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Background@#The clinical efficacy of preoperative 2D-echocardiographic assessment of pulmonary arterial pressure (PAP) has not been evaluated fully in liver transplantation (LT) recipients. @*Methods@#From October 2010 to February 2017, a total of 344 LT recipients who underwent preoperative 2D-echocardiography and intraoperative right heart catheterization (RHC) was enrolled and stratified according to etiology, disease progression, and clinical setting. The correlation of right ventricular systolic pressure (RVSP) on preoperative 2D-echocardiography with mean and systolic PAP on intraoperative RHC was evaluated, and the predictive value of RVSP > 50 mmHg to identify mean PAP > 35 mmHg was estimated. @*Results@#In the overall population, significant but weak correlations were observed (R = 0.27; P 50 mmHg identifying mean PAP > 35 mmHg were 37.5% and 49.9%, respectively. In the subgroup analyses, correlations were not significant in recipients of deceased donor type LT (R = 0.129; P = 0.224 for systolic PAP, R = 0.163; P = 0.126 for mean PAP) or in recipients with poorly controlled ascites (R = 0.215; P = 0.072 for systolic PAP, R = 0.21; P = 0.079 for mean PAP). @*Conclusion@#In LT recipients, the correlation between RVSP on preoperative 2D-echocardiography and PAP on intraoperative RHC was weak; thus, preoperative 2D-echocardiography might not be the optimal tool for predicting intraoperative PAP. In LT candidates at risk of pulmonary hypertension, RHC should be considered.
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Background@# The allocation policy for deceased donor livers in Korea was changed in June 2016 from Child-Turcotte-Pugh (CTP) scoring system-based to Model for End-stage Liver Disease (MELD) scoring system-based. Thus, it is necessary to review the effect of allocation policy changes on anesthetic management. @*Methods@# Medical records of deceased donor liver transplantation (DDLT) from December 2014 to May 2017 were reviewed. We compared the perioperative parameters before and after the change in allocation policy. @*Results@# Thirty-seven patients underwent DDLT from December 2014 to May 2016 (CTP group), and 42 patients underwent DDLT from June 2016 to May 2017 (MELD group). The MELD score was significantly higher in the MELD group than in the CTP group (36.5 ± 4.6 vs. 26.5 ± 9.4, P < 0.001). The incidence of hepatorenal syndrome (HRS) was higher in the MELD group than in the CTP group (26 vs. 7, P < 0.001). Packed red blood cell transfusion occurred more frequently in the MELD group than in the CTP group (5.0 ± 3.6 units vs. 3.4 ± 2.2 units, P = 0.025). However, intraoperative bleeding, vasopressor support, and postoperative outcomes were not different between the two groups. @*Conclusions@# Even though the patient’s objective condition deteriorated, perioperative parameters did not change significantly.
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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.
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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.
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Background@#; Liver transplantation usually requires blood transfusion, and a red blood cell (RBC) antibody screen is essential for the prevention of a hemolytic reaction. Since proper ABO-compatible grafts are lacking, ABO-incompatible living donor liver transplantation (ABO-i LDLT) with desensitization is a feasible therapy. Desensitization includes intravenous rituximab injection and plasmapheresis before surgery.Case: A 60-year-old female was diagnosed with hepatitis B virus-related hepatocellular carcinoma and planned for ABO-i LDLT. She tested positive in a RBC antibody screen over two years; however, she tested negative for the test after desensitization. Clinicians noted the seroconversion during induction, and thus, a delay in the preparation of adequate packed RBC was unavoidable. @*Conclusions@#Even when the latest RBC antibody screen is negative after immunosuppression, clinicians should consider the possibility of a prior positive result to promote safer medical treatment and management.
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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.
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Background@#Familial amyloid polyneuropathy (FAP) is caused by mutation in a gene transcribing transport protein produced mainly by the liver. Liver transplantation is required to stop FAP progression, but the pathology causes anesthetic management challenges.Case: We report a case of domino living donor liver transplantation in an FAP patient. No intraoperative events occurred; however, during postoperative day 1 in the intensive care unit (ICU), the FAP patient underwent multiple cardiopulmonary resuscitation (CPR) sessions due to pulseless electrical activity following a sudden drop in blood pressure and ventricular tachycardia. Despite ICU management, the patient died after the third CPR session. @*Conclusions@#Various anesthetic management techniques should be considered for FAP patients. Anesthetic management was carefully assessed with the use of isoflurane, isoproterenol, and an external patch. The cause of deterioration in the ICU is unclear, but further investigation is needed to prevent and better manage postoperative morbidity and mortality.
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Background@#There have been many reports about decreased analgesic requirements in liver transplant recipients compared with patients undergoing other abdominal surgery.Case: Herein we describe a case in which a 42-year-old man underwent living donor liver transplantation from his monozygotic twin. Because innate pain thresholds may be similar in monozygotic twins, we could effectively investigate postoperative pain in the donor and the recipient. Concordant with previous reports, the recipient used less analgesic than the donor in the present study. @*Conclusions@#Physicians caring for patients who have received liver transplantation should consider their comparatively low requirement for analgesic, to prevent delayed recovery due to excessive use of analgesic.
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PURPOSE: Laparoscopic major liver resection (major LLR) remains a challenging procedure because of the technical difficulty. Several significant technical innovations have been applied in our center since 2012. They include routine application of bipolar electrocautery, initiation of temporary increase of intra-abdominal pressure during bleeding events from veins to balance the central venous pressure, and use of temporary inflow control of the Glissonean pedicle. This study evaluated the impact of these technique modifications in patients with major LLR. METHODS: Between January 2004 and February 2015, a total of 606 patients underwent LLR at Samsung Medical Center in Seoul, Korea. Major LLR was employed in 233 cases. All major LLR procedures were anatomical resections performed with a totally laparoscopic approach. We compared surgical parameters of right hepatectomy (RH), left hepatectomy (LH), and right posterior sectionectomy (RPS) before and after 2012. RESULTS: Open conversion rates of RH and LH and estimated blood loss in RPS significantly decreased after 2012. The postoperative complication rate of major LLR was 12.7% and was similar before and after 2012. Bile leakage was the most common complication (3.2%). CONCLUSION: The modifications of surgical techniques resulted in good outcomes for laparoscopic major LLR. We recommend routine application of these techniques to improve outcomes, especially in patients requiring major liver resection.
Subject(s)
Humans , Bile , Central Venous Pressure , Electrocoagulation , Hemorrhage , Hepatectomy , Korea , Laparoscopy , Learning Curve , Liver , Minimally Invasive Surgical Procedures , Postoperative Complications , Seoul , VeinsABSTRACT
The coagulation profile of patients with end-stage liver disease (ESLD) is different from that of healthy individuals. Because hemostasis is rebalanced in chronic liver disease, prophylactic transfusion of blood products may be not necessary for these patients even if they show severe coagulation dysfunction in conventional coagulation results. A 44-year-old man with hepatocellular carcinoma, cholangiocarcinoma and liver cirrhosis was scheduled for extra-hepatic mass excision under general anesthesia. His preoperative tests showed severe thrombocytopenia 19 × 10⁹/L. The patient underwent extrahepatic mass excision surgery under general anesthesia without transfusion of blood products. The post-operative course was uneventful without requiring any further hemostatic therapy. In this case report, we focus on the concept of rebalanced hemostasis in ESLD, and coagulation management based on rotational thromboelastometry.
Subject(s)
Adult , Humans , Anesthesia, General , Blood Coagulation , Blood Platelets , Carcinoma, Hepatocellular , Cholangiocarcinoma , Hemostasis , Liver Cirrhosis , Liver Diseases , Liver , Platelet Count , Thrombelastography , ThrombocytopeniaABSTRACT
A 25-year old female singer was scheduled to undergo a right hepatectomy for her father's liver transplantation. Her two main requests were rapid recovery and prevention of cosmetic complications, and the avoidance of postoperative laryngeal damage. Thus, we decided to use a laparoscopic surgical approach and the second-generation supraglottic airway (Protector™ supraglottic airway). After anesthetic induction, the supraglottic airway was placed at the first attempt, and its performance was tested using the oropharyngeal leak pressure and maximal minute volume ventilation tests. Throughout the surgery, the cuff pressure of the supraglottic airway was maintained in the green zone. The Protector™ supraglottic airway was successfully used during 300 minutes of anesthesia, and it only caused mild postoperative sore throat without hoarseness or aspiration. Anesthesiologists should consider using the supraglottic airway proactively in laparoscopic living donor right hepatectomies when professional voice users undergo surgery.
Subject(s)
Female , Humans , Anesthesia , Hepatectomy , Hoarseness , Laparoscopy , Laryngeal Masks , Liver Transplantation , Living Donors , Pharyngitis , Pulmonary Ventilation , Singing , VoiceABSTRACT
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.
Subject(s)
Adult , Humans , Carcinoma, Hepatocellular , Fatty Liver , Hypertension, Pulmonary , Inflammation , Liver Transplantation , Liver , Living Donors , Postoperative CareABSTRACT
Intraoperative hypothermia occurs frequently, but hyperthermia is relatively rare during general anesthesia. We experienced a case of hyperthermia during living donor liver transplantation that appeared to be significantly associated with biliary obstruction. A 65-year-old male patient was diagnosed with intrahepatic cholangiocarcinoma, and living donor liver transplantation was planned after confirmation of no metastasis via intraoperative frozen biopsy. Following resection of a segment of common bile duct for frozen biopsy, the surgeon clamped the common bile duct, and the patient's body temperature increased gradually to 39.5°C. As the congested bile was drained, the body temperature decreased to the normal range. This case report suggests that when a patient develops unexplained hyperthermia during hepatobiliary surgery or in a chance of biliary obstruction, clinicians should consider bile congestion as a possible reason for hyperthermia.
Subject(s)
Aged , Humans , Male , Anesthesia, General , Bile , Biopsy , Body Temperature , Cholangiocarcinoma , Common Bile Duct , Estrogens, Conjugated (USP) , Fever , Hypothermia , Liver Transplantation , Liver , Living Donors , Neoplasm Metastasis , Reference ValuesABSTRACT
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.
Subject(s)
Adult , Humans , Acidosis , Arrhythmias, Cardiac , Hyperkalemia , Insulin , Liver Diseases , Liver Transplantation , Liver , Medical Records , Mortality , Perioperative Period , Potassium , Renal Replacement Therapy , Reperfusion , Retrospective Studies , Sodium Bicarbonate , Transplant RecipientsABSTRACT
<p><b>INTRODUCTION</b>This prospective observational study compared the postoperative analgesic effectiveness of intrathecal morphine (ITM) and surgical-site infusion (SSI) of ropivacaine as adjuncts to intravenous (IV) patient-controlled analgesia (PCA) (fentanyl) in living-donor kidney transplant recipients.</p><p><b>METHODS</b>Patients undergoing living-donor kidney transplantation who received ITM or SSI in addition to IV PCA were included. Rescue analgesia was achieved with IV meperidine as required. The primary outcome, measured using the Numeric Pain Rating Scale (NRS), was pain at rest and when coughing. Patients were assessed for 48 hours after surgery.</p><p><b>RESULTS</b>A total of 53 patients (32 ITM, 21 SSI) were included in the study. The ITM group showed significantly lower NRS scores, at rest and when coughing, for up to 12 and eight hours. NRS scores were comparable between the groups at other times. The ITM group had significantly less postoperative systemic opioid requirement in the first 24 hours, but there was no significant difference between the systemic opioid consumption of the groups on postoperative Day 2. In the ITM group, 3 (9.4%) patients presented with bradypnoea and 1 (3.1%) with excessive sedation in the first 12 postoperative hours. More patients in the ITM group developed pruritus requiring treatment during the first 24 hours. There were no differences between the groups in other outcomes (e.g. nausea/vomiting, change in pulmonary or kidney functions).</p><p><b>CONCLUSION</b>Compared with SSI, ITM reduced immediate postoperative pain and IV opioid consumption on postoperative Day 1 after living-donor kidney transplantation, but at the cost of increased pruritus and respiratory depression.</p>
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Since the implementation of the model for end-stage liver disease (MELD) scoring system in 2002, the liver transplantation (LT) society has observed a substantial increase in the number of recipients with renal dysfunction. Intraoperative renal replacement therapy (ioRRT) has emerged as one of the solutions available to manage high-MELD score recipients; however, its usefulness has not yet been proven. To date, we have experienced five cases of simultaneous liver and kidney transplantation (SLKT). Recipients of SLKT tend to have a lower pre-transplant kidney function and the longer operation time mandates a larger amount of fluid than LT alone. Hence, anesthetic care is more prone to be challenged by hyperkalemia, metabolic acidosis, and volume overload, making ioRRT a theoretically valuable intervention. However, in all five cases, recipients were managed without ioRRT, resulting in excellent graft and patient survival. As such, in this case series, we discuss current issues about ioRRT and SLKT.
Subject(s)
Humans , Acidosis , Hyperkalemia , Kidney Transplantation , Kidney , Liver Diseases , Liver Transplantation , Liver , Renal Replacement Therapy , TransplantsABSTRACT
The diagnosis of brain death is essential for deceased donor organ transplantation. Currently, extracorporeal membrane oxygenation (ECMO) is used to increase the chance of survival of patients with severe cardiac and respiratory failure. Therefore, cases of ECMO-dependent potential donors are increasing. The apnea test (AT) is a mandatory component in the clinical determination of brain death. However, conventional AT is not easily applicable to ECMO-dependent potential donors because both the ventilator and ECMO play an important role in carbon dioxide elimination. Accordingly, different methods of AT from those used in routine procedures must be considered. We report here a case of conventional AT with time delay and two cases of AT within 3 minutes by adjusting sweep gas flow rate of ECMO in ECMO-dependent potential donors.
Subject(s)
Humans , Apnea , Brain Death , Carbon Dioxide , Diagnosis , Extracorporeal Membrane Oxygenation , Membranes , Organ Transplantation , Respiratory Insufficiency , Tissue Donors , Transplants , Ventilators, MechanicalABSTRACT
BACKGROUND: Hemodialysis via the internal jugular vein (IJV) has been widely used for patients with end stage renal disease (ESRD) patients, as they have a higher risk of arterial diseases. We investigated the ultrasonographic findings of the IJV and carotid artery (CA) in recipients of kidney transplantation (KT) and identified factors influencing IJV/CA abnormalities. METHODS: We enrolled 120 adult KT recipients. Patients in group A (n = 57) had a history of IJV hemodialysis, while those in group B (n = 63) were not yet on dialysis or undergoing dialysis methods not involving the IJV. The day before surgery, we evaluated the state of the IJV and CA using ultrasonography. We followed patients with IJV stenosis for six months after KT. RESULTS: Ultrasonography revealed that four patients (7%) in group A had IJV abnormalities, while no patients in group B had abnormalities (P = 0.118). Of the four patients with abnormalities, one with 57.4% stenosis normalized during follow- up. However, another patient with 90.1% stenosis progressed to occlusion, while the two patients with total occlusion remained the same. Twenty patients in group A (n = 11) and B (n = 9) had several CA abnormalities (P = 0.462). Upon multivariate analysis with stepwise selection, height and age were significantly correlated with IJV stenosis (P = 0.043, odds ratio = 0.9) and CA abnormality (P = 0.012, odds ratio = 1.1), respectively. CONCLUSIONS: IJV abnormalities (especially with a history of IJV hemodialysis) and CA abnormalities may be present in ESRD patients. Therefore, we recommend ultrasonographic evaluation before catheterization.
Subject(s)
Adult , Humans , Carotid Arteries , Catheterization , Catheterization, Central Venous , Catheters , Constriction, Pathologic , Dialysis , Jugular Veins , Kidney Failure, Chronic , Kidney Transplantation , Kidney , Multivariate Analysis , Odds Ratio , Renal Dialysis , Transplant Recipients , UltrasonographyABSTRACT
A 26-year-old parturient with Eisenmenger's syndrome and complete atrioventricular block was presented for emergency Cesarean section due to preterm labor. Ventricular tachycardia (VT), which progressed to ventricular fibrillation (VF), started immediately after the incision. Cardiopulmonary resuscitation with electric shocks was given by anesthesiologists while the obstetrician delivered the baby between the shocks. A cardiac surgeon was ready for extracorporeal membrane oxygenation institution in case of emergency but spontaneous circulation of the patient returned after the 3rd shock and the delivery of the baby. The newborn's Apgar score was 4 at 1 minute and 8 at 5 minutes. An implantable cardioverter-defibrillator was inserted before the discharge because the patient had recurrent episodes of VT and VF postoperatively.
Subject(s)
Adult , Female , Humans , Pregnancy , Apgar Score , Atrioventricular Block , Cardiopulmonary Resuscitation , Cesarean Section , Defibrillators, Implantable , Eisenmenger Complex , Emergencies , Extracorporeal Membrane Oxygenation , Heart Arrest , Obstetric Labor, Premature , Shock , Tachycardia, Ventricular , Ventricular FibrillationABSTRACT
<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>