Relationship Between Provider Volume and Outcomes For Orthotopic Liver Transplantation

Introduction  Recent data suggests that the previously demonstrable relationship between hospital volume and outcomes for liver transplant procedures may no longer exist. Furthermore, to our knowledge, no study has been published examining whether individual surgeon volume is associated with outcomes in liver transplantation. Materials and methods  The Nationwide Inpatient Sample database was used to obtain early clinical outcome and resource utilization data for liver transplant procedures performed in the USA from 1988 through 2003. The relationship between surgeon and hospital volume and early clinical outcomes was analyzed with and without adjustment for certain confounding variables such as patient age and presence of co-morbid disease. Results  The in-hospital mortality rate, major postoperative complication rate, and length of hospital stay after liver transplantation did not differ significantly based on hospital procedural volume. These outcome variables did, however, exhibit a statistically significant inverse relationship with individual surgeon volume of liver transplant procedures. A significant relationship between procedure volume and outcomes for liver transplantation cannot be demonstrated at the level of transplant center, but does appear to exist at the level of the individual transplant center. Conclusion  Minimal volume requirements for individual liver transplant surgeons may be justified, pending validation of this volume–outcomes relationship using a clinical data source. Presented on March 12, 2006 at the Annual Meeting of the American Hepato-Pancreatico-Biliary Association in Miami Beach, Miami.     

Risk Factors and Outcomes of Intracardiac Thrombosis During Orthotopic Liver Transplantation

BackgroundIntracardiac thrombosis incidence during orthotopic liver transplantation is estimated at 0.36% to 6.2% with mortality up to 68%. We aimed to evaluate risk factors and outcomes related to intracardiac thrombosis during orthotopic liver transplantation.Materials and MethodsA comprehensive retrospective data review of 388 patients who underwent orthotopic liver transplantation at an urban transplant center from January 2013 to October 2016 was obtained.ResultsSix patients were found to have documented intracardiac thrombosis; 4 cases were recognized during the reperfusion stage and 1 during pre-anhepatic stage. All allografts were procured from decreased donors with a median donor age of 44 years (interquartile range, 35.25-49.75) and the cause of death was listed as cerebrovascular accident in 5 donors. Preoperative demographic, clinical, laboratory, and historical risk factors did not differ in patients with thrombosis. None had a prior history of trans-jugular intrahepatic portosystemic shunt or gastrointestinal bleeding. Three patients had renal injury, but no intraoperative hemodialysis was performed. Transesophageal echocardiographic findings included elevated pulmonary artery pressure (1/6), right ventricular strain (1/6), and pulmonary artery thrombus (1/6). Three patients died intraoperatively. Tissue plasminogen activator alone was given to 1 patient who did not survive, intravenous heparin only to 1 patient with resolution, and a combination of both was used in 2 patients with clot resolution achieved.ConclusionCardiac thrombosis should be considered in patients having hemodynamic compromise during liver transplantation. Transesophageal echocardiography is a useful diagnostic tool. Intracardiac thrombosis treatment remains challenging; however, using both thrombolytics and heparin could achieve better results.     

Impact of Anesthesiologist Experience on Early Outcomes in Adult Orthotopic Liver Transplantation

BackgroundLiver transplantation is a complex surgical procedure. The experience of the anesthesiologist, and its potential relationship to patient morbidity and mortality, is yet to be determined. We sought to explore this possible association using our institutional training patterns as the subject of study.MethodsThis is a single center retrospective analysis investigating the association of an anesthesiologist's experience with liver transplantation and its potential effect on early patient outcomes in adult liver transplant recipients from January 2010 to September 2016. Training of team members consisted of a 6-month period of clinical shadowing with a senior anesthesiologist and co-staffing 8 liver transplant procedures before solo staffing a liver transplant. Specifically, patient outcomes for the first 5 transplants after this training were investigated.ResultsThe only independent risk factor for early death or early graft loss was the amount of packed red blood cells administered during transplantation. With respect to secondary outcomes, the amount of packed red blood cells and hospitalization at the time of transplant were associated with the number of days on a ventilator, length of intensive care unit stay, and overall hospital length of stay.ConclusionsThe results of this study conclude that the training model currently in place for our new team members has no negative impact on patient outcomes after liver transplantation.     

大鼠原位肝移植动物模型制作要点

目的建立稳定的大鼠原位肝移植模型。方法参照Kamada等法建立大鼠原位肝移植模型，经门静脉灌注肝脏，改进肝上下腔静脉吻合法为单线连续缝合法。结果210只大鼠原位肝移植24h存活率为91．0％(191／210)，平均无肝期17min，1周生存率为85．2％(179／210)。结论改进大鼠原位肝移植肝上下腔静脉吻合法，可缩短受体无肝期，减少手术并发症发生率，并能提高原位肝移植大鼠的生存率。     

原位肝移植手术的麻醉管理

肝移植术是治疗晚期肝病最有效的措施。同种异体原位肝移植术可分为无肝前期（从切皮开始至阻断门静脉、下腔静脉为止）,无肝期（从门静脉、下腔静脉阻断开始至开放门静脉或下腔静脉为止）,及新肝期（即开放门静脉或下腔静脉,使供肝得到血液灌注）。不同时期的血流动力学及内环境变化部各有特点。根据本院多年的实践,我们对此类手术的麻醉管理宗旨是：提前干预、良性循环、目标管理,维持内稳态及重要器官功能稳定。     

External Biliary Fistula in Orthotopic Liver Transplantation

During orthotopic liver transplantation (OLT), various situations may occur in which biliary reconstruction is neither technically feasible nor recommended. One bridge to a delayed anastomosis can be an external biliary fistula (EBF). This procedure allows the surgeon to execute hemostatic maneuvers, such as abdominal packing; therefore, biliary reconstruction can be subsequently performed in a bloodless operative field without edematous tissues. EBF can be made by placing in the donor biliary tract a cannula that is fixed to the bile duct using 2-0 silk ties and secured outside the abdominal wall. The biliary anastomosis will be performed within 2 days after the OLT. The aim of this study was to examine the safety of EBF in terms of the incidence of biliary complications compared with a direct anastomosis. Among 1634 adult OLTs performed in 17 years in our center, 1322 were carried out with termino-terminal hepaticocholedochostomy (HC-TT); two with side-to-side hepaticocholedochostomy; 208 with hepaticojejunostomy (HJ); 31 with EBF and delayed HC-TT, and 71 with EBF and delayed HJ. Biliary complication rates in the EBF group were 24.5%, including 23.9% in the delayed HJ and 25.8% in the delayed HC-TT. Biliary complication incidence among all OLTs was 24.6% (P = NS). No complications related to the procedure were observed. Therefore, EBF is a safe technique without a higher biliary complication rate. It may be useful when a direct biliary anastomosis is dangerous.     

Renal Dysfunction After Orthotopic Liver Transplantation

Background

Identification of risk factors of acute renal failure (ARF) after orthotopic liver transplantation (OLT) may avoid the development and attenuate the impact on patient outcome. Therefore, the incidence and risk factors of ARF after OLT at Siriraj Hospital were analyzed.

Methods

The study was retrospectively analyzed from the OLT patients at the Siriraj Hospital between January 2002 and December 2009. ARF was defined as an increased in serum creatinine level more than 1.5 times within the first week postoperation compared with the preoperative level.

Results

A total of 81 liver transplant patients were analyzed. The mean age was 52.45 years (range, 22 to 71) and there were 25 women (30.86%) and 56 men (69.14%). Indications for OLT were end-stage liver cirrhosis (n = 43, 53.09%), hepatocellular carcinoma (n = 36, 44.44%), and fulminant hepatic failure (n = 2, 2.47%). Fifty-eight patients (71.60%) developed ARF, and the perioperative mortality of these was 18.97%. The univariate analysis identified the presence of preoperative coagulopathy, prolonged intraoperative hypotension, more blood loss, and postoperative hypotension as the risk factors of ARF. By the multivariate analysis, prolonged intraoperative hypotension more than 30 minutes and presence of postoperative hypotension were the independent risk factors of ARF. During the intraoperative and postoperative periods, ARF group required more blood and blood components transfusion, longer intensive care unit stay, and higher in-hospital mortality. Seven patients (12.07%) in the ARF group required postoperative renal replacement therapy. Four patients (9.52%) developed chronic renal failure, and one of them required long-term hemodialysis.

Conclusions

ARF was a common complication after OLT, which caused increased morbidity and mortality. Although some patients required dialysis, most of them recovered normal renal function. Prolonged intraoperative hypotension and presence of postoperative hypotension were the independent risk factors of ARF after OLT.     

Metabolic Alkalosis After Orthotopic Liver Transplantation

To ascertain the etiology of metabolic alkalosis (MA) following orthotopic liver transplantation (OLT) the records of patients with 123 consecutive OLTs from 1995 to 2000 were reviewed. Metabolic alkalosis occurred in 51.2% of patients. Patients with MA had a larger fluid deficit (-3991 +/- 4324 vs. -1018 +/- 4863, p < 0.05), cumulative furosemide dose (406 +/- 356 vs. 243 +/- 189, p < 0.02), and citrate load from blood transfusions (9164 +/- 4870 vs. 7809 +/- 3967, p < 0.05). There was no difference in serum lactate concentration (3.15 +/- 1.63 vs. 3.11 +/- 1.91) in patients with and without MA. The duration of ICU stay was longer in patients with MA (14.9 +/- 15.3 vs. 5.3 +/- 3.9 days, p < 0.004). Treatment of severe MA in 19 (15.4%) patients consisted of 0.1 N hydrochloric acid and/or acetazolamide. Hypokalemia and hypomagnesemia occurred in 37.4% and 59.3% of patients, respectively. In conclusion, MA is a common post-OLT complication that is associated with a longer ICU stay. Diuretic-induced volume depletion, the citrate load from blood transfusions, hypokalemia, and hypomagnesemia contribute to the pathogenesis of MA in OLT.     

肝脏良性疾病的肝移植

肝脏移植作为终末期肝病的治疗，自上个世纪80年代在欧美国家获得公认以来，已在世界各国得到迅速开展。我国自90年代后期以来，在全国掀起了第二个肝移植的热潮，迄今已完成1000余例肝移植．在围手术期处理、手术技术、介人放射、移植免疫、抗感染治疗等各个方面均获得丰富的经验．我国肝移植的效果及长期生存率亦逐步赶上国际先进水平。     

背驮式原位肝移植的手术配合

回顾1例乙型肝炎肝硬化病人(失代偿期)行背驮式原位肝脏移植的手术配合过程.提示术前做好病人心理护理、器械准备,熟悉手术步骤、确定最佳配合程序,量化分类管理器械物品等,是确保手术顺利进行的关键.     

治疗原发性肝癌行肝移植的相关问题

肝移植是20世纪60年代后期兴起的重大新技术，已成为终末期肝病最有效的临床治疗手段。国内自20世纪70年代后期开展此技术，因为各种原因至90年代后期方进入成熟阶段，迄今全国肝移植例数已逾4000例。原发性肝癌作为终末期肝病，一直是肝移植的重要适应证之一，但由于早年肝癌肝移植的结果并不理想，患者多在2年内肿瘤复发死亡，因而国外不少中心已经不把晚期肝癌作为手术适应证，而仅把小肝癌作为肝移植受者。国内在肝移植早期，多以晚期肝癌为主要指征，近年由于肝移植手术技术的成熟，亦逐渐趋于以小肝癌为主要指征。但由于我国肝癌每年有11万多人死于此病，占全世界肝癌死亡人数的53％，临床     

Alcohol Abstinence and Orthotopic Liver Transplantation in Alcoholic Liver Cirrhosis

Patients diagnosed with acute alcoholic hepatitis (AAH) are routinely managed medically and not considered suitable for orthotopic liver transplantation (OLT). The eligibility for OLT in these patients has been questioned due to the social stigma associated with alcohol abuse, based on the fact that AAH is “self-induced” with an unacceptably high recidivism rate. Many centers in Europe and the United States require abstinence periods between 6 and 12 months before OLT listing. AAH outcomes in the literature are poor, in particular due to patient noncompliance during the immediate 3 months preceeding OLT. Between January 1997 and December 2007, 246 patients were evaluated in our center for alcoholic liver disease: 133 (54%) were listed for OLT (I-OLT), including 110 (83%) who underwent transplantation and 8 (6%) still listed as well as 15 (11%) removed from consideration. One hundred thirteen (46%) patients had no indication for OLT (NO I-OLT), including 18 (16%) who died, 81 (71%) still monitored, and 14 (12%) lost to follow-up. Patient survival rates post-OLT were 79%, 74%, 68%, and 64% at 1, 3, 5, and 10 years, respectively. Explant (native liver) pathologic examination revealed AAH in 8 (7.2%) patients who underwent OLT. In this group, patient survival and the post-OLT recidivism rate were statistically identical to the overall group of transplant recipients.     

同种原位肝移植肝脉重建技巧

目的：探讨和总结同种原位肝移植术中肝动脉重建技术。方法：回顾性分析我院近一年来所施行18例原位肝移植术中肝动脉重建方式和技巧。结果15例行供受体肝固有动脉端端吻合,2例供体肝总动脉与受体肝固有动脉吻合,1例供体总动脉与受体脾动脉吻合。术后彩色色普勒超声监测显示肝动脉血流通畅,均未发现有血栓菜成或肝动脉狭窄,全部病例未发生胆道并发症。结论：成功的肝动脉重建技术防止肝移植术后肝动脉血栓形成或肝动脉狭窄的关键。     

大鼠肝移植后肝再生的实验研究

目的：探讨部分肝移植术后移植肝的再生问题。方法：建立大鼠部分肝移植模型，实验分为肝切除组（PLR组）、全肝移植组（OLT组）和部分肝移植组（POLT组）3组，分别于术后不同时间段取外周血检测总胆红素和谷丙转氨酶水平；取肝组织行组织学检查及流式细胞仪检测移植肝的增殖活性。结果：移植术后1w，肝功能酶学指标增高，后逐步降低；组织学检查术后可见单核细胞浸润，特别在门静脉周围汇管区，肝实质可见点状坏死。术后1个月可见胆管增殖；PLR组和POLT组还可见二倍体和多倍体的肝细胞，中央小静脉、肝窦和叶间静脉轻度扩张。PLR组和POLT组肝细胞增生活跃，3组分别于术后1d、2d、4d达到增殖高峰。结论：部分移植肝和肝切除后肝脏具有同样的增殖活性，但增殖高峰POLT组及OLT组均要晚于肝切除后的肝脏，但移植组增殖周期长。这可能是由于手术操作及肝脏缺血再灌注损伤所致。而持续时间长可能与受体免疫系统产生的细胞因子和激素的调控相关。     

Renal Function in Patients with Orthotopic Liver Transplantation

Due to multiple reasons, acute renal failure (ARF) commonly develops in the early postoperative period of orthotopic liver transplantation (OLT) recipients. The records of OLT recipients between 1999 and 2004 were evaluated. Age, gender, primary disease, history of diabetes, immunosuppressive drugs, pre- and postoperative renal function tests, serum electrolytes, dialysis, liver functions tests, and renal function tests in follow-up period were noted. We followed 16 patients with OLT in our center. ARF developed in 8 patients. Dialysis was performed in only 2 patients, and other patients with ARF were managed with conservative measures. Hypertensive crisis and cerebrovascular stroke developed in 1 diabetic hypertensive patient.     

Serum Vasopressin Concentrations During Orthotopic Liver Transplantation

Background

We report measurements of the temporal response of serum vasopressin concentrations in the period after reperfusion of the liver graft during orthotopic liver transplantation (OLT).

Methods

Vasopressin concentrations were determined in 11 adult patients undergoing OLT by radioimmunoassay of samples collected after induction, at 5 minutes prior to reperfusion, and at 10, 20, 30, 40, 50, 60, 90, and 120 minutes after reperfusion.

Results

Pre-incision vasopressin concentrations ranged from <0.5 to 2.6 pg/mL (reference serum vasopressin, <1.7 pg/mL). Overall, levels increased before reperfusion, but fell thereafter. Individual patients manifested elevated levels during the period after reperfusion. Values immediately before reperfusion exhibited most variability, ranging from 0.8 to 40 pg/mL (median, 15; interquartile range [IQR], 4-29) Median vasopressin concentrations 10 minutes postreperfusion were 7.6 pg/mL (IQR, 3-27). Only 3 of the 11 patients failed to generate vasopressin levels >20 pg/mL. In each of these patients, hemodynamics were satisfactory without the need for additional pressor infusion. Maximum vasopressin concentration measured in any patient was 85 pg/mL. There was no correlation between vasopressin concentration and mean blood pressure or systemic vascular resistance index.

Conclusion

Vasopressin concentrations during OLT vary widely and are elevated periodically during the anhepatic and postreperfusion stages, with no apparent relationship between vasopressin concentrations and blood pressure. Although vasopressin concentrations were not as high as those measured during some other clinical situations, these data suggest that a relative vasopressin deficiency is not a direct cause of hypotension during OLT.     

Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Complications After Orthotopic Liver Transplantation: Outcomes and Complications

Biliary complications after orthotopic liver transplantation (OLT) still remain a major cause of morbidity and mortality. The most frequent complications are strictures and leakages in OLT cases with duct-to-duct biliary reconstruction (D-D), which can be treated with dilatation or stent placement during endoscopic retrograde cholangiopancreatography (ERCP), although this procedure is burdened with potentially severe complications, such as retroperitoneal perforation, acute pancreatitis, septic cholangitis, bleeding, recurrence of stones, strictures due to healing process. The aim of the study was to analyze the outcome of this treatment and the complications related to the procedure. Among 1634 adult OLTs, we compared postprocedural complications and mortality rates with a group of 5852 nontransplanted patients (n-OLTs) who underwent ERCP. Of 472 (28,8%) post-OLT biliary complications, 319 (67.6%) occurred in D-D biliary anstomosis cases and 94 (29.5%) patients underwent 150 ERCP sessions. Among 49/80 patients (61.2%) who completed the procedure, ERCP treatment was successful. Overall complication rate was 10.7% in OLT and 12.8% in n-OLT (P = NS). Compared with the n-OLT group, post-ERCP bleeding was more frequent in OLT (5.3% vs 1.3%, P = .0001), while the incidence of pancreatitis was lower (4.7% vs 9.6%, P = .04). Procedure-related mortality rate was 0% in OLT and 0.1% in n-OLT (P = NS). ERCP is a safe procedure for post-OLT biliary complications in the presence of a D-D anastomosis. Morbidity and mortality related with this procedure are acceptable and similar to those among nontransplanted population.     

Liver Transplantation in Recipients With High Model for End-stage Liver Disease Score

Objectives

The score in the Model of End-stage Liver Disease, or MELD, is a good indicator of the survival in patients on the liver transplant waiting list. In this study, an analysis is performed on the benefits of liver transplant on those patients with a very high MELD score and who thus start from a very severe baseline state that could affect the surgical outcome.

恒河猴同种异体原位肝移模型的改进

目的探讨恒河猴原位肝移植模型建立的最佳方案。方法选用10对健康恒河猴进行同种异体肝移植,借鉴各种动物模型建立的方法 ,使用门静脉袖套法建立稳定的恒河猴原位肝移植模型。结果 10只恒河猴原位肝移植模型手术均成功。供体切取手术时间（20&#177;5）min,供肝修整时间（30&#177;7）min;受体手术时间（180&#177;35）min,受体无肝期（17&#177;4）min。术后24h存活者9只,1只术后9h死于腹腔内出血;72h存活者8只,于术后38h因消化道出血再死亡1只;1周存活5只,3只分别于术后9、11和11d死于排斥反应;最长存活32d者也死于排斥反应。所有受体均无门静脉血栓形成及胆道并发症发生。结论改进后的恒河猴同种异体原位肝移植模型具有操作简便、手术成功率高的优点,是肝移植临床前期研究较理想的动物模型。