Chirurgia (Bucur). 2021 Aug;116(4):451-465. doi: 10.21614/chirurgia.116.4.451.
The need to maximize the use of donor organs and the issue of ischemia-reperfusion injury led to the use of thermoregulated oxygenated machine perfusion that improves the function of liver graft prior to transplantation. Among these methods, the HOPE (hypothermic oxygenated perfusion) protocol shows significant benefits. The aim of the paper is to analyze the early experience in using such procedure in a high-volume liver transplantation center. Normal liver grafts with cold ischemia time â?¥6 hours, marginal grafts and discarded (beyond ECD criteria) grafts were perfused using HOPE. Our selection criteria for dual HOPE (hepatic artery and portal perfusion) were steatosis, at least 3 associated ECD criteria, and discarded grafts. The main criteria to establish graft improvement were the progressive increase of arterial and portal flows, with lactate under 3 mmol/L or, even if over this value, with a decreasing trend during perfusion. Whole liver grafts harvested from 28 donors between February 2016 and June 2021 benefitted from HOPE: 9 otherwise discarded grafts were assessed and considered not fit for transplantation, while the other 19 were ECD or standard grafts that were subsequently transplanted. Dual HOPE was used in 8 out of the 19 procedures (42.1%). We obtained a significant increase of arterial and portal flow (p=0.005 and p=0.001, respectively). In recipients, significant improvement of AST, ALT, INR and lactate values were recorded (p 0.001, p 0.001, p 0.001, and p=0.05, respectively). The rate of major postoperative complications (Dindo-Clavien grade 3) after LT was 26.3%, while the rate of early graft dysfunction was 15.8%. No PRS or acute rejection was recorded. The postoperative mortality rate was 15.8%. After a median follow-up of 9.3 months (range 2-44), the late major complication rate was 15.8%, without mortality. Conclusion: Machine perfusion is nowadays part of current clinical practice. This way, marginal liver grafts (DCD, ECD-DBD) may be safely used for transplantation improving the outcome, thus effectively enhance the use of a persistent scarce pool of donors. For best results, we believe that both techniques of HOPE (mono and dual HOPE) should be used based on specific selection criteria.
需要最大限度地利用供体器官，解决缺血再灌注损伤问题，这导致了使用热调节充氧机器灌注，以改善移植前肝移植物的功能。在这些方法中，HOPE（低温充氧灌注）方案显示出显著的益处。本文的目的是分析在一个大容量肝移植中心使用这种方法的早期经验。冷缺血时间 â?Â¥6 小时的正常肝移植物、边缘供体和废弃（超出 ECD 标准）的移植物使用 HOPE 进行灌注。我们进行双 HOPE（肝动脉和门静脉灌注）的选择标准是脂肪变性、至少 3 个相关的 ECD 标准和废弃的移植物。确定移植物改善的主要标准是动脉和门静脉流量的逐渐增加，乳酸低于 3mmol/L，或者即使超过该值，在灌注过程中呈下降趋势。2016 年 2 月至 2021 年 6 月期间，从 28 名供体中采集的整个肝移植物受益于 HOPE：9 个原本废弃的移植物被评估为不适合移植，而其他 19 个是 ECD 或标准移植物，随后进行了移植。在 19 例手术中，有 8 例（42.1%）采用了双 HOPE。我们观察到动脉和门静脉流量显著增加（p=0.005 和 p=0.001）。在接受者中，AST、ALT、INR 和乳酸值的显著改善也被记录下来（p 0.001，p 0.001，p 0.001，p=0.05）。LT 后主要术后并发症（Dindo-Clavien 3 级）的发生率为 26.3%，而早期移植物功能障碍的发生率为 15.8%。未记录到 PRS 或急性排斥反应。术后死亡率为 15.8%。中位随访 9.3 个月（2-44 个月）后，晚期主要并发症发生率为 15.8%，无死亡。结论：机器灌注现在是当前临床实践的一部分。这样，边缘肝移植物（DCD、ECD-DBD）可以安全地用于移植，改善预后，从而有效地增加持续稀缺的供体资源的利用。为了获得最佳效果，我们认为应该根据具体的选择标准，同时使用 HOPE 的两种技术（单 HOPE 和双 HOPE）。
