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Gao Q, Cai JZ, Dong H. A Review of the Risk Factors and Approaches to Prevention of Post-Reperfusion Syndrome During Liver Transplantation. Organogenesis 2024; 20:2386730. [PMID: 39097866 PMCID: PMC11299628 DOI: 10.1080/15476278.2024.2386730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 06/22/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024] Open
Abstract
Post-reperfusion syndrome (PRS) is a severe and highly lethal syndrome that occurs after declamping the portal vein forceps during liver transplantation. It is marked by severe hemodynamic disturbances manifested by decreased mean arterial pressure, increased heart rate and elevated pulmonary artery pressure. The complex pathogenesis of PRS remains understudied. It is generally believed to be related to the large amount of acidic, cold blood that enters the circulation after release of the portal clamp. This blood is rich in oxygen-free radicals and metabolic toxins, which not only aggravate the ischemia-reperfusion injury of the liver but also further attack the systemic organs indiscriminately. Considering the range of possible adverse prognoses including acute kidney injury, delirium and graft nonfunction, it is imperative that clinicians increase their awareness and prevention of PRS. The aim of this article is to review the current risk factors, pathophysiological mechanisms and prevention strategies for PRS.
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Affiliation(s)
- Qian Gao
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jin-Zhen Cai
- Organ Transplant Center, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - He Dong
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
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Noh Y, Kim J, Lee S, Choi J, Kim GS. Discrepancy Between Pulmonary Artery Catheter and Co-Oximeter Value of Mixed Venous Oxygen Saturation After Graft Reperfusion During Living Donor Liver Transplantation. Transplant Proc 2024; 56:2191-2195. [PMID: 39617683 DOI: 10.1016/j.transproceed.2024.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Accepted: 11/05/2024] [Indexed: 12/17/2024]
Abstract
BACKGROUND Monitoring tissue oxygenation is critical in liver recipients. The pulmonary artery catheter (PAC) provides continuous monitoring of mixed venous oxygen saturation (SvO2) using fiberoptic reflectance spectrophotometry. Despite the need for in vivo calibration during liver transplantation, recalibration guidelines are absent, and we frequently observed a significant discrepancy between PAC and reference co-oximeter SvO2 values after graft reperfusion. This study aimed to assess the incidence and risk factors of a significant discrepancy after reperfusion during living donor liver transplantation. METHODS This retrospective study included 54 recipients who underwent living donor liver transplantation at our institution between October 2021 and April 2022. A PAC was inserted, and in vivo calibration was conducted using the co-oximeter SvO2 value. We defined a significant discrepancy as a drift was ≥ 3% at 1 hour after reperfusion. Logistic regression analysis was performed to determine the association between perioperative variables and the risk of significant discrepancy. RESULTS PAC SvO2 was higher than co-oximeter SvO2 in 51 recipients. A significant discrepancy was observed in 37 recipients (68.5%). The risk of significant discrepancy decreased with a high preoperative hemoglobin concentration (odds ratio [OR] = 0.65 [0.47-0.91], P = .011) and a high arterial oxygen partial pressure (PaO2) at 1 hour after reperfusion (OR = 0.96 [0.94-0.99], P = .004) but increased with a high baseline co-oximeter SvO2 value (OR = 1.29 [1.05-1.59], P = .015). CONCLUSIONS PAC SvO2 significantly drifted from the reference co-oximeter value in over two-thirds of recipients after reperfusion. Therefore, in vivo recalibration is required for the reliable measurement of PAC SvO2 during living donor liver transplantation.
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Affiliation(s)
- Yeonji Noh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sooyeon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jisun Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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González-Suárez S, Serrano HA, Chocron IZ, Tormos P, Cano E, Galán P, de Nadal M, Matarín S, Cabeza M, Rodríguez-Tesouro AB. Postreperfusion Syndrome in Patients Receiving Vasoactive Drugs During Liver Graft Reperfusion. EXP CLIN TRANSPLANT 2024; 22:43-51. [PMID: 38284374 DOI: 10.6002/ect.2023.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
OBJECTIVES The most widely used definition of postreperfusion syndrome in liver transplant is a 30% decrease in mean arterial pressure during the first 5 minutes after vascular unclamping. With these criteria, increased postoperative morbidity has been reported. Vasoactivedrugs couldpreventthis syndrome.Themain objective of our study was to determine the incidence and complications associated with postreperfusion syndrome inpatientswho receivedvasoactive support. MATERIALS AND METHODS We studied 246 patients who received norepinephrine infusions to maintain mean arterial pressure ≥60 mm Hg and who were monitored with a Swan-Ganz catheter. Patients received a bolus of adrenaline after vascular unclamping in cases of insufficient response to norepinephrine. RESULTS Among the study patients, 57 (23.17%) developed postreperfusion syndrome. Patients who developed postreperfusion syndrome did not present with morepostoperative complications interms ofrenal dysfunction (P = .69), repeat surgery (P = .15), graft rejection (P = .69), transplant replacement surgery (P = .76), hospital stay (P = .70), or survival (P = .17) compared with patients without postreperfusion syndrome. CONCLUSIONS In patients who underwent orthotopic liver transplant, in whom vasoactive drugs were administered, a diagnosis of self-limited postreperfusion syndrome during the first 5 minutes after unclamping may not be associated with postoperative complications. The administration of vasoconstrictors may have a preventive effect on the postoperative complications associated with postreperfusion syndrome or they may mask the real incidence of postreperfusion syndrome. A broader definition of postreperfusion syndrome should be accepted.
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Affiliation(s)
- Susana González-Suárez
- From the Department of Surgery, Universitat Autònoma de Barcelona, Unitat Docent Vall d'Hebron, Barcelona, Spain; and the Department of Anesthesiology and Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
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Umehara K, Karashima Y, Yoshizumi T, Yamaura K. Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study. Anesth Analg 2022; 135:354-361. [PMID: 35343925 DOI: 10.1213/ane.0000000000006002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postreperfusion syndrome (PRS) after portal vein reperfusion during liver transplantation (LT) has been reported to cause rapid hemodynamic changes and is associated with a prolonged postoperative hospital stay, renal failure, and increased mortality. Although there are some reports on risk factors for PRS in brain-dead donor LT, there are a few reports on those in living donor LT. Therefore, we retrospectively reviewed the factors associated with PRS to contribute to the anesthetic management so as to reduce PRS during living donor LT. METHODS After approval by the ethics committee of our institution, 250 patients aged ≥20 years who underwent living donor LT at our institution between January 2013 and September 2018 were included in the study. A decrease in mean arterial pressure of ≥30% within 5 minutes after portal vein reperfusion was defined as PRS, and estimates and odds ratio (OR) for PRS were calculated using logistic regression. The backward method was used for variable selection in the multivariable analysis. RESULTS Serum calcium ion concentration before reperfusion (per 0.1 mmol/L increase; OR, 0.74; 95% confidence interval (CI), 0.60-0.95; P < .001), preoperative echocardiographic left ventricular end-diastolic diameter (per 1-mm increase: OR, 0.90; 95% CI, 0.85-0.95; P < .001, men [versus women: OR, 2.45; 95% CI, 1.26-4.75; P = .008]), mean pulmonary artery pressure before reperfusion (restricted cubic spline, P = .003), anhepatic period (restricted cubic spline, P = .02), and graft volume to standard liver volume ratio (restricted cubic spline, P = .03) were significantly associated with PRS. CONCLUSIONS In living donor LT, male sex and presence of small left ventricular end-diastolic diameter, large graft volume, and long anhepatic period are associated with PRS, and a high calcium ion concentration and low pulmonary artery pressure before reperfusion are negatively associated with PRS.
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Affiliation(s)
- Kaoru Umehara
- From the Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Karashima
- From the Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Shahbazov R, Azari F, Xu T, Saracino G, Maluf D, Pelletier SJ. Effects of Initial Hepatic Artery Followed by Portal Reperfusion Technique on Deceased Donor Liver Transplant Outcomes. EXP CLIN TRANSPLANT 2021; 19:671-675. [PMID: 33928876 DOI: 10.6002/ect.2020.0555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although initial portal vein reperfusion of a liver allograft is nearly standardized, limited data suggest initial hepatic artery reperfusion may improve hemodynamics and posttransplant outcomes. MATERIALS AND METHODS We retrospectively reviewed orthotopic liver transplants performed between January 2013 and February 2018. Parameters of liver recipients with initial hepatic artery reperfusion were compared with those with initial portal vein reperfusion. RESULTS Of 204 recipients, 53 (26%) were initially perfused from the hepatic artery and 151 (74%) were initially perfused from the portal vein. Demographics between groups did not differ. There were no significant differences in the incidence of acute rejection between recipients with initial hepatic artery reperfusion versus portal vein reperfusion at 3 months and 1 year (1.9% vs 7.9% and 7.5% vs 10.6%; not significant), hepatic artery thrombosis (1.9% vs 4.0% and 1.9% vs 7.3%; not significant), biliary leakage (7.5% vs 4.0% and 9.4 vs 6.6; not significant), biliary strictures (7.5% vs 5.3% and 11.3% vs 7.9%; not significant), or portal or hepatic venous thrombosis/stenosis (5.7% vs 5.3% and 7.5% vs 7.9%; not significant). Furthermore, recipients with initial hepatic artery reperfusion and portal vein reperfusion were both hospitalized for a median of 8.5 days (interquartile range, 6.5-15.5 vs 7.0-14.0 days, respectively), and both groups were in the intensive care unit for a median of 3 days (interquartile range, 2-7 vs 2-4 days, respectively). Initial hepatic artery reperfusion was associated with significantly less intraoperative packet red blood cell transfusion (median, 11.9 U [interquartile range, 11.1-13.1 U] vs 15.5 U [interquartile range, 12.9-17.9 U]; P < .001). The 2 groups did not differ in terms of patient and graft survival. CONCLUSIONS Initial reperfusion of liver allografts with arterial, rather than portal, blood has benefits to hemodynamic stability, did not have deleterious effects on outcomes, and resulted in less intraoperative blood utilization.
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Affiliation(s)
- Rauf Shahbazov
- From the Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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Pietersen LC, Sarton E, Alwayn I, Lam HD, Putter H, van Hoek B, Braat AE. Impact of Temporary Portocaval Shunting and Initial Arterial Reperfusion in Orthotopic Liver Transplantation. Liver Transpl 2019; 25:1690-1699. [PMID: 31276282 DOI: 10.1002/lt.25592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 06/06/2019] [Indexed: 01/13/2023]
Abstract
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
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Affiliation(s)
- Lars Cornelis Pietersen
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian Alwayn
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hwai-Ding Lam
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andries Erik Braat
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Identifying the Superior Reperfusion Technique in Liver Transplantation: A Network Meta-Analysis. Gastroenterol Res Pract 2019; 2019:9034263. [PMID: 31641349 PMCID: PMC6766671 DOI: 10.1155/2019/9034263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 08/21/2019] [Indexed: 01/26/2023] Open
Abstract
Objective To investigate the clinical effects of different reperfusion techniques in liver transplantation based on network meta-analysis. Method Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, EMBASE, and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the clinical effects of respective reperfusion techniques in liver transplantation. Short- and long-term parametric data, including ICU stay, dysfunction rate (DFR), biliary complications (BC), 1-year graft survival (GS), and patient survival (PS), were quantitatively pooled and estimated based on the Bayesian theorem. The P values of surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated and ranked by various techniques. The Grades of Recommendations Assessment, Development and Evaluation (GRADE) criteria were utilized for the recommendations of evidence from pairwise direct comparisons. Results Seven RCTs containing 6 different techniques were finally included for network meta-analysis. The results indicated that retrograde vena cava (RVC) reperfusion possessed the highest possibility of revealing the best clinical effects on DFR (SUCRA, P = 0.93), ICU stay (SUCRA, P = 0.76), and GS (SUCRA, P = 0.44), while portal-arterial reperfusion (simultaneous initialize) seemed to exhibit the most benefits in reducing BC (SUCRA, P = 0.67) and enhancing PS rate (SUCRA, P = 0.48). Moreover, sensitivity analysis with the inconsistency approach clarified the reliability of the main results, and the evidence of the most direct comparisons was ranked low or very low. Conclusions Current evidence demonstrated that RVC and portal-arterial reperfusion (simultaneously initialized) revealed superior clinical effects, compared to other interventions. Investigation of these 2 techniques should be a future research direction, and more high-quality RCTs are expected.
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Efficacy of IgM-enriched Immunoglobulin for Vasopressor-resistant Vasoplegic Shock After Liver Transplantation. Transplantation 2019; 103:381-386. [PMID: 29944619 DOI: 10.1097/tp.0000000000002344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Vasoplegia is a clinical condition typically manifested by cardiovascular instability unresponsive to the usual doses of inotropes or vasopressors. It can occur in a variety of clinical settings including liver transplantation (LT). Immunoglobulins have been used to treat sepsis-related vasoplegia. We performed a retrospective study to evaluate the efficacy of IgM-enriched immunoglobulin (IgMIg) on 30-day mortality and its ability to reverse vasoplegia in patients undergoing LT. METHODS Between May 2013 and November 2017, 473 LT were performed at our institution. We identified 21 patients who received IgMIg for 3 days to treat vasoplegia. Patients included in the study met the criteria for having vasoplegia and required noradrenaline administration greater than 1 μg·kg·min for more than 24 hours to maintain a mean arterial pressure of 70 mm Hg or greater. Procalcitonin and interleukin-6 (IL-6) levels were used as surrogate markers for inflammation and were measured at the beginning and end of IgM treatment. RESULTS After IgMIg administration, median noradrenaline infusion rates could be significantly reduced from 1.6 μg·kg·min (1.3-2 μg·kg·min) to 0.16 μg·kg·min (0.08-0.34 μg·kg·min) (P < 0.001). In addition, after treatment, procalcitonin levels decreased significantly from 44 ng/mL (24-158) to 26.1 ng/mL (10.9-48.7) (P < 0.001) and IL-6 levels decreased significantly from 63 pg/mL (29-102) to 20 pg/mL (11-20) (P < 0.001). Thirty-day morality was 14.3%. CONCLUSIONS The administration of IgMIg in patients with vasoplegia after LT is associated with a return of hemodynamic stability. Despite a predicted mortality of over 90% by Sepsis-Related Organ Failure Assessment score, the mortality rate of patients receiving IgMIg in our study was less than 20%.
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Fayed NA, Murad WS. Goal directed preemptive ephedrine attenuates the reperfusion syndrome during adult living donor liver transplantation. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Nirmeen A. Fayed
- Department of Anesthesia, National Liver Institute , Menoufeya University , Egypt
| | - Wessam S. Murad
- Public Health and Community, National Liver Institute , Menoufeya University , Egypt
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Order of liver graft revascularization in deceased liver transplantation: A systematic review and meta-analysis. Surgery 2019; 166:237-246. [PMID: 31085045 DOI: 10.1016/j.surg.2019.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/15/2019] [Accepted: 03/29/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ideal order for liver graft revascularization during liver transplantation remains unknown. The majority of liver transplant centers prefer portal venous reperfusion followed by arterial reperfusion to shorten the warm ischemia time. The aim of this study was to review the different revascularization techniques used in clinical liver transplantation to identify any potential clinical benefits. METHODS A systematic search of 5 databases was performed to identify all available original articles that reported liver transplantation and compared different techniques of reperfusion. The primary outcomes were patient and graft survival. Secondary outcomes were defined by postreperfusion syndrome, primary nonfunction, vascular complications, biliary complications, and retransplantation. RESULTS A total of 1,160 patients undergoing liver transplantation from 15 studies were included in this review and meta-analysis. There were no differences regarding the 1-year patient and graft survival for the revascularization techniques. The incidence of primary nonfunction, vascular complications, and retransplantation did not differ between the groups. Although there were no differences regarding biliary complications between the different groups, there were more nonanastomotic strictures in patients with initial portal revascularization (9%) compared with those with simultaneous revascularization (2%; risk ratio 1.07; 95% confidence interval, 1.00-1.14; P = .05; I2 = 51%). CONCLUSION The order of liver graft revascularization does not influence patient and graft survival. Each revascularization technique offers potential benefits that can be used under specific clinical situations.
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Bekheit M, Catanzano M, Shand S, Ahmed I, ELKayal ELS, Shehata GM, Zaki A. The role of graft reperfusion sequence in the development of non-anastomotic biliary strictures following orthotopic liver transplantation: A meta-analysis. Hepatobiliary Pancreat Dis Int 2019; 18:4-11. [PMID: 30579736 DOI: 10.1016/j.hbpd.2018.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/22/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Liver transplant is a potential cure for liver failure and hepatic malignancy but there are many techniques which have been described for vascular reconstruction. This study was to compare the prevalence of non-anastomotic biliary stricture and other surgical complications based on Clavien-Dindo scoring system, in initial portal reperfusion (sequential) versus simultaneous or initial artery reperfusion. DATA SOURCES Meta-analysis of published studies comparing the outcomes of both techniques was carried out. Data search was conducted across the major databases and studies were selected under the guidance of the Cochrane guidelines for systematic reviews and meta-analysis. RESULTS Seven studies were included to address the primary and the secondary outcomes. No statistical difference was found in the incidence of non-anastomotic biliary strictures (OR = 0.40; P = 0.14), regardless of reperfusion technique. The pooled estimate of the Clavien-Dindo grading of complications was not significantly different between the techniques, though Clavien-Dindo II complications were higher in the simultaneous or initial artery reperfusion group than the initial portal reperfusion group (OR = 2.73; P = 0.01). Similarly, there was no difference in the operative time, hospital stay and other outcomes addressed in this report. CONCLUSIONS The available evidence suggests that there is no significant difference demonstrated in the rate of non-anastomotic biliary strictures or other complications, between the two techniques, except for Clavien-Dindo II complications.
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Affiliation(s)
- Mohamed Bekheit
- Center of Liver Surgery and Transplantation, Paul Brousse Hospital, University of Paris-Sud, Villejuif Cedex, France; Medical Research Institute, University of Alexandria, Alexandria, Egypt; HPB Surgery Unit Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK; Department of Surgery, Elkabbary General Hospital, Alexandria, Egypt; University of Aberdeen, Aberdeen, UK.
| | | | - Stuart Shand
- HPB Surgery Unit Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Irfan Ahmed
- HPB Surgery Unit Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK; University of Aberdeen, Aberdeen, UK
| | - ELSaid ELKayal
- Department of Surgery, Alexandria Main University Hospital, Faculty of Medicine, Alexandria, Egypt
| | | | - Adel Zaki
- Medical Research Institute, University of Alexandria, Alexandria, Egypt
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Effect of Prereperfusion Ephedrine on Postreperfusion Syndrome and Graft Function in Living Donor Liver Transplantation. Transplant Proc 2017; 49:1815-1819. [DOI: 10.1016/j.transproceed.2017.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/27/2017] [Accepted: 05/13/2017] [Indexed: 01/29/2023]
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Siniscalchi A, Gamberini L, Laici C, Bardi T, Ercolani G, Lorenzini L, Faenza S. Post reperfusion syndrome during liver transplantation: From pathophysiology to therapy and preventive strategies. World J Gastroenterol 2016; 22:1551-1569. [PMID: 26819522 PMCID: PMC4721988 DOI: 10.3748/wjg.v22.i4.1551] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 10/20/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
This review aims at evaluating the existing evidence regarding post reperfusion syndrome, providing a description of the pathophysiologic mechanisms involved and possible management and preventive strategies. A PubMed search was conducted using the MeSH database, “Reperfusion” AND “liver transplantation” were the combined MeSH headings; EMBASE and the Cochrane library were also searched using the same terms. 52 relevant studies and one ongoing trial were found. The concept of post reperfusion syndrome has evolved through years to a multisystemic disorder. The implications of the main organ, recipient and procedure related factors in the genesis of this complex syndrome are discussed in the text as the novel pharmacologic and technical approaches to reduce its incidence. However the available evidence about risk factors, physiopathology and preventive measures is still confusing, the presence of two main definitions and the numerosity of possible confounding factors greatly complicates the interpretation of the studies.
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14
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Jeong SM. Postreperfusion syndrome during liver transplantation. Korean J Anesthesiol 2015; 68:527-39. [PMID: 26634075 PMCID: PMC4667137 DOI: 10.4097/kjae.2015.68.6.527] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 07/31/2015] [Accepted: 08/07/2015] [Indexed: 02/07/2023] Open
Abstract
As surgical and graft preservation techniques have improved and immunosuppressive drugs have advanced, liver transplantation (LT) is now considered the gold standard for treating patients with end-stage liver disease worldwide. However, despite the improved survival following LT, severe hemodynamic disturbances during LT remain a serious issue for the anesthesiologist. The greatest hemodynamic disturbance is postreperfusion syndrome (PRS), which occurs at reperfusion of the donated liver after unclamping of the portal vein. PRS is characterized by marked decreases in mean arterial pressure and systemic vascular resistance, and moderate increases in pulmonary arterial pressure and central venous pressure. The underlying pathophysiological mechanisms of PRS are complex. Moreover, risk factors associated with PRS are not fully understood. Rapid and appropriate treatment with vasopressors, volume replacement, or venesection must be provided depending on the cause of the hemodynamic disturbance when hemodynamic instability becomes profound after reperfusion. The negative effects of PRS on postoperative early morbidity and mortality are clear, but the effect of PRS on postoperative long-term mortality remains a matter of debate.
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Affiliation(s)
- Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Wang JZ, Liu Y, Wang JL, Lu L, Zhang YF, Lu HW, Li YM. Sequential vs simultaneous revascularization in patients undergoing liver transplantation: A meta-analysis. World J Gastroenterol 2015; 21:7036-46. [PMID: 26078582 PMCID: PMC4462746 DOI: 10.3748/wjg.v21.i22.7036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/08/2015] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM We undertook this meta-analysis to investigate the relationship between revascularization and outcomes after liver transplantation. METHODS A literature search was performed using MeSH and key words. The quality of the included studies was assessed using the Jadad Score and the Newcastle-Ottawa Scale. Heterogeneity was evaluated by the χ(2) and I (2) tests. The risk of publication bias was assessed using a funnel plot and Egger's test, and the risk of bias was assessed using a domain-based assessment tool. A sensitivity analysis was conducted by reanalyzing the data using different statistical approaches. RESULTS Six studies with a total of 467 patients were included. Ischemic-type biliary lesions were significantly reduced in the simultaneous revascularization group compared with the sequential revascularization group (OR = 4.97, 95%CI: 2.45-10.07; P < 0.00001), and intensive care unit (ICU) days were decreased (MD = 2.00, 95%CI: 0.55-3.45; P = 0.007) in the simultaneous revascularization group. Although warm ischemia time was prolonged in simultaneous revascularization group (MD = -25.84, 95%CI: -29.28-22.40; P < 0.00001), there were no significant differences in other outcomes between sequential and simultaneous revascularization groups. Assessment of the risk of bias showed that the methods of random sequence generation and blinding might have been a source of bias. The sensitivity analysis strengthened the reliability of the results of this meta-analysis. CONCLUSION The results of this study indicate that simultaneous revascularization in liver transplantation may reduce the incidence of ischemic-type biliary lesions and length of stay of patients in the ICU.
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Sahmeddini MA, Zahiri S, Khosravi MB, Ghaffaripour S, Eghbal MH, Shokrizadeh S. Effect of mannitol on postreperfusion cardiac output and central venous oxygen saturation during orthotopic liver transplant: a double-blind randomized clinical trial. Prog Transplant 2014; 24:121-5. [PMID: 24919727 DOI: 10.7182/pit2014483] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Attenuating postreperfusion syndrome during orthotopic liver transplant is very important for transplant anesthesiologists because of the syndrome's complications. Oxygen-derived free radicals play an important role in the genesis of postreperfusion syndrome, but the effect of mannitol (a free radical scavenger) on attenuating the syndrome is unclear.OBJECTIVES-To investigate the effectiveness of infusing mannitol during the anhepatic phase in preventing postreperfusion syndrome, as indicated by postreperfusion cardiac output and central venous oxygen saturation. DESIGN In a randomized clinical trial, 53 patients who had undergone orthotopic liver transplant were allocated to 2 groups. During the anhepatic phase, patients in the mannitol group received 1g/kg mannitol, whereas those in the control group received physiological saline. Mean arterial pressure, cardiac output, and central venous oxygen saturation were measured before and after the portal vein was declamped. Serum levels of sodium and potassium were recorded at baseline and after portal vein declamping.Setting-Shiraz Organ Transplant Center, Shiraz, Iran. RESULTS In the mannitol group, no significant change was found in mean arterial pressure, cardiac output, and central venous oxygen saturation before and after declamping of the portal vein (P= .78, P= .59, and P= .83, respectively). However, after declamping in the control group, mean arterial pressure, cardiac output, and central venous oxygen saturation were significantly lower than before declamping (P=.003, P=.001, and P<.001, respectively). No significant change in serum levels of sodium and potassium from baseline to after declamping were found in either group. CONCLUSION Infusion of mannitol 1 g/kg during the anhepatic phase was effective in attenuating postreperfusion syndrome without stress about hyperkalemia or hyponatremia during anesthesia.
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Affiliation(s)
- Mohammad Ali Sahmeddini
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Siamak Zahiri
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Bagher Khosravi
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sina Ghaffaripour
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Eghbal
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sakine Shokrizadeh
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Park YS, Oh JY, Hwang BY, Moon Y, Lee HM, Hwang GS. Prolonged post-reperfusion syndrome during multivisceral organ transplantation in a pediatric patient: a case report. Korean J Anesthesiol 2014; 66:467-71. [PMID: 25006372 PMCID: PMC4085269 DOI: 10.4097/kjae.2014.66.6.467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 03/18/2013] [Accepted: 03/29/2013] [Indexed: 11/21/2022] Open
Abstract
Multivisceral organ transplantation involves the transplantation of three or more abdominal organs, including small bowel, duodenum, stomach, liver, pancreas, colon, and so on. The large amounts of cold and acidic loading into systemic circulation from the graft during multivisceral organ transplantation may result in severe post-reperfusion syndrome (PRS). We describe here a 6-year-old pediatric patient with chronic intestinal pseudo-obstruction who experienced prolonged PRS and severe metabolic acidosis during seven abdominal organ transplantation including the liver, spleen, stomach, duodenum, small bowel, colon and pancreas. The hypotensive period lasted approximately 10 minutes after graft reperfusion and was accompanied by severe metabolic acidosis and hypothermia. Since PRS can be easily associated with adverse outcomes, such as poor early graft function and primary non-function, not only meticulous surveillance for aggravating factors for PRS but also their immediate correction were necessary in managing a pediatric patient undergoing multivisceral organ transplantation.
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Affiliation(s)
- Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Young Oh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Young Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngjin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa-Mi Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Fukazawa K, Nishida S, Hibi T, Pretto EA. Crystalloid flush with backward unclamping may decrease post-reperfusion cardiac arrest and improve short-term graft function when compared to portal blood flush with forward unclamping during liver transplantation. Clin Transplant 2013; 27:492-502. [PMID: 23656400 DOI: 10.1111/ctr.12130] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2013] [Indexed: 12/17/2022]
Abstract
During liver transplant (LT), the release of vasoactive substances into the systemic circulation is associated with severe hemodynamic instability that is injurious to the recipient and/or the post-ischemic graft. Crystalloid flush with backward unclamping (CB) and portal blood flush with forward unclamping (PF) are two reperfusion methods to reduce reperfusion-related cardiovascular perturbations in our center. The primary aim of this study was to compare these two methods. After institutional review board (IRB) approval, cadaveric whole LT cases performed between 2003 and 2008 were reviewed. Patients were divided into two groups based on reperfusion methods: CB or PF. After background matching with propensity score, the effect of each method on post-operative graft function was assessed in detail. In our cohort of 478 patients, CB was used in 313 grafts and PF in 165. Thirty-day graft survival was lower, and risk of retransplantation was higher in PF. Multivariable model showed that CB is an independent factor to reduce primary non-function, cardiac arrest and improve 30-d graft survival. Also, the incidence of ischemic-type biliary lesions was significantly higher in the PF group. Reperfusion methods affect intraoperative hemodynamics and post-transplant outcome. CB allows for control over temperature and composition of the perfusate, perfusion pressure, and the rate of infusion.
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Affiliation(s)
- Kyota Fukazawa
- Division of Solid Organ Transplantation, Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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Manzini G, Kremer M, Houben P, Gondan M, Bechstein WO, Becker T, Berlakovich GA, Friess H, Guba M, Hohenberger W, Ijzermans JNM, Jonas S, Kalff JC, Klar E, Klempnauer J, Lerut J, Lippert H, Lorf T, Nadalin S, Nashan B, Otto G, Paul A, Pirenne J, Pratschke J, Ringers J, Rogiers X, Schilling MK, Seehofer D, Senninger N, Settmacher U, Stippel DL, Tscheliessnigg K, Ysebaert D, Binder H, Schemmer P. Reperfusion of liver graft during transplantation: techniques used in transplant centres within Eurotransplant and meta-analysis of the literature. Transpl Int 2013; 26:508-16. [PMID: 23517278 DOI: 10.1111/tri.12083] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 10/21/2012] [Accepted: 02/11/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Giulia Manzini
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Michael Kremer
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Philipp Houben
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Matthias Gondan
- Institute of Medical Biometry and Informatics; University of Heidelberg; Heidelberg; Germany
| | - Wolf O. Bechstein
- Department of General and Visceral Surgery; Johann Wolfgang Goethe- University; Frankfurt am Main; Germany
| | - Thomas Becker
- Department of General and Thoracic Surgery; Christian-Albrechts-University Kiel; Kiel; Germany
| | | | - Helmut Friess
- Department of General Surgery; Klinikum Rechts der Isar; Technical University of Munich; Munich; Germany
| | - Markus Guba
- Department of General Surgery; Campus Grosshadern; University of Munich; Munich; Germany
| | - Werner Hohenberger
- Department of General Surgery; University of Erlangen; Erlangen; Germany
| | - Jan N. M. Ijzermans
- Department of Surgery; Erasmus Medisch Centrum-Daniel den Hoed; Rotterdam; Netherlands
| | - Sven Jonas
- Department of Visceral Transplant, Thoracic and Vascular Surgery; University of Leipzig; Leipzig; Germany
| | - Jörg C. Kalff
- Department of General Surgery; University of Bonn; Bonn; Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery; University of Rostock; Rostock; Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery; Klinikum der Medizinischen Hochschule; Hannover; Germany
| | - Jan Lerut
- Department of Liver Transplant Surgery; University Clinic Saint-Luc; Bruxelles; Belgium
| | - Hans Lippert
- Department of General, Visceral and Vascular Surgery; Otto-von-Guericke University; Magdeburg; Germany
| | - Thomas Lorf
- Department of General and Visceral Surgery; University of Goettingen; Goettingen; Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery; Eberhard-Karls University; Tuebingen; Germany
| | - Björn Nashan
- Department of Hepatobiliary and Transplant Surgery; University of Hamburg-Eppendorf; Hamburg; Germany
| | - Gerd Otto
- Department of Transplant and Hepato-biliary-pancreatic Surgery; Johannes-Gutenberg-University; Mainz; Germany
| | - Andreas Paul
- Department of General, Visceral and Transplant Surgery; University of Essen; Essen; Germany
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery; University of Leuven; Leuven; Belgium
| | - Johann Pratschke
- Department of Visceral, Transplant and Thoracic Surgery; University of Innsbruck; Innsbruck; Austria
| | - Jan Ringers
- Department of Transplant Surgery; University of Leiden; Leiden; Netherlands
| | - Xavier Rogiers
- Department of Transplant Surgery; University of Gent; Gent; Belgium
| | - Martin K. Schilling
- Department of General, Visceral, Vascular and Pediatric Surgery; University of Saarland; Homburg/Saar; Germany
| | - Daniel Seehofer
- Department of General, Visceral and Transplantation Surgery; Charité Campus Virchow-Klinikum; University of Berlin; Berlin; Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery; University of Muenster; Muenster; Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery; Friedrich Schiller University; Jena; Germany
| | - Dirk L. Stippel
- Department of General, Visceral and Cancer Surgery; University of Cologne; Cologne; Germany
| | | | - Dirk Ysebaert
- Department of Hepatobiliary, Transplant and Endocrine Surgery; University Hospital of Antwerpen; Edegem; Belgium
| | - Heidrun Binder
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
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20
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Bezinover D, Kadry Z, Uemura T, Sharghi M, Mastro AM, Sosnoski DM, Dalal P, Janicki PK. Association between plasma cyclic guanosine monophosphate levels and hemodynamic instability during liver transplantation. Liver Transpl 2013; 19:191-8. [PMID: 23161851 DOI: 10.1002/lt.23570] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/23/2012] [Indexed: 12/19/2022]
Abstract
The activation of cyclic guanosine monophosphate (cGMP) production in patients with end-stage liver disease (ESLD) has been associated with hemodynamic instability during orthotopic liver transplantation (OLT). The aim of this prospective, observational study was to investigate the involvement of cGMP in the mediation of profound hypotension during liver graft reperfusion. An additional objective was to determine whether preoperative cGMP levels are associated with intraoperative hemodynamic instability. Forty-four consecutive patients undergoing OLT were included in the study. Blood samples for cGMP analysis were obtained from (1) the radial artery before the surgical incision; (2) the radial artery, portal vein, and flush blood during the anhepatic phase; and (3) the radial artery 20 minutes after liver graft reperfusion. On the basis of a statistical analysis, the patients were divided into 2 groups: group 1 (preoperative cGMP level ≥ 0.05 μmol/L) and group 2 (preoperative cGMP level < 0.05 μmol/L). We demonstrated a significant correlation between the preoperative levels of cGMP and the amount of catecholamine required to maintain hemodynamic stability during reperfusion (r = 0.52, P < 0.001), the length of the hospital stay (r = 0.38, P = 0.01), and the length of the intensive care unit (ICU) stay (r = 0.44, P = 0.004). We also demonstrated a significantly higher intraoperative catecholamine requirement (P < 0.001) and a prolonged postoperative ICU stay (P = 0.02) in group 1 patients versus group 2 patients. In conclusion, this study demonstrates increased baseline cGMP production in patients with ESLD, which is significantly associated with severe hypotension during OLT. We suggest that preoperative levels of cGMP correlate with hemodynamic instability during liver graft reperfusion.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, PA 17033-0850, USA.
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21
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Aufhauser DD, Rose T, Levine M, Barnett R, Ochroch EA, Aukburg S, Greenblatt E, Olthoff K, Shaked A, Abt P. Cardiac arrest associated with reperfusion of the liver during transplantation: incidence and proposal for a management algorithm. Clin Transplant 2012; 27:185-92. [DOI: 10.1111/ctr.12052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 11/30/2022]
Affiliation(s)
- David D. Aufhauser
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Tom Rose
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Matthew Levine
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Rebecca Barnett
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - E. Andrew Ochroch
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Stanley Aukburg
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Eric Greenblatt
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Kim Olthoff
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Abraham Shaked
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Peter Abt
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
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22
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Preservation solutions for liver transplantation in adults: celsior versus custodiol: a systematic review and meta-analysis with an indirect comparison of randomized trials. Transplant Proc 2012; 45:25-32. [PMID: 23267794 DOI: 10.1016/j.transproceed.2012.02.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 02/28/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND The University of Wisconsin (UW) solution has been recognized as the gold standard for liver preservation; however, it possesses some limitations, and other solutions exist for organ preservation. The aim of this study was to compare the liver functions of transplanted grafts that had been stored in Celsior and Custodiol solutions. METHODS We searched the MEDLINE, EMBASE, LILACS, Cochrane Central Register of Controlled Trials, and SCIELO databases. We included randomized and quasi-randomized, controlled trials that compared the efficacy and safety of Celsior and Custodiol with UW solution for liver preservation in adults. The factors that were considered for analysis were their impacts on primary dysfunction (primary nonfunction and initial poor function), ischemic-type biliary lesions, and patient and graft survival rates. Because of the lack of direct evidence, an indirect comparison of Celsior and Custodiol was calculated. RESULTS We identified 3 randomized controlled trials and 1 quasi-randomized, controlled trial to pool in a meta-analysis of Celsior versus UW solutions. The number of episodes of primary dysfunction was lower in the Celsior group (7.4%) than in the UW group (9.8%), but the difference was not significant (relative risk [RR], 0.68; 95% confidence interval [CI], 0.22-1.97). Two randomized controlled trials compared Custodiol and Wisconsin solutions were identified. The number of episodes of primary dysfunction was also lower in the Custodiol group (3.0%) compared with the Wisconsin group (8.4%), but the difference was not significant (RR, 0.36; 95% CI, 0.08-1.70). An indirect comparison using data from the main analysis revealed no difference between the Celsior and Custodiol solutions (RR, 1.88; 95% CI, 0.57-6.16). CONCLUSION The Celsior and Custodiol solutions performed similarly to UW solution as preservation solutions in liver transplantation clinical settings.
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23
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Protection of the intrahepatic biliary tree by contemporaneous portal and arterial reperfusion: results of a prospective randomized pilot study. Updates Surg 2012; 64:173-7. [DOI: 10.1007/s13304-012-0164-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 06/21/2012] [Indexed: 01/26/2023]
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Gurusamy KS, Naik P, Abu-Amara M, Fuller B, Davidson BR. Techniques of flushing and reperfusion for liver transplantation. Cochrane Database Syst Rev 2012:CD007512. [PMID: 22419324 DOI: 10.1002/14651858.cd007512.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Various techniques of flushing and reperfusion have been advocated to improve outcomes after liver transplantation. There is considerable uncertainty as to which method is superior. OBJECTIVES To compare the benefits and harms of different methods of flushing and reperfusion during liver implantation in the transplant recipients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2011. SELECTION CRITERIA We included all randomised clinical trials that were performed to compare different techniques of flushing and reperfusion during liver transplantation. DATA COLLECTION AND ANALYSIS Two authors independently identified the trials and extracted the data. We analysed the data with both the fixed-effect model and the random-effects model using RevMan analysis. For each outcome we calculated the hazard ratio (HR), risk ratio (RR), rate ratio, mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on available case analysis. MAIN RESULTS We included six trials involving 418 patients for this review. The sample size in the trials varied from 30 to 131 patients. Only one trial involving 131 patients was of low risk of bias for mortality. This trial was at high risk of bias for other outcomes. Four trials excluded patients who underwent liver transplantation for acute liver failure. All the trials included livers obtained from cadaveric donors. The remaining five trials were of high risk of bias for all outcomes. Liver transplantation was performed by the conventional method (caval replacement) in two trials and piggy-back method (caval preservation) in one trial. The method of liver transplantation was not available in the remaining three trials. The comparisons performed included an initial hepatic artery flush versus initial portal vein flush; blood venting via inferior vena cava in addition to venting of storage fluid versus no blood venting; initial hepatic artery reperfusion versus initial portal vein reperfusion; simultaneous hepatic artery and portal vein reperfusion versus initial portal vein reperfusion; and retrograde inferior vena cava reperfusion versus simultaneous hepatic artery and portal vein reperfusion. Only one or two trials could be included under each comparison. There was no significant difference in mortality, graft survival, or severe morbidity rates in any of the comparisons. Quality of life was not reported in any of the trials. AUTHORS' CONCLUSIONS There is currently no evidence to support or refute the use of any specific technique of flushing or reperfusion during liver transplantation. Due to the paucity of data, absence of evidence should not be confused with evidence of absence of any differences. Further well designed trials with low risk of systematic error and low risk of random errors are necessary.
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25
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Sabaté A, Acosta Villegas F, Dalmau A, Koo M, Sansano Sánchez T, García Palenciano C. [Anesthesia in the patient with impaired liver function]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 58:574-81. [PMID: 22279877 DOI: 10.1016/s0034-9356(11)70142-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.
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Affiliation(s)
- A Sabaté
- Servicio de Anestesiología y Reanimación, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona.
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Chung IS, Kim HY, Shin YH, Ko JS, Gwak MS, Sim WS, Kim GS, Lee SK. Incidence and predictors of post-reperfusion syndrome in living donor liver transplantation. Clin Transplant 2011; 26:539-43. [PMID: 22168355 DOI: 10.1111/j.1399-0012.2011.01568.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A characteristic pattern of hemodynamic changes that may occur in reperfusion phase of liver transplantation (LT) is known as post-reperfusion syndrome (PRS). In this study, we determined the frequency of PRS and evaluated possible predictors of PRS. The medical records of 152 patients who underwent living donor LT were reviewed. PRS was defined as a decrease in mean arterial pressure of more than 30% from the baseline value for more than one min during the first five min after reperfusion. The frequency of PRS was determined, and patients were divided into two groups: PRS group and non-PRS group. Donor factors, preoperative and intraoperative recipient factors, and postoperative outcomes were compared between the two groups. PRS occurred in 58 recipients (34.2%). Preoperative model for end-stage liver disease scores of recipients and percentage of graft steatotic changes were higher in PRS group. PRS group showed higher heart rates and lower hemoglobin values preoperatively. Before reperfusion, PRS group received more transfusion and their urine output was less than that of non-PRS group. Postoperatively, peak bilirubin during the first five d after LT was higher in PRS group. In conclusion, both severity of liver disease and graft steatosis may increase risk for PRS in LT. Further prospective studies of PRS in its relationship to outcome are indicated.
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Affiliation(s)
- In S Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-Gu, Seoul, South Korea
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García-Gil FA, Serrano MT, Fuentes-Broto L, Arenas J, García JJ, Güemes A, Bernal V, Campillo A, Sostres C, Araiz JJ, Royo P, Simón MA. Celsior versus University of Wisconsin preserving solutions for liver transplantation: postreperfusion syndrome and outcome of a 5-year prospective randomized controlled study. World J Surg 2011; 35:1598-607. [PMID: 21487851 DOI: 10.1007/s00268-011-1078-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Celsior solution (CS) is a high-sodium, low-potassium, low-viscosity extracellular solution that has been used for liver graft preservation in recent years, although experience with it is still limited. We performed an open-label randomized active-controlled trial comparing CS with the University of Wisconsin solution (UW) for liver transplantation (LT), with a follow-up period of 5 years. METHODS Adult transplant recipients (n=102) were prospectively randomized to receive either CS (n=51) or UW (n=51). The two groups were comparable with respect to donor and recipient characteristics. The primary outcome measure was the incidence of postreperfusion syndrome (PRS). Secondary outcome measures included primary nonfunction (PNF) or primary dysfunction (PDF), liver retransplantation, and graft and patient survival. Other secondary outcome measures were days in the intensive care unit (ICU) and the rates of acute rejection, chronic rejection, infectious complications, postoperative reoperations, and vascular and biliary complications. RESULTS In all, 14 posttransplant variables revealed no significant differences between the groups. There were no cases of PNF or PDF. The incidence of PRS was 5.9% in the CS group and 21.6% in the UW group (P=0.041). After reperfusion, CS revealed greater control of serum potassium (P=0.015), magnesium levels (P=0.005), and plasma glucose (P=0.042) than UW. Respective patient survivals at 3, 12, and 60 months were 95.7, 87.2, and 82.0% for the CS group and 95.7, 83.3, and 66.6% for the UW group (P=0.123). CONCLUSIONS While retaining the same degree of safety and effectiveness as UW for LT, CS may yield postliver graft reperfusion benefits, as shown in this study by a significant reduction in the incidence of PRS and greater metabolic control.
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Affiliation(s)
- Francisco A García-Gil
- Department of Surgery, University of Zaragoza, Domingo Miral s/n, 50009, Zaragoza, Spain.
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Sequential versus contemporaneous portal and arterial reperfusion during liver transplantation. Transplant Proc 2011; 43:1107-9. [PMID: 21620064 DOI: 10.1016/j.transproceed.2011.01.123] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Although sequential portal and arterial revascularization (SPAr) is the most common method of graft reperfusion at liver transplantation (OLT), contemporaneous portal and hepatic artery revascularization (CPAr) has been used to reduce arterial ischemia to the bile ducts. The aim of this study was to prospectively compare SPAr (group 1; n=19) versus CPAr (group 2; n=21) among 40 consecutive OLT from heart-beating donors. There were no differences in the demographics characteristics, Model for End-stage Liver Disease scores, indication for OLT and donor parameters between the groups. OLT was performed using the piggyback technique. The biliary anastomosis was performed in all cases by a duct-to-duct technique with a T-tube in 32% versus 29% of cases without a T tube (P=.83). In the CPAr group, the liver was reperfused simultaneously via the portal vein and hepatic artery. CPAr showed a longer warm ischemia (66 ± 8 vs 37 ± 7 minutes; P<.001), while SPAr had a longer arterial ischemia 103 ± 42 vs 66 ± 8 minutes (P=.0004). Recovery of graft function was similar. There was no primary nonfunction and delayed graft function occurred among 10% versus 9%. Liver function tests were similar between the two groups up to 90 days case of follow-up- One-year graft and patient survivals were, respectively, 89% and 95% versus 94% and 100% (P=.29). At a median follow-up of 13 ± 6 versus 14 ± 7 months, biliary complications included anastomotic stenoses in 15% versus 19% (P=.78) and intrahepatic non-anastomotic biliary strictures in 26% versus none (P=.01) for SPAr and CPAr, respectively. CPAr was safe and feasible, reducing the incidence of intrahepatic biliary strictures by decreasing the duration of arterial ischemia to the intrahepatic bile ducts.
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Bärthel E, Rauchfuss F, Hoyer H, Habrecht O, Jandt K, Götz M, Voigt R, Heise M, Marx G, Settmacher U. Impact of stable PGI₂ analog iloprost on early graft viability after liver transplantation: a pilot study. Clin Transplant 2011; 26:E38-47. [PMID: 21919966 DOI: 10.1111/j.1399-0012.2011.01516.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ischemia/reperfusion injury after liver transplantation (LT) may be associated with primary graft dysfunction (PDF) or non-function. Prostaglandins were demonstrated to be beneficial in reducing ischemic injury by improving microcirculation and protecting endothelial cells. The aim of this study was to analyze the effect of the continuously administered prostaglandin I(2) analog iloprost on allograft function after LT. METHODS Eighty patients were prospectively randomized and assigned to two groups. Patients in the treatment group received iloprost for seven d after transplantation, and those in the control group did not. The primary end point was graft dysfunction. RESULTS The incidence of PDF was 20% (n = 8) in the control group and 5% (n = 2) in the treatment group, respectively (p = 0.087). Four patients in the control group underwent re-transplantation for initial non-function (INF). There was no evidence for INF in the treatment group. Iloprost was associated with improved allograft function. Clinical course and outcome were comparable. CONCLUSIONS We suggest iloprost to be beneficial for early post-transplant liver function. If the rate of PDF can be significantly reduced with this treatment concept, it should be analyzed in a larger number of patients (ISRCTN95672167).
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Affiliation(s)
- Erik Bärthel
- Department of General, Visceral and Vascular Surgery, Friedrich-Schiller-University, Jena, Germany.
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Contemporaneous Portal-Arterial Reperfusion during Liver Transplantation: Preliminary Results. J Transplant 2011; 2011:251656. [PMID: 21559253 PMCID: PMC3087889 DOI: 10.1155/2011/251656] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/18/2011] [Accepted: 02/07/2011] [Indexed: 11/17/2022] Open
Abstract
We prospectively compared sequential portal-arterial revascularization (SPAr, group 1 no. 19) versus contemporaneous portal-hepatic artery revascularization (CPAr, group 2 no. 21) in 40 consecutive liver transplantation (LT). There were no differences in the demographics characteristics, MELD score, indication to LT, and donor's parameters between the two groups. CPAr had longer warm ischemia 66 ± 8 versus 37 ± 7 min (P < .001), while SPAr had longer arterial ischemia 103 ± 42 min (P = .0004). One-year patient's and graft survival were, respectively, 89% and 95% versus 94% and 100% (P = .29). At median followup of 13 ± 6 versus 14 ± 7 months biliary complications were anastomotic stenosis in 15% versus 19% (P = .78), and intrahepatic nonanastomotic biliary strictures in 26% versus none (P = .01), respectively, in SPAr and CPAr. CPAr reduces the incidence of intrahepatic biliary strictures by decreasing the duration of arterial ischemia.
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Bezinover D, Kadry Z, McCullough P, McQuillan PM, Uemura T, Welker K, Mastro AM, Janicki PK. Release of cytokines and hemodynamic instability during the reperfusion of a liver graft. Liver Transpl 2011; 17:324-30. [PMID: 21384515 DOI: 10.1002/lt.22227] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The objectives of this prospective, observational study were (1) to determine whether a transplanted liver graft releases proinflammatory cytokines into the systemic circulation upon reperfusion and (2) to determine whether they contribute to any subsequent hemodynamic instability observed after graft reperfusion (if this release occurs). Blood samples from 17 consecutive patients undergoing liver transplantation were analyzed for cytokines, including tumor necrosis factor α (TNF-α), interleukin-1β (IL-1β), IL-2, IL-6, and IL-8. Blood samples were obtained from the radial artery, portal vein, and flush blood (a sample taken from a catheter placed above the infrahepatic inferior vena cava clamp). The amount of catecholamines necessary to maintain a mean arterial pressure between 65 and 75 mm Hg during graft reperfusion was compared with the level of cytokines. A statistical analysis was performed with the least squares method, Kendall's tau-b test, and regression analysis. We demonstrated that flush blood from the liver grafts contained a significant amount and variety of cytokines. Most of these were removed by graft irrigation. The concentration of TNF-α in samples obtained from flush blood at the end of liver irrigation was significantly higher than the concentration in samples obtained from the radial artery (P = 0.0067) or portal vein (P = 0.0003) before reperfusion. This correlated directly with the amount of catecholamines used to treat hemodynamic instability. Although there were increased levels of IL-1β, IL-2, and IL-8 in the flush blood, there was no statistically significant correlation between the levels of these cytokines and the amount of catecholamines used.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center/Penn State College of Medicine, Hershey, PA 17033-0850, USA.
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Sabaté A, Ferreres E, Valcárcel M, Dalmau A, Koo M, Fabregat J. Rocuronium Profile During Orthotopic Liver Transplantation: Effect of Changing the Order of Vascular Clamp Release at Reperfusion of the Hepatic Graft. Transplant Proc 2010; 42:1760-2. [DOI: 10.1016/j.transproceed.2010.02.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 01/11/2010] [Accepted: 02/26/2010] [Indexed: 10/19/2022]
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de Armas LC, Jiménez Paneque RE, López BG, Romero EIR, Castillo YA, Menéndez MBV. Rapid and Homogeneous Reperfusion as a Risk Factor for Postreperfusion Syndrome during Orthotopic Liver Transplantation. Braz J Anesthesiol 2010. [DOI: 10.1016/s0034-7094(10)70020-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Paugam-Burtz C, Kavafyan J, Merckx P, Dahmani S, Sommacale D, Ramsay M, Belghiti J, Mantz J. Postreperfusion syndrome during liver transplantation for cirrhosis: outcome and predictors. Liver Transpl 2009; 15:522-9. [PMID: 19399736 DOI: 10.1002/lt.21730] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
During orthotopic liver transplantation (OLT), a marked decrease in blood pressure following unclamping of the portal vein and liver reperfusion is frequently observed and is termed postreperfusion syndrome (PRS). The predictive factors and clinical consequences of PRS are not fully understood. The goal of this study was to identify predictors of PRS and morbidity/mortality associated with its occurrence during OLT in patients with cirrhosis. During a 3-year period, all consecutive OLT procedures performed in patients with cirrhosis were studied. Exclusion criteria were OLT for acute liver failure, early retransplantation, combined liver/kidney transplantation, and living-donor related transplantation. PRS was defined as a decrease in the mean arterial pressure of more than 30% of the value observed in the anhepatic stage, for more than 1 minute during the first 5 minutes after reperfusion of the graft. Transplantation was performed with preservation of the inferior vena cava with or without temporary portocaval shunt. Associations between PRS and donor and recipient demographic data, recipient operative and postoperative outcomes were tested with bivariate statistics. Independent predictors of PRS were determined in multivariable logistic regression analysis. Of the 75 patients included in the study, 20 patients (25%) developed PRS. In a multivariable analysis, absence of a portocaval shunt [odds ratio (95% confidence interval) = 4.42 (1.18-17.6)] and duration of cold ischemia [odds ratio (95% confidence interval) = 1.34 (1.07-1.72)] were independent predictors of PRS. Patients who experienced PRS displayed more postoperative renal failure and lower early (<15 days after OLT) survival (80% versus 96%; P = 0.04). In conclusion, the absence of portocaval shunt and the duration of cold ischemia were independent predictors of intraoperative PRS. PRS was associated with significant adverse postoperative outcome. These results provide realistic clinical targets to improve patient outcome after OLT for cirrhosis.
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Dahm-Kähler P, Wranning C, Lundmark C, Enskog A, Mölne J, Marcickiewicz J, El-Akouri RR, McCracken J, Brännström M. Transplantation of the uterus in sheep: Methodology and early reperfusion events. J Obstet Gynaecol Res 2008; 34:784-93. [DOI: 10.1111/j.1447-0756.2008.00854.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE OF REVIEW The present review describes new trends and ongoing controversies in the anesthetic care of liver transplant recipients. RECENT FINDINGS Recent studies have improved our knowledge of conditions increasing perioperative risk, such as portopulmonary hypertension and renal failure. Improved surgical and anesthetic management has reduced intraoperative blood loss, as more studies identify an independent association between blood transfusion and poor outcome. New concepts in the coagulopathy of liver failure are emerging, with clear implications for clinical practice, including greater awareness of the risks of intraoperative thromboembolism. Less invasive intraoperative hemodynamic monitoring has been advocated, as has wider use of transoesophageal echocardiography. Early extubation is becoming more routinized. SUMMARY Anesthetic management still varies widely between liver transplant centers with little data to indicate best practice. Future research should focus on fluid replacement, prevention and treatment of coagulopathy, care of the acutely ill patient and the safety and benefits of early extubation.
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Mandell MS, Tsou MY. The development of perioperative practices for liver transplantation: advances and current trends. J Chin Med Assoc 2008; 71:435-41. [PMID: 18818135 DOI: 10.1016/s1726-4901(08)70145-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Transplantation is a young medical specialty that has grown rapidly over the past 50 years. Anesthesiologists, surgeons and hepatologists are all essential partners in the process of determining patient outcome. Each specialty has made landmark improvements in patient outcome. However, there is still variability in practice patterns in each of the 3 major specialties. This review will use a historic perspective to explore the unique forces that shaped specific transplant practices and those that gave rise to differences in perioperative practices. Anesthesiologists and surgeons have made significant improvements in the management of blood loss, and coagulation monitoring and intervention. This has improved operative survival and early patient outcome. Perioperative survival has improved despite a worldwide shortage of donor organs and a trend to transplant sicker patients. A smaller pool of donor organs is required to meet the needs of an expanding waiting list. The innovations to reduce deaths on the transplant wait list are reviewed along with their impact on overall patient outcome. The evolving organ shortage is the pinnacle point in shaping future transplant practices. Currently, institutional-specific practices may be reinforced by the informal "tutorship" that is used to train physicians and by the resources available at each site of practice. However, there is evidence that specific intraoperative practices such as the use of a low central venous pressure, selection of vasopressors and certain surgical techniques can modify patient outcome. Further investigation is needed to determine whether the good or the bad associated with each practice prevails and in what unique circumstance.
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Affiliation(s)
- Merceds Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Aurora, Colorado, USA
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Registry of Randomized Controlled Trials in Transplantation: July 1 to December 31, 2006. Transplantation 2007; 84:940-53. [DOI: 10.1097/01.tp.0000286319.97951.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Polak WG, Porte RJ. The sequence of revascularization in liver transplantation: it does make a difference. Liver Transpl 2006; 12:1566-70. [PMID: 17058245 DOI: 10.1002/lt.20797] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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