Portal vein complications after liver transplantation for biliary atresia.

The objective of this report is to review portal complications (PC) after pediatric liver transplantation (LT) for biliary atresia (BA) in the Bicêtre surgical series. From January 1, 1988, to February 28, 1995, 96 children with BA underwent 115 LTs Portal anastomosis was done on either the recipient portal vein (n = 85) or superior mesenteric vein (n = 11). No antiaggregative agents were administered postoperatively. Median follow-up was 50 months (range, 12 to 97). Nineteen PC (16.5%) occurred in 17 recipients: 16 portal thrombosis (PT) and 3 portal stenosis (PS). Fifteen instances of early PT occurred between days 0 and 17 (median, day 2). Emergency thrombectomy was performed in 9 cases (successful in 5). Three children underwent a secondary portosystemic shunt (successful in 2). Three PS were cured by either surgery or balloon dilatation. Four children died, 3 are alive with portal hypertension (PHT), and 10 are alive without PHT. Three-year patient actuarial survival is 82.4% in PC cases and 82% in others (NS). Significant risk factors of PC are young age and weight at the time of LT, small portal vein, and emergency LT. Analysis of our own results and review of the literature suggest that prevention of PC depends primarily on appropriate surgical technique. Reduction of postoperative hypercoagulability may also play an important role: a meta-analysis of 1,257 published pediatric LT show an overall risk of PT of 2.2% in teams using aspirin with or without dipyridamole compared with 7.8% when no antiaggregative agents are given (P = .0001).

The use of calcium antagonists to treat intra-operative hypertension--evaluation of efficacy and safety of a new dihydropyridine derivative, intravenous isradipine, during abdominal surgery.

Twenty-three patients who developed intraoperative hypertension (mean arterial pressure greater than 110 mmHg) during abdominal surgery under balanced general anaesthesia were randomly assigned to two groups. The isradipine group (n = 12) received 0.5 mg of isradipine, and the placebo group (n = 11) received 10 ml of isradipine solvent over a 5-min period in a blind manner. Arterial pressure was recorded 12 min after the injection was started. If the mean arterial pressure had not decreased by at least 10% at 12 min, patients received in an open manner 0.5 mg of isradipine. None of the patients in the isradipine group received isradipine in an open manner, in contrast with nine of the 11 patients in the placebo group (P less than 0.0001, Fisher's exact test). During both the blind period and the open trial, isradipine induced a 40% decrease in systolic, diastolic, and mean arterial pressures within the first two min of infusion. Arterial pressure remained below the pre-isradipine injection values for at least 45 min. Transient hypotension (mean arterial pressure less than 70 mmHg) was noted in 6/21 patients (29%). Mean heart rate remained statistically unchanged during the decrease in arterial pressure in both groups, but a tachycardia (increase in heart rate greater than 20 beats min-1) was noted in 4/21 patients (19%). This study indicates that intravenous isradipine is an effective therapy with sustained efficacy for intraoperative hypertension during abdominal surgery. The safety of its use needs a close monitoring of arterial pressure.

Intravenous nicardipine for treatment of intraoperative hypertension during abdominal surgery.

Twenty patients, American Society of Anesthesiologists class I or II, who developed intraoperative hypertension (mean arterial pressure greater than 110 mm Hg) during abdominal surgery under balanced general anesthesia were randomly assigned to two groups. The nicardipine group (n = 10) received 5 mg of nicardipine hydrochloride, and the placebo group (n = 10) received 5 mL of nicardipine solvent injected intravenously over a 5-minute period in a blind manner. Arterial pressure was recorded for 15 minutes after the injection was started. If the mean arterial pressure did not decrease at least 10% at 15 minutes, the trial was opened and patients received 5 mg of nicardipine. None of the patients in the nicardipine group received nicardipine in an open manner, in contrast with 7 of the 10 patients in the placebo group (P less than 0.03, Fisher exact test). During both the blind period and the open trial, nicardipine induced a 34% decrease in systolic, diastolic, and mean arterial pressure. Minimal values of pressure were noted at 6 minutes; however, arterial pressure remained below the pre-nicardipine injection values and near preoperative values for 45 minutes. No severe hypotension was observed, but the nicardipine injection was stopped at 3 mg in two cases during the blind period because of the rate of pressure reduction. Heart rate remained unchanged during the decrease in arterial pressure in both groups. This study indicates that nicardipine is an effective, long lasting, and safe therapy for intraoperative hypertension during abdominal surgery.