Hepatopulmonary syndrome: the anaesthetic considerations.

Hepatopulmonary syndrome (HPS) is a pulmonary complication observed in patients with chronic liver disease and/or portal hypertension, attributable to an intrapulmonary vascular dilatation that induces severe hypoxaemia. Considering the favourable long-term survival of HPS patients as well as the reversal of the syndrome with a functional liver graft, HPS is now an indication for orthotopic liver transplantation (OLT). Consequently, blood gas analysis and imaging techniques should be performed when cirrhotic patients present with shortness of breath as well as when OLT candidates are placed on the transplant waiting list. If the arterial partial pressure of oxygen (PaO2) is more than 10.7 kPa when breathing room air, HPS can be excluded and no other investigation is needed. When the PaO2 when breathing room air is 10.7 kPa or less, contrast-enhanced echocardiography should be performed to exclude pulmonary vascular dilatation. Lung function tests may also help detect additional pulmonary diseases that can contribute to impaired oxygenation. When contrast-enhanced echocardiography is negative, HPS is excluded and no follow-up is needed. When contrast-enhanced echocardiography is positive and PaO2 less than 8 kPa, patients should obtain a severity score that provides them with a reasonable probability of being transplanted within 3 months. In mild-to-moderate HPS (PaO2 8 to 10.6 kPa), periodic follow-up is recommended every 3 months to detect any further deterioration in PaO2. Although no intraoperative deaths have been directly attributed to HPS, oxygenation may worsen immediately following OLT due to volume overload and postoperative infections. Mechanical ventilation is often prolonged with an extended stay in the ICU. A high postoperative mortality (mostly within 6 months) is observed in this group of patients in comparison to non-HPS patients. However, the recovery of an adequate PaO2 within 12 months after OLT explains the similar outcome of HPS and non-HPS patients following OLT over a longer time period.

Complications of elective liver resections in a center with low mortality: a simple score to predict morbidity.

OBJECTIVE: To develop a score predicting the morbidity of liver resections in a center with low mortality. DESIGN, SETTING, AND PATIENTS: The study was based on a prospective database of all liver resections performed at the Geneva University Hospitals between January 1, 1991, and October 30, 2009 (a total of 726 elective liver resections in 689 patients). Perioperative complications and their severity were graded according to the original classification by Clavien et al. Variables independently associated with the occurrence of complications were identified using a linear regression analysis model. A score was computed with all independent variables in an assessment population including two-thirds of the liver resections and was further validated in a population including one-third of the liver resections. RESULTS: Overall mortality was 0.7% (5 of 726 liver resections). We recorded 375 different complications in 259 hepatic resections (36% of resections had ≥ 1 complication). In the assessment group, resection of 3 or more segments, an American Society of Anesthesiologists score of 3 or higher, and resection for a malignant neoplasm independently predicted the risk of complications. A score integrating these 3 factors significantly predicted the risk of postoperative complications. The score also correlated with the occurrence of major complications. CONCLUSION: The score allows for identification of patients most susceptible to complications, in whom efforts against specific postoperative morbidities can be concentrated.