Department of Hepatobiliary Surgery, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shanxi Province, China; Third Deparmemt of General Surgery, The First Affiliated Hospital, Shihezi University, Shihezi, Xinjiang province, China.
J Surg Res. 2013 Dec;185(2):923-33. doi: 10.1016/j.jss.2013.07.025. Epub 2013 Aug 3.
In the first posttransplant month, the most frequent complications are due to technical problems related to complex vascular and bile duct reconstructions during the operation. Moreover, despite great improvements in suturing technique and materials, severe organ ischemia-reperfusion caused by time-consuming hand suturing is still an important factor in graft survival. During the operation, severe hypotension, hypoxic acidosis, hyperkalemia, and renal dysfunction may occur during the anhepatic phase due to the prolonged venous clamping time required for hand suturing. Therefore, hand suturing is a handicap in the development of further advancements in liver transplantation. In this study, we aimed to test a new "mechanical installation method" for rapid vascular reconstruction.
The magnetic pinning-ring device was developed consisting of paired magnetic rings coated with titanium oxide and embedded in a polypropylene shell. The rings were equipped with alternately spaced holes and titanium pins. Forty adult mongrel dogs were randomly divided into groups: A (n = 16), all vascular and bile duct reconstruction by magnetic ring without venous bypass; B (n = 16), all vascular and bile duct reconstruction by hand suturing with venous bypass; C (n = 8), sham transplantation group, transection of all vessels and common bile duct followed by anastomosis with the magnetic rings without liver transplantation. From groups A and B, dogs were randomly selected as donors (n = 8) or recipients (n = 8) of liver transplantations. We recorded operation time, vascular and bile duct anastomosis time, anhepatic time, administration of supplemental fluids during operation, and survival; blood samples were collected for the detection of liver damage (alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) and tumor necrosis factor α level. Patency was confirmed using ultrasound scans at various time points as late as 24 wk after surgery. Angiography was used to evaluate the anastomoses formed with magnetic rings. In group C, gross observation, histologic staining, and scanning electron microscopy were used to evaluate the vessels and bile ducts 12 wk postoperatively.
In group A, the total operation time, inferior vena cava, and portal vein anastomosis times were significantly shortened, and the anhepatic phase was reduced to about one-fifth that of group B, which was a significant difference between the two groups (P < 0.01). The mean total operative time was 2.54 ± 0.45 h. In order to maintain adequate blood pressure, the mean fluid volume infused was 800.56 ± 60.56 mL in the recipients of group A, which was lower than that in group B (2241.67 ± 390.78 mL, P < 0.01). Use of a pressor agent in group A was unnecessary. After operation, five of eight animals in group A survived more than 7 d after operation. The main cause of death was acute rejection. Only three of eight animals in group B survived more than 1 wk after operation due to chronic anastomotic bleeding, kidney failure, heart failure, and gastrointestinal bleeding. There was a statistically significant difference (P < 0.01) between the short-term survival rate in the two groups (75.0% versus 37.5%). The ALT (1544.46 ± 286.27) U/L and AST (1710.74 ± 252.27) U/L levels after operation in the animals with hand suturing were significantly higher than those in the sutureless group (ALT = 1116.41 ± 210.55 U/L; AST = 1176.95 ± 248.25) U/L after reperfusion (P < 0.01). The serum tumor necrosis factor α levels (45.56 ± 10.78) ng/L in group B were significantly higher than those of group A (26.64 ± 10.84) ng/L after reperfusion (P < 0.01). Re-endothelialization was confirmed in all vessels in group C, with neither formation of aneurysms nor thickening of the vascular wall noted after 12 wk. The bile duct anastomoses also healed well.
The magnetic pinning-ring device offers a simple, fast, reliable, and efficacious technique for nonsuturing vascular and bile duct anastomoses. Use of this device shortens operation time, maintains a high patency rate, and improves the healing of tissue. Application of the magnetic ring anastomosis technique can effectively reduce the complications caused by hand suturing, and can reduce the extent of ischemia-reperfusion injury, leading to smoother operations and improved prognosis.
在移植后的第一个月，最常见的并发症是由于手术中复杂的血管和胆管重建导致的技术问题。此外，尽管缝合技术和材料有了很大的改进，但由于耗时的手工缝合导致严重的器官缺血再灌注，仍然是移植后移植物存活的一个重要因素。在手术过程中，由于需要长时间的静脉夹闭，在手缝线过程中可能会发生严重的低血压、缺氧性酸中毒、高钾血症和肾功能障碍。因此，手工缝合是肝移植进一步发展的障碍。在这项研究中，我们旨在测试一种新的“机械安装方法”，用于快速血管重建。
我们开发了一种磁性钉环装置，由涂有氧化钛的成对磁性环和嵌入聚丙烯壳组成。这些环配备了交替间隔的孔和钛钉。40 只成年杂种狗被随机分为三组：A 组（n = 16），所有血管和胆管均通过无静脉旁路的磁性环重建；B 组（n = 16），所有血管和胆管均通过带静脉旁路的手工缝合重建；C 组（n = 8），假手术组，所有血管和胆总管均横断，然后用无肝移植的磁性环吻合。从 A 组和 B 组中随机选择供体（n = 8）或受体（n = 8）进行肝移植。我们记录手术时间、血管和胆管吻合时间、无肝时间、手术期间补充液体的用量和存活率；采集血样检测肝损伤（丙氨酸氨基转移酶[ALT]和天冬氨酸氨基转移酶[AST]）和肿瘤坏死因子α水平。术后不同时间点使用超声扫描确认通畅性，最晚可达 24 周。使用血管造影术评估磁性环形成的吻合口。在 C 组中，术后 12 周使用大体观察、组织染色和扫描电子显微镜评估血管和胆管。
在 A 组中，总手术时间、下腔静脉和门静脉吻合时间明显缩短，无肝时间减少到 B 组的约五分之一，两组之间有显著差异（P < 0.01）。平均总手术时间为 2.54 ± 0.45 小时。为了维持足够的血压，A 组受体的平均液体输注量为 800.56 ± 60.56 mL，低于 B 组（2241.67 ± 390.78 mL，P < 0.01）。A 组不需要使用升压剂。术后，A 组 8 只动物中有 5 只存活超过术后 7 天。主要死亡原因是急性排斥反应。由于慢性吻合口出血、肾衰竭、心力衰竭和胃肠道出血，B 组只有 3 只动物存活超过 1 周。两组的短期生存率有统计学差异（P < 0.01）（75.0%对 37.5%）。手缝线组术后丙氨酸氨基转移酶（1544.46 ± 286.27）U/L 和天冬氨酸氨基转移酶（1710.74 ± 252.27）U/L 水平明显高于无缝线组（丙氨酸氨基转移酶= 1116.41 ± 210.55 U/L；天冬氨酸氨基转移酶= 1176.95 ± 248.25）U/L 再灌注后（P < 0.01）。B 组术后血清肿瘤坏死因子α水平（45.56 ± 10.78）ng/L 明显高于 A 组（26.64 ± 10.84）ng/L 再灌注后（P < 0.01）。C 组所有血管均证实再内皮化，12 周后未见动脉瘤形成或血管壁增厚。胆管吻合口也愈合良好。
磁性钉环装置提供了一种简单、快速、可靠、有效的非缝合血管和胆管吻合技术。使用该装置可缩短手术时间，保持较高的通畅率，促进组织愈合。磁性环吻合技术的应用可有效减少手工缝合引起的并发症，减轻缺血再灌注损伤程度，使手术更加顺利，预后更好。
