Anesthesia for liver transplantation: the experience of the University of Bologna in the MELD era.

AIM: The hepatic cirrhosis is associated with an important cardiovascular alterations. In this report, we review our transplant center experience with liver transplantation in the Model for End-Stage Liver Disease (MELD) era, in particular this study investigate the relationship between severity of liver disease assessed by MELD score and postoperative events. METHODS: Our retrospective review was performed on 242 cirrhotic patients underwent liver transplanation at the Department of Surgery and Transplantation of the University of Bologna. Biochemical and hemodynamic variables were evaluated by Swan-Ganz catherization. Dindo's classification of postoperative complications was used for the evaluation of postoperative course. RESULTS: Morbidity occurred in 158 patients (65.2%) and 13 patients died during the hospital stay. Considering the highest grade of complication occurred, non life-threatening complications occurred in the 47.9% of cases (116 patients) and life-threatening complications, excluding patient death, in 17.3% (42 patients). Patients with MELD >30 showed a longer ICU stay, tracheal intubation and in-hospital stay. CONCLUSION: In conclusion MELD score is tightly related to postoperative complications.

Fluid management of patients undergoing intestinal and multivisceral transplantation.

Small bowel transplantation can be associated with large fluid shifts due to massive blood loss, dehydration, vascular clamping, long ischemia times, intraoperative visceral exposure, intestinal denervation, ischemic damage, and lymphatic interruption. Fluid management is the major intra- and postoperative problem after small bowel and multiple organ transplantation, because of the highly variable fluid and electrolyte needs of the transplant recipient. Third-space fluid requirements can be massive; inadequate replacement leads to end-organ dysfunction, particularly renal failure. Several liters of fluid may be required in the initial 24 to 48 hours postoperatively to simply maintain an adequate central pressure to provide a satisfactory urine output. During this time patients may develop extensive peripheral edema, which dissipates over the next few days as the fluids are mobilized and requirements stabilize. Based on our experience in 29 cases of intestinal transplantation and 4 cases of multivisceral transplantation, we have herein described the intraoperative fluid management and hemodynamic changes. Our study confirmed a large quantity of fluid administration during and after small bowel transplantation that required adequate volume monitoring.

Acute renal failure after liver transplantation in MELD era.

Model for End-Stage Liver Disease (MELD) score was used in our center from 2003 to assess the position of orthotopic liver transplantation (OLT) candidates on a waiting list. A key component of MELD score in the assessment of the degree of the illness is renal function. In this study, we measured the effects of this new scoring system on renal function and therapeutic strategies. We evaluated the incidence of acute renal function (ARF) after OLT requiring renal replacement therapy (hemofiltration or hemodialysis) in two patient groups: 240 transplanted before MELD era and 224 after the introduction of this parameter to select candidates. ARF occurred in 8.3% of patients in the pre-MELD group versus 13% in the MELD group, while the mortality rates were 40% and 27%, respectively. The creatinine level before OLT seemed to be a good predictor of ARF (P < .001), and blood transfusion rates (P < .05) as well as intraoperative diuresis (P < .05). In our analysis we did not observe a correlation between MELD score and postoperative ARF.

Assessment of metabolic cerebral damage using proton magnetic resonance spectroscopy in mild traumatic brain injury.

AIM: We want to appraise, through proton magnetic resonance spectroscopy (H1-MRI), the NAA's values and it's changing in cerebral tissue in consequence of cranial trauma. METHODS: Six patients with TBI undergo to H1-MRI to asses the changes occurring briefly after trauma in the spectrum's composition. RESULTS: As far as the first two cases we founded a lowering of the NAA's values. In the other four cases the NAA values were normal in all but one, which slightly brought the values of the NAA/Cr and NAA/Cho lower in comparison to the standard values. CONCLUSIONS: Existing a correlation between NAA and ATP it can be drawn that the reduction of NAA is correlated to energetic type damage. Despite the smallness of data, it remains really important that we should have a tool to monitor the cerebral metabolic picture after a mild trauma.

Analysis of the causal factors of prolonged mechanical ventilation after orthotopic liver transplant.

BACKGROUND: Prolonged mechanical ventilation and the consequently long stay in the intensive care unit (ICU) appear to be important infection risk factors in patients undergoing liver transplant. METHODS: We analyzed the data relating to 70 liver transplants performed on 67 patients during the past year's activities. For each patient we have considered the presence of preoperative pulmonary alterations, the first radiological result of the postoperative thorax, the PaO(2)/FiO(2) ratio recorded in the peroperative phase immediately after induction of general anesthesia (T0), and arrival at the ICU at the end of the operation (T1). We also considered the enzyme trend (glutamate-oxalacetic transaminase [GOT] and glutamate-pyruvate transaminase [GPT]) recorded every 6 hours for the first 42 hours of the postoperative period (times T1 to T7). RESULTS: There was an evident correspondence between the values of PaO(2)/FiO(2) < or = 300 ratio at time T1 and the subsequent duration of mechanical ventilation (P = .001). There was also a correlation between the PaO(2)/FiO(2) < or = 300 ratio at time T1 and the trend of the GPT in the first 24 hours postsurgery (P = .021; P = .026; P = .018; P = .048) or GOT trend over the same span of time (P = .027; P = .035; P = .048). CONCLUSIONS: Graft malfunction as expressed by the enzyme trend affects both the duration of mechanical ventilation and the postoperative PaO(2)/FiO(2) ratios. This metric may be useful to reinforce infection surveillance and to perform an early percutaneous tracheostomy in these patients.

Brain metastases from hepatocellular carcinoma. A case report.

Brain metastasis from hepatocarcinoma are a decidedly rare occurrence in countries where this pathology is most frequent. The authors describe a case of metastases from hepatocellular carcinoma in a patient suffering from post-HBV hepatic cirrhosis with hemorrhagic onset. The "stroke-like" presentation of the cerebral localization of the disease can be explained by both the important vascularization of the tumor and the frequent hemocoagulative alterations caused by the cirrhosis. The importance of diagnostic neuroradiology is briefly addressed, with reference to the fundamental role played by MRI. Surgery of these lesions does not present any particular technical problems as long as they are located in accessible areas and the patient's general and neurological conditions allow it. Postoperative radiotherapy seems to improve the quality and quantity of residual life, although the number of patients described in the literature is too small to draw any definite conclusion. Promising molecular biology studies are under way to evaluate the role of oncosuppresor gene expression in hepatocarcinogenesis and in the way the disease spreads.

Hyperdynamic circulation in cirrhosis: predictive factors and outcome following liver transplantation.

BACKGROUND: Liver cirrhosis is associated with a hyperdynamic circulation (HC). In this observational study, we aimed to investigate the predictive factors of HC, its impact on intraoperative hemodynamic and postoperative outcome, early ICU and in-hospital mortality, in cirrhotic patients undergoing orthotopic liver transplantation (OLT). METHODS: Two hundred and forty-two patients with cirrhosis undergoing cadaveric OLT were included. Before starting the transplant procedure and under general anesthesia, a pulmonary artery catheter was introduced to assess hemodynamic parameters. The baseline assessment was carried out approximately 30 minutes after the catheter placement and repeated during the anhepatic phase, 10 minutes after the reperfusion and at the end of surgery. The patients were divided into two groups: in group 1 the patients had SVR>900dynes s-1 m-2 cm-5, in group 2 SVR ≤900 dynes s-1 m-2 cm-5. RESULTS: Eighty-two patients (33%) presented severe HC. In multivariate analysis 2 factors were associated with the occurrence of HC: beta-blockers use (Exp [B]=4.42 (95% CI 1.18-17); P=0.001, [34% and 12% in groups 1 and 2, P<0.001, respectively]) and model for end-stage liver disease (MELD) score (Exp [B]=1.066; 95% CI=1.025-1.109; P=0.001). CONCLUSION: MELD score was an independent predictor of HC, and beta-blockers resulted associated with lower incidence of HC in cirrhotic patients undergoing cadaveric OLT. Intraoperative HC correlates with hemodynamic alterations, requiring more blood products and vasopressor use, this may increase the risk of renal failure, early ICU death and in-hospital mortality.

Postoperative troponin T elevation as a predictor of early acute kidney injury after orthotopic liver transplantation: a preliminary retrospective study.

BACKGROUND: Slight alterations in cardiac enzymes are frequently observed perioperatively among liver transplant patients. The significance of these changes in the absence of ongoing acute cardiac pathology is unknown. We sought to evaluate the link between early postoperative anomalies of serum cardiac troponin T (cTnT) in the absence of an evident cardiac cause and kidney injury during the first week of hospital stay. METHODS: We retrospectively enrolled 30 patients in the study, recording several perioperative variables, particularly cTnT on intensive care unit ICU arrival as well as 6 and 12 hours later. We grouped patients with cTnT levels >0.03 ng/mL as the high-TnT group; the others were control subjects. We recorded the highest serum creatinine, aspartate aminotransferase, alanine aminotransferase, and bilirubin levels during the first week of the hospital stay. Glomerular filtration rate (GFR) was calculated according to the Cockroft-Gault formula. RESULTS: Ten patients composed the high-TnT group. Their perioperative variables showed higher Model for End-Stage Liver Disease (MELD) scores and significantly greater incidences of acute kidney injury, failure, and dialysis need than control patients. GFR dropped from 118 to 66 mL/min among this group versus 112 to 105 mL/min in control subjects (P = .021). Binary logistic regression analysis revealed a higher association between the high-TnT group and acute kidney injury (P = .036) than with the MELD score (P = .719). CONCLUSIONS: Serum cTnT levels could be influenced by both preoperative and intraoperative conditions that predispose to kidney injury.

Hyperdynamic circulation in acute liver failure: reperfusion syndrome and outcome following liver transplantation.

BACKGROUND/AIMS: Liver transplantation (OLT) is a valid therapeutic option for patients with fulminant hepatic failure (FHF). The most critical phase during OLT is considered to be graft reperfusion, where in large changes in patient homeostasis occur. The aims of the present study were to evaluate the hemodynamic and cardiac changes among a large series of patients with FHF, to determine independent clinical predictors of the occurrence of postreperfusion syndrome (PSR) and its relationship to clinical and hemodynamic parameters and transplant outcomes. METHODS: Systemic hemodynamic and cardiac functions were evaluated by Swan-Ganz catheterization in 58 patients before OLT. The patients were divided into two subgroups on the basis of PSR, which was defined as a mean arterial blood pressure 30% lower than the immediate previous value lasting for at least 1 minute within 5 minutes after unclamping. RESULTS: PSR occurred in 24 patients (41%). Significant differences upon bivariate analysis was observed for the Model for End-stage Liver Disease score, which was significantly higher among patients with PSR, namely 32 (range = 18-43) versus 23 (range = 12-32) (P = .001). Higher serum creatinine values were significantly different among patients with PSR: 1.4 (range = 1.2-2.2) versus 2.1 (range = 2.5-3.2) mg/dL (P < .01). CONCLUSION: Systemic hemodynamic alterations of FHF progressively worsen with increasing severity of liver disease. PSR developed in approximately 40% of patients; its prevalence was significantly related to the severity of the disease. Finally, patients with renal failure showed greater risk to develop an PSR during OLT.

Pretransplant model for end-stage liver disease score as a predictor of postoperative complications after liver transplantation.

The model for end-stage liver disease (MELD) is used to determine organ allocation priorities for orthotopic liver transplantation (OLT), although its value to predict posttransplantation mortality and morbility is controversial. The aim of this study was to analyze postoperative courses and (to evaluate the relationships between MELD score and postoperative) complications. We retrospectively examined the courses of 242 patients including 186 males and 56 females of overall mean age of 53 +/- 10 years who underwent primary liver transplantation. The classification of Dindo-characterized 5 grades of severity to evaluate postoperative events. The data showed that 171 patients (70.7%) experienced complications, while 71 (29.3%) had none. We observed that MELD score and complications were related (P < .05). Patients with complicated courses post-OLT displayed a 22.80 mean value of the MELD score, while those without complications showed a 17.64 mean value. The MELD score was also significantly associated with the time of intensive care unit stay and in hospital. Finally, we noted that MELD score and mortality were significantly correlated (P < .05). In conclusion, MELD score can be considered to be an objective system to predict the prevalence and severity of postoperative complications after liver transplantation.

Lumbar spinal angiolipomas: report of two cases and review of the literature.

STUDY DESIGN: Case report and review of the literature. OBJECTIVES: To describe two patients with angiolipoma in the ventral aspect of the lumbar epidural space, to discuss the clinical, radiologic, and surgical features of these lesions, and to review previously reported cases. SETTING: Rome, Italy. METHODS: Two cases, a 60-year-old man and a 54-year-old woman presented with lumbar-sciatic pain but with no abnormal neurological signs. Investigation (CT and MRI) demonstrated lumbar tumours. RESULTS: Laminectomy and excision of the tumors were performed, and symptoms improved immediately. CONCLUSIONS: Magnetic resonance imaging with suppression fat sequences allows the recognition of these lesions. The prognosis after surgical removal of spinal angiolipoma is favorable.