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Akbulut A, Alim A, Karatas C, Oğuz BH, Kanmaz T, Gürkan Y. Anesthesia Management in Laparoscopic Donor Hepatectomy: The First Report from Turkey. Transplant Proc 2023:S0041-1345(23)00163-X. [PMID: 37121860 DOI: 10.1016/j.transproceed.2023.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/05/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND We aimed to report a single-center experience in laparoscopic donor left-side and right-side hepatectomy cases regarding preoperative evaluation, perioperative and anesthetic management protocols, and postoperative follow-up. METHODS Laparoscopic donor left-side and right-side hepatectomy cases were included in the study because of their excessive transection area and bleeding potential. Medical records of living donors were reviewed in terms of age, sex, body mass index (BMI), presence of consanguinity with the recipient, perioperative and early postoperative biochemical parameters, hemodynamic changes during surgery, duration of surgery, the ratio of liver volume to total liver volume, perioperative complications, and length of hospital stay. RESULTS Eighty-one laparoscopic living-donor hepatectomy procedures were performed in our unit between 2018 and 2022. Six laparoscopic donor right-side cases and two left-side cases were retrospectively reviewed. Donors' mean age and BMI were 29.6 ± 8.6 years and 23.1 ± 4.3, respectively. The average weights of the right and left lobe liver grafts were 727 g and 279 g, respectively, constituting 65.8% and 22.7% of the total liver volume, respectively. The mean operation time was 593 ± 94 minutes, and the mean volume of blood loss was 437 ± 294 mL. A major complication, namely portal vein stenosis, developed in 1 donor (1/8), and portal vein patency was achieved postoperatively. CONCLUSIONS Anesthesia management and teamwork between surgeons and anesthesiologists are the most important building blocks for donor safety, which is of the utmost priority. Effective communication and cooperation in the operating room may prevent potential donor complications and improve postoperative recovery time.
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Affiliation(s)
- Akın Akbulut
- Anesthesiology and Reanimation Department, Koç University Hospital, Topkapi Zeytinburnu/Istanbul, Turkey
| | - Altan Alim
- Organ Transplantation Department, Koç University Hospital, Topkapi Zeytinburnu/Istanbul, Turkey
| | - Cihan Karatas
- Organ Transplantation Department, Koç University Hospital, Topkapi Zeytinburnu/Istanbul, Turkey.
| | - Bahadır Hakan Oğuz
- Anesthesiology and Reanimation Department, Koç University Hospital, Topkapi Zeytinburnu/Istanbul, Turkey
| | - Turan Kanmaz
- Organ Transplantation Department, Koç University Hospital, Topkapi Zeytinburnu/Istanbul, Turkey
| | - Yavuz Gürkan
- Anesthesiology and Reanimation Department, Koç University Hospital, Topkapi Zeytinburnu/Istanbul, Turkey
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Almario Alvarez JA, Okoye O, Tulla K, Spaggiari M, Di Cocco P, Benedetti E, Tzvetanov I. Tracheostomy Following Liver Transplantation. Transplant Proc 2020; 52:932-937. [PMID: 32139274 DOI: 10.1016/j.transproceed.2020.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 11/08/2019] [Accepted: 01/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With increased demand for liver transplantation, sicker patients are being transplanted frequently. These patients are at a higher risk of significant postoperative morbidity, including respiratory failure. This study evaluated the phenotype that characterizes liver transplant candidates who may benefit from early tracheostomy. METHODS A single center retrospective review of all liver transplant candidates between January 2012 and December 2017. Patients who eventually required tracheostomies were identified and compared to their counterparts. RESULTS Of the 130 liver transplants performed during the study period, 11 patients required tracheostomy. Although patients in the tracheostomized population (TP) did not have significantly worse preoperative functional status (<4 metabolic equivalents; 64% vs 42%, P = .21), they had a higher native model for end-stage liver disease (MELD) score (37 vs 30, P < .05) at the time of transplantation. Patients who eventually succumbed to respiratory failure had lower arterial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratios at the start of surgery and remained unchanged for the duration of surgery compared with the nontracheostomy group (P < .05). TP patients required more net fluid intraoperatively (7.3 vs 5.0 L, P < .05), increased length of time to attempted extubation (3.5 vs 1 day, P < .05), longer ventilation days (15 vs 1 day, P < .05), increased length of stay (37 vs 9 days, P < .05), and higher 1-year mortality (36% vs 8%, P < .05). CONCLUSIONS Based on our findings, patients with a high MELD score (>30), net postoperative fluid balance >6 L, and PaO2/FiO2 ratio ≤300 who fail to wean off mechanical ventilation after 72 hours may benefit from tracheostomy during the postoperative period.
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Affiliation(s)
| | - Obi Okoye
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Kiara Tulla
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Mario Spaggiari
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Pierpaolo Di Cocco
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Enrico Benedetti
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Ivo Tzvetanov
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
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Sakka SG. Assessment of liver perfusion and function by indocyanine green in the perioperative setting and in critically ill patients. J Clin Monit Comput 2017; 32:787-796. [PMID: 29039062 DOI: 10.1007/s10877-017-0073-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/06/2017] [Indexed: 12/13/2022]
Abstract
Indocyanine green (ICG) is a water-soluble dye that is bound to plasma proteins when administered intravenously and nearly completely eliminated from the blood by the liver. ICG elimination depends on hepatic blood flow, hepatocellular function and biliary excretion. ICG elimination is considered as a useful dynamic test describing liver function and perfusion in the perioperative setting, i.e., in liver surgery and transplantation, as well as in critically ill patients. ICG plasma disappearance rate (ICG-PDR) which can be measured today by transcutaneous systems at the bedside is a valuable method for dynamic assessment of liver function and perfusion, and is regarded as a valuable prognostic tool in predicting survival of critically ill patients, presenting with sepsis, ARDS or acute liver failure.
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Affiliation(s)
- Samir G Sakka
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Center Cologne-Merheim, University Witten/ Herdecke, Ostmerheimerstrasse 200, 51109, Cologne, Germany.
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Moss CR, Caldwell JC, Afilaka B, Iskandarani K, Chinchilli VM, McQuillan P, Cooper AB, Gusani N, Bezinover D. Hepatic resection is associated with reduced postoperative opioid requirement. J Anaesthesiol Clin Pharmacol 2016; 32:307-13. [PMID: 27625476 PMCID: PMC5009834 DOI: 10.4103/0970-9185.188827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Aims: Postoperative pain can significantly affect surgical outcomes. As opioid metabolism is liver-dependent, any reduction in hepatic volume can lead to increased opioid concentrations in the blood. The hypothesis of this retrospective study was that patients undergoing open hepatic resection would require less opioid for pain management than those undergoing open pancreaticoduodenectomy. Material and Methods: Data from 79 adult patients who underwent open liver resection and eighty patients who underwent open pancreaticoduodenectomy at our medical center between January 01, 2010 and June 30, 2013 were analyzed. All patients received both general and neuraxial anesthesia. Postoperatively, patients were managed with a combination of epidural and patient-controlled analgesia. Pain scores and amount of opioids administered (morphine equivalents) were compared. A multivariate lineal regression was performed to determine predictors of opioid requirement. Results: No significant differences in pain scores were found at any time point between groups. Significantly more opioid was administered to patients having pancreaticoduodenectomy than those having a hepatic resection at time points: Intraoperative (P = 0.006), first 48 h postoperatively (P = 0.001), and the entire length of stay (LOS) (P = 0.002). Statistical significance was confirmed after controlling for age, sex, body mass index, and American Society of Anesthesiologists physical status classification (adjusted P = 0.006). Total hospital LOS was significantly longer after pancreaticoduodenectomy (P = 0.03). A multivariate lineal regression demonstrated a lower opioid consumption in the hepatic resection group (P = 0.03), but there was no difference in opioid use based on the type of hepatic resection. Conclusion: Patients undergoing open hepatic resection had a significantly lower opioid requirement in comparison with patients undergoing open pancreaticoduodenectomy. A multicenter prospective evaluation should be performed to confirm these findings.
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Affiliation(s)
- Caitlyn Rose Moss
- Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Julia Christine Caldwell
- Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Babatunde Afilaka
- Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Khaled Iskandarani
- Department of Public Health Sciences, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Vernon Michael Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Patrick McQuillan
- Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Amanda Beth Cooper
- Department of Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Niraj Gusani
- Department of Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Dmitri Bezinover
- Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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Mahmoud G, Sayed E, Eskander A, ElSheikh M, Lotfy M, Yassen K. Effect of intraoperative magnesium intravenous infusion on the hemodynamic changes associated with right lobe living donor hepatotomy under transesophageal Doppler monitoring-randomized controlled trial. Saudi J Anaesth 2016; 10:132-7. [PMID: 27051361 PMCID: PMC4799602 DOI: 10.4103/1658-354x.168799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Liver donors are subjected to specific postresection hemodynamic changes. The aim was to monitor these changes and to evaluate the effect of magnesium sulfate infusion (MgSO4) on these changes together with total anesthetic agents consumption. PATIENTS AND METHODS A total of 50 donors scheduled for right hepatotomy were divided into two equal groups. Controls (C) received saline and magnesium group (Mg) received MgSO4 10% (30 mg/kg over 20 min) administered immediately after induction of anesthesia, followed by infusion (10 mg/kg/h) till the end of surgery. Hemodynamics, transesophageal Doppler (TED) data and anesthetic depth guided by Entropy were recorded. RESULTS Postresection both groups demonstrated an increase in heart rate (HR) and cardiac output (COP) in association with lowering of systemic vascular resistance (SVR). The increase in HR with Mg was lower when compared with C, P = 0.00. Increase in COP was lower with Mg compared to (C) (6.1 ± 1.3 vs. 7.5 ± 1.6 L/min, P = 0.00) and with less reduction in SVR compared to C (1145 ± 251 vs. 849.2 ± 215 dynes.s/cm(5), P < 0.01), respectively. Sevoflurane consumption was lower with Mg compared to C (157.1 ± 35.1 vs. 187.6 ± 25.6 ml, respectively, P = 0.001). Reduced fentanyl and rocuronium consumption in Mg group are compared to C (P = 0.00). Extubation time, postoperative patient-controlled fentanyl were lower in Mg than C (P = 0.001). CONCLUSION TED was able to detect significant hemodynamic changes associated with major hepatotomy. Prophylactic magnesium helped to reduce these changes with lower anesthetic and analgesics consumption and an improvement in postoperative pain relief.
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Affiliation(s)
- G Mahmoud
- Department of Anesthesia, National Liver Institute, Menoufiya University, Sheben ELkom City, Menoufiya, Egypt
| | - E Sayed
- Department of Anesthesia, National Liver Institute, Menoufiya University, Sheben ELkom City, Menoufiya, Egypt
| | - A Eskander
- Department of Anesthesia, Faculty of Medicine, Menoufiya University, Sheben ELkom City, Menoufiya, Egypt
| | - M ElSheikh
- Department of Anesthesia, National Liver Institute, Menoufiya University, Sheben ELkom City, Menoufiya, Egypt
| | - M Lotfy
- Department of Anesthesia, Faculty of Medicine, Menoufiya University, Sheben ELkom City, Menoufiya, Egypt
| | - K Yassen
- Department of Anesthesia, National Liver Institute, Menoufiya University, Sheben ELkom City, Menoufiya, Egypt
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Bıcakcıoglu M, Aydogan MS, Sayan H, Toprak HI, Isik B, Yılmaz S, Yologlu S. Effects of different positive end-expiratory pressure values on liver function and indocyanine green clearance test in liver transplantation donors: a prospective, randomized, double-blind study. Transplant Proc 2015; 47:1190-3. [PMID: 26036551 DOI: 10.1016/j.transproceed.2015.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/26/2014] [Accepted: 01/13/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim of this study was demonstrate the influence of different positive end-expiratory pressure (PEEP) values on blood flow of the liver by indocyanine green (ICG) clearance test in donor patients. METHODS ICG clearance tests were conducted concurrently using a noninvasive monitor that tracks the plasma disappearance rate of ICG (PDR-ICG%/min) and 15-minute retention rate after administration of ICG (ICG-R15%). This study was performed in 40 patients who underwent right hepatectomy. RESULTS The positive end-expiratory pressure (PEEP) was 0 cm H20 in the first (control) group (group K) and 10 mm Hg in the second study group (group P). ICG clearance test values before general anesthesia (T0), after induction of general anesthesia (T1), after transection (T2), 24 hours postoperative (T3), and 72 hours postoperative (T4) were recorded. Simultaneously, hemoglobin (Hgb), hematocrit (Hct), platelet count, plasma levels of prothrombin (PT), International Normalized Ratio (INR), total bilirubin, direct bilirubin, albumin, aspartate aminotransferase, and alanine aminotransferase values were analyzed. In terms of the plasma disappearance rate and retention rate of ICG 15 minutes after administration, significant difference was not observed between groups. PT and INR values were different within comparisons groups (P < .05). There were significant differences in Hgb and Hct values compared with the baseline values (T0) within group (T1, T2, T3, T4) measurements and between group comparisons at T0 and T4 (P < .05). Systemic arterial pressure, mean arterial pressure, and central venous pressure were significantly different between the groups (P < .05). CONCLUSIONS Given the small magnitude and limited clinical significance of these changes, we conclude that PEEP values between 0 and 10 cm H2O have no effect on global liver function and liver-related liabilities tests in patients undergoing elective liver donor surgery.
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Affiliation(s)
- M Bıcakcıoglu
- Department of Anesthesiology and Reanimation, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - M S Aydogan
- Department of Anesthesiology and Reanimation, Inonu University, Faculty of Medicine, Malatya, Turkey.
| | - H Sayan
- Department of Anesthesiology and Reanimation, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - H I Toprak
- Department of Anesthesiology and Reanimation, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - B Isik
- Department of General Surgery, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - S Yılmaz
- Department of General Surgery, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - S Yologlu
- Department of Biostatics, Inonu University, Faculty of Medicine, Malatya, Turkey
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Jawan B, Wang CH, Chen CL, Huang CJ, Cheng KW, Wu SC, Shih TH, Yang SC. Review of anesthesia in liver transplantation. ACTA ACUST UNITED AC 2014; 52:185-96. [PMID: 25477262 DOI: 10.1016/j.aat.2014.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/26/2014] [Indexed: 01/10/2023]
Abstract
Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.
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Affiliation(s)
- Bruno Jawan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chih-Hsien Wang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Jung Huang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kwok-Wai Cheng
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsung-Hsiao Shih
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-Chun Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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El Sharkawy OA, Refaat EK, Ibraheem AEM, Mahdy WR, Fayed NA, Mourad WS, Abd Elhafez HS, Yassen KA. Transoesophageal Doppler compared to central venous pressure for perioperative hemodynamic monitoring and fluid guidance in liver resection. Saudi J Anaesth 2013; 7:378-86. [PMID: 24348287 PMCID: PMC3858686 DOI: 10.4103/1658-354x.121044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Major hepatic resections may result in hemodynamic changes. Aim is to study transesophageal Doppler (TED) monitoring and fluid management in comparison to central venous pressure (CVP) monitoring. A follow-up comparative hospital based study. METHODS 59 consecutive cirrhotic patients (CHILD A) undergoing major hepatotomy. CVP monitoring only (CVP group), (n=30) and TED (Doppler group), (n=29) with CVP transduced but not available on the monitor. Exclusion criteria include contra-indication for Doppler probe insertion or bleeding tendency. An attempt to reduce CVP during the resection in both groups with colloid restriction, but crystalloids infusion of 6 ml/kg/h was allowed to replace insensible loss. Post-resection colloids infusion were CVP guided in CVP group (5-10 mmHg) and corrected flow time (FTc) aortic guided in Doppler group (>0.4 s) blood products given according to the laboratory data. RESULTS Using the FTc to guide Hydroxyethyl starch 130/0.4 significantly decreased intake in TED versus CVP (1.03 [0.49] versus 1.74 [0.41] Liter; P<0.05). Nausea, vomiting, and chest infection were less in TED with a shorter hospital stay (P<0.05). No correlation between FTc and CVP (r=0.24, P > 0.05). Cardiac index and stroke volume of TED increased post-resection compared to baseline, 3.0 (0.9) versus 3.6 (0.9) L/min/m(2), P<0.05; 67.1 (14.5) versus 76 (13.2) ml, P<0.05, respectively, associated with a decrease in systemic vascular resistance (SVR) 1142.7 (511) versus 835.4 (190.9) dynes.s/cm(5), P<0.05. No significant difference in arterial pressure and CVP between groups at any stage. CVP during resection in TED 6.4 (3.06) mmHg versus 6.1 (1.4) in CVP group, P=0.6. TED placement consumed less time than CVP (7.3 [1.5] min versus 13.2 [2.9], P<0.05). CONCLUSION TED in comparison to the CVP monitoring was able to reduced colloids administration post-resection, lower morbidity and shorten hospital stay. TED consumed less time to insert and was also able to present significant hemodynamic changes. Advanced surgical techniques of resection play a key role in reducing blood loss despite CVP more than 5 cm H2O. TED fluid management protocols during resection need to be developed.
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Affiliation(s)
- Osama A El Sharkawy
- Department of Anesthesia, Faculty of Medicine, Liver Institute, Menoufiya University, Egypt
| | - Emad K Refaat
- Department of Community Medicine and Statistics, Liver Institute, Menoufiya University, Egypt
| | | | - Wafiya R Mahdy
- Department of Anesthesia, Faculty of Medicine, Liver Institute, Menoufiya University, Egypt
| | - Nirmeen A Fayed
- Department of Community Medicine and Statistics, Liver Institute, Menoufiya University, Egypt
| | - Wesam S Mourad
- Department of Community Medicine and Statistics, Liver Institute, Menoufiya University, Egypt
| | - Hanaa S Abd Elhafez
- Department of Community Medicine and Statistics, Liver Institute, Menoufiya University, Egypt
| | - Khaled A Yassen
- Department of Community Medicine and Statistics, Liver Institute, Menoufiya University, Egypt
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Abstract
Patients undergoing abdominal organ transplantation have extensive comorbidities that can affect many organ systems including the cardiovascular system. Intraoperative anesthesia care can be very challenging and requires thorough understanding of the disease specific physiology as well as knowledge of the comorbidities and the surgical procedure. There is no approach to intraoperative anesthesia care that will work equally well for every center but standardization of protocols for each transplant center will improve patient care and safety and ultimately contributes to superior outcomes. In this article we provide background and suggestions that will help with the development of standardized protocols for intraoperative management.
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Affiliation(s)
- Michael D Spiro
- Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, 513 Parnassus Avenue, Room S-436, Box 0427, San Francisco, CA 94143, USA
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Beebe D, Singh H, Jochman J, Luikart P, Gruessner R, Gruessner A, Belani K. Anesthetic complications including two cases of postoperative respiratory depression in living liver donor surgery. J Anaesthesiol Clin Pharmacol 2011; 27:362-6. [PMID: 21897509 PMCID: PMC3161463 DOI: 10.4103/0970-9185.83683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Living liver donation is becoming a more common means to treat patients with liver failure because of a shortage of cadaveric organs and tissues. There is a potential for morbidity and mortality, however, in patients who donate a portion of their liver. The purpose of this study is to identify anesthetic complications and morbidity resulting from living liver donor surgery. Patients and Methods: The anesthetic records of all patients who donated a segment of their liver between January 1997 and January 2006 at University of Minnesota Medical Center-Fairview were retrospectively reviewed. The surgical and anesthesia time, blood loss, hospitalization length, complications, morbidity, and mortality were recorded. Data were reported as absolute values, mean ± SD, or percentage. Significance (P < 0.05) was determined using Student's paired t tests. Results: Seventy-four patients (34 male, 40 female, mean age = 35.5 ± 9.8 years) donated a portion of their liver and were reviewed in the study. Fifty-seven patients (77%) donated the right hepatic lobe, while 17 (23%) donated a left hepatic segment. The average surgical time for all patients was 7.8 ± 1.5 hours, the anesthesia time was 9.0 ± 1.3 hours, and the blood loss was 423 ± 253 ml. Forty-six patients (62.2%) received autologous blood either from a cell saver or at the end of surgery following acute, normovolemic hemodilution, but none required an allogenic transfusion. Two patients were admitted to the intensive care unit due to respiratory depression. Both patients donated their right hepatic lobe. One required reintubation in the recovery room and remained intubated overnight. The other was extubated but required observation in the intensive care unit for a low respiratory rate. Twelve patients (16.2%) had complaints of nausea, and two reported nausea with vomiting during their hospital stay. There were four patients who developed complications related to positioning during the surgery: Two patients complained of numbness and tingling in the hands which resolved within two days, one patient reported a blister on the hand, and one patient complained of right elbow pain that resolved quickly. Postoperative hospitalization averaged 7.4 ± 1.5 days. There was no patient mortality. Discussion: Living liver donation can be performed with low morbidity. However, postoperative respiratory depression is a concern and is perhaps due to altered metabolism of administered narcotics and anesthetic agents.
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Affiliation(s)
- David Beebe
- Department of Anesthesiology, University of Minnesota Medical School, Minnesota, USA
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Anesthesia and outcome after partial hepatectomy for adult-to-adult donor transplantation. Curr Opin Organ Transplant 2010; 15:377-82. [PMID: 20308895 DOI: 10.1097/mot.0b013e3283387f75] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The worldwide adoption of live liver donors as a source of donor organs for transplantation has been curtailed by the very real risk of complications in otherwise healthy people. Our objective in this review is to outline the perioperative management of the live liver donor for adult-to-adult transplantation. RECENT FINDINGS The incidence and severity of complications following live liver donation is extremely variable, and reporting needs to be standardized if we are to improve the perioperative management and outcomes. Agreed definitions would clarify the incidence and severity of postoperative complications, allow identification of areas in which management can be improved and suggest areas for future investigation. Such an effort will require the cooperation of centers around the world. SUMMARY Live liver donation is a valuable option for organ donation that can be conducted safely with a multidisciplinary perioperative approach. Future considerations should focus on the recovery period and how the intraoperative management can be optimized to minimize the impact of surgery on donors' quality of life.
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12
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Ho CM, Lin RK, Tsai SF, Hu RH, Liang PC, Sheu TWH, Lee PH. Simulation of Portal Hemodynamic Changes in a Donor After Right Hepatectomy. J Biomech Eng 2010; 132:041002. [DOI: 10.1115/1.4000957] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Remnant livers will be regenerated in live donors after a large volume resection for transplantation. How the structures and hemodynamics of portal vein will evolve with liver regeneration remains unknown. This prompts the present hemodynamic simulation for a 25 year-old man who received a right donor lobectomy. According to the magnetic resonance imaging/computed tomography images taken prior to the operation and one month after the operation, three sequential models of portal veins (pre-op, immediately after the operation, and one-month post-op) were constructed by AMIRA® and HYPERMESH®, while the immediately after the operation model was generated by removing the right branch in the pre-op model. Hemodynamic equations were solved subject to the sonographically measured inlet velocity. The simulated branch velocities were compared with the measured ones. The predicted overall pressure in the portal vein after resection was found to increase to a magnitude that has not reached to an extent possibly leading to portal hypertension. As expected, blood pressure has a large change only in the vicinity of the resection region. The branches grew considerably different from the original one as the liver is regenerated. Results provide useful evidence to justify the current computer simulation.
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Affiliation(s)
- Cheng-Maw Ho
- Department of Surgery, National Taiwan University Hospital, Taipei, 100 Taiwan, R.O.C
| | - Reui-Kuo Lin
- Department of Engineering Science and Ocean Engineering, National Taiwan University, Taipei, 104 Taiwan, R.O.C
| | - Shun-Feng Tsai
- Department of Marine Engineering, National Taiwan Ocean University, Keelung, 202 Taiwan, R.O.C
| | - Rey-Hen Hu
- Department of Surgery, National Taiwan University Hospital, Taipei, 100 Taiwan, R.O.C
| | - Po-Chin Liang
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, 100 Taiwan, R.O.C
| | - Tony Wen-Hann Sheu
- Department of Engineering Science and Ocean Engineering, National Taiwan University, Taipei, 104 Taiwan, R.O.C
| | - Po-Huang Lee
- Department of Surgery, National Taiwan University Hospital, Taipei, 100 Taiwan, R.O.C
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13
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Akita H, Sasaki Y, Yamada T, Gotoh K, Ohigashi H, Eguchi H, Yano M, Ishikawa O, Imaoka S. Real-time intraoperative assessment of residual liver functional reserve using pulse dye densitometry. World J Surg 2009; 32:2668-74. [PMID: 18841411 DOI: 10.1007/s00268-008-9752-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND For a safe major hepatectomy, preoperative methods that can reliably estimate postoperative liver function are necessary. The aim of this study was to assess the utility of ICG-R15 measured by pulse dye densitometry to predict residual liver function prior to hepatectomy. PATIENTS AND METHOD In 29 patients who underwent various types of hepatectomies, indocyanine green (ICG)-R15 was measured by pulse dye densitometry at the time of opening the abdomen (laparotomy phase), clamping the Glisson's pedicles to cutting (clamping phase), and closing abdomen after hepatectomy (resection phase). The relationships among these measurements and postoperative liver function were examined. RESULTS The mean ICG-R15 was 12.3 +/- 6.0% preoperatively (+/-SD), 9.3 +/- 7.0% at laparotomy, 18.8 +/- 11.6% at clamping, and 20.1 +/- 10.9% at resection. The preoperative and laparotomy and the clamping and resection ICG-R15 values correlated significantly. Eleven (38%) patients developed postoperative hyperbilirubinemia [total bilirubin (T-Bil) >3.0 mg/dl]. The postoperative peak T-Bil correlated significantly with clamping ICG-R15 (r = 0.637, p = 0.0002), but not with preoperative ICG-R15 (r = 0.283, p = 0.137), total clamp time (r = 0.005, p = 0.975), and blood loss (r = 0.097, p = 0.615). Multivariate analysis identified ICG-R15 measured at clamping as the only determinant of postoperative peak T-Bil (r = 0.612). ICG-R15 measured at clamping correlated with the postoperative hospital stay (p = 0.046). CONCLUSIONS ICG-R15 can be measured in real time during surgery by pulse dye densitometry. ICG-R15 measured by this technique before hepatectomy provides a direct and reliable measure of postoperative residual liver function, thus helping in surgical decision making regarding the extent of hepatectomy.
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Affiliation(s)
- Hirofumi Akita
- Department of Surgery and Clinical Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka Suita, Osaka, 565-0871, Japan
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14
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Hori T, Yagi S, Iida T, Taniguchi K, Yamagiwa K, Yamamoto C, Hasegawa T, Yamakado K, Kato T, Saito K, Wang L, Torii M, Hori Y, Takeda K, Maruyama K, Uemoto S. Optimal systemic hemodynamic stability for successful clinical outcomes after adult living-donor liver transplantation: prospective observational study. J Gastroenterol Hepatol 2008; 23:e170-e178. [PMID: 18422962 DOI: 10.1111/j.1440-1746.2008.05394.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIM Most living-donor liver transplantation (LDLT) recipients show characteristic systemic hemodynamics due to liver cirrhosis, and systemic hemodynamics after LDLT influenced postoperative graft function corresponding to outcomes. However, identities of optimal systemic hemodynamics for excellent outcomes and precise parameters for clinical strategy remain unclear. METHODS Therefore, we performed prospective study in adult LDLT recipients from 2003. Hemodynamic parameters were prospectively recorded, and were analyzed in 40 recipients classified into three groups: cirrhotic (group I-C) or non-cirrhotic recipients (group I-NC) with good outcomes, and cirrhotic recipients (group II-C) without good outcomes. RESULTS Group I-C retained characteristic hyperdynamics even after LDLT. However, absolute values of parameters revealed no significant differences between groups I-C and II-C, because group II-C also tended to show hyperdynamics. It is suggested that successful outcomes in cirrhotic recipients require maintenance of optimal hyperdynamic stability after LDLT, because cirrhotic vascular alterations still occurred. Because hemodynamic behaviors were different between groups I-C and I-NC, absolute values were also significantly different even in these successful two groups. Thus, absolute values themselves were not necessarily satisfactory for accurate evaluation of optimal hemodynamic stability. Cirrhotic hyperdynamics are symbolized in large blood volume (BV) circulated by high cardiac output (CO); therefore, we standardized CO against BV. CO/BV was significantly different between groups I-C and II-C, reflecting subtle variability of hyperdynamics in groups II-C, and was interestingly constant in the two successful groups. Therefore, CO/BV reliably evaluated optimal hemodynamic stability after LDLT, and accurately predicted outcomes. CONCLUSION Identification of inappropriate hemodynamics after LDLT is advantageous to further improve LDLT outcomes.
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Affiliation(s)
- Tomohide Hori
- Department of Hepato-pancreato-biliary Surgery and Transplantation, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan.
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15
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Hori T, Yagi S, Iida T, Taniguchi K, Yamagiwa K, Yamamoto C, Hasegawa T, Yamakado K, Kato T, Saito K, Wang L, Torii M, Hori Y, Takeda K, Maruyama K, Uemoto S. Stability of cirrhotic systemic hemodynamics ensures sufficient splanchnic blood flow after living-donor liver transplantation in adult recipients with liver cirrhosis. World J Gastroenterol 2007; 13:5918-5925. [PMID: 17990357 PMCID: PMC4205438 DOI: 10.3748/wjg.v13.i44.5918] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 08/15/2007] [Accepted: 10/17/2007] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the correlation between systemic hemodynamics and splanchnic circulation in recipients with cirrhosis undergoing living-donor liver transplantation (LDLT), and to clarify how systemic hemodynamics impact on local graft circulation after LDLT. METHODS Systemic hemodynamics, indocyanine green (ICG) elimination rate (K ICG) and splanchnic circulation were simultaneously and non-invasively investigated by pulse dye densitometry (PDD) and ultrasound. Accurate estimators of optimal systemic hyperdynamics after LDLT [i.e., balance of cardiac output (CO) to blood volume (BV) and mean transit time (MTT), defined as the time required for half the administered ICG to pass through an attached PDD sensor in the first circulation] were also measured. Thirty recipients with cirrhosis were divided into two groups based on clinical outcomes corresponding to postoperative graft function. RESULTS Cirrhotic systemic hyperdynamics characterized by high CO, expanded BV and low total peripheral resistance (TPR) were observed before LDLT. TPR reflecting cirrhotic vascular alterations was slowly restored after LDLT in both groups. Although no significant temporal differences in TPR were detected between the two groups, CO/BV and MTT differed significantly. Recipients with good outcomes showed persistent cirrhotic systemic hyperdynamics after LDLT, whereas recipients with poor outcomes presented with unstable cirrhotic systemic hyperdynamics and severely decreased K ICG. Systemic hyperdynamic disorders after LDLT impacted on portal venous flow but not hepatic arterial flow. CONCLUSION We conclude that subtle systemic hyperdynamics disorders impact on splanchnic circulation, and that an imbalance between CO and BV decreases portal venous flow, which results in critical outcomes.
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16
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Kamei H, Fujimoto Y, Nagai S, Suda R, Yamamoto H, Kiuchi T. Impact of non-congestive graft size in living donor liver transplantation: new indicator for additional vein reconstruction in right liver graft. Liver Transpl 2007; 13:1295-301. [PMID: 17763381 DOI: 10.1002/lt.21231] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Addition of the middle hepatic vein (MHV) or reconstruction of its tributaries to increase noncongestive graft volume is expected to improve graft function in right liver living donor liver transplantation (LDLT). However, the relationship between noncongestive graft volume and graft function after transplantation has not been clarified and definitive criteria for the reconstruction of MHV tributaries have yet to be established. We analyzed 29 right liver LDLT cases. The noncongestive graft weight was calculated as the total weight of the graft regions drained by hepatic veins reconstructed without postoperative occlusion. We calculated the noncongestive graft-to-recipient weight ratio (ncGRWR) by comparing it to the GRWR. Indocyanine green (ICG) clearance results on days 1 and 3 were significantly correlated with ncGRWR, but not with GRWR. Patients were then divided into 2 groups based on ncGRWR: lower than the median (L-ncGRWR group) and above the median (H-ncGRWR group). ICG clearance in the H-ncGRWR group was significantly better on days 1 and 3. For a different analysis, the patients were again divided into 2 groups, those with and without prolonged cholestasis after transplantation. ncGRWR was significantly lower in patients with prolonged cholestasis, and 7 of 9 patients with an ncGRWR value lower than 0.65 suffered from prolonged cholestasis. Our results demonstrated that the noncongestive volume of a right liver graft has a significant association with early graft function. Further, ncGRWR can play a key role in preoperative determination for additional vein reconstruction of MHV tributaries. When the estimated ncGRWR value with reconstruction of only the right hepatic vein (RHV) (+ inferior right hepatic vein [IRHV]) is less than 0.65, additional vein reconstruction of MHV tributaries should be planned.
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Affiliation(s)
- Hideya Kamei
- Department of Transplantation Surgery, Nagoya University Hospital, Nagoya, Japan.
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17
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Saner FH, Pavlakovic G, Gu Y, Gensicke J, Paul A, Radtke A, Bockhorn M, Fruhauf NR, Nadalin S, Malagó M, Broelsch CE. Effects of positive end-expiratory pressure on systemic haemodynamics, with special interest to central venous and common iliac venous pressure in liver transplanted patients. Eur J Anaesthesiol 2006; 23:766-71. [PMID: 16723056 DOI: 10.1017/s026502150600072x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2006] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES Positive end-expiratory pressure may alter cardiac function and systemic haemodynamics. As transplanted livers may be sensitive to liver congestion, the aim of our study was to evaluate the effect of positive end-expiratory pressure on the cardiovascular system and in particular on central venous and iliac venous pressure in liver transplanted patients. PATIENTS AND METHODS Seventy-two liver transplant patients were enrolled in this prospective, interventional study. On admission to our Intensive Care Unit all patients were ventilated in a biphasic positive airway pressure mode. Haemodynamic effects of three randomly set levels of end-expiratory pressures (0, 5 and 10 mbar) were studied in the immediate postoperative period in all patients. Mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, central iliac venous pressure and cardiac index were recorded and analysed at each of the three end-expiratory pressure levels. RESULTS The values of central- and wedge-pressure significantly increased with increased end-expiratory pressure. Central venous pressure increased by 24% and wedge pressure showed a 6% increase at 10 mbar in comparison to 0 mbar. The values for cardiac index and mean arterial pressure showed no statistically significant difference at 10 mbar as compared to 0 and 5 mbar. The mean pulmonary arterial and common iliac venous pressure were unaffected by different positive end-expiratory pressure levels. CONCLUSIONS Short-term pressure controlled ventilation with end-expiratory pressure up to 10 mbar does not significantly impair systemic haemodynamics in liver-transplanted patients. Further studies are needed to determine whether these findings could be confirmed with higher pressure levels and/or over a longer period of ventilation time.
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Affiliation(s)
- F H Saner
- University Essen, Department of General Surgery and Transplantation, Germany.
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18
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Hori T, Iida T, Yagi S, Taniguchi K, Yamamoto C, Mizuno S, Yamagiwa K, Isaji S, Uemoto S. K(ICG) value, a reliable real-time estimator of graft function, accurately predicts outcomes in adult living-donor liver transplantation. Liver Transpl 2006; 12:605-613. [PMID: 16555326 DOI: 10.1002/lt.20713] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Reliable monitoring enabling evaluation of graft function is crucial after living-donor liver transplantation (LDLT). A method to identify poor graft function at an early postoperative period would allow opportune intensive clinical management to bring about further improvements in LDLT outcomes. This study assessed the reliability of the indocyanine green (ICG) elimination rate constant (K(ICG)) value as an estimator of graft function and determined the actual temporal changes of K(ICG) after LDLT. K(ICG) values were measured using a noninvasive method in 30 adult recipients up to 28 days after LDLT. The receptor index (LHL15) based on liver scintigraphy, and graft parenchymal damage score based on histopathological findings were evaluated after LDLT and correlated well with simultaneous K(ICG). Thus, K(ICG) measured by noninvasive method was confirmed as accurately evaluating graft function. Changes of K(ICG) after LDLT in recipients with good graft function were maintained, after some falls in the early periods, and had a significant difference compared with those for recipients without good graft function; moreover, there were already significant differences in K(ICG) 24 hours after LDLT. Mean transit time reflecting systemic hemodynamics revealed that recipients without good outcomes fell into an unstable systemic hemodynamic state, and effective hepatic blood flow has a large influence on liver regeneration after LDLT. In conclusion, we suggested that K(ICG) values can predict clinical outcomes at the early postoperative period after LDLT by sharply reflecting the influence of systemic dynamics on splanchnic circulation.
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Affiliation(s)
- Tomohide Hori
- First Department of Surgery, School of Medicine, Mie University, Tsu City, Mie Prefecture, Japan.
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Abstract
Organ transplantation occupies the center stage in the treatment of many forms of end-stage organ disease. When the limits of conventional medical care are exhausted, bridging therapies, cadaveric transplantation, and posttransplant medical care come to the fore. Living donor transplantation has grown out of the numerical and immunosuppression limitations of this process. Living donor transplantation medicine and surgery encompass two of the most fascinating and compelling social and ethical dilemmas of modern health care. This article provides an overview of medical and ethical concerns for those who decide to become living donors and those who care for them in the perioperative period.
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Affiliation(s)
- William T Merritt
- Department of Anesthesiology/Critical Care Medicine and Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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20
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Abstract
This article demonstrates the broad range of considerations that affect the outcome of patients undergoing hepatectomy. The progressive improvements in survival, despite the increasing complexity of the surgery, area testament to advances in both surgery and anesthesia. The key elements include careful patient selection, appropriate monitoring, and mechanical and pharmacologic protection of the liver and other vital organs.
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Affiliation(s)
- Imre Redai
- Department of Anesthesiology, College of Physicians and Surgeons at Columbia University, New York Presbyterian Hospital, PH-5, 622 West 168th Street, New York, NY 10032, USA
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