Isolated Liver Perfusion Research Articles

Chimiothérapie par perfusion isolée du foie avec clampage cave endovasculaire : expériences préliminaires chez le porc

Very high concentrations of cytotoxic drug may be obtained with chemotherapy performed with vascular exclusion. Objective : To study the pharmacokinetics and toxicity of melphalan during in situ isolated liver perfusion, and to test an endovascular occlusion catheter. Methods : Isolated liver perfusion with melphalan (15 mg bolus) was performed in 6 pigs (50–60 kg) for 30 min, with non-oxygenated Ringer’s solution. Hepatic outflow, collected by a double balloon catheter inserted into the retrohepatic inferior vena cava, was pumped into the gastro-duodenal artery, while the common hepatic artery and portal vein were clamped. Results : A maximum concentration of 30,000 ng/mL was obtained in the circuit before an exponential decrease, while the concentration in systemic blood was less than 500 ng/mL ( n = 3). Before closing the abdomen, melphalan concentrations were about 2,000 ng/mg in the liver, and undetectable in the muscle. Postoperative course (2 weeks, n = 2) was uneventful with minor alterations in blood tests and hepatic histology. Conclusion : This method of local chemotherapy with melphalan appears to be safe with minor leakage and minimal toxicity.

Isolated hepatic cholinergic denervation impairs glucose and glycogen metabolism.

Hepatic innervation plays an essential role in insulin extraction and glucose production, but the specific role of hepatic cholinergic innervation remains unclear. We sought to establish a model of isolated hepatic cholinergic denervation (IHCD), and to assess whether glycogen storage or the control of net hepatic glucose production (HGP) was altered by IHCD. Sprague-Dawley rats underwent either hepatic vagotomy or sham operation. Liver tissue was stained for vesicular acetylcholine transporter (VAChT) and (nonspecific neural) protein gene product 9. 5 (PGP) for verification of IHCD. Liver glycogen content was quantified in fed and fasted IHCD or sham-operated animals. HGP was determined after single-pass isolated liver perfusion, during which a 30-min 12 ng/ml glucagon infusion was begun after equilibration, and after 10 min, a 200 microU/ml insulin infusion was added. Uniform staining of PGP and absence of VAChT staining in hepatic vagotomized rats demonstrated the validity of our model. Glycogen content of sham-operated livers (n = 8) increased from 6.0 +/- 1.7 in the fasting state to 10.6 +/- 1.8 mg/g liver, after feeding (P < 0.05). IHCD livers (n = 8) showed no comparable increase (3.5 +/- 0.6 to 4.0 +/- 0.7 mg/g liver). Perfusion with glucagon alone resulted in less HGP in IHCD livers (n = 12) compared with sham-operated livers (n = 10) (integrated HGP 3.3 +/- 0.3 mg/g liver min(-1) vs 5.1 +/- 0.5 mg/g liver min(-1), P < 0.05). Insulin infusion revealed impaired responsiveness to insulin after IHCD; the ratio of HGP in the final 10 min of perfusion (glucagon and insulin) to HGP in the initial 10 min (glucagon alone) was 90.3 +/- 2.4% for IHCD livers versus 68.1 +/- 4.4% for sham-operated controls, respectively (P = 0.0002). Our study shows that IHCD results in significant impairment in liver glycogen storage and impaired hepatic sensitivity to glucagon and, possibly, to insulin. We conclude that hepatic cholinergic integrity is essential to normal hepatic glucose metabolism.

Gluconeogenesis in the liver of arthritic rats.

The gluconeogenic response in the liver from rats with chronic arthritis to various substrates and the effects of glucagon were investigated. The experimental technique used was the isolated liver perfusion. Hepatic gluconeogenesis in arthritic rats was generally lower than in normal rats. The difference between normal and arthritic rats depended on the gluconeogenic substrate. In the absence of glucagon the following sequence of decreasing differences was found: alanine (-71.8 per cent) reverse similarglutamine (-71.7 per cent)>pyruvate (-60 per cent)>lactate+pyruvate (-44.9 per cent)>xylitol (n.s.=non-significant) reverse similarglycerol (n.s.). For most substrates glucagon increased hepatic gluconeogenesis in both normal and arthritic rats. The difference between normal and arthritic rats, however, tended to diminish, as revealed by the data of the following sequence: alanine (-48.9 per cent) reverse similarpyruvate (-47.6 per cent)>glutamine (-33.8 per cent)>glycerol (n.s.) reverse similarlactate+pyruvate (n.s.) reverse similarxylitol (n.s.). The causes for the reduced hepatic gluconeogenesis in arthritic rats are probably related to: (a) lower activities of key enzymes catalyzing most probably steps preceding phosphoenolpyruvate (e.g. phosphoenolpyruvate carboxykinase, pyruvate carboxylase, etc. ); (b) a reduced availability of reducing equivalents in the cytosol; (c) specific differences in the situations induced by hormones or by the individual substrates. Since glycaemia is almost normal in chronically arthritic rats, it seems that lower gluconeogenesis is actually adapted to the specific needs of these animals.

Gluconeogenesis in the liver of arthritic rats

The gluconeogenic response in the liver from rats with chronic arthritis to various substrates and the effects of glucagon were investigated. The experimental technique used was the isolated liver perfusion. Hepatic gluconeogenesis in arthritic rats was generally lower than in normal rats. The difference between normal and arthritic rats depended on the gluconeogenic substrate. In the absence of glucagon the following sequence of decreasing differences was found: alanine (−71·8 per cent)∽glutamine (−71·7 per cent)>pyruvate (−60 per cent)>lactate+pyruvate (−44·9 per cent)>xylitol (n.s.=non-significant)∽glycerol (n.s.). For most substrates glucagon increased hepatic gluconeogenesis in both normal and arthritic rats. The difference between normal and arthritic rats, however, tended to diminish, as revealed by the data of the following sequence: alanine (−48·9 per cent)∽pyruvate (−47·6 per cent)>glutamine (−33·8 per cent)>glycerol (n.s.)∽lactate+pyruvate (n.s.)∽xylitol (n.s.). The causes for the reduced hepatic gluconeogenesis in arthritic rats are probably related to: (a) lower activities of key enzymes catalyzing most probably steps preceding phosphoenolpyruvate (e.g. phosphoenolpyruvate carboxykinase, pyruvate carboxylase, etc.); (b) a reduced availability of reducing equivalents in the cytosol; (c) specific differences in the situations induced by hormones or by the individual substrates. Since glycaemia is almost normal in chronically arthritic rats, it seems that lower gluconeogenesis is actually adapted to the specific needs of these animals. Copyright © 1999 John Wiley & Sons, Ltd.

Interaction of polystyrene microspheres with liver cells: roles of membrane receptors and serum proteins

Our previous studies have demonstrated that serum would play an important role in the hepatic disposition of polystyrene microspheres (MS) and that complement C3 should be involved as the serum opsonin. In this study, we tried to identify the entity of other serum opsonins and dysopsonin for the hepatic uptake of MSs with particle sizes of 50 nm (MS-50) and 500 nm (MS-500) by isolated liver perfusion studies using a recirculation procedure in rats. Pretreatment of the liver by trypsin significantly suppressed the serum-dependent hepatic uptake of both MSs, suggesting that some protein components on the cell surface should be necessary for the serum-dependent phagocytosis of MSs. Pretreatment of the serum by the anti-fibronectin antibody resulted in a significant reduction in the hepatic disposition of MS-500 (49% of control), suggesting that fibronectin should also work as the opsonin for the hepatic uptake of MS-500. The hepatic disposition of both MSs in the presence of serum was inhibited by the addition of N-acetylgalactosamine into the perfusate, suggesting the possible involvement of lectin in the serum-dependent hepatic uptake of MSs. Furthermore, a more intensive hepatic disposition of MSs was observed in the presence of plasma compared with that in the presence of serum in the perfusate, suggesting the possible involvement of blood coagulation factors, such as fibrinogen, as the opsonin in the hepatic disposition of MSs.

Mechanisms of hepatic disposition of polystyrene microspheres in rats: Effects of serum depend on the sizes of microspheres

To study the mechanisms of the hepatic disposition of polystyrene microspheres (MS), effects of serum on their hepatic disposition characteristics were investigated for MSs with particle sizes of 50 nm (MS-50) and 500 nm (MS-500) by isolated liver perfusion experiments. It was revealed that serum in the perfusate inhibited and promoted the hepatic disposition of MS-50 and MS-500 at 37°C, respectively. However, pre-heating at 56°C or pre-treatment with anti-C3 antibody of serum reduced the promotive effect of serum on the hepatic uptake of MS-500, suggesting that the complement system should be involved as opsonins for the hepatic uptake of MS-500. Hepatic disposition of both MSs at 4°C was reduced by the addition of serum into the perfusate, which could be ascribed to the reduction of the surface hydrophobicity of MSs due to the adsorption of serum proteins onto the surface of MSs and to resultant decrease in non-specific disposition to the liver. From these results, serum was found to function both as the opsonin to enhance the hepatic uptake of MSs and as the inhibitor by reducing non-specific interaction between MSs and the plasma membrane. Whether serum promotes or inhibits the hepatic disposition of MSs would be dependent on the particle sizes of MSs.

The serum interleukin 8 level reflects hepatic mitochondrial redox state in hyperthermochemohypoxic isolated liver perfusion with use of a venovenous bypass

Background: We have recently developed a simple method of hyperthermochemohypoxic isolated liver perfusion (HILP) as a regional therapy for unrecognized liver micrometastases. However, little is known about the influence of HILP on cytokine production and liver function. We investigated the influence of HILP on interleukin 8 (IL-8) production and the hepatic mitochondrial function and assessed the relationship between these 2 parameters. We also measured the serum tumor necrosis factor-α (TNF-α) and interleukin 1β (IL-1β) levels to examine the involvement of HILP-induced cytokines in the tumor response. Methods: Sixteen patients with metastatic liver tumors were randomly assigned to undergo hepatectomy with HILP (group A, n = 9) or hepatectomy alone (group B, n = 7). The isolated liver was perfused for 30 minutes with Ringer's lactate solution containing chemotherapeutic agents warmed to 42°C to 43°C without oxygenation. Results: The serum IL-8 levels in group A were markedly increased, with peaks at 3 hours after reperfusion, which was significantly higher than levels in group B (P < .01). In group A the arterial ketone body ratio, which reflects the hepatic mitochondrial redox state, decreased during perfusion and was gradually restored to the preperfusion level 1 hour after reperfusion. However, in group B it decreased during hepatectomy but rapidly recovered 5 minutes after hepatectomy. There was a significant negative correlation between the peak serum IL-8 level and the initial velocity of arterial ketone body ratio recovery for the first 5 minutes after reperfusion r = –0.83, P < .001). The serum TNF-α and IL-1β were temporarily detected only in 3 of 9 patients in group A. Conclusions: We have shown that HILP resulted in augmented IL-8 release but not TNF-α and IL-1β and that the serum IL-8 level reflects the hepatic mitochondrial redox state. These findings suggest that IL-8 production may be associated with hepatic mitochondrial impairment during ischemia. This work may contribute to new therapeutic strategies not only for hepatic ischemia reperfusion injury but also for metastatic liver tumors. (Surgery 1999;125:304-14.)

The serum interleukin 8 level reflects hepatic mitochondrial redox state in hyperthermochemohypoxic isolated liver perfusion with use of a venovenous bypass

Background: We have recently developed a simple method of hyperthermochemohypoxic isolated liver perfusion (HILP) as a regional therapy for unrecognized liver micrometastases. However, little is known about the influence of HILP on cytokine production and liver function. We investigated the influence of HILP on interleukin 8 (IL-8) production and the hepatic mitochondrial function and assessed the relationship between these 2 parameters. We also measured the serum tumor necrosis factor-α (TNF-α) and interleukin 1β (IL-1β) levels to examine the involvement of HILP-induced cytokines in the tumor response. Methods: Sixteen patients with metastatic liver tumors were randomly assigned to undergo hepatectomy with HILP (group A, n = 9) or hepatectomy alone (group B, n = 7). The isolated liver was perfused for 30 minutes with Ringer's lactate solution containing chemotherapeutic agents warmed to 42°C to 43°C without oxygenation. Results: The serum IL-8 levels in group A were markedly increased, with peaks at 3 hours after reperfusion, which was significantly higher than levels in group B ( P < .01). In group A the arterial ketone body ratio, which reflects the hepatic mitochondrial redox state, decreased during perfusion and was gradually restored to the preperfusion level 1 hour after reperfusion. However, in group B it decreased during hepatectomy but rapidly recovered 5 minutes after hepatectomy. There was a significant negative correlation between the peak serum IL-8 level and the initial velocity of arterial ketone body ratio recovery for the first 5 minutes after reperfusion r = –0.83, P < .001). The serum TNF-α and IL-1β were temporarily detected only in 3 of 9 patients in group A. Conclusions: We have shown that HILP resulted in augmented IL-8 release but not TNF-α and IL-1β and that the serum IL-8 level reflects the hepatic mitochondrial redox state. These findings suggest that IL-8 production may be associated with hepatic mitochondrial impairment during ischemia. This work may contribute to new therapeutic strategies not only for hepatic ischemia reperfusion injury but also for metastatic liver tumors. (Surgery 1999;125:304-14.)

Endothelial dysfunction and decreased production of nitric oxide in the intrahepatic microcirculation of cirrhotic rats.

Increased intrahepatic resistance in cirrhotic livers is in part caused by increased vascular tone. Several morphological abnormalities have been described in the sinusoidal endothelial cells of cirrhotic livers, but the functional impact of these abnormalities on the intrahepatic vascular tone has not been studied. The aim of this study was to investigate the intrahepatic endothelial function and the role of nitric oxide (NO) with regard to vascular tone in cirrhotic livers. Isolated rat liver perfusions were performed in cirrhotic rats (induced by chronic carbon tetrachloride inhalation) and weight-matched normal controls. After preconstricting the intrahepatic microcirculation with methoxamine (10(-4) mol/L), response to cumulative doses of receptor-mediated endothelial agonist, acetylcholine (10(-7) mol/L-10(-5) mol/L), was obtained. In another series, response to the receptor-independent endothelial agonist, calcium ionophore A23187 (10(-7) mol/L and 3 x 10(-7) mol/L), was obtained in the absence and presence of Nomega-nitro-L-arginine (NNA) and indomethacin. In a third series of rats, nitrate and nitrite production was measured in the perfusate of perfused normal and cirrhotic livers. There was significantly less vasorelaxation in cirrhotic livers as compared with normal livers in response to acetylcholine and calcium ionophore A23187 (P < .0001). The impaired vasorelaxation was a result of a decrease in both NO-mediated and non-NO-mediated components of vasorelaxation. Cirrhotic livers from ascitic rats had significantly less vasorelaxation as compared with livers from nonascitic rats (P < .005). There was significantly less production of nitrates and nitrites in cirrhotic livers (P < .05). The liver microcirculation of cirrhotic livers is characterized by endothelial dysfunction that results in impaired release of endothelial relaxing factors including NO.

First experience and technical aspects of isolated liver perfusion for extensive liver metastasis

Background: New drugs and modalities for locoregional tumor treatment in recent years may offer new potential for isolated liver perfusion in patients with nonresectable liver tumors. The purpose of this study was to prove the feasibility of arterial isolated liver perfusion and to assess the tolerance of perfusion with high-dose tumor necrosis factor (TNF). Methods: Twelve patients with extensive liver metastases previously treated unsuccessfully with systemic chemotherapy underwent isolated hyperthermic liver perfusion using a heart-lung machine. High doses of mitomycin were administered in the first six and a combination of TNF and melphalan in the last six patients. Results: No operative death occurred and no direct postoperative liver failure was observed in any patient. In cases of variations of the arterial hepatic blood supply, the perfusion was done through the splenic artery or an angiography catheter. Histologic analysis of tumor biopsy specimens obtained on the first postoperative day revealed major tumor necrosis in 8 of 12 patients. Conclusions: Isolated arterial perfusion of the liver is a complex surgical procedure that is feasible in patients with anatomic variations of the hepatic artery. The remarkable histologic response to perfusion in several pretreated patients, especially after application of high-dose TNF and melphalan, suggests that this modality is very effective in tumor killing. (Surgery 1998;123:622-31.)

First experience and technical aspects of isolated liver perfusion for extensive liver metastasis

First experience and technical aspects of isolated liver perfusion for extensive liver metastasis

Hyperosmolarity associated with diabetes insipidus alters hepatocyte structure and function but not survival after orthotopic liver transplantation in rats.

This study was designed to evaluate the effect of donor hyperosmolarity secondary to diabetes insipidus, an almost universal occurrence among brain-dead patients, on hepatic function. In vitro (isolated liver perfusion) and in vivo (hyaluronic acid and indocyanine green uptake, arterial ketone body ratio, orthotopic liver transplantation) experiments were conducted using Brattleboro rats, with hereditary hypothalamic diabetes insipidus, and Sprague-Dawley rats, with normal pituitary function. ATP content and recovery after cold preservation were measured during the perfusion. Cold-preserved livers from hyperosmolar rats were observed to have elevated hepatic enzyme release and decreased bile production compared with normosmolar controls. Moreover, in these livers, the recovery of ATP after cold preservation was completely absent. Transmission electron microscopy of liver biopsies collected from hyperosmolar rats demonstrated profound ultrastructural changes, particularly in the mitochondria, that were not evident in the biopsies from normosmolar rats. All the experimental groups demonstrated similar hyaluronic acid uptake, whereas indocyanine green uptake was markedly impaired in the hyperosmolar group, suggesting that hepatocyte and not sinusoidal endothelial cell function is adversely affected by hyperosmolarity. The arterial ketone body ratio was profoundly compromised by chronic and, to an even greater degree, by acute hyperosmolarity. Survival after transplantation using hyperosmolar donors was not affected in this study. These results are an important step toward understanding the mechanism whereby brain death, a complicated pathophysiologic phenomenon, adversely affects the hepatic allograft.

Hyperthermo-chemo-hypoxic isolated liver perfusion for hepatic metastases: a possible adjuvant approach.

As a possible intraoperative adjuvant approach to treating hepatic metastases we developed a method of hyperthermo-chemo-hypoxic isolated liver perfusion in combination with hepatic resection. This method was applied to 11 patients with colorectal hepatic metastases between 1992 and 1995. One patient died on postoperative day 14 of hepatic failure (9% mortality), the cause of which was live temperature that reached 42.9 degree C, which seems to be the maximum limit for thermal toxic effect on the human liver. The other 10 patients tolerated the perfusion well, with mild hepatic and non systemic toxicity after minor or even major hepatic resection; the serum aminotransferase and total bilirubin levels returned to normal levels by postoperative day 14. Only one of eight patients (13%) for whom cytotoxic drugs were added to the perfusate (mitomycin C 10 micrograms/ml or cisplatin 2 micrograms/ml) had hepatic recurrence by 19 months after the perfusion (mean follow-up 25.8 months; median 23 months; range 8-57 months). Two patients were alive with no evidence of disease at 13 and 57 months, respectively after the perfusion; the other five patients had postperfusion extrahepatic recurrences (median: 19 months; range 7-20 months). In contrast, hepatic metastases recurred 7 and 20 months after the perfusion, respectively, in the two patients not given a cytotoxic drug.

Role of ultrasonography for monitoring tumor necrosis after chemotherapy.

Ultrasonography for monitoring the response of malignant liver lesions to regional therapy offers several advantages. The instrument is easy to transport and can be used in intensive care units, so it is the procedure of choice within the first few days after invasive techniques, such as isolated liver perfusion, to demonstrate tumor response. Changes in size or in the sonomorphological pattern of liver lesions early after therapy indicate a therapeutic response. There are no data available on the sensitivity of ultrasonography for differentiating the necrotic and viable parts of the tumor. If information on the extent of tumor necrosis is crucial for decisions on further treatment of a patient, ultrasonography should be complemented with other techniques, such as fine-needle puncture or imaging techniques such as computed tomography, nuclear magnetic resonance, and single photon emission computed tomography. The contribution of more recent developments in ultrasonography, such as color Doppler analysis of intratumoral blood flow or three-dimensional ultrasonography, for monitoring tumor necrosis remains to be evaluated.

Isolated Hypoxic Hepatic Perfusion With Tumor Necrosis Factor-Alpha, Melphalan, and Mitomycin C Using Balloon Catheter Techniques

To validate the methodology of isolated hypoxic hepatic perfusion (IHHP) using balloon catheter techniques and to gain insight into the distribution of tumor necrosis factor-alpha (TNF), melphalan, and mitomycin C (MMC) through the regional and systemic blood compartments when applying these techniques. There is no standard treatment for unresectable liver tumors. Clinical results of isolated limb perfusion with high-dose TNF and melphalan for the treatment of melanoma and sarcoma have been promising, and attempts have been made to extrapolate this success to the isolated liver perfusion setting. The magnitude and toxicity of the surgical procedure, however, have limited clinical applicability. Pigs underwent IHHP with TNF, melphalan, and MMC using balloon catheters or served as controls, receiving equivalent dosages of these agents intravenously. After a 20-minute perfusion, a washout procedure was performed for 10 minutes, after which isolation was terminated. Throughout the procedure and afterward, blood samples were obtained from the hepatic and systemic blood compartments and concentrations of perfused agents were determined. During perfusion, locoregional plasma drug concentrations were 20- to 40-fold higher than systemic concentrations. Compared with systemic concentrations after intravenous administration, regional concentrations during IHHP were up to 10-fold higher. Regional MMC and melphalan levels steadily declined during perfusion, indicating rapid uptake by the liver tissue; minimal systemic concentrations indicated virtually no leakage to the systemic blood compartment. During isolation, concentrations of TNF in the perfusate declined only slightly, indicating limited uptake by the liver tissue; no leakage of TNF to the systemic circulation was observed. After termination of isolation, systemic TNF levels showed only a minor transient elevation, indicating that the washout procedure at the end of the perfusions was fully effective. Complete isolation of the hepatic vascular bed can be accomplished when performing IHHP using this balloon catheter technique. Thus, as in extremities, an ideal leakage-free perfusion of the liver can now be performed, and repeated, without major surgery. The effective washout allows the addition of TNF in this setting.

A Porcine Model for Investigation of Hyperthermic Isolated Liver Perfusion

Our study was aimed at developing a reliable method of hyperthermic isolated liver perfusion (HILP) in pigs and at assessing its local and systemic side effects. HILP was performed via the hepatic artery and portal vein in 15 animals. The perfusate consisted of blood (200 ml), oxypolygelatine (500 ml), Ringer's solution (1000 ml), and trapped intrahepatic blood. HILP was carried out for 45 min at a mean perfusate inflow temperature of 41.2°C. The mean portal flow and pressure were adjusted to 500 ml/min and 20-25 mm Hg; the mean arterial flow and pressure were 130 ml/min and 40-60 mm Hg, respectively. After 20 min of perfusion the mean temperature in the right and the left liver lobe were 40.8°C and 40.3°C and remained almost constant over the whole perfusion period. Liver enzymes (alanine aminotransferase and aspartate aminotransferase) and serum lactate levels showed slight increases after perfusion but normalized within 1 week. Histology of liver parenchyma showed only mild pathological changes, which were also reversible within 7 days. The presented method of HILP is a safe and reproducible technique for isolated hyperthermic liver perfusion. Based on this animal model, experimental HILP with different chemotherapeutic agents can be investigated in order to assess hepatic and systemic toxicity of this therapy.

SIZE-DEPENDENT HEPATIC DISPOSITION OF POLYSTYRENE MICROSPHERES

Colloidal particles are good candidates for efficient drug carriers. However, the rapid clearance by macrophages of the reticuloendothelial system (RES), mainly Kupffer cells of liver and to a lesserextent macrophages of the spleen and the bone marrow, limits their application as carriers to other tissues and/or cells. To achieve a rational design of particulate carrier system, the basic information about in vivo disposition and the uptake mechanisms by RES of particle itself should be required. Therefore, in the present study, the in vivo disposition of polystyrene microsphere (MS) with the particle size of 50 nm (MS-50) or 500 nm (MS-500) was characterized after intravenous administration to rats. To study the mechanisms of the hepatic disposition of MSs, effects of serum on their disposition were investigated for both MSs by isolated liver perfusion experiments in rats. From these studies, it was found that serum would function both as opsonin to enhance the hepatic uptake of MSs and as inhibitor by reducing non-specific interaction between MSs and the plasma membrane. Whether serum promotes or inhibits the hepatic disposition of MSs would be dependent on the particle sizes of MSs.

The isolated perfused porcine liver: assessment of viability during and after six hours of perfusion.

Isolated liver perfusion was developed for the study of liver physiology and preservation. The recent development of new perfusion devices and appropriate liver preservation solutions prompted us to reconsider liver perfusion for the specific purpose of evaluating viability in terms of biochemical changes, paying special attention to modifications in the histological ultrastructure. Twenty-two isolated pig livers were perfused with autologous blood. Arterio-portal perfusions were carried out using an extracorporeal perfusion circuit with a hollow fibre membrane oxygenator. Four groups of pig livers were studied using three different liver flushing solutions [Ringer's lactate, ELOHES, and University of Wisconsin (UW)] and two different oxygenation modalities. Liver function tests and histological studies were done. Our results revealed that a high partial oxygen pressure (PO2) level was deleterious to the ultrastructural elements of hepatocytes, in particular to the mitochondria. It was also associated with deficient metabolic performance, i.e., poor bile production and lack of aerobic metabolism. Normal blood gas values could be obtained with the use of air for liver oxygenation. Flushing of the liver with Ringer's lactate or a macromolecular solution such as ELOHES was associated with severe liver cell injuries, as reflected by a marked rise in liver enzymes and histological lesions. Satisfactory results were obtained when UW solution was used for liver harvesting. We conclude that an appropriate liver preservation solution, normal blood gas values, and normal physiological arterio-portal pressure and blood flow are essential for appropriate liver function with preservation of liver architecture and of hepatocyte ultrastructures. Total bilirubin in bile and Factor V are sensitive indicators of good liver function.

Liver and tumour tissue concentrations of TNF-alpha in cancer patients treated with TNF-alpha and melphalan by isolated liver perfusion

In this study we determined the level of tumour necrosis factor alpha (TNF-alpha) in liver and tumour tissue samples obtained from patients with colorectal metastases confined to the liver, who were treated with isolated liver perfusion with TNF-alpha and melphalan. We adapted a standard enzyme-linked immunosorbent assay kit for the quantification of TNF-alpha in serum to measure the amount of this cytokine in solid tissue. For this purpose, we developed a buffer that lysed the tissues without affecting the TNF-alpha present. The minimum detection level was about 2 pg of TNF-alpha per mg tissue. Using this technique, we found a significant increase in the TNF-alpha level after perfusion in the liver tissue of all evaluable patients, which may explain the transient liver toxicity we observed in all patients. In tumour tissue, a significant TNF-alpha increase was observed in one out of five patients. The level of TNF-alpha in all liver tissue samples and some of the tumours after treatment by isolated liver perfusion was much higher than the peak serum concentrations obtained after systemic administration of the maximum tolerated dose of TNF-alpha. Furthermore, we demonstrated that the level of TNF-alpha in the liver tissue samples was about seven to eight times higher than in tumour tissue. We concluded that regional liver treatment resulted in a relatively high local level of TNF-alpha, but also that this cytokine did not preferentially accumulate in tumour tissue.

Biochemical and morphological changes in the liver during isolated liver perfusion with double bypass using automatic blood pumps

Isolated organ perfusion is used in clinical practice for chemotherapy in adults with malignant tumors. However, it has not been performed in children because of the size mismatch with the adult circuits. The authors have previously studied isolated liver perfusion in small animals using the self-regulating extracorporeal membrane oxygenation circuit. The present study was designed to investigate the biochemical and morphological changes in the liver during isolated liver perfusion with double bypass using automatic blood pumps. Isolated liver perfusion was performed with bypass between the hepatic and portal veins in seven weanling Yorkshire swine weighing 8.2 to 12.2 kg, at a flow rate of 20 mL/min/kg for up to 4 hours. Venous blood from the intestine and lower body was bypassed to the superior vena cava. As a result, perfusate glutamic pyruvic transaminase and lactate concentrations did not change during liver perfusion. On gross inspection, the surface of the liver was mottled. Microscopically, normal histology of the hepatic parenchyma and portal tract structures was preserved. Transmission electron microscopy showed no gross structural abnormalities in most of the hepatocytes for up to 4 hours. However, swelling of the mitochondria and smooth endoplasmic reticulum was seen occasionally in a very small number of the hepatocytes after more than 3 hours of perfusion. Glycogen granules decreased with time in some animals. Isolated liver perfusion at 20 mL/min/kg of perfusion flow can be performed safely for up to 4 hours with nearly intact hepatocellular function and morphology.