Name: isolated hepatic perfusion as a treatment for liver metastases of uveal melanoma
Uploaded: 2015-01-25T14:00:00.000+00:00
Duration: 9 min 52 s
Description: Watch this Scientific Journal Video about Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma at JoVE.com

Lennart Wiman (photographer) is acknowledged for excellent video recording.

Pacientes desde consentimento informado eo estudo foi aprovado pelo Conselho de Revisão de Ética Regional da Universidade de Gotemburgo. 1. Anestesia <ol><li> Configurar todo o acompanhamento (ECG, manguito de pressão arterial) 17. </li><li> Insira um cateter peridural no baixo e médio nível torácico 17. </li><li> Induzir a anestesia com propofol 2 mg / kg, 150 mcg de fentanil e Rocuronium 0,6 mg / kg através de um cateter venoso periférico inserido anteriormente. </li><li> Preoxygenate e entubar o paciente. Manter a anestesia com sevoflurano, oxigênio e ar 17. </li><li> Insira um cateter venoso central duplo lúmen e um cateter arterial. Monitorar CVP e pressão arterial 17. </li></ol> 2. Isolamento do Fígado e canulação da Vessels <ol><li> Administrar 100 IE / kg de heparina e dar a profilaxia com antibióticos (por exemplo, 160 mg de trimetoprim e 800 mg de sulfametoxazol). </li><li> Usando a técnica de Seldinger percutânea, coloque um 17 Fr cateter na veia femoral e a 15 Fr cateter na veia jugular externa 18. Verificar as posições dos cateteres por fluoroscopia. </li><li> Realize uma laparotomia por uma incisão em forma de L do apêndice xifóide abaixo da linha média e depois estendido para uma incisão subcostal direita 19. </li><li> Verifique se não há metástases extra-hepática existem no abdômen por uma inspeção completa e palpação. <ol><li> Se quaisquer lesões suspeitas são encontrados, verificar malignidade por congelação. </li><li> Encerrar o processo se houver provas de manifestação extra-hepática (adenopathy periaortal, metástases abdominais). Linfadenopatia no porta hepática não é considerada uma contra-indicação. </li></ol></li><li> Mobilizar o fígado através da divisão do ligamento falciforme, o ligamento triangular esquerda e direita e do ligamento coronário 19. </li><li> Dissecar a cavaveia começando a partir das veias renais até o diafragma com ligadura de veias tributárias retroperitônio. </li><li> Identifique a veia adrenal direita e coloque um laço navio em torno dele. </li><li> Identifique a veia gonadal direita. Dissecá-lo por 5-10 cm. Coloque uma sutura em bolsa em torno da entrada da veia cava. <ol><li> Coloque uma ligadura distal na veia gonadal. Com uma tesoura, abra a veia gonadal 3-5 cm a partir da veia cava. </li><li> Insira um 18 Fr cateter reforçado com fio através da veia gonadal direita e coloque a ponta retrohepatically acima das veias renais. </li><li> Colocar uma ligadura em torno da veia gonadal para fixar a posição do cateter. </li><li> Verificar o retorno do sangue através do cateter. Heparinização do cateter 18. </li></ol></li><li> Dissecar o ligamento hepatoduodenal e visualizar a artéria hepática comum, a artéria gastroduodenal e da artéria hepática própria. <ol><li> Lugar embarcação laços em torno da arte hepático comumry e a artéria gastrodoudenal. </li><li> Dissecar a veia portal e colocar um laço em torno dele navio. </li><li> Isolar o resto do ligamento contendo o ducto biliar comum e incluem tudo isto num ciclo navio. </li></ol></li><li> Levante a artéria gastroduodenal com o ciclo de navio. Depois de interromper o fluxo arterial, fazer uma incisão com uma tesoura. <ol><li> Insira um 8-12 Fr cateter com a ponta para dentro da artéria hepática própria. Fixe a posição com uma ligadura em torno da artéria gastroduodenal. </li><li> Verifique o retorno do sangue no cateter e depois heparinizar ele 18. </li></ol></li><li> Primeiro o sistema de perfusão com uma unidade de eritrócitos, 100 ml de albumina (50 g / L), 100 ml de Tribonat (bicarbonato de sódio), 2500 unidades de heparina (5.000 IE / ml) e 250 ml de cristalóides. </li><li> Ligue o arterial e os cateteres da veia cava para o sistema de perfusão que consiste de uma máquina coração pulmão equipado com uma bomba de cilindro e um aquecedor together com um reservatório, oxigenador e tubos venosos sistemas do tipo descartável. </li><li> Ligar os cateteres jugulares externas femorais e para a bomba de bypass veno consiste de uma bomba centrífuga, juntamente com uma unidade de aquecimento e iniciar desvio. </li><li> Complete o isolamento do fígado, apertando um torniquete Rumel em torno da veia cava infrahepatically acima das veias renais e fixação da veia cava suprahepatically usando uma pinça vascular Klintmalm. <ol><li> Aperte um torniquete Rumel em torno do ducto biliar comum, a veia porta ea veia adrenal direita e finalmente prender a artéria hepática usando uma pinça vascular. </li></ol></li></ol> 3. A perfusão <ol><li> Iniciar a perfusão e monitorizar o nível de sangue manualmente no reservatório venoso. Ajustar o caudal até um nível de estado estacionário é atingido, geralmente uma taxa de fluxo entre 500-1,200 ml / min. </li><li> Coloque sondas thermistor em lobos direito e esquerdo do fígado e outro diretamentedo cateter arterial. </li><li> Aqueça o perfusato visando a uma temperatura de fígado meta de 40 o C. Manter esta temperatura em toda a perfusão. </li><li> Coloque uma sonda cintilação sobre a cabeça da bomba de bypass venovenoso. </li><li> Calibrar o sistema de controlo de fugas, por injecção de uma pequena dose de 10 MBq de 99m Tc-albumina (1 ml) para a circulação sistémica e registar a actividade da linha de base. <ol><li> Injectar uma dose de dez vezes superior, com 100 MBq de 99m Tc-albumina (1 ml), para a unidade de perfusão hepática. </li><li> Grave qualquer fuga do sistema de perfusão para a circulação sistémica como um aumento na actividade medida pela sonda de cintilação. </li><li> Grave qualquer fuga a partir da circulação sistémica para o sistema de perfusão como um aumento no volume no reservatório venoso. </li></ol></li><li> Quando em estado de equilíbrio da taxa de fluxo é estabelecido, qualquer fuga está presente e a temperatura fígado atingiu 40 ° C, injectar o melfalano, a uma dose de1 mg / kg de peso corporal para o sistema de perfusão dividida em duas doses, administradas de 30 min. </li></ol> 4. Acabar com a perfusão e remoção dos cateteres <ol><li> Após 60 min de perfusão, esvaziar o perfusato do sistema e irrigar o fígado, com 1.000 ml de cristalóide. </li><li> Adicionar uma unidade de eritrócitos para a unidade de perfusão, infundir no fígado e, em seguida, parar a perfusão. </li><li> Solte a braçadeira Klintmalm e do torniquete Rumel da veia cava. </li><li> Solte o torniquete Rumel do ligamento hepatoduodenal. </li><li> Remover a ligadura da artéria gastroduodenal. Remover o cateter e ligar o vaso. </li><li> Solte o grampo da artéria hepática. </li><li> Remover o cateter da veia gonadal e ligar o vaso. </li><li> Pare a bomba de desvio veno-venosa e desconectar os tubos. </li><li> Feche o abdômen com uma sutura fascial ininterrupta e, em seguida, uma sutura intradérmica da pele. </li><li> Remover o catheters nas veias jugulares femorais e externos e aplicar pressão local para 5 min. </li></ol> 5. Cuidados Pós-Operatórios <ol><li> Extubação do paciente e transferência para unidade de cuidados pós-operatórios, durante 24 horas. Manter o monitoramento da pressão venosa central e pressão arterial. </li><li> Transferir o paciente a um serviço de cirurgia para um típico de 3-7 dias de cuidados pós-operatórios. </li><li> Continuar com a heparina de baixo peso molecular (HBPM) a uma dose de 5.000 IE / dia para um total de 4 semanas. </li></ol>

<ol>
	<li>Virgili, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+of+uveal+melanoma+in+Europe.">Incidence of uveal melanoma in Europe.</a> Ophthalmology. 114 (12), 2309-2315 (2007).</li><li>Pereira, P. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+and+emerging+treatment+options+for+uveal+melanoma.">Current and emerging treatment options for uveal melanoma.</a> Clinical Ophthalmology. 7, 1669-1682 (2013).</li><li>Bergman, L., Nilsson, B., Lundell, G., Lundell, M., Seregard, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ruthenium+brachytherapy+for+uveal+melanoma,+1979-2003:+survival+and+functional+outcomes+in+the+Swedish+population.">Ruthenium brachytherapy for uveal melanoma, 1979-2003: survival and functional outcomes in the Swedish population.</a> Ophthalmology. 112 (5), 834-840 (2005).</li><li>Diener-West, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+metastatic+disease+after+enrollment+in+the+COMS+trials+for+treatment+of+choroidal+melanoma:+Collaborative+Ocular+Melanoma+Study+Group+Report+No.+26.">Development of metastatic disease after enrollment in the COMS trials for treatment of choroidal melanoma: Collaborative Ocular Melanoma Study Group Report No. 26.</a> Archives of Ophthalmology. 123 (12), 1639-1643 (2005).</li><li>Kujala, E., Makitie, T., Kivela, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Very+long-term+prognosis+of+patients+with+malignant+uveal+melanoma.">Very long-term prognosis of patients with malignant uveal melanoma.</a> Investigative Ophthalmology &#38; Visual Science. 44 (11), 4651-4659 (2003).</li><li>Bedikian, A. Y., Papadopoulos, N., Plager, C., Eton, O., Ring, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Phase+II+evaluation+of+temozolomide+in+metastatic+choroidal+melanoma.">Phase II evaluation of temozolomide in metastatic choroidal melanoma.</a> Melanoma Research. 13 (3), 303-306 (2003).</li><li>Kivela, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=vincristine,+lomustine+and+dacarbazine+(BOLD)+in+combination+with+recombinant+interferon+alpha-2b+for+metastatic+uveal+melanoma.">vincristine, lomustine and dacarbazine (BOLD) in combination with recombinant interferon alpha-2b for metastatic uveal melanoma.</a> European Journal Of Cancer. 39 (8), 1115-1120 (2003).</li><li>Schmittel, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Phase+II+trial+of+cisplatin,+gemcitabine+and+treosulfan+in+patients+with+metastatic+uveal+melanoma.">Phase II trial of cisplatin, gemcitabine and treosulfan in patients with metastatic uveal melanoma.</a> Melanoma Research. 15 (3), 205-207 (2005).</li><li>Leyvraz, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hepatic+intra-arterial+versus+intravenous+fotemustine+in+patients+with+liver+metastases+from+uveal+melanoma+(EORTC+18021):+a+multicentric+randomized+trial.">Hepatic intra-arterial versus intravenous fotemustine in patients with liver metastases from uveal melanoma (EORTC 18021): a multicentric randomized trial.</a> Annals Of Oncology : Official Journal Of The European Society for Medical Oncology / ESMO. 25 (3), 742-746 (2014).</li><li>Huppert, P. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transarterial+chemoembolization+of+liver+metastases+in+patients+with+uveal+melanoma.">Transarterial chemoembolization of liver metastases in patients with uveal melanoma.</a> European Journal Of Radiology. 74 (3), 38-44 (2010).</li><li>Klingenstein, A., Haug, A. R., Zech, C. J., Schaller, U. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radioembolization+as+locoregional+therapy+of+hepatic+metastases+in+uveal+melanoma+patients.">Radioembolization as locoregional therapy of hepatic metastases in uveal melanoma patients.</a> Cardiovascular and Interventional Radiology. 36 (1), 158-165 (2013).</li><li>Mariani, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+liver+metastases+from+uveal+melanoma:+16+years'+experience+at+the+Institut+Curie.">Surgical management of liver metastases from uveal melanoma: 16 years' experience at the Institut Curie.</a> European Journal Of Surgical Oncology : The Journal Of The European Society Of Surgical Oncology And The British Association of Surgical Oncology. 35 (11), 1192-1197 (2009).</li><li>Ausman, R. K., Aust, J. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+perfusion+of+the+liver+with+HN2.">Isolated perfusion of the liver with HN2.</a> Surgical Forum. 10, 77-79 (1960).</li><li>Dahl, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interaction+of+hyperthermia+and+chemotherapy.">Interaction of hyperthermia and chemotherapy.</a> Recent results in cancer research. Fortschritte der Krebsforschung. Progres Dans Les Recherches Sur Le Cancer. 107, 157-169 (1988).</li><li>Barker, W. C., Andrich, M. P., Alexander, H. R., Fraker, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Continuous+intraoperative+external+monitoring+of+perfusate+leak+using+iodine-131+human+serum+albumin+during+isolated+perfusion+of+the+liver+and+limbs.">Continuous intraoperative external monitoring of perfusate leak using iodine-131 human serum albumin during isolated perfusion of the liver and limbs.</a> European Journal Of Nuclear Medicine. 22 (11), 1242-1248 (1995).</li><li>Olofsson, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+hepatic+perfusion+for+ocular+melanoma+metastasis:+registry+data+suggests+a+survival+benefit.">Isolated hepatic perfusion for ocular melanoma metastasis: registry data suggests a survival benefit.</a> Annals of Surgical Oncology. 21 (2), 466-472 (2014).</li><li>Redai, I., Emond, J., Brentjens, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anesthetic+considerations+during+liver+surgery.">Anesthetic considerations during liver surgery.</a> The Surgical Clinics of North America. 84, 401-411 (2004).</li><li>Sakai, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Insertion+and+management+of+percutaneous+veno-venous+bypass+cannula+for+liver+transplantation:+a+reference+for+transplant+anesthesiologists.">Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists.</a> Clinical Transplantation. 24 (5), 585-591 (2010).</li><li>Skandalakis, J. E., Skandalakis, L. J., Skandalakis, P. N., Mirilas, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hepatic+surgical+anatomy.">Hepatic surgical anatomy.</a> The Surgical Clinics of North America. 84 (2), 413-435 (1016).</li><li>Alexander, H. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+phase+I-II+study+of+isolated+hepatic+perfusion+using+melphalan+with+or+without+tumor+necrosis+factor+for+patients+with+ocular+melanoma+metastatic+to+liver.">A phase I-II study of isolated hepatic perfusion using melphalan with or without tumor necrosis factor for patients with ocular melanoma metastatic to liver.</a> Clinical Cancer Research : An Official Journal Of The American Association for Cancer Research. 6 (8), 3062-3070 (2000).</li><li>Alexander, H. R., Jr, , et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hyperthermic+isolated+hepatic+perfusion+using+melphalan+for+patients+with+ocular+melanoma+metastatic+to+liver.">Hyperthermic isolated hepatic perfusion using melphalan for patients with ocular melanoma metastatic to liver.</a> Clinical Cancer Research : An Official Journal Of The American Association For Cancer Research. 9 (17), 6343-6349 (2003).</li><li>Rizell, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+hepatic+perfusion+for+liver+metastases+of+malignant+melanoma.">Isolated hepatic perfusion for liver metastases of malignant melanoma.</a> Melanoma research. 18 (2), 120-126 (2008).</li><li>Iersel, L. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+hepatic+perfusion+with+200+mg+melphalan+for+advanced+noncolorectal+liver+metastases.">Isolated hepatic perfusion with 200 mg melphalan for advanced noncolorectal liver metastases.</a> Annals of Surgical Oncology. 15 (7), 1891-1898 (2008).</li><li>Carvajal, R. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+selumetinib+vs+chemotherapy+on+progression-free+survival+in+uveal+melanoma:+a+randomized+clinical+trial.">Effect of selumetinib vs chemotherapy on progression-free survival in uveal melanoma: a randomized clinical trial.</a> JAMA : the Journal Of The American Medical Association. 311 (23), 2397-2405 (2014).</li><li>Sharma, K. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hepatic+arterial+chemoembolization+for+management+of+metastatic+melanoma.">Hepatic arterial chemoembolization for management of metastatic melanoma.</a> AJR. American Journal Of Roentgenology. 190 (1), 99-104 (2008).</li><li>Eldredge-Hindy, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Yttrium-90+Microsphere+Brachytherapy+for+Liver+Metastases+From+Uveal+Melanoma:+Clinical+Outcomes+and+the+Predictive+Value+of+Fluorodeoxyglucose+Positron+Emission+Tomography.">Yttrium-90 Microsphere Brachytherapy for Liver Metastases From Uveal Melanoma: Clinical Outcomes and the Predictive Value of Fluorodeoxyglucose Positron Emission Tomography.</a> American Journal Of Clinical Oncology. , (2014).</li><li>Etten, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+hypoxic+hepatic+perfusion+with+orthograde+or+retrograde+flow+in+patients+with+irresectable+liver+metastases+using+percutaneous+balloon+catheter+techniques:+a+phase+I+and+II+study.">Isolated hypoxic hepatic perfusion with orthograde or retrograde flow in patients with irresectable liver metastases using percutaneous balloon catheter techniques: a phase I and II study.</a> Annals of Surgical Oncology. 11 (6), 598-605 (2004).</li><li>Ku, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extracorporeal+adriamycin-removal+following+hepatic+artery+infusion:+use+of+direct+hemoperfusion+combined+with+veno-venous+bypass.">Extracorporeal adriamycin-removal following hepatic artery infusion: use of direct hemoperfusion combined with veno-venous bypass.</a> Nihon Geka Gakkai Zasshi. 90 (10), 1758-1764 (1989).</li><li>Curley, S. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hepatic+arterial+infusion+chemotherapy+with+complete+hepatic+venous+isolation+and+extracorporeal+chemofiltration:+a+feasibility+study+of+a+novel+system.">Hepatic arterial infusion chemotherapy with complete hepatic venous isolation and extracorporeal chemofiltration: a feasibility study of a novel system.</a> Anti-Cancer Drugs. 2 (2), 175-183 (1991).</li><li>Beheshti, M. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+isolated+liver+perfusion+for+treatment+of+hepatic+malignancy:+preliminary+report.">Percutaneous isolated liver perfusion for treatment of hepatic malignancy: preliminary report.</a> Journal of Vascular And Interventional Radiology : JVIR. 3 (3), 453-458 (1992).</li></ol>

The authors have nothing to disclose.

Pacientes com melanoma uveal metastático têm poucas opções terapêuticas. Quimioterapia 6, a imunoterapia 23 e terapia-alvo 24 não ter sido capaz de mostrar um melhor OS. Para pacientes com poucas metástases hepáticas, ressecção hepática é uma opção 12. Outros tratamentos incluem quimioterapia hepática intra-arterial (HIA) 9, quimioembolização transarterial (TACE) 25 e terapia seletivo interno radiação (SIRT) 26. <p class=...

Melanoma da úvea é o tumor maligno intra-ocular mais comum em adultos, com a incidência ser maior em populações caucasianas 1. O tratamento local consiste de enucleação ou placa local radioterapia 2,3. Independentemente do tratamento local, doença metastática acabará por se desenvolver em cerca de 35-50% dos pacientes 4,5. O fígado é o sítio mais comum de metástases e aproximadamente 50% dos pacientes apresentam-se com metástases do fígado isoladas. A sobrevida global mediana (OS) para pacientes com metástases hepáticas é 6-12 meses 4. Várias estratégias de tratamento sistêmicos e regionais diferentes foram exploradas, mas as taxas de sobrevivência não melhoraram 2. O tratamento com quimioterapia sistêmica, tanto substância única (dacarbazina ou temozolomida 6) ou tratamentos combinados (regime BOLD 7, gemcitabina com treosulfan 8), mostra taxas de resposta de menos de10%. Quimioterapia intra-arterial hepática (HIA) mostrou uma taxa ligeiramente superior global de resposta em comparação com a quimioterapia sistêmica, mas nenhum aumento na sobrevida global 9. Quimioembolização transarterial (TACE) com cisplatina e carboplatina mostrou uma resposta parcial em 57% dos pacientes com uma sobrevida média de 9 meses 10. Terapia de radiação interna seletiva (SIRT) mostrou uma resposta parcial em 62% dos pacientes com uma sobrevida média de 7 meses 11. Em um estudo sobre a ressecção hepática, incluindo 255 pacientes, uma sobrevida global de 14 meses foi relatado; em 76 dos pacientes, onde a ressecção completa microscopicamente foi possível, a sobrevivência foi de 27 meses 12. Perfusão hepática isolada (IHP) é uma opção de tratamento regional, originalmente desenvolvido por Ryan e Ausman. A lógica por trás da técnica é isolar cirurgicamente e aspergir o fígado com uma alta dose de um agente quimioterapêutico, evitando sistêmica paraxicity 13. Além disso, a hipertermia concomitante medeia um aumento da absorção do agente quimioterapêutico por alterações no fluxo de sangue do tumor e a permeabilidade da membrana celular 14. Isolamento vascular completo é confirmado com uma técnica marcador radioativo usando Tc-99 marcado albumina sérica humana 15. Um estudo retrospectivo de fase II mostrou um benefício potencial de sobrevivência de 14 meses (26 x 12 meses) para os pacientes que foram submetidos a IHP em comparação com os sobreviventes mais longas com metástases hepáticas melanoma uveal na Suécia 16. Aqui apresentamos a técnica de IHP com uma breve avaliação dos resultados atuais e perspectivas futuras.

<table><tbody><tr><td>Wire re-inforced catethers</td><td>Medtronic Inc, Minnesota, USA</td><td></td><td>12-18Fr</td></tr><tr><td>St&amp;ouml;ckert S5</td><td>Sorin Group, Mirandola, Italy</td><td></td><td>Heart-lung machine</td></tr><tr><td>Rotaflow</td><td>Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany</td><td></td><td>Centrifugal pump</td></tr><tr><td>HU 35</td><td>Maquet cardiopulmonary AG, Hirrlingen, Germany</td><td></td><td>Heater unit</td></tr><tr><td>Flexbumin 200 g/l</td><td>Baxter Medical AB, Kista, Sweden</td><td></td><td></td></tr><tr><td>Tribonat</td><td>Fresenius Kabi AB, Uppsala, Sweden</td><td></td><td></td></tr><tr><td>Heparin LEO, 5000 IE/ml</td><td>LEO Pharma AB, Sweden</td><td></td><td></td></tr><tr><td>Ringer Acetate</td><td>Baxter Medical AB, Kista, Sweden</td><td></td><td></td></tr><tr><td>Vasculosis</td><td>Cis-Bio International, Gif-Sur-Yvette, France</td><td></td><td>99mTc-albumin</td></tr><tr><td>MedicView</td><td>SystemData AB, Gothenburg, Sweden</td><td></td><td>Leakage monitoring system</td></tr><tr><td>Alkeran</td><td>Aspen Europe GmbH, Bad Oldesloe, Germany</td><td></td><td>melphalan</td></tr></tbody></table>

isolated hepatic perfusion as a treatment for liver metastases of uveal melanoma

Perfusão hepática Isolado (IHP) é um procedimento em que o fígado é cirurgicamente isolado e perfundido com uma elevada concentração do melfalano agente quimioterapêutico. Resumidamente, o processo inicia-se com a configuração de um desvio veno-venosa percutânea a partir da veia femoral para a veia jugular externa. Através de uma laparotomia, cateteres são então inserido na artéria hepática adequada e a veia cava. A veia porta ea veia cava, tanto supra e infrahepatically, são então presos. O cateteres arteriais e venosas são ligados a uma máquina coração pulmão e do fígado é submetido a perfusão com o melfalano (1 mg / kg de peso corporal) durante 60 min. Desta forma, é possível perfundir localmente o fígado com uma dose elevada de um agente quimioterapêutico, sem fugas, para a circulação sistémica. Em estudos anteriores, incluindo pacientes com metástases hepáticas isoladas de melanoma da úvea, uma taxa de resposta de 33-100% e uma sobrevida média entre 9 e 13 meses,têm sido relatados. O objectivo deste protocolo é para dar uma descrição clara de como realizar o procedimento e para discutir IHP como uma opção de tratamento para metástases hepáticas de melanoma uveal.

Um relatório inicial incluiu 22 pacientes tratados com melfalano com ou sem TNF-alfa. Os resultados mostraram uma taxa de resposta de 62%, incluindo dois pacientes com CR (10%), e uma sobrevida global mediana de 11 meses 20. Um estudo posterior informou sobre o resultado de 29 pacientes consecutivos tratados utilizando o melfalano sozinho. O resultado foi muito semelhante com uma resposta global de 62%, incluindo 10% de resposta completa e uma sobrevida média de 12 meses 21. <p class="jove_co...

Watch this Scientific Journal Video about Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma at JoVE.com

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

Isolado hepática Perfusão como um tratamento para o fígado Metástases de Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

isolated-hepatic-perfusion-as-treatment-for-liver-metastases-uveal

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

13.3K visualizações.  Institute of Clinical Sciences. Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

Vídeo: Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Murine Model of Metastatic Liver Tumors in the Setting of Ischemia Reperfusion Injury

Liver ischemia and reperfusion (I/R) injury, a common clinical challenge, remains an inevitable pathophysiological process that has been shown to induce multiple tissue and organ damage. Despite recent advances and therapeutic approaches, the overall morbidity has remained unsatisfactory especially in patients with underlying parenchymal abnormalities. In the context of aggressive cancer growth and metastasis, surgical I/R is suspected to be the promoter regulating tumor recurrence. This article aims to describe a clinically relevant murine model of liver I/R and colorectal liver metastasis. In doing so, we aim to assist other investigators in establishing and perfecting this model for their routine research practice to better understand the effects of liver I/R on promoting liver metastases.

We describe in detail a clinically relevant colorectal cancer liver metastases (CRLM) tumor model and the influence of liver ischemia reperfusion (I/R) in tumor growth and metastasis. This model can help to better understand the mechanisms underlying surgery-induced promotion of liver metastatic growth.

Modelo murino de tumores hepáticos metastáticos no cenário de lesão de reperfusão de isquemia

Liver ischemia and reperfusion (I/R) injury, a common clinical challenge, remains an inevitable pathophysiological process that has been shown to induce ...

Pesquisa do câncer

Generation of a Liver Orthotopic Human Uveal Melanoma Xenograft Platform in Immunodeficient Mice

In recent decades, subcutaneously implanted patient-derived xenograft tumors or cultured human cell lines have been increasingly recognized as more representative models to study human cancers in immunodeficient mice than traditional established human cell lines in vitro. Recently, orthotopically implanted patient-derived tumor xenograft (PDX) models in mice have been developed to better replicate features of patient tumors. A liver orthotopic xenograft mouse model is expected to be a useful cancer research platform, providing insights into tumor biology and drug therapy. However, liver orthotopic tumor implantation is generally complicated. Here we describe our protocols for the orthotopic implantation of patient-derived liver-metastatic uveal melanoma tumors. We cultured human liver metastatic uveal melanoma cell lines into immunodeficient mice. The protocols can result in consistently high technical success rates using either a surgical orthotopic implantation technique with chunks of patient-derived uveal melanoma tumor or a needle injection technique with cultured human cell line. We also describe protocols for CT scanning to detect interior liver tumors and for re-implantation techniques using cryopreserved tumors to achieve re-engraftment. Together, these protocols provide a better platform for liver orthotopic tumor mouse models of liver metastatic uveal melanoma in translational research.

Orthotopic human liver metastatic uveal melanoma xenograft mouse models were created using surgical orthotopic implantation techniques with patient-derived tumor chunk and needle injection techniques with cultured human uveal melanoma cell lines.

Geração de uma plataforma de xenoenxerto de melanoma uveal humano ortotópico do fígado em camundongos imunodeficientes

In recent decades, subcutaneously implanted patient-derived xenograft tumors or cultured human cell lines have been increasingly recognized as more ...

Portal Vein Injection of Colorectal Cancer Organoids to Study the Liver Metastasis Stroma

Hepatic metastasis of colorectal cancer (CRC) is a leading cause of cancer-related death. Cancer-associated fibroblasts (CAFs), a major component of the tumor microenvironment, play a crucial role in metastatic CRC progression and predict poor patient prognosis. However, there is a lack of satisfactory mouse models to study the crosstalk between metastatic cancer cells and CAFs. Here, we present a method to investigate how liver metastasis progression is regulated by the metastatic niche and possibly could be restrained by stroma-directed therapy. Portal vein injection of CRC organoids generated a desmoplastic reaction, which faithfully recapitulated the fibroblast-rich histology of human CRC liver metastases. This model was tissue-specific with a higher tumor burden in the liver when compared to an intra-splenic injection model, simplifying mouse survival analyses. By injecting luciferase-expressing tumor organoids, tumor growth kinetics could be monitored by in vivo imaging. Moreover, this preclinical model provides a useful platform to assess the efficacy of therapeutics targeting the tumor mesenchyme. We describe methods to examine whether adeno-associated virus-mediated delivery of a tumor-inhibiting stromal gene to hepatocytes could remodel the tumor microenvironment and improve mouse survival. This approach enables the development and assessment of novel therapeutic strategies to inhibit hepatic metastasis of CRC.

Portal vein injection of colorectal cancer (CRC) organoids generates stroma-rich liver metastasis. This mouse model of CRC hepatic metastasis represents a useful tool to study tumor-stroma interactions and develop novel stroma-directed therapeutics such as adeno-associated virus-mediated gene therapies.

Portal Injeção de Veia de Organoides de Câncer Colorretal para Estudar o Estroma metástase hepática

Hepatic metastasis of colorectal cancer (CRC) is a leading cause of cancer-related death. Cancer-associated fibroblasts (CAFs), a major component of the ...

Technique of Subnormothermic Ex Vivo Liver Perfusion for the Storage, Assessment, and Repair of Marginal Liver Grafts

The success of liver transplantation has resulted in a dramatic organ shortage. In most transplant regions 20-30% of patients on the waiting list for liver transplantation die without receiving an organ transplant or are delisted for disease progression. One strategy to increase the donor pool is the utilization of marginal grafts, such as fatty livers, grafts from older donors, or donation after cardiac death (DCD). The current preservation technique of cold static storage is only poorly tolerated by marginal livers resulting in significant organ damage. In addition, cold static organ storage does not allow graft assessment or repair prior to transplantation.
These shortcomings of cold static preservation have triggered an interest in warm perfused organ preservation to reduce cold ischemic injury, assess liver grafts during preservation, and explore the opportunity to repair marginal livers prior to transplantation. The optimal pressure and flow conditions, perfusion temperature, composition of the perfusion solution and the need for an oxygen carrier has been controversial in the past.
In spite of promising results in several animal studies, the complexity and the costs have prevented a broader clinical application so far. Recently, with enhanced technology and a better understanding of liver physiology during ex vivo perfusion the outcome of warm liver perfusion has improved and consistently good results can be achieved.
This paper will provide information about liver retrieval, storage techniques, and isolated liver perfusion in pigs. We will illustrate a) the requirements to ensure sufficient oxygen supply to the organ, b) technical considerations about the perfusion machine and the perfusion solution, and c) biochemical aspects of isolated organs.

Technique of Subnormothermic Ex Vivo Liver Perfusion for the Storage, Assessment, and Repair of Marginal Liver Grafts

Marginal grafts, such as fatty livers, grafts from older donors, or livers retrieved after cardiac death (DCD) tolerate conventional, cold static storage only poorly. We developed a novel model of subnormothermic ex vivo liver perfusion for preservation, assessment, and repair of marginal liver grafts prior to transplantation.

Técnica de Subnormothermic<em&gt; Ex Vivo</em&gt; Fígado de Perfusão para o armazenamento, Avaliação e Reparação de enxertos de fígado Marginal

The success of liver transplantation has resulted in a dramatic organ shortage. In most transplant regions 20-30% of patients on the waiting list for ...

Medicina

Implantation and Evaluation of Melanoma in the Murine Choroid via Optical Coherence Tomography

Establishing experimental choroidal melanoma models is challenging in terms of the ability to induce tumors at the correct localization. In addition, difficulties in observing posterior choroidal melanoma in vivo limit tumor location and growth evaluation in real-time. The approach described here optimizes techniques for establishing choroidal melanoma in mice via a multi-step sub-choroidal B16LS9 cell injection procedure. To enable precision in injecting into the small dimensions of the mouse uvea, the complete procedure is performed under a microscope. First, a conjunctival peritomy is formed in the dorsal-temporal area of the eye. Then, a tract into the sub-choroidal space is created by inserting a needle through the exposed sclera. This is followed by the insertion of a blunt needle into the tract and the injection of melanoma cells into the choroid. Immediately after injection, noninvasive optical coherence tomography (OCT) imaging is utilized to determine tumor location and progress. Retinal detachment is evaluated as a predictor of tumor site and size. The presented method enables the reproducible induction of choroid-localized melanoma in mice and the live imaging of tumor growth evaluation. As such, it provides a valuable tool for studying intraocular tumors.

Implantation and Evaluation of Melanoma in the Murine Choroid via Optical Coherence Tomography

The present protocol describes the implantation and evaluation of melanoma in the murine choroid utilizing optical coherence tomography.

Implantação e Avaliação do Melanoma na Coroide Murina via Tomografia de Coerência Óptica

Establishing experimental choroidal melanoma models is challenging in terms of the ability to induce tumors at the correct localization. In addition, ...

Percutaneous Hepatic Perfusion (PHP) with Melphalan as a Treatment for Unresectable Metastases Confined to the Liver

Unresectable liver metastases of colorectal cancer can be treated with systemic chemotherapy, aiming to limit the disease, extend survival or turn unresectable metastases into resectable ones. Some patients however, suffer from side effects or progression under systemic treatment. For patients with metastasized uveal melanoma there are no standard systemic therapy options. For patients without extrahepatic disease, isolated liver perfusion (IHP) may enable local disease control with limited systemic side effects. Previously, this was performed during open surgery with satisfying results, but morbidity and mortality related to the open procedure, prohibited a widespread application. Therefore, percutaneous hepatic perfusion (PHP) with simultaneous chemofiltration was developed. Besides decreasing morbidity and mortality, this procedure can be repeated, hopefully leading to a higher response rate and improved survival (by local control of disease). During PHP, catheters are placed in the proper hepatic artery, to infuse the chemotherapeutic agent, and in the inferior caval vein to aspirate the chemosaturated blood returning through the hepatic veins. The caval vein catheter is a double balloon catheter that prohibits leakage into the systemic circulation. The blood returning from the hepatic veins is aspirated through the catheter fenestrations and then perfused through an extra-corporeal filtration system. After filtration, the blood is returned to the patient by a third catheter in the right internal jugular vein. During PHP a high dose of melphalan is infused into the liver, which is toxic and would lead to life threatening complications when administered systemically. Because of the significant hemodynamic instability resulting from the combination of caval vein occlusion and chemofiltration, hemodynamic monitoring and hemodynamic support is of paramount importance during this complex procedure.

Percutaneous Hepatic Perfusion PHP with Melphalan as a Treatment for Unresectable Metastases Confined to the Liver

In this manuscript, we describe percutaneous isolated hepatic perfusion with simultaneous chemofiltration as treatment for unresectable liver metastases. This procedure is performed under general anaesthesia in the angiosuite by an experienced team, consisting of an interventional radiologist, a clinical perfusionist and anaesthesiologist.

Percutânea hepática Perfusão (PHP) com melfalano como um tratamento para Unresectable Metástases confinado ao fígado

Unresectable liver metastases of colorectal cancer can be treated with systemic chemotherapy, aiming to limit the disease, extend survival or turn ...

Visualization of Vascular and Parenchymal Regeneration after 70% Partial Hepatectomy in Normal Mice

A modified silicone injection procedure was used for visualization of the hepatic vascular tree. This procedure consisted of in-vivo injection of the silicone compound, via a 26 G catheter, into the portal or hepatic vein. After silicone injection, organs were explanted and prepared for ex-vivo micro-CT (&#181;CT) scanning. The silicone injection procedure is technically challenging. Achieving a successful outcome requires extensive microsurgical experience from the surgeon. One of the challenges of this procedure involves determining the adequate perfusion rate for the silicone compound. The perfusion rate for the silicone compound needs to be defined based on the hemodynamic of the vascular system of interest. Inappropriate perfusion rate can lead to an incomplete perfusion, artificial dilation and rupturing of vascular trees.
The 3D reconstruction of the vascular system was based on CT scans and was achieved using preclinical software such as HepaVision. The quality of the reconstructed vascular tree was directly related to the quality of silicone perfusion. Subsequently computed vascular parameters indicative of vascular growth, such as total vascular volume, were calculated based on the vascular reconstructions. Contrasting the vascular tree with silicone allowed for subsequent histological work-up of the specimen after &#181;CT scanning. The specimen can be subjected to serial sectioning, histological analysis and whole slide scanning, and thereafter to 3D reconstruction of the vascular trees based on histological images. This is the prerequisite for the detection of molecular events and their distribution with respect to the vascular tree. This modified silicone injection procedure can also be used to visualize and reconstruct the vascular systems of other organs. This technique has the potential to be extensively applied to studies concerning vascular anatomy and growth in various animal and disease models.

Tools used for visualizing vascular regeneration require methods for contrasting the vascular trees. This film demonstrated a delicate injection technique used to achieve optimal contrasting of the vascular trees and illustrate the potential benefits resulting from a detailed analysis of the resulting specimen using &#181;CT and histological serial sections.

Visualização dos Vascular e parênquima regeneração após 70% hepatectomia parcial em ratos normais

A modified silicone injection procedure was used for visualization of the hepatic vascular tree. This procedure consisted of in-vivo injection of the ...

A Small Animal Model of Ex Vivo Normothermic Liver Perfusion

There is a significant shortage of liver allografts available for transplantation, and in response the donor criteria have been expanded. As a result, normothermic ex vivo liver perfusion (NEVLP) has been introduced as a method to evaluate and modify organ function. NEVLP has many advantages in comparison to hypothermic and subnormothermic perfusion including reduced preservation injury, restoration of normal organ function under physiologic conditions, assessment of organ performance, and as a platform for organ repair, remodeling, and modification. Both murine and porcine NEVLP models have been described. We demonstrate a rat model of NEVLP and use this model to show one of its important applications &#8212; the use of a therapeutic molecule added to liver perfusate. Catalase is an endogenous reactive oxygen species (ROS) scavenger and has been demonstrated to decrease ischemia-reperfusion in the eye, brain, and lung. Pegylation has been shown to target catalase to the endothelium. Here, we added pegylated-catalase (PEG-CAT) to the base perfusate and demonstrated its ability to mitigate liver preservation injury. An advantage of our rodent NEVLP model is that it is inexpensive in comparison to larger animal models. A limitation of this study is that it does not currently include post-perfusion liver transplantation. Therefore, prediction of the function of the organ post-transplantation cannot be made with certainty. However, the rat liver transplant model is well established and certainly could be used in conjunction with this model. In conclusion, we have demonstrated an inexpensive, simple, easily replicable NEVLP model using rats. Applications of this model can include testing novel perfusates and perfusate additives, testing software designed for organ evaluation, and experiments designed to repair organs.

A Small Animal Model of Ex Vivo Normothermic Liver Perfusion

There is a significant liver donor shortage, and criteria for liver donors have been expanded. Normothermic ex vivo liver perfusion (NEVLP) has been developed to evaluate and modify organ function. This study demonstrates a rat model of NEVLP and tests the ability of pegylated-catalase, to mitigate liver preservation injury.

Um pequeno modelo Animal de perfusão de fígado normotérmica Ex Vivo

There is a significant shortage of liver allografts available for transplantation, and in response the donor criteria have been expanded. As a result, ...

Isolation of Regenerating Hepatocytes after Partial Hepatectomy in Mice

Partial hepatectomy has been widely used to investigate liver regeneration in mice, but the isolation of high yields of viable hepatocytes for downstream single-cell applications is challenging. A marked accumulation of lipids within regenerating hepatocytes is observed during the first 2 days of normal liver regeneration in mice. This so-called transient regeneration-associated steatosis (TRAS) is temporary but partially overlaps the major proliferative phase. Density-gradient purification is the backbone of most existing protocols for the isolation of primary hepatocytes. As gradient purification relies on the density and size of cells, it separates non-steatotic from steatotic hepatocyte populations. Therefore, fatty hepatocytes often are lost, yielding non-representative hepatocyte fractions. 
The presented protocol describes an easy and reliable method for the in vivo isolation of regenerating hepatocytes regardless of their lipid content. Hepatocytes from male C57BL/6 mice are isolated 24-48 h after hepatectomy by a classic two-step collagenase perfusion approach. A standard peristaltic pump drives the warmed solutions via the catheterized inferior vena cava into the remnant, using a retrograde perfusion technique with outflow through the portal vein. Hepatocytes are dissociated by collagenase for their release from the Glisson's capsule. After washing and careful centrifugation, the hepatocytes can be used for any downstream analyses. In conclusion, this paper describes a straightforward and reproducible technique for the isolation of a representative population of regenerating hepatocytes after partial hepatectomy in mice. The method may also aid the study of fatty liver disease.

Lipid-laden hepatocytes are inherent to liver regeneration but are usually lost upon density-gradient centrifugation. Here, we present an optimized cell isolation protocol that retains steatotic hepatocytes, yielding representative populations of regenerating hepatocytes after partial hepatectomy in mice.

Isolamento de Hepatócitos Regeneradores após Hepatectomia Parcial em Camundongos

Partial hepatectomy has been widely used to investigate liver regeneration in mice, but the isolation of high yields of viable hepatocytes for downstream ...

Development and Validation of a Porcine Ex Situ Isolated Liver Perfusion Model 

Porcine Normothermic Isolated Liver Perfusion

Porcine models of liver ex situ normothermic machine perfusion (NMP) are increasingly being used in transplant research. Contrary to rodents, porcine livers are anatomically and physiologically close to humans, with similar organ size and bile composition. NMP preserves the liver graft at near-to-physiological conditions by recirculating a warm, oxygenated, and nutrient-enriched red blood cell-based perfusate through the liver vasculature. NMP can be used to study ischemia-reperfusion injury, preserve a liver ex situ before transplantation, assess the liver's function prior to implantation, and provide a platform for organ repair and regeneration. Alternatively, NMP with a whole blood-based perfusate can be used to mimic transplantation. Nevertheless, this model is labor-intensive, technically challenging, and carries a high financial cost.
In this porcine NMP model, we use warm ischemic damaged livers (corresponding to donation after circulatory death). First, general anesthesia with mechanical ventilation is initiated, followed by the induction of warm ischemia by clamping the thoracic aorta for 60 min. Cannulas inserted in the abdominal aorta and portal vein allow flush-out of the liver with cold preservation solution. The flushed-out blood is washed with a cell saver to obtain concentrated red blood cells. Following hepatectomy, cannulas are inserted in the portal vein, hepatic artery, and infra-hepatic vena cava and connected to a closed perfusion circuit primed with a plasma expander and red blood cells. A hollow fiber oxygenator is included in the circuit and coupled to a heat exchanger to maintain a pO2 of 70-100 mmHg at 38 &#176;C. NMP is achieved by a continuous flow directly through the artery and via a venous reservoir through the portal vein. Flows, pressures, and blood gas values are continuously monitored. To evaluate the liver injury, perfusate and tissue are sampled at predefined time points; bile is collected via a cannula in the common bile duct.

The porcine model of liver normothermic machine perfusion (NMP), described here, can be successfully used to study NMP as a preservation strategy, a tool for viability assessment, and a platform for organ repair. It holds a high translational value, however it is technically challenging and labor-intensive.

Porcine models of liver ex situ normothermic machine perfusion (NMP) are increasingly being used in transplant research. Contrary to rodents, porcine ...