| Research background and objective:To prolong the survival of patients with end-stage liver disease,Professor Starzl of the United States performed the first orthotopic liver transplantation in 1963.With a growing shortage of donor livers,many potential liver transplant patients die while waiting.In 1998,the surgical team at the Hannover School of Medicine in Germany supported techniques such as extracorporeal venous bypass and hypothermic perfusion.The first liver focus excision and autologous liver transplantation were completed in the world,and the combination of liver resection and liver transplantation was realized.To some extent,the development of the operation alleviated the problem of liver donor deficiency.However,due to the difficulty of the operation,the patient was born pathologically during the operation.The changes are very complicated,especially the influence on hemodynamics and coagulation system.At present,there are only small sample reports and studies at home and abroad,and lack of more clinical studies to confirm its feasibility,safety and anesthetic management experience.Since 2009,Modified hepatectomy and autologous liver transplantation have been carried out in our hospital.Compared with previous in vitro hepatectomy and autologous liver transplantation,we have reduced the fatal complications and equipment requirements associated with extracorporeal bypass.The perioperative pathophysiological changes of patients are more complicated and anesthesia management is more difficult.43 cases of modified isolated hepatectomy and autologous liver transplantation in our hospital were the only maximum sample size.The purpose of this study was to conduct a retrospective study on perioperative anesthesia management in patients with modified extracorporeal hepatectomy and autologous liver transplantation in our hospital,and to explore the regulation of hemodynamics,fluid management and coagulation function during the operation.Anesthetic management experience and treatment measures such as organ function protection strategy.Materials and Methods:1.From 2009 to 2016(deadline:December 30,2016),all patients underwent modified ex vivo liver resection and autotransplantation in our hospital were collected.The basic data of 43 patients were retrieved through the hospital records room network management system.2.The statistical items include the general characteristics of the patients,the intraoperative monitoring indexes of each time point include hemodynamic parameters(such as CVP,MPAP,PCWP,CO,SV,EF,LEDV,SVRI,EVLW,ITBV,coagulation function index:TEG parameter,plasma coagulation test monitoring value,blood gas analysis value change,etc.)Use of vasoactive drugs and others.3.The statistical software spss 21.0 was used to analyze the data of normal distribution in the form of mean±standard deviation(±S).Comparison between groups using independent sample t-test.The measurement data of skewness distribution were expressed as median(quartile fraction)[M(Q)],rank sum test was used for inter-group comparison,?~2 test was used for counting data comparison.P<0.05 was statistically significant.Results:1.43 patients(mean age 52.2 years)were treated with fast induction intubation general anesthesia.The operation time was 8.2±2.3 h,the duration of anhepatic period was 250±4.5 min,the output was 1587±434 ml,and 9 cases died(including automatic discharge)after operation.The main postoperative complications were biliary leakage in 11 cases(25.6%),liver failure in 8 cases(16.7%)and massive hemorrhage in 5 cases(11.6%).The average hospital stay was 26.1 days.2.With the support of balanced fluid therapy and vasoactive drugs,hemodynamics remained stable during hepatectomy.After the first occlusion of inferior vena cava,HR,SVR,LVP increased significantly(p<0.01),CVP,PVR and CO decreased significantly(p<0.01),and the mean arterial pressure decreased slightly(p<0.05).Pulmonary capillary resistance and cardiac output increased significantly(p<0.01),and there was no significant difference in hemodynamics between the second occlusion of inferior vena cava and the first time(p>0.05).3.The change of TEG monitoring value at each time point during operation is complicated,and the incidence of fibrinolytic prefibrinolysis in long-term anhepatic phase(35.5%)should be monitored and treated.The coagulation index of the patients increased first and then decreased,which was 3.45±0.25 before operation,and reached the peak at the first time when the blood vessel was reconstructed.After the second vascular reconstruction,it decreased to about 1.22(p<0.05).R time and K time remained stable before the first vascular reconstruction,and increased significantly at the later stage(p<0.05).?angle and Ma remained stable before the second vascular reconstruction.By the end of the operation,there was a significant decline.There was no significant change in CL-30 during the whole operation.No fibrinolysis occurred in all patients before the first vascular reconstruction,3 cases during the first vascular reconstruction,4 cases during the second vascular reconstruction and 4 cases during the reperfusion of the new liver.Fibrinogen concentration decreased slowly from 3.24±0.28 g/L to 3.24±0.28 g/L before operation.There was no significant change in APTT,PT,TT before and after operation.4.In the aspect of blood gas monitoring,the change of arterial partial pressure of oxygen and concentration of carbon dioxide in the process was not statistically significant(P>0.05),which was the result of strict monitoring and active intervention.There was no statistical difference at each time point(P>0.05).However,the PH value decreased from the beginning of the operation to the lowest value of 7.26±0.03 at the beginning of the second reperfusion(p<0.05).The increase of lactic acid value(p<0.05)was the main reason for the fluctuation of PH value.Conclusion:With the development of surgical techniques and anesthetic management,modified in vitro hepatectomy and autologous liver transplantation have become a new operative method,which can not be solved by conventional liver resection in clinic.Complicated surgical procedures and patient pathophysiological changes pose a great challenge to perioperative safety.Good anesthesia management is the key to the success of the operation.43 cases of isolated liver resection and autologous liver transplantation have been reported as the largest sample size in our hospital,but more large samples are still needed. |
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