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Yl MK, Patil NS, Mohapatra N, Sindwani G, Dhingra U, Yadav A, Kale P, Pamecha V. Temporary Portocaval Shunt Provides Superior Intraoperative Hemodynamics and Reduces Blood Loss and Duration of Surgery in Live Donor Liver Transplantation: A Randomized Control Trial. Ann Surg 2024; 279:932-944. [PMID: 38214167 DOI: 10.1097/sla.0000000000006200] [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: 09/03/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To compare intraoperative hemodynamic parameters, blood loss, renal function, and duration of surgery with and without temporary portocaval shunt (TPCS) in live donor liver transplantation (LT) recipients. Secondary objectives were postoperative early graft dysfunction, morbidity, mortality, total intensive care unit, and hospital stay. BACKGROUND Blood loss during recipient hepatectomy for LT remains a major concern. Routine use of TPCS during LT is not yet elucidated. METHODS This study is a single-center, open-label, randomized control trial. The sample size was calculated based on intraoperative blood loss. After exclusion, a total of 60 patients, 30 in each arm (TPCS vs no TPCS) were recruited in the trial. RESULTS The baseline recipient and donor characteristics were comparable between the groups. The median intraoperative blood loss ( P = 0.004) and blood product transfusions ( P < 0.05) were significantly less in the TPCS group. The TPCS group had significantly improved intraoperative hemodynamics in the anhepatic phase as compared with the no TPCS group ( P < 0.0001), requiring significantly less vasopressor support. This led to significantly better renal function as evidenced by higher intraoperative urine output in the TPCS group ( P = 0.002). Because of technical simplicity, the TPCS group had significantly fewer inferior vena cava injuries (3.3 vs 26.7%, P = 0.026) and substantially shorter hepatectomy time and total duration of surgery (529.4 ± 35.54 vs 606.83 ± 48.13 min, P < 0.0001). The time taken for normalization of lactate in the immediate postoperative period was significantly shorter in the TPCS group (median, 6 vs 13 h; P = 0.04). Although postoperative endotoxemia, major morbidity, 90-day mortality, total intensive care unit, and hospital stay were comparable between both groups, tolerance to enteral feed was earlier in the TPCS group. CONCLUSIONS In live donor LT, TPCS is a simple and effective technique that provides superior intraoperative hemodynamics and reduces blood loss and duration of surgery.
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Affiliation(s)
| | | | | | | | | | | | - Pratibha Kale
- Microbiology, Institute of Liver and Biliary Sciences, DL, India
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2
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Shaker TM, Eason JD, Davidson BR, Barth RN, Pirenne J, Imventarza O, Spiro M, Raptis DA, Fung J. Which cava anastomotic techniques are optimal regarding immediate and short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14681. [PMID: 35567584 PMCID: PMC10078200 DOI: 10.1111/ctr.14681] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has long been debated whether cava anastomosis should be performed with the piggyback technique or cava replacement, with or without veno-venous bypass (VVB), with or without temporary portocaval shunt (PCS) in the setting of liver transplantation. OBJECTIVES To identify whether different cava anastomotic techniques and other maneuvers benefit the recipient regarding short-term outcomes and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021240979). RESULTS Of 3205 records screened, 307 publications underwent full-text assessment for eligibility and 47 were included in qualitative synthesis. Four studies were randomized control trials. Eighteen studies were comparative. The remaining 25 were single-center retrospective noncomparative studies. CONCLUSION Based on existing data and expert opinion, the panel cannot recommend one cava reconstruction technique over another, rather the surgical approach should be based on surgeon preference and center dependent, with special consideration toward patient circumstances (Quality of evidence: Low | Grade of Recommendation: Strong). The panel recommends against routine use of vevo-venous bypass (Quality of evidence: Very Low | Grade of Recommendation: Strong) and against the routine use of temporary porto-caval shunt (Quality of evidence: Very Low | Grade of Recommendation: Strong).
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Affiliation(s)
- Tamer M Shaker
- Division of Transplant, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - James D Eason
- James D. Eason Transplant Institute, University of Tennessee, Memphis, Tennessee, USA
| | - Brian R Davidson
- UCL Division of Surgery & Interventional Science, University College London, Royal Free Campus, Rowland Hill Street, London, United Kingdom of Great Britain and Northern Ireland
| | - Rolf N Barth
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Jacques Pirenne
- Department of Microbiology, Immunology, and Transplantation, Lab of Abdominal Transplantation, Transplantation Research Group, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplantation Surgery and Coordination, University Hospitals of Leuven, Leuven, Belgium
| | - Oscar Imventarza
- Liver Transplant Unit, Hospital Argerich, Hospital Garrahan, Stalyc Representative, Buenos Aires, Argentina
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, 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
| | - John Fung
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
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Safety of Intraoperative Blood Salvage During Liver Transplantation in Patients With Hepatocellular Carcinoma. Ann Surg 2022; 276:239-245. [PMID: 36036990 PMCID: PMC9259047 DOI: 10.1097/sla.0000000000005476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: The effects of intraoperative blood salvage (IBS) on time to tumor recurrence, disease-free survival and overall survival in hepatocellular carcinoma (HCC) patients undergoing liver transplantation were assessed to evaluate the safety of IBS. Background: IBS is highly effective to reduce the use of allogeneic blood transfusion. However, the safety of IBS during liver transplantation for patients with HCC is questioned due to fear of disseminating malignant cells. Methods: Comprehensive searches through June 2021 were performed in 8 databases. The methodological quality of included studies was assessed using the Robins-I tool. Meta-analysis with the generic inverse variance method was performed to calculate pooled hazard ratios (HRs) for disease-free survival, HCC recurrence and overall survival. Results: Nine studies were included (n=1997, IBS n=1200, no-IBS n=797). Use of IBS during liver transplantation was not associated with impaired disease-free survival [HR=0.90, 95% confidence interval (CI)=0.66–1.24, P=0.53, IBS n=394, no-IBS n=329], not associated with increased HCC recurrence (HR=0.83, 95% CI=0.57–1.23, P=0.36, IBS n=537, no-IBS n=382) and not associated with impaired overall survival (HR=1.04, 95% CI=0.79–1.37, P=0.76, IBS n=495, no-IBS n=356). Conclusions: Based on available observational data, use of IBS during liver transplantation in patients with HCC does not result in impaired disease-free survival, increased HCC recurrence or impaired overall survival. Therefore, use of IBS during liver transplantation for HCC patients is a safe procedure.
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Nutu OA, Sneiders D, Mirza D, Isaac J, Perera MTPR, Hartog H. Safety of intra-operative blood salvage during liver transplantation in patients with hepatocellular carcinoma, a propensity score-matched survival analysis. Transpl Int 2021; 34:2887-2894. [PMID: 34724271 DOI: 10.1111/tri.14150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/12/2021] [Accepted: 09/15/2021] [Indexed: 01/03/2023]
Abstract
Intra-operative blood salvage (IBS) reduces the use of allogeneic blood transfusion. However, safety of IBS during liver transplantation (LT) for hepatocellular carcinoma (HCC) is questioned due to fear for dissemination of circulating malignant cells. This study aims to assess safety of IBS. HCC patients who underwent LT from January 2006 through December 2019 were included. Patients in whom IBS was used were propensity score matched (1:1) to control patients. Disease-free survival and time to HCC recurrence were assessed with Cox regression models and competing risk models. IBS was used in 192/378 HCC LT recipients, and 127 patients were propensity score matched. Cumulative disease-free survival at 12 and 60 months was 85% and 63% for the IBS group versus 90% and 68% for the no-IBS group. Use of IBS was not associated with impaired disease-free survival (HR 1.07, 95%CI: 0.65-1.76, P = 0.800) nor with increased HCC recurrence (Cause-specific cox model: HR 0.79, 95%CI: 0.36-1.73, P = 0.549, Fine and Gray model: HR: 0.79, 95%CI 0.40-1.57, P = 0.50). In conclusion, IBS during LT did not increase the risk for HCC recurrence. IBS is a safe procedure in HCC LT recipients to reduce the need for allogenic blood transfusion.
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Affiliation(s)
| | - Dimitri Sneiders
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Darius Mirza
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Hermien Hartog
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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5
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Protective Role of the Portocaval Shunt in Liver Transplantation. Transplant Proc 2020; 52:1455-1458. [PMID: 32217010 DOI: 10.1016/j.transproceed.2020.01.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Advances in medical management and surgical technique have resulted in stepwise improvements in early post-transplant survival rates. Modifications in the surgical technique, such as the realization of the portocaval shunt (PCS), could influence survival rates. The aim of this study was to evaluate the mortality rate for 12 months after liver transplantation, analyzing the causes and risk factors related to its development and assessing the impact that PCS could have on them. METHODS A total of 231 recipients were included in the retrospective, longitudinal, and nonrandomized study. RESULTS The overall survival of the transplant was 85.2% (197 patients). The most frequent cause of death was infection (38.2%), followed by the multiorgan failure of multiple etiology (23.5%). Most of the risk factors related to mortality correspond to variables of the postoperative period. The results of the multivariate analysis identified the main risk factors for death: the presence of surgical complications and the need for renal replacement therapy. In contrast, the performance of PCS exerted a protective effect, reducing the probability of death by 70%. CONCLUSIONS Despite the good results obtained in several studies, there is still debate regarding the benefit of its realization. In our study, PCS was a factor associated with a reduction in mortality, with a markedly lower probability of adverse events. However, we agree with other authors on the need for larger and randomized studies to adequately determine the validity of such results.
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Pietersen LC, Sarton E, Alwayn I, Lam HD, Putter H, van Hoek B, Braat AE. Impact of Temporary Portocaval Shunting and Initial Arterial Reperfusion in Orthotopic Liver Transplantation. Liver Transpl 2019; 25:1690-1699. [PMID: 31276282 DOI: 10.1002/lt.25592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 06/06/2019] [Indexed: 01/13/2023]
Abstract
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
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Affiliation(s)
- Lars Cornelis Pietersen
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian Alwayn
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hwai-Ding Lam
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andries Erik Braat
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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7
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Passive mesenterico-saphenous shunt: An alternative to portocaval anastomosis for tailored portal decompression during liver transplantation. Surgery 2019; 165:970-977. [DOI: 10.1016/j.surg.2018.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/30/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023]
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8
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Nacif LS, Zanini LY, Sartori VF, Kim V, Rocha-Santos V, Andraus W, Carneiro D'Albuquerque L. Intraoperative Surgical Portosystemic Shunt in Liver Transplantation: Systematic Review and Meta-Analysis. Ann Transplant 2018; 23:721-732. [PMID: 30323164 PMCID: PMC6248172 DOI: 10.12659/aot.911435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Expanded clinical and surgical techniques in liver transplantation can markedly improve patient and graft survival. The main purpose of this study was to evaluate the efficacy of intraoperative portocaval shunts in liver transplantation. Material/Methods Searches were conducted in Cochrane, MEDLINE, and EMBASE databases, and updated in January 2018. The following specific outcomes of interest were defined and evaluated separated using 2 different reviews and meta-analyses for 1) hemi-portocaval shunt (HPCS) and 2) temporary portocaval shunt (TPCS). Comparative studies were analyzed separately for both surgical portocaval shunt modalities. Results Only 1 well-designed randomized controlled trial was found. Most studies were retrospective or prospective. Initially, we found 1479 articles. Of those selected, 853 were from PubMed/MEDLINE, 32 were from Cochrane and 594 were from EMBASE. Our meta-analysis included a total of 3232 patients for all the included studies. Results found that 41 patients with HPCS experienced increased 1-year patient survival (OR 16.33; P=0.02) and increased 1-year graft survival (OR 17.67; P=0.01). The TPCS analysis with 1633 patients found patients had significantly shorter intensive care unit length of stay (days) (P=0.006) and hospital length of stay (P=0.02) and had decreased primary nonfunction (PNF) (OR 0.30, P=0.02) and mortality rates (OR 0.52, P=0.01). Conclusions Intraoperative surgical portosystemic shunt in relation to liver transplantation with TPCS was able to prevent PNF, decrease hospital length of stay and unit care length of stay. Furthermore, in analyzing data for patients with HPCS, we observed increases in the 1-year graft and patient survival rates. More prospective randomized trials are needed to arrive at a more precise conclusion.
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Affiliation(s)
- Lucas Souto Nacif
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Leonardo Yuri Zanini
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vinicius Farina Sartori
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vera Kim
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Wellington Andraus
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Luiz Carneiro D'Albuquerque
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
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9
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Rayar M, Levi Sandri GB, Cusumano C, Locher C, Houssel-Debry P, Camus C, Lombard N, Desfourneaux V, Lakehal M, Meunier B, Sulpice L, Boudjema K. Benefits of temporary portocaval shunt during orthotopic liver transplantation with vena cava preservation: A propensity score analysis. Liver Transpl 2017; 23:174-183. [PMID: 27706895 DOI: 10.1002/lt.24650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/20/2016] [Accepted: 09/26/2016] [Indexed: 02/07/2023]
Abstract
During orthotopic liver transplantation (OLT), clamping of the portal vein induces splanchnic venous congestion and accumulation of noxious compounds. These adverse effects could increase ischemia/reperfusion injury and subsequently the risk of graft dysfunction, especially for grafts harvested from extended criteria donors (ECDs). Temporary portocaval shunt (TPCS) could prevent these complications. Between 2002 and 2013, all OLTs performed in our center were retrospectively analyzed and a propensity score matching analysis was used to compare the effect of TPCS in 686 patients (343 in each group). Patients in the TPCS group required fewer intraoperative transfusions (median number of packed red blood cells-5 versus 6; P = 0.02; median number of fresh frozen plasma-5 versus 6; P = 0.02); had improvement of postoperative biological parameters (prothrombin time, Factor V, international normalized ratio, alkaline phosphatase, and gamma-glutamyltransferase levels); and showed significant reduction of biliary complications (4.7% versus 10.2%; P = 0.006). Survival analysis revealed that TPCS improved 3-month graft survival (94.2% versus 88.6%; P = 0.01) as well as longterm survival of elderly (ie, age > 70 years) donor grafts (P = 0.02). In conclusion, the use of TPCS should be recommended especially when considering an ECD graft. Liver Transplantation 23 174-183 2017 AASLD.
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Affiliation(s)
- Michel Rayar
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Giovanni B Levi Sandri
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Caterina Cusumano
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Clara Locher
- Service de Pharmacologie Clinique et Épidémiologique, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Pauline Houssel-Debry
- Service des Maladies du Foie, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Christophe Camus
- Réanimation Médicale, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France
| | - Nicolas Lombard
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Veronique Desfourneaux
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Mohamed Lakehal
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Bernard Meunier
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Laurent Sulpice
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Karim Boudjema
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
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Seiberlich E, Sanches MD, Morais BS, Maciel JF. Influência do propranolol pré‐operatório no índice cardíaco durante a fase anepática do transplante hepático. Rev Bras Anestesiol 2015; 65:170-6. [DOI: 10.1016/j.bjan.2014.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 02/05/2014] [Indexed: 11/29/2022] Open
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11
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Seiberlich E, Sanches MD, Morais BS, Maciel JF. Influence of preoperative propranolol on cardiac index during the anhepatic phase of liver transplantation. Braz J Anesthesiol 2015; 65:170-6. [PMID: 25925027 DOI: 10.1016/j.bjane.2014.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 02/05/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Liver transplantation is the best therapeutic option for end-stage liver disease. Non-selective beta-blocker medications such as propranolol act directly on the cardiovascular system and are often used in the prevention of gastrointestinal bleeding resulting from HP. The effects of propranolol on cardiovascular system of cirrhotic patients during liver transplantation are not known. OBJECTIVE Evaluate the influence of propranolol used preoperatively on cardiac index during the anhepatic phase of liver transplantation. METHOD 101 adult patients (73 male [72.2%]) who underwent cadaveric donor orthotopic liver transplantation by piggyback technique with preservation of the retrohepatic inferior vena cava performed at Hospital das Clinicas, Federal University of Minas Gerais were evaluated. There was no difference in severity between groups by the MELD system, p=0.70. The preoperative use of propranolol and the cardiac index outcome were compared during the anhepatic phase of liver transplantation in 5 groups (I: increased cardiac index, II: cardiac index reduction lower than 16%, III: cardiac index reduction equal to or greater than 16% and less than 31%, IV: cardiac index reduction equal to or greater than 31% and less than 46%, V: cardiac index reduction equal to or greater than 46%). RESULTS Patients in group I (46.4%) who received propranolol preoperatively were statistically similar to groups II (60%), III (72.7%), IV (50%) and V (30.8%), p=0.57. CONCLUSION The use of propranolol before transplantation as prophylaxis for gastrointestinal bleeding may be considered safe, as it was not associated with worsening of cardiac index in anhepatic phase of liver transplantation.
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Affiliation(s)
- Emerson Seiberlich
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
| | - Marcelo D Sanches
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | | | - Jader F Maciel
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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12
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Beneficial Impact of Temporary Portocaval Shunt in Living-Donor Liver Transplantation With a Difficult Total Hepatectomy. Transplant Proc 2015; 47:694-9. [DOI: 10.1016/j.transproceed.2014.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/31/2014] [Indexed: 12/24/2022]
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13
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Manzini G, Kremer M, Houben P, Gondan M, Bechstein WO, Becker T, Berlakovich GA, Friess H, Guba M, Hohenberger W, Ijzermans JNM, Jonas S, Kalff JC, Klar E, Klempnauer J, Lerut J, Lippert H, Lorf T, Nadalin S, Nashan B, Otto G, Paul A, Pirenne J, Pratschke J, Ringers J, Rogiers X, Schilling MK, Seehofer D, Senninger N, Settmacher U, Stippel DL, Tscheliessnigg K, Ysebaert D, Binder H, Schemmer P. Reperfusion of liver graft during transplantation: techniques used in transplant centres within Eurotransplant and meta-analysis of the literature. Transpl Int 2013; 26:508-16. [DOI: 10.1111/tri.12083] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 10/21/2012] [Accepted: 02/11/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Giulia Manzini
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Michael Kremer
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Philipp Houben
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Matthias Gondan
- Institute of Medical Biometry and Informatics; University of Heidelberg; Heidelberg; Germany
| | - Wolf O. Bechstein
- Department of General and Visceral Surgery; Johann Wolfgang Goethe- University; Frankfurt am Main; Germany
| | - Thomas Becker
- Department of General and Thoracic Surgery; Christian-Albrechts-University Kiel; Kiel; Germany
| | | | - Helmut Friess
- Department of General Surgery; Klinikum Rechts der Isar; Technical University of Munich; Munich; Germany
| | - Markus Guba
- Department of General Surgery; Campus Grosshadern; University of Munich; Munich; Germany
| | - Werner Hohenberger
- Department of General Surgery; University of Erlangen; Erlangen; Germany
| | - Jan N. M. Ijzermans
- Department of Surgery; Erasmus Medisch Centrum-Daniel den Hoed; Rotterdam; Netherlands
| | - Sven Jonas
- Department of Visceral Transplant, Thoracic and Vascular Surgery; University of Leipzig; Leipzig; Germany
| | - Jörg C. Kalff
- Department of General Surgery; University of Bonn; Bonn; Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery; University of Rostock; Rostock; Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery; Klinikum der Medizinischen Hochschule; Hannover; Germany
| | - Jan Lerut
- Department of Liver Transplant Surgery; University Clinic Saint-Luc; Bruxelles; Belgium
| | - Hans Lippert
- Department of General, Visceral and Vascular Surgery; Otto-von-Guericke University; Magdeburg; Germany
| | - Thomas Lorf
- Department of General and Visceral Surgery; University of Goettingen; Goettingen; Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery; Eberhard-Karls University; Tuebingen; Germany
| | - Björn Nashan
- Department of Hepatobiliary and Transplant Surgery; University of Hamburg-Eppendorf; Hamburg; Germany
| | - Gerd Otto
- Department of Transplant and Hepato-biliary-pancreatic Surgery; Johannes-Gutenberg-University; Mainz; Germany
| | - Andreas Paul
- Department of General, Visceral and Transplant Surgery; University of Essen; Essen; Germany
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery; University of Leuven; Leuven; Belgium
| | - Johann Pratschke
- Department of Visceral, Transplant and Thoracic Surgery; University of Innsbruck; Innsbruck; Austria
| | - Jan Ringers
- Department of Transplant Surgery; University of Leiden; Leiden; Netherlands
| | - Xavier Rogiers
- Department of Transplant Surgery; University of Gent; Gent; Belgium
| | - Martin K. Schilling
- Department of General, Visceral, Vascular and Pediatric Surgery; University of Saarland; Homburg/Saar; Germany
| | - Daniel Seehofer
- Department of General, Visceral and Transplantation Surgery; Charité Campus Virchow-Klinikum; University of Berlin; Berlin; Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery; University of Muenster; Muenster; Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery; Friedrich Schiller University; Jena; Germany
| | - Dirk L. Stippel
- Department of General, Visceral and Cancer Surgery; University of Cologne; Cologne; Germany
| | | | - Dirk Ysebaert
- Department of Hepatobiliary, Transplant and Endocrine Surgery; University Hospital of Antwerpen; Edegem; Belgium
| | - Heidrun Binder
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
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14
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Muscari F, Guinard JP, Kamar N, Peron JM, Otal P, Suc B. Impact of preoperative α-fetoprotein level on disease-free survival after liver transplantation for hepatocellular carcinoma. World J Surg 2012; 36:1824-31. [PMID: 22532309 DOI: 10.1007/s00268-012-1587-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative α-fetoprotein (AFP) levels may have an influence on disease-free survival (DFS) of patients after liver transplantation for hepatocellular carcinoma (HCC) located on a cirrhotic liver. METHODS Between 2000 and 2009, two groups were distinguished according to preoperative AFP level: normal-level group (<10 ng/ml) and increased-level group (>10 ng/ml). The increased-level group was further divided into three levels of preoperative AFP: 10-150, 150-500, and ≥ 500 ng/ml. DFS and recurrence rates were compared. All patients underwent transplantation using the preoperative 5/5 criteria. RESULTS Of the 122 patients in this study, 63 had normal and 59 had increased preoperative AFP. There were no differences between the two groups concerning perioperative or pathologic data. Those with an increased preoperative AFP level had a significantly shorter 5-year DFS, and their recurrence rate was higher than that of the normal AFP group. The 5-year DFS and recurrence rates were 71 and 4 %, respectively, for those with normal AFP; 57 and 10 %, respectively, for those with AFP 10-150 ng/ml; 46 and 24 %, respectively, for those with AFP 150-500 ng/ml; and 28 and 62 %, respectively, for those with AFP ≥ 500 ng/ml. CONCLUSIONS This study shows the prognostic value of preoperative AFP levels on DFS after a liver transplant for HCC in a population of patients undergoing transplantation with the same preoperative criteria.
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Affiliation(s)
- Fabrice Muscari
- Department of Digestive Surgery and Liver Transplantation, CHU Rangueil, 1 Avenue Jean Poulhès, 31059, Toulouse Cedex, France.
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15
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Ghinolfi D, Martí J, Rodríguez-Laiz G, Sturdevant M, Iyer K, Bassi D, Scher C, Schwartz M, Schiano T, Sogawa H, del Rio Martin J. The beneficial impact of temporary porto-caval shunt in orthotopic liver transplantation: a single center analysis. Transpl Int 2010; 24:243-50. [PMID: 20875093 DOI: 10.1111/j.1432-2277.2010.01168.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The use of temporary porto-caval shunt (TPCS) has been shown to improve hemodynamic stability and renal function in patients undergoing orthotopic liver transplantation (OLT). We evaluated the impact of TPCS in OLT and analyzed the differences according to model for end-stage liver disease (MELD), donor risk index (DRI) and D-MELD. This is a retrospective single-center analysis of 148 consecutive OLT. Fifty-eight OLT were performed using TPCS and 90 without TPCS. Donor and recipient data with pre-OLT, intraoperative and postoperative variables were reviewed. Overall graft survival was 89.9% at 3 months and 81.7% at 1 year. Graft survival at 3 months and 1 year was 93.1% and 79.2%, respectively, in TPCS group versus 85.6% and 82.2%, respectively, in non-TPCS group (P = NS). Intraoperative packed red blood cells requirement was lower in TPCS group (7.5 ± 5.8 vs. 12.2 ± 14.2, P = 0.006) and non-TPCS group required higher intraoperative total dose of phenylephrine (16% vs. 28%, P = 0.04). TPCS group had lower 30-day postoperative mortality (1.7% vs. 10%, P = 0.04), no difference was observed at 90 days. Graft survival was lower in patients with high DRI; in this group graft loss was higher at 1 month (25% vs. 4.3%, P = 0.005) and 3 months (25% vs. 4.3%, P = 0.005) when TPCS was not used. TPCS improves perioperative outcome, this being more evident when high-risk grafts are placed into high-risk patients.
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Affiliation(s)
- Davide Ghinolfi
- Department of General Surgery and Liver Transplantation, University of Pisa, Cisanello Hospital, Pisa, Italy
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16
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Paugam-Burtz C, Kavafyan J, Merckx P, Dahmani S, Sommacale D, Ramsay M, Belghiti J, Mantz J. Postreperfusion syndrome during liver transplantation for cirrhosis: outcome and predictors. Liver Transpl 2009; 15:522-9. [PMID: 19399736 DOI: 10.1002/lt.21730] [Citation(s) in RCA: 168] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
During orthotopic liver transplantation (OLT), a marked decrease in blood pressure following unclamping of the portal vein and liver reperfusion is frequently observed and is termed postreperfusion syndrome (PRS). The predictive factors and clinical consequences of PRS are not fully understood. The goal of this study was to identify predictors of PRS and morbidity/mortality associated with its occurrence during OLT in patients with cirrhosis. During a 3-year period, all consecutive OLT procedures performed in patients with cirrhosis were studied. Exclusion criteria were OLT for acute liver failure, early retransplantation, combined liver/kidney transplantation, and living-donor related transplantation. PRS was defined as a decrease in the mean arterial pressure of more than 30% of the value observed in the anhepatic stage, for more than 1 minute during the first 5 minutes after reperfusion of the graft. Transplantation was performed with preservation of the inferior vena cava with or without temporary portocaval shunt. Associations between PRS and donor and recipient demographic data, recipient operative and postoperative outcomes were tested with bivariate statistics. Independent predictors of PRS were determined in multivariable logistic regression analysis. Of the 75 patients included in the study, 20 patients (25%) developed PRS. In a multivariable analysis, absence of a portocaval shunt [odds ratio (95% confidence interval) = 4.42 (1.18-17.6)] and duration of cold ischemia [odds ratio (95% confidence interval) = 1.34 (1.07-1.72)] were independent predictors of PRS. Patients who experienced PRS displayed more postoperative renal failure and lower early (<15 days after OLT) survival (80% versus 96%; P = 0.04). In conclusion, the absence of portocaval shunt and the duration of cold ischemia were independent predictors of intraoperative PRS. PRS was associated with significant adverse postoperative outcome. These results provide realistic clinical targets to improve patient outcome after OLT for cirrhosis.
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18
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Muscari F, Guinard JP, Foppa B, Trocard P, Danjoux M, Kamel MS, Duffas JP, Rostaing L, Fourtanier G, Suc B. Biological changes after liver transplantation according to the presence or not of graft steatosis. Transplant Proc 2009; 40:3562-5. [PMID: 19100438 DOI: 10.1016/j.transproceed.2008.06.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 05/13/2008] [Accepted: 06/18/2008] [Indexed: 01/22/2023]
Abstract
AIM To assess the consequences of graft steatosis on postoperative liver function as compared with normal liver grafts. PATIENTS AND METHODS From January 2005 to December 2007, liver transplant patients were prospectively included, excluding those who experienced arterial or biliary complications or presented acute rejection. All patients had a surgical biopsy after reperfusion. Patients were compared according to the rate of macrovacuolar steatosis: namely above or below 20%. RESULTS Fifty-three patients were included: 10 in the steatosis group and 43 in the control group. No significant difference was observed in terms of morbidity, mortality, and primary non- or poor function. Nevertheless, biological changes after the procedure were significantly different during the first postoperative week. Prothrombin time, serum bilirubin, and transaminases were significantly increased among the steatosis group compared with the control group (P < .05). CONCLUSION This case-controlled study including a small number of patients, described postoperative biological changes among liver transplantations with steatosis in the graft.
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Affiliation(s)
- F Muscari
- Digestive and Liver Transplantation Department, CHU Rangueil, Toulouse, France.
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19
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Davila D, Bartlett A, Heaton N. Temporary portocaval shunt in orthotopic liver transplantation: need for a standardized approach? Liver Transpl 2008; 14:1414-9. [PMID: 18825702 DOI: 10.1002/lt.21603] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Maintenance of portal and systemic venous return during the anhepatic phase of liver transplantation (LT) improves hemodynamic stability. With the piggyback technique, caval return is maintained; however, temporary clamping of the portal vein is still necessary. The use of a temporary portocaval shunt (TPCS) has been proposed to minimize the effect of portal venous interruption. The aim of this study was to perform a systematic review of the literature to determine whether there is evidence to support the routine use of a TPCS in LT. An electronic search of the literature from 1963 to 2007 was performed. A total of 4386 articles were identified, of which 8 met all the criteria and were included in the study. Because of the variability in reporting and the small number of studies, statistical comparison was not possible; however, a trend toward a shorter operative time, less blood product transfusion, and maintenance of higher mean arterial pressures during portal vein clamping was seen in patients with a TPCS. In conclusion, the available evidence, albeit scarce, supports the use of a TPCS in patients undergoing LT. A prospective randomized study of patients most likely to benefit from a TPCS is necessary to substantiate these findings.
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Affiliation(s)
- Diego Davila
- King's College London School of Medicine at Denmark Hill, Institute of Liver Studies, King's College Hospital, Denmark Hill, Camberwell, London, United Kingdom
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20
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Suárez-Munoz MA, Santoyo J, Fernández-Aguilar JL, Sánchez-Pérez B, Pérez-Daga JA, Ramírez-Plaza C, Rodríguez Cañete A. Transfusion Requirements During Liver Transplantation: Impact of a Temporary Portacaval Shunt. Transplant Proc 2006; 38:2486-7. [PMID: 17097976 DOI: 10.1016/j.transproceed.2006.08.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED We evaluated the consumption of blood products during liver transplantation in cirrhotic patients association with the placement of a temporary portacaval shunt (TPCS). PATIENTS AND METHODS We retrospectively divided 349 cirrhotic patients transplanted in our unit between March 1997 and October 2005 into two groups: transplants without a TPCS (group I, 189 cases) and those with a TPCS (group II, 160 cases). In all cases, we preserved the inferior vena cava (piggyback). The dependent variables were consumption of blood-derived products (banked red cells, recovered red cells, fresh frozen plasma, platelets), surgery time, kidney function, intensive care unit stay, and hospital stay. RESULTS Consumption of blood products was significantly lower among patients who received a TPCS. In group II, no platelet transfusion was required in 54% of the patients, and no banked red cells in 12% compared with 18% and 3%, respectively, among group I patients (P < .005). The mean overall transplant procedure time was 74 minutes shorter in group II (361 minutes) compared with group I (435 minutes) (P < .001). The overall hospital stay was shorter among patients transplanted after TPCS. CONCLUSION Liver transplantation with a TPCS was accompanied by a reduction in the intraoperative use of blood-derived products, especially platelet transfusion. Among other advantages, this reduction resulted in a shorter posttransplant hospital stay.
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Affiliation(s)
- M A Suárez-Munoz
- HBP Surgery and Liver Transplant Unit, General and Digestive Surgery Service, Hospital Regional Universitario Carlos Haya, Malaga, Spain.
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21
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Muscari F, Suc B, Vigouroux D, Duffas JP, Migueres I, Mathieu A, Lavayssiere L, Rostaing L, Fourtanier G. Blood salvage autotransfusion during transplantation for hepatocarcinoma: does it increase the risk of neoplastic recurrence? Transpl Int 2005; 18:1236-9. [PMID: 16221153 DOI: 10.1111/j.1432-2277.2005.00207.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Impact of intraoperative blood salvage autotransfusion (IBSA) on neoplastic recurrence. during liver transplantations for hepatocellular carcinoma (LT-HCC). Between January 1989 and February 2003, 16 patients received a LT-HCC without IBSA. This group was compared with 31 patients who received the same surgical procedure during the same period, but with IBSA. Data were prospectively collected. All patients had at least a 1-year postoperative follow up. Pairing was made according to the size of the largest nodule. The percentage of recurrence observed in the two groups was similar: 6.4% in the IBSA group vs. 6.3% in the group without IBSA. The median amount of transfused salvage blood was 1558 ml. The differences observed between the two groups concerned the Child score which was A in 58% patients of the IBSA group vs. 80% in the other group; the percentage of severe portal hypertension was 55% in the IBSA group vs. 31%; the median number of packed red blood cell units transfused intraoperatively was 7 in the IBSA group vs. 0, and the median number of frozen fresh plasma units transfused intraoperatively was 11 in the IBSA group vs. 4.5. It appears that IBSA, essentially used during the most haemorrhagic transplantations, could be used in the case of HCC because it does not modify the risk of neoplastic recurrence.
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Affiliation(s)
- Fabrice Muscari
- Digestive Surgery Department, University Hospital, Rangueil, Toulouse, France
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