Volume 88  ·   Issue 43  ·  2008

Recipients of liver transplantation are generally in poor condition, and liver transplantation surgery is invasive, and there will be drastic pathophysiological changes during the perioperative period, which are life-threatening in severe cases, and affect the recovery after liver transplantation. To understand the changes in the perioperative period of liver transplantation, and to formulate reasonable perioperative management plan of liver transplantation, it will affect the recovery of various organ functions after liver transplantation, which is related to the success or failure of liver transplantation.

Since the development of liver transplantation in the 1960s, especially after the application of cyclosporine has greatly improved the success rate of liver transplantation, liver transplantation has been the most effective treatment scheme for liver diseases in the terminal stage.Because of the serious pathophysiological changes caused by liver failure and the particularity of liver transplantation, the perioperative anesthesia management of liver transplantation is very challenging, and the intraoperative fluid management is an important guarantee for the success of liver transplantation.

Liver transplantation is an important way to treat end-stage liver disease and liver and biliary tract tumors. At present, the main problems existing in liver transplantation in China are: (1) the source of donor and the quality of donor liver; (2) the choice of operation timing and operation mode; (3) Perioperative management. The management of coagulation function is one of the difficulties in perioperative management.

The pathophysiological changes associated with patients with advanced liver disease, the severe effects of different liver transplantation stages on hemodynamics, the inflammatory damage of organs caused by systemic inflammatory reaction, the volume management mode and the effect of vasoactive drugs on organ perfusion, low temperature and electrolyte disorder, the damage of remote organs such as lung caused by ischemia/reperfusion injury of transplanted liver, the anaphylactic reaction/anaphylactic reaction caused by the transfusion of various heterologous blood products and synthetic biological products, the imbalance of systemic oxygen supply and demand caused by massive blood loss caused by improper management of coagulation function, etc. are the key to the correct treatment of liver transplantation anesthesiologists.

The first liver transplantation (OLT) was completed in the United States in 1963. OLT in China started in the 1970s and set off the second climax in the 1990s. In 2007, the total number of OLT cases reached 190 000 worldwide, and the one-year survival rate exceeded 90%. OLT has become the main treatment for end-stage liver disease (ESLD). The number of OLT cases in China has reached more than 3,000 annually, second only to the United States, ranking second in the world, and the one-year survival rate has exceeded 80%, which is close to the international advanced level. At the same time, OLT anesthesia in China has been rapidly popularized and improved, and many aspects have reached or approached the international advanced level. Every year, 3 million people in China develop liver cirrhosis, and 10% of them die due to ESLD. With the development of OLT and the current situation of liver disease in China, more and more ESLD patients will receive OLT. In recent years, parental partial liver transplantation (LRLT) has developed rapidly and has gradually become a standard routine operation. Therefore, it is necessary to summarize the experience of OLT anesthesia in China, find the gap, make up the shortcomings, and further improve the quality of OLT anesthesia, and then improve the quality of OLT.

Objective To analyze the early risk factors of acute lung injury (ALI) following orthotopic liver transplantation (OLT). Methods Ninety-one patients with end-stage liver disease, 79 males and 12 females, underwent OLT. The general condition, serum total bilirubin, albumin, creatinine, and prothrombin activity, Child-Turcotte-Pugh(CTP) score, and model for end-stage liver disease (MELD) score 48 h before operation were recorded. The operation time, cold ischemia time of donor's liver, time of anhepatic phase, ascitic fluid, blood loss, RBC infusion amount, crystal infusion, and total infusion during operation were recorded too. Follow-up was conducted for 14 days to observe the clinical manifestation, and time of ventilatory support, arterial blood gas analysis and radiological examination of chest were performed. Univariate analysis and logistic stepwise regression analysis were done to investigate the early risk factors of ALI. Result 53 patients (58.2%) suffered from pulmonary complications following OLT, including ALI (27.5%) and adult respiratory distress syndrome (ARDS) (5.5%). Univariate analysis showed that preoperative senior age, severe hepatitis B, high serum total bilirubin, low prothrombin activity, and high CTP and MELD scores, and large amount of blood loss and RBC infusion during operation were all risk factors of ALI following OLT (all P<0.05). Logistic stepwise regression analysis screened out serum total bilirubin as an independent predictor for ALI following OLT. Conclusion A little more than a quarter of the patients undergoing OLT develop ALI after operation. High preoperative serum total bilirubin is an important early risk factor for ALI following OLT.

Objective To assess the preoperative depression and anxiety levels of the patients undergoing liver transplantation (LT). Methods Zung self-rating depression scale (SDS) and Zung self-rating anxiety scale (SAS) were used to assess the preoperative depression and anxiety levels of 40 patients undergoing LT, 40 patients with gastrointestinal cancer, and 40 patients undergoing cholecystectomy. Results The preoperative anxiety levels of the patients undergoing LT, with gastrointestinal cancer, and undergoing cholecystectomy were all significantly higher than that of the national norm (all P<0.01), without significant differences among the 5 groups of patients. The depression level of the patients undergning LT was significantly higher than those of the national norm, and the patients with gastrointestinal cancer and undergoing cholecystectomy (all P<0.01). There were not significant differences in the preoperative depression and anxiety levels between the patients with gastrointestinal cancer and those undergoing cholecystectomy. The depressive rate of the patients undergoing LT was 40.0% (16/40), significantly higher than those of cholecystectnmy group (17.5%) and cancer resection group (15.0%) , and the depression score of the 6 female patients undergoing LT was 53, significantly higher than that of the male patients in the same group (P<0.01). There was no significant differences in the depression and anxiety levels between the patients undergoing living donor liver transplantation (LDLT) and the patients undergoing orthotopic liver transplantation(OLT). Educational level was not correlated with the preoperative anxiety and depression levels. Conclusion Patients scheduled for LT have high risks of prenperative depressinn and anxiety, especially the former. Suitable pre-medication, optimal psychosocial assessment, and treatment, especially for the female patients, are needed.

Objective To identify the predictors of massive blood transfusion in liver transplantation for patients with benign end-stage liver disease (ESLD). Methods The clinical data of 268 patients with ESLI) mainly caused by hepatitis B who were to receive cadaver liver transplantation performed by 5 groups of anesthesiologists respectively were retrospectively reviewed. The patients were divided into 2 groups according to the transfusion amount:massive blood transfusion (MBT) group (n=120) receiving the blood transfusion of more than 12 units of red blood cells (RBCs) during the operation,and non- massive blood transfusion (NBT) group (n=148). Univariate analysis and stepwise logistic regression were used. The influence of anesthesiologists on administration of blood cells was analyzed. Results During the liver transplantation, 98.13% of the patients received RBC transfusion of the mean dose of 13.32 units. Different group of anesthesiologists exerted no influence on the amount of RBC transfusion. Logistic regression showed that the preoperative MELD score, hemoglobin, platelet, interactional normalized ratio of prothrombin time, kaolin partial thromboplastin time, total protein, serum creatinine, total bilirubin, ascite, and severity of hepatitis were risk factors of MBT. Multivariable logistic regression showed that 2 independent predictors of MBT were identified: preoperative MELD score and hemoglobin. Accordingly, MBT during liver transplantation was predicted by 0.593 -0.049 × preoperative hemoglobin + 0.137 × preoperative MELD score, with a cut off value of -0.67, a sensitivity of 84.1% and a specify of 71.2%. The area under receiver operating characteristic curves of prognostic score was 0.832. Conclusion MBT during liver transplantation can be predicted by preoperative MELD score and hemoglobin value in patients with ESLD secondary to type B hepatids.

Objective To study the protein expression of adenkylate kinsaes (AK)-2 in the brain tissues of patients with drug-refractory temporal epilepsy and the clinical value thereof. Methods Specimens of brain from 40 patients with refractory temporal epilepsy, and 20 sex- and age-matched persons with brain trauma. Immunohistochemistry and immunofluoreseence examination were used to test the levels of AK2. Results AK2 was expressed in the temporal lobes and hippocampuses of all epileptics, mainly in the cell bodies, and not in the brain tissues of the controls. Conclusion The overexpression of AK2 may be involved in the pathogenesis of drug-refractory epilepsy and become an important symbol thereof.

Objective To investigate whether the signal intensity ratio in magnetic resonance imaging (MRI) and clinical manifestations can reflect prognosis in patients with cervical compressive myelopathy. Methods Seventy-three patients with cervical compressive myelopathy treated with anterior, posterior, or posterior-anterior united decompression underwent 1.5-T MRI before surgery. T2-weighted images (T2WI) of the sagittal signal intensity on the cervical severe compression cord were obtained, and the regions of interest (ROIs) were taken by 0.05 cm2. T2-weighted MR images of sagittal normal cord signal on the cervical between C7-T1 disc levels were obtained, and the ROIs were taken by 0.3 cm2. Signal value is measured by computer and the signal ratio between the regions of the 0.05 cm2 and 0.3 cm2 was calculated. If no intramedullary high signal intensity was noted on T2-weighted MR images, the ROIs were taken by 0.05 cm2 of the severe compression cord. The 73 patients were divided into 3 groups:low, medium, and high signal ratio groups (Group 1, 2, and 3, n = 18, 32, and 23 respectively). Results The recovery rate and JOA score of Group 1 were significantly higher, the age and Babinaki sign positive rate were significantly lower, and disease duration was shorter in Group 1 than in Groups 2 and 3 (F=22.009, P < 0.001 ,F = 5.561,P=0.006,F=6.371,P=0.003,χ2 = 15.719,P<0.001, and χ2=13.952,P=0.001). There was no significant differences in sex among these 3 groups (χ2=1. 898,P=0.387). Conclusion The patients with light or without intramedullary signal change on T2WI experience a good surgical outcome. However, the patients with increase of signal intensity ratio and the occurrence of pyramidal sign show a poor prognosis after surgery.

Objective To evaluate the effectiveness of radiofrequency modified maze operation for the treatment of atrial fibrillation (AF) and compare the results of the left versus bi-atrial procedures. Methods 305 patients of organic heart disease combined with AF, 117 males and 188 females, aged (53 ± 10), that underwent cardiac valve operation (n = 293) and/or coronary artery bypass graft surgery (n = 14), received concomitant atrial fibrillation, hi-atrial (n = 160) or left atrial (n = 145) with a mean duration of (36±43) months. Follow-up was conducted for (28±5)(3-42) months. Results Thirteen patients (4.3%) died postoperatively:7 died of muhisystem and organ failure, 3 of low cardiac output, 1 of rupture of left ventricle, 1 of arrhythmia, and 1 of sudden death. During the follow-up, 1 patient died of heart failure, 1 of encephalorrhagia and 1 of unknown reason in the bi-atrial group. At the end of the procedure 223 patients (73.1%) had sinus rhythm, with a sinus rhythm rate of 66.9% (107/160) in the hi-atrial group, significant lower than that in the left atrial group (80.0%, 116/145, P<0.05). At late follow-up, 215 of the 266 patients (80.8%) were in stable sinus rhythm. Sinus rhythm rate of the bi-atrial group was 80.0%, not significantly different from that of the left atrial group (81.9% ,P>0.05). The Kaplan-Meier survival analysis showed there was no significant difference in the AF rhythm rate between these 2 groups (P = 0.33). Logistic regression analysis showed that the left atrial diameter of ≥ 80 mm was an independent predictor of AF recurrence. Conclusion Both the left and bi-atrial procedures are successful in terms of restoring sinus rhythm. Left atrial ablation in severe cases and where the incision of right atrium is nut needed is a reasonable choice.

Objective To investigate the Short- and medium-term clinical effects of clinical value of CT guided radioactive seed 125I implantation in treating recurrent/metastatic malignant pelvic tumors. Methods 30 patients (10 males and 20 females, the age ranges from 31 to 85, median 55 years) with recurrent/metastatic malignant pelvic tumors after combined therapy such as surgery , chemotherapy and radiotheray et al , were enrolled in this study. The total lessions were 32 and the max diameter of each lesion ranges from 3.0 cm to 12. 2 cm ,median 4.8 cm. Under CT guidance, the operations were performed under local anesthesia and 125I seeds of 2. 96 × 107 Bq were implanted into tumors at a distance of 0.5 cm according to TPS(Treatment Plan System), and the M PG(matched peripheral doses) was 100-160 Gy Observate the the local control rate ,overall survival rate, pain reliefs and clinical complications after 2-40 months follow-up (median 28 months). Results After 2 - 40 months follow-up (median 28 months), 10/32 obtained CR, 13/32 obtained PR, 5/32 NC and 4/32 PD. The clinical effective rate was 87.5% (CR + PR + SD > 2 months), 1- and 2-year Local control rate were 83.3% and 62.5%, and overall 1- and 2- and 3- year survival rate were 87.7% ,73.1% and 45.7%, respectively, the median survival time was 28 months. The rate of pain relief was 21/23(91.3%). Complications in the long term were Grade Ⅰ - Ⅱ radioactive rectum proctitis observed in 3 cases, Grade Ⅰ radioactive cystitis observed in 1 case, insensible feeling in lower limb observed in 1 case for a long time. No other severe complications such as hemorrhoea ,acute pulmonary embolism, abscess, intestinal fistula, intestinal perforation, sinus tract were encountered in all patients. Conclusion CT guided radioactive seed 125I implantation procedure can be a simple, safe and effective method in treating recurrent/metastatic malignant pelvic tumors, which can ease the pain of patients and improve the qualities of patients' lives and obtain good clinical effects with minimal damage and few complications.

Objective To study the associations between XRCC2 and XRCC5 single nucleotide polymorphisms (SNPs) and chemosensitivity of human lung cancer cells. Methods Specimens of human lung cancer were collected from 150 patients, 120 males and 30 females, aged 58. 1, during operation. MTT method was used to detect the sensitivity of the lung cancer cells to cisplatin (DDP) and carboplatin (CBP), and the patients were genotyped for polymorphisms in XRCC2 and XRCC5 genes. The polymorphisms of XRCC2 41657T C41657T and XRCC5 G74582A were detected by polymerase chain reaction-restriction fraction length polymorphism (PCR-RFLP), and the polymorphisms of XRCC2 G4234C and XRCC5 C74468A were detected by primer- introduced restriction analysis- polymerase chain reaction (PIRA-PCR). The correlation of these polymorphisms of these polymorphisms with the drug-sensitivity of lung cancer cells was analyzed. Results The sensitive rates of the lung cancer cells to CBP and DDP in the patients with XRCC2 41657T allele (C/T+T/T genotype) were 70.2% and 66.7% respectively, both significantly higher the those in the patients with C/C genotype [53.7% (χ2 = 3.97, P = 0.046) and 49.5% (χ2 =4.25 ,P=0.039) respectively]. The sensitivity levels to CBP and DDP in the patients with at least one T allele was 2. 06 times (pathological type adjusted OR = 2.06,95% CI = 1.02 - 4. 18) and 2.07 times (pathological type adjusted OR = 2. 07,95% CI = 1.04 - 4.14) higher than those in the patients with C/C genotype. There was no significant difference in the distribution of genotypes of XRCC2 G4234C C allele (C/C + G/C) and G/C genotype between the sensitive group and resistant groups (χ2 = 0.09, P = 0.766 for CBP and χ2 = 1.63, P = 0.202 for DDP). The sensitivity rate to DDP of the patients with 41657T/4234G haplotype was 2.28 times as high as that of the patients with 41657T/4234C (OR = 2.18, 95% CI = 1.15 -4.12). The sensitivity rates to CBP and DDP of the tumor tissues from the patients with the XRCC5 G74582A G allele (A/G + G/G), were 57.9% and 61.8% respectively, and those of the patients with the A/A genotype were 62.2% and 50.0% respectively. There was no significant differences in the genotype distribution between the sensitive and resistant groups (χ2 = 0.28, P = 0.594 for CBP, and χ2 = 2.13, P = 0.144 for and DDP). Conclusion The XRCC2 C41657T SNP is associated with the sensitivity to CBP and DDP. The sensitive rate to the drugs of the cancer cells with the combination of C/T + T/T genotype is higher than that with C/C genotype. In the subject with 41657T/4234G the sensitivity to the drugs of the cancer cells is higher than that with 41657C/4234G haplotypes. The XRCC5 G74582A and C74468A SNPs are not associated with the sensitivity to CBP and DDP.

Objective To investigate the association of FBN3 gene polymorphism with abnormal growth pattern in adolescent idiopathic scoliosis (AIS) patients. Methods Blood samples were obtained from 273 AIS patients, aged (14. 6 ± 2. 1) (10-18), and 287 healthy age-matched females adolescents. The anthropometric parameters of the AIS group, including age, body height, weight, arm span, Cobb angle, time of menarche, and Risser's sign were recorded. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique was used to detect the FBN3 gene distribution. Results The genotype and allele frequency distribution were comparable between the AIS and normal control groups. There was no association with curve severity, arm span, BMI in patients with AIS. In the rs7257948 , There were not significant differences in the FBN3 gene polymorphism sites rs35579498, rs12608849, and rs7257948, and allele distribution between these 2 groups. In the AIS group, the patients with GG genotype the number of those whose body height was ≥160 cm was higher than those whose body height was < 160 cm (P=0.01). In rs35579498, the frequency of allele T was relatively higher in the AIS patients than in the controls(P=0.051). In the AIS patients, the expression rate of CT genotype in those whose menarche age was ≥ 12 years was significantly higher than those whose menarche was < 12 years (P=0.042). Conclusion The polymorphisms of the 4 SNPs in the exons of FBN3 gene are neither associated with the occurrence nor the curve severity of AIS. However, in rs35579498, T allele appears to be overrepresented in the patients compared with the controls. Mutation in this site my plays a role in the occurrence and progression of AIS, and in rs7257948, polymorphism of FBN3 gene may be associated with body height of the AIS patients.

Objective To study the effect of CO on neurocytes. Methods Human neuroblastoma cells of the line SH-SYSY were cultured and exposed to CO of the concentrations of 100, 1000, and 10 000 ppm for 12 h, and some SH-SY5Y ceils were cultured and exposed to 5% CO2 to be used as control group. The cell viability was observed with MTT assay. The DNA content and percentage of apoptosis were measured by flow cytometry and DNA agarose gel electrophoresis. Laser scanning confocal microscopy (LSCM) was used to detect the reactive oxygen species and the reduction in mitochondrial membrane potential. The activation of caspase-3 was measured with the caspase-3 activity assay kit. The expression of Bax was detected with Western blotting. Results After exposure to 1000 and 10 000 ppm CO for 12 h the viability of the cells decreased to 85.6 ± 9.2 and 63.4 ± 8.1 respectively (both P<0.05), the apoptotic rates of the cells were 29.03% and 41.67% respectively, DNA agarose gel electrophoresis showed clear DNA ladder band, the caspase-3 activity increased by 129% and 443% respectively, LSCM showed that the number of the SH-SY5Y cells decreased and the fluorescence intensity inside the cells increased significantly (both P<0.05), the red/green fluorescence ratio inside the cells decreased from the baseline level of (5.91±0.21) to (1.56±0.07) and (0.34±0.02) respectively, and the Bax protein expression increased greatly. However, 100 ppm CO had no obvious effects on the cell viability, reactive oxygen species, mitochondrial membrane potential, caspase-3 activity, and expression of Bax. Conclusion High concentration CO has direct cytotoxicity on neurocytes cultured in vitro, but low concentration CO does not induce marked injuries of neurocytes.

Objective The human papillomavirns type 16 (HPV16) early gene (ES) could stimulate cell proliferation and transformation in different ways, and complement or enhancement the function of E6 and E7. It is closely sociated with the carcinogenes of cervical cancer. This study was to investigate the effects of HPVI6 E5 on the human cervical cancer cell line SiHa. Methods The sense sequence of HPV16 E5 was cloned into eukaryotic expression vector pEGFP-C1 to prepare recombinant plasmid, which was stable transfected into SiHa cells. The mRNA and protein levels of E5 and p21 gene were detected by Western blot and reverse transcription-polymerase chain reaction (RT-PCR). Cell proliferation after stable transfection was evaluated by MTr assay. The tumorigenesis of SiHa/16E5 cells was assessed both in vitro and in vivo by soft agar clone form test and naked mouse form test. Results After stable transfection of HPV16 E5 sense DNA, the mRNA and protein levels of HPV16 E5 in SiHa cells were obviously increased, but that of P21 were decreased. The proliferation activity of SiHa/16E5 cells was significantly higher than that of SiHa /pEGFP-C1 and SiHa cells (P<0.05) .The clone numbers of SiHa/16E5 cells, were significantly more than SiHa / pEGFP-C1 and SiHa cells [(33.4±1.6) vs (15.1±3.1),(16.3±2.5), P<0.05] in vitro. The growth of tumors on naked mouse was much faster in SiHa/16E5 group than those in the SiHa /pEGFP-C1 and SiHa cells groups (P<0. 05). Conclusion HPV16 E5 decreased the expression of P21 in SiHa cells, and enhancement the proliferation of SiHa cells and the ability of tumorigenesis.

Traumatic cerebral infarction (PTCI) is a complication after craniocerebral injury, which is easy to be misdiagnosed or misdiagnosed, and rarely attracted attention in the past. With the development of imaging, it has been paid more and more attention by the neurosurgical community. The Armed Police Corps Hospital of Jiangsu Province retrospectively analyzed 47 patients with post-traumatic cerebral infarction (accounting for 2.97% of patients with craniocerebral injury in the same period) from March 2005 to March 2007. The pathogenesis, clinical characteristics and preventive measures are reported as follows.

A 40-year-old female was admitted to the Department of Respiratory Medicine of Peking Union Medical College Hospital on May 27, 2008 due to fever, cough for 2 months and dyspnea for 3 weeks.

The 19th Great Wall International Cardiology Conference and ACC Forum (GW-ICC), co-sponsored by the Organizing Committee of Great Wall International Cardiology Conference, American College of Cardiology (ACC), Asia-Pacific Heart Federation (APHA), European Hypertension Society (ESH), Japan Circulator Society (JCS) and the Cardiovascular Professional Committee of Beijing Branch of Chinese Medical Association, was held at Beijing International Convention Center from October 23 to 26, 2008. The conference attracted thousands of delegates from more than 20 countries and regions.

Hello, editorial department of Chinese medical journal! Your journal published a review written by Professor Wu Xinmin-"Recent Situation of Anesthesiology Development in China" on pages 577-579, Issue 9, 2008. I read this article with great interest. The article is well written and comprehensive, but there is no mention of acupuncture anesthesia in the article.