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      Reperfusão Retrógrada no Transplante de Fígado: Uma Revisão Integrativa da Literatura Translated title: Retrograde Reperfusion in Liver Transplantation: An Integrative Literature Review

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          Abstract

          RESUMO Introdução: o transplante de fígado é um processo complexo, o qual possui controvérsias sobre qual a técnica de reperfusão é a mais adequada para minimizar os danos gerados por lesão isquêmica, não havendo consenso sobre uma técnica de reperfusão de escolha primária. Portanto, este estudo visa investigar a produção científica a respeito da reperfusão retrógrada e sua implicação no contexto do transplante hepático. Método: revisão integrativa da literatura desenvolvida por meio de buscas nas bases de dados PubMed, Scielo e Lilacs. Para compor esta revisão, após análise e aplicação dos critérios definido pelos autores, foram selecionados 6 artigos publicados, sem limitação da data de publicação. Resultados: a revascularização retrógrada durante o transplante hepático parece ser uma boa alternativa para redução de complicações intraoperatórias e diminuição do tempo de isquemia do enxerto, além de não possuir desvantagem importante que justifique a não utilização da técnica durante o procedimento. A maior limitação dos estudos incluídos na revisão foi a pouca quantidade de transplantes de fígado que utilizam da técnica, já que há preferência pela revascularização anterógrada, principalmente portal. Conclusão: a reperfusão retrógrada se mostrou eficiente para reduzir metabólitos tóxicos e síndrome pós-reperfusão, além de possuir certa influência na estabilidade hemodinâmica e na menor incidência de perda do enxerto por disfunção primária. Porém, faz-se necessária a produção de novos estudos que possam comprovar tais repercussões dessa técnica.

          Translated abstract

          ABSTRACT Introduction: liver transplantation is a complex process, which has controversies about which reperfusion technique is the most suitable to minimize the damage caused by ischemic injury. There is no consensus on a technique of reperfusion of primary choice in the evidence found. Therefore, we can´t reach a conclusion. Purpose: this study aims to investigate the scientific production of retrograde reperfusion and its implication in liver transplants. Method: integrative review of the literature, developed through searches in the PubMed, Scielo, and Lilacs Databases. After the analysis and application of the inclusion and exclusion criteria defined by the authors, we selected 6 published articles to write this review, without restricting the dates of publication. Results: Retrograde revascularization during liver transplantation seems to be a correct option for reducing intrasurgical complications and decreasing graft ischemia time, in addition to having no significant disadvantage that justifies the non-use of the technique during the procedure. The major limitation of the studies included in the review was the small number of liver transplants in which the technique was used, since there is a preference for anterograde revascularization, mainly portal. Conclusion: retrograde reperfusion proved being efficient in reducing toxic metabolites and post-reperfusion syndrome, in addition to having a certain influence on hemodynamic stability and a lower incidence of graft loss due to primary dysfunction. However, it is necessary to develop new studies that can prove the repercussions of this technique.

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          Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem

          A prática baseada em evidências é uma abordagem que encoraja o desenvolvimento e/ou utilização de resultados de pesquisas na prática clínica. Devido à quantidade e complexidade de informações na área da saúde, há necessidade de produção de métodos de revisão de literatura, dentre estes, destacamos a revisão integrativa. Assim, o objetivo do estudo foi apresentar os conceitos gerais e as etapas para a elaboração da revisão integrativa, bem como aspectos relevantes sobre a aplicabilidade deste método para a pesquisa na saúde e enfermagem. A revisão integrativa é um método de pesquisa que permite a busca, a avaliação crítica e a síntese das evidências disponíveis do tema investigado, sendo o seu produto final o estado atual do conhecimento do tema investigado, a implementação de intervenções efetivas na assistência à saúde e a redução de custos, bem como a identificação de lacunas que direcionam para o desenvolvimento de futuras pesquisas.
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            A single-center experience with retrograde reperfusion in liver transplantation.

            Poor graft function secondary to injury by ischemia and reperfusion remains a major problem with regard to morbidity and mortality in clinical liver transplantation (LTX). Up to one fifth of patients suffer from poor initial liver function due to severe damage to hepatocytes. This situation leads either to primary nonfunction described in approximately 6% of LTX or to slow recovery. We present a new method of reperfusion during LTX. From July 1998 to July 2002, 42 LTX in 39 recipients, (10 female, 52 years old (26-70) were performed. LTX was carried out in piggy-back technique. After completing the piggy-back anastomosis, the caval vein was declamped immediately, and retrograde low pressure reperfusion of the graft with low oxygenated venous blood was established. Portal anastomosis was performed using a running suture. In order to provide optimal retrograde liver perfusion, no clamping of the donor portal vein was done. After completing portal anastomosis, the recipient portal vein was declamped immediately. During arterial anastomosis, the transplanted liver was antegradely perfused via the portal vein. After completing hepatic artery anastomosis, declamping of the hepatic artery was done and arterial perfusion started. No backtable or in-situ-flushing except the described reperfusion technique was performed. Forty-two LTX in 39 recipients using piggy-back technique and retrograde reperfusion via the caval vein followed by antegrade reperfusion via the portal vein were performed; 38 out of 39 patients (97.44%) were alive and well at day 8 after LTX. One patient (2.56%) died of a pre-existing portal vein thrombosis on day 2 after LTX. Three patients had to undergo retransplantation for hepatic artery thrombosis (7.14%). Liver enzymes, bilirubine, prothrombine time and AT III on day 1, 3, 5 and 8 after LTX showed favourable values. Median aspartate aminotransferase (ASAT) was 219 U/l on day 1 after LTX. One-month survival rate was 95.23%, and 1-year survival rate 87.88%. Two patients died of liver-associated causes (5.12%). One patient died of a late hepatic artery thrombosis, and one more of rejection. No other severe case of rejection appeared. We can conclude that retrograde reperfusion might be highly sufficient method of removing perfusion fluid from the transplanted liver. Low pressure perfusion with low oxygenated blood might reduce the production of free oxygen radicals. Retrograde reperfusion via the caval vein and antegrade reperfusion via the portal vein seemed to lower postoperative liver enzyme values and to improve initial liver function after LTX.
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              Retrograde reperfusion via vena cava lowers the risk of initial nonfunction but increases the risk of ischemic-type biliary lesions in liver transplantation--a randomized clinical trial.

              Initial nonfunction (INF) and biliary complications such as ischemic-type biliary lesion (ITBL) remain two major complications in clinical orthotopic liver transplantation (OLT). The influence of ischemia and reperfusion injury (I/R) as a significant risk factor for both complications is widely unquestioned. A new reperfusion technique that reduces I/R injury should lead to a reduction in both INF and ITBL. One hundred and thirty two OLT patients were included in this study and randomized into two groups. Group A underwent standard reperfusion with anterograde simultaneous arterial and portal reperfusion and group B received retrograde reperfusion via the vena cava before sequential anterograde reperfusion of portal vein and hepatic artery. Serum transaminase level as a surrogate parameter for I/R injury and serum bilirubin level as a parameter for graft function were significantly reduced during the first week after OLT in group B. INF rate was 7.7% in group A and 0% in group B (P = 0.058). ITBL incidence was 4.55% in group A versus 12.3% in group B (P = 0.053). Retrograde reperfusion seemed to be beneficial for hepatocytes, but was detrimental for the biliary epithelium. The unexplained increased incidence of ITBL after retrograde reperfusion will be focus of further investigation.
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                Author and article information

                Journal
                bjt
                Brazilian Journal of Transplantation
                Braz. J. Transplant.
                Associação Brasileira de Transplante de Órgãos (São Paulo, SP, Brazil )
                2764-1589
                2023
                : 26
                : e1423
                Affiliations
                [01] Recife PE orgnameUniversidade Maurício de Nassau orgdiv1Faculdade de Medicina Brasil
                [02] Recife PE orgnameHospital Universitário OswaldoCruz orgdiv1Serviço de Cirurgia Geral e Transplante de Fígado Brasil
                Author information
                https://orcid.org/0000-0001-9007-4238
                https://orcid.org/0000-0002-2383-8610
                Article
                S2764-15892023000100505 S2764-1589(23)02600000505
                10.53855/bjt.v26i1.499_port
                a1a7c6da-a6b7-4e84-a694-bdd489294606

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 24 January 2023
                : 30 March 2023
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 13, Pages: 0
                Product

                SciELO Brazil

                Categories
                Artigo de Revisão

                Revascularization,Retrograde Reperfusion,Liver Transplant,Reperfusão Retrógrada,Transplante de Fígado,Revascularização

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