Delayed epidural catheter removal: the impact of postoperative coagulopathy.

A retrospective analysis of 413 patients who received postoperative epidural analgesia under a standardized protocol found that 84 (20%) had a duration of epidural catheterization of greater than four days. The most common reasons were significant pain (n=64, 15%) and coagulopathy (n=26, 6%). Risk factor analysis for coagulopathy showed an odds ratio of 10.1 (95% confidence interval 4.2-24.5) for prolonged epidural catheterization among patients undergoing hepatectomy. Magnetic resonance imaging, performed in four patients with clinical signs suggestive of epidural haematoma, was negative for a space-occupying lesion in all cases. Eleven patients developed fever and clinical signs suggestive of epidural catheter-related infection, necessitating early catheter removal. Sixteen patients had persistent lower limb weakness at 24 hours after catheter removal. The signs soon resolved in all except two, one of whom had neuropathy related to intraoperative positioning and the other preoperative weakness. Accidental epidural catheter dislodgement occurred in 29 patients (7%) and is potentially hazardous if coagulopathy is unresolved. The risk-benefit ratio and factors complicating catheter removal, especially coagulopathy, should be considered when deciding whether to use epidural techniques.

Right lobe living donor liver transplantation with or without venovenous bypass.

BACKGROUND: Venovenous bypass was considered necessary to maintain haemodynamic stability and avoid splanchnic and retroperitoneal congestion during the anhepatic phase of liver transplantation. It was essential for right lobe living donor liver transplantation (LDLT) in which the inferior vena cava needed to be cross-clamped to construct wide and short hepatic vein anastomoses. However, many complications related to venovenous bypass have been reported. This study aimed to determine whether venovenous bypass was necessary for right lobe LDLT. METHODS: Between June 1996 and June 2001, 72 patients underwent right lobe LDLT. The outcomes for the first 29 patients who had venovenous bypass during the operation were compared with those of the remaining 43 patients who did not have venovenous bypass. In patients without bypass, blood pressure was maintained during the anhepatic phase by boluses of fluid infusion and vasopressors. RESULTS: Compared with patients undergoing operation without venovenous bypass, patients who had venovenous bypass required significantly more blood, fresh frozen plasma and platelet infusion, and had a lower body temperature; their postoperative hepatic and renal function in the first week was worse than that in patients who did not have a bypass. The time to tracheal extubation was longer and the incidence of reintubation for ventilatory support was higher with venovenous bypass. Six of the 29 patients with venovenous bypass died in hospital, compared with two of the 43 patients without a bypass (P = 0.05). By multivariate analysis, the lowest body temperature during the transplant operation was the most significant factor that determined hospital death. CONCLUSION: Venovenous bypass is not necessary and is probably harmful to patients undergoing right lobe LDLT, and should therefore be avoided.

Ten-year experience with liver transplantation at Queen Mary Hospital: retrospective study.

OBJECTIVE: To report the experience with liver transplantation at the Queen Mary Hospital from 1991 to 2000. DESIGN: Retrospective study. SETTING: Liver transplant centre of a University teaching hospital, Hong Kong. PATIENTS: One hundred and forty-eight patients (127 adults and 21 children) who underwent a total of 155 liver transplants using 75 cadaver grafts (full-size, 67; reduced-size, 5; split, 3) and 80 living donor grafts (left lateral segment, 15; left lobe, 6; right lobe, 59) from October 1991 to December 2000 were reviewed. MAIN OUTCOME MEASURES: Graft and patient survival rate. RESULTS: The most common disease indications for liver transplantation were chronic hepatitis B-related liver disease (n=74) in adults and biliary atresia (n=14) in children. Eighteen patients had hepatocellular carcinoma. Forty-eight (31%) liver transplants (three ABO-incompatible) were performed in high-urgency situations for patients requiring intensive care. The proportion of living donor liver transplants was 47.7% in adults and 73.9% in children. The overall 1-year and 5-year patient survival rates were 82% and 77%, respectively. The survival of high-risk recipients, such as those with fulminant hepatic failure (80%), chronic hepatitis B (81%), or hepatocellular carcinoma (94%), was not inferior to that of other patients. CONCLUSION: Over the last decade, the promotion of (cadaver) organ donation through public education coupled with innovative techniques in living donor liver transplantation have enabled a liver transplantation programme to be established in Hong Kong with gratifying results.

Living donor liver transplantation without the use of blood products.

We report on two patients who presented with unresectable hepatocellular carcinoma complicating hepatitis B liver cirrhosis. After evaluation, both patients were accepted for liver transplantation. Being aware of the scarce availability of cadaveric liver grafts and the long waiting time, family members volunteered to be donors for the two patients. Living donor liver transplantation using right lobe liver grafts, including the middle hepatic vein, was subsequently performed without the use of blood products in both the donors and recipients. All involved recovered uneventfully from their respective operations.

Right-lobe live donor liver transplantation improves survival of patients with acute liver failure.

BACKGROUND: Right-lobe live donor liver transplantation (LDLT) is used by many liver transplant centres for treating adult patients with terminal liver disease, but its incremental benefit for the intended recipient over cadaveric liver graft transplantation has not been determined. The impact of LDLT as a proactive approach on the outcome of patients with acute liver failure was analysed. METHODS: From January 1999 to March 2001, right-lobe LDLT was offered proactively to 50 consecutive patients with acute liver failure and their families. The outcome of those who opted for right-lobe LDLT (n = 34) was compared with that of those who did not opt for LDLT (n = 16). RESULTS: In the group that opted for right-lobe LDLT, 16 patients eventually received a live donor right-lobe graft (14 patients survived) and three patients received a cadaveric liver graft that became available while the potential live donor was undergoing evaluation (all three patients survived). Among the group who did not opt for LDLT, only one patient received a cadaveric liver graft and survived. The former group had a higher overall survival rate (17 of 34 versus one of 16). With a proactive approach, the overall transplant rate was increased from four of 50 to 20 of 50. The morbidity rate among donors was low and none died. CONCLUSION: Right-lobe LDLT improves the overall survival rate of patients with acute liver failure and should be considered as one of the treatment options for adult patients with acute liver failure.

Safety of donors in live donor liver transplantation using right lobe grafts.

HYPOTHESIS: Right lobe donation was advocated for adult-to-adult live donor liver transplantation but the safety of the donor is still a major concern. We hypothesize that right lobe donation is safe if the lowest limit of volume of liver remnant that can support donor survival is known. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Tertiary hepatobiliary surgery referral center. PATIENTS: Twenty-two live donors involved in adult-to-adult right lobe liver transplantation from May 1996 to June 1999. INTERVENTIONS: The right lobe grafts were obtained by transecting the liver on the left side of the middle hepatic vein. Liver transection was performed by using an ultrasonic dissector, without using the Pringle maneuver. The left lobe volume was measured by computed tomographic volumetry and the ratio of left lobe volume to the total liver volume was calculated. MAIN OUTCOME MEASURES: Hospital mortality rate and complication rate. RESULTS: The median blood loss was 719 mL (range, 200-1,600 mL). Only one donor, who had thalassemia, received 1 U of homologous blood transfusion. Postoperative complications included wound infection, incision hernia, and cholestasis in 1 donor whose liver showed 20% fatty change and who had a left lobe-total liver volume of 0.34. Another donor with 15% fatty change in the liver and a left lobe-total liver volume ratio of 0.27 developed prolonged cholestasis. Two other donors with left lobe-total liver volume ratios of 0.27 but with mild steatosis (<5%) did not develop postoperative cholestasis. Postoperative complications also included 1 case of biliary stricture and 1 case of small bowel obstruction. Both complications were adequately treated. There was no donor mortality. All donors are well and have returned to their previous occupations. CONCLUSION: Live donation of right lobe graft for adult-to-adult liver transplantation is safe provided that the residual liver volume exceeds 30% of the total liver volume and the liver itself is normal or only mildly affected by steatosis.