RU2765017C1 - Method for isolated left-sided lobar arterio-umbilical liver perfusion in an experiment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to surgery, oncology, transplantology. Cadaveric liver exteriorization is performed. The portal vein is mobilized, one’s own hepatic artery, their branches and the retro-hepatic segment of the inferior vena cava, as well as the short hepatic veins that flow into the inferior vena cava are ligated and crossed. Next, the umbilical vein is mobilized in the round ligament of the liver and its recanalization is performed. The ends of the arteries in the round ligament are sealed. Then a cholecystectomy is performed. A venous cannula with an external diameter of 6 to 12 mm is installed and fixed in the umbilical vein. Next, an arterial cannula with a diameter of 2 to 4 mm is installed in the left branch of its own hepatic artery (OHA). Then a vascular turnstile is applied to the left branch of the OHA for sealing. The left branch of the portal vein (PV) is sealed to prevent perfusate leakage. After that, sealing is performed at the level of the terminal section of the intermediate and left hepatic veins, or in the presence of their common trunk. After that, a perfusion circuit is formed by connecting the inflow system, from the perfusion tank to the drug, to the cannula in the left branch of the OHA, the outflow system, from the drug to the reservoir, to the cannula in the umbilical vein. The circuit also includes tanks with perfusion solution and for collecting it at the outlet of the circuit, a perfusion pump, a thermostatic bath and connectors. Then, to determine the interlobular border of the liver, a solution of a water-soluble dye in a volume of 20 to 150 ml is injected bolus into the arterial cannula. Further, the identified interline boundary is marked with X-ray-positive objects. After that, isolated left-sided lobar arterio-umbilical perfusion of the liver is performed in the mode: perfusate flow rate 110-350 ml/min, duration 20-60 min, perfusate temperature 4-430°C. Further, during perfusion, in order to control the spread of perfusate in the parenchyma and possible leakage, a water-soluble X-ray contrast solution with a total volume of 100-150 ml is injected and fluoroscopy is performed. After that, the liver preparation is examined.

EFFECT: method makes it possible to improve the treatment of multiple mono- and bilobate liver lesions, as well as to create a basis for the development of new transplantation (“ex vivo”) technologies in abdominal surgery.

1 cl, 1 dwg, 2 ex

Description

The invention relates to medicine, in particular to surgery, oncology, transplantation, and can be used in carrying out techniques related to the need to isolate the arterio-portal blood flow of the left lobe of the liver and its selective perfusion.

Currently, the treatment of patients with liver metastases is an urgent problem. The average life expectancy of patients with liver metastases without specific treatment averages 6-18 months, while the median survival is 4.8-12 months (Yu.I. Patyutko et al., 2011; M.F. Cherkasov, 2015; S. V. Gorchakov, 2016; Y. A. Shavrina, 2017).

Currently, combined methods of treatment with the use of preoperative regional chemotherapy are being developed, the purpose of which is to increase the resectability of the identified metastatic foci (Patyutko Yu.I., 2014).

These methods in some cases have severe postoperative complications (A.F. Lazarev, 2014). In addition, the methods of isolated liver perfusion have become quite widely used, however, they also have a number of disadvantages: complications caused by leakage of the chemotherapy drug into the systemic circulation, the need to use equipment to create a roundabout artificial blood flow due to the forced HPB block (F. Molly, 2013; T Voron, 2013; T.J. Vog1, 2017). Currently, there is a need to improve these methods, which will make it possible to level their negative aspects, and to develop methods applicable in combination with staged liver resections.

There is a known method of isolated liver perfusion (method of isolated hyperthermic chemoperfusion of the liver, patent of the Russian Federation No. 2664631, published on September 21, 2018), in which the liver is isolated from the systemic blood flow, a perfusion circuit is formed, and the liver affected by metastases is perfused with an antitumor drug. However, this method does not provide for the possibility of perfusion of individual lobes of the liver, and therefore, in some cases, the possibilities of its use are limited.

There is a known method of isolated lobar arterio-caval perfusion of the liver in the experiment (RF patent No. 2726591, published on 07/14/2020), where the perfusion of the isolated lobe is performed through the arterial bed, and the outflow occurs through the HPB, however, it does not provide for the ability to perform perfusion through the bed of the left branch portal vein (BB), which may be necessary under certain circumstances.

A known method of experimental arterio-umbilical perfusion of the left lobe of the liver (Akbashev, R.A., et al. Evaluation of vascular isolation during experimental arterio-umbilical perfusion of the left lobe of the liver / R.A. Akbashev [et al.] Proceedings of the V St. Petersburg International Oncological Forum "White Nights", AHHMO "Issues of Oncology", St. Petersburg, 2019. - P. 522-523), in which the left lobe of the liver is perfused through the left branch of the proper hepatic artery (HPA) and the recanalized umbilical vein. However, a significant disadvantage of this method is the lack of sealing of the cannulated left branch of the SPA branch, which can serve as a way for leakage of perfusate into the right lobe of the liver. In addition, in the absence of sealing and disjunction of the short hepatic veins, there is a high chance of leakage of perfusate into the HPV. At the same time, the preservation of the gallbladder in some cases can lead to leakage of perfusate into the arterial bed of the right lobe of the liver.

A method for isolated left-sided lobar arterio-umbilical perfusion of the liver in an experiment is proposed, the purpose of which is to perform sequential surgical techniques that allow isolating the arterio-portal blood flow of the left lobe of the liver and conducting its selective perfusion with the necessary pharmaceutical preparation. This method is proposed to be used in oncology for high-dose regional chemotherapy or in combination with the methods of staged liver resections, ex vivo operations, as well as in transplantology. When describing this method, the term “left/right branch” of the SPA is used according to the International anatomical terminology, however, given the cases of variant anatomy, when these anatomical formations originate from other arteries, the term “left/right hepatic artery” should be used as a synonym.

The problem is solved by the fact that in the method of isolated left-sided lobar arterio-umbilical perfusion of the liver in the experiment, after explantation of the cadaveric liver, BB, SPA, their branches and the retrohepatic segment (PC) of HPB are mobilized, and short hepatic veins that flow into HPB; further, the umbilical vein is mobilized in the round ligament of the liver, and its recanalization is carried out, the ends of the arteries as part of the round ligament are sealed; then produce cholecystectomy; after that, a return venous cannula with an outer diameter of 6 to 12 mm is installed and fixed in the umbilical vein; then an arterial cannula with a diameter of 2 to 4 mm is placed in the left branch of the SGIA; then a vascular tourniquet is applied to the left branch of the SPA for sealing; the left branch of the BB is sealed to prevent leakage of perfusate; after which, at the level of the terminal section of the intermediate and left hepatic veins, or, if available, their common trunk, sealing is performed; after that, a perfusion circuit is formed by connecting the inflow system (from the reservoir with the perfusate to the drug) to the cannula in the left branch of the spa, the outflow system (from the drug to the reservoir) - to the cannula in the umbilical vein, the circuit also includes reservoirs with perfusion solution and for its collection at the outlet of the circuit, perfusion pump, thermostatic bath and connectors; then, to determine the interlobar border of the liver, a solution of a water-soluble dye is injected into the arterial cannula in a volume of 20 to 150 ml; further, the identified interlobar border is marked with X-ray-positive objects; after that, isolated left-sided lobar arterio-umbilical perfusion of the liver is performed in the following mode: perfusate flow rate - 110-350 ml/min, duration - 20-60 min, perfusate temperature - 4-43°C; then, during perfusion, in order to control the spread of perfusate in the parenchyma and possible leakage, a water-soluble X-ray contrast solution with a total volume of 100-150 ml is injected, and fluoroscopy is performed; after which, the preparation of the liver is subjected to research.

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

These ranges were selected empirically during the experiment. The presented values of the diameter of the vascular cannulas are determined by the need to maintain proper speed indicators, 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 return venous cannula, the more efficient the outflow of perfusate from the liver and, consequently, the less resistance to the perfusate flow in the vascular bed of the perfused lobe. In this regard, the diameter of the cannula in the umbilical vein (6-12 mm) is always larger than that of the cannula installed in the SPA branch (2-4 mm). When using cannulas of a smaller diameter, it is difficult to carry out perfusion on a liver preparation using the presented method and will not correspond to physiological ones.

With the minimum and maximum morphometric characteristics of the explanted preparation, from 20 ml to 150 ml of a water-soluble dye, respectively, was injected to determine the topography of the interlobar border. When the volume of the injected solution is reduced to less than 20 ml, conditions arise under which it is impossible or difficult to determine the interlobar boundary, which leads to experimental errors. Also, we have experimentally determined that 150 ml is sufficient for effective mapping of the vascular bed, and the introduction of a larger volume of dye is impractical.

The speed parameters of perfusion were as close as possible to physiological ones. However, they were corrected taking into account work on cadaveric tissue. Thus, at a rate of less than 110 ml/min, the efficiency of perfusion decreased, as evidenced by the nature of the distribution of the perfusate along the vascular bed. An increase in the perfusate flow rate above 350 ml/min led to damage to the cadaveric liver parenchyma, which affected the quality of the study. The duration of perfusion in the experiment was determined in accordance with the requirements of clinical practice.

The volume of injected water-soluble X-ray contrast solution of 100-150 ml was determined by the rate of perfusion. However, the introduction of a smaller volume reduced the information content of fluoroscopic data, and a larger one was inappropriate.

The use of this method clearly demonstrates the possibility of isolating the arterio-portal blood flow of the left lobe of the liver in order to conduct its selective perfusion with a solution of the necessary pharmaceutical preparation. In addition, the method of isolated left-sided lobar arterio-umbilical perfusion of the liver can be indicated in cases of technical difficulties in performing 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 lesions of the liver, as well as create the basis for the development of new transplantation ("ex vivo") technologies in abdominal surgery.

The invention is illustrated in figure 1, which shows a diagram of a perfusion circuit for conducting an isolated left-sided lobar arterio-umbilical perfusion of the liver in the experiment, and experimental examples are given.

As shown in figure 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 left branch of the SPA, the outflow to the cannula in the umbilical vein - dotted lines. The circuit also includes tanks with perfusate 1 and for collecting spent perfusate 6. A thermostatic bath is installed on the path of the solution inflow to the perfused lobe 2. The movement of perfusate in the circuit creates a perfusion pump 3, the flow direction is indicated by arrows. If necessary, drug injections and additional devices are connected using connectors 4.

Example No. 1 - illustrated in Fig.1.

The liver preparation was explanted from the unembalmed corpse of patient B., who died from a disease not directly related to the organ under study.

At the first stage, after explantation of the liver preparation, the necessary vascular formations (PC HPB, BB, SPA and their branches) were mobilized and the short hepatic veins were ligated and crossed. Next, the hepatic vein was mobilized in the round ligament of the liver and recanalized using a Billroth forceps. The round ligament arteries were also ligated. Then a cholecystectomy was performed. After that, for perfusate inflow, a cannula (arterial straight reinforced cannula 6 Fr, Maquet, Germany) was installed in the left branch of the SPA and for outflow of perfusate a cannula (venous straight reinforced cannula 18 Fr, Maquet, Germany) was installed into the umbilical vein. To exclude retrograde leakage of perfusate through the left branches of the BB and SPA, a vascular tourniquet was placed on the latter. Vascular tourniquets were placed on the terminal section of the mobilized intermediate and left hepatic veins for sealing.

The second stage formed an open perfusion circuit as shown in figure 1, which included a tank with perfusate 1 in figure 1, a thermostatic bath 2 in figure 1, a peristaltic pump "LOIP 1s-301" (manufactured by OAO "Laboratory equipment and instruments ”, Russia) 3 in figure 1, acquired with the support of the government of St. Petersburg (diploma PSP No. 18787) and injection connectors 4 in figure 1. To collect the spent perfusate, a container made of polymer material 6 in Fig.1 was installed. Then, in order to determine the interlobar border of the liver, a bolus was introduced into the cannula installed in the left branch of the SPA, 55 ml of a 1% solution of methylene blue. As a result of the injection of the dye, the interlobar border of the liver was determined by the arterial sign, which was located in the projection of the line drawn between the sulcus of the HPB and the middle of the fossa of the gallbladder. Further, in order to compare the external topographic data with the X-ray picture, the revealed interlobar border was marked with X-ray-positive objects.

The third stage was the perfusion of the left lobe of the liver in the following mode: flow rate - 330 ml/min, duration - 25 min, perfusate temperature 18°C. During the perfusion of the left lobe of the liver, in order to control the leakage of perfusate, an X-ray contrast solution "Omnipak" was introduced into the arterial cannula at a dilution with physiological in a ratio of 1: 1 with a total volume of 100 ml and, using the X-ray diagnostic surgical mobile unit "PTC-612 (3AO NIPK Elektron, Russia) performed X-ray examination. The results of fluoroscopy made it possible to compare the external topographic data of the interlobar border and prove the possibility of determining the intrahepatic interlobar border of the liver by external signs in cases of normal anatomy. So on the radiograph, the distribution of contrast was determined within the boundaries of the left lobe of the liver.

At the end of perfusion, the liver preparation was subjected to anatomical examination.

Example No. 2 - illustrated in Fig.1.

The liver preparation was explanted from the unembalmed corpse of patient N., who died from a disease not directly related to the organ under study.

At the first stage, after explantation of the liver preparation, the necessary vascular formations (PC HPB, BB, SPA and their branches) were mobilized, the short hepatic veins were ligated and crossed. Next, the hepatic vein was mobilized in the round ligament of the liver and recanalized using a vascular bougie. The round ligament arteries were also ligated. Then a cholecystectomy was performed. After that, for perfusate inflow, a cannula (arterial straight reinforced cannula 6 Fr, Maquet, Germany) was installed in the left branch of the SPA and for outflow of perfusate a cannula (venous straight reinforced cannula 18 Fr, Maquet, Germany) was installed into the umbilical vein. To exclude retrograde leakage of perfusate through the left branches of the BB and SPA, vascular tourniquets were placed on the latter. A vascular tourniquet was placed on the terminal section of the mobilized common trunk of the intermediate and left hepatic veins for sealing.

The second stage formed an open perfusion circuit as shown in figure 1, which included a reservoir with perfusate 1 in figure 1, a thermostatic bath 2 in figure 1, a peristaltic pump "LOIP 1s-301" (manufactured by OAO "LOiP", Russia ) 3 in figure 1, acquired with the support of the government of St. Petersburg (diploma PSP No. 18787) and injection connectors 4 in figure 1. To collect the spent perfusate, a container made of polymer material 6 in Fig. 1 was installed. Then, in order to determine the interlobar border of the liver, 70 ml of a 0.4% solution of basic fuchsin was bolused into the cannula installed in the left branch of the SPA. As a result of the injection of the dye, the interlobar border of the liver was determined by the arterial sign, which was located in the projection of the line drawn between the sulcus of the HPB and the middle of the fossa of the gallbladder. Further, in order to compare the external topographic data with the X-ray picture, the revealed interlobar border was marked with X-ray-positive objects.

The third stage was the perfusion of the left lobe of the liver in the following mode: flow rate - 300 ml/min, duration - 30 min, perfusate temperature - 27°C. During the perfusion of the left lobe of the liver, in order to control the leakage of perfusate, an X-ray contrast solution "Omnipaque" was introduced into the arterial cannula at a dilution with physiological in a ratio of 1: 1 with a total volume of up to 150 ml and, using the X-ray diagnostic surgical mobile "PTC- 612” (3AO “NIPK “Elektron”, Russia) performed fluoroscopy. On the radiograph, the distribution of contrast was determined within the boundaries of the left lobe of the liver.

At the end of perfusion, the liver preparation was subjected to anatomical examination.

Thus, the possibility of vascular isolation of the arterio-portal blood flow of the left lobe of the liver for its selective perfusion has been demonstrated.

Claims (1)

The method of isolated left-sided lobar arterio-umbilical perfusion of the liver in the experiment, characterized in that after explantation of the cadaveric liver, the portal vein, the proper hepatic artery, their branches and the retrohepatic segment of the inferior vena cava are mobilized, and the short hepatic veins that flow into the inferior vena cava are ligated and crossed. vena cava; further, the umbilical vein is mobilized in the round ligament of the liver and its recanalization is performed, the ends of the arteries as part of the round ligament are sealed; then produce cholecystectomy; after that, a venous cannula with an outer diameter of 6 to 12 mm is installed and fixed in the umbilical vein; then an arterial cannula with a diameter of 2 to 4 mm is installed in the left branch of the own hepatic artery (SHA); then a vascular tourniquet is applied to the left branch of the SPA for sealing; the left branch of the portal vein (BB) is sealed to prevent leakage of perfusate; then at the level of the terminal section of the intermediate and left hepatic veins, or in the presence of their common trunk, sealing is performed; after that, a perfusion circuit is formed by connecting the inflow system, from the reservoir with the perfusate to the drug, to the cannula in the left branch of the SPA, the outflow system, from the drug to the reservoir, to the cannula in the umbilical vein, the circuit also includes reservoirs with a solution for perfusion and for its collection at the outlet of the circuit, perfusion pump, thermostatic bath and connectors; then, to determine the interlobar border of the liver, a solution of a water-soluble dye is injected into the arterial cannula in a volume of 20 to 150 ml; further, the identified interlobar border is marked with X-ray-positive objects; after that, an isolated left-sided lobar arterio-umbilical perfusion of the liver is performed in the following mode: perfusate flow rate 110-350 ml/min, duration 20-60 min, perfusate temperature 4-43°C; then, during perfusion, in order to control the spread of perfusate in the parenchyma and possible leakage, a water-soluble X-ray contrast solution with a total volume of 100-150 ml is injected and fluoroscopy is performed; after which, the preparation of the liver is subjected to research.

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