Résumé
Along with the increasing quantity of patients with end-stage liver diseases year by year, as an efficacious treatment, the safety and efficacy of liver transplantation are critical issues to be considered. In addition, liver transplant techniques have become a new research hot spot. In recent years, liver transplant techniques are constantly innovating and developing with the unremitting efforts of researchers. Researchers have successively developed multiple liver transplant techniques, such as split liver transplantation, ischemia-free liver transplantation, liver xenotransplantation, domino liver transplantation, delayed total hepatectomy combined with liver resection and segment Ⅱ-Ⅲ liver transplantation, heterotopic auxiliary liver transplantation on splenic fossa and magnetic anastomosis. It has laid a foundation for expanding the donor pool, improving clinical efficacy of liver transplantation and enhancing the quality of life of liver transplant recipients. In this article, the exploration, development, innovation and improvement of liver transplant techniques were reviewed and prospected, aiming to provide reference for clinical application of liver transplantation.
Résumé
Objective To develop a magnetic anastomosis device for infrahepatic inferior vena cava and verify its feasibility and safety in rat models. Methods According to the anatomical characteristics of rat inferior vena cava, a magnetic device suitable for end-to-end anastomosis of infrahepatic inferior vena cava was designed and manufactured. The device consisted of the inner and outer rings. The inner ring was a coated neodymium-iron-boron magnetic ring, and the outer ring was made of polyetheretherketone by 3D printing. Ten fine holes are evenly distributed on the outer ring, of which 5 fine holes were used to load the fine needles, and the other 5 fine holes were mutually connected with the fine needles of the contralateral anastomosis ring during anastomosis. The outer ring was uniformly loaded with fine needles and then bonded with the inner ring to form a magnetic anastomosis complex. Bilateral ends of vessels passed through the anastomosis ring and were fixed to the fine needles, and then end-to-end vascular anastomosis was performed by mutual attraction of two magnetic anastomosis rings. Twenty SD rats were selected and received end-to-end anastomosis of infrahepatic inferior vena cava with magnetic anastomosis device. The time of vascular occlusion, postoperative survival, postoperative anastomotic patency, gross observation and histological examination of anastomotic stoma were analyzed. Results All rats successfully completed end-to-end magnetic anastomosis of the infrahepatic inferior vena cava, and the time of vascular occlusion was 4~6 min. One rat died at 10 d after operation, and the other rats survived within postoperative 2 months. The patency rates of anastomotic stoma in surviving rats at postoperative 1 d, 3 d, 1 month and 2 months were 100%, 100%, 95% and 95%, respectively. At 2 months after operation, no obvious displacement and angulation of the anastomosis device were seen. No signs of corrosion and cracking of the anastomosis rings were observed. No evident hyperplasia and edema of surrounding tissues were noted. Bilateral ends of vessels were completely healed, and no obvious stenosis or thrombosis was found at the anastomotic stoma. Histological examination showed high continuity of bilateral vascular walls of anastomotic stoma, the inner surface of anastomotic stoma was covered by endothelial cells, and no thrombus or fibrous tissue was attached. Conclusions It is safe and feasible to utilize the self-designed magnetic anastomosis device to perform end-to-end magnetic anastomosis of infrahepatic inferior vena cava in rat models.
Résumé
Objective To evaluate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP)-based comprehensive minimally invasive treatment for biliary anastomotic stenosis (BAS) after liver transplantation. Methods Clinical data of 60 BAS recipients after liver transplantation were retrospectively analyzed, 54 male and 6 female, aged (48±10) years. ERCP was initially carried out. If it succeeded, plastic or metallic stents were placed into the biliary tract. If it failed, percutaneous transhepatic cholangial drainage (PTCD) or single-operator cholangioscopy (SpyGlass) was adopted to pass through the stenosis. If all these procedures failed, magnetic anastomosis or other special methods were delivered. The incidence and treatment of BAS after liver transplantation were summarized. The efficacy, stent removal and recurrence were observed. Results The median time of incidence of BAS after liver transplantation was 8 (4, 13) months. Within postoperative 1 year, 1-2 years and over 2 years, 39, 16 and 5 recipients were diagnosed with BAS, respectively. All 60 BAS recipients after liver transplantation were successfully treated, including 56 cases initially receiving ERCP, and 41 completing BAS treatment, with a success rate of 73%. The failure of guide wire was the main cause of ERCP failure. The success rates of PTCD, SpyGlass and magnetic anastomosis were 5/9, 5/7 and 7/8, respectively. Two recipients were successfully treated by percutaneous choledochoscope-assisted blunt guide wire technique and stent placement in the biliary and duodenal fistula. After 3 (3, 4) cycles of ERCP and 13 (8, 18) months of stent indwelling, 38 recipients reached the stent removal criteria, including 25 plastic stents and 13 metallic stents. The indwelling time of plastic stents was longer than that of metallic stents (P < 0.05). Six cases suffered from stenosis recurrence at 12 (8, 33) months after stent removal, and the recurrence rate was 16%. Six patients were treated with ERCP, and 5 of them did not recur after the stents were successfully removed. Multivariate analysis showed that delayed diagnosis of stenosis and frequent ERCP before stent removal were the independent risk factors for BAS recurrence (both P < 0.05). Conclusions ERCP-based comprehensive minimally invasive treatment may improve the success rate of BAS treatment after liver transplantation and yield satisfactory long-term efficacy. Delayed diagnosis of BAS and high frequent ERCP required for stent removal are the independent risk factors for BAS recurrence.
Résumé
Objective To invent a set of novel veno-venous bypass (VVB) device based on magnetic anastomosis technique which can be used in ex situ liver resection, and verify its clinical value and performance in animal models.Methods Each VVB device was constructed using three magnetic rings and an inverted Y-shaped tube with magnetic rings on each end.The magnetic ring was made of NdFeB with electrode cutting, and the tube was made of polyvinyl chloride (PVC) and preconditioned with heparin coating on the surface of the lumen.Ten dogs underwent the ex situ liver resection, and VVB was established via magnetic anastomosis technique with the novel VVB device during the operation.The time for completing VVB was recorded, and the hemodynamic indexes including the venous flow velocity, carotid pressure, central venous pressure and portal pressure was detected.The changes of intestinal lumen and kidney were also observed.Results It only took 6 ～ 10 minutes to establish VVB by the novel VVB device in the operation,and the hemodynamics stability was maintained smoothly during the anheptic phase.The shunt index of inferior vena cava and portal vein was 76.2％ and 75.5％, respectively.The congestion of intestinal canal and kidney were also alleviated during the anheptic phase.Conclusions It could reduce the time to establish VVB with magnetic anastomosis technique in ex situ liver resection.This study showed that utilizing the novel VVB device for intraabdominal VVB during the anheptic phase could be helpful to maintain the hemodynamics stability.