Anesthesia Aspects of Multivisceral Transplantation: A Case Series Study

Background

Multi-visceral transplantation (MvTx) usually refers to the transplantation of more than three intra-abdominal organs. A successful MvTx requires strong multidisciplinary teamwork of transplant surgeons, anesthesiologists, and intensivists.

Case presentation

We present five cases of MvTx with a history of short bowel syndrome admitted to the Abu-Ali Sina Hospital, Shiraz, Iran from May 2019 to January 2020 and describe anesthetic considerations in MvTx. Subjects were identified (4F/1M) with a mean age of 43 years old (range 35-51). The most frequent cause of intestinal failure was portal vein thrombosis, followed by bowel gangrene and short bowel syndrome. The mean ±SD duration of the operation was 360±60 min. The bleeding volume was approximately 2600±1474 cc, and 4±1 bags of packed red blood cells were transfused. Sepsis was the main cause of death in our series.

Conclusion

Careful preoperative planning, vigilant intraoperative anesthetic management, and prevention of postoperative infection are imperative to achieve the best outcomes.

Liver Transplantation in Hepatocellular Carcinoma: Experiences from the Shiraz Transplant Center

BACKGROUND

Studies evaluating liver transplantation (LT) in hepatocellular carcinoma (HCC) in the Middle East have been scarce, mainly due to intricacy of this type of surgery.

OBJECTIVE

In here we report our experiences with LT among patients with HCC cirrhosis.Methods: All patients who underwent LT with primary diagnosis of HCC older than 18 years old, during 2004 to 2019, were initially included in our study.

RESULTS

Overall, 124 patients entered our study, among which majority were males (86.3%). Mean (SD) age of patients was 53.1±10.6 years old. Most common underlying liver diseases were HBV (55.6%) and HCV infections (12.1%). Mean MELD score of patients was 18±5.5. Child-Pugh score of most patients was class B (50%). Mean (SD) duration of hospitalization was 12.1±3.5 days. Patients were followed for a median of 32 (9, 62) months. The most common causes of death were recurrence of HCC (47.7%) and sepsis (34.1%). Median (IQR) duration to recurrence and death were 18 (4, 34) months and 17.5 (5.7, 44.5) months, respectively. One-year survival (89%, 86.4%, and 63.2%, respectively) (p=0.011) and one-year DFS (89%, 86.4%, and 57.9%, respectively) (p=0.001) was significant different between those who were selected based on the Milan, UCSF and extended criteria.

CONCLUSION

Our study provides valuable experiences on LT and HCC from one of the largest LT centers in the world. Accordingly, we found that the Milan criterion provides the best survival compared to the UCSF and our extended criteria for patient selection.

Donors' Quality of Life after Living Donor Liver Transplantation: Shiraz Organ Transplant Center Experience

BACKGROUND

Probable effects of living donor liver transplantation on the wellbeing of the donor and psychological difficulties are necessary to be understood.

OBJECTIVE

To assess the quality of life of living donors after liver donation.

METHODS

140 living donors who underwent hepatectomy between 2012 and July 2015 were enrolled in this study. Donors were asked to complete the Short Form 36-question Health Survey (SF-36) through face to face or by telephone interview.

RESULTS

The mean±SD age of donors at transplantation was 32.1±7.3 years; 83 (59.3%) of donors were female. 134 (95.7%) were married. The mean±SD BMI was 23.8±3.5 (kg/m²). "Mother-to-child" was the most frequent relationship (n=79, 56.4%). 22 (15.7%) complications were reported by participants. The mean±SD score of Physical Component Summary and Mental Component Summary were 48.8±14.6 and 50.1±6.9, respectively.

CONCLUSION

Most living donors sustain a near average quality of life post-donation. It seems that living donation does not negatively affect the quality of life.

Effects of Different Cold Preservation Solutions on the Functions of Cultured Isolated Human Hepatocytes

BACKGROUND

Hepatocyte transplantation using isolated human hepatocytes is an alternative source that can be used for the treatment of metabolic diseases and acute liver failure as a time bridge to liver transplantation. These cells can also be used for bioartificial liver systems and in vitro study of drug toxicity.

OBJECTIVE

To determine which cold preservation solution is better maintain the liver function.

METHODS

We prepared 4 cold preservation solutions made of different combination of antioxidants, chelating, membrane protective, and anti-apoptotic agents as well as inhibitor of cyclophilin D. For hepatocyte isolation, we used livers obtained from unused deceased donor livers and the liver of patients with Crigler-Najjar syndrome who were candidates of partial liver transplantation. After culture and cold preservation, the level of albumin, and urea production were measured as indices of liver functionality.

RESULTS

We found that albumin production significantly decreased after cold preservation in solution 1. There was no significant difference in urea production after cold preservation in solution 1 compared with control 24 h. No significant differences in albumin production were found after cold storage in solution 2 and solution 4 compared with control 24 h. Urea production significantly decreased after cold storage in solutions 2 and 4 compared with control 24 h. As a whole albumin and urea production were significantly decreased after cold preservation. Although albumin and urea production were decreased after cold preservation, but the results of albumin production of two solutions were not significantly different from that of the control group (p=0.109 and 0.951).

CONCLUSION

Cold preservation of cultured human hepatocytes in solution 2 and solution 4 could maintain the function of albumin production better than other cold preservation solutions in our experiments; solution 1 was more effective on urea production of cultured human hepatocytes at 4 °C for 24 h. To determine if these hepatocytes are suitable candidates for transplantation, further studies should be performed.

The Effects of Cold Preservation Solutions Supplemented with UDCA and α-Lipoic Acid on the Viability and Function of Isolated Human Hepatocytes

BACKGROUND

Liver transplantation is the only treatment for end-stage and genetic liver diseases. The main burden of this treatment is the shortage of both living and cadaveric liver donors. An alternative treatment is using liver cell transplantation, which can be obtained from unused livers for transplantation. These hepatocytes should be kept ready in viable and functional situation in a frozen state to be instantly used when they would be needed. In our previous experience, we had isolated hepatocytes from unused livers.

OBJECTIVE

To find a preserving solution for increasing viability and function of the isolated hepatocytes that are stored to be transplanted.

METHODS

9 cadaveric donor livers, which were not used for transplantation due to various causes such as severe steatosis, were selected to isolate hepatocytes. Various cold storage solutions were tried to find the best temperature for more viability and functionality for preservation of hepatocytes. University of Wisconsin (UW) solution and Williams E media were used as control media. 2 anti-apoptotic and anti-oxidative solutions, i.e., α-lipoic acid and ursodeoxycholic acid (UDCA), were used as cold preservatives solutions. The numbers of viable hepatocytes were estimated by trypan blue method; the functionality was assessed by the cells ability to produce urea.

RESULTS

The highest number of viable and functional hepatocytes was obtained from freshly isolated cells. However, after preservation, the number of these viable hepatocytes and their functionality were not significantly different in cold storage solutions comparing to the control media used. Functionality of the isolated hepatocytes stored in UW with and without UCDA solution was similar to freshly isolated hepatocytes.

CONCLUSION

Preservatives with anti-apoptotic and antioxidant activity could not increase the number of viable hepatocytes. Functionality of cold storing hepatocytes could be preserved similar to freshly isolated hepatocytes by UW solution with and without UCDA.

Multivisceral and small bowel transplantation at shiraz organ transplant center

BACKGROUND

Multivisceral transplantations were initially done in animal models to understand the immunological effects. Later on, in human beings, it has been considered a salvage procedure for unresectable complex abdominal malignancies. With advancement in surgical techniques, availability of better immunosuppressive drugs, and development of better post-operative management protocols, outcomes have been improved after these complex surgical procedures.

OBJECTIVE

To analyze and report results of multivisceral, modified multivisceral, and small bowel transplantations done at Shiraz Organ Transplant Center, Shiraz, southern Iran.

METHODS

Medical records of all patients who underwent multivisceral, modified multivisceral, and small bowel transplants were retrospectively analyzed.

RESULTS

There were 18 patients. The most common indications for the procedure in our series were unresectable carcinoma of pancreas followed by short bowel syndrome. 10 patients were alive after a median follow-up of 8.7 (range: 3-32) months. The remaining 8 patients died post-operatively, mostly from septicemia.

CONCLUSION

Multivisceral and small bowel transplantations are promising treatments for complex abdominal pathologies.

Liver transplantation for homozygous familial hypercholesterolemia: two case reports

Homozygous familial hypercholesterolemia (HFHC) is a rare inherited condition with an incidence of one in one million. It is associated with severe premature atherosclerosis and early death from cardiovascular complications. Mutation in the gene that encodes the synthesis of the cellular receptor for low-density lipoprotein (LDL) is responsible for this metabolic disorder. Currently, the only effective treatment for this disease is liver transplantation, which alone or in association with medications, normalizes plasma cholesterol level. The authors report the results of liver transplantation for two cases of HFHC. The first case, a 15-year-old boy received a whole liver from a deceased donor, and the second, an 11-year-old boy, received a left liver lobe transplant from his mother's sister. Their preoperative fasting lipid concentrations were grossly raised. The older boy had severe atherosclerotic heart disease and had undergone coronary artery bypass grafting 5 months before transplantation. Both had preoperative plasma cholesterol levels higher than 750 mg/dL with normal thyroid and liver function tests. After the operation, the patients received methylprednisolone as pulse therapy followed by oral prednisolone, mycophenolate mofetil, and tacrolimus for immunosuppression. Their hospital stays were 24 and 13 days, respectively. The first case needed reexploration because of bleeding on the second day after the operation. The lipid concentrations rapidly returned to the normal range in the first week after the operation, remaining in this range over the first 6 months of follow-up. Liver transplantation offers an highly effective treatment for HFHC. It is better to operate on patients before severe atherosclerotic changes in the coronary arteries. All patients must undergo a complete cardiac evaluation before surgery.

Liver transplantation in the presence of old portal vein thrombosis

BACKGROUND

Portal vein thrombosis (PVT) has been mentioned as a potential obstacle to liver transplantation (LTx).

OBJECTIVE

To review the impact of PVT on orthotopic liver transplant (OLT) outcome.

METHOD

Between January 2006 and April 2009, 440 OLT were performed in Shiraz Transplant Unit of whom, 35 (7.9%) cases had old PVT with recanalization. Data were retrospectively collected regarding the demographics, indication for OLT, Child-Turgot-Pugh classification, pre-transplant diagnosis of PVT, perioperative course and managements, relapse of PVT, early post-operative mortality and morbidity. All patients received liver from deceased donors, underwent thrombendvenectomy with end-to-end anastomosis without interposition graft and evaluated daily for 5 days and thereafter, biweekly by duplex sonography during the follow-up period for 2 months. They were treated by therapeutic doses of heparin followed by warfarin to maintain an INR of 2-2.5.

RESULTS

The causes of end-stage liver disease were hepatitis B in 11, cryptogenic cirrhosis in 11, primary sclerosing cholangitis in 5 and other causes in 8 recipients. Extension of thrombosis was through confluence of superior mesenteric and splenic vein in 32 and to superior mesenteric vein in 3 patients. The mean±SD operation time was 7.2±1.5 hrs. The mean±SD transfusion requirement was 5.4±2.8 units of packed cells. The mean±SD duration of hospital stay in these patients was 17.7±10.9 days. Eight patients died; 1 developed early in-hospital PVT, 1 had hepatic vein thrombosis, and 1 died of in-hospital ischemic cerebrovascular accident, despite a full anticoagulant therapy. The mean±SD follow-up period for those 28 patients discharged from hospital was 16.6±7.9 months; none of them developed relapse of PVT. The overall mortality and morbidity was 28% and 32%, respectively. There was no relapse of PVT in the other patients.

CONCLUSION

The presence of PVT at the time of OLT is not a contraindication for the operation but those with PVT have a more difficult surgery, develop more postoperative complications, and experience a higher in-hospital mortality.