Evaluation of surgical and anesthetic strategy as a key factor in the postoperative results of liver transplant.

Since the inauguration of our liver transplant program two years ago, retrospectively we can distinguish two different periods as regards postoperative results. The patients studied were distributed in two groups by chronological order and date of introduction of an improved surgical and anesthetic strategy: retrohepatic dissection during the veno-venous bypass phase and meticulous hemostasis in the anhepatic phase: Group A: 11 transplants in 10 patients and Group B: 22 transplants in 21 patients. Preoperatively, both groups were homogeneous with respect to the clinical situation. During the operation, significantly larger transfusion volumes were given in group A (25.4 +/- 10.5 ml/kg/hr) than in group B (10.0 +/- 5.7 ml/kg/hr) (p less than 0.01). The anhepatic phase lasted 1'50" +/- 20" in group B (p less than 0.05). The postoperative outcome of group B was better than that of A as regards hemodynamic and respiratory parameters, functional impairment of the graft and mortality (p less than 0.05). We conclude that the realization of retrohepatic dissection and careful hemostasis during the anhepatic phase, which prolongs the duration of venovenous by-pass but does not increase intraoperative morbidity, reduces the need for blood transfusion, and yields better postoperative results.

[Orthotopic liver transplantation: results at the "12 de Octubre" Hospital]. / Trasplante hepático ortotópico: resultados del Hospital "12 de Octubre".

The authors report their experience on 132 liver transplants performed on 111 patients. Eighteen have a re-transplantation and in 3 of them a second retransplantation (total re-transplanted patients 21 = 15.9%). Hepatic cirrhosis was the most common indication (57.65%) for transplantation (34.37% of alcoholic etiology). The authors report briefly their operative techniques and the results of their experience. The per-operative mortality (30 days) was 16.21% (18/111). The most important complications were: 9 hepatic arterial thromboses (6.8%), 4 arterial strictures (3.03%), 1 portal stricture (0.75%), 4 portal vein thromboses (3.03%), 5 biliary fistulae (3.78%) (3 following biliary duct-to-duct anastomosis and 2 following hepatic-jejunoanastomosis) and 2 strictures of the choledocus (1.51%). The actuarial survival rate (48 months) is 80%.

[Early and late results of orthotopic liver transplantation]. / Früh- und Spätresultate nach orthotoper Lebertransplantation.

Between 4/1986 to 1/1989, 74 orthotopic liver transplantation were performed in 62 patients (62 first liver transplants, 10 as second graft and two as a third graft); 57 in adults and 17 in children. The main indication for the operation was liver cirrhosis (61.4%) (the most frequent etiology was alcoholic cirrhosis, 28.5%). Six cirrhotic patients had a hepatocarcinoma (9.6%). Two received a liver and kidney transplant due to terminal renal insufficiency and hemodialysis. The most frequent indication in children was biliary atresia (33.3%). Six patients had a fulminal liver failure (9.6%). AB0 blood group compatibility was identical in 87.5%, compatible in six and incompatible in three patients. Total orthotopic liver transplantation was performed in 67 patients, and size-reduced liver was indicated in 7 patients. Extracorporeal veno-venous bypass was used in adults but never in children. In 93.1% of the transplants a single hepatic artery was anastomosed to the recipient and in 6.9% a double anastomosis was performed. In 62.5% of the patients a end-to-end choledocho-choledochostomy was performed and in 34.8% hepatico-jejunostomy was indicated. Three months postoperative mortality rate was 12.9%. Arterial stenosis and thrombosis were the most frequent complication.

[Reduction of transfusion needs by the early introduction of venovenous bypass in liver transplant]. / Disminución de las necesidades transfusionales mediante la introducción precoz del by-pass venovenoso en el trasplante hepático.

A study was made of 44 patients who underwent liver transplant, distributed into three groups: Group A: patients who had ample liver dissection before entering bypass. Group B: patients who entered bypass after dissection of the hepatic hilum and prior to any other dissection; bypass time was prolonged for meticulous hemostasia. Group C: patients with perfectly defined hemodynamic problems, not secondary to bleeding, during the anhepatic phase. Preoperatively the three groups were homogeneous as regards clinical situation. During the operation a significantly larger transfusion volume (p less than 0.01) was administered in group C during phase II (70.1 +/- 27.2 ml/kg/h), phase III (32.6 +/- 9.6 ml/kg/h) and throughout surgery (32.7 +/- 10.3 ml/kg/h) than in the other two groups. Group B received a smaller transfusion volume during phase II (14.6 +/- 8.1 ml/kg/h), phase III (12.7 +/- 5.5 ml/kg/h) and throughout surgery (11.6 +/- 4.9 ml/kg/h) than the other two groups (p less than 0.01). The transfusion needs of group A were 28.4 +/- 15.6 ml/kg/h in phase II, 26.8 +/- 17.1 ml/kg/h in phase III and 21.2 +/- 11.2 ml/kg/h throughout surgery. The duration of the anhepatic phase was significantly shorter (p less than 0.01) in group A (1 h 10' +/- 10) than in (1 h 50' +/- 10) and C (1 h 40' +/- 45'). In the postoperative period a higher mortality was associated with group C (37.5%) and a lower mortality with group B (3.33%), the mortality of group A being 16.6%. The differences were statistically significant with p less than 0.01.