Journal of Liver Transplantation最新文献

Liver transplantation has evolved from an initial experimental procedure to a successful treatment for end-stage liver disease. This study explored milestones in liver transplantation anaesthetic care that contributed to improved outcomes in a single centre.

An analysis of transplant mortality outcomes was performed on adults and children who underwent liver transplantation between 1988 and 2019. A qualitative enquiry involved a thematic analysis of the opinions of retired and current anaesthetists.

Four overarching themes were identified:

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  The evolving status of liver transplantation service

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  The importance of multi-disciplinary teams

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  The surgical process

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  The experimental nature of liver transplantation

Improved management of (a) intraoperative blood loss through the use of techniques such as preoperative coagulation screening, intraoperative blood salvage, and the use of blood transfusions (b) enhanced intraoperative monitoring through the use of techniques such as continuous echocardiography, transesophageal echocardiography, and pulmonary artery catheters and (c) the establishment of dedicated theatre space and staff for liver transplantation achieved through the construction of new dedicated liver transplantation units and the hiring of specialized staff were the key anaesthetic milestones that contributed to improved patient outcome following liver transplantation.

Background

Liver volume measurement plays a critical role in the clinical success of living donor liver transplantation (LDLT). CT liver volumetry is used for volumetric assessment of the donor hepatectomy. However, the degree of accuracy of the preoperative predicted volumetric measurements remains unclear.

Purpose

This systematic review will assess the accuracy of CT liver volumetry.

Materials and Methods

A systematic literature search was conducted to evaluate the accuracy of the CT based liver volumetry. To assess the difference between the left and right liver lobe the ratio between preoperative estimated graft volume (EGV) and actual graft weight (AGW) was calculated. A meta-analysis was performed to compare the EGV to the AGW of the left and right lobe with automated and manual CT volume prediction.

Results

Thirty-one studies met the inclusion criteria and 1336 patients were included in the meta-analysis. The EGV of the right liver is overestimated with a mean of 4.01% and 2.99% for automated and manual volumetry respectively. The left lobe is overestimated with 6.28% and 14.41% for automated and manual volumetry respectively. For a right lobe liver graft automated volume prediction showed a mean difference of 43.9 g (95% confidence interval (CI): 21.21–66.54, p<0.001) between EGV and AGW. For manual volume prediction this was 34.0 g (95% CI: 11.85–56.11, p = 0.003). For a left lobe with automated volume prediction the mean difference was 46.0 g (95% CI: 20.91–71.09, p<0.001) between EGV and AGW. For manual volume prediction this was 39.6 g (95% CI: 8.40–70.74, p = 0.01).

Conclusion

The volumes of the right and left liver lobe seem to be overestimated with automated and manual CT volume prediction. Considering the larger estimation error in the prediction of the left liver lobe, special attention should be paid to the volume when performing a LDLT with a left liver lobe to prevent small for size syndrome.

Fast Tracking in Liver Transplantation has been around for the past 25 years, although no substantial advancement, in the form of a comprehensive protocol, had been readily available. Few centers had embraced this goal, so before we started our program, a little over a decade ago, we adopted most of these ideas into a comprehensive pathway that would swiftly carry our patients from the preoperative stage through a safe home discharge. From day one, we have used this Fast Track pathway and applied it prospectively to every single patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our results after 10 years.

Patients and Methods

All liver transplants performed at our center for the first 10 years since the start of the program (September 2012–September 2022) were included. Our standard protocol included balanced general anesthesia, fluid restriction, avoidance of transfusions, inferior vena cava preservation with temporary porto-caval shunt and thromboelastography. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.

Results

385 transplants were performed in 367 patients (287♂/80♀) over 120 months, mean age 57.4±9.5 years, raw MELD score 15.4±8.1. Predominant etiologies were alcohol (n=217) and HCV (n=108), with hepatocellular carcinoma present in 197 (53.7%). Eighteen patients underwent combined liver-and-kidney transplants. Mean operating time was 313±66 min with cold ischemia times of 281±85 min. Fifty-nine patients (15.3%) were transfused in the OR (2.3±1.1 units of PRBC). Extubation was immediate (< 30 min) in 365 cases (94.8%). Median ICU length of stay was 12.6 h, and median post-transplant hospital stay was 4 days (2–97) with 55 patients (15.8%) discharged home by the 2nd day, 141 (40.5%) by the 3rd day and 203 (58.3%) by the 4th day, which defined our Fast-Track group. The overall thirty-day-readmission rate was (34.5%), which became significantly lower (27.6% vs 44.1%, p=0.0014) in the Fast-Track group when compared to the regular discharge group. Patient survival was 87.6% at 1 year and 79.7% at 5 years.

Conclusion

Fast-Tracking of Liver Transplant patients is very feasible and can be applied as the standard of care.

A 66-year-old male with end-stage liver disease (ESLD) secondary to non-alcoholic fatty liver disease (NAFLD), complicated by hepatocellular carcinoma (HCC), underwent deceased donor liver transplantation from a Coronavirus disease 2019 (COVID-19) positive donor. He presented a month later with fever, diarrhea and pancytopenia which led to hospitalization. The hospital course was notable for respiratory failure, attributed to invasive aspergillosis, as well as a diffuse rash. A bone marrow biopsy revealed hypocellular marrow without specific findings. In the following days, laboratory parameters raised concern for secondary hemophagocytic lymphohistiocytosis (HLH). Clinical concern also grew for solid organ transplant graft-versus-host-disease (SOT-GVHD) based on repeat marrow biopsy with elevated donor-derived CD3+ T cells on chimerism. After, a multidisciplinary discussion, the patient was started on ruxolitinib, in addition to high dose steroids, to address both SOT-GVHD and secondary HLH. Patient developed symptoms concerning for hemorrhagic stroke and was transitioned to comfort care.

Although GVHD has been studied extensively in hematopoietic stem cell transplant (HSCT) patients, it is a rare entity in SOT with a lack of guidelines for management. Additionally, whether COVID-19 may play a role in development of SOT-GVDH has not been explored.

Over the last decades, minimally invasive surgery has advanced from the initiation of laparoscopic surgery in the 1990′s to robotic assisted techniques, gaining popularity in several surgical subspecialties. Living-donor hepatectomy, utilizing robotic surgery has matured and is slowly but steadily growing in specialized transplant centers world-wide. Both, living-donor hepatectomies as well as robotic surgery come with unique challenges for the anesthesia team. The literature on perioperative anesthesia care for this emerging subspecialty is currently limited. The aim of this narrative review is to provide a summary of the current literature on enhanced recovery after robotic living donor hepatectomy and describe the 3 year experience and protocol in the first robotic living donor hepatectomy program in the United States.

The COVID-19 pandemic has had a remarkable impact on the field of liver transplantation. Increasing evidence demonstrates a minimal risk of transmission of SARS-CoV-2 from non-lung donors who test positive for SARS-CoV-2; however, the risks of donor-derived SARS-CoV-2 from liver donors are unknown. We present our experience with two cases in which a liver was transplanted successfully from a brain-dead donor with incidental SARS-CoV-2 infection. Both donors were asymptomatic SARS-CoV-2-positive with negative bronchoalveolar lavage polymerase chain reaction (BAL PCR) and mechanism of death unrelated to COVID-19. Both the recipients did well after transplant and went home with a well-functioning liver. One patient did get readmitted and was found to be SARS-CoV-2-positive; however, it was probably related to hospital exposure rather than donor-derived. SARS-CoV-2-positive donors in select cases may be used for organ donation and liver transplant is safe for recipients.

Background

The experience of liver transplantation is incompletely understood from the patient perspective. The purpose of this investigation was to characterize patient experiences central to the process of liver transplantation from the time of diagnosis through the first year after liver transplantation.

Methods

Semi-structured interviews were conducted at a liver transplant center from January 2021-August 2021 with liver transplant recipients one year following liver transplantation.

Results

Twenty patients and eight caregivers participated in the study. Participants described diverse experiences recognizing and accepting their illness. Motivations for pursuing transplantation were varied as was severity of illness, the perioperative course itself, and the process of recovery after transplant. The establishment of a “new normal” was a consistent theme across participants. Interestingly, we found a tension between the motivations described by many patients and the reality of the outcome many of them faced after transplantation. While, the motivation for many patients was to return to a previous level of physical and mental function they had before their liver disease they often were faced with a new improved status as opposed to a return to their previous full function. This new normal describes tension between restoration of physical function, acceptance of new limitations and a progression toward a new sense of values created by the transplant experience itself.

Conclusions

Many recognize that liver transplantation restores physical wellbeing, but few recognize that transplant often fundamentally recreates personhood. Sensitivity, to these changes should be recognized to maximize the success of liver transplantation patients.