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Zhang L, Ipaktchi R, Ben Brahim B, Arenas Hoyos I, Jenni H, Dietrich L, Despont A, Shaw-Boden J, Büttiker S, Siegrist D, Gultom M, Parodi C, Garcia Casalta L, Petrucci M, Petruccione I, Mirra A, Nettelbeck K, Wang J, de Brot S, Voegelin E, Casoni D, Rieben R. Prolongation of the Time Window From Traumatic Limb Amputation to Replantation From 6 to 33 Hours Using Ex Vivo Limb Perfusion. Mil Med 2024; 189:83-92. [PMID: 39160844 DOI: 10.1093/milmed/usae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/18/2024] [Accepted: 02/06/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Continuous extracorporeal perfusion (ECP), or machine perfusion, holds promise for prolonged skeletal muscle preservation in limb ischemia-reperfusion injury. This study aimed to extend the amputation-to-replantation time window from currently 6 hours to 33 hours using a 24-hour ECP approach. MATERIALS AND METHODS Six large white pigs underwent surgical forelimb amputation under general anesthesia. After amputation, limbs were kept for 9 hours at room temperature and then perfused by 24-hour ECP with a modified histidine-tryptophan-ketoglutarate (HTK) solution. After ECP, limbs were orthotopically replanted and perfused in vivo for 12 hours. Clinical data, blood, and tissue samples were collected and analyzed. RESULTS All 6 forelimbs could be successfully replanted and in vivo reperfused for 12 hours after 9 hours of room temperature ischemia followed by 24 hours ECP. Adequate limb perfusion was observed after replantation as shown by thermography and laser Doppler imaging. All pigs survived without severe organ failure, and no significant increase in inflammatory cytokines was found. Macroscopy and histology showed marked interstitial muscular edema of the limbs, whereas myofiber necrosis was not evident, implying the preservation of muscular integrity. CONCLUSIONS The use of a 24-hour ECP has successfully extended limb preservation to 33 hours. The modified histidine-tryptophan-ketoglutarate perfusate demonstrated its ability for muscle protection. This innovative approach not only facilitates limb replantation after combat injuries, surmounting geographical barriers, but also broadens the prospects for well-matched limb allotransplants across countries and continents.
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Affiliation(s)
- Lei Zhang
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
- Department of Plastic- and Hand Surgery, Inselspital, Bern University Hospital, Bern 3010, Switzerland
| | - Ramin Ipaktchi
- Department of Plastic- and Hand Surgery, Inselspital, Bern University Hospital, Bern 3010, Switzerland
| | - Bilal Ben Brahim
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
| | - Isabel Arenas Hoyos
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
- Department of Plastic- and Hand Surgery, Inselspital, Bern University Hospital, Bern 3010, Switzerland
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern 3010, Switzerland
| | - Lena Dietrich
- Department of Plastic- and Hand Surgery, Inselspital, Bern University Hospital, Bern 3010, Switzerland
| | - Alain Despont
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
| | - Jane Shaw-Boden
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
| | - Svenja Büttiker
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
| | - David Siegrist
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
| | - Mitra Gultom
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
| | - Chiara Parodi
- Experimental Surgery Facility, EAC, University of Bern, Bern 3010, Switzerland
| | | | | | - Ilaria Petruccione
- Experimental Surgery Facility, EAC, University of Bern, Bern 3010, Switzerland
| | - Alessandro Mirra
- Section of Anaesthesiology and Pain Therapy, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern 3012, Switzerland
| | - Kay Nettelbeck
- Experimental Surgery Facility, EAC, University of Bern, Bern 3010, Switzerland
| | - Junhua Wang
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
| | - Simone de Brot
- COMPATH, Institute of Animal Pathology, University of Bern, Bern 3012, Switzerland
| | - Esther Voegelin
- Department of Plastic- and Hand Surgery, Inselspital, Bern University Hospital, Bern 3010, Switzerland
| | - Daniela Casoni
- Experimental Surgery Facility, EAC, University of Bern, Bern 3010, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, DBMR, University of Bern, Bern 3008, Switzerland
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Berkane Y, Lellouch AG, Goudot G, Shamlou A, Filz von Reiterdank I, Goutard M, Tawa P, Girard P, Bertheuil N, Uygun BE, Randolph MA, Duisit J, Cetrulo CL, Uygun K. Towards Optimizing Sub-Normothermic Machine Perfusion in Fasciocutaneous Flaps: A Large Animal Study. Bioengineering (Basel) 2023; 10:1415. [PMID: 38136006 PMCID: PMC10740951 DOI: 10.3390/bioengineering10121415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/23/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Machine perfusion has developed rapidly since its first use in solid organ transplantation. Likewise, reconstructive surgery has kept pace, and ex vivo perfusion appears as a new trend in vascularized composite allotransplants preservation. In autologous reconstruction, fasciocutaneous flaps are now the gold standard due to their low morbidity (muscle sparing) and favorable functional and cosmetic results. However, failures still occasionally arise due to difficulties encountered with the vessels during free flap transfer. The development of machine perfusion procedures would make it possible to temporarily substitute or even avoid microsurgical anastomoses in certain complex cases. We performed oxygenated acellular sub-normothermic perfusions of fasciocutaneous flaps for 24 and 48 h in a porcine model and compared continuous and intermittent perfusion regimens. The monitored metrics included vascular resistance, edema, arteriovenous oxygen gas differentials, and metabolic parameters. A final histological assessment was performed. Porcine flaps which underwent successful oxygenated perfusion showed minimal or no signs of cell necrosis at the end of the perfusion. Intermittent perfusion allowed overall better results to be obtained at 24 h and extended perfusion duration. This work provides a strong foundation for further research and could lead to new and reliable reconstructive techniques.
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Affiliation(s)
- Yanis Berkane
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
- Shriners Children’s Boston, Boston, MA 02114, USA
- SITI Laboratory, UMR1236, INSERM, Université de Rennes, 35000 Rennes, France
| | - Alexandre G. Lellouch
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Innovative Therapies in Haemostasis, INSERM UMR-S 1140, University of Paris, 75006 Paris, France
| | - Guillaume Goudot
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA;
- INSERM U970 PARCC, Université Paris Cité, 75000 Paris, France
| | - Austin Shamlou
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Irina Filz von Reiterdank
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02115, USA
- University Medical Center Utrecht, 3584 Utrecht, The Netherlands
| | - Marion Goutard
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- SITI Laboratory, UMR1236, INSERM, Université de Rennes, 35000 Rennes, France
| | - Pierre Tawa
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Paul Girard
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
- SITI Laboratory, UMR1236, INSERM, Université de Rennes, 35000 Rennes, France
| | - Basak E. Uygun
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02115, USA
| | - Mark A. Randolph
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Jérôme Duisit
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
- Iris South Hospitals, 1040 Brussels, Belgium
| | - Curtis L. Cetrulo
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Korkut Uygun
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02115, USA
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