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Objective To evaluate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP)-based comprehensive minimally invasive treatment for biliary anastomotic stenosis (BAS) after liver transplantation. Methods Clinical data of 60 BAS recipients after liver transplantation were retrospectively analyzed, 54 male and 6 female, aged (48±10) years. ERCP was initially carried out. If it succeeded, plastic or metallic stents were placed into the biliary tract. If it failed, percutaneous transhepatic cholangial drainage (PTCD) or single-operator cholangioscopy (SpyGlass) was adopted to pass through the stenosis. If all these procedures failed, magnetic anastomosis or other special methods were delivered. The incidence and treatment of BAS after liver transplantation were summarized. The efficacy, stent removal and recurrence were observed. Results The median time of incidence of BAS after liver transplantation was 8 (4, 13) months. Within postoperative 1 year, 1-2 years and over 2 years, 39, 16 and 5 recipients were diagnosed with BAS, respectively. All 60 BAS recipients after liver transplantation were successfully treated, including 56 cases initially receiving ERCP, and 41 completing BAS treatment, with a success rate of 73%. The failure of guide wire was the main cause of ERCP failure. The success rates of PTCD, SpyGlass and magnetic anastomosis were 5/9, 5/7 and 7/8, respectively. Two recipients were successfully treated by percutaneous choledochoscope-assisted blunt guide wire technique and stent placement in the biliary and duodenal fistula. After 3 (3, 4) cycles of ERCP and 13 (8, 18) months of stent indwelling, 38 recipients reached the stent removal criteria, including 25 plastic stents and 13 metallic stents. The indwelling time of plastic stents was longer than that of metallic stents (P < 0.05). Six cases suffered from stenosis recurrence at 12 (8, 33) months after stent removal, and the recurrence rate was 16%. Six patients were treated with ERCP, and 5 of them did not recur after the stents were successfully removed. Multivariate analysis showed that delayed diagnosis of stenosis and frequent ERCP before stent removal were the independent risk factors for BAS recurrence (both P < 0.05). Conclusions ERCP-based comprehensive minimally invasive treatment may improve the success rate of BAS treatment after liver transplantation and yield satisfactory long-term efficacy. Delayed diagnosis of BAS and high frequent ERCP required for stent removal are the independent risk factors for BAS recurrence.
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@#Objective To systematically summarize the effect of flipped classroom (FC) in physiotherapy teaching.Methods The following electronic bibliographic databases were searched from inception to June, 2021: CENTRAL, Medline, EMBASE, CINAHL plus, Academic Search Premier, Teacher Reference Center, ERIC, and Education Research. Original researches about FC for physiotherapy teaching were searched. The researches were screened, selected, extracted and assessed independently by two researchers, and, systematically reviewed.Results and Conclusion A total of 1 307 literatures were retrieved, and seven studies involving at least 770 student participants were finally included, which published mainly from 2013 to 2019. The subjects were students majored in physiotherapy, and the primary outcome index was exam results. FC teaching model generally can improve students' written test scores and enhance their high-level thinking ability. Students and teachers generally hold a positive attitude towards the FC teaching model.
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Objective:To explore the characteristics of biliary stricture after liver transplantation (LT) under SpyGlass peroral choledochoscopy and to investigate its treatment value for difficult stricture.Method:A total of 24 patients of biliary stricture after LT at the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University underwent SpyGlass examination from January 2019 to December 2020, 15.5 months (2-58 months) after surgery. The characteristics of different types of strictures and the selective guidewire placement results by SpyGlass were recorded and analyzed.Results:Of the 24 patients, 9 were anastomostic strictures (AS) and 15 others were non-anastomostic strictures (NAS). The main characteristic of 5 initial AS patients was scar constriction. Whether treated or not, all of the 15 NAS patients showed evident inflammatory hyperplasia in hilar bile duct under SpyGlass, 80% (12/15) of which were accompanied with intrahepatic biliary stones. The strictures disappeared with mild hyperplasia in 8 patients (4 AS and 4 NAS) whose biliary stents were extracted. Eleven patients (5 AS and 6 NAS) needed guidwire placement under SpyGlass, six (54.5%) of whom succeeded. The successful rate in AS patients was higher than that of NAS (4/5 VS 2/6).Conclusion:The main characteristic of AS is scar constriction and that of NAS is inflammatory hyperplasia. Selective guidewire placement can be achieved by SpyGlass peroral choledochoscopy with a satisfactory successful rate in the difficult AS.
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Objective:To discuss the type, treatment and results of different therapies of biliary fistula after orthotopic liver tansplantation(OLT).Methods:Data of 24 patients who developed biliary fistula after OLT in the First Affiliated Hospital of Xi′an Jiaotong University from January 2000 to March 2019 were retrospectively analyzed. Patients with biliary fistula were classified into 4 types according to presence or absence of stricture. All patients were treated by endoscopic retrograde cholangiopancreatography (ERCP) or interventional therapy, including endoscopic nasobiliary drainage (ENBD), endoscopic retrograde biliary drainage (ERBD) or percuteneous transhepatic cholangial drainage (PTCD). Main outcome measurements were the onset time of biliary fistula, the site of biliary fistula, the complications of ERCP or PTCD, the time of removing abdominal or biliary drainage tube, and the onset of new biliary stricture.Results:Biliary fistula was found in (46.5±36.6) days (6-122 days) after OLT. The numbers of patients in four types of biliary fistula were 6, 14, 2 and 2, respectively. Biliary fistula was cured in 22 patients, with clinical cure rate of 91.7%. All patients underwent ERCP first, and the technical success rate and clinical cure rate were 87.5% (21/24) and 85.7% (18/21), respectively. The clinical cure rates of ERCP forⅠ-Ⅳ biliary fistula were 6/6, 84.6%(11/13), 1/2, and 0, respectively. The clinical cure rates of ENBD and ERBD were 8/10 and 6/8, respectively. Five cases in whom ERCP failed, underwent PTCD, with technical success and clinical cure rates of 4/5 and 3/4 respectively. Eight patients(33.3%)developed cholangitis after treatment, and the incidence rate seemed higher in type Ⅱ biliary fistula than that in type Ⅰ [35.7% (5/14) VS 16.7% (1/6)]. Incidence of cholangitis was higher in patients with non-anastomotic stricture than those with anastomotic stricture [83.3%(5/6) VS 16.7%(3/18)].Conclusion:The first line treatment for biliary fistula after OLT is ERCP, followed by PTCD. The best procedures of biliary fistula typeⅠ-Ⅳ were ENBD, ENBD combined with ERBD, ENBD and PTCD, respectively.
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Objective:To study our initial experience on feasibility and safety of magnetic compression anastomosis in laparoscopic pancreaticoduodenectomy(LPD).Methods:A retrospective analysis was conducted on the data of 7 patients who underwent LPD with laparoscopic magnetic compression choledochojejunostomy (LMC-CJ) or pancreaticojejunostomy (LMC-PJ) at the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University from May 2018 to September 2019. There were 6 males and 1 female. The median age of patients was 63 (56-83) years. Data analyzed included the model of the magnetic anastomosis device, operation time of the LMC-CJ or LMC-PJ, other operation-related parameters, postoperative complications, time to perform magnetic anastomosis, and time of discharge of the magnet from patients’ body.Results:All 7 patients completed LPD successfully, including 7 LMC-CJ and 2 LMC-PJ. The median operation time was 340 (310-450) minutes. The median diameter of the biliary-enteric magnetic anastomosis ring used was 10 (9-12) mm, and the median time of the biliary-enteric magnetic anastomosis was 11 (8-16) min. The diameter of the pancreaticojejunal magnetic anastomosis ring was 5 mm in the two anastomoses, and the times taken were 12 min and 15 min. Complications occurred in 4 patients, including 1 patient each for grade A and grade B pancreatic fistula, 2 patients with abdominal infection, 2 patients with postoperative gastric emptying disorder, and 1 patient with abdominal hemorrhage. All patients responded to conservative treatment. There was no biliary or pancreatic fistula at the magnetic anastomoses. Pancreaticojejunostomy functioned at 24 and 30 days after operation. The median time for the magnets to pass out from the body of all patients was 50 (40-170) days. The median follow-up was 11 (4-18) months. No biliary-enteric or pancreaticojejunostomy stenosis was detected.Conclusion:Magnetic compressive anastomosis was simple, feasible, and safe for choledochojejunostomy or pancreaticojejunostomy in LPD.
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Objective:To investigate the risk factors for abdominal infection after liver transplantation (LT).Methods:The retrospective case-control study was conducted. The clinical data of 356 patients who underwent LT in the First Affiliated Hospital of Xi′an Jiaotong University from January 2015 to December 2018 were collected. There were 273 males and 83 females, aged from 21 to 67 years, with the median age of 46 years. Observation indications: (1) abdominal infec-tion after LT and distribution of pathogens; (2) analysis of risk factors for abdominal infection after LT; (3) follow-up and survival. Follow-up was performed using outpatient examination and tele-phone interview to detect postoperative 1-year survival rate and cases of death up to June 2020. Measurement data with normal distribution were represented as Mean±SD. Measurement data with skewed distribution were described as M(range). Count data were expressed as absolute numbers or percentages. Univariate analysis was conducted using the chi-square test, t test, Mann-Whitney U test and Fisher exact probability. Multivariate analysis was done using the Logistic regression model. The Kaplan-Meier method was used to calculate sruvival time and survival rates. Log-Rank test was used for survival analysis. Results:(1) Abdominal infection after LT and distribution of pathogens: 63 of 356 recipients had abdominal infection after LT, with the overall incidence of 17.70%(63/356). Of the 63 recipients, 41 cases had abdominal infection within postoperative 2 weeks, 17 cases had multi-drug resistant organism infection. A total of 116 strains of bacteria were isolated from 63 recipients with abdominal infection, 52 of which were gram-negative bacteria, 48 were gram-positive bacteria, 16 were fungi. (2) Analysis of risk factors for abdominal infection after LT: results of univariate analysis showed that preoperative model for end-stage liver disease (MELD) score, preoperative serum albumin, preoperative leukocytes, preoperative prothrombin time, preoperative alanine aminotransferase, preoperative aspartate aminotransferase, operation time, volume of intraoperative blood loss, days of postoperative antibiotic use, postoperative renal failure, postoperative delayed graft function,duration of postoperative intensive care unit stay were related factors for abdominal infection after LT ( Z=-2.456, t=-1.982, Z=-3.193, -2.802, -2.336, -2.276, -2.116, -3.217, χ2=15.807, 10.395, 6.750, Z=-4.468, P<0.05). Liver retransplantaiton and postoperative bile leakage were related factors for abdominal infection after LT ( P<0.05). Results of multivariate analysis showed that preoperative MELD score>20 and liver retransplantation were independent risk factors for abdominal infection after LT ( odds ratio=2.871, 12.875, 95% confidence interval as 1.106-7.448, 1.290-128.521, P<0.05). (3) Follow-up and survival: 356 recipients were followed up for 1-66 months, with a median follow-up time of 32 months. The postoperative 1-year overall survival rate of 63 recipients with abdominal infection and 293 recipients without abdominal infection were 84.60% and 97.03%, respectively, showing a significant difference ( χ2=11.660, P<0.05). During the follow-up, 58 recipients died. Conclusion:Preoperative MELD score>20 and liver retransplantation are independent risk factors for abdominal infection after LT.
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Objective:To investigate the diagnosis and treatment of hepatic artery thrombosis (HAT) after adult orthotopic liver transplantation.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 411 patients who underwent adult orthotopic liver transplantation in the First Affiliated Hospital of Xi ′an Jiaotong University from December 2011 to July 2018 were collected. There were 328 males and 83 females, aged from 21 to 66 years, with a median age of 46 years. Observation indicators: (1) incidence of HAT and its clinical characteristics; (2) diagnosis of HAT; (3) treatment of HAT; (4) follow-up. Follow-up using outpatient service, telephone interview or WeChat group communication was conducted to detect the incidence of biliary stricture and survival of patients up to August 2018. Measurement data with normal distribution were represented as Mean± SD, measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers or percentages. Survival rate was estimated using the Kaplan-Meier method. Results:(1) Incidence of HAT and its clinical characteristics: 11 of 411 patients had HAT after orthotopic liver transplantation with the incidence of 2.68%(11/411), including 10 males and 1 female, aged 44 years(range, 22-63 years). The time to occurrence of postoperative HAT was 4 days(range, 1-15 days). The etiologies of 11 patients included 6 cases of hepatitis B virus-related cirrhosis, 1 case of hapatitis related cirrhosis, 1 case of hepato-cellular carcinoma, 1 case of liver cirrhosis, 1 case of alcoholic hepatitis related cirrhosis, 1 case of wilson disease. All the 11 patients were ABO compatible. The cold ischemic time and warm ischemic time of donor liver were (316±89)minutes and (13±4)minutes, respectively. Type Ⅰ arterial anasto-mosis was conducted in 11 patients. The clinical manifestations included asymptomatic type in 10 patients and sepsis type in 1 patient. (2) Diagnosis of HAT: all the 11 patients were confirmed with HAT by endovascular angiography, including 7 cases showed no arterial flow under Color Doppler ultrasound, and contrast-enhanced ultrasound indicated HAT. Two patients showed increased hepatic artery resistance index under Color Doppler ultrasound, and contrast-enhanced ultrasound indicated 1 case of HAT and 1 case of anastomotic stenosis. One patient showed slow velocity of hepatic artery blood flow and low resistance index under color Doppler ultrasound, and contrast-enhanced ultrasound indicated HAT. One patient showed slight blood flow signals under Color Doppler ultrasound, and contrast-enhanced ultrasound indicated HAT. (3) Treatment of HAT: 11 patients received endovascular therapy. Six patients had HAT completely disappeared after thrombolytic therapy, 5 patients with residual thrombosis continued thrombolytic therapy with microcatheter urokinase. Six patients with complications were improved after symptomatic treatment. HAT completely disappeared after (6.7±2.6)days of treatment and the clinical success rate was 11/11. (4) Follow-up: 11 patients were followed up for 19-1 722 days, with a median follow-up time of 46 days. During the follow-up, 4 patients had biliary stricture and underwent stent implantation. Nine patients survived with 1-, 3-, 5-year overall survival rates of 75%, 75%, 75%, and 2 patients died.Conclusions:The incidence of HAT after adult orthotopic liver transplantation is low and clinical manifestations are atypical. Contrast enhanced ultrasound can improve diagnosis of suspected thrombosis. Endovascular therapy is safe and effective, which can significantly improve the blood flow of hepatic artery.
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Objective:To review experience on the diagnosis and treatment of patients with pancreatic injury.Methods:There were 65 patients with pancreatic injuries who were managed in the First Affiliated Hospital of Xi’an Jiaotong University between January 1995 and December 2017. After excluding 6 patients with inadequate data and 4 patients with other associated injuries, the remaining 55 patients were enrolled in this retrospective study. All data, including the type of abdominal trauma, general information of patients, clinical manifestations, methods of diagnosis, treatment, operation and complication were collected and analysed. Analyze the cause, degree of injury, treatment measures, treatment results and complications of patients with pancreatic injury.Results:The most common cause of pancreatic injury was traffic accidents (23 patients, 41.8%), with a correct preoperative diagnostic rate of 61.8% for pancreatic injury. Compute tomography (CT) had a significantly higher sensitivity than sonography (80% vs. 37.5%, P<0.05). The number of patients with grade I-V pancreatic injury were 7, 19, 24, 1 and 4, respectively. Sixteen patients were successfully managed by conservative treatment, and 39 patients underwent various surgeries depending on the injury grade. Significantly more patients having severe grades (III-V) underwent surgical treatment than those having mild grades (I-II) (53.8% vs. 86.2%, P<0.05). Two patients died after surgery (mortality rate 5.1%, 2/39). Pancreatic fistula developed in 29 patients (74.4%), intra-abdominal infection in 10 patients (25.6%) and these were the main surgical complications. Patients having severe grades had a significantly higher pancreatic fistula rate than those having mild grades. Pancreatic pseudocyst was the most common complication on long-term follow-up (8 patients, 14.5%). This complication was significantly higher in patients who were managed with consecutive treatment than with operation (31.2% vs. 7.7%, P<0.05). Conclusions:The preoperative diagnosis of pancreatic injury was difficult, and CT should be the first line investigation. Grade I -II injuries could be managed by conservative treatment, while grade III-V should be treated by operations. The most common short- and long-term complications of pancreatic injury were pancreatic fistula and pancreatic pseudocyst, respectively.
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Objective:To investigate the clinical efficacy of endoscopic magnetic compression bilio-enteric anastomosis for the treatment of biliary obstruction after complex abdominal surgery.Methods:The retrospective and descriptive study was conducted. The clinical data of 3 patients with biliary obstruction after complex abdominal surgery who were admitted to the First Affiliated Hospital of Xi′an Jiaotong University between January 2012 and December 2019 were collected. There were 2 males and 1 female, aged from 27 to 57 years, with a median age of 56 years. The 3 patients underwent endoscopic magnetic compression bilio-enteric anastomosis to complete internal drainage of bile ducts after several unsuccessful endoscopic or interventional therapy. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow up using outpatient examination was performed to detect the biliary stent, liver function and patency of anastomotic stoma up to December 2019.Results:(1) Surgical situations: all the 3 patients underwent successful endoscopic magnetic compression bilio-enteric anastomosis, including 2 cases with magnetic compression choledochoduodenal anastomosis and 1 case with magnetic compression choledochojejunostomy. The length of biliary stricture, length and width of magnetic device subsidiary magnet/patent magnet, time of magnetic compression for the 3 patients were 7.1 mm, 3.0 mm, 2.0 mm, 7 mm/8 mm, 6 mm/6 mm, 5 mm/5 mm, 130 minutes, 90 minutes, 75 minutes, respectively. (2) Postoperative situations: the time to biliary tract recanalization after operation for the 3 patients were 15 days, 8 days, 9 days, respectively. None of the patients encountered gastrointestinal perforation, hemorrhage or infection. (3) Follow-up: the biliary stents were inserted into the anastomotic stoma for the 3 patients after biliary tract recanalization, including a catheter of percutaneous transhepatic cholangiodrainage (PTCD) with 12 Fr size, a biliary plastic stent with 7 Fr size, a catheter of PTCD with 14 Fr size, respectively. The biliary stents were removed after 17 months, 2 months, and 6 months from the 3 patients, respectively. The 3 patients were followed up for 40 months, 20 months, and 5 months respectively after removing biliary stents, and the concentration of total bilirubin, concentration of aspartate aminotransferase, concentration of alanine aminotransferase for the 3 patients were 5-19 μmol/L, 25-40 U/L, and 20-35 U/L, respectively. The results of ultrasonic examination or magnetic resonance cholangiopancreatography examination showed that no intra-hepatic bile duct dilation or stricture of choledochojejunostomy was found within the 3 patients. One of the 3 patients was hospitalized for biliary tract infection after 37 months from removing biliary stents, and the results of ultrasonic examination or magnetic resonance cholangiopancreatography examination showed intrahepatic cholelithiasis. The cholelithiasis was removed under endoscopy and stricture of choledochojejunostomy was not found within patient by the endoscopic examination or cholangiography examination.Conclusion:The endoscopic magnetic compression bilio-enteric anastomosis is a safe and feasible technique for the treatment of biliary obstruction after complex abdominal surgery with good long-term effects.
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In recent years, the incidence of adenocarcinoma of esophagogastric junction (AEG) keeps increasing. Siewert type II and type III AEG invades at 2-4 cm in the lower esophagus, and it has a higher rate of lower mediastinal lymph node metastasis. Lower mediastinal lymph node clearing through the abdomino-transhiatal (TH) approach is preferred, which can be accomplished by entering the lower mediastinum through the hiatus and mobilize the esophagus upward and the surrounding lymph and connective tissue for approximately 6.5 cm. Using the infracardiac bursa (IBC) as an anatomical landmark improves the safety and operability of the thorough dissection of the lower mediastinum. Total resection of the mesenterium at the esophagogastric junction can entirely dissect the lower mediastinal lymph nodes, which conforms to the safety principles in oncology.
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Magnetic anchor technique can reduce the number of trocar in laparoscopic surgery. The laparoscopic magnetic anchor system consists of an external anchor magnet and the magnetic clutch system. Electromagnetic control laparoscopic surgery clutch system includes the internal grasper and the operating forceps. In this design, a permanent magnet is set at the tail of the internal grasper, and an electromagnetic device is installed at the head of the operating forceps. The magnetic field direction of the electromagnetic device can be changed by switching the positive pole and the negative pole of the electromagnetic device, so as to control the separation and combination of the operating forceps and the internal grasper. The design of this system is ingenious, easy to manufacture and the operation is simple.
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Electromagnetic Phenomena , Equipment Design , Laparoscopy , Magnetics , Surgical InstrumentsABSTRACT
Objective To investigate the risk factors and prognosis of acute kidney injury (AKI) after orthotopic liver transplantation (OLT).Methods The retrospective case-control study was conducted.The clinical data of 127 patients who underwent OLT in the First Affiliated Hospital of Xi'an Jiaotong University from January 2013 to December 2015 were collected.Of 127 patients,24 were complicated with postoperative AKI,including 17 in grade 1,5 in grade 2 and 2 in grade 3,and 103 were not complicated with AKI.AKI after OLT was treated according to the diagnostic criteria of AKI from 2012 guidelines of Kidney Disease:Improving Global Outcomes (KDIGO).Observation indicators:(1) risk factors analysis affecting AKI after OLT;(2) comparison of postoperative recovery in patients with different AKI grade;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed up to July 2017.Measurement data with nornal distribution were represented as x±-s,and measurement data with skewed distribution were described as M (range).Univariate analysis was done using the t test and rank sum test.Comparisons of count data and univariate analysis were done using chi-square test or Fisher exact probability.Multivariate analysis was done using the logistic regression model.The survival rate and curve were respectively calculated and drawn by the KaplanMeier method,and Log-rank test was used for survival analysis.Results (1) Risk factors analysis affecting AKI after OLT:results of univariate analysis showed that age,combined hypertension,preoperative Child-Pugh score,preoperative model for end-stage liver disease score (MELD),preoperative hemoglobin,preoperative serum albumin,preoperative blood urea nitrogen,preoperative glomerular filtration rate,preoperative prothrombin time,operation time,inferior vena cava occlusion time,duration of anhepatic phase,volume of intraoperative blood loss,total volume of intraoperative blood transfusion,volumes of intraoperative plasma and red blood cells transfusion,duration of postoperative ICU stay,use time of postoperative vasoactive drugs,time of postoperative mechanical ventilation,cases with postoperative infection,body mass index of donor and donor liver cold-ischemia time were related factors affecting occurrence of AKI after OLT (t =4.154,x2 =8.482,t =5.129,3.694,1.294,9.223,5.418,Z=4.287,t=2.105,5.168,8.182,10.042,Z=1.074,0.664,6.274,3.712,1.289,t=1.056,x2 =10.617,t=2.447,3.371,1.476,P＜0.05).Results of multivariate analysis showed that age,preoperative MELD score,preoperative serum albumin,volume of intraoperative blood loss and donor liver cold-ischemia time were independent factors affecting occurrence of AKI after OLT [odds ratio (OR) =0.812,0.866,1.392,1.001,0.516,95％ confidence interval:0.717-0.919,0.751-0.997,1.104-1.755,1.000-1.001,0.282-0.944,P＜0.05].(2) Comparison of postoperative recovery in patients with different AKI grade:cases with complete recovery,partial recovery and chronic renal failure were respectively 14,3,0 in 17 patients with grade 1 of AKI and 3,2,0 in 5 patients with grade 2 of AKI and 0,1,1 in 2 patients with grade 3 of AKI,with a statistically significant difference (x2=14.140,P＜0.05).(3) Follow-up and survival situations:127 patients were followed up for 9-44 months,with a median of 23 months.The 1-year overall survival rate of 127 patients was 95.3％.During the follow-up,22 patients died,including 9 with multiple organ failure,8 with primary disease recurrence and 5 with respiratory complication.The median overall survival time after OLT was 36 months in 24 patients with AKI and 40 months in 103 patients without AKI,with no statistically significant difference (x2=3.033,P＞0.05).Conclusion Age,preoperative MELD score,preoperative serum albumin,volume of intraoperative blood loss and donor liver cold-ischemia time are independent factors affecting occurrence of AKI after OLT,and there is better recovery in patients with grade 1 of AKI.
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Objective To investigate the diversity of gut microbiota and its dynamic changes in very low birth weight infants (VLBWIs) during the first six months after birth.Methods From January to December in 2015,53 VLBWIs admitted to the Neonatal Intensive Care Unit (NICU) were recruited.Stool samples were collected from each subject on day 1,7,14 and 28 after birth as well as on day 180 during a follow-up visit.High-throughput 16S rRNA gene sequencing and bioinformatics analysis of bacterial DNA extracted from stool samples were performed using Illumina MiSeq platform double-end sequencing.Results (1) Phyla level:At all five time points,the dominant phyla were all Proteobacteria,Firmicutes,Bacteroidetes and Actinobacteria.The median relative abundance of Proteobacteria was 0.598 5 (0.122 3～0.942 6) on day 1,then rose to 0.893 2 (0.478 1～0.987 0) after one week,maintained at 0.943 2～0.966 0 within 28 days,and later dropped back to the same level as day 1 on day 180 (all P＜0.05).In contrast,the median relative abundance of Actinobacteria on day 180 was significantly higher than that on days 1,7,14 and 28 (all P＜0.05).(2) Genus level:The relative abundance of Klebsiella increased significantly between days 7 and 28 as compared with the lower level on day 1 [0.326 5～0.368 2 vs 0.003 1(0.000 8～0.026 0),all P＜0.05],but significantly decreased to a lower level on day 180 [0.008 1 (0.000 5～0.067 1)].There was no significant difference in the relative abundance of Escherichia within 14 days after birth.However,it significantly increased since day 28 (P＜0.05) and reached a peak on day 180 (P＜0.05).Infants were born with a certain abundance of Bifidobacterium [0.000 5 (0.000 1～0.004 2)],which remained at a very low level for 28 days before reaching to a higher level of 0.045 1 (0.010 2～0.124 8) on day 180 (P＜0.05).(3)The Shannon index on day 14 and 28 were lower than that of day 1 and day 180 (1.81±0.71,1.89±1.270.56 vs 2.33±1.29,2.2±0.5,all P＜0.05),respectively.Conclusions The diversity of gut microbiota in VLBWIs decreases during NICU hospitalization as compared with that at birth when Proteobacteria and Klebsiella becoming the dominant bacteria.However,the diversity was regained after discharge with the increase of Bifidobacterium,Escherichia and other residential bacteria,which indicates that NICU hospitalization is a risk factor for dysbiosis in VLBWIs.
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Objective To study the safety and efficacy of magnetic compression anastomosis (MCA) in treatment of biliary anastomotic stricture after orthotopic liver transplantation (LT).Methods Five patients who were treated unsuccessfully by ERCP were admitted to The First Affiliated Hospital of Xi'an Jiaotong University from 2012 January to 2018 May to undergo MCA.The treatment results were analyzed retrospectively.Results In four patients,the treatment was successful while in one patient it failed.For the four successful patients,the biliary stricture length was 2～4 mm.Re-canalization was achieved within 7～12 days and these patients were discharged home without any adverse events.Multiple plastic stents (in 2 patients) or full-covered self-expansion mental stents (in 2 patients) were inserted into the new fistulae after re-canalization.In two patients whose stents were removed,there was no recurrence of biliary strictures after follow-up for 64 months and 59 months,respectively.Conclusion The MCA technique is a revolutionary and effective method of performing interventional choledochocholedochostomy in patients with biliary anastomotic stricture after LT for whom the conventional endoscopic procedures were not successful.
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Objective To develop a pulling device using magnetic positioning to optimize the procedures of repairment of donor liver from organ donation . Methods The pig liver specimens were used to measure the pull force of repairment of donor liver, magnetic spiderman was developed based on the measurement results. The magnetic spiderman was applied to simulate the repairment of donor liver from organ donation on the pig liver specimens. The effectiveness of magnetic spiderman was also evaluated. Results The pulling force was required all less than 2 N during the repairment of donor liver. The magnetic spiderman was successfully manufactured. The magnets of magnetic spiderman could generate 3 N magnetic forces with paramagnetic basin of hepatic repairment. The self-retraction pull wire of the magnetic spiderman could provide 2.5 N pulling forces. The magnetic spiderman was successfully applied to the simulated experiment of repairment of donor liver from organ donation in 6 cases. The operation time was (54±5) min. No clip slippage,displacement and slippage of the base occurred during the operation. With the cooperation of multiple magnetic spidermen,the remaining surgical procedures were performed by one single surgeon except for the vascular ligation. Conclusions The magnetic spiderman has small volume and implements flexible positioning, can perform pulling operation and nottake up operational space. It can effectively optimize the procedures of repairment of donor liver from organ donation and reduce the quantity of surgeons.
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Objective To analyze the risk factors of early acute kidney injury (AKI) after liver transplantation from donation after cardiac death(DCD) donor liver. Methods Clinical data of 184 donors and recipients undergoing liver transplantation from DCD donor liver were retrospectively analyzed. According to the incidence of early AKI, all participants were divided into the AKI and non-AKI groups. The patients in the AKI group were subject to AKI staging. Baseline data, preoperative, intraoperative and postoperative related parameters were statistically compared between two groups. The cumulative survival rate and clinical prognosis of patients in non-AKI group and AKI group with different staging were statistically analyzed by Kaplan-Meier curve analysis. Results Among 184 patients, 68 cases (37.0%) presented with early AKI after liver transplantation including 31 stage 1 AKI, 26 stage 2 AKI and 11 stage 3 AKI, mainly occurring within postoperative 3 d. Univariate analysis revealed that preoperative levels of albumin <35 g/L, preoperative levels of serum sodium ≤137 mmol/L, operation time>7.5 h, intraoperative hemorrhage volume>3 000 mL, intraoperative red cell infusion volume>15 U and intraoperative urine amount ≤100 mL/h were the risk factors of early AKI after liver transplantation (all P<0.05). Multi-variate Logistic regression analysis demonstrated that intraoperative red cell infusion >15 U was an independent risk factor of early AKI after liver transplantation [odds ratio(OR) 1.061, 95% confidence interval(CI)1.008-1.118,P=0.024].Result of Kaplan-Meier survival curve suggested that the cumulative survival rate was gradually reduced along with the aggravation of AKI with statistical significance (all P<0.05). Conclusions The incidence of early AKI following liver transplantation is relatively high. The severity of early AKI is intimately correlated with the short- and long-term prognosis of the recipients. A large quantity of intraoperative red blood cell infusion is an independent risk factor of AKI.
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Objective To investigate the relationship of central venous pressure (CVP) and organ function in early period after orthotopic liver transplantation (OLT).Methods A retrospective study was conducted on 111 patients who underwent OLT.According to the value of mean CVP after OLT,all patients were divided into three groups:low CVP group (CVP＜8 rnmHg,1 rnmHg =0.133 kPa),normal CVP group (CVP 8-12 mmHg) and high CVP group (CVP ＞12 mmHg).Meanwhile,According to whether the CVP dropped below 8 mmHg or not in the past 48h after surgery,all patients were divided into two groups.Results There were significant differences in serum total bilirubin,serum creatinine and serum lactate among low,normal,and high CVP groups (P＜0.05).The time of vasoactive agent,fluid balance,time of mechanical ventilation and incidence of acute kidney injury in groups with CVP not dropped below 8 rnmHg were higher than those in groups with CVP dropped below 8 mmHg (P＜0.05).Conclusion CVP was associated with liver,kidney,lung function and lactate.Controlling a lower CVP can significantly shorten the time of mechanical ventilation and reduce the incidence of acute kidney injury after OLT.
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Objective To design a new type of biliary stent to be used in the common bile duct probe and evaluate its biocompatibility, safety and effectiveness in a canine model.Methods Magnesium alloy (AZ 31B) was used to make biliary stents.A canine model of acute obstructive jaundice was established by ligating the distal end of the common bile duct.These dogs were divided into two groups with either placement of magnesium stent or not.The incidence of bile duct leakage and survival were evaluated.Meanwhile, we determined the concentration of magnesium in various body fluids and organs, liver function test, and ultrasonic and histological studies.Results The concentrations of magnesium in the blood, feces, liver, heart, brain and lungs were similar between the two groups.Bile leakage rate in experimental group and control group was 0％ and 16.7％, respectively.The mortality was 16.7％ and 33.3％.There were no significant differences in ALP and TBIL between experimental group and control group (P>0.05) before building and bile duct exploration.There were significant differences in ALP andTBIL between the two groups one and three months after bile duct probe (P<0.05).Biliary tract specimens showed obviously anastomotic stenosis performances and expansion performances of extrahepatic biliary in the control group, but in experimental group such changes were not observed.Ultrasonography showed that the patency of biliary anastomosis was good and there was no anastomotic biliary stricture in experimental group.However, progressive stenosis and expansion performances of extrahepatic biliary occurred in control group.There were fewer collagen fibers but more muscle fibers in experimental group than in control group.Conclusion Biliary stent made of magnesium alloy is of good biocompatibility and has the potential to prevent the postoperative stenosis in the common bile duct probe.
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Objective To summarize the experience of clinical diagnosis and treatment of portal vein stenosis after liver transplantation. Methods Clinical data of 18 patients presenting with portal vein stenosis after undergoing liver transplantation were retrospectively analyzed. The incidence, treatment and prognosis of portal vein stenosis were summarized. Results Seventeen patients had a medical history of liver cirrhosis before liver transplantation, 7 cases with a medical history of portal vein thrombosis and 8 cases with a medical history of devascularization or shunt with splenectomy. Three cases received the pediatric liver grafts. Eighteen patients suffered from portal vein stenosis from postoperative 23 d to 24 months with a median time of 2.2 months, which was detected by color Doppler ultrasound (CDU) and diagnosed by CT angiography (CTA) of the portal vein or interventional therapy. After the diagnosis was confirmed,all cases received anticoagulant treatment by warfarin. Five patients with portal hypertension underwent balloon dilatation,and one of them received endovascular stent implantation simultaneously. The remaining 13 patients received conservative therapy. After corresponding treatment, 9 cases were mitigated, 7 patients remained unchanged and 2 cases were aggravated. Conclusions For the recipients with a medical history of liver cirrhosis before liver transplantation, portal vein stenosis should be monitored by conventional CDU and diagnosed by CTA or interventional therapy after transplantation. Patients without clinical symptoms can receive conservative treatment. Those complicated with portal hypertension can undergo interventional therapy. Favorable clinical prognosis is obtained in most cases.
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Objective To summarize the clinical efficacy of liver transplantation from donation after cardiac death (DCD). Methods Clinical data of both the donors and recipients (n=182) undergoing liver transplantation from DCD were retrospectively analyzed. According to the type of primary diseases, 182 recipients were divided into the benign group (n=135) and hepatocellular carcinoma (liver cancer) group (n=47). Perioperative conditions, 1- and 3-year survival rate of the recipients were statistically compared between two groups. Clinical prognosis and the incidence of postoperative complications of the recipients were summarized. Postoperative complications mainly included early allograft dysfunction (EAD), vascular complications, acute kidney injury (AKI), pulmonary infection, acute rejection, cytomegalovirus (CMV) infection and billiary tract complication. Results No statistical significance was identified in the anhepatic phase, operation time and length of intensive care unit (ICU) stay between two groups (all P>0.05). The 1-year survival rates of the 182 recipients and grafts were 93.1%, and 84.9% for the 3-year survival rates. In the benign group, the 1- and 3-year survival rates of the recipients were 92.5% and 88.1%. In the liver cancer group, the 1-year survival rate of the recipients was 95%, 91% for the disease-free survival rate, and 78% for the 3-year survival rate, respectively. No statistical significance was noted in the overall survival rate of the recipients between two groups (P=0.879). In terms of postoperative complications, billiary tract complications occurred in 26 patients, vascular complications in 14, AKI in 34, pulmonary infection in 22, acute rejection in 11, EAD in 11 and CMV infection in 10. The incidence of postoperative billiary tract complications in patients with T-tube insertion was significantly lower than that in their counterparts without T-tube insertion (8% vs. 19%, P<0.05). Conclusions Liver transplantation from DCD is an efficacious treatment for end-stage liver diseases and liver cancer, which yields relatively high short-term clinical efficacy.