Orthotopik karaciğer transplantasyonunda total porta kaval klempaj ve lateral klempaj tekniklerinin peroperatuvar dönemde hemodinamik etkilerinin karşılaştırmalı olarak araştırılması

Abstract

ÖZET Son yıllarda orjinal bir teknik olarak side to side kava-kaval anastomoz veya lateral klempaj tekniklerinin İVC'nın tam olarak oklüze olmasını engelliyerek karaciğer transplantasyon vakalarında kaval rekonstrüksiyonu sağladığı belirtilmiştir. Böylece kaval akım tüm işlem süresince korunmuş ve venöz bypass uygulanmasına gerek kalmamıştır. Çalışmamızda tüm karaciğer transplantasyon süresinde, Total Porta Kaval Klempaj (VVB'lı veya VVB'sız) veya Lateral Klempaj (temporary porta kaval şantlı TPCS'li veya TPCS'siz) tekniklerinin hemodinamik parametrelerini karşılaştırmayı amaçladık. Çalışma 01.01.1994-30.08.1995 tarihleri arasında Paris-Paul Brousse Hastanesi, Hepato-Bilier merkezinde son dönem karaciğer yetmezliği bulunan 40 hastada yapıldı. Her dört grupta; indüksiyondan iki saat sonra (Zı) anhepatik devre başlangıcından 5 dakika sonra (Z2), anhepatik devrenin sonlandırılmasından beş dakika önce (Z3) İVC ve PV'in deklempajından sanraki ilk beş dakika içersinde (Z4) ve PV'in deklempajından sonraki 60 dakika içersinde (Z4) intraoperatif olarak KH, OAB, OPAB, PKAB, SVB, Kİ, SVR, PVR, saatlik idrar çıkışı, K+, Ca++, pH, HC03`1 ısı parametreleri moniterize edildi. Ayrıca intraoperatif kan ve plazma kullanımı 40 karaciğer transplant hastasında kaydedildi. Lateral klempajın yapıldığı dördüncü grupta, anhepatik devrede hemodinamik parametrelerin değişmediğini saptadık. Ayrıca İVC ve PV'nin deklempajından sonra III. ve IV grupların hemodinamik olarak aynı stabiliteyi gösterdiğini, venöz dönüşün I. ve II. grupa göre daha az engellendiğini bulduk. 64

SUMMARY Liver transplantation has found a wide acceptance after 1982 with the introduction of the cyclosporine as an effective treatment with over a 90% one- year-survival rate for end stage liver diseases. Although cyclosporine has made a major contribution to the improved results, refinements in surgical techniques with a consequent reduction in operative morbidity have also had their part in the success. Reqular orthotopic liver transplantation (OLT) includes resection of the retrohepatic inferior vena cava (IVC) as part of the recipient hepatectomy, and therefore requires occlusion of the IVC and portal vein (PV). Such an interruption of the infradiaphragmatic venous return may lead to hemodynamic instability and renal failure, which are best prevented by an extracorporeal venous bypass used by most teams on adult recipients. On the other hand, recently an original technique is reported on caval reconstruction during OLT which avoids complete occlusion of the IVC in almost all cases, by lateral partial clamping and side-to-side cavo-caval anastomosis. The caval flow is thus preserved throughout the procedure and venous bypass (VVB) becomes unnecessary. This method has been used in Paul Brousse Hospital since 1993. The aim of this study is to compare the hemodynamic parameters of various stages of all the procedures performed by either total porto-caval clamping with or without VVB or lateral clamping with or without temporary porto-caval shunt (TPCS), involving a prospective study on comparable patients groups. During an eight-month period, 40 patients, aged 43±4.1 years (mean ±) and weighing 67±2.2 kg (mean ±), underwent OLT. The indications for transplantation (Child Paul Brousse Classification). Patients were allocated to four groups: 1. Porto-caval total clamping with VVB 2. Porto-caval total clamping without VVB 3. Lateral caval clamping with TPCS 4. Lateral cava clamping without TPCS 65intraoperative hemodymomic monitoring included: HR, MAP, MPAP, PAWP, CI, SVR, PVR and hourly urinary output. Temparature, pH, serum bicorbonate, serum potassium and serum ionized calcium were recorded at intervals throughout the surgical operation. Hemodynamic profiles were obtained two hours following the induction (Tt), 5 minutes after the beginning of the anhepatic phase (T2), 5 minutes before the end of the anhepatic phase (T3) 5 minutes after the unclamping of IVC and PV (T4), and 60 minutes after the unclamping of the PV (T5). Intraoperative data obtained from the measurements were assessed by Wilcoxon test. The lateral clamping without TPCS is main advantage seems to hemodynamic stability throughout the procedure, obviating the need for VVB or fluid over load. The value and indications of this technique should be defined more precisely by further prospective studies. This surgical technique assures a better anesthesiological management during liver transplantations.