Wan Ismail Wan Faisham Numan B, Bin Wan Sulaiman Wan Azman, Saad Arman Zaharil Bin Mat, Mokthar Ariffin Marzuki Bin, Paiman Mohammad Bin, Jusoh Mohd Hanifah Bin, Mamat Ahmad Zuhdi Bin, Eu Chong Soon
Department of Orthopaedic, Hospital USM, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia.
Department of Reconstructive Sciences, Hospital USM, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia.
Microsurgery. 2023 Oct;43(7):722-729. doi: 10.1002/micr.31086. Epub 2023 Jul 10.
Replantation of amputated limbs after long ischemic hours almost always comes with reperfusion syndrome and poor outcomes. An ischemic time of greater than 6 h is often considered unsuitable for major limb replantation. However, usage of extracorporeal perfusion has been shown to prolong the viability of major limbs in animal studies. The aim of this report is to show that extracorporeal perfusion with cardiopulmonary bypass machine (CPBM) is a safe and reliable technique in improving limb survival as illustrated by our cases. We report two cases of successful major limb replantation with late presentation. One case involved a 31-year-old man with shoulder disarticulation and the other involved a 30-year-old man sustained proximal transtibial amputation. Both patients, who were generally fit, were involved in major road traffic accidents. The amputated segments were connected to a CPBM to expedite reperfusion and to flush away anaerobic metabolic products. The major vessels were cannulated and connected to a bypass machine that was initially primed with heparinized saline and perfused with packed cells at 100% oxygen concentration. The perfusion was carried out at 35°C with low pressure to prevent edema and low flow to reduce reperfusion injury. Venous blood was drained completely before replantation. Total ischemia times were 7 h 40 min and 9 h, respectively. No evidences of perioperative reperfusion syndrome were seen. Both of the replanted limbs survived and patients had regained better-than-expected limb functional outcomes at 5-year and 2-year follow-up, respectively. CPBM may be safely used in major replantation surgery to enhance limb survival and therefore warrants further research.
长时间缺血后进行断肢再植几乎总会伴有再灌注综合征且预后不佳。缺血时间超过6小时通常被认为不适于进行大肢体再植。然而，在动物研究中，体外灌注已被证明可延长主要肢体的存活时间。本报告的目的是表明，如我们的病例所示，使用心肺旁路机（CPBM）进行体外灌注是一种安全可靠的提高肢体存活率的技术。我们报告两例大肢体延迟再植成功的病例。一例为一名31岁男性，肩部离断；另一例为一名30岁男性，胫骨近端截肢。两名患者身体状况总体良好，均遭遇重大道路交通事故。将离断肢体连接到CPBM以加快再灌注并冲走无氧代谢产物。主要血管插管并连接到一台旁路机，该旁路机最初用肝素化盐水预充，并以100%氧气浓度灌注浓缩红细胞。在35°C下进行低压灌注以防止水肿，低流量灌注以减少再灌注损伤。再植前将静脉血完全引流。总缺血时间分别为7小时40分钟和9小时。未观察到围手术期再灌注综合征的迹象。再植的肢体均存活，患者在分别随访5年和2年时，肢体功能恢复情况均好于预期。CPBM可安全用于大肢体再植手术以提高肢体存活率，因此值得进一步研究。
