Hypothermic in situ perfusion of the porcine liver using Celsior or Ringer-lactate solution

Complex liver resection under hepatic vascular exclusion and hypothermic perfusion with versus without veno-venous bypass: a comparative study

BACKGROUND

While hypothermic liver perfusion has been shown to improve parenchymal tolerance to complex resections in patients requiring prolonged hepatic vascular exclusion (HVE), the benefit of associated veno-venous bypass (VVB) in this setting remains poorly evaluated.

METHODS

All patients undergoing liver resection requiring HVE and hypothermic liver perfusion for at least 55 min between 2006 and 2017 were retrospectively reviewed. Perioperative outcomes were compared between patients with (VVB+) or without VVB (VVB-).

RESULTS

Twenty-seven patients were analyzed, including 13 VVB+ and 14 VVB-. Median HVE duration was similar in VVB+ and VVB- patients (96 vs. 75 min, respectively). VVB+patients had longer operative time (460 vs. 375 min, p = 0.023) but less blood loss (p = 0.010). Five (19%) patients died postoperatively from liver failure or sepsis, without difference between groups. Postoperative major morbidity rate was similar between VVB+ and VVB- patients (30% vs. 50%, respectively) such as rates of liver failure, haemorrhage, renal insufficiency and sepsis, but VVB- patients experienced more respiratory complications (64% vs. 15%, p = 0.012).

CONCLUSION

During liver resection under HVE and hypothermic liver perfusion, use of VVB allows for reducing blood loss and postoperative respiratory complications. VVB should be recommended in case of liver resection with prolonged HVE.

Protective Mechanisms of Hypothermia in Liver Surgery and Transplantation

Hepatic ischemia/reperfusion (I/R) injury is a side effect of major liver surgery that often cannot be avoided. Prolonged periods of ischemia put a metabolic strain on hepatocytes and limit the tolerable ischemia and preservation times during liver resection and transplantation, respectively. In both surgical settings, temporarily lowering the metabolic demand of the organ by reducing organ temperature effectively counteracts the negative consequences of an ischemic insult. Despite its routine use, the application of liver cooling is predicated on an incomplete understanding of the underlying protective mechanisms, which has limited a uniform and widespread implementation of liver-cooling techniques. This review therefore addresses how hypothermia-induced hypometabolism modulates hepatocyte metabolism during ischemia and thereby reduces hepatic I/R injury. The mechanisms underlying hypothermia-mediated reduction in energy expenditure during ischemia and the attenuation of mitochondrial production of reactive oxygen species during early reperfusion are described. It is further addressed how hypothermia suppresses the sterile hepatic I/R immune response and preserves the metabolic functionality of hepatocytes. Lastly, a summary of the clinical status quo of the use of liver cooling for liver resection and transplantation is provided.

Presumed and actual concentrations of reduced glutathione in preservation solutions

Reduced glutathione (GSH), an important radical scavenger, has been added to various organ preservation solutions. Because GSH oxidizes into oxidized glutathione (GSSG) and only GSH has scavenging capacity, only GSH in the solution at the time of clinical use is relevant. The concentrations of GSH (GSH(conc)) and GSSG(conc) were determined in 2 static preservation solutions--University of Wisconsin (UW) and Celsior--and in 1 machine preservation solution--Kidney Preservation Solution 1 (KPS-1). We determined the half-life (T(1/2)) of freshly added GSH. The GSH(conc) in UW and KPS-1 was 0.006 ± 0.0018 mmol/L and 0.13 ± 0.30 mmol/L, respectively. The GSH(conc) in Celsior was 2.7 ± 0.17 mmol/L. The manufacturers of these solutions reported 3 mmol/L GSH. GSSG(conc) in UW, KPS-1, and Celsior was 1.58 ± 0.61 mmol/L, 1.13 ± 0.16 mmol/L, and 0.24 ± 0.01 mmol/L, respectively. T(1/2) of GSH in UW, KPS-1, and Celsior was 18 days, 86 days, and 83 days, respectively. The actual GSH(conc) in UW and KPS-1 at the time of clinical use was substantially lower than reported by the manufacturer, owing to the relatively short T(1/2) of GSH. For Celsior, the GSH(conc) was maintained. Therefore, addition of fresh GSH to UW and KPS-1 before clinical use is recommended.

Hepatic ischemia and reperfusion injury and trauma: current concepts

Context

Ischemia-reperfusion injury is a fascinating topic which has drawn a lot of interest in the last several years. Hepatic ischemia reperfusion injury may occur in a variety of clinical situations. These include transplantation, liver resection, trauma, and vascular surgery.

Evidence Acquisition

The purpose of this review was to outline the molecular mechanisms underlying hepatic I/R injury and present the latest approaches, both surgical and pharmacological, regarding the prevention of it. A comprehensive electronic literature search in MEDLINE/PubMed was performed to identify relative articles published within the last 2 years.

Results

The basic mechanism of hepatic ischemia – reperfusion injury is one of blood deprivation during ischemia, followed by the return of flow during reperfusion. It involves a complex series of events, such as mitochondrial deenergization, adenosine-5'-triphosphate depletion, alterations of electrolyte homeostasis, as well as Kupffer cell activation, oxidative stress changes and upregulation of proinflammatory cytokine signaling. The great number of variable pathways, with several mediators interacting with each other, leads to a high number of candidates for potential therapeutic intervention. As far as surgical approaches are concerned, the modification of existing clamping techniques and the ischemic preconditioning are the most promising techniques till recently. In the search for novel techniques of protecting against hepatic ischemia reperfusion injury, many different strategies have been used in experimental models. The biggest part of this research lies around antioxidant therapy, but other potential solutions have been explored as well.

Conclusions

The management of hepatic trauma, in spite of the fact that it has become increasingly nonoperative, there still remains the possibility of hepatic resection in the hepatic trauma setting, especially in severe injuries. Hence, clinicians should be familiar with the concept of hepatic ischemia-reperfusion injury and respond appropriately and timely.

Efficacy of liver graft washout as a function of the perfusate, pressure, and temperature

Donor graft washout can be impaired by colloids in organ preservation solutions that increase the viscosity and agglutinative propensity of red blood cells (RBCs) and potentially decrease organ function. The colloid-induced agglutinative effects on RBCs and RBC retention after liver washout with Ringer's lactate (RL), histidine tryptophan ketoglutarate solution, University of Wisconsin solution, and Polysol were determined as a function of the washout pressure (15 or 100 mm Hg) and temperature (4 or 37°C) in a rat liver washout model with (99m) Tc-pertechnetate-labeled RBCs. Colloids (polyethylene glycol in Polysol and hydroxyethyl starch in University of Wisconsin) induced RBC agglutination, regardless of the solution's composition. RL was associated with the lowest degree of (99m) Tc-pertechnetate-labeled RBC retention after simultaneous arterial and portal washout at 37°C and 100 mm Hg. RL washout was also associated with the shortest washout time. A single portal washout with any of the solutions did not result in differences in the degree of RBC retention, regardless of the temperature or pressure. In conclusion, no differences were found in portal washout efficacy between colloidal solutions, histidine tryptophan ketoglutarate, and RL. Simultaneous arterial and portal washout with RL at 37°C and 100 mm Hg resulted in the least RBC retention and the shortest washout time.

Liver resection under hypothermic total vascular exclusion

Despite progress in the field of liver surgery, centrally located tumors that involve the inferior vena cava or the hepatic veins adjacent to the vena cava are a technical challenge. These patients usually need to be operated upon under total vascular exclusion to prevent massive blood loss. The duration of vascular exclusion often exceeds the maximum permissible warm ischemia time tolerated by the liver, particularly when vascular reconstructions are necessary as part of the resection. The role of hypothermia as an adjunct to total vascular exclusion (TVE) was first introduced in 1974 but is used infrequently. A clearer understanding of this technique might allow clinicians to consider tumors in these awkward situations for resection. Additional techniques that may extend the benefits of hypothermic TVE are ante situm and ex vivo resections with autotransplantation. This review discusses the role of hypothermic TVE in the modern management of liver tumors.

Resection of an intra-operative ruptured hepatocellular carcinoma with continuous pringle maneuver and in situ hypothermic perfusion through the inferior mesenteric vein: a case report

Intra-operative tumor rupture is a serious complication during resection of large hepatocellular carcinoma (HCC) leading to more blood loss. We report our experience in applying continuous Pringle maneuver with in situ hypothermic perfusion via inferior mesenteric vein catheterization to the portal vein of the remnant liver for resection during an extended left lobectomy of a large HCC which ruptured intraoperatively. Using this method, we successfully managed the patient without any further morbidity. This technique provides easier accessibility of in situ perfusion, decreases operative blood loss and prevents warm ischemic injury to the remnant liver during parenchymal transection. This method could be effective for the resection of large ruptured HCC.

[Prevention of normothermic hepatic ischemia during in situ liver perfusion with three different preservation solutions: experimental analysis by realtime infrared radiation thermography]

OBJECTIVE

To establish the usefulness of infrared radiation thermography on monitoring in situ liver perfusion with different preservation solutions during liver harvesting.

METHODS

Twenty-four adult male Wistar rats, weighing 385.31 g were randomly divided into four groups of six animals each according to the solution used to perfuse the liver (Euro-Collins® solution--EC group; Custodiol® solution--CUST group; Celsior® solution--CEL group and Ringer-Lactate solution--RL group). Under inhalatory ether anesthesia, animals were submitted to upper transversal laparotomy, exposure of median and left-lateral hepatic lobes, heparin injection (500 UI/Kg) through infrahepatic vena cava, portal vein infusion through 18G catheter of cold (4°C) solution according to the group of study. Infrared images, with respective temperature evaluations from hepatic surface, were picked up in real time by Therma CAM SC500® infrared camera positioned at constant distance from three fixed points of the diaphragmatic surface of median and left lateral lobes at the following moments regarding liver perfusion: immediately after laparotomy; after portal vein cannulation and immediately before solution infusion; at each minute from the beginning of liver perfusion during five minutes. Mean temperatures of each moment were compared intra and intergroups with the difference between means test with normal distribution, with significance level of 5% (p=0.05).

RESULTS

There was statistically significant difference of means temperatures between the moment of laparotomy and immediately after cannulation; between this later and after the first minute of perfusion; and between the first and fifth minutes of infusion in all groups of study in a similar way. CEL group showed additional difference between the first and second minutes means temperatures. Intergroup comparison showed Euro-Collins solution with significant less cooling power when compared to all others solutions.

CONCLUSION

It was possible to follow the liver cooling process during preservation solutions perfusion using infrared radiation images. Preservation solutions had similar behaviors, with Celsior® solution showing additional cooling power until the second minute of perfusion. Euro-Collins solution had less cooling power than other solutions studied.

In situ hypothermic liver preservation during radical liver resection with major vascular reconstruction

BACKGROUND

The in situ hypothermic liver preservation technique may allow a more aggressive approach to tumours of the caval confluence and/or all three hepatic veins, which would otherwise be deemed irresectable.

METHODS

All descriptive data regarding patient demographics, operative characteristics, perioperative complications and outcomes of nine patients in whom this technique was used were collected prospectively.

RESULTS

Seven patients underwent liver trisegmentectomy and two had primary retrohepatic venal caval resection. Total hepatic vascular occlusion with in situ hypothermic liver preservation was used for venous reconstruction in all patients. The vena cava was reconstructed with prosthetic graft in seven patients. All main hepatic veins were reconstructed in the seven liver resections. In situ hypothermic liver preservation was well tolerated as evidenced by preserved hepatic synthetic function early after operation. One patient died 66 days after surgery. There were two recurrences after a median follow-up of 14 (range 2-33) months; local recurrence was identified in one patient after 4 months and distant metastasis in another after 8 months.

CONCLUSION

The in situ hypothermic liver preservation technique appears to be a useful adjunct to radical hepatobiliary tumour excision procedures that require total hepatic vascular exclusion and major vascular reconstruction.

Hypoxic single-pass isolated hepatic perfusion of hypotonic Cisplatin: safety study in the pig

BACKGROUND

Isolated hepatic perfusion (IHP) of chemotherapy has been proposed to deliver high doses of drug while avoiding systemic toxicity. Hypotonic cisplatin has a high in vitro activity on human colon cancer cells. We studied the safety of a 30-min hypoxic single-pass IHP with hypotonic cisplatin.

METHODS

A preliminary in vitro assay was performed to compare the cytotoxicity of cisplatin and oxaliplatin, in either a normotonic or hypotonic medium. Cisplatin in hypotonic medium was then chosen for the in vivo IHP. Eleven pigs underwent 30 min of IHP with 0, 50, 75, or 100 mg/L of cisplatin in a hypotonic solution under total vascular exclusion of the liver. Clinical and biological parameters were recorded for 30 days, and liver histology was performed at necropsy. The cytotoxic activity of the effluent against resistant human colon cancer cells was tested in vitro.

RESULTS

No hepatic failure was recorded after IHP with cisplatin, but limited foci of necrosis were found at necropsy in animals receiving 75 or 100 mg/L of cisplatin. No clinical, biological, macroscopic, or microscopic toxicity was observed after IHP with 50 mg/L of hypotonic cisplatin. The liver effluent showed high in vitro cytotoxic activity against colon cancer cells.

CONCLUSIONS

A hypoxic single-pass isolated liver perfusion with hypotonic cisplatin is feasible and safe. Effluent from the liver is highly cytotoxic on cancer cells. A clinical study with 50 mg/L of hypotonic cisplatin is warranted in patients with unresectable liver metastases from colon cancer.