發(fā)布時(shí)間：2018-02-27 07:13

  本文關(guān)鍵詞： 兔 肝臟解剖 SFSS 動(dòng)物模型 門靜脈壓力 門-腔分流 肝再生　出處：《昆明醫(yī)科大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：背景 小肝綜合征(small-for-size syndrome, SFSS)是發(fā)生在擴(kuò)大肝切除或部分原位肝移植后由于肝臟體積過小導(dǎo)致功能上不能滿足受體的代謝需求而出現(xiàn)的一種臨床綜合征。SFSS最常見于成人—成人部分原位活體肝移植,供肝體積較小時(shí)可能導(dǎo)致受體門靜脈血流高灌注和持續(xù)性門靜脈高壓,由此引起一系列嚴(yán)重的病理生理紊亂。其臨床表現(xiàn)為：術(shù)后持續(xù)性黃疸、凝血功能障礙、門靜脈高壓、頑固性腹水,嚴(yán)重者進(jìn)一步誘發(fā)膿毒血癥、胃腸道出血等并發(fā)癥。 SFSS的病因及發(fā)病機(jī)制至今尚未完全清楚,目前普遍認(rèn)為主要是由于功能性肝臟體積過小,從而引起持續(xù)性門靜脈高壓,持續(xù)性的門靜脈高灌注進(jìn)一步導(dǎo)致肝竇內(nèi)皮細(xì)胞損傷繼而造成肝實(shí)質(zhì)細(xì)胞的損傷,影響肝細(xì)胞再生,最終導(dǎo)致肝功能不全。除此之外,還可能與其他多種因素有關(guān),如移植物的大小、潛在病變、肝再生能力、流入道和流出道情況,受者病情輕重等等。正因?yàn)槿绱?SFSS的防治措施也一直在不斷的積極探索之中。 目前預(yù)防SFSS的策略主要集中在以下3個(gè)方面[6]:(1)增加肝臟移植物的體積；(2)控制門靜脈的壓力；(3)改進(jìn)肝臟靜脈回流的方式。大部分學(xué)者普遍認(rèn)同門靜脈高灌注和門靜脈高壓對(duì)小體積肝臟移植物有破壞作用,因此降低門靜脈灌流和壓力也成為預(yù)防SFSS的主要手段。而目前常用的手術(shù)方式包括脾動(dòng)脈結(jié)扎術(shù)和門-體分流術(shù)。 脾動(dòng)脈結(jié)扎、栓塞操作簡單,創(chuàng)傷小,對(duì)門靜脈灌注壓力的調(diào)節(jié)作用有限,可并發(fā)術(shù)后門靜脈血栓和腹腔感染；門靜脈分流能有效調(diào)節(jié)門靜脈的灌注壓,近年來,一些研究者采用門靜脈-腔靜脈分流來防治SFSS的發(fā)生。但是,有學(xué)者發(fā)現(xiàn)門-腔靜脈分流在活體肝移植術(shù)后數(shù)周內(nèi)雖能有效減少SFSS的發(fā)生,并能提高移植肝的存活率,后期卻出現(xiàn)移植物逐漸萎縮、肝再生受到抑制的現(xiàn)象。 由此看來,在擴(kuò)大肝切除或部分肝移植術(shù)后維持適當(dāng)?shù)拈T靜脈灌注壓在余肝再生過程中發(fā)揮了重要作用。本實(shí)驗(yàn)擬建立SFSS實(shí)驗(yàn)動(dòng)物模型,并實(shí)施門-腔分流調(diào)控門靜脈的灌注血流,觀察門靜脈灌注壓對(duì)肝再生的影響。 目的 1.對(duì)兔肝臟分葉及附屬管道進(jìn)行應(yīng)用解剖學(xué)研究,并在此基礎(chǔ)上建立兔SFSS動(dòng)物模型。 2.在SFSS動(dòng)物模型的基礎(chǔ)上實(shí)施門-腔分流,觀察門靜脈灌注壓力的變化對(duì)肝功能和肝再生的影響。方法 1.兔肝臟及其附屬管道應(yīng)用解剖學(xué)研究：選擇由昆明醫(yī)科大學(xué)實(shí)驗(yàn)動(dòng)物中心提供的健康成年日本大耳兔20只,體重范圍1.5kg-2.5kg。經(jīng)耳緣靜脈按照1ml/kg注射3%戊巴比妥鈉麻醉。固定其四肢,腹部褪毛。(1)肝臟在體與離體解剖學(xué)觀察：取正中切口進(jìn)入腹腔,離斷肝周韌帶,充分暴露肝臟并對(duì)其進(jìn)行在體解剖學(xué)觀察。處死動(dòng)物后,經(jīng)門靜脈灌注生理鹽水沖洗血管。完整取下肝臟對(duì)其進(jìn)行離體解剖學(xué)觀察。(2)全肝及各肝葉稱重,并計(jì)算各肝葉占全肝臟及兔體重百分比。(3)制作門靜脈和肝靜脈管道灌注標(biāo)本。經(jīng)腸系膜上靜脈插管結(jié)扎其尾側(cè)端,注入管道鑄型劑(自凝造牙粉和自凝牙托水按10g：10ml混合)制作門靜脈管道鑄型標(biāo)本。結(jié)扎肝后腔靜脈頭側(cè)、尾側(cè)端,同上注射管道鑄型劑制作肝靜脈管道鑄型標(biāo)本。待管道鑄型標(biāo)本硬固后,取出肝臟。將其放置于20%氫氧化鈉溶液中浸泡腐蝕顯露管道標(biāo)本。SPSS13.0軟件對(duì)數(shù)據(jù)進(jìn)行描述性分析,計(jì)量數(shù)據(jù)結(jié)果以“均數(shù)±標(biāo)準(zhǔn)差(x±s)”表示。 2. SFSS動(dòng)物模型的建立：將42只兔隨機(jī)分為5組,分別為假手術(shù)組(n=2),A組(n=10)為切除“左中葉+右中葉”組,B組(n=10)為切除“左外葉+左中葉+右中葉”組,C組(n=10)為切除“尾狀葉+左中葉+右中葉+右外葉”組,D組(n=10)為切除“左外葉+左中葉+右中葉+右外葉”組。經(jīng)耳緣靜脈按照1ml/kg注射3%戊巴比妥鈉麻醉。固定四肢,腹部褪毛,碘伏消毒,鋪無菌單。取腹部正中切口進(jìn)入腹腔。應(yīng)用無血切肝技術(shù),分別對(duì)A組、B組、C組及D組實(shí)施肝葉切除術(shù)。觀察術(shù)后兔活動(dòng)及進(jìn)食情況。術(shù)前和術(shù)后存活兔分別于第1、3、5、7天麻醉后經(jīng)耳緣靜脈采血留取標(biāo)本檢測(cè)ALT、TB、PT,然后開腹獲取肝組織標(biāo)本行組織病理學(xué)檢查。術(shù)后死亡兔行肝臟剖檢。計(jì)量數(shù)據(jù)結(jié)果以“均數(shù)±標(biāo)準(zhǔn)差(x±s)”表示,應(yīng)用SPSS13.0統(tǒng)計(jì)軟件對(duì)數(shù)據(jù)進(jìn)行F檢驗(yàn)和x2檢驗(yàn),檢驗(yàn)水準(zhǔn)a=0.05。 3.在SFSS的基礎(chǔ)上實(shí)施門-腔分流,調(diào)控門靜脈灌注壓力,觀察肝再生：將120只兔隨機(jī)分為3組,分別為E組(n=40)為“SFSS模型”組,F組(n=40)為‘'SFSS基礎(chǔ)上的門-腔分流”組,G組(n=40)為“門-腔分流調(diào)控”組。同樣經(jīng)耳緣靜脈以1ml/kg注射3%戊巴比妥鈉麻醉,之后固定四肢,腹部褪毛,碘伏消毒,鋪無菌單。取腹部正中切口進(jìn)入腹腔。應(yīng)用無血切肝技術(shù),分別對(duì)E組、F組及G組實(shí)施“左外葉+左中葉+右中葉”的肝葉切除術(shù),同時(shí)對(duì)F組、G組進(jìn)一步行改良后的門-腔靜脈分流術(shù)。觀察術(shù)后兔生存情況。術(shù)前和術(shù)后E組、F組存活兔分別于第1、3、5、7、9、11、13、15、17、19天再次開腹測(cè)量門靜脈壓力值并對(duì)余肝進(jìn)行稱重觀察肝再生。而G組存活兔則統(tǒng)一于術(shù)后第7天開腹結(jié)扎封閉分流口后分別于第9、11、13、15、17、19天開腹測(cè)量門靜脈壓力值及余肝重量進(jìn)一步觀察調(diào)控門-腔分流后的門靜脈壓力值變化對(duì)肝再生的影響。計(jì)量數(shù)據(jù)結(jié)果以“均數(shù)±標(biāo)準(zhǔn)差(x±s)”表示,應(yīng)用SPSS13.0統(tǒng)計(jì)軟件對(duì)生存率組間比較行Log Rank檢驗(yàn),組間差異采用重復(fù)測(cè)量方差分析,以P0.05有統(tǒng)計(jì)學(xué)意義。 結(jié)果 1.兔肝肝裂明顯,依據(jù)肝葉形態(tài)、肝裂走形和門靜脈主干分支形式將兔肝臟分為五葉：尾狀葉、左外葉、左中葉、右中葉和右外葉。全肝質(zhì)量為(60.13±16.11)g,占其質(zhì)量百分比為(2.88±0.06)%,各肝葉質(zhì)量分別為(3.93±1.13)g、(15.93±3.50)g、(14.83±3.31) g、(15.08±4.34) g、(12.08±3.55) g占全肝質(zhì)量百分比分別為(6.22±1.02)%、(25.44±2.55)%、(23.72±2.71)%、(24.15±5.21)%、(19.32±4.23)%。左中葉和右中葉根部肝組織融合,其余各肝葉相對(duì)獨(dú)立,尾狀葉包括相對(duì)獨(dú)立的乳頭突和尾狀突兩部分。各肝葉有相對(duì)獨(dú)立的Glisson系統(tǒng)且肝靜脈走行于肝蒂內(nèi) 2.根據(jù)上述測(cè)得的各肝葉質(zhì)量及不同肝葉組合占全肝質(zhì)量百分比數(shù)據(jù),A、B、C、D四組保留肝葉占全肝質(zhì)量百分比分別約為50%、28%、25%和6%,術(shù)后一周存活率分別為100%、50%、20%和0%。術(shù)后A組與假手術(shù)組比較,ALT、TB、PT數(shù)值變化不明顯(P0.05)；B、C兩組ALT、TB、PT在術(shù)后第1天明顯升高,第3天達(dá)到高峰,隨后逐漸降低,至第7天仍較對(duì)照組和A組增高(P0.05)；而B、C兩組數(shù)值術(shù)后第1、3、5、7天組間比較,C組雖較B組有所升高,但兩者差值較小(P0.05)。剖檢術(shù)后7d內(nèi)自然死亡的兔肝,可見不同程度的淤血、淤膽、出血,余肝腫脹、壞死,胃腸道淤血,渾濁腹水；相比之下,存活7d者則可見肝體積明顯增大,與周圍組織致密粘連,邊緣圓鈍,似圓盤狀,腹腔內(nèi)少量清亮腹水。肝組織病檢可見：A組匯管區(qū)無明顯有絲分裂象和多倍體細(xì)胞；B、C兩組肝組織淤血水腫明顯,可見中央小靜脈及肝竇擴(kuò)張,匯管區(qū)中性粒細(xì)胞浸潤明顯,毛細(xì)血管內(nèi)膽栓形成,肝實(shí)質(zhì)可見點(diǎn)狀壞死,肝細(xì)胞氣球樣變和脂肪變性,隨著時(shí)間延長,肝實(shí)質(zhì)細(xì)胞增生逐漸活躍,并逐步出現(xiàn)多倍體細(xì)胞,但肝實(shí)質(zhì)細(xì)胞增生比A組延遲。 3.根據(jù)上述實(shí)驗(yàn)結(jié)果,選擇實(shí)驗(yàn)B組建立較穩(wěn)定的SFSS動(dòng)物模型,并在其基礎(chǔ)上實(shí)施門-腔分流手術(shù)。術(shù)后19天E、F、G三組存活率分別為10%、30%和60%。術(shù)后E組表現(xiàn)為典型的SFSS特點(diǎn),余肝組織充血水腫,肝實(shí)質(zhì)破壞較多,肝再生表現(xiàn)不明顯,并且隨著時(shí)間的延長,余肝逐漸出現(xiàn)不能程度的壞死、胃腸道淤血等情況,實(shí)驗(yàn)動(dòng)物相繼死亡,最后僅4只存活時(shí)間達(dá)到19天。而F、G兩組因在擴(kuò)大肝切除的基礎(chǔ)上實(shí)施門-腔分流手術(shù),術(shù)后短時(shí)間內(nèi)降低了門靜脈的灌注壓力,從而減少了過高的門靜脈灌注血流量對(duì)余肝組織的損壞作用,余肝組織充血水腫程度較輕,術(shù)后動(dòng)物死亡率均較E組明顯下降,生存時(shí)間有所延長,并表現(xiàn)出不同程度的肝臟再生。至術(shù)后7天,因F組的門靜脈壓力持續(xù)降低,對(duì)余肝再生的機(jī)體代謝支持逐漸減少,從而導(dǎo)致肝臟再生減緩,肝功能逐漸惡化,則繼續(xù)出現(xiàn)動(dòng)物死亡現(xiàn)象,最后有12只存活時(shí)間達(dá)到19天。因此,G組在術(shù)后第7天又再次開腹結(jié)扎門-腔分流口后,門靜脈灌注壓力再次逐漸升高,從而滿足了余肝持續(xù)再生的機(jī)體代謝需求,動(dòng)物死亡率較F組進(jìn)一步下降,肝臟再生明顯,最后有24只存活時(shí)間達(dá)到19天。 結(jié)論 1.兔肝臟解剖學(xué)既與犬、鼠、豬等哺乳類動(dòng)物類似,又具有其自身的特點(diǎn)。本實(shí)驗(yàn)通過對(duì)兔肝臟在體、離體解剖學(xué)和肝臟管道灌注標(biāo)本的觀察,規(guī)范了文獻(xiàn)中對(duì)兔肝解剖學(xué)的混亂描述。并在此基礎(chǔ)上,通過測(cè)量全肝及各肝葉質(zhì)量,計(jì)算出各肝葉所占全肝質(zhì)量百分比,為在該方面的基礎(chǔ)研究提供數(shù)據(jù)支持。 2.根據(jù)兔肝解剖學(xué)特點(diǎn)行不同質(zhì)量百分比肝葉切除術(shù)制作SFSS模型,當(dāng)保留右外葉和手術(shù)切除相對(duì)困難的尾狀葉后,即余肝占全肝質(zhì)量百分比約為28%時(shí),術(shù)后存活率較高并可表現(xiàn)出典型的SFSS。而且兔體積適中,圍手術(shù)期管理和手術(shù)操作相對(duì)簡便,可作為研究SFSS發(fā)病機(jī)制及防治措施較為理想的實(shí)驗(yàn)動(dòng)物模型。 3.門-腔分流術(shù)后可明顯降低門靜脈灌注壓,促進(jìn)肝再生,有效延長術(shù)后動(dòng)物生存時(shí)間；過度分流,門靜脈灌注壓低于正常值則肝再生受到抑制。在擴(kuò)大肝切除術(shù)后發(fā)生SFSS情況下,采用門-腔分流手術(shù)維持適度增高的門靜脈灌注壓可明顯促進(jìn)肝再生。
[Abstract]:background
Small liver syndrome (small-for-size, syndrome, SFSS) occurs in hepatic resection or partial orthotopic liver transplantation after due to liver volume is too small to function can not meet the demand of the metabolic receptor a clinical syndrome.SFSS is most common in adult adult living donor liver transplantation for partial orthotopic liver volume is small, may lead to the receptor of portal vein blood flow perfusion and high persistence of portal hypertension, which caused a series of serious pathophysiological disorder. Its clinical manifestations include persistent postoperative jaundice, coagulopathy, portal hypertension, refractory ascites, which further induce sepsis, gastrointestinal bleeding and other complications.
The etiology and pathogenesis of SFSS has not yet entirely clear, the prevailing view was mainly due to functional liver volume is too small, resulting in persistent portal hypertension, persistent portal hyperperfusion and further lead to injury of sinusoidal endothelial cells and caused liver parenchyma cell damage, liver cell regeneration, eventually lead to liver function. In addition, it may be related to other factors, such as graft size, potential lesions, liver regeneration, inflow and outflow tract, the severity and so on. Because of this, SFSS control measures have also been active in exploring.
At present, SFSS prevention strategies mainly focus on the following 3 aspects: (1) [6] increased liver graft volume; (2) control of portal vein pressure; (3) improvement of hepatic venous return way. Most scholars generally agree on portal vein perfusion and portal hypertension have a destructive effect on the small volume of liver graft plants, therefore reduce portal vein pressure and perfusion has become the main means of preventing SFSS. And the current commonly used surgical methods including splenic artery ligation and portosystemic shunt.
Ligation of splenic artery embolization, simple operation, small trauma, portal vein perfusion pressure regulation is limited, can be complicated with postoperative portal vein thrombosis and infection of abdominal cavity; portal vein shunt can effectively regulate the portal vein perfusion pressure, in recent years, some researchers use the portal vein to vena cava shunt occurred to the prevention and treatment of SFSS. However, there are researchers found that portacaval shunt in living donor liver transplantation after a few weeks can effectively reduce the incidence of SFSS, and can improve the survival rate of liver transplantation, but late graft gradually atrophic, inhibited the phenomenon of liver regeneration.
Therefore, to maintain the proper pressure in the portal vein perfusion during liver regeneration than plays an important role in hepatic resection or liver transplantation. This study was to establish the animal model of SFSS, and the implementation of perfusion portocaval shunt regulation of portal vein, to observe the effect of portal vein perfusion pressure on liver regeneration.
objective
1. the applied anatomy of the rabbit's liver lobules and accessory pipes was carried out, and a rabbit SFSS animal model was established on the basis of this.
2. the portal cavity shunt was carried out on the basis of the SFSS animal model, and the effects of the changes of portal vein perfusion pressure on liver function and liver regeneration were observed.
Study on applied anatomy of 1. rabbit liver and its affiliated pipeline: from the experimental animal center of Kunming Medical University health 20 adult Japanese white rabbits, weight 1.5kg-2.5kg. intravenously with 1ml/kg injection of 3% pentobarbital anesthesia. The fixation of limbs, abdominal faded hair. (1) the liver in vivo and in vitro anatomy observation: the median incision into the abdominal cavity, severed ligaments around the liver, liver and fully exposed were observed in vivo anatomy on it. Kill the animal, via the portal vein infusion of saline irrigation vessels. The complete pathological anatomy observation in vitro. (2) and the total hepatic lobe of the liver and liver and weighing, calculation the rabbit liver weight percentage. Ye Zhanquan (3) made of portal vein and hepatic vein perfusion specimens. After ligation of the superior mesenteric vein intubation caudal, injection pipe casting agents (self curing polymer and self curing denture water by 10g:10ml Mixed) making cast specimens of portal vein ligation of hepatic vena cava pipeline. Cephalic, caudal, ditto injection pipe casting agents making cast specimens of hepatic vein duct. To cast specimens of hardened pipe, remove the liver. Placed in 20% sodium hydroxide solution immersion exposure pipe specimens.SPSS13.0 for descriptive analysis of data the results of measurement data, the standard deviation (x + s) ".
2. SFSS鍔ㄧ墿妯″瀷鐨勫緩绔嬶細(xì)灝，

本文編號(hào)：1541669