Perioperative hemodynamic optimization in laparoscopic sleeve gastrectomy using stroke volume variation to reduce postoperative nausea and vomiting.

BACKGROUND: Risk of postoperative nausea and vomiting (PONV) is usually high among patients undergoing laparoscopic sleeve gastrectomy (LSG). Perioperative hemodynamic optimization using goal-directed fluid therapy (GDFT) based on stroke volume variation (SVV) has been suggested to reduce PONV. OBJECTIVES: This study aimed to investigate the effectiveness of GDFT on reducing PONV. SETTING: The operating rooms in China Medical University Hospital. METHODS: This prospective cohort study included 75 patients undergoing LSG. Patients were randomized into 3 groups: controls (conventional fluid therapy), GDFT-hydroxyethyl starch (GH), and GDFT-lactated Ringer's (GL) groups. In both GDFT groups, optimization of fluid administration was achieved by continuous monitoring and adjusting of SVV. Severity of PONV was evaluated using a standardized questionnaire. Other clinically relevant events, including in-hospital surgical site infections and length of hospital stay were also investigated. RESULTS: In the GH group, the total volume of fluid administered intraoperatively was significantly lower than that in the GL and control groups (P < .001). Assessment of PONV severity showed a significantly higher score at postoperative 24 hours in the GH group (P < .05), while no significant differences were found between the 3 groups at postoperative 48 hours. No significant differences were observed between the 3 groups in surgical site infections and length of hospital stay. CONCLUSION: No significant benefit is found in reducing PONV by using GDFT in patients undergoing LSG, although GDFT effectively avoids excessive volume of fluid administration. PONV incidence appears to be higher with intraoperative colloid infusion for GDFT during LSG. Further investigation is warranted to elucidate the mechanism underlying PONV in postoperative LSG.

ABO-Incompatible Living Donor Liver Transplantation with Reduced Rituximab Dose: A Retrospective Analysis of 65 Patients - Can We Fast-Track Liver Transplant Surgery and Improve Long-Term Survival?

BACKGROUND ABO-incompatible (ABO-i) living donor liver transplantation (LDLT) is a feasible alternative for donor liver allograft in emergency situations, especially in Asia, where deceased-donor organs remain scarce. The reported outcomes of ABO-i LDLT after optimal desensitization are comparable to those of ABO-compatible LDLT. In this retrospective study, we found improved outcomes after ABO-i LDLT with a low-dose rituximab in combination with double-filtration plasmapheresis (DFPP) and prophylactic antibiotic therapy. MATERIAL AND METHODS Between January 2006 and December 2018, a total of 65 recipients underwent ABO-i LDLT surgeries at our center. The study cohort consisted of 50 recipients (Era III) who underwent ABO-i LDLT using the recently updated desensitization protocol, which included rituximab 200 mg intravenous injection once a week prior to LDLT, 4 sessions of DFPP in all patients, and prophylactic antibiotics for 3 months. RESULTS The 3-year overall survival rate achieved in ABO-i LDLT patients was 72.7% (66.6% for Era I and 33.3% for Era II patients). In the study population, 11 patients developed complications due to infection. Five of these patients (10%) died due to overwhelming sepsis. Four patients (8%) were diagnosed with multiple strictures and diffusely scattered dilatation of intrahepatic bile ducts on computed tomography, without vascular complications. Three of them had evidence of antibody-mediated rejection (AMR). CONCLUSIONS Our experience shows that the ABO-i LDLT protocol of lowered rituximab combined with pre-transplant sessions of plasmapheresis and a quadruple immunosuppressive regimen can be effective in chronic liver failure patients with clinical urgency in the absence of an ABO-compatible donor. Fast-tracking the use of ABO-i LDLT is feasible in patients with an acute liver failure (ALF) and can safely increase the donor liver pool, with an acceptable outcome.

Isoflurane attenuates carbogen-induced blood-brain barrier disruption independent of body temperature in mice and rats.

Isoflurane protects the blood-brain barrier (BBB) against cerebral extravasation of Evans blue dye (EBD), a commonly used serum protein tracer, in animals subjected to BBB disruption. As such, it has been implicated as a therapeutic agent that can prevent brain edema and damage caused by a number of brain insults, including focal ischemia and subarachnoid hemorrhage. Recently, it has been shown that isoflurane inhibits the cerebral extravasation of EBD following ischemic stroke chiefly by inducing hypothermia, raising the intriguing possibility that isoflurane protected against other causes of BBB disruption also through hypothermia. To test this hypothesis, we subjected mice and rats to inhalation of 20-30% carbogen, an inducer of BBB disruption, in the presence or absence of isoflurane while measuring their rectal temperature. In mice, carbogen inhalation on its own decreased rectal temperature from 36.4 ± 0.4 to 26.2 ± 0.6°C over a period of 60 minutes, and under this condition, isoflurane had no additional effect on body temperature. Nevertheless, isoflurane protected against carbogen-induced cerebral extravasation of EBD. In addition, when the body temperature was maintained in the normothermic range using an automated heating pad, isoflurane remained protective against cerebral extravasation of EBD. In rats, isoflurane also protected against cerebral extravasation of EBD, while having no effect on plasma pH, electrolyte concentrations, or osmolarity. In conclusion, isoflurane protected against BBB disruption caused by carbogen inhalation in mice and rats, but unlike isoflurane-mediated protection against ischemic BBB disruption, the effect could not be explained by anesthesia-induced hypothermia.

Living Donor Liver Transplantation in Acute Liver Failure Patients with Grade IV Encephalopathy: Is Deep Hepatic Coma Still an Absolute Contraindication? A Successful Single-Center Experience.

BACKGROUND The prognosis of the patients of acute liver failure (ALF) with onset of hepatic coma is often dismal. ALF is a well-accepted indication for liver transplantation (LT) and has markedly improved the prognosis of these patients. However, its role in ALF patients with onset of hepatic coma has never been elucidated before. The aim of our study was to analyze the outcome in patients of ALF with hepatic coma who underwent LT. MATERIAL AND METHODS From January 2002 to December 2015, a total of 726 liver transplantations were done at China Medical University Hospital, Taiwan. The hospital database of 59 recipients that underwent LT for ALF was analyzed. Eleven ALF patients with the onset of hepatic coma (grade IV encephalopathy) requiring mechanical ventilatory support were retrospectively analyzed. The patients were sub-grouped in 2 groups depending on the timing of LT after the onset of hepatic coma: Group A had LT within 48 h of onset of coma (n=7) and Group B had LT after 48 h of onset of coma (n=4). RESULTS The study cohort (group A and B) comprised 8 males and 3 females, with an average age of 39.63±13.95 years (range, 13 to 63). Ten patients received living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) was done in 1 recipient. All the patients in group A had complete neurological recovery and were extubated within 48 h after LT, whereas extubation was delayed for various reasons for group B patients. At a mean follow up of 36 months (range, 20 to 76 months), the overall survival of all the recipients (group A and B) was 72%. Three-year survival for Group A (n=7) was 85% and for Group B (n=4) it was 50%. There were no acute rejection episodes. CONCLUSIONS LT is an acceptable modality of treatment for patients of ALF with new onset of hepatic coma. Neurological recovery is expected in all patients if LT can be done within 48 h of onset of hepatic coma without increasing the risk of morbidity. Due to shortage of deceased donor organs in Asia, LDLT can be used proactively, with a success rate comparable to that of non-ALF patients undergoing LT.

Assessing the role of everolimus in reducing hepatocellular carcinoma recurrence after living donor liver transplantation for patients within the UCSF criteria: re-inventing the role of mammalian target of rapamycin inhibitors.

BACKGROUNDS/AIMS: The protective effect of everolimus (EVR) in hepatocellular carcinoma (HCC) patients who receive liver transplantation in terms of reducing the recurrence has not been sufficiently investigated in clinical trials. In this second stage of our ongoing study, we intend to analyze the effects of EVR as an immunosuppressant, when it is started in the early phase after living donor liver transplantation (LDLT), on HCC recurrence in patients with HCC within the University of California at San Francisco (UCSF) criteria. METHODS: From January 2011 to June 2013, a total of 250 patients underwent LDLT for HCC at our institute. The patients with HCC within the UCSF criteria were included in the study and divided in two groups depending upon the postoperative immunosuppression. Group A: HCC patients that received EVR+TAC based immunosuppressive regimen (n=37). Group B: HCC patients that received standard TAC based immunosuppressive regimen without EVR (n=29). The target trough level for EVR was 3 to 5 ng/ml while for TAC it was 8-10 ng/ml. RESULTS: For group A patients, the mean trough level of the EVR was 3.47±1.53 ng/ml (range, 1.5-11.2) with a daily dose of 1.00±0.25 mg/day. For group A and B, the average TAC trough levels were 6.97±3.98 ng/ml (range, 2.50 to 11.28 ng/ml) and 6.93±2.58 (range, 2-16.30), respectively. The 1-year, 3-year and 4-year overall survival achieved for Group A patients was 94.95%, 86.48% and 86.48%, respectively while for Group B patients it was 82.75%, 68.96%, and 62.06%, respectively (p=0.0217). CONCLUSIONS: EVR use in liver transplant recipients in the early stage after transplantation reduces the HCC recurrence rates in HCC patients within the UCSF criteria.

Plasma exosomal miR-223 expression regulates inflammatory responses during cardiac surgery with cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) induces inflammatory responses, and effective endogenous homeostasis is important for preventing systemic inflammation. We assessed whether plasma exosomal microRNAs in patients undergoing cardiac surgery with CPB are involved in the regulation of inflammatory responses. Plasma samples were isolated from CPB patients (n = 21) at 5 specified time points: pre-surgery, pre-CPB and 2 hours (h), 4 h and 24 h after CPB began. Plasma TNF-α expression was increased after CPB began compared to that in the pre-surgery samples. Plasma IL-8 and IL-6 expression peaked at 4 h after CPB began but was downregulated at 24 h. The number of plasma exosomes collected at 2 h (55.1 ± 8.3%), 4 h (63.8 ± 10.1%) and 24 h (83.5 ± 3.72%) after CPB began was significantly increased compared to that in the pre-CPB samples (42.8 ± 0.11%). These exosomes had a predominantly parental cellular origin from RBCs and platelets. Additionally, the plasma exosomal miR-223 levels were significantly increased after CPB began compared to those in the pre-CPB samples. Further, exosomal miR-223 from plasma collected after CPB began downregulated IL-6 and NLRP3 expression in the monocytes. Here, we present the novel findings that increased plasma exosomal miR-223 expression during cardiac surgery with CPB might play homeostatic roles in downregulating inflammatory responses through intercellular communication.

Extracorporeal Membrane Oxygenation Support for Rituximab-Induced Acute Respiratory Distress Syndrome in an ABO-Incompatible Living Donor Liver Transplant Recipient: Successful Management of a Rare Complication and a Review of the Literature.

BACKGROUND Rituximab is commonly used to reduce the agglutinin titer in ABO-incompatible liver transplant recipients. Although well-tolerated, rituximab infusion therapy may result in severe pulmonary adverse effects such as drug-induced pneumonitis, leading to acute respiratory distress syndrome (ARDS), which has a high mortality rate. Management of such rare cases in an ABO-incompatible patient has never been described before. Herein, we present successful use of extracorporeal membrane oxygenation (ECMO) support for rituximab-induced ARDS in an ABO-incompatible living donor liver transplantation (LDLT) recipient. CASE REPORT A 57-year-old man patient presented with acute-on-chronic hepatic failure. Due to worsening clinical condition and unavailability of a deceased donor organ, ABO-incompatible LDLT was considered. The patient received rituximab therapy and plasmapheresis 1 week before the transplantation to reduce the B cell count. However, he suddenly developed acute respiratory distress-like symptoms, with a chest X-ray suggesting organized pneumonia. Infectious etiology was excluded as evidenced from negative sputum and blood culture, which were repeated after 48 h. LDLT was performed and ECMO support was instituted in the immediate postoperative period due to worsening of the ARDS. The pulmonary signs improved, with a chest X-ray showing clear lung fields on the 5th postoperative day. The patient recovered well and was discharged with normal liver functions in the 4th postoperative month. CONCLUSIONS This is first reported experience of successful use of ECMO in an ABO-incompatible liver transplant recipient with rituximab-induced ARDS. This experience shows the feasibility and effectiveness of ECMO support in liver transplant recipients with poor respiratory functions.

Assessing the Safety of Expanded Polytetrafluoroethylene Synthetic Grafts in Living Donor Liver Transplantation: Graft Migration Into Hollow Viscous Organs - Diagnosis and Treatment Options.

BACKGROUND Our recent studies have highlighted the importance and safety of backtable venoplasty for middle hepatic vein (MHV) and inferior right hepatic veins (IRHV) reconstruction using expanded polytetrafluoroethylene (ePTFE) vascular grafts. In this study, we aim to analyze the complications associated with ePTFE graft use and discuss the management of the rare, but, potentially life threatening complications directly related to ePTFE conduits. MATERIAL AND METHODS From January 2012 to October 2015 a total of 397 patients underwent living donor liver transplantation (LDLT). The ePTFE vascular grafts were used during the backtable venoplasty for outflow reconstruction in 262 of the liver allografts. Recipients who developed ePTFE-related complications were analyzed. RESULTS ePTFE-related complications developed in 1.52% (4/262) of the patients. One patient (0.38%) developed complete thrombosis with sepsis at 24 months post-transplantation and died due to multiorgan failure. Three patients (1.1%) developed graft migration into the second portion of the duodenum, without overt peritonitis. Surgical exploration and ePTFE graft removal was done in all the patients. One patient died due to overwhelming sepsis. CONCLUSIONS ePTFE graft migration into the duodenum causing perforation is a new set of complications that has been recently described in LDLT and can be treated effectively by surgical removal of the infected vascular graft and duodenal perforation closure. Despite of such complications, in our experience, ePTFE use in LDLT continues to have wide safety margin, with a complication rate of only 1.52%.

Hepatic artery reconstruction in living donor liver transplantation using surgical loupes: Achieving low rate of hepatic arterial thrombosis in 741 consecutive recipients-tips and tricks to overcome the poor hepatic arterial flow.

The reconstruction of the hepatic artery (HA) is the most complex step in living donor liver transplantation (LDLT) because of the smaller diameter of the artery and the increased risk of HA-related complications. Because of the smaller diameter of the HA, many centers use a microsurgical technique with interrupted sutures for arterial anastomosis. The aim of our study was to retrospectively investigate the outcomes after HA reconstruction performed under magnifying loupes using the "parachute technique." From August 1, 2002 to August 31, 2016, LDLT was performed in 766 recipients. HA reconstruction for the initial 25 LDLT surgeries was performed using a microsurgery technique (era 1). From May 2007 until the end date, HA reconstruction was performed in 741 recipients by a "parachute technique" under surgical loupes (era 2). HA reconstruction was performed using surgical loupes in 737 adults (male:female, 526:211) and 4 pediatric patients (male:female, 3:1). The average diameter of the donor graft HA was 2.8 mm (range, 1-6.5 mm). The most notable factor in this era was the quick HA anastomosis procedure with a mean time of 10 ± 5 minutes (range, 5-30 minutes). In era 2, 9 (1.21%) patients developed hepatic artery thrombosis (HAT), whereas 2 patients developed nonthrombotic HA-related complications. Extra-anatomic HA reconstruction was performed in 14 patients due to either primary HA anastomosis failure or a poor caliber recipient HA. The use of magnifying surgical loupes to perform HA reconstruction is safe, feasible, and yields a low incidence of HA-related complications. The "parachute technique" for HA reconstruction can achieve a speedy reconstruction without increasing the risk of HAT. Liver Transplantation 23 887-898 2017 AASLD.

Management of Liver Allograft Trauma Resulting in Massive Subcapsular Hematoma After Living Donor Liver Transplantation: Can We Salvage the Liver Allograft?

BACKGROUND Liver allograft trauma resulting in subcapsular hematoma after living donor liver transplantation (LDLT), although rare, is a life-threatening condition and requires prompt management to avoid any catastrophe. Herein we describe our successful experience in dealing with liver allograft hematoma that developed in the post-operative period after LDLT. MATERIAL AND METHODS From January 2002 to May 2015, a total of 616 recipients underwent LDLT at our institute. The intra-operative and postoperative records of these patients were analyzed to study the cases of liver allograft hematoma. Four patients (n=4) who developed liver allograft subcapsular hematoma during the intra-operative and post-operative periods were included in study. The outcomes of these patients were studied after the administration of the medical, surgical, or combined modalities of treatment. RESULTS Out of 616 LDLT recipients, 4 (0.64%) developed subcapsular hematoma. Patients were managed by a stepwise approach: Initial non-operative management with transarterial embolization (if extravasation of the contrast was noticed during imaging studies) was performed (n=1). Three patients developed hemodynamic instability with signs of hematoma rupture and were successfully treated by surgical exploration. CONCLUSIONS Timely diagnosis and suitable management can successfully salvage a liver allograft even in the presence of massive subcapsular hematoma. Our emphasis is on perihepatic packing rather than open surgical drainage if exploration is required, which can achieve a 100% success rate.