KARACİĞER NAKLİ SONRASI ENZİM DEĞİŞİKLİKLERİ VASKULER HASAR MI, İSKEMİ REPERFÜZYON HASARI MI? Prof.Dr.Yaman Tokat Florence Nightingale Hastanesi Karaciğer ğ Transplantasyonu ve Hepatobilier Cerrahi Bölümü İstanbul
İskemi Reperfüzyon Hasarı İskemi reperfüzyon hasarı doku ve organlarda oluşan iskemi i sonrası tekrar perfüze olup kanlanmasını takip eden süreçte gelişen fonksiyon bozukluğu ve yapısal hasarı tarif eder.
Konuşma Akışı Kendi serimiz İyi bir canlı nakil nasıl olmalı Canlı KC naklinde enzim yükselten nedenler? Vasküler problemler nelerdir? Canlı karaciğer naklinde yeni deyimler -Anterior sektör drenajı -MHV drenajı -Small for size sendromu -Portal hiper/hipoperfüzyon İskeminin KC nakline etkileri Öneriler ve Sonuç
Karaciğer Nakli Deneyimi 1994 2011 100 90 80 70 60 50 Total-823 40 LDLT 504 30 DDLT-319 20 10 0 94-99 2001 2003 2005 2007 2009 2011 97
Bugünkü konuşmam 2005-2010 yılları arasında ardışık olarak yapılmış 200 canlı sağ lob karaciğer transplantasyonunun retrospektif olarak iskemi/reperfüzyon i/ hasarının ve vaskuler problemlerin incelenmesini göstermektedir
Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft Sung-Gyu Lee
Canlı karaciğer ğ naklinde enzimleri Vaskuler hasar yükselten nedenler Inflow sorunları, Portal ven ve Hepatik arter Outflow sorunları, Sağ hepatik ven, Anterior sektor drenajı, aksesuar venler Akut Rejeksiyon Small for size sendromu Uzamış iskemi ve reperfüzyon hasarı Safra yolu hasarı Sepsis
Donor Right Hepatic Vein Recipient Right Hepatic Vein
Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft Sung-Gyu Lee Lee (J of HBP Surg. 2006,13: 131-138)
CONGESTION OF RIGHT LIVER GRAFT IN LIVING DONOR LIVER TRANSPLANTATION T A K O T n a m t a e n Y. l. i r ak f.d n o r z a P r t p e a n c.. l i ak ww n w z T a r A p K a O c. T n ww a w m T a.y KA r O D. T f n ro a P m t a e l.n.y i r k D a. f n za Pro r p a.c w w w
Vascular Territory Volume (in ml) (relative) (% of total) Graft 1062 ( 61.4%) Vascular Territory Volume (in ml) (relative) (% of total) MV4bs 1 ( 6.7%) MV5i 71 ( 6.7%) MV5s 84 ( 7.9%) MV8d 5 ( 0.5%) MV8i 17 ( 1.6%) MV8s 29 ( 2.7%) RHV 815 ( 76.7%) inf.hv 40 ( 3.8%) Total 1062 (100.0%) Remnant 655 ( 37.8%) Resection Plane 15 ( 0.9%) Total 1732 (100.0%)
S5 Saphenous Vein Graft S8 Saphenous Vein Graft Right Hepatic Vein
Cadaveric Iliac Artery Graft
Saphaneous Vein Graft S 8 S 5
Sağ Hepatik Ven Middle Hepatik Ven
Venöz outflow darlığı veya trombozu sonrası gelişen vaskuler hasar Serimizde hiç hepatik ven trombozu olmamıştırş Anterior sektör drenajı: 45% Segment 5-8 ven drenajı uygulanan, 18 hasta (9%) MHV alınan, 71 hasta (36%) Anterior sektör drenajı uygulanmayan,% 55
Outflow a bağlı vasküler hasar In the present study of 200 cases, recipients with anterior sector drainage, either using MHV or selective segment V-VIII VIII drainage using interposition vascular grafts had significantly lower mean peak ALT levels during first postoperative week (405±602 U/L vs. 643±906 U/L, p=0.03). (U/L) ALT levels 600 500 400 300 200 100 0 Change in mean postoperative ALT levels in recipients 1 2 3 4 5 6 7 With anterior sector drainage No anterior sector drainage
Outflow a bağlı vasküler hasar Recipients with anterior sector drainage also showed significantly lower mean peak AST levels during first postoperative week (347±551 U/L vs. 586±444 U/L, p=0.03). AST levels (U/L) 400 350 300 250 200 150 100 50 Change in mean postoperative AST levels in recipients 0 1 2 3 4 5 6 7 With anterior sector drainage No anterior sector drainage
Outflow a bağlı vasküler hasar Recipients with anterior sector drainage had lower postoperative day 7 total bilirubin level, which did not reach statistical significance (7.0±6.1 mg/dl vs. 9.1±8.8 mg/dl, p=0.1) l bilirubin lev vels (mg/dl) 10,0 9,0 8,0 7,0 60 6,0 5,0 4,0 3,0 2,0 1,0 0,0 Change in mean postoperative bilirubin levels in recipients Tota 1 2 3 4 5 6 7 9,1 7,0 With anterior sector drainage No anterior sector drainage
Anterior sektör drenajı
Inflow bağımlı vasküler hasar Hepatik arter thrombozu: 3 hasta (1,5%) 1 hasta donör arterindeki intimal disseksiyon nedeni ile hiç revaskülerize edilemedi Başarılı revaskularizasyon, 2 vaka Hasta kaybı, 1 vaka (geç HAT) Graft kaybı, 1 vaka (retransplanted, DDLT) Portal vein thrombosis: 2 vaka (1%) Hasta kaybı bir vaka
Arter Anastomozu için Mikrovasküler teknik
Portal Problemler Hipoperfüzyon Tromboz
SFSS Graft Injury -Ischemic Time -Portal Hiperperfüzyon -Venous outflow problems -Rejection Functional Graft Mass -Graft Volume -Fatty changes - Age -Type of the graft Metabolic Demand - Pretransplant status - Post transplant komp.
İskemi-reperfüzyon hasarı Mean portal iskemi zamanı (donor hepatik arter baglanmasından portal reperfüzyona kadar geçen zaman): 78.0 ±25.5 min (range, 29-160 min) Mean arterial iskemi zamanı (donor hepatik arter baglanmasından arterial reperfusiona kadar geçen süre): 141.8 ±45.9 min (range, 62-330 min)
İskemi-reperfüzyon hasarı Mean postoperative peak ALT level did not show significant correlation with portal ischemia time (p=0.3)
İskemi-reperfüzyon hasarı Mean postoperative peak ALT level showed a significant correlation with arterial ischemia time (p=0.002)
Intermittent inflow oklüzyonu Prospektiv randomize, kontrollü intermittent portal triad klempajı (PTK grup) vs. Klempaj yapılmayan grup (no PTK grup) Donör sağ hepatektomi 72 Vaka
Bilgilendirme Hepatic inflow occlusion is a well-established technique for decreasing hemorrhage during the transection of liver parenchyma. Man K, et al. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study. Ann Surg 1997 Recent surveys revealed that vascular clamping during liver resection is commonly applied by European and Japanese surgeons. Nakajima Y, et al. Control of intraoperative bleeding during liver resection: analysis of a questionnaire sent to 231 Japanese hospitals. Surg Today 2002 van der Bilt JD, et al. European Survey on the Application of Vascular Clamping in Liver Surgery. Dig Surg 2007
Intermittent inflow oklüzyonu In recipients, PTC group had higher postoperative peak ALT levels (544±560 U/L vs. 355±324 U/L), which showed a marginal significance (p=0.08) s (U/L) ALT level 500 450 400 350 300 250 200 150 100 50 0 Change in mean postoperative ALT levels in recipients 1 2 3 4 5 6 7 No inflow occlusion Inflow occlusion
Intermittent inflow oklüzyonu PTC group had higher postoperative peak AST levels (454±462 vs. 306±290 U/L), which did not reach statistical significance. AST leve els (U/L) 350 300 250 200 150 100 50 Change in mean postoperative AST levels in recipients 0 1 2 3 4 5 6 7 No inflow occlusion Inflow occlusion
Intermittent inflow oklüzyonu Total bilirubin levels showed similar trends in both groups. PTC group had higher postoperative day 7 total bilirubin (9.6±8.9 vs. 8.3±6.8 mg/dl), which did not reach statistical significance. vels (mg/dl) Change in mean postoperative bilirubin levels in recipients 12,0 10,0 8,0 Bilirubin le 6,0 4,0 20 2,0 0,0 1 2 3 4 5 6 7 No inflow occlusion Inflow occlusion
Intermittent inflow oklüzyonu In PTC group, postoperative peak ALT level in recipients did not show a significant correlation with inflow occlusion time: p=0.1
Sonuç Canlı KC naklinde iskemi reperfüzyon hasarı iskemik zamanın kısa olması nedeni ile Kadavra nakiller kadar olmaz Gelişen yeni cerrahi teknikler vaskuler problemleri minimale indirsede drenaj problemleri hala önemli bir sorundur. İskemi reperfüzyon hasarı en çok uzamış arterial iskemi sonucu ortaya çıkar
Sonuç Erken dönem enzim yüksekliklerinde sağ lob greftlerinde yetersiz venöz drenaj ilk akla gelmelidir İlk hafta her gün yapılan Doppler US ve gerektiğinde CT anjio, problemlerin erken yakalanmasına ve tedavisine olanak sağlarğ