猪原位肝移植围手术期管理

Peri - operative management of swine orthotopic liver transplantation

目的 总结猪原位肝移植围手术期管理经验.方法 项目组自2013年9月至2016年8月共使用巴马小型猪124只,实施各类原位肝移植术62例,其中标准原位肝移植30例,劈离式肝移植10例,心脏死亡捐献（DCD）供肝肝移植11例,经体外膜肺氧合（ECMO）修复后DCD供肝肝移植5例,经常温机械灌注（NMP）修复后DCD供肝肝移植6例.结果 124例供、受体手术中121例气管插管顺利,3例出现插管失败行气管切开术.62例不同术式肝移植,无肝期时间近似18～26 min,平均（22.3±2.6）min,未使用任何血管活性药物,通过快速的胶体输注,可以维持平均动脉压（MAP） ≥50 mmHg（1 mmHg =0.133 kPa）.术中因出血死亡5例,均为劈离式肝移植.肝移植术后共死亡14例,其中标准原位肝移植3例,均为项目组早期建立动物模型阶段,1例死于腹腔出血,2例死于胆漏腹腔感染;DCD供肝肝移植11例,均死于模型本身造成的肝功能衰竭.术后5d存活率：标准原位肝移植90％,劈离式肝移植50％,DCD供肝肝移植0％,经ECMO修复后DCD供肝肝移植100％,经NMP修复后DCD供肝肝移植100％.结论 精细的围手术期管理是猪原位肝移植成功的保证,其中熟练掌握猪气管插管及气管切开术,精确的液体管理,动物模型的成熟建立,尽量缩短无肝期时间是围手术期管理的关键.

Objective To summarize the peri-operative management experience of swine orthotopic liver transplantation.Methods From September 2013 to August 2016,62 liver transplantations （LT） were performed with 124 Bama mini-pigs,including 30 cases of standard LT,10 cases of split LT,11 cases of donation after cardiac death （DCD） LT,5 cases of extracorporeal membrane oxygenation （ECMO） repaired DCD LT and 6 cases of normothermic machine perfusion （NMP） repaired DCD LT.Results For all of the 124 pigs,3 underwent tracheotomy after failed tracheal intubation.Anhepatic time was （22.3 ±2.6） min （range 18-26 min）,similar among the 62 different type LTs.Mean arterial pressure could be mainted ≥ 50 mmHg （1 mmHg =0.133 kPa） through rapid colloid solution infusion without administration of any vasoactive substances.5 receipts of split LTs died during the operation because of bleeding.14 cases died after operation.3 were of standard LT,all in the very beginning period when we first build this animal model,1 died of abdominal bleeding,the other 2 died of bile leak induced severe infection.11 cases from the DCD LT died of model related hepatic failure.Post-operative 5-day survival rates of standard,split,DCD,ECMO-repaired DCD,NMP-repaired DCD were 90%,50%,0%,100%,100%,respectively.Conclusion Precise peri-operative management is essential for successful swine orthotopic liver transplantation.Skilled trachea intubation and tracheotomy procedure,accurate liquid management,well-practiced animal model are the key points,and anhepatic period should be shortened as much as possible.