Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.
Liver Transpl. 2019 Nov;25(11):1690-1699. doi: 10.1002/lt.25592. Epub 2019 Sep 26.
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
在原位肝移植（OLT）中，使用临时门腔分流术（TPCS）以及再灌注顺序（初始动脉再灌注[IAR]与初始门脉再灌注）存在争议，因此仍在讨论中。本研究旨在评估 4 种可能组合（TPCS 联合 IAR、TPCS 联合初始门脉再灌注、无 TPCS 联合 IAR、无 TPCS 联合初始门脉再灌注）在基于中心的队列研究中的结果，该研究包括来自脑死亡供体和循环死亡供体（DCD）的肝移植。主要结局是围手术期红细胞（RBC）输注，次要结局是手术时间和患者及移植物存活率。2005 年 1 月至 2017 年 5 月，我院所有首次 OLT 均纳入上述 4 组。IAR 和 TPCS 联合应用可显著减少围手术期 RBC 输注（P<0.001），且无需输注 RBC 的受者比例也更高（P<0.001）。多变量分析显示，实验室终末期肝病模型（MELD）评分（P<0.001）和 IAR（P=0.01）是 RBC 输注的独立决定因素。在比较所有组时，尽管 A+S+组中更多的 LT 来自 DCD 供体，但手术时间或 1 年患者和移植物存活率均无统计学差异（P=0.005）。总之，除了实验室 MELD 评分较低外，IAR 的使用还显著降低了围手术期输血的需求。IAR 和 TPCS 之间没有显著的相互作用。此外，使用 TPCS 和/或 IAR 不会导致手术时间延长，因此是一种合理的替代手术策略。
