Administration of a recombinant factor Vlla in patients undergoing liver transplantation for fulminant hepatic failure.

BACKGROUND: Fulminant hepatic failure (FHF) is associated with profound clotting disturbances leading to the risk of a major blood loss during orthotopic liver transplantation (OLT). Application of a recombinant factor VIIa (rVIIa) that promptly corrects clotting abnormalities remains controversial in the OLT setting. We conducted a retrospective analysis of the effect of rVIIa on the prothrombin time (PT) and other perioperative parameters in patients transplanted for FHF in our center. MATERIALS AND METHODS: Nineteen consecutive patients (9 males/10 females) of overall mean age of 33 +/- 13 years underwent the procedure due to: Wilson's (n = 8), non-A-non-B hepatitis (n = 6) or Amanita phalloides toxicity (n = 5). All subjects received rVIIa at a mean dose of 54 +/- 16 microg/kg body weight at 10 minutes before the skin incision. The PT was measured at 15 minutes and 12 hours after injection. Data were analyzed with StatView program with P < .05 considered significant. RESULTS: Rapid correction of PT was observed in all patients: the mean PT before injection was 37 +/- 14 versus 14 +/- 3 after 15 minutes (P < .0001). Twelve hours after the injection the PT was 19 +/- 5 (P < .0001 vs before injection and P < .0007 vs 15 minutes after injection). Two patients died at 1 and 4 days after OLT. Mean red blood cell requirement was 5 +/- 4 U and fresh frozen plasma was 11 +/- 5 U. The mean operative time was 527 +/- 126 minutes and intensive care unit stay 8 +/- 9 days. None of the patients developed thromboembolic complications. CONCLUSION: Administration of rVIIa caused a rapid improvement in the PT shortly after injection. It was safe and not associated with any thromboembolic events in our series.

Reduction of biliary complication rate using continuous suture and no biliary drainage for duct-to-duct anastomosis in whole-organ liver transplantation.

Biliary complications (BC) following orthotopic liver transplantation (OLT) are related to various factors including surgical technique and use of biliary drains for a duct-to-duct (DD) anastomosis. Herein we have reported the influence of changes in surgical technique on BC following OLT in our center. From February 2002 to February 2007, we performed 101 whole-organ OLT with a DD anastomosis in 99 adults, of whom we analyzed 84 subjects. We excluded recipients who died within 30 days of OLT without any evidence of BC and 1 patient with a biliary stricture secondary to a hepatic artery thrombosis. Until late 2004, a DD anastomosis with interrupted sutures over an external biliary drain (DD/BD) was performed in 35 patients (Group I). Subsequently, no biliary drain was used for the DD anastomosis (DD/non-BD), using a continuous suture in 49 patients (Group II). The DD anastomosis with interrupted sutures over a biliary drain was associated with a higher incidence of both total (31% vs 8%; P = .008) and late BC (>30 days; 20% vs 2%; P = .008) with a trend toward more leaks (17% vs 4%; P = .06). All biliary leaks in patients with DD/BD reconstruction occurred at the exit site of the biliary drain following its removal. No significant differences were observed when we compared the incidence of biliary strictures and the necessity for surgical intervention. One patient died due to a BC. Our results indicated that a DD anastomosis performed with a continuous suture technique and no external biliary drainage reduced the incidence of BC after whole-organ OLT.

Vascular complications following adult piggyback liver transplantation with end-to-side cavo-cavostomy: a single-center experience.

BACKGROUND: Vascular complications remain a significant cause of morbidity, graft loss, and mortality following orthotopic liver transplantation (OLT). These problems predominantly include hepatic artery and portal vein thrombosis or stenosis. Venous outflow obstruction may be specifically related to the technique of piggyback OLT. MATERIALS AND METHODS: Between February 2002 and February 2009, we performed 200 piggyback OLT in 190 recipients. A temporary portacaval shunt was created in 44 (22%) cases, whereas end-to-side cavo-cavostomy was routinely performed for graft implantation. Pre-existent partial portal or superior mesenteric vein thrombosis was present in 17 (12%) cirrhotics in whom we successfully performed eversion thrombectomy, which was followed by a typical end-to-end portal anastomosis. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft in 31 (16%) patients. RESULTS: The 14 (7%) vascular complications included hepatic artery thrombosis (n = 5), hepatic artery stenosis (n = 3), aortic/celiac trunk rupture (n = 2), portal vein stenosis (n = 2), and isolated left and middle hepatic venous outflow obstruction (n = 1). There was also 1 case of arterial steal syndrome via the splenic artery. No patient experienced portal or mesenteric vein thrombosis. Therapeutic modalities included re-OLT, arterial/aortic reconstruction and splenic artery ligation. Vascular complications resulted in death of 5 (36%) patients. CONCLUSION: Our experience indicated that piggyback OLT with an end-to-side cavo-cavostomy showed a low risk of venous outflow obstruction. Partial portal or mesenteric vein thrombosis is no longer an obstacle to OLT; it can be successfully managed with the eversion thrombectomy technique.

Outcome of emergency liver transplantation including mortality on the waiting list: a single-center experience.

Patients with irreversible fulminant hepatic failure (FHF) as well as recipients with primary graft nonfunction (PNF) and early hepatic artery thrombosis (HAT) die unless they undergo emergent liver transplantation (OLT). Therefore, they have the highest priority in organ allocation systems. Herein we describe our initial experience with 18 emergency among 103 OLT procedures performed in 99 adults from February 2002 through February 2007. Their diagnoses were FHF (n = 16), PNF (n = 1), and early HAT (n = 1). Ten subjects (56%) underwent emergency OLT after a mean 1.6 (range, 1 to 4) days after listing, whereas 8 (44%) patients died while awaiting a graft for a mean of 5.9 days (range, 2 to 17). All the transplants were performed according to the piggyback technique with routine preoperative use of intravenous recombinant factor VIIa (rVIIa) to control the coagulopathy, which resulted in significant (P < .0001), prompt correction of prothrombin time from a mean of 61 (range, 22 to 300) to 14 (range, 11 to 22) seconds at 15 minutes after drug administration. A mean of 4 (range, 0 to 14) units of RBC and 9 (range, 3 to 18) units of fresh frozen plasma were transfused during the procedure. Eight (80%) transplanted patients are alive in good condition with normal liver function at a mean of 18 (range, 4 to 36) months follow-up. Two patients died in the early postoperative period after massive aortic bleeding and biliary sepsis. In summary, only 56% of patients requiring emergency OLT received grafts achieving good medium and long-term survivals, which was significantly lower compared with Western European centers where this proportion reaches 90%. This outcome could be improved by international organ-sharing arrangements for emergency transplantation or living donation alternatives.

Liver transplantation for fulminant hepatic failure without venovenous bypass and without portacaval shunting.

Preservation of the caval vein during liver transplantation (OLT) has gained wide acceptance but portosystemic bypass or temporary portocaval shunt is still believed to be indicated in patients with fulminant hepatic failure. Herein we have described our initial experience with piggyback OLT without venovenous bypass and without portocaval shunting in five such patients. Division of the portal vein was always delayed until the native liver was completely dissected off the caval vein. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft placed in the supraceliac position in two and at an infrarenal site in three patients. The ahepatic phase urinary output was low in the two patients in whom we applied supraceliac cross-clamping of the aorta. The mean ahepatic phase was 53 (45 to 67) minutes in four recipients who remained hemodynamically stable throughout surgery and prolonged to 5 hours in one patient due to a complicated supraceliac aortic anastomosis. Its repair resulted in hemodynamic instability, multiorgan failure, and death at 4 days following OLT. Four (80%) patients are alive in good condition with normal liver function after a mean of 12 (5 to 25) months of follow-up. In summary, liver transplantation for fulminant hepatic failure may be safely performed without venovenous bypass and without temporary portocaval shunting if the ahepatic phase is minimized and portal flow to the liver maintained up to the moment of hepatic excision. Arterial anastomosis with the supraceliac aorta prolongs the ahepatic phase and may impair kidney function: therefore, it should be avoided in these patients.

Rapid correction of prothrombin time after low-dose recombinant factor VIIA in patients undergoing orthotopic liver transplantation.

Orthotopic liver transplantation (OLTx) is associated with a major risk of blood loss resulting from portal hypertension, collateral circulation, and clotting disturbances. Application of a recombinant factor VIIa (rFVIIa) has been reported to promptly correct clotting abnormalities reducing the risk of intraoperative bleeding. This study included 8 patients who underwent OLTx for end-stage liver cirrhosis, with protrombin times (PT) exceeding the upper limit of normal by more than 4 seconds before surgery. All subjects were administered a small single intravenous dose of rFVIIa [mean 68.37 microg/kg body mass (range, 32.88-71.64)] 10 minutes prior to the skin incision. The PT was then measured 15 minutes later, following graft reperfusion, and 12 hours since drug application. All patients showed rapid correction of PT within 15 minutes after injection (median PT before injection 20.25 seconds vs 11.5 seconds after injection, P <.0001). Following the reperfusion PT was found to be prolonged again. These values are not significantly differ from those before surgery and are comparable to PT values after reperfusion in patients who did not receive rFVIIa. None of the patients developed thromboembolic complications. In conclusion, lower than recommended dose of rFVIIa caused rapid improvement in the PT shortly after injection. After reperfusion PT became prolonged again, which may account for the lack of thromboembolic complications observed in this group of patients.