RU2747908C1 - Method for isolated shared porto-caval liver perfusion in experiment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to surgery, oncology, transplantology. Cadaveric liver explantation is carried out, the perfused lobe is determined. Next, the portal vein is mobilized and the short veins of the liver are also ligated; after that, a venous cannula with an external diameter of 6 to 12 mm is installed into the branch of the portal vein of the perfused lobe, with additional fixation with a vascular turnstile to prevent the perfusate from being thrown into the contralateral branch of the portal vein. Next, a cannula with an external diameter of 14 to 35 mm is inserted into the retrohepatic segment of the inferior vena cava. After that, a perfusion circuit is formed by connecting the inflow systems from the reservoir with perfusate to the liver - to the cannula in the portal vein branch, outflow from the liver to the reservoir - to the cannula in the retrohepatic segment of the inferior vena cava. The circuit also includes reservoirs with a solution for perfusion and for collecting it at the outlet of the circuit, a pump for perfusion, a thermostatic bath and connectors for connecting infusion filters, branch pipes, extension cords, tee-connectors for infusion systems. Then, to determine the interlobar border of the liver, a solution of a water-soluble dye in a volume of 20 to 150 ml is injected bolus into the venous cannula. Further, the identified inter-lobe boundary is marked with X-ray-positive objects. After that, isolated lobar portocaval liver perfusion is performed in the following mode: flow rate - 110-650 ml/min, duration - 20-60 min, perfusate temperature - 37-43°C. Then, during perfusion, comparative thermometry of the perfused and contralateral lobes of the liver is performed to assess the dynamics of temperature rise. During perfusion, in order to control the spread of perfusate in the parenchyma, a water-soluble X-ray contrast solution is injected with a total volume of up to 100-150 ml / min and fluoroscopy is performed; then, at the end of the perfusion, cholecystectomy is performed; after which the liver preparation is examined and disposed of.

EFFECT: method ensures performing sequentially operational techniques allowing isolating lobar portal blood flow of the liver and carrying out its selective perfusion, as well as delivering of various pharmaceuticals with the exclusion of their leakage into the contralateral lobe of the liver.

1 cl, 2 ex, 4 dwg

Description

The invention relates to medicine, in particular to surgery, oncology, transplantology, and can be used when carrying out techniques associated with the need to isolate the shared vascular blood flow of the liver and its selective perfusion.

Currently, a number of authors' works are devoted to the problem of treating bilobar liver metastases using isolated liver perfusion (F. Molly et al., 2013; T. Voron et al., 2013; T.J. Vogl et al., 2017). However, the proposed methods are used as a separate method of treatment and have their negative sides. First, due to the forced block of the inferior vena cava (IVC), there is a need to use additional equipment to create a cava-caval shunt. Secondly, this is the forced use of high-tech consumables for closed perfusion with ineffective isolation of the liver blood flow. And, thirdly, these are pronounced side effects associated with the leakage of perfusate into the systemic circulation. In addition, there is no information in the available literature on the possibility of performing perfusion techniques associated with vascular isolation of one of the liver lobes.

The known method of isolated liver perfusion (method of isolated hyperthermic chemoperfusion of the liver, RF patent No. 2664631, A61P 35/00, A61K 38/36, A61K 38/19, A61B 17/00 publ. 09/21/2018). In this method, the liver is isolated from the systemic blood flow, a perfusion circuit is formed and perfusion of the metastatic liver with an antitumor drug is performed. However, this method requires additional technical means to create a roundabout way of artificial blood supply due to the need to block blood flow in the PIV and does not provide for the possibility of perfusion of individual liver lobes, and therefore, in some cases, the possibilities of its use are limited.

A method is proposed for isolated lobar port-caval liver perfusion in an experiment, the purpose of which is to perform sequential surgical procedures that allow isolating the lobar portal blood flow of the liver and conduct its selective perfusion with the necessary pharmaceutical. This method is proposed to be used in oncology for high-dose chemoregional therapy or in combination with methods of staged liver resections, "ex vivo" operations, as well as in transplantology.

The problem is solved by the fact that in the method of isolated lobar port-caval perfusion of the liver in the experiment, after explantation of the cadaveric liver, the share for perfusion with the necessary drug is determined (hereinafter referred to as "perfused share"); then the portal vein (IV), its right (PV) and left (PV) branches and the retrohepatic segment (PC) of the IVC are mobilized, as well as the short hepatic veins are ligated; after that, a venous cannula with an external diameter of 6 to 12 mm is installed into the IV branch of the perfused lobe, with its additional fixation with a vascular turnstile to prevent the perfusate from being thrown into the contralateral branch of the IV; then a cannula with an external diameter of 12 to 35 mm is inserted into the IVC PC using the selected method; after which a perfusion circuit is formed by connecting the inflow systems (from the reservoir with perfusate to the drug) to the cannula in the IV branch, outflow (from the drug to the reservoir) to the cannula in the IVC PC, the circuit also includes reservoirs with perfusion solution and for it collection at the outlet from the circuit, a peristaltic (centrifugal) pump, a thermostatic bath and connectors (for connecting infusion filters, splitters, extension cords, tees for infusion systems, etc.); then, to determine the interlobar border of the liver, a solution of a water-soluble dye (for example, 0.05% brilliant green, 1% mytilene blue, 0.4% basic fuchsin, etc.) is injected into the venous cannula in a volume of 20 to 150 ml; further, the identified inter-lobe boundary is marked with X-ray-positive objects; after that, an isolated lobar port-caval liver perfusion is performed in the following mode: flow rate - 110-650 ml / min, duration - 20-60 min, perfusate temperature - 37-43 ° С; then, during perfusion, comparative thermometry of the perfused and contralateral lobes of the liver is performed to assess the dynamics of temperature rise; then, during perfusion, in order to control the spread of perfusate in the parenchyma, a water-soluble X-ray contrast solution is injected with a total volume of up to 100-150 ml / min, and fluoroscopy is performed; then, at the end of the perfusion, the gallbladder (GB) is removed; after which, the liver preparation is examined and disposed of in accordance with the requirements of the guidelines.

The technical characteristics of the cannulas, the composition of the contour and the solution, the perfusion parameters, as well as the need for an X-ray contrast study are determined depending on the actual requirements and the optimal ones are selected.

The use of this method clearly demonstrates the possibility of isolating the portal lobar blood flow of the liver in order to carry out its selective perfusion with a solution of the required pharmaceutical preparation. In addition, the method of isolated lobar porto-caval liver perfusion is indicated in cases of pronounced variant anatomy of arterial angioarchitectonics and the presence of associated technical difficulties in conducting isolated lobar arterio-caval perfusion. The introduction of the presented method into clinical practice will improve the previous and propose new methods of combined treatment of multiple mono- and bilobar liver lesions, as well as create a basis for the development of new transplant ("ex vivo") technologies in abdominal surgery.

The indicated ranges were selected empirically during the experiment. The presented values of the diameter of the venous cannulas are determined by the need to maintain proper velocity parameters, and cannot be larger than the diameter of the vessels used. Since it is difficult to create adequate hydrodynamic conditions on cadaveric tissue, the higher the diameter of the venous cannula installed in the IVC PC, the more efficient the outflow of the perfusate from the liver and, therefore, the less resistance to the flow of the perfusate in the vascular bed of the perfused lobe. In this regard, the diameter of the cannula in the IVC PC (12-35 mm) is always larger than that among the cannulas installed in the IVC branch (6-12 mm). When using cannulas with a smaller diameter, portal perfusion on a liver specimen is difficult and will not correspond to physiological ones.

At the minimum and maximum morphometric characteristics of the explanted preparation, 20 ml to 150 ml of a water-soluble dye were injected to determine the topography of the interlobar boundary, respectively. With a decrease in the volume of the injected solution less than 20 ml, conditions arise under which it is not possible or difficult to determine the inter-lobe boundary, which leads to experimental errors. Also, empirically, we determined that 150 ml is sufficient for effective mapping of the portal channel, and the introduction of a larger volume of dye, from the point of view of economic justification, is inappropriate.

The rate parameters of perfusion were as close to physiological as possible. However, their amendment was made taking into account the work on cadaveric tissue. So, at a rate of less than 110 ml / min, the efficiency of perfusion decreased, as evidenced by the nature of the spread of perfusate along the vascular bed. An increase in the perfusate flow rate above 650 ml / min led to damage to the parenchyma of the cadaveric liver, which affected the quality of the study. The duration of perfusion and hyperthermia in the experiment was determined in accordance with the requirements of clinical practice.

The volume of the injected water-soluble X-ray contrast solution from 100 to 150 ml / min was determined by the rate of perfusion. However, the introduction of a smaller volume reduced the informativeness of fluoroscopic data, and a larger one was economically inexpedient.

The use of this method clearly demonstrates the possibility of isolating the portal lobar blood flow of the liver in order to carry out its selective perfusion with a solution of the required pharmaceutical preparation. In addition, the method of isolated lobar porto-caval liver perfusion is indicated in cases of pronounced variant anatomy of arterial angioarchitectonics and the presence of associated technical difficulties in conducting isolated lobar arterio-caval perfusion. The introduction of the presented method into clinical practice will improve the previous and propose new methods of combined treatment of multiple mono- and bilobar liver lesions, as well as create a basis for the development of new transplant ("ex vivo") technologies in abdominal surgery.

The invention is illustrated in FIG. 1, which shows a schematic diagram of a perfusion circuit for carrying out isolated lobar porto-caval liver perfusion in an experiment, and gives experimental examples, which are illustrated in Figs. 1, fig. 2, fig. 3, fig. 4. In FIG. 2 shows the appearance of the liver preparation after the installation of the perfusion circuit and the injection of a water-soluble dye into the portal bed of the right lobe. FIG. 3 shows an X-ray image obtained in the process of isolated porto-caval perfusion of the right lobe of the liver using an X-ray contrast agent. FIG. 4 shows an X-ray image obtained in the process of isolated porto-caval perfusion of the left lobe of the liver using an X-ray contrast agent.

As shown in FIG. 1, the first stage is preparation for perfusion of the liver preparation 5. Next, an open perfusion circuit is formed by connecting the inflow systems to the cannula installed in the IV branch of the perfused lobe, the outflow systems to the cannula in the IVC PC - dotted lines. The circuit also includes reservoirs with perfusate 1 and for collecting the spent perfusate 6. The thermostatic bath is installed on the path of the solution inflow to the perfused portion 2. The movement of the perfusate in the circuit creates a peristaltic (centrifugal) pump 3, the direction of flow is indicated by arrows. If necessary, injections of drugs and connection of additional devices are performed through connectors 4.To control the temperature of the perfused lobe, thermometry is performed 7.

Example No. 1 - port-caval perfusion of the right lobe of the liver, illustrated in FIG. 1, fig. 2, fig. 3

Liver specimen No. 53 was explanted from the unbalanced corpse of patient R., who died from a disease not directly related to the organ under study.

At the first stage, after preliminary preparation of the preparation, the necessary vascular formations (PC IVC, IV, and its branches) were mobilized and the short hepatic veins were ligated. Then a cannula was installed (venous straight reinforced cannula 12 Fr, Maquet, Germany) 8 in Fig. 2, fig. 3 in the PV and for the outflow of perfusate cannula 9 in FIG. 2, fig. 3 in PC NIP. To exclude retrograde leakage of perfusate through the PV, the venous cannula installed in the PV was additionally squeezed with vascular ties. In order to drain the perfusate into the contour, the ends of the IVC were sealed with a twisted seam.

In the second step, an open perfusion circuit was formed as shown in FIG. 1, which included the perfusate reservoir 1 in FIG. 1, thermostatic bath 2 in FIG. 1, a LOIP LS-301 peristaltic pump (manufactured by OAO Laboratory Equipment and Instruments, Russia) 3 in Fig. 1, purchased with the support of the Government of St. Petersburg (diploma PSP No. 18787) and injection connectors 4 in FIG. 1. To collect the spent perfusate, a container made of polymeric material 6 in FIG. 1 Temperature rise control was assessed at the beginning and at the end of perfusion using a contact thermometer 7 in FIG. 1. Then, in order to determine the interlobar border of the liver, 60 ml of a 1% solution of methylene blue was bolted into the cannula installed in the PT, which led to staining of the right lobe of the liver 11 in Fig. 2, fig. 3 in the color of the dye. A characteristic difference of the external picture in color mapping of the portal bed of a liver preparation, in comparison with arterial, is the presence on its surface of rare stellate elements of an irregular shape. As a result of the injection of the dye by the portal sign, the interlobar border of the liver was determined - the dotted line and triangles in Fig. 2, fig. 3, which was located in the projection of the line drawn between the left edge of the IVC notch and the left edge of the gallbladder notch, the projection of the bed of which is indicated by P in Fig. 2, fig. 3. In this case, the so-called anatomical interlobar boundary in the form of a projection of the falciform ligament 12 in FIG. 2, 3 remained within the left lobe of the liver 10 in FIG. 2, fig. 3. Further, in order to compare the external topographic data with the X-ray picture, the revealed inter-lobe boundary is the dotted line and triangles in FIG. 2, fig. 3 - marked with X-ray-positive objects indicated by circles in FIG. 3, fig. four.

The third step was perfusion of the right lobe of the liver 11 in FIG. 2, fig. 3 in the mode: flow rate - 230 ml / min, duration - 30 min, perfusate temperature - 40 ° С. During perfusion of the right lobe of the liver in order to control the leakage of perfusate into the venous cannula 8 in FIG. 2, fig. 3 introduced an X-ray contrast solution "Omnipak" in a dilution with physiological in a ratio of 1: 1 with a total volume of up to 110 ml and, using an X-ray diagnostic surgical mobile device "RTS-612" (ZAO NIPK "Electron", Russia) performed an X-ray , the results of which are shown in FIG. 3. The results of fluoroscopy allowed us to compare the external topographic data of the interlobar border of the liver - the dotted line with the triangles in FIG. 2, fig. 3, and to prove the possibility of determining the intrahepatic interlobar border of the liver by external signs in cases of normal anatomy. So on the roentgenogram, the spread of contrast within the boundaries of the perfused right lobe of the liver 11 in Fig. 2, fig. 3. At the end of the perfusion, when performing thermometry, there was a significant difference in indicators between the right (perfused) and left lobes of the liver.

At the end of the perfusion, the preparation was prepared for the next experiment, which is described in example No. 2.

Example No. 2 - port-caval perfusion of the left lobe of the liver, illustrated in FIG. 1, fig. 2, fig. four

Liver preparation No. 53 after perfusion of the right lobe (as indicated in example No. 1) was prepared for its left-sided porto-caval perfusion. The venous cannula 8 in FIG. 2, fig. 4 were installed in the LP.

Next, the left liver lobe 10 was perfused in FIG. 2, fig. 4 in the mode: flow rate - 230 ml / min, duration - 20 min, perfusate temperature - 39 ° С. During perfusion in order to control the leakage of perfusate into the venous cannula 8 in FIG. 2, fig. 4 introduced the X-ray contrast solution "Omnipak" in dilution with physiological in a ratio of 1: 1 with a total volume of up to 120 ml and, using an X-ray diagnostic surgical mobile device "RTS-612" (CJSC "NIPK" Electron ", Russia) performed an X-ray , the results of which are shown in FIG. 4. Fluoroscopy made it possible to confirm the fact of the spread of perfusate within the boundaries of the left lobe of the liver 10 in FIG. 2, fig. 4, while in the projection of the right lobe of the liver 11 of FIG. 4, no perfusate leakage was observed. When comparing X-ray data with the external topography of the interlobar border of the liver, the dotted line and triangles in Fig. 2, fig. 4, the latter passed intraparenchymally in the same way in the projection of a line drawn from the left edge of the IVC notch to the left edge of the gallbladder notch. So, the so-called anatomical interlobar border is the serum ligament, the projection of which is indicated 12 in Fig. 2, fig. 4, was within the left lobe of the liver.

Then, at the end of the perfusion, cholecystectomy was performed, and the liver specimen was subjected to anatomical examination, which confirmed the data of previous experiments.

Thus, the possibility of vascular isolation of the portal blood flow by the liver lobes for their selective perfusion has been demonstrated.

Claims (1)

The method of isolated lobar port-caval liver perfusion in the experiment, characterized in that after explantation of the cadaveric liver, the perfused lobe is determined; then the portal vein is mobilized and the short veins of the liver are also ligated; after that, a venous cannula with an external diameter of 6 to 12 mm is installed into the branch of the portal vein of the perfused lobe, with additional fixation with a vascular turnstile to exclude the injection of perfusate into the contralateral branch of the portal vein; then a cannula with an external diameter of 14 to 35 mm is inserted into the retrohepatic segment of the inferior vena cava, after which a perfusion circuit is formed by connecting the inflow systems from the reservoir with perfusate to the liver - to the cannula in the portal vein branch, outflow from the liver to the reservoir - to the cannula in the retrohepatic segment of the inferior vena cava, the circuit also includes reservoirs with a solution for perfusion and for collecting it at the outlet from the circuit, a perfusion pump, a thermostatic bath and connectors for connecting infusion filters, branching units, extension cords, tees for infusion systems; then, to determine the interlobar border of the liver, a solution of a water-soluble dye in a volume of 20 to 150 ml is injected into the venous cannula bolus; further, the identified inter-lobe boundary is marked with X-ray-positive objects; after that, isolated lobar portocaval liver perfusion is performed in the following mode: flow rate - 110-650 ml / min, duration - 20-60 min, perfusate temperature - 37-43 ° C; then, during perfusion, comparative thermometry of the perfused and contralateral lobes of the liver is performed to assess the dynamics of temperature rise; then, during perfusion, in order to control the spread of perfusate in the parenchyma, a water-soluble X-ray contrast solution is injected with a total volume of up to 100-150 ml / min and fluoroscopy is performed; then, at the end of the perfusion, cholecystectomy is performed; after which the liver preparation is examined and disposed of.

Images