The clinical value of early extubation.

PURPOSE OF REVIEW: The trend to extubate patients as soon as possible following large and complex surgery is supported by a large body of evidence showing early extubation is safe and saves money. However, the use of early extubation in liver transplant recipients is still debated. This review will explore the reasons why there is still resistance to the use of early extubation in liver transplantation. RECENT FINDINGS: Studies show the majority of liver transplant recipients can be extubated immediately after surgery. A multiinstitutional study addressed the safety of immediate postoperative intubation and confirmed that the rate of complications and reintubation was similar to the very low rate observed in recovery room patients. Investigators, however, cannot agree on what patient or donor factors predict successful extubation. These variables seem to differ between institutions. SUMMARY: There is robust evidence to support the use of immediate postoperative ventilation in liver transplant recipients. There is no evidence, however, to show that routine ventilation of all transplant recipients provides outcomes that are as good as those documented in extubated patients. It is probably time to turn the evidentiary tables around and ask proponents of routine ventilation to prove that they have done no harm and that they meet the new minimal performance standards established by immediate postoperative extubation.

Adjustable gastric banding in a morbidly obese patient during liver transplantation.

The increase in morbidly obese (MO; BMI >35) patients requiring liver transplant has mirrored the growing prevalence of obesity in the USA. However, there is considerable debate among physicians whether these patients should undergo transplantation. This is because outcome analysis shows that long-term survival following transplant is adversely affected by complications caused by MO. To date, there is little experience treating MO in transplant patients. Sustained weight reduction in MO liver transplant recipients would likely improve long-term survival and resolve the debate over whether these patients should receive a transplant. Three investigators have described good outcomes from bariatric surgical interventions following liver transplantation. But this requires a second operation with all the attendant risks of additional surgery and anesthesia. This report details an innovative step in the care of the MO transplant recipient: the placement of a gastric band at the time of transplantation. We describe the success of the combined procedure at 6 months following transplantation.