心内型完全性肺静脉畸形引流漏诊合并肝左静脉异常引流1例心内型完全性肺静脉畸形引流漏诊合并肝左静脉异常引流1例

患者女，19岁，自幼发现心脏杂音，生长发育较同龄人略迟缓，活动后胸闷、心慌、气短，无晕厥、喜蹲踞，紫绀（＋）。血压：96/60mmHg，心率：61次／分。心界向两侧扩大。律不齐，可闻及早搏、大炮音；胸骨左缘第二、三肋间4/6级收缩期杂音，传导广泛。并可触及震颤，周围血管征阴性。心电图：交界性心律，Ⅰ度岛室传导阻滞，频发房早二联律伴室内差异性传导。     

晚期主动脉-左室通道1例

病人 男,43岁.活动后胸闷、气促2年余,四肢水肿、不能平卧、伴有粉红色泡沫样痰1年. 心尖搏动位于第5肋间左锁骨中线外2m处，心浊音界明显扩大，心率85次/min，S1强弱不等，律不齐。主动脉瓣听诊区闻及3/VI级收缩期杂音，向颈部传导，舒张期闻及叹气样杂音，二尖瓣听诊区可闻及3/VI级收缩期吹风样杂音，向腋下传导。     

鲁登巴赫综合征合并右肺静脉异位引流1例

鲁登巴赫综合征合并右肺静脉异位引流１例关敬堂，郭好学，林武英，刘书勇，吴志强，罗静病人女，３８岁。唇绀、活动后心慌、胸闷３０余年。查体：轻度唇绀，轻度杵状指。心界扩大，律齐，胸骨左缘第２～４肋间可闻及３级收缩期杂音，心尖可闻及４级舒张期杂音。Ｘ线胸片...     

主动脉瓣及瓣上狭窄合并升主动脉扩张一例

患者男,29岁。主诉：发现心脏杂音13年,心前区痛1周余。查体：血压120/80 mm Hg,心率70次/分,律齐,主动脉瓣听诊区可闻及3/6级收缩期喷射样杂音,向颈部传导,P2〉A2。心电图示：窦性心律,左心室高电压;心脏超声心动图提示：主动脉瓣重度狭窄、轻度关闭不全,主动脉瓣上隔膜型狭窄,升主动脉及弓部增宽,升主动脉直径53 mm,左心室内径44 mm,左心室肥厚,室间隔厚度19 mm,射血分数（EF）85%。术前CT示：主动脉根部狭窄,升主动脉扩张（图1）。     

异搏定钾心停液与心脏的传导

本临床研究分析含有盐酸异搏定(1 mg/L)的钾心停液在开放主动脉以后和恢复过程中对心脏传导系统的作用。以50名依序经受心内直视手术的病人为一单位,研究术后传导异常。根据自动室律转复为正常心律(54%)、需一次直流电转复(32%)或多次直流电转复(14%)把病人分为几组进行分析。分析结果表明,自动室律转复与主动脉阻断时间没有关系。以10瓦·秒行直流电转复对心肌或传导异常的发生无不良效应。需要暂时术中起搏者极少自动室律转复,但是与一次或多次直流电转复者比较,无统计学上的差异。只有3例病人(6%)需要在监护室起搏。术后房性和室性心律失常的发生率各组相同,没有发生死亡或恶性室性心律失常发生。     

介入与全胸腔镜外科杂交手术治疗复杂先心病1例

病儿 男,8岁.体检时闻及心脏杂音1个月.心尖搏动位于胸骨左缘第5肋间锁骨中线外侧1cm处,心浊音界明显扩大,心率113次/min,律齐.胸骨左缘2、3肋间可闻及3/Ⅵ级收缩期加强的连续性机器样杂音,向两肺及左锁骨下传导.     

右心室海绵状血管瘤冠状动脉旁路移植术一例

患者 男，76岁。因上腹部疼痛20余天，偶感心前区疼痛，无心悸和胸闷，院外心脏彩色超声心动图提示心脏肿瘤，收入我院。查体：一般情况好，血压110/60mmHg（1kPa=7.5mmHg），心率84次/分，律齐、款闻及心脏杂音。心脏彩色超声心动图提示：     

负压封闭引流技术应用不当二例

例1 男,25岁,2010年3月21日被10 kV高压电致四肢、躯干烧伤后6h急诊入院。患者意识清晰,体温37.2℃,心率92次/min、伴有早搏,血压163/88 mm Hg(1 mm Hg=0.133 kPa),呼吸22次/min、双肺呼吸音正常。双上肢、双足、右大腿前上1/3为电接触烧伤创面,左手毁损严重,左腕部为环状焦痂,多普勒超声检查示左前臂尺、桡动脉阻塞。其余致伤部位为火焰烧伤创面。右大腿前侧肌群肌力Ⅱ级。白细胞计数30.5×109/L,Hb 193 g/L,血红蛋白尿,心肌酶谱超高,心电图示窦性心动过速伴偶发室性早搏。肌电图示右股神经传导速度较对侧减慢12％,右股内肌插入电位延长,正锐波(++),纤颤电位(+),轻收缩时限延长8％,重收缩波幅2.5 mV,混合相。诊断：(1)四肢电烧伤,面积为8％ TBSA,Ⅲ～Ⅳ度;(2)躯干、右大腿火焰烧伤,面积为2％ TBSA,Ⅱ～Ⅲ度;(3)右大腿股神经电损伤。     

犬化学去细胞神经同种异体移植的神经电生理研究

目的：以化学去细胞同种异体坐骨神经，移植修复犬坐骨神经的粗大和长段缺损，观察其近期神经电生理恢复。方法：12只犬随机分成去细胞神经移植组（实验组）和自体神经移植组（对照组）各6只。右侧坐骨神经造成5.0cm长缺损，以两种神经移植物桥接修复。术后6个月行神经电生理观察，包括小腿三头肌运动诱发电痊、神经移植段运动传导速度、感觉诱发电位等。结果：（1）方波（1.0mA-2.0mA，0.1ms，1.0Hz）刺激移植段近侧神经，均在小腿三头肌上记录到运动诱发电位曲线。（2）神经移植段运动传导速度，实验组平均为47.2m/s、对照组为60.9m/s、正常值为122.0m/s。（3）方波（5.0mA-10.0mA，0.2ms，1.9Hz）刺激胫神经远端，均在颅顶部记录到感觉诱发电位曲线；两组动物的感觉恢复程度相似，但均不及正常侧。结论：化学去细胞神经同种异体移植修复犬坐骨神经长段缺损，术后6个月近期感觉及运动传导功能恢复与自体神经移植相似。     

全胸腔镜主动脉瓣置换术1例

病人 男,16岁.发现心脏杂音伴心悸10余年.心浊音界稍向左扩大,心率78次/min,律齐,胸骨右缘第2肋间闻及舒张期叹气样杂音,向心尖部传导.心脏彩超示主动脉瓣轻度狭窄并中-重度关闭不全,升主动脉增宽,左心室增大(舒张期末径57 mm、收缩期末径40 mm).     

A new technique for resecting 'unresectable' liver tumors

BACKGROUND/PURPOSE: Liver tumors that surround the three major hepatic veins traditionally have been considered unresectable. This report describes an extended atypical left hepatectomy technique for tumors around the major hepatic veins. METHODS: Three children with tumors surrounding the 3 hepatic veins underwent intraoperative evaluation for extended atypical left hepatectomy. The left hepatic artery, left branch of the portal vein, and the 3 hepatic veins are occluded with vascular clamps. Perfusion of the remaining liver is through the right hepatic artery and portal vein into the retrohepatic vena cava via the retro hepatic veins. If the liver remains soft and does not become mottled, division of the 3 hepatic veins and resection of the tumor are carried out. RESULTS: Extended atypical left hepatectomy was successful in 2 children. Bile leak occurred in 1 instance and healed spontaneously. Both patients had transiently elevated serum bilirubin and transaminase levels and an elevated prothrombin time for 2 weeks. Both survived after treatment with chemotherapy. In the third child the liver became tense and mottled, and the procedure was abandoned. CONCLUSIONS: Successful extended atypical left hepatectomy depends on the ability of the retro hepatic veins to adequately drain blood into the vena cava after interruption (clamping) of the main hepatic veins. If the liver becomes mottled and tense the procedure must be abandoned and the patient should be considered for hepatic transplantation.     

主肝静脉和肝短静脉的解剖学研究及其临床意义

目的:探讨主肝静脉和肝短静脉（SHVs）的数量、位置、分型、口径等参数。方法:取60具成人尸体标本, 测量肝左、中、右静脉的肝外长度、注入下腔静脉（IVC）管径;按其SHVs汇入下腔静脉左侧壁、前壁和右侧壁分为左、中、右3排，测量SHVs的数量、位置、口径及其与主肝静脉的关系。结果:肝左、中、右静脉开口于IVC肝后段上l/4段，其中肝左、中静脉共干者73.3%（44例），肝左、中、右静脉共开口者1.7%（1例），3支分别汇入者25.0%（15例），SHVs直径为1.5～17.8（5.4±1.4）mm,3～35支SHV从不同方向和节段注入下腔静脉。肝右静脉直径与SHVs直径呈负相关（r=-0.34，P＜0.05);肝左静脉直径与SHVs数目呈负相关（r=0.24， P＜0.05)。肝右后下静脉（IRHV）出现率为83.3%，平均直径为2.6～8.0（4.3±1.2）mm。结论:SHVs变异较大，管径粗者数量少。SHVs的口径、数目与主肝静脉口径、数目呈相互消长。肝右静脉直径愈大，SHVs直径愈小;反之SHVs直径愈大。肝左静脉直径愈大，SHVs数量愈少;反之SHVs数量愈多。     

Venous outflow reconstructions with the piggyback technique in liver transplantation: a single-center experience of 431 cases

The ideal method of venous outflow reconstruction with the piggyback technique (PB) in orthotopic liver transplantation (OLT) is not well-established. The complications related to PB in 431 primary OLTs were analyzed comparing the orifices used for the anastomosis (cuff of the recipient left and middle hepatic veins [LM], LM with a >1 cm cavoplasty [LM+], or also including the right hepatic vein [LMR]). Treatment strategies and outcome were also evaluated. Twenty patients (4.6%) experienced complications: 13 of 120 (10.8%) with LM, four of 225 (1.8%) with LM+, and three of 86 (3.5%) with LMR (LM versus LM+: P < 0.0001; LM versus LMR: P = NS; LM+ versus LMR = NS). Balloon dilation was successful in 10 of 13 cases in which it was attempted (77%). Eight patients required retransplantation (40%). Three patients (0.7%) died from causes linked to stenosis. Five-year survival of patients with and without complications was 75% and 79%, respectively (P =NS); 5-year graft survival was 50% and 76%, respectively (P = 0.001). The stump formed by the recipient left and middle hepatic veins with a transversal incision >1 cm of the caval wall constantly provides an adequate width for the caval anastomosis with the PB.     

Course and anastomoses of the large hepatic veins to main structures on the liver surface

The upper liver veins of fifty adult people were dissected from their orifices up to their second ramifications. The courses of the hepatic veins to the main portal fissure and umbilical fissure were determined. Three large upper hepatic veins can be expected in 74%, an accessory one occurs in 26%. The three or four upper hepatic veins join V. cava inferior by two (66%) or three (34%) common terminal branches (length 0.9 cm). Mean diameters of right hepatic vein 1.5 cm, middle hepatic and left hepatic veins 1 cm, accessory upper hepatic vein 0.6 cm. The course of the middle hepatic vein to "cava-gallbladder-line" was determined. The most common vein of the umbilical fissure joins the left, occasionally the middle hepatic vein. The intrahepatic distribution of the liver veins was projected to the surface of the liver considering the typical resection lines. We recommend the following anatomical way of proceeding: right extended and left lateral lobectomy remain right to lig. falciforme hepatis; right lobectomy 1 cm right, left lobectomy 1 cm left to "cava-gallbladder-line".     

Glisson蒂横断联合肝静脉阻断在肝切除术中的应用

目的探讨Glisson蒂横断联合肝静脉阻断术在肝脏手术中的运用。方法回顾性分析我院2009年1月至2011年12月20例采用Gllsson蒂横断联合肝静脉阻断术行肝脏切除患者的资料。结果其中解剖性肝切除15例,非解剖性肝切除5例。包括左外叶切除（Ⅱ＋Ⅲ）3例,左半肝切除（Ⅱ＋Ⅲ＋Ⅳ）8例,右前叶切除（Ⅴ＋Ⅷ）2例,右后叶切除（Ⅵ＋Ⅷ）1例,右半肝切除（Ⅴ＋Ⅵ＋Ⅶ＋vm）1例,局部剜除5例。20例肝脏手术中解剖性肝切除占75％（15／20）,非解剖性占25％（5／20）,平均手术时间220（120～380）min,平均失血量300（100～600）mL,术后并发胆瘘1例,经保守治疗后好转。结论Glisson蒂横断联合肝静脉阻断肝切除术能够最大限度的减少肝脏出血,保护残肝功能,提高术后患者的预后。     

Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation

Shirouzu Y, Ohya Y, Hayashida S, Asonuma K, Inomata Y. Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation.
Clin Transplant 2011: 25: 625–632. © 2010 John Wiley & Sons A/S. Abstract: Background: Hepatic outflow block is one of the major complications leading to severe graft dysfunction after left lobe living donor liver transplantation (LDLT). Methods: Medical records of 46 recipients of a left lobe LDLT were reviewed. The method of outflow reconstruction and post‐transplant morphological changes of hepatic veins were investigated. The subjects were followed up until September 2008, with a median follow‐up period of 2.0 yr (range: 0.5–5.9 yr). Results: There were no multiple outflow tracts to be reconstructed, and the median caliber of the single orifices with or without venoplasty was 32.0 mm. The difference between the angle of hepatic veins to the sagittal plane measured on computed tomography was calculated for pre‐operative donors and post‐operative recipients a month after LDLT. Both left and middle hepatic veins showed a significantly greater change in angle than the right hepatic vein. Both left and middle hepatic veins more frequently showed a nearly flat wave form on Doppler study one month after LDLT. In the 46 recipients of left lobe grafts, three developed outflow block (6.5%). Conclusions: The middle and left hepatic veins tend to distort and stretch during graft regeneration. These characteristics seem to be associated with outflow disturbances.     

肝静脉阻断技术在肝切除术中的应用

目的 探讨肝静脉阻断技术在复杂肝脏肿瘤切除术中防止肝静脉破裂大出血及空气栓塞的作用。方法 对71例肝脏肿瘤手术切除病例施行了1根以上主肝静脉阻断。所有肿瘤均位于第二肝门并侵犯或压迫1根以上主肝静脉。肝静脉阻断方法采用绕线结扎、血管带阻断或血管夹及心耳钳夹闭法。结果 71例中无1例肝静脉分离破裂，行肝静脉结扎28例，血管带阻断26例，血管夹阻断17例；阻断右肝静脉34例，右肝静脉＋中肝静脉2例，左、中肝静脉共干24例，左、中肝静脉分干2例，左、中、右三干9例。施行半肝全血流阻断35例（右侧24例，左侧11例）。交替半肝全肝血流阻断4例，第一肝门阻断加部分肝静脉阻断23例。第一肝门阻断加全部肝静脉阻断（不阻断下腔静脉的全肝血流阻断）9例。71例肝肿瘤均顺利切除。结论 肝静脉阻断技术是一种安全、有效的血流阻断技术。不阻断下腔静脉的全肝血流阻断术既能控制术中出血，又能保证全身血流动力学稳定。     

Contribution of Arantius' ligament to the control of left and middle hepatic veins

Control of the left hepatic vein or of the common trunk left hepatic vein-middle hepatic vein during a hepatic resection is presumed difficult. This control is facilitated by the knowledge of the Arantius' ligament anatomy. The combined manoeuvre which associates lowering the top of segment I and section-traction of the Arantius' ligament allows exposure of the inferior aspect of the left or middle hepatic veins and allows safe dissection of these veins.     

MR血管成像在介入诊疗Budd-Chiari综合征合并肝静脉血栓中的应用

目的探讨MRA在介入诊疗Budd-Chiari综合征（BCS）合并肝静脉血栓中的应用价值。方法 20例患者经DSA证实为BCS合并肝静脉血栓并接受介入治疗,均于术前1周内接受MRA检查,对比分析MRA与DSA对显示肝静脉血栓的能力及BCS合并肝静脉血栓的影像学表现。结果 20例患者中,MRA共显示肝脏静脉51支,包括肝静脉血栓40支,副肝静脉血栓8支,肝静脉通畅3支;对其中40支肝脏静脉行DSA检查,发现肝静脉血栓33支,副肝静脉血栓4支,3支肝静脉通畅。与DSA对比,MRA诊断BCS合并肝静脉血栓的敏感度为97.22%（35/36）,特异度为75.00%（3/4）,准确率为95.00%（38/40）。两种检查方法诊断BCS合并肝静脉血栓的一致性良好（Kappa=0.722,P〈0.01）,临床检出率差异无统计学意义（χ2=0.5,P〉0.05）。结论 MRA能全面、准确诊断BCS合并肝静脉血栓,对介入治疗有重要指导作用。     

Budd-Chiari syndrome treated by Senning's procedure

Two patients with Budd-Chiari syndrome who underwent a new surgical procedure developed by Senning are reported. A 33-year-old man was diagnosed as having Budd-Chiari syndrome with a membranous obstruction of the inferior vena cava (IVC) and right hepatic vein and short segmental obstruction of the left hepatic vein. Removal of the obstruction by dorsocranial resection of the liver and reconstruction of the veins by hepatoatrial anastomosis was carried out. In a 53-year-old female, the same procedure was carried out for a short segmental obstruction of the IVC and left hepatic vein. In both patients, postoperative examination revealed good patency of the IVC and the hepatic veins and increased portal venous flow as measured by Doppler-echography. This procedure is considered the method of choice for Budd-Chiari syndrome with membranous and/or short segmental obstruction of the IVC and hepatic veins.