2019年 · 第57卷第09期

ex vivo lung perfusion (EVLP) can accurately reassess donor lung function and repair lung injury ex vivo, improving the situation of donor lung insufficiency in lung transplantation^[1]。 However, the high cost of implementing EVLP limits the application of this technology in China. We tried to localize the core links of EVLP to reduce the application cost and conducted preclinical studies, successfully repairing the marginal donor lung^[2]。 According to our preliminary estimate, the cost can be controlled at 1/15~1/10 of the original import system cost. On this basis, we applied the domestic EVLP technology to the clinic, and the patient was successfully discharged from the hospital after transplantation. The experience is reported below.

ventriculoperitoneal shunt (VPS) is the most commonly used surgical method for the treatment of hydrocephalus. There are more postoperative complications in Open VPS (OVPS)^[1]According to the literature, 40% of patients develop shunt dysfunction within 1 year after surgery^[2]with distal shunt dysfunction accounting for 30% of all complications^[3]Nearly 1/3 of patients requiring shunt adjustment surgery^[2,4]。 The main causes of distal shunt dysfunction are catheter blockage, displacement and ectopia^[1,2,3,5]OVPS place the distal shunt into the abdominal cavity under non-direct vision, which is easy to cause visceral damage. The free shunt can be displaced with intestinal peristalsis, and it is easy to be wrapped by the omentum and other tissues in the abdominal cavity, causing blockage, secondary infection and even penetration of the intestine, which affects the efficacy and safety of the operation. In addition, it can also cause postoperative abdominal incision pain, incision hematoma, infection and incision hernia. laparoscopy-assisted ventriculoperitoneal shunt (LAPPS)^[6]Placing the catheter under direct vision reduces the occurrence of complications such as organ injury, distal shunt blockage and incisional hernia, and is expected to become the standard surgical procedure for the treatment of hydrocephalus. Since January 2016, the Department of Biliary and Pancreatic Surgery of Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine has carried out two-hole LAVPS to treat patients with hydrocephalus, and improved the technical details such as the way and place of shunt insertion into the abdominal cavity, and achieved good results. The report is as follows.

The patient, a 72-year-old female, was admitted to the hospital on June 26, 2018 due to "physical examination found that the spleen occupied space for 5 years". Physical examination showed no obvious abnormalities. Outpatient ultrasonography showed that the spleen occupied space, the capsule was intact, well-bordered, and the size was approximately 63 mm ×64 mm. On April 13, 2018, the patient underwent bone marrow examination in the hematology department of our hospital. The results showed that nucleated cells were active in proliferation, granulocytes were active in proliferation, the proportion (63%) was high, the morphology was roughly normal, and red blood cells were active in proliferation, the proportion (25%) and the morphology were roughly normal, lymphocytes accounted for 5.5%, plasma cells accounted for 4%, and platelets were scattered. Blood routine after admission: red blood cell count 3.51×10¹²/L, hemoglobin 104.0 g/L, hematocrit 31.3%, white blood cell count 7.0×10⁹/L, platelet count 181×10⁹/L; Hepatitis C virus IgG antibody negative; Hepatitis B surface antibody positive; HIV, syphilis and other antibodies are negative; There were no obvious abnormalities in electrocardiogram and echocardiogram; There were no abnormalities in liver and kidney function, blood lipid level and tumor indexes; Coagulation function: D-dimer 394 μ g/L (reference value: 0-300 μ g/L). Abdominal CT examination showed that the spleen was in good shape, and there was a round low-density shadow, about 71 mm ×64 mm in size, which showed unobvious and uniform enhancement after enhancement. The edge of the lesion was still smooth and clear, and it was diagnosed as space-occupying lesion of the spleen (Figure 1）。

Cardiopulmonary fitness is directly related to the comprehensive functions of physiological systems such as respiratory system, cardiovascular system and musculoskeletal system, and is considered to be the best indicator to reflect the systemic functional status^[1]。 Recently, the American Heart Association issued a statement recommending cardiopulmonary fitness as the fifth vital sign after heart rate, pulse, blood pressure, and respiratory rate^[2]。 Epidemiological and clinical evidence shows that the value of cardiopulmonary fitness in predicting cardiovascular disease and all-cause death is greater than that of known risk factors (such as smoking, hypertension, high cholesterol, and type 2 diabetes, etc.), and the value of predicting postoperative risk and prognosis exceeds that of traditional indicators such as electrocardiogram, echocardiogram, and static lung function. In addition, cardiopulmonary fitness combined with traditional risk factors can significantly optimize the postoperative risk prediction model^[3]。 In 2014, the American Heart Association recommended cardiopulmonary fitness as a method for cardiovascular risk assessment and management before non-cardiac surgery with Level B evidence, and recommended that high-risk patients should be evaluated before surgery to predict their postoperative risk^[2]。 Cardiopulmonary fitness assessment can adopt exercise test method to objectively and non-invasively evaluate the cardiopulmonary function of patients in resting and exercise states, as well as the physiological response of physiological system to exercise, judge the pathophysiological mechanism of exercise restriction, and then help to stratify prognosis, which has high practicality^[4]。 To explore the predictive value of common indicators of cardiopulmonary fitness on the risk after thoracic and abdominal surgery, it can guide the selection of clinical intervention measures more accurately.

A 24-year-old male was admitted for "upper abdominal distension for 7 d". Preoperative MRI showed that the mass of the right lobe of the liver was mostly intrahepatic cholangiocarcinoma with peritumoral sub-foci formation, and the involvement of the right hepatic vein and the right posterior branch of the portal vein may be (Figure 1）。 An enhanced CT scan of the upper abdomen further confirmed the above diagnosis (Figure 2), no tumor metastasis was found in chest CT and head CT. Preoperative diagnosis: 1. Right liver occupation: primary liver cancer (Barcelona Clinical Hepatocellular Carcinoma stage C); 2. Chronic hepatitis B. The patient's preoperative liver function was Child-Pugh grade A, and the 15-min retention rate of indocyanine green was 2.82%. After comprehensive evaluation, laparoscopic right hemihepatectomy was proposed.