Journal of Liver Transplantation最新文献

Introduction

In 2012, the German transplant scandal was uncovered and reported in the national and international media. This article offers an anthropological analysis of the scandal and examines its ‘scandalous’ characteristics by taking a close look at its extraordinary and ordinary features.

Methods

The article is based on ethnographic research using multiple methods including participant observation, interviewing as well as media and document analysis.

Results

The transplant scandal in Germany revealed systemic ‘scandalous’ features of the national transplant system. From a significant lack of transparency in decision making, a weak legal framework for accountability, adherence to moralizing rules about alcohol and abstinence, to media coverage that individualized the scandal.

Conclusions

Looking at extraordinary events such as transplant scandals from an anthropological perspective offers an analysis that goes beyond the singular, scandalous event. An anthropological analysis allows to highlight the ordinary and ambivalent ‘scandalous’ features of transplant medicine It examines transplant medicine at the intersection of biomedicine, politics, and morality.

Introduction

Obesity-associated comorbidities increase risks for patients undergoing liver transplant. In this study, we explore patient perspectives and motivation for healthy weight management among patients on the liver transplant waiting list.

Methods

This is a cross-sectional, observational, electronic survey-based study. A survey on weight management was administered to patients on the liver transplant waiting list. Demographic and clinical data were collected from patients’ medical records. Data was analyzed using Pearson's chi-squared, Fisher's exact, and Student's t-tests.

Results

Respondents had a mean age of 54.4 years, were predominately male (62.0%) with a mean BMI of 29.2 kg/m² with alcoholic cirrhosis as the leading etiology of liver disease (33.9%). Among patients with a BMI≥30 kg/m², 59.0% perceived that they were overweight and 23.1% believed they were underweight. Among patients with BMI≥30 kg/m² who perceived they were overweight, 39.1% were actively trying to lose weight and 60.9% were trying to keep from gaining weight. Regardless of current weight, there was a median increase in BMI for patients who categorized themselves as having lost weight or maintained weight since being waitlisted.

Conclusion

Many patients with a BMI≥30 kg/m² did not perceive themselves as overweight and were not actively trying to lose weight. Weight perception was not consistent with actual weight change while waitlisted for liver transplant. Further research is needed to understand how weight awareness and weight perception impacts motivation for weight loss.

In patients undergoing orthotopic liver transplantation (OLTx) surgery, the intraoperative hemodynamic monitoring technique that is most utilized is still the pulmonary artery catheter (PAC). The popularity of transesophageal echocardiography (TEE) is increasing, so today's updated issue is the following: should the use of PAC and/or volumetric monitoring with transpulmonary thermodilution and/or advanced volumetric PAC be limited in clinical practice, only for some high risk patients? Could we use the TEE, if necessary, in less critical ill patients undergoing OLTx surgery?

We can integrate all of the aforementioned monitoring techniques in an increasing modular step wise monitoring concept. But in an uncertain hemodynamic situation, transthoracic and/or transoesophageal echocardiographic evaluation represents a cornerstone.

The use of echocardiography during OLTx is more and more common with several benefits demonstrated particularly by the TEE in this patient population.

To achieve and maintain adequate tissue perfusion becomes difficult in case of major bleeding, an event quite possible to occur during OLTx, affecting the immediate and the late outcome.

All the clinicians agree that bleeding interfere with the choice of hemodynamic monitoring and or vice versa.

A reasonable compromise is to find a balance between the need to extend monitoring in high-risk surgical patients and the average consumption of blood products that characterizes each individual transplant center. This is also in line with what is shown in literature in terms of Maximum Surgical Blood Ordering Schedule (MSBOS).

Portopulmonary hypertension (PoPH) is a rare but serious disorder carrying a very poor prognosis. PoPH is defined as the presence of pulmonary arterial hypertension (PAH) associated with portal hypertension, with or without underlying liver disease. We are reporting our institutional experience of anaesthetic management of an 8-year old female child weighing 20 kg with severe PoPH who underwent liver transplantation (LT). The use of pulmonary vasodilators in the perioperative period along with a carefully planned anaesthetic strategy was critical in the successful outcome of this potentially lethal disorder.

Purpose

Cirrhotic cardiomyopathy (CCM) is a major comorbidity of cirrhosis. The diagnostic performance of conventional echocardiography is poor. Two-dimensional-strain echo-cardiography (2D-strain) detects myocardial dysfunction earlier than conventional echocardiography, with a significant prognostic value. The aim of our study is to assess whether the 2D-strain will allow a more relevant assessment of CCM in cirrhotic patients than conventional echocardiography. The secondary objective is to determine if altered strain or strain rate are associated with cirrhotic patient's outcome in intensive care unit (ICU).

Methods

Conventional echocardiography and 2D-strain were performed on 44 consecutive patients within 24 hours of admission to the ICU. Using 2D-strain, the global-longitudinal-strain (GLS) was assessed.

Results

GLS was impaired in 64% of patients. GLS was significantly higher in the patients who died compared with those who survived, using 28-day mortality rate (-17 vs -14 p < 0.039). Regarding conventional echocardiography, no factor was associated with increased mortality.

Conclusion

GLS is correlated to cirrhotic patient's prognosis in intensive care, while conventional echocardiography shows no dysfunction.

Background

Pediatric liver transplantation is performed with either whole, reduced, split livers depending on the technical aspects of the surgery and the discrepancy between donor and recipient body dimensions. The optimal method of partial hepatectomy for pediatric transplants remains debated to this day: either in situ (i.e. occurring before liver removal from the donor) or ex situ (i.e. taking place after liver removal). In 2007, our tertiary academic center changed its surgical protocol from ex situ to in situ partial hepatectomy in deceased donor mainly to decrease bleeding complication risk among other amendments. Our study aimed to evaluate the clinical impact of this major modification on the post-operative blood products volume transfusion.

Methods

A retrospective analysis of 104 patients who underwent liver transplantation at our pediatric center between 1998 and 2016 was performed. Patients receiving multiple organ transplantations or re-transplantation were excluded from the study. Differences in blood products transfusion volume, post-operative complications and mortality rates were compared between two periods implementing different surgical transplantation protocols: ex situ partial hepatectomy from 1998 to 2006 and in situ partial hepatectomy from 2007 to 2016.

Results

42 children from the original ex situ protocol group and 62 children from the modified in situ protocol group were included in the study. The median age and weight were 1.5 years (0.7–4.8 kg) and 11.1 kg (7.9–18.2), respectively. There were no significant differences in demographic data between groups. A significant decrease in liver transplant cold ischemia time was observed in the in situ group compared to the ex situ group (p < 0.001). A significant increase in vasopressor use was observed for the in situ group (64% (IS) vs. 24% ex situ group (p < 0.001)), as part of the protocol modifications. Median perioperative blood products transfusion volume was not significantly different between both groups: 275 ml/kg (76–497) ex situ group vs. 229 ml/kg (76–499) in situ group (p = 0.82). We observed a 28-day and 90-day mortality rate of 14.3% and 16.6%, respectively, for the ex situ group and 6.5% and 8.1%, respectively, for the in situ group. Hepatic artery thrombosis was found in the first 7 days in 7% of the ex situ group patients and 6% of the in situ group patients. There were no significant differences in post-operative mortality and morbidity rates observed between groups (p value of 0.29 and 0.28 for 28-days and 90-days mortality rates, respectively).

Conclusions

Although the median amount of transfusion was higher in the ex-situ group, our stud