Postoperative outcomes of purely laparoscopic donor hepatectomy compared to open living donor hepatectomy: a preliminary observational study

Purpose@#To lessen the physical, cosmetic, and psychological burden of donors, purely laparoscopic donor hepatectomy (PLDH) has been proposed as an ideal method for living donors. Our study aimed to prospectively compare the effect of PLDH and 2 other types of open living donor hepatectomy (OLDH) on postoperative pain and recovery. @*Methods@#Sixty donors scheduled to undergo donor hepatectomy between March 2015 and November 2017 were included.Donors were divided into 3 groups by surgical technique: OLDH with a subcostal incision (n = 20), group S; OLDH with an upper midline incision (n = 20), group M; and PLDH (n = 20), group L. The primary outcomes were postoperative pain and analgesic requirement during postoperative day (POD) 3. Other variables regarding postoperative recovery were also analyzed. @*Results@#Although pain relief during POD 3, assessed by visual analog scale (VAS) score and analgesic requirement, was similar among the 3 groups, group L showed lower VAS scores and opioid requirements than group M. Moreover, group L was associated with a rapid postoperative recovery evidenced by the shorter hospital length of stay and more frequent return to normal activity on POD 30. @*Conclusion@#This pilot study failed to verify the hypothesis that PLDH reduces postoperative pain. PLDH did not reduce postoperative pain but showed faster recovery than OLDH.

Postoperative outcomes of purely laparoscopic donor hepatectomy compared to open living donor hepatectomy: a preliminary observational study

Purpose@#To lessen the physical, cosmetic, and psychological burden of donors, purely laparoscopic donor hepatectomy (PLDH) has been proposed as an ideal method for living donors. Our study aimed to prospectively compare the effect of PLDH and 2 other types of open living donor hepatectomy (OLDH) on postoperative pain and recovery. @*Methods@#Sixty donors scheduled to undergo donor hepatectomy between March 2015 and November 2017 were included.Donors were divided into 3 groups by surgical technique: OLDH with a subcostal incision (n = 20), group S; OLDH with an upper midline incision (n = 20), group M; and PLDH (n = 20), group L. The primary outcomes were postoperative pain and analgesic requirement during postoperative day (POD) 3. Other variables regarding postoperative recovery were also analyzed. @*Results@#Although pain relief during POD 3, assessed by visual analog scale (VAS) score and analgesic requirement, was similar among the 3 groups, group L showed lower VAS scores and opioid requirements than group M. Moreover, group L was associated with a rapid postoperative recovery evidenced by the shorter hospital length of stay and more frequent return to normal activity on POD 30. @*Conclusion@#This pilot study failed to verify the hypothesis that PLDH reduces postoperative pain. PLDH did not reduce postoperative pain but showed faster recovery than OLDH.

Liver transplantation in an adult patient with hepatocellular carcinoma following liver cirrhosis as a complication of the Fontan procedure -A case report-

Background@#Fontan-associated liver disease (FALD) is a hepatic disorder caused by hemodynamic changes and systemic venous congestion following the Fontan procedure. FALD includes liver cirrhosis and hepatocellular carcinoma (HCC), both of which may require liver transplantation (LT). However, the Fontan circulation, characterized by elevated central venous pressure and reduced cardiac output, is a challenging issue for surgeons and anesthesiologists.Case: We report a living-donor LT for the treatment of HCC. The patient was a 24-year-old male who underwent the Fontan procedure for pulmonary atresia and right ventricle hypoplasia. We focused on maintaining enough blood volume for cardiac output without causing pulmonary edema, as the patient is not well adapted to changes in volume. Owing to a multidisciplinary approach, the surgery was successfully performed without fatal adverse events. @*Conclusions@#To our knowledge, this is the first case of isolated LT in a recipient who became an adult after having undergone the Fontan procedure.

Intraoperative abortion of adult living donor liver transplantation: 15 cases from 1,179 cases in 20 years of experience in a single center

PURPOSE: This study aimed to report intraoperative abortion of adult living donor liver transplantation (LDLT). METHODS: From June 1997 to December 2016, 1,179 adult LDLT cases were performed. 15 cases (1.3%) of intraoperative abortions in LDLT were described. RESULTS: Among 15 cases, 5 intraoperative abortions were donor-related, and remaining 10 cases were recipient-related. All donor-related abortions were due to unexpected steatohepatitis. Among remaining 10 recipient-related intraoperative abortions, unexpected extension of hepatocellular carcinoma was related in 5 cases. Two cases of intraoperative abortions were related to bowel inflammation, and 2 cases were associated with severe adhesion related to previous treatment. One recipient with severe pulmonary hypertension was also aborted. CONCLUSION: Complete prevention of aborted LDLT is still not feasible. In this regard, further efforts to minimize intraoperative abortion are required.

Intraoperative management of liver transplant recipients having severe renal dysfunction: results of 42 cases

PURPOSE: Whereas continuous renal replacement therapy (CRRT) has been utilized during liver transplantation (LT), there was a lack of evidence to support this practice. We investigated the adverse events at the perioperative periods in recipients of LT who received preoperative CRRT without intraoperative CRRT. METHODS: We retrospectively reviewed medical records of adult patients (age ≥ 18 years) who received LT between December 2009 and May 2015. Perioperative data were collected from the recipients, who received preoperative CRRT until immediately before LT, because of refractory renal dysfunction. RESULTS: Of 706 recipients, 42 recipients received preoperative CRRT. The mean (standard deviation) Model for end-stage liver disease score were 49.6 (13.4). Twenty-six point two percent (26.2%) of recipients experienced the serum potassium > 4.5 mEq/L before reperfusion and treated with regular insulin. Thirty-eight point one percent (38.1%) of recipients were managed with sodium bicarbonate because of acidosis (base excess 5.5 mEq/L), refractory acidosis, or critical arrhythmias. Mortality was 19% at 30 day and 33.3% at 1 year. CONCLUSION: Although intraoperative CRRT was not used in recipients with severe preoperative renal dysfunction, LT was safely performed. Our experience raises a question about the need for intraoperative CRRT.

Optimal head rotation and puncture site for internal jugular vein cannulation after laryngeal mask airway insertion

<p><b>INTRODUCTION</b>We studied the effect of head rotation on the relative position of the right common carotid artery (CCA) and the right internal jugular vein (IJV) in patients with laryngeal mask airway (LMA) insertion to evaluate the accuracy of anatomical landmarks for right IJV cannulation.</p><p><b>METHODS</b>We simulated needle insertion to the right IJV on sonograms via the central landmark approach and an approach using the external jugular vein, in patients with LMA insertion (n = 50) or endotracheal intubation (E-tube, n = 50). Overlap index and successful simulation rates were measured according to the different degrees of head rotation.</p><p><b>RESULTS</b>The overlap index between the right CCA and the right IJV increased with greater degrees of head rotation. It was significantly greater in the LMA insertion group than in the E-tube group in the following head rotation positions: neutral, 15° and 45°. The success rate of the simulation was lower in the LMA insertion group than in the E-tube group. In the LMA insertion group, the success rate of the simulation was highest (62%) with the central landmark approach and in the 15° head rotation position.</p><p><b>CONCLUSION</b>In the LMA insertion group, the overlap index increased incrementally with greater head rotation degrees (from neutral to 45°). The central landmark approach and 15° head rotation position appear to be the optimal puncture site and degree of head rotation for right IJV cannulation in patients with LMA insertion.</p>

Pre-transplant Predictors for 3-Month Mortality after Living Donor Liver Transplantation / 대한이식학회지

BACKGROUND: High model for end-stage liver disease (MELD) scores (> or =35) is closely associated with poor posttransplantation outcomes in patients who undergo living donor liver transplantation (LDLT). There is little information regarding factors that negatively impact the survival of patients with high MELD scores. The aim of this study was to identify factors associated with 3-month mortality of patients after LDLT. METHODS: We retrospectively analyzed 774 patients who underwent adult LDLT with right lobe grafts between 1996 and 2012. Exclusion criteria were re-transplantation, left graft, auxiliary partial orthotopic liver transplantation, and inadequate medical recording. Preoperative variables were analyzed retrospectively. RESULTS: The overall 3-month survival rate was 92%. In univariate analysis, acute progression of disease, severity of hepatic encephalopathy, Child-Pugh class C, hepatorenal syndrome, use of continuous renal replacement therapy, use of ventilator, intensive care unit (ICU) care before transplantation, and MELD scores > or =35 were identified as potential risk factors. However, only ICU care before transplantation and MELD scores > or =35 were independent risk factors for 3-month mortality after LDLT. Three-month and 1-year patient survival rates for those with no risk factors were 95.5% and 88.6%, respectively. In contrast, patients with at least one risk factor had 3-month and 1-year patient survival rates of 88.4% and 81.1%, respectively, while patients with two risk factors had 3-month and 1-year patient survival rates of 55.6% and 55.6%, respectively. CONCLUSIONS: Patients with both risk factors (ICU care before LDLT and MELD scores > or =35) should be cautiously considered for treatment with LDLT.

Association between the use of gel pads under patients' knees and the incidence of peroneal neuropathy following liver transplantation

<p><b>INTRODUCTION</b>There have been intermittent reports of peroneal neuropathy (PN) occurring after liver transplantation. Although PN may not be viewed as a serious complication by liver transplant (LT) recipients who require the transplant for survival, PN can significantly reduce quality of life. The incidence of PN appears to have increased after the use of gel pads was introduced. These gel pads, which are placed under patients' knees during surgery, are used to reduce lower back strain and prevent contact between the peroneal nerve at the fibular head and the hard surface of the operating table. The aim of the present study was to investigate the association, if any, between the use of gel pads and the incidence of PN.</p><p><b>METHODS</b>The medical records of 261 adult LT recipients were retrospectively reviewed. The recipients were divided into gel pad (n = 167) and non-gel pad (n = 94) groups. The incidence and possible risk factors of PN were compared between the two groups.</p><p><b>RESULTS</b>The overall incidence of PN was 8.0% (21/261). The occurrence of PN was significantly higher in the gel pad group than in the non-gel pad group (10.8% vs. 3.2%; p < 0.05). Other possible risk factors were comparable between the two patient groups.</p><p><b>CONCLUSION</b>As the use of gel pads may increase the incidence of PN, we recommend against the use of gel pads under the knees of LT recipients.</p>

Unilateral laryngeal hematoma after combined carotid endarterectomy and off-pump coronary artery bypass grafting surgery / 대한마취과학회지

No abstract available.

Anesthetic management including extracorporeal membrane oxygenation therapy of liver transplant recipient with life-threatening hypoxemia: a case report / 대한마취과학회지

We present a rare case of successful anesthetic management for a patient who had refractory hypoxia during liver transplantation (LT) with intraoperative veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support. A 49 year-old female patient underwent living donor LT. After reperfusion of the grafted liver, graft congestion and massive oozing developed. Thus it was decided to reoperate with a temporary gauze packing. However, the patient's condition deteriorated with azotemia and severe hypoxemia. VV ECMO with continuous renal replacement therapy was started 24 hours before secondary LT and maintained during secondary LT. VV ECMO was weaned 32 hours after secondary LT. This case indicates that not only after the LT but also before and during LT, VV ECMO can be a treatment option for the patient with end-stage liver disease combined with respiratory failure when there is the possibility of lung recovery.

Ultrasound-guided femoral nerve, femoral branch of genitofemoral nerve and sciatic nerve block for femoro-popliteal or tibial arterial bypass surgery on patients with cardiac dysfunction: Report of two cases

We report two cases of high-risked patients with cardiac dysfunction undergoing femoro-popliteal or tibial arterial bypass surgery anesthetized by ultrasound guided peripheral nerve blocks; femoral nerve, femoral branch of genitofemoral nerve and sciatic nerve block. We used an anesthetic solution consisting of 0.375% ropivacaine with epinephrine. We provided sufficient surgical anesthesia. These nerve blockades provided stable intraoperative and postoperative hemodynamic status, which is valuable knowledge from the perspective of postoperative pain control as well as satisfaction of both patients and surgeons. We believe that femorosciatic nerve block with concurrent femoral branch block of genitofemoral nerve could be an excellent anesthetic choice for patients receiving femoro-popliteal or tibial arterial bypass surgery, especially in patients with cardiac dysfunction.

Ultrasound-guided femoral nerve, femoral branch of genitofemoral nerve and sciatic nerve block for femoro-popliteal or tibial arterial bypass surgery on patients with cardiac dysfunction: Report of two cases

We report two cases of high-risked patients with cardiac dysfunction undergoing femoro-popliteal or tibial arterial bypass surgery anesthetized by ultrasound guided peripheral nerve blocks; femoral nerve, femoral branch of genitofemoral nerve and sciatic nerve block. We used an anesthetic solution consisting of 0.375% ropivacaine with epinephrine. We provided sufficient surgical anesthesia. These nerve blockades provided stable intraoperative and postoperative hemodynamic status, which is valuable knowledge from the perspective of postoperative pain control as well as satisfaction of both patients and surgeons. We believe that femorosciatic nerve block with concurrent femoral branch block of genitofemoral nerve could be an excellent anesthetic choice for patients receiving femoro-popliteal or tibial arterial bypass surgery, especially in patients with cardiac dysfunction.

Pulse pressure variation and stroke volume variation to predict fluid responsiveness in patients undergoing carotid endarterectomy / 대한마취과학회지

BACKGROUND: During carotid endarterectomy (CEA), hemodynamic stability and adequate fluid management are crucial to prevent perioperative cerebral stroke, myocardial infarction and hyperperfusion syndrome. Both pulse pressure variation (PPV) and stroke volume variation (SVV), dynamic preload indices derived from the arterial waveform, are increasingly advocated as predictors of fluid responsiveness in mechanically ventilated patients. The aim of this study was to evaluate the accuracy of PPV and SVV for predicting fluid responsiveness in patients undergoing CEA. METHODS: Twenty seven patients undergoing CEA were enrolled in this study. PPV, SVV and cardiac output (CO) were measured before and after fluid loading of 500 ml of hydroxyethyl starch solution. Fluid responsiveness was defined as an increase in CO > or = 15%. The ability of PPV and SVV to predict fluid responsiveness was assessed using receiver operating characteristic (ROC) analysis. RESULTS: Both PPV and SVV measured before fluid loading are associated with changes in CO caused by fluid expansion. The ROC analysis showed that PPV and SVV predicted response to volume loading (area under the ROC curve = 0.854 and 0.841, respectively, P or = 9.5% identified responders (Rs) with a sensitivity of 71.4% and a specificity of 90.9%, and a SVV > or = 7.5% identified Rs with a sensitivity of 92.9% and a specificity of 63.6%. CONCLUSIONS: Both PPV and SVV values before volume loading are associated with increased CO in response to volume expansion. Therefore, PPV and SVV are useful predictors of fluid responsiveness in patients undergoing CEA.

Intractable metabolic acidosis in a child with propionic acidemia undergoing liver transplantation: a case report / 대한마취과학회지

Propionic acidemia (PA) is a rare autosomal recessive disorder of metabolism caused by deficient activity of the mitochondrial enzyme propionyl-CoA carboxylase. The clinical manifestations are metabolic acidosis, poor feeding, lethargy, vomiting, osteoporosis, neurological dysfunction, pancytopenia, developmental retardation and cardiomyopathy. Liver transplantation has recently been considered as one of the treatment options for patients with PA. This case report describes several anesthetic considerations for patients with PA undergoing liver transplantation. Understanding the patient's status and avoiding events that may precipitate metabolic acidosis are important for anesthetic management of patients with PA. In conclusion, anesthesia should be focused on minimizing the severity of metabolic acidosis with following considerations: (1) maintaining optimal tissue perfusion by avoiding hypotension, (2) preventing hypoglycemia, and (3) providing bicarbonate to compensate for the acidosis.

The effect of midazolam dose and age on the paradoxical midazolam reaction in Korean pediatric patients / 대한마취과학회지

BACKGROUND: Although midazolam administration may occasionally induce a paradoxical episode, such as threatened crying and violent behavior in children, systematic studies on the causes of paradoxical reaction are limited. We investigated the effect of children's age and a dose of midazolam on the paradoxical reaction. METHODS: A total of one hundred sixty four children of 1-3 years and 3-5 years, were enrolled in this study. Each age group randomly received 0.05 mg/kg or 0.1 mg/kg of intravenous midazolam (41 patients/group). RESULTS: The incidence of paradoxical midazolam reaction in the study groups, 1-3 years with 0.1 mg/kg of intravenous midazolam, 1-3 years with 0.05 mg/kg, 3-5 years with 0.1 mg/kg, and 3-5 years with 0.05 mg/kg were as follows: 29.3%, 12.2%, 7.3% and 2.4%, respectively. The incidence among the 4 groups was significantly different (P = 0.002), highest in the 1-3 years receiving 0.1 mg/kg of midazolam (29.3%). Both age (P = 0.004, OR [95%CI] = 5.3 [1.7-16.8]) and dose of midazolam (P = 0.036, OR [95%CI] = 3.0 [1.1-8.4]) were risk factors. Perioperative clinical data including anxiety scales of children were not associated with the paradoxical midazolam reaction. CONCLUSIONS: In conclusion, we suggest that children less than 3 years old receiving higher dose of intravenous midazolam are at risk for the paradoxical midazolam reaction.

A case report of anesthesia management in the liver transplantation recipient with porphyria: A case report / 대한마취과학회지

Porphyrias are a group of diseases characterized by an enzyme deficiency in the heme biosynthesis pathway, resulting in accumulation of precursor molecules in the tissue. Some porphyric patients develop progressive liver disease that requires liver transplantation. This case report describes special anesthetic challenges, including careful selection of drugs and the use of special filters that can exclude harmful wavelengths of ultraviolet, in a patient with porphyria who underwent living donor liver transplantation. Understanding the patient's status and disease process, and avoiding triggering factors of porphyria attacks, are important for successful liver transplantation anesthesia in patients with porphyria.

Accidental malpositioning of 9Fr central venous catheter in the right subclavian vein via right internal jugular vein: A case report

Central venous catheters can provide important hemodynamic information in patients with cardiopulmonary disease and access for medicine, fluid, and blood administration during surgery. The placement of central venous catheters is associated with a complication rate of 0.4% to 20%, including pneumothorax, arterial puncture, infection and cardiac tamponade. In addition, malposition of central venous catheter is another complication of central venous catheterization. We report a case of malpositioning of central venous catheter which is located in the right subclavian vein via internal jugular vein in a liver transplant recipient. The malpositioning was confirmed by portable X-ray after several field attempts to advance Swan-Ganz catheter and achieve normal sequences of pressure waves.

Protective Effects of Gabapentin on Allodynia and alpha2delta1-Subunit of Voltage-dependent Calcium Channel in Spinal Nerve-Ligated Rats

This study was designed to determine whether early gabapentin treatment has a protective analgesic effect on neuropathic pain and compared its effect to the late treatment in a rat neuropathic model, and as the potential mechanism of protective action, the alpha2delta1-subunit of the voltage-dependent calcium channel (alpha2delta1-subunit) was evaluated in both sides of the L5 dorsal root ganglia (DRG). Neuropathic pain was induced in male Sprague-Dawley rats by a surgical ligation of left L5 nerve. For the early treatment group, rats were injected with gabapentin (100 mg/kg) intraperitoneally 15 min prior to surgery and then every 24 hr during postoperative day (POD) 1-4. For the late treatment group, the same dose of gabapentin was injected every 24 hr during POD 8-12. For the control group, L5 nerve was ligated but no gabapentin was administered. In the early treatment group, the development of allodynia was delayed up to POD 10, whereas allodynia was developed on POD 2 in the control and the late treatment group (p<0.05). The alpha2delta1-subunit was up-regulated in all groups, however, there was no difference in the level of the alpha2delta1-subunit among the three groups. These results suggest that early treatment with gabapentin offers some protection against neuropathic pain but it is unlikely that this action is mediated through modulation of the alpha2delta1-subunit in DRG.

Risk factors of postoperative delirium following liver transplantation / 대한마취과학회지

BACKGROUND: Postoperative delirium (POD) after liver transplantation is a serious complication. This study investigated the incidence and the risk factors of POD in liver transplantation recipients. METHODS: Three hundred and sixty eight adult recipients who had undergone liver transplantation were included. We reviewed medical records and the POD was determined by either psychiatric consultation or established diagnostic criteria. Recipients were divided into two groups according to the occurrence of POD: POD group (n = 150) and non-POD group (n = 218), and risk factors were assessed. RESULTS: One hundred fifty (40.8%) of the 368 recipients developed POD after liver transplantation. History of alcohol consumption and alcoholic liver disease, history of hepatic encephalopathy, preoperative mental status changes, ventilator care, dialysis, hypotension, and ICU care were significantly higher in the POD group. In the preoperative laboratory test, sodium was lower while bilirubin, PT (INR) and MELD score were higher in the POD group. Postoperative variables including dialysis, ventilator care duration, ICU stay, hospital stay, glucose and ammonia were significantly higher in the POD group. Three variables were identified as independent predictors of POD in a multiple regression analysis: history of alcohol consumption (odds ratio, 2.04; 95% confidence interval [CI], 1.12-3.72; P = 0.02), history of hepatic encephalopathy (odds ratio, 2.54; 95% CI, 1.46-4.41, P<0.01), and MELD score (odds ratio, 1.03; 95% CI, 1.00-1.06; P = 0.02). CONCLUSIONS: The development of POD and related morbidity and mortality would be reduced if we identified the recipients with risk factors preoperatively and applied early intervention.

Is Intravenous Patient Controlled Analgesia Enough for Pain Control in Patients Who Underwent Thoracoscopy?

This prospective randomized study was conducted to evaluate the efficacy of two common analgesic techniques, thoracic epidural patient-controlled analgesia (Epidural PCA), and intravenous patient-controlled analgesia (IV PCA), in patients undergoing lobectomy by the video-assisted thoracic surgical (VATS) approach. Fifty-two patients scheduled for VATS lobectomy were randomly allocated into two groups: an Epidural PCA group receiving an epidural infusion of ropivacaine 0.2%+fentanyl 5 microg/mL combination at a rate of 4 mL/hr, and an IV PCA group receiving an intravenous infusion of ketorolac 0.2 mg/kg+fentanyl 15 microg/mL combination at a rate of 1 mL/hr. Pain scores were then recorded using the visual analogue scale at rest and during motion (VAS-R and VAS-M, 0-10) for five days following surgery. In addition, we measured the daily morphine consumption, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), satisfaction score, and the incidence of side effects. Thirty-seven patients out of 52 completed the study (18 in the Epidural PCA group, 19 in the IV PCA group). There were no differences in the pain scores, analgesic requirements, pulmonary function, satisfaction score, and the incidence of side effects between groups. This indicates that IV PCA and Epidural PCA are equally effective to control the postoperative pain after VATS lobectomy, which suggests that IV PCA may be used instead of Epidural PCA.