.

BACKGROUND:Intertrochanteric fracture showed shattered state of different degrees in the clinic. The medial cortex is often a lack of continuity. Indentation and lesser trochanter displacement often cause destruction of biomechanics of femoral calcar to different degrees. Under this condition, it is very important to perform detailed classification of fractures and to strictly master indication of dynamic hip screw. OBJECTIVE:To further analyze the reasons for failure of internal fixation with dynamic hip screw for intertrochanteric fracture. METHODS:Data of 82 patients with intertrochanteric fracture repaired by internal fixation with dynamic hip screw, who were treated at the Department of Orthopedics, Kangtai Branch of the Second Hospital of Lanzhou University from March 2004 to December 2013, were retrospectively analyzed. The reason for failure of internal fixation and prevention method were explored. RESULTS AND CONCLUSION:Al patients were fol owed up for 4-48 months. Time of fracture healing was 12-38 weeks. Fixation failure was found in 12 cases, with an incidence of 15%. Of 12 failure cases, 7 cases affected hip screw cutting out femoral head neck (including 1 case combined with avascular necrosis of the femoral head), 1 case suffered from compression screw slipping out of the tube, 3 cases experienced screw pul ing out and breaking, plate loosening, and 1 case affected steel plate breakage. There were 1 case of Evans II type (8%), 3 cases of type III (25%), 5 cases of type IV (42%), and 3 cases of type V (25%). Lesser trochanter was not completely reset in 5 cases (42%). There were tip-apex distance>25 mm in 7 cases (58%) and early weight loading (3 weeks after fixation) in 1 case (8%). These data confirmed that the selection of indications, the degree of stability after reduction, accuracy of implant position and postoperative unreasonable exercise wil cause fixation failure of dynamic hip screw. Preoperative careful and comprehensive analysis, intraoperative precise operation and postoperative reasonable functional exercise are the keys to ensure success of fixation.