Multidisciplinary team assisted by ECMO escorts Shulan Medical's hospitals to complete the "impossible mission"

Last Friday, 64-year-old Mr. Song was successfully discharged from Shulan (Hangzhou) Hospital, a subsidiary of Shulan Medical. Before he was discharged from the hospital, he felt a lot of emotions in his heart: "This is the place where my second life began, and I would like to thank all the medical team of Shulan (Hangzhou) Hospital who have helped us!"

Previously, due to cirrhosis of the liver combined with liver failure and serious underlying heart disease, Mr. Song went to many hospitals and finally sought help from Academician Zheng Shusen, a well-known organ transplant expert in mainland China. Under the escort of the multidisciplinary team of Shulan (Hangzhou) Hospital, a subsidiary of Shulan Medical, Mr. Song finally walked out of the ghost gate step by step without danger.

Traveled to several hospitals to wait for a liver transplant and suffered a sudden cardiac arrest on the night of admission

Mr. Song's hometown is in Jiangxi, where he is a mathematics teacher at a local middle school. He has a habit of drinking, and has been using seven taels of liquor every day for more than 30 years. Over time, it slowly developed into alcoholic cirrhosis.

In the second half of last year, Mr. Song's condition deteriorated further, and he developed liver failure and was dying. His family accompanied him to many major hospitals inside and outside the province, and the answer was unanimous, the only hope for saving his life was to have a liver transplant.

The trouble is that after evaluation, in addition to severe liver cirrhosis, Mr. Song also suffers from coronary heart disease, atrial fibrillation, arrhythmia and other underlying heart diseases, and his heart function is very poor, and the risk of surgery is very high. For this reason, Mr. Song and his family finally came to Shulan (Hangzhou) Hospital, a subsidiary of Shulan Medical, and found Academician Zheng Shusen to seek surgical opportunities. Unexpectedly, less than 3 hours after being admitted to the ward, Mr. Song suddenly lost consciousness and was urgently transferred to the ICU for rescue.

The heart "strikes", can a liver transplant still be done?

The patient was admitted to the ICU and found that there was a serious arrhythmia, the heartbeat was only 10-30 beats/min (60-100 beats/min for normal people), and the blood from the heart could not meet the blood supply of the whole body, and the problem could not be solved by drug treatment alone, so he contacted the cardiology department to the ICU bedside to urgently install a temporary pacemaker.

Ma Liping, director of the Department of Cardiology at Shulan (Hangzhou) Hospital, said, "The situation was very urgent at that time, the heartbeat was very slow, and there was sinus rest. The most important thing at the moment is to maintain the heartbeat first!" So, the cardiology team performed a temporary pacemaker installation for Mr. Song that night.

Mr. Song's heart was temporarily restored to pumping function with a pacemaker, but the patient had repeated ventricular tachycardia and ventricular fibrillation, and he was rescued more than 10 times in 3 days, and the most serious one was rescued by 16 minutes of extracardiac compressions. Fortunately, after active treatment by ICU doctors, the arrhythmia was finally controlled. At this moment, a more serious question is in front of us: can the patient still have a liver transplant? If he does not have a liver transplant, it means "waiting for death", and if he does a liver transplant, the risk is too high, and the dilemma lies between life and death.

A multidisciplinary team escorts to discuss and develop a surgical plan

Therefore, led by Academician Zheng Shusen, a medical team composed of experts from the Department of Hepatobiliary and Pancreatic Surgery, Department of Infectious Diseases, Department of Cardiology, Department of Critical Care Medicine, Liver Transplantation ICU, Department of Anesthesiology and nursing team of Shulan Hospital decided to use extracorporeal membrane oxygenation machine (ECMO) in liver transplantation to assist cardiac function in liver transplantation, so as to avoid complications such as serious heart failure during surgery, and at the same time actively treat artificial liver before surgery to improve the general condition.

Chief physician Lu Anwei, director of the Department of Intensive Care Medicine of Shulan (Hangzhou) Hospital, introduced that there is a great problem in intraoperative ECMO assistance, normal ECMO intubation needs to cross the liver transplant surgical field, if the normal catheter is placed according to the operation, it will affect the surgical operation, and in addition to its own high risk and high difficulty in use, it cannot be anticoagulated during operation, which increases the risk of coagulation in ECMO membrane lung.

In addition, anesthesia management during surgery is also critical. Chief Physician Huang Suqin, director of the Department of Anesthesiology, said that intraoperative anesthesia should fully consider the patient's cardiopulmonary function, accurately control fluid rehydration, and protect the patient's cardiopulmonary function as much as possible.

According to Zhang Wu, chief physician of the Department of Hepatobiliary and Pancreatic Surgery, the biggest challenge of the operation is to be precise and precise and reduce the amount of intraoperative blood loss as much as possible. Secondly, "rapid liver resection" is achieved during the operation, "in the process of liver transplantation, the liver-free period is generally controlled within one hour, because our team is very experienced in liver transplantation surgery and very skilled, so the liver-free period will be relatively short, which is conducive to the postoperative recovery of patients."

Wang Zhuoyi, deputy chief physician of Shulan Liver Transplantation ICU, said that the perioperative management of patients is extremely important, and they also need to face multiple barriers such as infection and rejection after surgery.

In the face of the immediate difficulties, Mr. Song and his family, who had a strong desire to survive, did not hesitate at all, and they fully trusted Academician Zheng's team and made up their minds to carry out this ultra-difficult liver transplant operation.

The surgery was successfully completed with the assistance of ECMO, and the machine was successfully weaned only 14 hours after surgery

At the beginning of March, Mr. Song waited for a matching liver source, and the operation was performed by Academician Zheng Shusen. This is a difficult operation in a race against time and against death. During the operation, Lu Anwei, director of the Department of Intensive Care Medicine of Shulan Medical, paid close attention to the operation of the ECMO machine and monitored the normal indicators of various indicators, while Huang Suqin, director of the Department of Anesthesiology, accurately calculated the rehydration dose and coagulation time to ensure the safety of anesthesia......

The preparations were carried out in an orderly manner, and one difficulty after another was overcome by the medical team.

Academician Zheng Shusen quickly and accurately cut off the diseased liver and skillfully completed the liver transplantation operation, which took more than 5 hours and had very little bleeding. After returning to the ICU after surgery, Deputy Chief Physician Liu Xiangyan and Head Nurse Zhang Yuanyuan of Shulan Medical Liver Transplant Team closely monitored vital signs at the bedside, and the patient woke up 2 hours later, and the rescue drugs were withdrawn one after another, and 14 hours later, ECMO was successfully weaned. This also means that Mr. Song has passed this ultra-difficult operation smoothly and smoothly.

After a series of anti-rejection and anti-infection treatment and rehabilitation exercises, Mr. Song's transplanted liver function gradually improved, he was successfully removed from the ventilator, fed independently, and gradually moved to the ground, and was transferred from the ICU to the hepatobiliary and pancreatic general ward one week later. According to Ma Liping, chief physician of the Department of Cardiology, the tracking of the postoperative Holter electrocardiogram showed that Mr. Song's temporary pacemaker was pacing about 7.8% of the time, which indicated that he still had the possibility of cardiac arrest at any time and needed to implant a permanent pacemaker.

"At that time, the patient's platelets were still at a very low level, and the operation needed to avoid bleeding as much as possible, so after another multidisciplinary consultation, the cardiology team chose a leadless permanent pacemaker with a small incision for Mr. Song. ”

At present, Mr. Song's physical signs are stable, and his transplanted liver and heart function are good, which is similar to when he first arrived at the hospital. Last Friday, he met the discharge criteria for all physical indicators and was finally discharged from the hospital.

For Mr. Song, the success of the operation is inseparable from the family's 100% trust in the doctor. "Before the surgery, we fully trusted the medical team at Shulan Hospital, and we would not give up as long as there was a glimmer of hope. Even if the result fails, we don't regret it. Mr. Song's wife said.

"The trust of patients and their families in doctors is our confidence and confidence to dare to work hard. Academician Zheng Shusen said that in the past, patients like Mr. Song with end-stage liver disease and heart function problems often did not have the opportunity to have a liver transplant because the risk of surgery was too high. With the application of ECMO technology in the field of organ transplantation and the development of refined liver transplantation technologies such as "rapid liver resection", it will bring hope to more difficult patients like Mr. Song in the future.

There are three types of difficult and complex liver transplants, accounting for 40% of the total number of liver transplants.

At Shulan (Hangzhou) Hospital, a subsidiary of Shulan Medical, there is a high proportion of patients and family members with accents from all over the country, and patients come to the hospital from all over the country and even abroad to let experts solve their difficult and serious diseases - a considerable number of these diseases have even left doctors helpless in hospitals around the country.

"Difficult and complex liver transplantation requires the cooperation of a multidisciplinary team, which requires the hospital to have a very strong transplant foundation and be able to routinely carry out difficult and complex liver transplantation, which is the embodiment of the comprehensive strength of a hospital. Over the years, the liver transplantation team of Shulan Hospital has been working hard in the field of liver transplantation, among which difficult and complex surgeries account for 40% of the total number of surgeries, and have accumulated a lot of clinical experience. In liver transplant surgery, we use the 'rapid liver resection technique', which can reduce bleeding and have fewer complications, and we have 1/3 of liver transplants with almost no blood transfusion, and patients recover faster. ”

According to Academician Zheng Shusen, there are three main types of difficult and complex liver transplantation: one is the primary disease with severe primary disease and other important organ function damage. For example, a case like Mr. Song, with liver failure and serious underlying heart disease, is not only more difficult, but also more likely to cause complications after surgery. The second is that a patient who has undergone multiple liver surgeries before, such as a patient from another province who has undergone three liver cancer surgeries, and the last one is still recurring, and the chest cavity is widely adhesed, which is more difficult than ordinary liver transplantation. There are also patients with poor vascular conditions, such as poor vascular conditions such as the portal vein, and cavernous lesions, which will also increase the difficulty of liver transplantation.

"In the past, we always thought that there was no hope for these difficult and complex patients, but in Shulan Hospital, we are still patient-centered and people-centered, and try our best to use innovative technologies and means to save the lives of these patients.