Artery anatomy of localized renal cell carcinoma: an initial study based on 3D Slicer software / 现代泌尿外科杂志

【Objective】 To analyze the position of the feeding artery entering the renal cell carcinoma (RCC) with 3D Slicer software, so as to explore the distribution pattern of the tumor artery and to provide an anatomical basis for the accurate surgical resection. 【Methods】 The clinical data of RCC patients who underwent partial nephrectomy in the Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University during Jan.2021 and Jun.2022 were collected.The preoperative renal artery CT angiography data were imported into 3D Slicer software in DICOM format to construct the relative positions of tumor-feeding artery from horizontal, sagittal and coronary planes.The number and distribution of tumor feeding arteries in each plane were analyzed. 【Results】 A total of 112 patients (59 male and 53 female) with single tumor were involved.RENAL score was 4-10.The tumor stages were T1a in 58 cases, T1b in 48 cases, and T2a in 6 cases.Among them, 38 cases (33.93%) had 1 tumor artery, 53 cases (47.32%) had 2 tumor arteries, and 21 cases (18.75%) had 3 tumor arteries.Of these 207 tumor arteries, 22 (10.63%) entered the tumor through the superficial part of the tumor bed, and 185 (89.37%) through the deep part. 【Conclusion】 In localized RCC, nearly 90% of the feeding arteries enter the tumor from deep part of the tumor bed, which provides an anatomical basis for accurate tumor resection and wound suture in partial nephrectomy.

Research progress on protective effect of hydrogen molecule and its products on lung transplantation / 器官移植

Ischemia-reperfusion injury after lung transplantation is the main cause of primary graft dysfunction, which will subsequently reduce the function of lung allograft and lower the overall survival rate of lung transplant recipients. As a physiological regulatory molecule, hydrogen molecule has the functions of anti-inflammation, easing oxidative stress, alleviating direct cell injury and mitigating epithelial edema. Recent studies have demonstrated that hydrogen molecule and its products (hydrogen and hydrogen-rich solution) could significantly mitigate ischemia-reperfusion injury and postoperative complications after lung transplantation. In this article, the protective effect and exact mechanism of hydrogen molecule and its products in lung transplantation were reviewed, aiming to provide theoretical basis for the application of hydrogen molecule and its products as a novel treatment for lung transplantation-related complications, enhance the overall prognosis and improve the quality of life of lung transplant recipients

Influencing factors analysis and prediction model construction of postoperative MIC comprehensive outcome in patients with early renal cell carcinoma treated with NSS / 国际肿瘤学杂志

Objective:To investigate the influencing factors of postoperative surgical margin, warm ischemia time and severe postoperative complication (MIC) comprehensive outcome in patients with stage T 1b renal cell carcinoma treated with nephron sparing surgery (NSS) and to establish a predictive model. Methods:One hundred and seventy-four patients with stage T 1b renal cell carcinoma treated with NSS were retrospectively chosen in the period from January 2017 to January 2022 in 3201 Hospital. All patients were divided into MIC group ( n=66) and non-MIC group ( n=108) according to whether MIC was achieved after surgery or not. Univariate and multivariate analysis were used to evaluate the independent influencing factors of postoperative MIC comprehensive outcome, and a nomogram prediction model was constructed according to the influencing factors and its predictive value was evaluated using receiver operating characteristic (ROC) curve. Results:There were statistically significant differences in the body mass index ( t=2.81, P=0.006), lesion morphology ( χ2=41.41, P<0.001), hot ischemia time ( t=16.92, P<0.001), creatinine increase within 24 h after surgery ( t=16.79, P<0.001), hemoglobin (Hb) decreased within 24 h after surgery ( t=9.33, P<0.001), perioperative complications ( χ2=21.31, P<0.001), R.E.N.A.L. score ( t=4.74, P<0.001), PADUA score ( t=3.21, P=0.002) and Mayo perirenal adhesion index ( t=22.28, P<0.001) in MIC group and non-MIC group. Multivariate analysis showed that body mass index ( OR=0.31, 95% CI: 0.13-0.74, P=0.007), lesion morphology ( OR=0.36, 95% CI: 0.22-0.59, P<0.001), PADUA score ( OR=0.37, 95% CI: 0.17-0.81, P=0.013) and Mayo perirenal adhesion index ( OR=0.43, 95% CI: 0.24-0.70, P=0.004) were all independent factors of postoperative MIC comprehensive outcomes in patients with stage T 1b renal cell carcinoma treated with NSS. The C-index of the nomogram model built according to the selected variables was 0.89 with high prediction accuracy; area under the curve (AUC) was 0.84 (95% CI: 0.77-0.91), and it had good predictive performance. Conclusion:Body mass index, lesion morphology, PADUA score and Mayo perirenal adhesion index are independent influencing factors for the MIC comprehensive outcome of patients with stage T 1b renal cell carcinoma after NSS treatment. The nomogram model based on the above indicators has better predictive performance.

A modified mouse model of orthotopic left lung transplantation based on "pendulum" anastomosis of the reverse-view plane (with video demonstration) / 器官移植

Objective To modify the mouse model of orthotopic left lung transplantation from different perspectives, aiming to establish a simpler, faster and stabler mouse model of lung transplantation. Methods Based on preliminary modified rat model of orthotopic left lung transplantation established by our team, varying extent of modifications were made regarding the tracheal intubation, cannula preparation and anastomosis procedures of orthotopic left lung transplantation in the recipient mice. Orthotopic left lung transplantation in 40 mice were performed by an operator with microsurgical experience. The dissection of the recipient's hilar structure was carried out at the plane of the hilar clamp model within the reverse-view, and the three branches (left main bronchus, pulmonary artery and pulmonary vein) of the pulmonary hilum were anastomosed in turn by the "pendulum" anastomosis method. The operation time of each procedure was recorded. The recipient mice were sacrificed at postoperative 2 weeks, and the incidence of postoperative complications was recorded. Results Lung transplantation was successfully completed in 40 mice, with no bronchial and vascular tearing or twisting, and no bleeding at the anastomosis site. The overall cardiopulmonary procurement time was (10.7±1.5) min, cannula preparation time was (16.2±1.5) min, cold ischemia time was (25.1±2.4) min, warm ischemia time was (19.4±1.6) min, and the total operation time was (57.2±2.9) min, respectively. During the follow-up from 6 to 14 days after surgery, one recipient mouse died of pleural effusion, probably caused by infection. No pneumothorax, thrombosis or atelectasis was found in the remaining recipient mice during postoperative follow-up. Conclusions The modified mouse model of orthotopic left lung transplantation based on "pendulum" anastomosis of the reverse-view plane possesses multiple advantages of short operation time, high success rate and few complications, which is expected to become an alternative model of studying pathological changes after lung transplantation and worthy of further application.

Impact of warm ischemia time during partial nephrectomy on laparoscopic postoperative renal function / 中华泌尿外科杂志

Objective:To assess the association between warm ischemia time (WIT) and renal function in patients undergoing laparoscopic partial nephrectomy.Methods:A total of 344 patients treated with laparoscopic partial nephrectomy in Peking University People’s Hospital were included. There were 240 males (69.8%) and 104 females (30.2%) with a median age of 57 (23-89) years.The median BMI was 25.6 (16.7-36.0) kg/m 2.213 cases (61.9%) were associated with hypertension.There were 66 (19.2%) patients with diabetes mellitus. There were 92 cases (26.7%) with smoking history. The median preoperative creatinine was 73 (32-170) μmol/L. The median preoperative estimated glomerular filtration rate (eGFR) was 95 (33-142) ml/(min·1.73m 2). The maximum diameter of the tumor was 2.5 (7-9) cm.314 (91.3%) patients with renal cancer stage T 1. All patients underwent warm ischemia during the operation. The patients were divided into three groups for analysis. Restricted cubic spline regression analysis was used to assess the association between WIT as a continuous variable and percentage change of eGFR. Analysis of covariance was used to compare postoperative eGFR among the three groups, and to adjust for preoperative eGFR and tumor diameter. Results:There were statistically significant differences in the percentage change of postoperative eGFR ( P=0.009) and tumor diameter ( P<0.001) among the three groups. Restricted cubic spline regression analysis showed that with the prolongation of WIT, the percentage change of postoperative eGFR gradually decreased, and the curve began to stabilize after 30 minutes (R 2=0.044, P=0.015). The results of covariance analysis showed that after adjusting for baseline preoperative eGFR and tumor size, the effect of WIT on postoperative eGFR was significantly different among the three groups ( F=3.864, P=0.022). The postoperative eGFR in the WIT<20 min group was significantly higher than that in 20 min≤WIT<30 min group( P=0.009) and WIT≥30 min group( P=0.017). There was no significant difference in postoperative eGFR between the two groups with longer WIT( P=0.806). Conclusions:In partial nephrectomy, patients with WIT less than 20 minutes had higher postoperative eGFR levels than those with WIT greater than 20 minutes. However, when WIT exceeded 20 minutes, prolonged ischemia time did not lead to further decline in renal function.

Development and validation of a novel nephrometry nomogram model predicting perioperative outcomes of partial nephrectomy for T 1b renal masses / 中华泌尿外科杂志

Objective:To analyze the correlation between R. E.N.A.L., PADUA, C-index, DAP scoring system and the efficacy and safety of nephron-sparing surgery (NSS) for T 1b renal tumors, and to construct a nomogram model to predict the efficacy and safety of surgery by combining multiple parameters. Methods:The data of 80 patients with stage T 1b renal tumor who received NSS from March 2020 to July 2021 in Changhai Hospital of Naval Military Medical University were retrospectively analyzed. There were 59 males and 21 females, aged (56.9±10.2) years old. The tumor diameter was (4.7±0.9) cm, with 40 cases on the left and 40 on the right sides. Tumors were located in the upper/lower pole in 46 cases and in the middle in 34 cases. The tumors were located in 59 cases laterally, 21 cases medially, and 74 cases were bulging, 16 cases endogenous. There were 53 round tumors, 18 lobular tumors, and 9 irregular tumors. One case underwent open surgery, 43 cases underwent laparoscopic surgery, and 36 cases underwent robotic surgery.42 cases underwent transperitoneal approach, and 38 cases underwent retroperitoneal approach. The composite outcome (MIC) achieved by all three indicators, including negative surgical margins, warm ischemia time <20 min, and no serious complications, was used as the main indicator to evaluate the efficacy and safety of surgery. Secondary indicators were operation time, intraoperative blood loss, postoperative hospital stay, postoperative creatinine changes and hemoglobin changes. Relevant risk factors were analyzed by logistic regression, and a nomogram model for predicting surgical efficacy and safety was constructed. Receiver operating characteristic(ROC) curves were used to compare the predictive power of the nomogram model with other scoring systems. Results:Univariate logistic regression analysis showed that PADUA and R. E.N.A.L. scores were risk factors for MIC achievement( OR=1.419, P=0.038; OR=1.358, P=0.038). However, C-index and DAP were not risk factors for MIC achievement( P>0.05). The results of correlation analysis showed that R. E.N.A.L. score was significantly correlated with postoperative hemoglobin decrease(R 2=0.197). PADUA score was significantly correlated with postoperative hospital stay(R 2=0.186). C-index was significantly correlated with postoperative creatinine increase(R 2=-0.221). DAP was significantly associated with operation time (R 2=0.192). The results of univariate logistic regression analysis showed that body mass index ( OR=1.257, P=0.025), tumor morphology ( OR=18.741, P=0.005), longitudinal location of tumor ( OR=1.992, P=0.038), the relationship between tumor and collection system ( OR=4.886, P=0.002) were risk factors for MIC attainment. A nomogram prediction model was constructed by combining these indicators with the Mayo adhesive probability (MAP) index. The ROC curve showed that the area under the curve (AUC) of the nomogram model and R. E.N.A.L. score, PADUA score, C-index, and DAP were 0.834, 0.645, 0.643, 0.526, and 0.593, respectively. The nomogram model had the highest predictive power for T 1b renal tumors achieving MIC. Conclusions:In the renal tumor scoring system, PADUA and R. E.N.A.L. scores can predict whether the MIC of T 1b renal tumor NSS is achieved or not. The nomogram model composed of patient body mass index, tumor shape, longitudinal position of tumor, relationship between tumor and collecting system and MAP can better predict whether the MIC of T 1b renal tumor NSS is achieved or not.

Effect of air-oxygenated normothermic mechanical perfusion on rat kidney recovery following ischemic injury from donation after cardiac death / 中华器官移植杂志

Objective:To develop an ex vivo normothermic mechanical perfusion(NMP)and compare the effect of air-oxygenated NMP versus oxygen-oxygenated NMP on reducing renal injury from donor after cardiac death(DCD).Methods:All kidneys from DCD rats were subjected to 30 min in situ warm ischemia after cardiac attest.And harvested kidneys were stored for 8h under static cold preservation after NMP for 2h.In experimental groups, kidneys were subjected to either air-oxygenated NMP(group A, n=6)or oxygen-oxygenated NMP(group O, n=6). Sham operation(group C, n=6)and DCD kidneys under static cold preservation without NMP(group SCS, n=6)were employed as controls.The evaluation parameters included creatinine(Cr), aspartate amino transferase(AST)and lactate dehydrogenase(LDH)in perfusate, pathological changes by hematoxylin-eosin(HE)staining, histological criteria, expressions of myeloperoxidase and intercellular adhesion molecular-1(ICAM-1)by immunohistochemistry and Western blot, tumor necrosis factor-alpha(TNF-α)and interleukin-6(IL-6)by enzyme-linked immunoadsorbent assay and level of malondialdehyde(MDA)by thiobarbital method and activity of superoxide dismutase(SOD)by WST-8 in renal tissues.Differences between two groups were analyzed by two-tailed unpaired Student's test and differences among more than two groups by one-way ANOVA.Results:Renal arterial oxygen tensions in NMP perfusate were(576.3±68.2)mmHg with oxygen-oxygenation and(137.0±39.1)mmHg with air-oxygenation.There was significant difference( P<0.05). The pathological injury scores in groups SCS, O and A by HE staining were(7.0±0.1), (5.0±0.9)and(2.5±0.5); injury scores and the expressions of renal proximal tubular epithelial cell vacuolar degeneration in groups O and A were lower than those in group SCS( P<0.05)and injury score in group A was lower than group O( P<0.05). In perfusate, the levels of △Cr, △AST and △LDH in groups O and A were(43.9±52.8)μmol/L and(12.6±3.5)μmol/L, (532.3±52.8)U/L and(49.1±50.4)U/L and(9998.0±2014.4)U/L and(1477.0±810.4)U/L.There were significant differences( P<0.05). In perfused kidneys, the MDA level and SOD activity in groups O and A were(0.192±0.018)mmol/g, (0.162±0.023)mmol/g, (0.6±0.3)×10 3 U/g, (1.7±0.4)×10 3 U/g; TNF-α and IL-6 levels in groups O and A were(124.376±19.635)and(89.331±13.123)ng/g, and(4.038±1.026)×10 3 and(1.774±0.518)×10 3 ng/g.After air-oxygenated NMP, lower renal damage indices were characterized by a lower MDA level and a higher SOD activity, the lower levels of TNF-α and IL-6 and the lower expressions of MPO and ICAM-1 than those in oxygen-oxygenated NMP( P<0.05). Conclusions:NMP with air-oxygenation mimics renal perfusion under physiological conditions and decreases oxidative stress and inflammation injury.It may confer a better retrieval in DCD kidney against warm ischemia injury.

Quercetin as a nephroprotector after warm ischemia: histomorphometric evaluation in a rodent model

ABSTRACT Purpose: To quantitatively evaluate the possible long-term protective effects of quercetin during renal warm ischemia. Materials and Methods: Male rats were allocated into 4 groups: sham (S), sham quercetin (SQ), ischemia (I), and ischemia quercetin (IQ). Groups SQ and IQ received quercetin (50mg/kg) before and after surgery. Groups I and IQ had their left renal vessels clamped for 60 minutes. All animals were euthanized four weeks after the procedure, and serum urea and creatinine levels were measured. Renal weight and volume, cortex-non-cortex area ratio (C-NC), cortical volume (CV), glomerular volumetric density (Vv[glom]), volume-weighted glomerular volume (VWGV) and number of glomeruli per kidney (N[glom]) were evaluated by stereological methods. Results were considered statistically significant when p <0.05. Results: Serum urea levels in group I increased by 10.4% in relation to group S, but no differences were observed among the other groups. The C-NC of group I was lower than those of all other groups, and group IQ had similar results to sham groups. The Vv[glom] and N[glom] of group I were lower than those of group S (33.7% and 28.3%, respectively) and group IQ had no significant difference compared to the S group. Conclusions: Quercetin was effective as a nephroprotective agent in preventing the glomerular loss observed when the kidney was subjected to warm ischemia. This suggests that this flavonoid may be used preventively in kidney surgery, when warm ischemia is necessary, such as partial nephrectomy.

Design, fabrication, and preliminary experimental study of laparoscopic partial renal blood flow blocker / 中国医师杂志

Objective:To design a laparoscopic partial renal blood flow blocker (LPRB), and to explore the design rationality and effect of LPRB on blocking the blood flow of local renal tissue in rabbit kidney experiment.Methods:⑴ Design.According to the anatomical characteristics of the renal blood flow from the center to the periphery in the human, pig and rabbit, the blood flow at the distal part of the compression area could be blocked by the compression of the medial kidney tissue. LPRB included the first pressure arm, the second pressure arm and shaft. A built-in torsion spring made the two ends of the pressure arm to automatically close. The ends of pressure arm were provided with an arc-shaped compression component, on which, there were multiple adaptive compression plates. ⑵ Fabrication. 3D printer printed the finished product with titanium alloy material. ⑶ Animal experiments. Five New Zealand rabbits were anesthetized and fixed on the operating table in a semi-lateral position, with a lateral abdominal incision. Kidneys were exposed, only the renal pedicle vessels were retained. According to different methods of blocking blood flow, they were divided into conventional group and LPRB group for self-control. The effect of blocking blood flow was observed. The clamping force of LPRB was detected, and the degree of tissue damage at the clamping site was observed by naked eye and pathology.Results:LPRB had been licensed as a utility model and apperance patent. The device was successfully made from titanium alloy by 3D printer. In the experiment, the device was easily placed and removed. The two pressure arms were automatically closed and fixed under the action of torsion spring. The angle of the compression arm could be adjusted according to the position of clamping. The self-adaptive compression plates might be inclined in order to be consistent with the shape of the kidney; The pressure of LPRB was sufficient and the hemostasis was complete.Conclusions:LPRB is basicly rational and safe, and it can realize the partial hemostasis of the excised part and guarantee the blood flow of other parts at the same time. However, the larger size and harder adaptive component need to be improved in the future.

Oncological and functional outcomes of open versus laparoscopic partial nephrectomy in T1b tumors: A single-center analysis

ABSTRACT Purpose: This study aims to evaluate the oncological and functional results of open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) at the T1b clinical stage, which constitutes 25% of renal cell carcinomas (RCC) at diagnosis. Materials and Methods: The characteristics of 63 patients with stage T1b solitary tumor who underwent OPN (41) or LPN (22) were compared. The survival analysis was performed using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were performed to determine the factors affecting disease-free survival. Potential predictive factors, which might affect the postoperative glomerular filtration rate (GFR), were evaluated using multivariate linear regression analysis. Results: No differences were observed between OPN and LPN groups regarding patient and tumor characteristics. Although the warm ischemia time, intraoperative estimated blood loss, and operation duration were higher in the LPN group, no differences were noted between the two techniques regarding complication rates (p<0.001, p=0.023, p≤0.001, and p=0.190, respectively). The median hospitalization time was shorter in the LPN group than that in the OPN group (4 and 5 days, respectively), with less severe complications. No intergroup differences were observed regarding cancer-specific survival (CSS), disease-free survival (DFS), and overall survival (OS). The evaluation of the factors affecting DFS showed that age was an effective parameter (RR = 1.112, 95% CI: 1.010-8.254), but the surgical technique was not. Conclusion: No differences were observed between OPN and LPN techniques between oncological and functional outcomes in patients with clinical stage T1b RCC.

Immediate Revascularisation of Borderline Ischemic Limbs Followed by Replantation

Introduction: Salvage of complex limb injuries is not onlydependent on the skill, experience and attitude of the surgeonbut also on the ischemia time. If the revascularisation isnot possible within the golden period then the outcomeis unfavourable. There are very few reports of delayedreplantation. We are presenting a case series of replantationbeyond the golden hours i.e. 6 hours of warm ischemia byimmediate revascularisation before undertaking definitivereplantation. The definitive sequence of replantation is carriedout after the limb gets revascularised and the viscious cycle ofischemia is broken. Study aimed to salvage amputated limbs inthe borderline ischemia time by immediate revascularisation.Material and methods: A study was conducted between April2013 to March 2018 at SBM Plastic Surgery Hospital, cuttackand included all patients with limb amputations of 6-10 hoursduration. In this study the artery was anastomosed first to haltthe sequence of prolonged ischaemia. Temporary stability tothe repair was provided by taking deep bites to the proximaland distal muscle group with 2.0 vicryl sutures adjacent tothe anastomosis. After the limb was adequately revascularisedand proper hemostasis was achieved then the proper sequenceof replantation was started.Result: out of 31 patients presenting during this period, 9patients were excluded for poor preservation of the limb andpresenting after 10 hours of warm ischamia. Total no of casesincluded in the study were 22 patients who presented between4 to 9 hours of cold ischemia time. The break up accordingto the nature of injury was, 19 patients had avulsion injuries,two had assault with heavy sharp weapons and one hadcrush injury. Out of 22 cases of replantation 2 cases requiredamputation at a later date due to complications.Conclusion: In our country majority of patient come tohospital after 6-8 hrs of warm ischemia which is the upperlimit of ishaemia. If the ideal sequence of replantation willbe followed these limbs will undergo irreversible ischaemicdamage due to further delay. So the concept of immediatearterialisation gives the best opportunity for limb survival.

Protective Effect of remote ischemic preconditioning on liver warm ischemia-reperfusion injury in aged rats / 中国医师杂志

Objective To investigate the effect of remote ischemic preconditioning on nuclear factor erythroid-2 related factor 2 (Nrf2) signaling in the liver of aged rats after warm ischemia reperfusion injury.Methods A 70％ hepatic warm ischemia-reperfusion model was established in aged rats (15-16 months old) (1 hour after ischemia and 2 hours after reperfusion).12 male Sprague-Dawley rats were divided into two groups:pretreatment group and control group.The level of serum alanine aminotransferase (ALT) was detected after operation and the liver tissues were harvested for the determination of malondialdehyde (MDA) content and the activity of antioxidant enzyme-superoxide dismutase (SOD).The pathological changes of liver were observed.The change of Nrf2 protein expression in liver tissue was examined by Western blot.Results Serum ALT and MDA in the pretreatment group were significantly lower than those in the control group.The liver pathological damage of pretreatment group rats were lighter than the control group (P ＜ 0.05).Compared with the control group,the Nrf2 protein expression and the activity of SOD increased in the liver of pretreatment group (P ＜ 0.05).Conclusions Remote ischemic preconditioning can reduce 70％ hepatic ischemia-reperfusion injury in aged rats,and its mechanism may be related to its activation of Nrf2 signaling pathway.

Application of early sequential unclamping method in laparoscopic partial nephrectomy for patients with T1b renal tumor / 中华泌尿外科杂志

Objective To analyze the value of early sequential unclamping method in laparoscopic partial nephrectomy.Methods From April 2017 to October 2017,a total of 8 cases of renal tumor patients by early sequential unclamping method of laparoscopic partial nephrectomy (LPN) were reviewed,with 5 males and 3 females and average age of 56.4 years (43-70 years).Three cases of renal tumor were located on the left side,5 cases on the right side.The mean tumor diameter was 5.6 (4.6-6.4) cm.The preoperativeR.E.N.A.L.score was 8.8 (7-10),and the mean ASA score was 1.4 (1-2).Preoperative serum creatinine level was 89.5 (72.1-104.2) μmol/L,and the GFR level of the kidney with tumor before operation was 55.5 (40.4-62.3) ml/min.The early sequential unclamping method was used for retroperitoneal laparoscopic partial nephrectomy:according to the preoperative CTA results,the main branches and branches of the renal artery were routinely separated.Before the tumor resection,the branches of renal artery and the main renal artery were sequentially blocked.After removal of the tumor,the first layer of bare kidney wound blood vessels and collection system were sutured and repaired.Then released the main renal artery occlusion clamp,restored most of the blood supply to the kidney,but kept the tumor-specific segmental renal artery blocked.Continuous suture of the kidney created a rough combination of the renal wound.After second layers of suture completed,unclamped the segmental renal artery and sutured the renal wound again,made the third layers of suture intersecting with the second seam suture to strengthen the hemostatic effect.Results All the 8 patients were performed LPN with early sequential unclamping method successfully.The average operative time was 132.5 (90-180) min,the intraoperative blood loss was 142.5 (100-200) ml,the completely warm ischemia time was 15.5 (12.0-20.0) min,and no blood transfusion was performed intraoperatively and postoperatively.The operative margin was negative.The postoperative pathology showed that 7 cases were clear cell carcinoma and 1 cases of papillary cell carcinoma.Postoperative complications such as urinary leakage,incision infection and fever were not found.Drainage tube removal time was 3.5 (3-5) days and the time of postoperative hospitalization was 4.8 (4-6) days.At 1 months after operation,the serum creatinine level was 94.0 (83.6-101.2) μmol/L and the GFR level of one side kidney with tumor was 52.3 (43.2-59.6) ml/min.After 2-9 months of follow-up,there was no recurrence of the tumor.Conclusions Early sequential unclamping method could shorten the warm ischemia time and reduce the risk of bleeding during the operation.It also maintains a clear operative field,which could reduce the difficulty of laparoscopic partial nephrectomy and make a more accurate tumor resection in the complex renal tumor patients.

Diagnostic value of DTI in hot ischemia-reperfusion injury in rabbits / 中华器官移植杂志

Objective To evaluate the feasibility and diagnostic value of diffusion tensor imaging (DTI) in hepatic warm ischemia-reperfusion injury (WIRI) in rabbits.Methods Fifty healthy adult New Zealand white rabbits were randomly divided into control group (n =10) and four experimental groups (n =10 per group) according to different periods of hepatic warm ischemia.Four experimental groups were given hepatic arteries and portal veins clamp for 10,20,30,40 min respectively and reperfusion for 6 h to establish the rabbit model of hepatic WIRI.The control group was given perihepatic ligament separation but no vessel clamp.All the rabbits were scanned with MAGNETOM Trio Tim 3.0T MRI DTI MR Siemens and the data were collected by Nero 3D Siemens.The apparent diffusion coefficient (ADC),and fractional anisotropy (FA) values were separately measured by 2 qualified radiologists.Then intra class correlation coefficient (ICC) was used to check their consistency and repeatability.The liver function of rabbits was tested after MR examination,and pathologic examination was performed after sacrifice.Spearman correlation analysis was used to evaluate the correlation between ADC value and liver function parameters.The ROC curve was used to evaluate the diagnostic value of ADC value.Results The ADC and FA values of the two observers were consistent,with ICC values of 0.824 and 0.807,respectively.There were significant differences in ADC value between the control group and 4 experimental groups [P =0.000,(1.42 ± 0.15) 10-3mm2/s,(1.34± 0.11) 10-3mm2/s,(1.22 ± 0.20) 10-3mm2/s,(1.19 ± 0.13) 10 3mm2/s,(1.83 ±0.20) 10-3 mm2/s respectively],but there was no significant difference in the FA value among groups (0.40 ± 0.04,0.38 ± 0.03,0.41 ± 0.04 and 0.37 ± 0.04,respectively;P＞0.05).The differences in serum alanine aminotransferase (ALT),aspartate aminotransferase (AST),lactate dehydrogenase (LDH),the total superoxide dismutase (SOD),malondialdehyde (MDA) and myeloperoxidase (MPO) were statistically significant (P＜0.01).There was a negative correlation between ADC value and ALT,AST,LDH,MPO and MDA (P＜0.05),and a positive correlation between ADC value and total SOD (P =0.000).ADC value has a higher diagnostic efficacy to evaluate hepatic WIRI in T1,T2,T3,T4 group and the AUC was 0.985,0.900,0.970 and 0.833 respectively.Conclusion DTI can quantitatively and noninvasively evaluate the changes of liver water molecule diffusion caused by hepatic I/R injury in rabbits,and the ADC value could dynamically evaluate the degree of hepatic WIRI in rabbits.

Predicting liver warm ischemic injury from donor after cardiac death donors by microdialysis / 中华器官移植杂志

Objective To analyze the relative indicators associated with warm ischemia time (WIT).Methods We established the porcine donor after cardiac death (DCD) model and monitored biochemical parameters (glucose,lactate,pyruvate,glycerol,and glutamate) changes of porcine livers at different WIT by microdialysis technique.The pathological changes were also observed during different WIT by HE staining.Results As the extension of WIT,the morphology injury of the graft aggravated:glucose and pyruvate levels slightly declined in the early stage,and then increased with WIT entension;glycerol levels increased with WIT entension;lactate levels and lactate/pyruvate ratio increased significantly after 20 min of WIT.The expression of lactate and lactate/pyruvate ratio were increased with the prolonged WIT.Pearson correlation analysis of all factors with liver ischemia time and liver pathological injury degree (P＜0.05) showed the obvious correlation between lactate,lactate/pyruvic acid ratio with liver ischemia time and liver pathological injury degree,and of positive correlation (P＜0.001,and correlation coefficients were 0.682 and 0.453 respectively).The ROC curve analysis revealed that the area under the curve was 0.950 for lactate,and 0.885 for pyruvate,respectively.When the critical value of lactic acid was 2.3736,the sensitivity was 90％ and specificity was 95％.When the critical value of lactate/pyruvate ratio was 0.0257,the sensitivity was 80％ and specificity was 83％.Conclusion The level of lactic acid and lactate/pyruvate ratio are significantly related to the WIT.These factors may be used as a predictor of donor liver warm ischemia injury.Reference range of these indicators needs further discussion based on larger sample research.

The relationship between renal warm ischemia time and glomerular loss. An experimental study in a pig model

Abstract Purpose: To investigate the glomerular number after different warm ischemia times. Methods: Thirty two pigs were assigned into four groups. Three groups (G10, G20, and G30) were treated with 10, 20, and 30 minutes of left renal warm ischemia. The sham group underwent the same surgery without renal ischemia. The animals were euthanized after 3 weeks, and the kidneys were collected. Right kidneys were used as controls. The kidney weight, volume, cortical-medullar ratio, glomerular volumetric density, volume-weighted mean glomerular volume, and the total number of glomeruli per kidney were obtained. Serum creatinine levels were assessed pre and postoperatively. Results: Serum creatinine levels did not differ among the groups. All parameters were similar for the sham, G10, and G20 groups upon comparison of the right and left organs. The G30 group pigs' left kidneys had lower weight, volume, and cortical-medullar ratio and 24.6% less glomeruli compared to the right kidney. A negative correlation was found between warm ischemia time and glomerular number. Conclusions: About one quarter of glomeruli was lost after 30 minutes of renal warm ischemia. No glomeruli loss was detected before 20 minutes of warm ischemia. However, progressive glomerular loss was associated with increasing warm ischemia time.

Definition of warm ischemia and its influence on liver and kidney function / 中华肝胆外科杂志

Chinese donation after citizen's death (CDCD) is an important way to solve the donor shortage problem,but if we can't effectively control warm ischemia time of CDCD donor,it's easy to cause grafts primary nonfunction,early grafts dysfunction and biliary complications.Nowadays,with the development of surgical techniques,the definition of warm ischemia continues has been continuously updated.The understanding on different definitions may lay the foundation for improving the survival rate of liver and kidney and effectively protect liver and kidney function after transplantation.This paper overviewed the significance of different definitions of warm ischemia and its effect on liver and renal function,which could provide a reference for further experimental study and clinical practice.

Bone marrow mesenchymal stem cells in repairing donor liver after cardiac death for liver under normothermic machine perfusion in rats / 中华肝胆外科杂志

Objective To study the repairing effect of bone marrow mesenchymal stem cells (BMMSCs) on the donor liver after cardiac death (DCD) under normal temperature mechanical perfusion (NMP) in rats.Methods BMMSCs of Wistar rats were cultured in vitro,and 45-min warm ischemia after cardiac death model was established.The 30 Wistar rats were randomly divided into NMP,NMP + BMMSCs (N + B),cold storage (CS) groups,and the parameters were detected at 2 h and 4 h (n =10).Results N + B group was superior to NMP group and CS group in repairing the liver function and liver pathology including ultrastructure,improving the perfusate acidic environment,and increasing adenosine triphosphate level (P ＜ 0.05).The oxygen consumption of NMP group and N + B group were significantly different after 2h [2 h:(24.35 ±0.64) ml/min vs.(29.33 ±0.47) ml/min;3 h:(25.33 ±0.86) ml/min vs.(30.34 ± 0.49) ml/min;4 h:(26.88 ± 1.07) ml/min vs.(31.76 ± 0.96) ml/min;P ＜ 0.05],suggesting that the liver condition in N + B group was significantly better than that in the other two groups.Conclusion Bone marrow mesenchymal stem cells could obviously repair the DCD grafts under normal temperature mechanical perfusion.

Effect of hypothermia status in donors on renal graft function after renal transplantation from donation after citizen's death / 器官移植

Objective To evaluate the effect of hypothermia status in the donors upon the renal graft function after renal transplantation from donation after citizen's death. Methods Thirty-six eligible donors were randomly divided into the normal temperature (body temperature 36.5-37.5 ℃ , n=19) and hypothermia groups (body temperature 34.0-35.0 ℃ , n=17). The matched recipients undergoing renal transplantation were also assigned into the normal temperature (n=38) and hypothermia groups (n=34). Perioperative conditions of the donors and recipients were compared between two groups. And postoperative renal graft function of the recipients were statistically compared between two groups, including the incidence of delayed graft function (DGF) and primary nonfunction (PNF). Results No statistical significance was identified in the perioperative amount of urine volume, serum creatinine (Scr), systolic blood pressure, saturation oxygen, warm ischemia time and cold ischemia time of the donors between two groups (all P>0.05). No statistical significance was noted in terms of the operation time, intraoperative mean blood glucose and intraoperative mean arterial pressure of the recipients between two groups (all P>0.05). Postoperative incidence of DGF of the recipients in the hypothermia group was 6%, significantly lower than that in the normal temperature group (24%) (χ2=4.393, P=0.036). Postoperative incidence of PNF of the recipients was 3% in both the hypothermia and normal temperature groups with no statistical significance (χ2=0.000, P=1). Conclusions The hypothermia status of the donors can significantly reduce the incidence of DGF, whereas exerts no evident effect upon the incidence of PNF in the recipients.

Glomerular loss after arteriovenous and arterial clamping for renal warm ischemia in a swine model

ABSTRACT PURPOSE: To evaluate the glomerular loss after arteriovenous or arterial warm ischemia in a swine model. METHODS: Twenty four pigs were divided into Group Sham (submitted to all surgical steps except the renal ischemia), Group AV (submitted to 30 minutes of warm ischemia by arteriovenous clamping of left kidney vessels), and Group A (submitted to 30 minutes of ischemia by arterial clamping). Right kidneys were used as controls. Weigh, volume, cortical volume, glomerular volumetric density (Vv[Glom]), volume-weighted glomerular volume (VWGV), and the total number of glomeruli were measured for each organ. RESULTS: Group AV showed a 24.5% reduction in its left kidney Vv[Glom] and a 25.4% reduction in the VWGV, when compared to the right kidney. Reductions were also observed when compared to kidneys of sham group. There was a reduction of 19.2% in the total number of glomeruli in AV kidneys. No difference was observed in any parameters analyzed on the left kidneys from group A. CONCLUSIONS: Renal warm ischemia of 30 minutes by arterial clamping did not caused significant glomerular damage, but arteriovenous clamping caused significant glomerular loss in a swine model. Clamping only the renal artery should be considered to minimize renal injury after partial nephrectomies.