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Fernández J, Blasi A, Hidalgo E, Karvellas CJ. Bridging the critically ill patient with acute to chronic liver failure to liver transplantation. Am J Transplant 2024; 24:1348-1361. [PMID: 38548058 DOI: 10.1016/j.ajt.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
| | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Ernest Hidalgo
- Hepatolobiliary Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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2
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Belfiore J, Castellani Niccolini N, Fleissner Z, Chadha R, Biancofiore G. Pain management in liver transplant recipients: a focus on current and future strategies. Minerva Anestesiol 2024; 90:452-461. [PMID: 38571405 DOI: 10.23736/s0375-9393.24.17805-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Liver transplantation is the only curative treatment option for patients with end-stage liver disease. Anesthesiologists and intensivists are fully involved in this procedure due to the perioperative care focus on hemodynamic, respiratory and metabolic support. However, quite surprisingly, postoperative pain management does not have clinical primary consideration in this class of patients due to a combination of factors including the thought that liver transplantation recipients have less pain and require lower doses of analgesics than patients who undergo other types of major abdominal surgery. Other factors contribute to make the management of postoperative pain somewhat complex in this class of patients: 1) drug pharmacokinetics and metabolism by the new liver is not predictable; 2) the multifactorial nature of liver graft recovery; and 3) the alterations of homeostasis, including circulatory, respiratory and metabolic vulnerability, in the days postoperative period. As a result, post-liver transplantation analgesia is underestimated not only from the clinical point of view but also in the literature and only a few papers deal with the management of postoperative pain in this particular class of patients. Thus, in the experts' opinion paper we aimed to report the possible strategies for managing post-LT pain with a focus on opioids alternatives and possible future developments in this particular clinical setting also in the view that improvements in perioperative care have made it possible to adopt fast track and Enhanced Recovery After Surgery-oriented protocols also in this class of patients.
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Affiliation(s)
- Jacopo Belfiore
- Unit of Transplant Anesthesia and Critical Care, AOU Pisana, University of Pisa, Pisa, Italy
| | | | - Zachary Fleissner
- Unit of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Ryan Chadha
- Unit of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Gianni Biancofiore
- Unit of Transplant Anesthesia and Critical Care, AOU Pisana, University of Pisa, Pisa, Italy -
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Zhou XB, Xu Q, Chen L, Qian WM. Related factors associated with the prognosis of children undergoing liver transplantation under the enhanced recovery after surgery nursing concept. Medicine (Baltimore) 2024; 103:e37676. [PMID: 38579079 PMCID: PMC10994493 DOI: 10.1097/md.0000000000037676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/01/2024] [Indexed: 04/07/2024] Open
Abstract
This study aimed to investigate factors associated with the clinical outcomes of patients who underwent pediatric liver transplantation (LT) and received enhanced recovery after surgery (ERAS) nursing. A cohort of 104 pediatric patients was studied at our hospital. Data on 8 indicators and 2 clinical outcomes, including length of hospital stay (LOS) and 30-day readmission rates, were collected. Linear and logistic regression analyses were employed to examine the associations of the 8 indicators with hospital-LOS and readmission risks, respectively. The predictive value of these indicators for the outcomes was determined using the receiver operating characteristic (ROC) curve, decision curve analysis, and importance ranking through the XGBoost method. A comprehensive model was developed to evaluate its predictive accuracy. Regression analyses identified donor age, donor gender, and intensive care unit (ICU)-LOS of recipients as significant predictors of hospital LOS (all P < .05), whereas no indicators were significantly associated with readmission risk. Further, ROC analysis revealed that 3 indicators provided superior prediction for 28-day hospital LOS compared to the median LOS of 18 days. ICU-LOS demonstrated the highest clinical net benefit for predicting 28-day hospital-LOS. Multivariable regression analysis confirmed the independent predictive value of donor age and ICU-LOS for the hospital-LOS (all β > 0, all P < .05). Although the comprehensive model incorporating donor age and ICU-LOS showed stable predictive capability for hospital-LOS, its performance did not significantly exceed that of the individual indicators. In pediatric LT, hospital LOS warrants greater emphasis over readmission rates. Donor age and ICU-LOS emerged as independent risk factors associated with prolonged hospital LOS.
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Affiliation(s)
- Xin-Bin Zhou
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China
| | - Qin Xu
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China
| | - Li Chen
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China
| | - Wei-Ming Qian
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China
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Chanan EL, Wagener G, Whitlock EL, Berger JC, McAdams-DeMarco MA, Yeh JS, Nunnally ME. Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review. Transplantation 2024:00007890-990000000-00716. [PMID: 38557579 DOI: 10.1097/tp.0000000000005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.
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Affiliation(s)
- Emily L Chanan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth L Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA
| | - Jonathan C Berger
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Joseph S Yeh
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
- Department of Medicine, NYU Grossman School of Medicine, New York, NY
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Liu W, Li G, Jin Y, Feng Y, Gao Z, Liu X, Zhou B, Zheng X, Pei X, Ying Y, Yu Q, Yan S, Hu C. Autologous liver transplantation for unresectable hepatobiliary malignancies in enhanced recovery after surgery model. Open Med (Wars) 2024; 19:20240926. [PMID: 38584830 PMCID: PMC10998668 DOI: 10.1515/med-2024-0926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/07/2024] [Accepted: 02/11/2024] [Indexed: 04/09/2024] Open
Abstract
Ex vivo liver resection combined with autologous liver transplantation offers the opportunity to treat otherwise unresectable hepatobiliary malignancies and has been applied in clinic. The implementation of enhanced recovery after surgery (ERAS) program improves the outcome of surgical procedures. This is a retrospective single-center study including 11 cases of patients with liver cancer that underwent autologous liver transplantation and received ERAS: cholangiocarcinoma of the hilar region (n = 5), intrahepatic cholangiocarcinoma (n = 3), gallbladder cancer (n = 1), liver metastasis from colorectal cancer (n = 1), and liver metastasis from gastrointestinal mesenchymal tumor (n = 1). There were no deaths within 30 days and major complications occurred in two patients, and four patients were readmitted upon the first month after the surgery. Median hospital stay was 20 days (range 13-44) and median open diet was Day 4 (range 2-9) after surgery and median early post-operative activity was Day 5 (range 2-9) after surgery. In conclusion, autologous liver transplantation is feasible in the treatment of otherwise unresectable hepatobiliary malignancies, and our study showed favorable results with autologous liver transplantation in ERAS modality. ERAS modality provides a good option for some patients whose tumors cannot be resected in situ and offers a chance for rapid recovery.
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Affiliation(s)
- Weifeng Liu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Yitian Jin
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Yihui Feng
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Zhenzhen Gao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Xingyu Liu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Bo Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Xiang Zheng
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Xiangru Pei
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yulian Ying
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Qian Yu
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Yan
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Chenlu Hu
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Crouch CE, Stewart E, Hendrickse A. Enhanced recovery after surgery for liver transplantation: a review of recent literature. Curr Opin Organ Transplant 2024; 29:64-71. [PMID: 37937584 DOI: 10.1097/mot.0000000000001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW This review was created to highlight important articles from the past year related to the evolving field of enhanced recovery after surgery (ERAS) in liver transplantation that are relevant to the transplant anesthesiologist. RECENT FINDINGS The International Liver Transplantation Society (ILTS) recently completed a landmark project, the ERAS4OLT.org project, which culminated in 80 recommendations for ERAS in liver transplantation. These recommendations encompass management for deceased donor recipients, living donor recipients and living donors. This review highlights selected articles relevant to the perioperative management of deceased donor liver transplant recipients. SUMMARY Though, there are now published internationally agreed upon recommendations for ERAS topics specific to liver transplantation, there is an obvious need for further investigation into this area to provide high quality evidence to support these recommendations. It is reasonable to utilize these recommendations in ERAS protocols for individual institutions; however, more evidence is needed in several areas to confirm the effects of these protocols on short-term outcomes.
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Affiliation(s)
- Cara E Crouch
- University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
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Moore HB, LaRiviere W, Rodriguez I, Brown K, Hadley K, Pomposelli JJ, Adams MA, Wachs ME, Conzen KD, Kennealey PT, Kaplan B, Pomfret EA, Nydam TL. Early predictors of prolonged intensive care utilization following liver transplantation. Am J Surg 2023; 226:829-834. [PMID: 37604748 DOI: 10.1016/j.amjsurg.2023.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Creatinine, bilirubin, and fibrinolysis resistance are associated with multi-organ dysfunction and likely risk factors for prolonged intensive care unit (pICU) stay following liver transplantation (LT). We hypothesize postoperative day-1 (POD-1) labs will predict pICU. METHODS LT recipients had clinical laboratories and viscoelastic testing with tissue plasminogen activator thrombelastography (tPA TEG) to quantify fibrinolysis resistance (LY30) on POD-1. pICU was defined as one week or longer in the ICU. Logistic regression was used to identify the relationship between POD-1 labs and pICU. RESULTS Of 304 patients, 50% went to the ICU, with 15% experiencing pICU. Elevated creatinine (OR 6.6, P < 0.001) and low tPA TEG LY30 (OR 3.7, P = 0.004) were independent predictors of pICU after controlling for other risk factors. A 9-fold increase in the rate of 90-day graft loss (19% vs 2% p < 0.001) was observed patients who had these risk factors for pICU. CONCLUSION Elevated creatine and fibrinolysis resistance are associated with pICU and poor outcomes following LT.
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Affiliation(s)
- Hunter B Moore
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA.
| | - Wells LaRiviere
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Ivan Rodriguez
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kristen Brown
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kyndall Hadley
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - James J Pomposelli
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Megan A Adams
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Michael E Wachs
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kendra D Conzen
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Peter T Kennealey
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Bruce Kaplan
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Elizabeth A Pomfret
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
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Tanaka S, Mizuno Y, Nojiri S, Futamura D, Nagaya M, Nishida Y, Sano Y, Ishida S, Kato M, Kurata N, Jobara K, Fujimoto Y, Ogura Y. Efficacy of rehabilitation initiated in the early phase after simultaneous deceased donor liver and kidney transplantation: A case report. Medicine (Baltimore) 2023; 102:e35324. [PMID: 37746947 PMCID: PMC10519492 DOI: 10.1097/md.0000000000035324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/31/2023] [Indexed: 09/26/2023] Open
Abstract
RATIONALE The purpose of this case report is to describe a case of successful early rehabilitation intervention for simultaneous liver and kidney transplantation (SLKT). PATIENT CONCERNS A 51-year-old Japanese man was diagnosed with Caroli disease 27 years ago. Hemodialysis was introduced due to end-stage renal disease 17 years ago. DIAGNOSES After successful SLKT, the patient was extubated on postoperative day (POD) 1, liberated from dialysis on POD 4, and discharged from the intensive care unit on POD 9. INTERVENTIONS Supervised rehabilitation was started on POD 2, and the patient was able to walk 100 m on POD 9. Electrical muscle stimulation therapy was started to improve muscle weakness in both legs on POD 16, and aerobic exercise using a cycle-ergometer was started on POD 24. OUTCOMES The 6-minute walking distance improved from 324 m on POD 14 to 501 m on POD 28. The patient could walk 4000 to 5000 steps per day at hospital discharge, and was discharged home on POD 32. There were no adverse events, including worsening hepatic or renal function, during the rehabilitation period. One month after discharge, the patient was able to perform 30 to 40 minutes of aerobic exercise every day, and returned to work 5 months after discharge. LESSONS This case shows that early rehabilitation intervention immediately after SLKT safely and rapidly improved physical performance without adverse events. The results in the present case suggest that regular physical assessment and appropriate interventions with a variety of exercise modalities can contribute to improved physical performance in SLKT patients.
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Affiliation(s)
- Shinya Tanaka
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Yota Mizuno
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Shusuke Nojiri
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Daiki Futamura
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Motoki Nagaya
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Yoshihiro Nishida
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuta Sano
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shohei Ishida
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Kato
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuhiko Kurata
- Department of Transplantation Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Kanta Jobara
- Department of Transplantation Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Yasuhiro Fujimoto
- Department of Transplantation Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Yasuhiro Ogura
- Department of Transplantation Surgery, Nagoya University Hospital, Nagoya, Japan
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Pustavoitau A, Qin CX, Navarrete SB, Rao S, Almazan E, Ariyo P, Frank SM, Merritt WT, Rizkalla NA, Villamayor AJ, Cameron AM, Garonzik-Wang JM, Ottman SE, Philosophe B, Gurakar AO, Gottschalk A. Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant. J Clin Anesth 2023; 85:111040. [PMID: 36549035 DOI: 10.1016/j.jclinane.2022.111040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Immediate postoperative extubation (IPE) can reduce perioperative complications and length of stay (LOS), however it is performed variably after liver transplant across institutions and has historically excluded high-risk recipients from consideration. In late 2012, we planned and implemented a single academic institution structured quality improvement (QI) initiative to standardize perioperative care of liver transplant recipients without exceptions. We hypothesized that such an approach would lead to a sustained increase in IPE after primary (PAC) and delayed abdominal closure (DAC). METHODS We retrospectively studied 591 patients from 2013 to 2018 who underwent liver transplant after initiative implementation. We evaluated trends in incidence of IPE versus delayed extubation (DE), and reintubation, LOS, and mortality. RESULTS Overall, 476/591 (80.5%) recipients underwent PAC (278 IPE, 198 DE) and 115/591 (19.5%) experienced DAC (39 IPE, 76 DE). When comparing data from 2013 to data from 2018, the incidence of IPE increased from 9/67 (13.4%) to 78/90 (86.7%) after PAC and from 1/12 (8.3%) to 16/23 (69.6%) after DAC. For the same years, the incidence of IPE after PAC for recipients with MELD scores ≥30 increased from 0/19 (0%) to 12/17 (70.6%), for recipients who underwent simultaneous liver-kidney transplant increased from 1/8 (12.5%) to 4/5 (80.0%), and for recipients who received massive transfusion (>10 units of packed red blood cells) increased from 0/17 (0%) to 10/13 (76.9%). Reintubation for respiratory considerations <48 h after IPE occurred in 3/278 (1.1%) after PAC and 1/39 (2.6%) after DAC. IPE was associated with decreased intensive care unit (HR of discharge: 1.92; 95% CI: 1.58, 2.33; P < 0.001) and hospital LOS (HR of discharge: 1.45; 95% CI: 1.20, 1.76; P < 0.001) but demonstrated no association with mortality. CONCLUSION A structured QI initiative led to sustained high rates of IPE and reduced LOS in all liver transplant recipients, including those classified as high risk.
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Affiliation(s)
- Aliaksei Pustavoitau
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Caroline X Qin
- The Johns Hopkins University School of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Sergio B Navarrete
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Sneha Rao
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Erik Almazan
- The Johns Hopkins University School of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Promise Ariyo
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - William T Merritt
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Nicole A Rizkalla
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - April J Villamayor
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Andrew M Cameron
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Shane E Ottman
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Benjamin Philosophe
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmet O Gurakar
- Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Quandahl R, Vanneman MW, Wilke TJ, Kassel CA. 2022 Clinical Updates in Liver Transplantation. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00116-7. [PMID: 36964080 DOI: 10.1053/j.jvca.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Affiliation(s)
- Rachel Quandahl
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Trevor J Wilke
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Cale A Kassel
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
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11
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Yao J, Lei YG, Yi HM, Yang Y. Clinical strategies to improve the survival rate of liver recipients with acute-on-chronic liver failure. Hepatobiliary Pancreat Dis Int 2023; 22:41-44. [PMID: 36464623 DOI: 10.1016/j.hbpd.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Jia Yao
- Department of Hepatic Surgery, Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China; Guangdong Key Laboratory of Liver Disease Research, Guangzhou 510630, China
| | - Yun-Guo Lei
- Department of Hepatic Surgery, Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China; Guangdong Key Laboratory of Liver Disease Research, Guangzhou 510630, China
| | - Hui-Min Yi
- Surgical Intensive Care Unit, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Yang Yang
- Department of Hepatic Surgery, Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China; Guangdong Key Laboratory of Liver Disease Research, Guangzhou 510630, China.
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12
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Fabes J, Wells G, Abdi Z, Ravi B, Muehlschlegel P, Fortune-Ely M, Krzanicki D, Rahman S, Spiro M. Fast-Track Extubation After Orthotopic Liver Transplant Associates with Reduced Incidence of Acute Kidney Injury and Renal Replacement Therapy: a Propensity-matched Analysis. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2022.100137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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13
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Pollok JM, Tinguely P, Berenguer M, Niemann CU, Raptis DA, Spiro M, Dominguez B, Muller E, Rando K, Enoch MA, Tamir N, Healy P, Manser T, Briggs T, Chaudhary A, Humar A, Jafarian A, Soin AS, Eghtesad B, Miller C, Cherqui D, Samuel D, Broering D, Pomfret E, Villamil F, Durand F, Berlakovich G, McCaughan G, Auzinger G, Testa G, Klintmalm G, Belghiti J, Findlay J, Lai J, Fung J, Klinck J, Roberts J, Liu L, Cattral M, Ghobrial M, Selzner M, Ramsay M, Rela M, Ascher N, Man NK, Selzner N, Burra P, Friend P, Busuttil R, Hwang S, McCluskey S, Mas V, Vohra V, Vij V, Merritt W, Tokat Y, Kang Y, Chan A, Mazzola A, Hessheimer A, Rammohan A, Hogan B, Vinaixa C, Nasralla D, Victor D, De Martin E, Alconchel F, Roll G, Kabacam G, Sapisochin G, Campos-Varela I, Liu J, Patel MS, Izzy M, Kalisvaart M, Adams M, Goldaracena N, Tinguely P, Hernandez-Alejandro R, Chadha R, Shaker TM, Klair TS, Pan T, Tanaka T, Yoon U, Kirchner V, Hannon V, Cheah YL, Frola C, Morkane C, Milliken D, Lurje G, Potts J, Fernandez T, Badenoch A, Mukhtar A, Zanetto A, Montano-Loza A, Chieh AKW, Shetty A, DeWolf A, Olmos A, Mrzljak A, Blasi A, Berzigotti A, Malik A, Rajakumar A, Davidson B, O'Farrell B, Kotton C, Imber C, Kwon CHD, Wray C, Ahn CS, Morkane C, Krenn C, Quintini C, Maluf D, Mina DS, Sellers D, Balci D, Patel D, Rudow DL, Monbaliu D, Bezinover D, Krzanicki D, Milliken D, Kim DS, Brombosz E, Blumberg E, Weiss E, Wey E, Kaldas F, Saliba F, Pittau G, Wagener G, Song GW, Biancofiore G, Testa G, Crespo G, Rodríguez G, Palli GM, McKenna G, Petrowsky H, Egawa H, Montasser I, Pirenne J, Eason J, Guarrera J, Pomposelli J, Lerut J, Emond J, Boehly J, Towey J, Hillingsø JG, de Jonge J, Potts J, Caicedo J, Heimbach J, Emamaullee JA, Bartoszko J, Ma KW, Kronish K, Forkin KT, Chok KSH, Olthoff K, Reyntjens K, Lee KW, Suh KS, Denehy L, van der Laan LJ, McCormack L, Gorvin L, Ruffolo L, Bhat M, Ramírez MAM, Londoño MC, Gitman M, Levstik M, Selzner M, de Santibañes M, Lindsay M, Parotto M, Armstrong M, Kasahara M, Schofield N, Rizkalla N, Akamatsu N, Scatton O, Keskin O, Imventarza O, Andacoglu O, Muiesan P, Giorgio P, Northup P, Matins P, Abt P, Newsome PN, Dutkowski P, Bhangui P, Bhangui P, Tandon P, Brustia R, Planinsic R, Brown R, Porte R, Barth R, Ciria R, Florman S, Dharancy S, Pai SL, Yagi S, Nadalin S, Chinnakotla S, Forbes SJ, Rahman S, Hong SK, Liying S, Orloff S, Rubman S, Eguchi S, Ikegami T, Reichman T, Settmacher U, Aluvihare V, Xia V, Yoon YI, Soejima Y, Genyk Y, Jalal A, Borakati A, Gustar A, Mohamed A, Ramirez A, Rothnie A, Scott A, Sharma A, Munro A, Mahay A, Liew B, Hidalgo C, Crouch C, Yan CT, Tschuor C, Shaw C, Schizas D, Fritche D, Huda FF, Wells G, Farrer G, Kwok HT, Kostakis I, Mestre-Costa J, Fan KH, Fan KS, Fraser K, Jeilani L, Pang L, Lenti L, Kathirvel M, Zachiotis M, Vailas M, Milan MM, Elnagar M, Alradhawi M, Dimitrokallis N, Machairas N, Morare N, Yeung O, Khanal P, Satish P, Ghani SA, Makhdoom S, Arulrajan S, Bogan S, Pericleous S, Blakemore T, Otti V, Lam W, Jackson W, Abdi Z. Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference. Lancet Gastroenterol Hepatol 2023; 8:81-94. [PMID: 36495912 DOI: 10.1016/s2468-1253(22)00268-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 12/12/2022]
Abstract
There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.
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Affiliation(s)
- Joerg M Pollok
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, NHS Foundation Trust, London, UK
| | - Marina Berenguer
- Liver Unit, CIBERehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe-Universidad de Valencia, Valencia, Spain
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA, USA
| | - Dimitri A Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, NHS Foundation Trust, London, UK; The Royal Free Perioperative Research Group, Royal Free Hospital, NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK.
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14
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Sun LY, Gitman M, Malik A, Te Terry PL, Spiro M, Raptis DA, Ramsay M. Optimal management of perioperative analgesia regarding immediate and short-term outcomes after liver transplantation - A systematic review, meta-analysis and expert panel recommendations. Clin Transplant 2022; 36:e14640. [PMID: 35285074 DOI: 10.1111/ctr.14640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Adequate pain control is essential for patients undergoing liver transplantation (LT). Multiple analgesic strategies have been implemented during the perioperative period. There is no consensus on the optimal perioperative analgesia management. OBJECTIVES To provide recommendations, on the optimal perioperative analgesia management for LT. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review and meta-analysis following PRISMA guidelines and recommendations using GRADE. Studies describing outcomes, morbidity, mortality, pain scores, intensive care unit and hospital length of stay in patients that received different pain management techniques during and after LT were included (CRD42021243282). RESULTS One thousand nine hundred ten articles were screened, but only two randomized controlled trials, one prospective and six retrospective studies were included. The opioid-avoidance protocols included, thoracic epidural analgesia (TEA), Transversus Abdominis Plane (TAP) block, as well as other non-opioid analgesics, resulted in improved short-term outcomes. Mortality was reduced in this group versus control cohorts (OR = 0.51; CI 0.14, 1.83; P = 0.350), Time to extubation, and intensive care unit LOS were shorter; pain scores after surgery were lower in opioid-avoidance group (percentage decrease, 35%, 12%, and 55%, respectively). However, hospital LOS was longer (percentage increase 8%). CONCLUSIONS Opioid-avoidance analgesia management for LT results in improved short-term outcomes. (Quality of Evidence; Moderate to low | Grade of Recommendation; Weak). Medications such as acetaminophen(paracetamol), gabapentin, ketamine, tramadol and local anesthesia may be used instead of, or as adjuncts to opioids for postoperative analgesia. Overall evidence remains weak and more robust studies are required.
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Affiliation(s)
- Li-Ying Sun
- Liver Transplantation Center & Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Marina Gitman
- Department of Anesthesia Cleveland Clinic, Cleveland, Ohio, USA
| | - Ashish Malik
- Department of Anaesthesia and Critical Care, Indraprastha Apollo Hospital, New Delhi, India
| | | | - 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
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Michael Ramsay
- Department of Anesthesia Baylor University Medical Center, Dallas, Texas, USA
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15
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Tinguely P, Badenoch A, Krzanicki D, Kronish K, Lindsay M, Khanal P, Wells G, Spiro M, Raptis DA, McCluskey SA. The role of early extubation on short-term outcomes after liver transplantation - A systematic review, meta-analysis and expert recommendations. Clin Transplant 2022; 36:e14642. [PMID: 35266235 DOI: 10.1111/ctr.14642] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early extubation in liver transplantation (LT) and its potential benefits such as reduction in pulmonary complications and enhanced postoperative recovery have been described. The extent of the effect of early extubation on short-term outcomes after LT across the published literature is to the best of our knowledge unknown. OBJECTIVES The objective of this systematic review and meta-analysis was to determine whether early extubation improves immediate and short-term outcomes after LT and to provide expert recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review and meta-analysis on short-term outcomes after early extubation in LT was performed (CRD42021241402), following PRISMA guidelines and quality of evidence (QOE) and recommendations grading using the GRADE approach, derived from an international experts panel. Endpoints were reintubation rates, pulmonary and other complications/organ dysfunction, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS Of 831 screened articles, 20 observational studies with a total of 3573 patients addressing early extubation protocols were included, of which 12 studies compared results after early versus deferred extubation. Reintubation and pulmonary complication rates were lower in the early versus deferred extubation groups (OR 0.29, CI 0.22-0.39; OR 0.17, CI 0.09-0.33, respectively). ICU and hospital LOS were shorter in eight out of eight and seven out of eight comparative studies, respectively. CONCLUSIONS Early extubation after LT is associated with improved short-term outcomes after LT and should be performed in the majority of patients (QOE; Moderate to low | Grade of Recommendation; Strong). Randomized controlled trials using standardized definitions of early extubation and short-term outcomes are needed to demonstrate causality, validate and allow comparability of the results.
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Affiliation(s)
- Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK
| | - Adam Badenoch
- Flinders University, Adelaide, South Australia, Australia.,Department of Anaesthesia and Pain Management, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Dominik Krzanicki
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Martine Lindsay
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gemma Wells
- Department of Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK
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16
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Hannon VN, Tinguely P, McKenna GJ, Brustia R, Kaldas FM, Scatton O, Spiro M, Raptis DA, Busuttil RW, Klintmalm GB. New ERAS in liver transplantation - Past, present, and next steps. Clin Transplant 2022; 36:e14625. [PMID: 35238415 DOI: 10.1111/ctr.14625] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023]
Abstract
There are parallels between the history of Enhanced Recovery after Surgery (ERAS) and liver transplantation. Both have been established and advanced by innovative individuals, often going against perceived wisdom and convention. Liver transplantation has traditionally been considered too complex for ERAS pathways, despite a small number of trials showing them to be both safe and of benefit. To date, there are very few randomized controlled trials and cohort studies publishing outcomes on liver transplant patients enrolled in comprehensive ERAS pathways. To progress our field, the 2022 International Liver Transplantation Society's Consensus Conference has created expert panels to analyze the evidence in 32 domains of the liver transplantation pathway using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to generate expert recommendations. These recommendations will be voted on by the international community to gain consensus using the Danish model, and create the ERAS4OLT.org Enhanced Recovery after Liver Transplantation Pathway.
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Affiliation(s)
- Vivienne N Hannon
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | | | - Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Fady M Kaldas
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France.,Pierre et Marie Curie University, Paris, France
| | - 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
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Alconchel F, Tinguely P, Frola C, Spiro M, Ciria R, Rodríguez G, Petrowsky H, Raptis DA, Brombosz EW, Ghobrial M. Are short-term complications associated with poor allograft and patient survival after liver transplantation? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14704. [PMID: 36490223 DOI: 10.1111/ctr.14704] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/28/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Maximizing patient and allograft survival after liver transplant (LT) is important from both a patient care and organ utilization perspective. Although individual studies have addressed the effects of short-term post-LT complications on a limited scale, there has not been a systematic review of the literature formally assessing the potential effects of early complications on long-term outcomes. OBJECTIVES To identify whether short-term complications after LT affect allograft and overall survival, to identify short-term complications of particular clinical interest and significance, and to provide recommendations to improve post-LT graft and patient survival. 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. RESULTS The literature review and analysis provided show that short-term complications have a large impact on allograft and patient survival after LT. The complications with the strongest effect on survival are acute kidney injury (AKI), biliary complications, and early allograft dysfunction (EAD). CONCLUSION This panel recommends taking measures to reduce the risk and incidence of short-term complications post-LT. Clinicians should pay particular attention to preventing or ameliorating AKI, biliary complications, and EAD (Quality of evidence; Moderate | Grade of Recommendation; Strong).
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Affiliation(s)
- Felipe Alconchel
- Department of Surgery and Organ Transplantation, Virgen de la Arrixaca University Hospital, Murcia, Spain.,Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, UK
| | - Carlo Frola
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Ruben Ciria
- HPB Surgery and Liver Transplantation, Reina Sofía University Hospital, Córdoba, Spain
| | - Gonzalo Rodríguez
- Department of General & Digestive Surgery, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General Universitario de Alicante, Alicante, Spain
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | | | - Mark Ghobrial
- J.C. Walter Jr. Transplant Center, Department of Surgery, Weill Cornell Medical College, Houston Methodist Institute for Academic Medicine, Houston, USA
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Lv H, Zheng H, Liu J, Cai Q, Ren Y, Yi H, Yang Y, Hu X, Chen G. Expert consensus on liver transplantation perioperative evaluation and rehabilitation for acute-on-chronic liver failure. LIVER RESEARCH 2022. [DOI: 10.1016/j.livres.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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19
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Patel MS, Wang BK, MacConmara M, Hwang C, Shah JA, De Gregorio L, Hanish SI, Desai DM, Zhang S, Zeh HJ, Vagefi PA. Is there value in volume? An assessment of liver transplant practices in the United States since the inception of MELD. Surgery 2022; 172:1257-1262. [PMID: 35871852 DOI: 10.1016/j.surg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Liver transplantation has increased in volume and provides substantial survival benefit. However, there remains a need for value-based assessment of this costly procedure. METHODS Model for end stage liver disease era adult recipients were identified using United Network for Organ Sharing Standard Transplant Analysis file data (n = 75,988) and compared across time periods (period A: February 2002 to January 2007; B: February 2007 to January 2013; C: February 2013 to January 2019). Liver centers were divided into volume tertiles for each period (small, medium, large). Value for the index transplant episode was defined as percentage graft survival ≥1 year divided by mean posttransplant duration of stay. RESULTS All centers increased value over time due to ubiquitous improvement in 1-year graft survival. However, large centers demonstrated the most significant value change (large +17% vs small +7.0%, P < .001) due to a -8.5% reduction in large centers duration of stay from period A to C, while small centers duration of stay remained unchanged (-0.1%). Large centers delivered higher value despite more complex care: older recipients (54.8 ± 10.3 vs 53.0 ± 11.4 years P < .001), fewer model for end stage liver disease exceptions (34.0% vs 38.2%, P < .001), higher rates of candidate portal vein thrombosis (10.1% vs 8.5%, P < .001) and prior abdominal surgery (43.4% vs 37.4%, P < .001), and more marginal donor utilization (donor risk index 1.45 ± 0.38 vs 1.36 ± 0.33, P < .001). Mahalanobis metric matching demonstrated that compared with small centers, large centers progressively shortened recipient duration of stay per transplant in each period (A: -0.36 days, P = .437; B: -2.14 days, P < .001; C: -2.49 days, P < .001). CONCLUSION There is value in liver transplant volume. Adoption of value-based practices from large centers may allow optimization of health care delivery for this costly procedure.
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Affiliation(s)
- Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin K Wang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Christine Hwang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jigesh A Shah
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lucia De Gregorio
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Dev M Desai
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Song Zhang
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Herbert J Zeh
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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20
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Principles of enhanced recovery in gastrointestinal surgery. Langenbecks Arch Surg 2022; 407:2619-2627. [PMID: 35861873 DOI: 10.1007/s00423-022-02602-9] [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: 05/24/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND To reduce the impact of surgery-related stress, enhanced recovery after surgery (ERAS) pathways have been developed since over 15 years with subsequent improved postoperative outcome. This multimodal and evidence-based perioperative approach has spread to all fields of gastrointestinal surgery, from esophagus, stomach, duodenum and pancreas, liver, small intestine and colon, and rectum, as well as for other specialties like vascular and cardia surgeries or neurosurgery, among others. PURPOSE The aim of this state-of-the-art article is to assess current state of evidence on perioperative management specifically in gastrointestinal surgery, with a focus on surgery-related aspects, outcome benefit, and future directions. CONCLUSION The surgical team must promote continuous improvement of the patient's ERAS compliance to ensure optimal perioperative care. Everyday clinical practice should be performed according to latest evidence-based medicine and challenging surgical dogma. Moreover, the surgeon must lead and support a multidisciplinary and collaborative teamwork tailored to patient's need especially with anesthetists and nursing staff.
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21
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Saner FH, Hoyer DP, Hartmann M, Nowak KM, Bezinover D. The Edge of Unknown: Postoperative Critical Care in Liver Transplantation. J Clin Med 2022; 11:jcm11144036. [PMID: 35887797 PMCID: PMC9322367 DOI: 10.3390/jcm11144036] [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] [Received: 06/10/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Perioperative care of patients undergoing liver transplantation (LT) is very complex. Metabolic derangements, hypothermia, coagulopathy and thromboses, severe infections, and graft dysfunction can affect outcomes. In this manuscript, we discuss several perioperative problems that can be encountered in LT recipients. The authors present the most up-to-date information regarding predicting and treating hemodynamic instability, coagulation monitoring and management, postoperative ventilation strategies and early extubation, management of infections, and ESLD-related pulmonary complications. In addition, early post-transplant allograft dysfunction will be discussed.
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Affiliation(s)
- Fuat H. Saner
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
- Correspondence: ; Fax: +49-201-723-1145
| | - Dieter P. Hoyer
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Matthias Hartmann
- Department of Anaesthesia and Critical Care, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Knut M. Nowak
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA;
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22
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St Jules R, Blech D, Smith NK, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2021. Semin Cardiothorac Vasc Anesth 2022; 26:140-153. [PMID: 35608409 DOI: 10.1177/10892532221093955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. In 2021, we identified noteworthy papers from over 1,200 peer-reviewed publications on pancreatic transplantation, over 1,400 on intestinal transplantation, and over 9,000 on kidney transplantation. The liver transplantation section focuses on clinical trials and systematic reviews and meta-analyses published in 2021 and features 20 selected papers. COVID-19 and abdominal organ transplantation are featured in an independent section.
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Affiliation(s)
- Robert St Jules
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Daniel Blech
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA, USA
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23
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Zhou X, Zhou X, Cao J, Hu J, Topatana W, Li S, Juengpanich S, Lu Z, Zhang B, Feng X, Shen J, Chen M. Enhanced Recovery Care vs. Traditional Care in Laparoscopic Hepatectomy: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:850844. [PMID: 35392058 PMCID: PMC8980421 DOI: 10.3389/fsurg.2022.850844] [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] [Received: 01/08/2022] [Accepted: 02/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background Enhanced recovery care could alleviate surgical stress and accelerate the recovery rates of patients. Previous studies showed the benefits of enhanced recovery after surgery program in liver surgery, but the exact role in laparoscopic hepatectomy is still unclear. Aim We aimed to perform a meta-analysis to evaluate the safety and efficacy of enhanced recovery after a surgery program in laparoscopic hepatectomy. Methods The relative studies from a specific search of PUBMED, EMBASE, OVID, and Cochrane database from June 2008 to February 2022 were selected and included in this meta-analysis. The primary outcomes included length of hospital stay, duration to functional recovery, and overall postoperative complication rate. The secondary outcomes included operative time, intraoperative blood loss, cost of hospitalization, readmission rate, Grade I complication rate, and Grade II–V complication rate. Results A total of six studies with 643 patients [enhanced recovery care (n = 274) vs. traditional care (n = 369)] were eligible for analysis. These comprised three randomized controlled trials and three retrospective studies. Enhanced recovery care group was associated with decreased hospital stay [standard mean difference (SMD) = −0.56, 95% confidence interval (CI) = −0.83~−0.28, p < 0.0001], shorter duration to functional recovery (SMD = −1.14, 95% CI = −1.92~−0.37, p = 0.004), and lower cost of hospitalization Mean Difference (MD) = −1,539.62, 95% CI = −1992.85~−1086.39, p < 0.00001). Moreover, a lower overall postoperative complication rate was observed in enhanced recovery care group [Risk ratio (RR) = 0.64, 95% CI = 0.51~0.80, p < 0.0001] as well as lower Grade II–V complication rate (RR = 0.55, 95% CI = 0.38~0.80, p = 0.002), while there was no significant difference in intraoperative blood loss (MD = −65.75, 95% CI = −158.47~26.97, p = 0.16), operative time (MD = −5.44, 95% CI = −43.46~32.58, p = 0.78), intraoperative blood transfusion rate [Odds ratio (OR) = 0.71, 95% CI = 0.41~1.22, p = 0.22], and Grade I complication rate (RR = 0.73, 95% CI = 0.53~1.03, p = 0.07). Conclusion Enhanced recovery care in laparoscopic hepatectomy should be recommended, because it is not only safe and effective, but also can accelerate the postoperative recovery and lighten the financial burden of patients.
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Affiliation(s)
- Xueyin Zhou
- School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xueyi Zhou
- Department of Nursing, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jiasheng Cao
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jiahao Hu
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Win Topatana
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Shijie Li
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Sarun Juengpanich
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziyi Lu
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Bin Zhang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Xu Feng
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jiliang Shen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Mingyu Chen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
- *Correspondence: Mingyu Chen
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