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Sutureless anastomoses using magnetic rings in canine liver transplantation model

Published:August 05, 2013DOI:https://doi.org/10.1016/j.jss.2013.07.025

      Abstract

      Background

      In the first posttransplant month, the most frequent complications are due to technical problems related to complex vascular and bile duct reconstructions during the operation. Moreover, despite great improvements in suturing technique and materials, severe organ ischemia-reperfusion caused by time-consuming hand suturing is still an important factor in graft survival. During the operation, severe hypotension, hypoxic acidosis, hyperkalemia, and renal dysfunction may occur during the anhepatic phase due to the prolonged venous clamping time required for hand suturing. Therefore, hand suturing is a handicap in the development of further advancements in liver transplantation. In this study, we aimed to test a new “mechanical installation method” for rapid vascular reconstruction.

      Methods

      The magnetic pinning-ring device was developed consisting of paired magnetic rings coated with titanium oxide and embedded in a polypropylene shell. The rings were equipped with alternately spaced holes and titanium pins. Forty adult mongrel dogs were randomly divided into groups: A (n = 16), all vascular and bile duct reconstruction by magnetic ring without venous bypass; B (n = 16), all vascular and bile duct reconstruction by hand suturing with venous bypass; C (n = 8), sham transplantation group, transection of all vessels and common bile duct followed by anastomosis with the magnetic rings without liver transplantation. From groups A and B, dogs were randomly selected as donors (n = 8) or recipients (n = 8) of liver transplantations. We recorded operation time, vascular and bile duct anastomosis time, anhepatic time, administration of supplemental fluids during operation, and survival; blood samples were collected for the detection of liver damage (alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) and tumor necrosis factor α level. Patency was confirmed using ultrasound scans at various time points as late as 24 wk after surgery. Angiography was used to evaluate the anastomoses formed with magnetic rings. In group C, gross observation, histologic staining, and scanning electron microscopy were used to evaluate the vessels and bile ducts 12 wk postoperatively.

      Results

      In group A, the total operation time, inferior vena cava, and portal vein anastomosis times were significantly shortened, and the anhepatic phase was reduced to about one-fifth that of group B, which was a significant difference between the two groups (P < 0.01). The mean total operative time was 2.54 ± 0.45 h. In order to maintain adequate blood pressure, the mean fluid volume infused was 800.56 ± 60.56 mL in the recipients of group A, which was lower than that in group B (2241.67 ± 390.78 mL, P < 0.01). Use of a pressor agent in group A was unnecessary. After operation, five of eight animals in group A survived more than 7 d after operation. The main cause of death was acute rejection. Only three of eight animals in group B survived more than 1 wk after operation due to chronic anastomotic bleeding, kidney failure, heart failure, and gastrointestinal bleeding. There was a statistically significant difference (P < 0.01) between the short-term survival rate in the two groups (75.0% versus 37.5%). The ALT (1544.46 ± 286.27) U/L and AST (1710.74 ± 252.27) U/L levels after operation in the animals with hand suturing were significantly higher than those in the sutureless group (ALT = 1116.41 ± 210.55 U/L; AST = 1176.95 ± 248.25) U/L after reperfusion (P < 0.01). The serum tumor necrosis factor α levels (45.56 ± 10.78) ng/L in group B were significantly higher than those of group A (26.64 ± 10.84) ng/L after reperfusion (P < 0.01). Re-endothelialization was confirmed in all vessels in group C, with neither formation of aneurysms nor thickening of the vascular wall noted after 12 wk. The bile duct anastomoses also healed well.

      Conclusions

      The magnetic pinning-ring device offers a simple, fast, reliable, and efficacious technique for nonsuturing vascular and bile duct anastomoses. Use of this device shortens operation time, maintains a high patency rate, and improves the healing of tissue. Application of the magnetic ring anastomosis technique can effectively reduce the complications caused by hand suturing, and can reduce the extent of ischemia-reperfusion injury, leading to smoother operations and improved prognosis.

      Keywords

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      References

        • Carrel A.
        La technique opératoire des anastomoses vasculaires et la transplantation des viscères.
        Lyon Med. 1902; 98: 859
        • Verran D.J.
        • Asfar S.K.
        • Ghent C.N.
        • et al.
        Biliary reconstruction without T tubes or stents in liver transplantation: report of 502 consecutive cases.
        Liver Transpl Surg. 1997; 3: 365
        • Stratta R.J.
        • Wood R.P.
        • Langnas A.N.
        • et al.
        Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation.
        Surgery. 1989; 106: 675
        • Ramirez P.
        • Parrilla P.
        • Bueno F.S.
        • et al.
        Reoperation for biliary tract complications following orthotopic liver transplantation.
        Br J Surg. 1993; 80: 1426
        • Rouch D.A.
        • Emond J.C.
        • Thistlethwaite J.J.
        • et al.
        Choledochocholedochostomy without a T tube or internal stent in transplantation of the liver.
        Surg Gynecol Obstet. 1990; 170: 239
        • Nghiem H.V.
        • Tran K.
        • Winter T.R.
        • et al.
        Imaging of complications in liver transplantation.
        Radiographics. 1996; 16: 825
        • Wozney P.
        • Zajko A.B.
        • Bron K.M.
        • et al.
        Vascular complications after liver transplantation: a 5-year experience.
        AJR Am J Roentgenol. 1986; 147: 657
        • Orons P.D.
        • Sheng R.
        • Zajko A.B.
        Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications.
        AJR Am J Roentgenol. 1995; 165: 1145
        • Abbasoglu O.
        • Levy M.F.
        • Vodapally M.S.
        • et al.
        Hepatic artery stenosis after liver transplantation–incidence, presentation, treatment, and long term outcome.
        Transplantation. 1997; 63: 250
        • Langnas A.N.
        • Marujo W.
        • Stratta R.J.
        • et al.
        Vascular complications after orthotopic liver transplantation.
        Am J Surg. 1991; 161: 76
        • Orons P.D.
        • Zajko A.B.
        • Bron K.M.
        • et al.
        Hepatic artery angioplasty after liver transplantation: experience in 21 allografts.
        J Vasc Interv Radiol. 1995; 6: 523
        • Orons P.D.
        • Zajko A.B.
        Angiography and interventional procedures in liver transplantation.
        Radiol Clin North Am. 1995; 33: 541
        • Jain A.
        • Costa G.
        • Marsh W.
        • et al.
        Thrombotic and nonthrombotic hepatic artery complications in adults and children following primary liver transplantation with long-term follow-up in 1000 consecutive patients.
        Transpl Int. 2006; 19: 27
        • Zajko A.B.
        • Campbell W.L.
        • Logsdon G.A.
        • et al.
        Cholangiographic findings in hepatic artery occlusion after liver transplantation.
        AJR Am J Roentgenol. 1987; 149: 485
        • Denys A.L.
        • Qanadli S.D.
        • Durand F.
        • et al.
        Feasibility and effectiveness of using coronary stents in the treatment of hepatic artery stenoses after orthotopic liver transplantation: preliminary report.
        AJR Am J Roentgenol. 2002; 178: 1175
        • Glanemann M.
        • Settmacher U.
        • Langrehr J.M.
        • et al.
        Portal vein angioplasty using a transjugular, intrahepatic approach for treatment of extrahepatic portal vein stenosis after liver transplantation.
        Transpl Int. 2001; 14: 48
        • Karakayali H.
        • Boyvat F.
        • Coskun M.
        • et al.
        Venous complications after orthotopic liver transplantation.
        Transpl Proc. 2006; 38: 604
        • Cherqui D.
        • Duvoux C.
        • Rahmouni A.
        • et al.
        Orthotopic liver transplantation in the presence of partial or total portal vein thrombosis: problems in diagnosis and management.
        World J Surg. 1993; 17: 669
        • Kuang A.A.
        • Renz J.F.
        • Ferrell L.D.
        • et al.
        Failure patterns of cryopreserved vein grafts in liver transplantation.
        Transplantation. 1996; 62: 742
        • Sanchez-Bueno F.
        • Robles R.
        • Ramirez P.
        • et al.
        Hepatic artery complications after liver transplantation.
        Clin Transpl. 1994; 8: 399
        • Merion R.M.
        • Burtch G.D.
        • Ham J.M.
        • et al.
        The hepatic artery in liver transplantation.
        Transplantation. 1989; 48: 438
        • Goldstein R.M.
        • Secrest C.L.
        • Klintmalm G.B.
        • et al.
        Problematic vascular reconstruction in liver transplantation. Part I. Arterial.
        Surgery. 1990; 107: 540
        • Warner P.
        • Fusai G.
        • Glantzounis G.K.
        • et al.
        Risk factors associated with early hepatic artery thrombosis after orthotopic liver transplantation - univariable and multivariable analysis.
        Transpl Int. 2011; 24: 401
        • Pagnanelli D.M.
        • Pait T.G.
        • Rizzoli H.V.
        • et al.
        Scanning electron micrographic study of vascular lesions caused by microvascular needles and suture.
        J Neurosurg. 1980; 53: 32
        • Lidman D.
        • Daniel R.K.
        The normal healing process of microvascular anastomoses.
        Scand J Plast Reconstr Surg. 1981; 15: 103
        • Macchiarelli G.
        • Familiari G.
        • Caggiati A.
        • et al.
        Arterial repair after microvascular anastomosis. Scanning and transmission electron microscopy study.
        Acta Anat (Basel). 1991; 140: 8
        • Corti A.
        • Degasperi A.
        • Colussi S.
        • et al.
        [Evaluation of renal function during orthotopic liver transplantation].
        Minerva Anestesiol. 1997; 63: 221
        • Nakasuji M.
        • Bookallil M.J.
        • Asada A.
        [Causes of renal dysfunction during the anhepatic phase in patients for orthotopic liver transplantation and their postoperative renal function].
        Masui. 2000; 49: 956
        • Schwarz B.
        • Pomaroli A.
        • Hoermann C.
        • et al.
        Liver transplantation without venovenous bypass: morbidity and mortality in patients with greater than 50% reduction in cardiac output after vena cava clamping.
        J Cardiothorac Vasc Anesth. 2001; 15: 460
        • Sanchez-Urdazpal L.
        • Gores G.J.
        • Ward E.M.
        • et al.
        Ischemic-type biliary complications after orthotopic liver transplantation.
        Hepatology. 1992; 16: 49
        • Cerny R.
        Magneto-orthodontics: the application of magnetic forces to orthodontics.
        Aust Orthod J. 1978; 5: 105
        • Kubalak G.
        Mesh repair for midline ventral hernia without lateral fixation of the mesh.
        Am Surg. 2011; 77: 743
        • Hawn M.T.
        • Gray S.H.
        • Snyder C.W.
        • et al.
        Predictors of mesh explantation after incisional hernia repair.
        Am J Surg. 2011; 202: 28
        • Byrd J.F.
        • Agee N.
        • Nguyen P.H.
        • et al.
        Evaluation of composite mesh for ventral hernia repair.
        JSLS. 2011; 15: 298
        • Bloemen A.
        • van Dooren P.
        • Huizinga B.F.
        • et al.
        Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure.
        Br J Surg. 2011; 98: 633
        • Asarias J.R.
        • Nguyen P.T.
        • Mings J.R.
        • et al.
        Influence of mesh materials on the expression of mediators involved in wound healing.
        J Invest Surg. 2011; 24: 87
      1. “Recommended practices for skin preparation of patients,” AORN standards and recommended practices for perioperative nursing, 2002. Association of Operating Room Nursing, Inc., Denver2002
        • Osuna D.J.
        • Deyoung D.J.
        • Walker R.L.
        Comparison of three skin preparation techniques in the dog. Part 1: experimental trial.
        Vet Surg. 1990; 19: 14
        • Ku Y.
        • Maekawa Y.
        • Tominaga M.
        • et al.
        Suprahepatic vena cava anastomosis of the donor liver to the recipient retrohepatic vena cava in canine liver transplantation.
        Eur Surg Res. 1992; 24: 155
        • Dill D.B.
        • Costill D.L.
        Calculation of percentage changes in volumes of blood, plasma, and red cells in dehydration.
        J Appl Physiol. 1974; 37: 247
        • Wang J.Y.
        • Wang X.L.
        • Liu P.
        Detection of serum TNF-alpha, IFN-beta, IL-6 and IL-8 in patients with hepatitis B.
        World J Gastroenterol. 1999; 5: 38
        • Obora Y.
        • Tamaki N.
        • Matsumoto S.
        Nonsuture microvascular anastomosis using magnet rings: preliminary report.
        Surg Neurol. 1978; 9: 117
        • Heitmann C.
        • Khan F.N.
        • Erdmann D.
        • et al.
        Vein graft anastomoses with magnets.
        J Plast Reconstr Aesthet Surg. 2007; 60: 1296
        • Jacobs S.
        • Mohr F.W.
        • Falk V.
        Facilitated endoscopic beating heart coronary bypass grafting using distal anastomotic device.
        Int Congr Ser. 2004; 1268: 809
        • Klima U.
        • Macvaugh H.R.
        • Bagaev E.
        • et al.
        Magnetic vascular port in minimally invasive direct coronary artery bypass grafting.
        Circulation. 2004; 110: I55
        • Klima U.
        • Kofidis T.
        • Beilner J.
        • et al.
        Anastomotic obstruction after magnetic vascular coupling after minimally invasive direct coronary artery bypass grafting.
        Ann Thorac Surg. 2006; 81: 728
        • Vicol C.
        • Eifert S.
        • Oberhoffer M.
        • et al.
        Mid-term patency after magnetic coupling for distal bypass anastomosis in coronary surgery.
        Ann Thorac Surg. 2006; 82: 1452
        • Morbiducci U.
        • Lemma M.
        • Ponzini R.
        • et al.
        Does the Ventrica magnetic vascular positioner (MVP) for coronary artery bypass grafting significantly alter local fluid dynamics? A numeric study.
        Int J Artif Organs. 2007; 30: 628
        • Charitou A.
        • Panesar S.S.
        • Del S.R.
        • et al.
        Novel use of a magnetic coupling device to repair damage of the internal thoracic artery.
        J Card Surg. 2006; 21: 89
        • Matsuno N.
        • Uchiyama M.
        • Nakamura Y.
        • et al.
        A nonsuture anastomosis using magnetic compression for biliary stricture after living donor liver transplantation.
        Hepatogastroenterology. 2009; 56: 47
        • Jang S.I.
        • Kim J.H.
        • Won J.Y.
        • et al.
        Magnetic compression anastomosis is useful in biliary anastomotic strictures after living donor liver transplantation.
        Gastrointest Endosc. 2011; 74: 1040
        • Persin L.S.
        • Markov B.P.
        • Titov V.I.
        • et al.
        [The use of permanent magnets in the orthodontic clinic].
        Stomatologiia (Mosk). 1995; 74: 76
        • Blechman A.M.
        Magnetic force systems in orthodontics. Clinical results of a pilot study.
        Am J Orthod. 1985; 87: 201
        • Muller M.
        The use of magnets in orthodontics: an alternative means to produce tooth movement.
        Eur J Orthod. 1984; 6: 247
        • Bonnet B.
        • Bonvarlet J.M.
        • Loreille J.P.
        • et al.
        [Magnets and magnetic fields in orthodontics].
        Rev Orthop Dento Faciale. 1988; 22: 83
        • Vielfaure G.
        [The use of magnets in orthodontics: gadget or revolution?].
        Inf Dent. 1988; 70: 815
        • Maestripieri M.
        • Giorgetti R.
        • Nannelli P.
        • et al.
        [Magnets and orthodontics. Biological-clinical study. 2].
        Dent Cadmos. 1989; 57: 40
        • Sandler P.J.
        • Meghji S.
        • Murray A.M.
        • et al.
        Magnets and orthodontics.
        Br J Orthod. 1989; 16: 243
        • George T.M.
        • Valiathan A.
        • George A.I.
        • et al.
        Magnets in orthodontics.
        J Pierre Fauchard Acad. 1992; 6: 45
        • Duterloo H.S.
        Historic publication on the first use of magnets in orthodontics.
        Am J Orthod Dentofacial Orthop. 1995; 108: 15A
        • Darendeliler M.A.
        • Darendeliler A.
        • Mandurino M.
        Clinical application of magnets in orthodontics and biological implications: a review.
        Eur J Orthod. 1997; 19: 431
        • Noar J.H.
        • Evans R.D.
        Rare earth magnets in orthodontics: an overview.
        Br J Orthod. 1999; 26: 29
        • Latta G.J.
        • Mcdougal S.
        • Bowles W.R.
        Response of known nickel-sensitive patient to a removable partial denture with a titanium alloy framework: a clinical report.
        J Prosthet Dent. 1993; 70: 109
        • Kononen M.
        • Rintanen J.
        • Waltimo A.
        • et al.
        Titanium framework removable partial denture used for patient allergic to other metals: a clinical report and literature review.
        J Prosthet Dent. 1995; 73: 4
        • Nakajima H.
        • Kishi T.
        • Tsuchiya Y.
        • et al.
        Exposure of fibroblasts derived from keloid patients to low-energy electromagnetic fields: preferential inhibition of cell proliferation, collagen synthesis, and transforming growth factor beta expression in keloid fibroblasts in vitro.
        Ann Plast Surg. 1997; 39: 536
        • Matsumoto H.
        • Kira K.
        • Kondoh K.
        • et al.
        Effects of alternately aligned static micromagnetic fields on intravascular endothelial lining.
        Angiology. 1992; 43: 757
        • Bergan J.
        • Teixeira E.
        • Yu H.
        • et al.
        Hyperkalemia accompanying canine portal venous occlusion.
        Surgery. 1968; 64: 629
        • Nezu Y.
        • Tagawa M.
        • Sakaue Y.
        • et al.
        Kinetics of endotoxin concentration and tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 activities in the systemic and portal circulation during small intestinal ischemia and reperfusion in dogs.
        Am J Vet Res. 2002; 63: 1680
        • Colletti L.M.
        • Remick D.G.
        • Burtch G.D.
        • et al.
        Role of tumor necrosis factor-alpha in the pathophysiologic alterations after hepatic ischemia/reperfusion injury in the rat.
        J Clin Invest. 1990; 85: 1936
        • Rudiger H.A.
        • Clavien P.A.
        Tumor necrosis factor alpha, but not Fas, mediates hepatocellular apoptosis in the murine ischemic liver.
        Gastroenterology. 2002; 122: 202
        • Sankary H.N.
        • Foster P.
        • Brown E.
        • et al.
        Do splanchnic viscera contribute to liver preservation reperfusion injury?.
        Transplantation. 1996; 61: 1142
        • Delacure M.D.
        • Wang H.Z.
        Magnetic resonance imaging assessment of a microvascular anastomotic device for ferromagnetism.
        J Reconstr Microsurg. 1997; 13: 571