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Weinberg L, Caragata R, Hazard R, Ludski J, Lee DK, Slifirski H, Nugraha P, Do D, Zhang W, Nicolae R, Kaldas P, Fink MA, Perini MV. Venovenous bypass in adult liver transplant recipients: A single-center observational case series. PLoS One 2024; 19:e0303631. [PMID: 38820491 PMCID: PMC11142538 DOI: 10.1371/journal.pone.0303631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/29/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Very little information is currently available on the use and outcomes of venovenous bypass (VVB) in liver transplantation (LT) in adults in Australia. In this study, we explored the indications, intraoperative course, and postoperative outcomes of patients who underwent VVB in a high-volume LT unit. METHODS The study was a single-center, retrospective observational case series of adult patients who underwent VVB during LT at Austin Health in Melbourne, Australia between March 2008 and March 2022. Information on baseline preoperative status and intraoperative variables, including specific VVB characteristics as well as postoperative and VVB-related complications was collected. The lengths of intensive care unit and hospital stays as well as intraoperative and in-hospital mortality were recorded. RESULTS Of the 900 LTs performed at this center during the aforementioned 14-year period, 27 (3%) included a VVB procedure. VVB was performed electively in 16 of these 27 patients (59.3%) and as a rescue technique to control massive bleeding in the other 11 (40.1%). The median (interquartile range [IQR]) age of those who underwent VVB procedures was 48 (39-55) years; the median age was 56 (47-62) years in the non-VVB group (p<0.0001). The median model for end-stage liver disease (MELD) scores were similar between the two patient groups. Complete blood data was available for 622 non-VVB patients. Twenty-six VVB (96.3%) and 603 non-VVB (96.9%) patients required intraoperative blood transfusions. The median (IQR) number of units of packed red blood cells transfused was 7 (4.8-12.5) units in the VVB group compared to 3.0 units (1.0-6.0) in the non-VVB group (p<0.0001). Inpatient mortality was 18.5% and 1.1% for the VVB and non-VVB groups, respectively (p<0.0001). There were no significant differences in length of hospital stay or incidence of acute kidney injury, primary graft dysfunction, or long-term graft failure between the two groups. Patients in the VVB group experienced a higher rate of postoperative non-anastomotic biliary stricture compared to patients in the non-VVB group (33% and 7.9%, respectively; p = 0.0003). CONCLUSIONS VVB continues to play a vital role in LT. This case series highlights the heightened risk of major complications linked to VVB. However, the global transition to selective use of VVB underscores the urgent need for collaborative multi-center studies designed to address outstanding questions and parameters related to the safe implementation of this procedure.
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Affiliation(s)
- Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
- Department of Critical Care, Austin Health, The University of Melbourne, Heidelberg, Australia
| | | | - Riley Hazard
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Jarryd Ludski
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Hugh Slifirski
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Patrick Nugraha
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Daniel Do
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Wendell Zhang
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Robert Nicolae
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Peter Kaldas
- Department of Surgery, Austin Health, The University of Melbourne, Heidelberg, Australia
| | - Michael A. Fink
- Department of Surgery, Austin Health, The University of Melbourne, Heidelberg, Australia
| | - Marcos V. Perini
- Department of Surgery, Austin Health, The University of Melbourne, Heidelberg, Australia
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Laici C, Gamberini L, Allegri D, Bianchini A, Vitale G, Losito M, Morini L, Prosperi E, Ravaioli M, Cescon M, Siniscalchi A. The effects of venovenous bypass use in liver transplantation with piggyback technique: a propensity score-weighted analysis. Intern Emerg Med 2024:10.1007/s11739-024-03530-w. [PMID: 38334833 DOI: 10.1007/s11739-024-03530-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024]
Abstract
Venovenous bypass (VVB) use during liver transplantation (LT) is notably variable among the centres and it is actually restricted to surgically complex cases, severely unstable recipients or grafts from high-risk donors. Historically, VVB was associated with the classical LT with caval cross clamping, while not much is known about the safety of this technique applied to piggyback LT. This retrospective observational study evaluated the effects of VVB applied to piggyback LT on mortality, hospital outcomes, postoperative graft and other organ dysfunction. We retrospectively collected data about recipient status, surgical complexity and graft quality of all the piggyback LTs performed at the Transplant Unit of IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy, from January 2012 to December 2022. A propensity score (PS) was built taking into account the variables possibly associated with either VVB choice and the investigated outcomes with the average treatment overlap method. PS-weighted general linear models (GLMs) were developed to investigate the adjusted effect of VVB use on the selected outcomes. The final analysis included 874 LT cases, of whom 74 (8.5%) underwent VVB. The effective sample sizes after PS-weighting were 280.2 and 64.3 patients in the no-VVB and VVB groups, respectively. PS-weighted GLMs did not show any differences regarding hospital and graft-related outcomes. However, significantly higher odds ratios for serum creatinine > 2 mg/dL and AKIN stage 2 or 3 during the first 24 h after ICU admission together with a higher renal replacement therapy need during ICU stay were reported for VVB exposure in the weighted analyses. This study suggests similar mortality and length of stay but a higher risk for postoperative acute kidney injury in patients undergoing piggyback LT with VVB.
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Affiliation(s)
- Cristiana Laici
- Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | - Amedeo Bianchini
- Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Vitale
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Street Giuseppe Massarenti, 9, 40138, Bologna, Italy.
| | - Manuel Losito
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luca Morini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Enrico Prosperi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Matteo Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Hepatobiliary and Transplant Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Hepatobiliary and Transplant Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Using Transesophageal Echocardiography in Liver Transplantation with Veno-Venous Bypass Is a Tool with Many Applications: A Case Series from an Italian Transplant Center. J Cardiovasc Dev Dis 2023; 10:jcdd10010032. [PMID: 36661927 PMCID: PMC9866160 DOI: 10.3390/jcdd10010032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hemodynamic instability (HDI) is common during liver transplantation (LT); veno-venous bypass (VVB) is a tool used in selected cases to ensure hemodynamic stability and for surgical needs. Transesophageal echocardiography (TEE) allows the transplant team to identify the causes of HDI and to guide therapies. We present a case series of four patients showing the valuable role of TEE during LT in VVB. METHODS We report four explicative cases of TEE use in LT with VVB performed at IRCCS Azienda Ospedaliero-Universitaria di Bologna. Four transplants were performed between 2016 and 2022. RESULTS Many authors have highlighted the diagnostic value of TEE during LT in the case of HDI. However, its specific role during LT with VVB is poorly described. This paper illustrates multiple potential uses of TEE in LT with VVB: TEE as a guide for catheterization and optimal cannula positioning, TEE as a tool for intraoperative Patent Foramen Ovale management, TEE as help for anticoagulation therapy and finally, TEE as support when evaluating bypass efficiency and correcting hypovolemia. CONCLUSION TEE is a useful instrument during LT with VVB. However, further studies are needed to assess the suitable applications of TEE during LT in patients with HDI requiring VVB. TEE should be part of the anesthetist's cultural background.
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Fernandez TMA, Schofield N, Krenn CG, Rizkalla N, Spiro M, Raptis DA, De Wolf AM, Merritt WT. What is the optimal anesthetic monitoring regarding immediate and short-term outcomes after liver transplantation?-A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14643. [PMID: 35262975 PMCID: PMC10077907 DOI: 10.1111/ctr.14643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplant centers vary in approach to intraoperative vascular accesses, monitoring of cardiac function and temperature management. Evidence is limited regarding impact of selected modalities on postoperative outcomes. OBJECTIVES To review the literature and provide expert panel recommendations on optimal intraoperative arterial blood pressure (BP), central venous pressure (CVP), and vascular accesses, monitoring of cardiac function and intraoperative temperature management regarding immediate and short-term outcomes after orthotopic liver transplant (OLT). METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Recommendations made for: (1) Vascular accesses, arterial BP and CVP monitoring, (2) cardiac function monitoring, and (3) Intraoperative temperature management (CRD42021239908). RESULTS Of 2619 articles screened 16 were included. Studies were small, retrospective, and observational. Vascular access studies demonstrated low rates of insertion complications. TEE studies demonstrated low rates of esophageal hemorrhage. One study found lower hospital-LOS and 30-day mortality in patients monitored with both PAC and TEE. Other monitoring studies were heterogenous in design and outcomes. Temperature studies showed increased blood transfusion and ventilation times in hypothermic groups. CONCLUSIONS Recommendations were made for; routine arterial and CVP monitoring as a minimum standard of practice, consideration of discrepancy between peripheral and central arterial BP in patients with hemodynamic instability and high vasopressor requirements, and routine use of high flow cannulae while monitoring for extravasation and hematoma formation. Availability and expertise in PAC and/or TEE monitoring is strongly recommended particularly in hemodynamic instability, portopulmonary HT and/or cardiac dysfunction. TEE use is recommended as an acceptable risk in patients with treated esophageal varices and is an effective diagnostic tool for emergency cardiovascular collapse. Maintenance of intraoperative normothermia is strongly recommended.
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Affiliation(s)
- Thomas M A Fernandez
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand.,Department of Anesthesia, University of Auckland, Auckland, New Zealand
| | - Nick Schofield
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Claus G Krenn
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Nicole Rizkalla
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Andre M De Wolf
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - William T Merritt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
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Jo HS, Yu YD, Choi YJ, Kim DS. Left liver graft in adult-to-adult living donor liver transplantation with an optimal portal flow modulation strategy to overcome the small-for-size syndrome – A retrospective cohort study. Int J Surg 2022; 106:106953. [DOI: 10.1016/j.ijsu.2022.106953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/31/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
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Sakai T, Ko JS, Crouch CE, Kumar S, Little MB, Chae MS, Ganoza A, Gómez-Salinas L, Humar A, Kim SH, Koo BN, Rodriguez G, Sirianni J, Smith NK, Song JG, Ullah A, Hendrickse A. Perioperative management of adult living donor liver transplantation: Part 1 - recipients. Clin Transplant 2022; 36:e14667. [PMID: 35435293 DOI: 10.1111/ctr.14667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/06/2022] [Accepted: 03/31/2022] [Indexed: 11/29/2022]
Abstract
Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA, USA
| | - Justin Sangwook Ko
- Department of Anesthesiology & Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cara E Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sathish Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael B Little
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX, USA
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Armando Ganoza
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Luis Gómez-Salinas
- Department of Anesthesiology and Pain Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Abhi Humar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sang Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Republic of Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gonzalo Rodriguez
- Department of Surgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joel Sirianni
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Aisha Ullah
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Steggerda JA, Son AY, Pozo ME, Pawale A, Reynolds AS, Desai K, Galvez-Lima D, Herborn J, DeWolf A, Ladner D, Caicedo JC, Katariya N, Borja-Cacho D. Re-appropriation of a right anterior thoracotomy approach to portal-systemic bypass for liver transplantation in a patient with complete superior vena cava occlusion. TRANSPLANTATION REPORTS 2021. [DOI: 10.1016/j.tpr.2021.100086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Lapisatepun W, Lapisatepun W, Agopian V, Xia VW. Venovenous Bypass During Liver Transplantation: A New Look at an Old Technique. Transplant Proc 2020; 52:905-909. [DOI: 10.1016/j.transproceed.2020.01.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/26/2019] [Accepted: 01/02/2020] [Indexed: 02/04/2023]
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Vetrugno L, Barnariol F, Bignami E, Centonze GD, De Flaviis A, Piccioni F, Auci E, Bove T. Transesophageal ultrasonography during orthotopic liver transplantation: Show me more. Echocardiography 2018; 35:1204-1215. [PMID: 29858886 DOI: 10.1111/echo.14037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The first perioperative transesophageal echocardiography (TEE) guidelines published 21 years ago were mainly addressed to cardiac anesthesiologists. TEE has since expanded its role outside this setting and currently represents an invaluable tool to assess chamber sizes, ventricular hypertrophy, and systolic, diastolic, and valvular function in patients undergoing orthotopic liver transplantation (OLT). Right-sided microemboli, right ventricular dysfunction, and patent foramen ovale (PFO) are the most common intra-operative findings described during OLT. However, left ventricular outflow tract obstruction and left ventricular ballooning syndrome are more difficult to recognize and less frequent. Transesophageal ultrasonography (TEU) during OLT is also underused. Its applications are as follows: (1) assistance in the difficult placement of pulmonary arterial catheters; (2) help with catheterization of great vessels for external veno-venous bypass placement; (3) intra-operative evaluation of surgical liver anastomosis patency, if feasible, through the liver window; and (4) intra-operative investigation of "acute hypoxemia" due to pulmonary and cardiac issues using trans-esophageal lung ultrasound (TELU). The aims of this review are as follows: (1) to summarize the uses of TEE and TEU throughout all phases of OLT, and (2) to describe other new feasible applications.
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Affiliation(s)
- Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Barnariol
- Anesthesiology and Intensive Care 1, Department of Anesthesia and Intensive Care Medicine, University-Hospital of Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Grazia D Centonze
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Adelisa De Flaviis
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Piccioni
- Department of Critical Care Medicine and Support Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elisabetta Auci
- Anesthesiology and Intensive Care 2, Department of Anesthesia and Intensive Care Medicine, University-Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
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Malyshev M, Zotov S, Malyshev A, Rostovykh A. Primary leiomyosarcoma of inferior vena cava adjacent to hepatic veins: complete off-pump resection and inferior vena cava graft reconstruction with application of external skin surface cooling. Interact Cardiovasc Thorac Surg 2017; 25:683-686. [PMID: 28525631 DOI: 10.1093/icvts/ivx133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/03/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Resection of a leiomyosarcoma of the inferior vena cava (IVC) requires venovenous bypass, especially if IVC clamping above the hepatic veins is planned. This report describes the application of external skin surface cooling for off-pump resection of a primary IVC leiomyosarcoma adjacent to the hepatic veins with graft IVC reconstruction in conditions of suprahepatic caval clamping and uninterrupted Pringle's manoeuvre. METHODS A 62-year-old woman presented with IVC leiomyosarcoma adjacent to the hepatic veins. After anaesthesia induction, the patient's head, neck, abdomen, chest, thighs and shanks were covered by polyethylene bags containing granulated ice. The ice bag was also placed between the internal surfaces of the thighs. After 108 min, the target oesophageal temperature (29°C) was achieved, all bags were removed, except the bags that were used for temperature control during the operation located on head, neck and between internal surfaces of the thighs. Off-pump resection of the tumour was performed in conditions of suprahepatic IVC and portal triad clamping via median laparotomy. RESULTS IVC clamping was accompanied by arterial hypotension of 55-65 mmHg well-tolerating in the hypothermic background for 69 min. The simultaneous application of an uninterrupted Pringle's manoeuvre was accompanied by low levels of transaminases and bilirubin. There was no local relapse of the tumour or metastases over a 6-month follow-up. CONCLUSIONS External skin surface cooling in cases demanding IVC clamping above the hepatic veins and Pringle's manoeuvre allows avoiding venovenous bypass. This method is safe, cost effective, easily performed and may be used in clinical cases involving systemic arterial hypotension.
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Affiliation(s)
| | - Sergey Zotov
- Department of Vascular Surgery, Municipal Clinical Hospital N8, Chelyabinsk, Russian Federation
| | - Anton Malyshev
- Center of Cardiac Surgery, Chelyabinsk, Russian Federation
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Cauchy F, Brustia R, Perdigao F, Bernard D, Soubrane O, Scatton O. In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements. World J Surg 2017; 40:1448-53. [PMID: 26830907 DOI: 10.1007/s00268-016-3431-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION While total vascular exclusion (TVE) with veno-venous bypass and hypothermia may be undertaken to increase liver tolerance for complex liver resection, these procedures are still associated with elevated rates of postoperative complications and mortality. In particular, one of the main issues of this strategy is the management of bleeding after declamping, which is enhanced by both hypothermic state and acidosis. To overcome this high risk of morbidity, several technical refinements might be undertaken and here described (with video). METHODS All patients, requiring TVE >60 min and liver cooling during hepatectomy, were retrospectively included in this study. Technical key points as (a) patient selection, (b) anesthetic management, (c) two-surgeon's technique, (d) preparation for clamping, (e) veno-venous bypass, (f) cooling of the liver, and (g) parenchymal transection, rewarming, and declamping are described and detailed. RESULTS From 2011 to 2013, we included 8 cases of liver resection with TVE, veno-venous bypass, and hypothermia for malignant disease. Due to the technical refinements, median observed overall blood loss of 550 ml (300-900) including 200 ml (50-300) at declamping and transfusion of packed red blood cell (PRBC) units was required in 5 patients with a mean of 1.25 PRBC/patient. CONCLUSION The association of TVE, veno-venous bypass, and liver cooling can reduce the time of transection, and blue dye injection and liver rewarming before declamping can reduce blood loss and coagulopathy. Altogether, limited blood loss can be achieved for these complex procedures and may allow to decreasing morbidity.
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Affiliation(s)
- François Cauchy
- Department of Hepato-Pancreatic-Biliary Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Clichy, France
| | - Raffaele Brustia
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France.
| | - Fabiano Perdigao
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France
| | - Denis Bernard
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France
| | - Olivier Soubrane
- Department of Hepato-Pancreatic-Biliary Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Clichy, France
| | - Olivier Scatton
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France
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12
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Ye QF, Senninger N. The consensus on liver autotransplantation from an international panel of experts. Hepatobiliary Pancreat Dis Int 2017; 16:10-16. [PMID: 28119253 DOI: 10.1016/s1499-3872(16)60175-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Qi-Fa Ye
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China; Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The 3rd Xiangya Hospital of Central South University, Changsha 410013, China.
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Gregory SH, Yalamuri SM, McCartney SL, Shah SA, Sosa JA, Roman S, Colin BJ, Lentschener C, Munroe R, Patel S, Feinman JW, Augoustides JG. Perioperative Management of Adrenalectomy and Inferior Vena Cava Reconstruction in a Patient With a Large, Malignant Pheochromocytoma With Vena Caval Extension. J Cardiothorac Vasc Anesth 2017; 31:365-377. [DOI: 10.1053/j.jvca.2016.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Indexed: 12/19/2022]
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14
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Abstract
Anesthesia for liver transplantation pertains to a continuum of critical care of patients with end-stage liver disease. Hence, anesthesiologists, armed with a comprehensive understanding of pathophysiology and physiologic effects of liver transplantation on recipients, are expected to maintain homeostasis of all organ function. Specifically, patients with fulminant hepatic failure develop significant changes in cerebral function, and cerebral perfusion is maintained by monitoring cerebral blood flow and cerebral metabolic rate of oxygen, and intracranial pressure. Hyperdynamic circulation is challenged by the postreperfusion syndrome, which may lead to cardiovascular collapse. The goal of circulatory support is to maintain tissue perfusion via optimal preload, contractility, and heart rate using the guidance of right-heart catheterization and transesophageal echocardiography. Portopulmonary hypertension and hepatopulmonary syndrome have high morbidity and mortality, and they should be properly evaluated preoperatively. Major bleeding is a common occurrence, and euvolemia is maintained using a rapid infusion device. Pre-existing coagulopathy is compounded by dilution, fibrinolysis, heparin effect, and excessive activation. It is treated using selective component or pharmacologic therapy based on the viscoelastic properties of whole blood. Hypocalcemia and hyperkalemia from massive transfusion, lack of hepatic function, and the postreperfusion syndrome should be aggressively treated. Close communication between all parties involved in liver transplantation is also equally valuable in achieving a successful outcome.
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15
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Vannucci A, Rathor R, Vachharajani N, Chapman W, Kangrga I. Atrial fibrillation in patients undergoing liver transplantation-a single-center experience. Transplant Proc 2015; 46:1432-7. [PMID: 24935310 DOI: 10.1016/j.transproceed.2014.02.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 01/21/2014] [Accepted: 02/27/2014] [Indexed: 02/09/2023]
Abstract
BACKGROUND As the prevalence of atrial fibrillation rises with age and older patients increasingly receive transplants, the perioperative management of this common arrhythmia and its impact on outcomes in liver transplantation is of relevance. METHODS Retrospective review of 757 recipients of liver transplantation from January 2002 through December 2011. RESULTS Nineteen recipients (2.5%) had documented pre-transplantation atrial fibrillation. Sixteen patients underwent liver and 3 a combined liver-kidney transplantation. Three patients died within 30 days (84.2% 1-month survival) and another 3 within 1 year of transplantation (68.4% 1-year survival). Compared with patients without atrial fibrillation, the relative risk of death in the atrial fibrillation group was 5.29 at 1 month (P = .0034; 95% confidence interval [CI], 1.73-16.18) and 3.28 at 1 year (P = .0008; 95% CI, 1.63-6.59). Time to extubation and intensive care unit (ICU) and hospital readmissions were not different from the control cohort. Rapid ventricular response requiring treatment occurred in 4 patients during surgery and 7 after surgery, resulting in 3 ICU and 3 hospital readmissions. CONCLUSIONS The results suggest that patients with atrial fibrillation may be at increased risk of mortality after liver transplantation. Optimization of medical therapy may decrease ICU and hospital readmission due to rapid ventricular response.
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Affiliation(s)
- A Vannucci
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - R Rathor
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - N Vachharajani
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - W Chapman
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - I Kangrga
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri.
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16
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Azoulay D, Maggi U, Lim C, Malek A, Compagnon P, Salloum C, Laurent A. Liver resection using total vascular exclusion of the liver preserving the caval flow, in situ hypothermic portal perfusion and temporary porta-caval shunt: a new technique for central tumors. Hepatobiliary Surg Nutr 2014; 3:149-53. [PMID: 25019076 DOI: 10.3978/j.issn.2304-3881.2014.05.02] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/15/2014] [Indexed: 12/29/2022]
Abstract
Standard total vascular exclusion (TVE) of the liver is indicated for resection of tumors involving or adjacent to the vena cava and/or the confluence of the hepatic veins. The duration of liver ischemia can be prolonged by combined portal hypothermic perfusion of the liver (in or ex situ). The use of a venovenous bypass (VVB) during standard TVE maintains stable hemodynamics as well as optimal renal and splanchnic venous drainage. When the hepatic veins can be controlled, TVE preserving the caval flow negates the need for VVB. However this technique remains limited in duration as it is performed under warm ischemia (so-called normothermia) of the liver. To prolong the ischemia time, we have designed a modification of TVE with preservation of the caval flow including the use of temporary porta-caval shunt (PCS) and hypothermic perfusion of the liver. We describe here the first two cases of this new technique. Two patients underwent left hepatectomy extended to segments 5 and 8 (also called extended left hepatectomy) for large centrally located tumors. TVE lasted seventy-two and seventy-nine minutes, respectively. The postoperative course was uneventful and both patients were discharged on day ten and day twenty-five respectively. Both are alive without recurrence at ten and seven months following surgery. Provided the roots of the hepatic veins can be controlled, this technique combines the advantages of standard TVE with in situ hypothermic perfusion and VVB and obviates the need and the subsequent risks of the latter.
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Affiliation(s)
- Daniel Azoulay
- Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France
| | - Umberto Maggi
- Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France
| | - Chetana Lim
- Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France
| | - Alexandre Malek
- Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France
| | - Philippe Compagnon
- Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France
| | - Chady Salloum
- Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France
| | - Alexis Laurent
- Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France
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17
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Lu SY, Matsusaki T, Abuelkasem E, Sturdevant ML, Humar A, Hilmi IA, Planinsic RM, Sakai T. Complications related to invasive hemodynamic monitors during adult liver transplantation. Clin Transplant 2013; 27:823-8. [PMID: 24033433 DOI: 10.1111/ctr.12222] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 01/10/2023]
Abstract
The rate of complications directly related to invasive monitors during liver transplantation (LT) was reviewed in 1206 consecutive adult LTs performed over 8.6 yr (1/1/2004-7/31/2012). The designated anesthesiologists placed intra-operative monitors, including two arterial catheters (via the radial and the right femoral arteries), central venous catheters (a 9 Fr. catheter and an 18 Fr. veno-venous bypass [VVB] return cannula in an internal jugular vein), a pulmonary artery catheter, and a transesophageal echocardiography (TEE) probe. A 17 Fr. VVB drainage cannula was placed via the left femoral vein. No Clavien-Dindo Grade V (death) or Grade IV (organ dysfunction) complication was identified. Nine Grade III complications (requiring surgical intervention) and 15 Grade II complications (conservative treatment) were noted. Seven (0.58% in 1206 cases) were related to a femoral arterial line with Grade III of four; seven (0.58%) were due to VVB return cannula in the femoral vein with Grade III of one; four (0.33%) were related to central venous catheters with Grade III of two; four (0.33%) were due to a TEE probe with Grade III of two; and two minor complications (0.17%) that were related to a radial arterial line. No complication was observed with a pulmonary arterial catheter. Current invasive monitors placed during LT have an acceptable risk.
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Affiliation(s)
- Shu Y Lu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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18
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Lee SY, Kim J, Lee SH, Choi JH, Park YH, Kim JH, Chun KJ. Ventricular Fibrillation in a Patient with Tachycardia-Induced Cardiomyopathy after Liver Transplantation. Korean Circ J 2013; 43:839-41. [PMID: 24385997 PMCID: PMC3875702 DOI: 10.4070/kcj.2013.43.12.839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 07/05/2013] [Accepted: 08/07/2013] [Indexed: 11/21/2022] Open
Abstract
We report a case of atrial fibrillation-related tachycardia induced cardiomyopathy and ventricular fibrillation after liver transplantation in a 41-year-old man with end-stage liver failure. Atrial fibrillation and congestive heart failure occurred postoperatively. Cardiac arrests due to ventricular fibrillation occurred 6 months after the operation with subsequent implantations of an implantable cardioverter-defibrillator. Ventricular arrhythmias did not recur during the 18 months after normalization of heart functions with guideline-directed medical treatments.
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Affiliation(s)
- Soo Yong Lee
- Department of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jun Kim
- Department of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Hyun Lee
- Department of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jin Hee Choi
- Department of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yong Hyun Park
- Department of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - June Hong Kim
- Department of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kook Jin Chun
- Department of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Sidebotham D, Allen SJ, McGeorge A, Ibbott N, Willcox T. Venovenous extracorporeal membrane oxygenation in adults: practical aspects of circuits, cannulae, and procedures. J Cardiothorac Vasc Anesth 2012; 26:893-909. [PMID: 22503344 DOI: 10.1053/j.jvca.2012.02.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Indexed: 01/19/2023]
Affiliation(s)
- David Sidebotham
- Cardiothoracic Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.
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20
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Sabaté A, Acosta Villegas F, Dalmau A, Koo M, Sansano Sánchez T, García Palenciano C. [Anesthesia in the patient with impaired liver function]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 58:574-81. [PMID: 22279877 DOI: 10.1016/s0034-9356(11)70142-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.
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Affiliation(s)
- A Sabaté
- Servicio de Anestesiología y Reanimación, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona.
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21
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Rando K, Niemann CU, Taura P, Klinck J. Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to medium-income countries. Liver Transpl 2011; 17:1247-78. [PMID: 21837742 DOI: 10.1002/lt.22405] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) is a highly effective treatment, it has been considered too costly for publicly funded health systems in many countries with low to medium average incomes. However, with economic growth and improving results, some governments are reconsidering this position. Cost-effectiveness data for LT are limited, especially in perioperative care, and the techniques and costs vary widely between centers without overt differences in outcomes. Anesthesiologists working in new programs find it difficult to determine which modalities are essential, which are needed only in exceptional circumstances, and which may be omitted without effects on outcomes. We investigated key elements of preoperative evaluations, intraoperative management, and early postoperative care that might significantly affect costs in order to develop a best-value approach for new programs in resource-limited health systems. We identified all modalities of care commonly used in anesthesia and perioperative care for adult LT along with their costs. Those considered to be universally accepted as minimum requirements for safe care were excluded from the analysis, and so were those considered to be safe and low-cost, even when evidence of efficacy was lacking. The remaining items were, therefore, those with uncertain or context-restricted value and significant costs. A systematic review of the published evidence, practice surveys, and institutional guidelines was performed, and the evidence was graded and summarized. With respect to costs and benefits, each modality was then cited as strongly recommended, recommended or optional, or no recommendation was made because of insufficient evidence. Sixteen modalities, which included preoperative cardiovascular imaging, venovenous bypass, pulmonary artery catheterization, high-flow fluid warming devices, drug therapies for hemostasis, albumin, cell salvage, anesthetic drugs, personnel (staffing) requirements, and early extubation, were assessed. Only high-flow fluid warming was strongly recommended. The recommended modalities included preoperative echocardiography, cell salvage, tranexamic acid and early extubation. Six others were rated optional, and there was insufficient evidence for 5 modalities. We conclude that some costly techniques and treatments can be omitted without adverse effects on outcomes.
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Affiliation(s)
- Karina Rando
- Department of Hepatic Diseases, Military Hospital, Montevideo, Uruguay
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22
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Schreiber KL, Matsusaki T, Bane BC, Bermudez CA, Hilmi IA, Sakai T. Accidental insertion of a percutaneous venovenous cannula into the persistent left superior vena cava of a patient undergoing liver transplantation. Can J Anaesth 2011; 58:646-649. [DOI: 10.1007/s12630-011-9510-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 04/18/2011] [Indexed: 12/13/2022] Open
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23
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Sakai T, Matsusaki T, Marsh JW, Hilmi IA, Planinsic RM. Comparison of surgical methods in liver transplantation: retrohepatic caval resection with venovenous bypass (VVB) versus piggyback (PB) with VVB versus PB without VVB. Transpl Int 2010; 23:1247-58. [PMID: 20723178 DOI: 10.1111/j.1432-2277.2010.01144.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Use of piggyback technique (PB) and elimination of venovenous bypass (VVB) have been advocated in adult liver transplantation (LT). However, individual contribution of these two modifications on clinical outcomes has not been fully investigated. We performed a retrospective review of 426 LTs within a 3-year period, when three different surgical techniques were employed per the surgeons' preference: retrohepatic caval resection with VVB (RCR+VVB) in 104 patients, PB with VVB (PB+VVB) in 148, and PB without VVB (PB-Only) in 174. The primary outcomes were intraoperative blood transfusion and the patient and graft survivals. Demographic profiles were similar, except younger recipient age in RCR+VVB and fewer number of grafts with cold ischemic time over 16 h in PB-Only. PB-Only required lesser intraoperative red blood cells (P=0.006), fresh frozen plasma (P=0.005), and cell saver return (P=0.007); had less incidence of acute renal failure (P=0.001), better patient survival (P=0.039), and graft survival (P=0.003). The benefits of PB+VVB were only found in shortened total surgical time (P=0.0001) and warm ischemic time (P=0.0001), and less incidence of acute renal failure (P=0.001) than RCR+VVB. PB-Only method seemed to provide the best clinical outcome. The benefit of PB was not fully achieved when it was used with VVB.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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24
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Sakai T, Gligor S, Diulus J, McAffee R, Wallis Marsh J, Planinsic RM. Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists. Clin Transplant 2009; 24:585-91. [DOI: 10.1111/j.1399-0012.2009.01145.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Jeong SM, Lee YK, Kim JU, Hwang GS. Venovenous bypass using central venous catheter during liver transplantation. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.1.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sung-moon Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Yoon Kyung Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Joung Uk Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Gyu Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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