Restricted Crystalloid Fluid Therapy during Orthotopic Liver Transplant Surgery and its Effect on Respiratory and Renal Insufficiency in the Early Post-operative Period: A Randomized Clinical Trial.

BACKGROUND: Respiratory and renal insufficiencies are common dysfunctions during post-liver transplantation period that increase post-operative mortality and morbidity rates. Intra-operative fluid therapy is an important factor associated with pulmonary and renal insufficiency. OBJECTIVE: To evaluate the relation between intra-operative fluid therapy and early renal and respiratory insufficiency after liver transplantation. METHODS: In this randomized clinical study, 67 adult patients with end-stage liver disease who underwent orthotopic deceased donor liver transplantation were randomly allocated into two groups. The restricted fluid group, which received a controlled fluid administration of normal saline, 5 mL/kg/hr during anesthesia, and non-restricted fluid group received a controlled infusion of normal saline 10 mL/kg/hr during anesthesia. Early post-operative respiratory and renal insufficiency in both groups were assessed. The patients were monitored during the three stages of liver transplantation for their hemodynamic indices. The trial is registered with the Iranian Randomized Clinical Trial Registry, number IRCT2013101811662N4. RESULTS: The baseline demographic and clinical characteristics were similar in both studied groups. The prevalence of respiratory insufficiency in the non-restricted fluid group (15%) significantly (p=0.01) higher than that in the restricted fluid group (0%). The post-operative mean±SD serum creatinine was 1.0±0.1 mg/dL in the non-restricted fluid group and 1.1±0.2 in the restricted fluid group (p=0.43). No patients in the studied groups required post-operative continuous renal replacement therapy. CONCLUSIONS: Restricted crystalloid fluid administration during orthotropic liver transplantation though decreased post-operative chance of pulmonary insufficiency, did not increase renal dysfunction.

Very High Dose Epinephrine for the Treatment of Vasoplegic Syndrome during Liver Transplantation.

A 55-year-old man with hepatitis B and hepatocellular carcinoma was treated with liver transplantation without veno-venous bypass. During the procedure his arterial blood pressure remained at 55/30 mm Hg and did not respond to increasing doses of norepinephrine. Vasoplegia was managed aggressively with the intravenous infusion of high doses of epinephrine.

En-bloc Transplantation: an Eligible Technique for Unilateral Dual Kidney Transplantation.

BACKGROUND: Kidney transplantation is the best available treatment for patients with end-stage renal disease. OBJECTIVE: To evaluate the en bloc anastomosis technique for unilateral dual kidney transplantation (DKT). METHODS: From May to October 2011, 5 patients (4 women and 1 man) with mean age of 31.8 years underwent unilateral DKT with this technique in which distal end of the aorta and proximal end of inferior vena cava (IVC) were closed with running sutures. Then, proximal end of the aorta and distal end of the IVC were anastomosed to internal (or external) iliac artery and external iliac vein, respectively. RESULTS: Post-operative course was uneventful. No vascular and urologic complications developed; all patient had acceptable serum creatinine at discharge time and up of 2-6 months of post-operation follow up. CONCLUSION: Unilateral DKT is a safe method for performing DKT. The proposed en bloc anastomosis can improve the outcome of the graft by reducing the cold ischemia and the operation time.

Liver transplantation in the presence of old portal vein thrombosis.

BACKGROUND: Portal vein thrombosis (PVT) has been mentioned as a potential obstacle to liver transplantation (LTx). OBJECTIVE: To review the impact of PVT on orthotopic liver transplant (OLT) outcome. METHOD: Between January 2006 and April 2009, 440 OLT were performed in Shiraz Transplant Unit of whom, 35 (7.9%) cases had old PVT with recanalization. Data were retrospectively collected regarding the demographics, indication for OLT, Child-Turgot-Pugh classification, pre-transplant diagnosis of PVT, perioperative course and managements, relapse of PVT, early post-operative mortality and morbidity. All patients received liver from deceased donors, underwent thrombendvenectomy with end-to-end anastomosis without interposition graft and evaluated daily for 5 days and thereafter, biweekly by duplex sonography during the follow-up period for 2 months. They were treated by therapeutic doses of heparin followed by warfarin to maintain an INR of 2-2.5. RESULTS: The causes of end-stage liver disease were hepatitis B in 11, cryptogenic cirrhosis in 11, primary sclerosing cholangitis in 5 and other causes in 8 recipients. Extension of thrombosis was through confluence of superior mesenteric and splenic vein in 32 and to superior mesenteric vein in 3 patients. The mean±SD operation time was 7.2±1.5 hrs. The mean±SD transfusion requirement was 5.4±2.8 units of packed cells. The mean±SD duration of hospital stay in these patients was 17.7±10.9 days. Eight patients died; 1 developed early in-hospital PVT, 1 had hepatic vein thrombosis, and 1 died of in-hospital ischemic cerebrovascular accident, despite a full anticoagulant therapy. The mean±SD follow-up period for those 28 patients discharged from hospital was 16.6±7.9 months; none of them developed relapse of PVT. The overall mortality and morbidity was 28% and 32%, respectively. There was no relapse of PVT in the other patients. CONCLUSION: The presence of PVT at the time of OLT is not a contraindication for the operation but those with PVT have a more difficult surgery, develop more postoperative complications, and experience a higher in-hospital mortality.

Post-reperfusion Syndrome and Outcome Variables after Orthotopic Liver Transplantation.

BACKGROUND: Post-reperfusion syndrome (PRS) is an important complication during liver transplantation. OBJECTIVE: We studied the occurrence and severity of PRS in patients who underwent orthotopic liver transplantation (OLT) to investigate how PRS was correlated to clinical variables and outcomes. METHODS: We retrospectively recorded intra- and peri-operative data for 184 adult patients who received cadaveric OLT during a 3-year period from 2005 to 2008. Patients were divided into two groups according to the severity of PRS: Group 1 (mild or no PRS) comprised 152 patients; and group 2 (significant PRS) consisted of 32 patients. RESULTS: There were no significant differences in demographic and pre-operative data between groups. Group 2 had more total blood loss than group 1 (p=0.036), especially after reperfusion (p=0.023). Group 2 required more packed red cell transfusions (p=0.005), more fresh frozen plasma (p=0.003) and more platelets (p=0.043) than group 1. Fibrinolysis was more frequent in group 2 (p=0.004). Hospital stay in group 2 was significantly longer than in group 1 (p=0.034), but the frequencies of other outcomes including infection, retransplantation, dialysis, rejection and extended donor criteria did not differ significantly between groups. CONCLUSIONS: Bleeding, blood transfusion and fibrinolysis occurred more often in the group of severe PRS after reperfusion. Although postoperative complications like rejection, infection and the dialysis rate were not significantly different in the two groups, hospital stay was more prolonged in the group with severe PRS.

Transperitoneal laparoscopic living donor nephrectomy: 2 years' experience.

BACKGROUND: Due to the shortage of organ donations and the rising number of patients with terminal renal insufficiency, living donor kidney donation has become increasingly important during recent years. Hand-assisted laparoscopic living donor nephrectomy (LLDN) is an alternative to the conventional open approach and may decrease the surgical trauma to the donor. The aim of this study was to report our experience with this technique. MATERIALS AND METHODS: We reviewed demographic data, operative duration, hospital stay, and postoperative complications among 100 LLDNs performed from August 2006 to July 2008. We also performed a retrospective analysis of chemical and biochemical data of recipients. RESULTS: Thirty female and 70 male subjects of mean age of 35.88 +/- 12.21 years were operated on during this period. The mean operative time for donor nephrectomy was 138.30 +/- 31.92 minutes (range 60-205) and for recipients, 87.66 +/- 11.79 minutes (range = 75-120), with a mean warm ischemia time of 5.19 +/- 1.76 minutes (range = 2-8). The donors' mean hospital stay was 28.34 +/- 8.31 hours (range = 24-72). Five donor operations were converted to open nephrectomy because of uncontrolled bleeding or abnormal anatomy. There was no need for blood transfusions or reoperations in the donors. Mean hospital stay for the recipients was 9.44 +/- 3.61 days (range = 5-22). Creatinine and blood urea nitrogen decreased from preoperative values of 10.46 +/- 3.73 and 66.10 +/- 25.16 to 1.39 +/- 0.38 and 29.64 +/- 8.83 mg/dL at discharge. The renal graft was rejected in two cases due to immunologic causes without any response to therapy. There was no vascular thrombosis in the transplanted kidneys. CONCLUSION: LLDN is a viable alternative to the standard open nephrectomy. It may have a positive impact on the donor pool by minimizing disincentives to living donation. The results of our program were acceptable; this approach may be the procedure of choice in the future in our center.

Experience of living donor liver transplantation in Iran: a single-center report.

BACKGROUND: Living donor liver transplantation (LDLT) has been accepted as a valuable treatment for patients with end-stage liver disease seeking to overcome the shortage of organs and the waiting list mortality. The aim of this study was to report our experience with LDLT. METHODS: We retrospectively analyzed 50 LDLTs performed in our organ transplant center from January 1997 to March 2008. We reviewed the demographic data, family history, operative and hospital stay durations as well as postoperation complications among donors and recipients. We also performed a retrospective analysis of recipient chemical and biochemical data. RESULTS: Among 50 patients (30 males and 20 females) of overall mean age of 7.21 +/- 5.35 who underwent LDLT (10 right lobe, 38 left lobe, and 2 left lateral segments), 47 received a liver graft from their parent, two from a brother, and one from an uncle. The most common indications for LDLT were end-stage liver disease due to Wilson's disease (16%), cryptogenic cirrhosis (16%), tyrosinemia (14%), biliary atresia (12%), autoimmune hepatitis (12%), and progressive familial intrahepatic cholestasis (12%). The mean follow-up was 16.91 +/- 23.74 months. There were 13 (26%) recipient mortalities including vascular complications; three to sepsis after bowel perforation, two from liver dysfunction, two from chronic rejection due to noncompliance, and one from diffuse aspergillosis. The morbidity rate was 50%, including 19 reexplorations during the hospital course and five biliary complications. CONCLUSION: This study demonstrated that LDLT can decrease the number of patients awaiting liver transplantation especially in the pediatric group. However, because of relatively high mortality and morbidity, we must improve our treatment outcomes.

Non-marginal donor C-loop ulcers as a cause of gastrointestinal bleeding after pancreas transplantation: three case reports.

Unfortunately, pancreas transplantation (PTx) has been associated with the highest surgical complication rate of all the routinely performed organ transplant procedures. Complications can arise not only from the pancreas itself but also from the simultaneously transplanted duodenum. One of these complications is gastrointestinal bleeding, which might be from anastamotic site ulcer, pseudoaneurysm, arterioenteric fistula, severe rejection, or cytomegalovirus infection. In this case series, we present three patients presented with severe anemia 3 to 6 months after PTx with enteric drainage by end-to-end anastomosis of ascending loop of a Roux-en-Y to donor duodenal C-loop. The source of bleeding in all three cases was non-marginal donor duodenal C-loop ulcers. High donor pancreas exocrine output associated with relatively low drainage of a small end-to-end anastomosis may be the cause of these ulcers. It is recommended to use a side-to side anastomosis to prevent this complication.

The effect of clamping of inferior vena cava and portal vein on urine output during liver transplantation.

BACKGROUND: Intraoperative hypotension, massive transfusion, liver disease, coexistent renal dysfunction, and decreased glomerular filtration rate during the anhepatic phase are major hazards for kidney function. We undertook this study to determine the change in urine output during clamping. METHOD: Twenty-four patients without preexistent renal disease, who were undergoing liver transplantation using the piggyback method, were enrolled in this study. Patients with a serum creatinine level >1.2 mg/dL were excluded. Urine output was monitored over 30 minutes before inferior vena cava and portal vein clamping, during clamping, and for 30 minutes after declamping. None of the patients had a clamping time >70 minutes. Our goal was to maintain mean arterial blood pressure and heart rate just by fluid administration diuretics were avoided. RESULTS: Participants had a mean age of 39.12 +/- 13.52 years (range, 15-67 years) with a male to female ratio of 1:4. Urine output 30 minutes before clamping was 3.64 +/- 3.58 (range, 1.25-15.18) mL/kg/h, decreased to 1.28 +/- 2.58 (range, 0-11.39) mL/kg/h during clamping (P=.00), and increased to 3.56 +/- 3.64 (range, 0.51-15.18) mL/kg/h 30 minutes after declamping (P=.00). CONCLUSION: Urine output was significantly reduced in all patients after clamping of the IVC and portal veins. This observation may be explained by increased venous pressure leading to decreased renal perfusion pressure. It has been stated that one of the advantages of veno-veno bypass (VVB) is increased renal perfusion pressure. However, if the clamping time in the piggyback method is <70 minutes and patients have normal preoperative renal function, the decreased renal perfusion pressure will not cause postoperative kidney dysfunction.