Computed Tomography as Primary Screening for Appraisal of Pulmonary Small Nodules in Liver Transplant Candidates.

BACKGROUND: Chest computed tomography (CT) as a primary screening method in candidates for living donor liver transplantation (LDLT) is not yet a standardized procedure. The aim of this study is to present our methods and result of evaluation of pulmonary small nodules (PSN) after CT as a primary screening tool. PATIENTS AND METHODS: A total of 360 primary adult LDLTs were performed between October 2009 and December 2012. The 37 candidates with PSNs found on CT were divided into two groups, with 23 patients in the group that was chest radiography (CXR) positive (+) and 14 in the group that was CXR negative (-). RESULTS: The nodular size in the CXR (-) group was significantly smaller than in the CXR (+) group (3.86 ± 1.24 vs 7.56 ± 4.08, P = .004). The sensitivity of CT for PSN was 37/360 (10.28%), much higher than the 14/360 (3.89%) for CXR alone. A total of 27 patients underwent video-assisted thoracoscopic surgery for pathologic diagnosis, and 10 were diagnosed as having benign PSNs by stationary sizes on serial CT scans. In the CXR (-) group, there were 2 cases of malignancy, 3 tuberculosis (TB), 3 Cryptococcus, and 15 other benign PS. In the CXR (+) group, there were 1 malignancy, 3 TB, 4 Cryptococcus, and other 6 benign PSNs. Recurrent infection was not seen in the posttransplantation follow-up of 13 candidates with infections. Excluding the 3 malignant PSNs, the 34 candidates in both groups survived 100% for more than 2 years after LDLT. CONCLUSION: To exclude malignancy and to diagnose infectious PSN for further treatment in a timely manner, chest CT should be used as the primary screening tool for asymptomatic candidates for LDLT.

Combined Hepatocellular Carcinoma and Cholangiocarcinoma: Diagnosis and Prognosis After Resection or Transplantation.

BACKGROUND: Primary liver malignancy is the leading cause of cancer death worldwide, with hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) representing the majority. Combined HCC-CC, in contrast, accounts for less than 5% of these liver cancers and has not been clearly characterized by imaging, making diagnosis and management difficult. MATERIALS AND METHODS: This retrospective study investigated 32 patients with early-stage combined HCC-CC tumor who underwent hepatectomy (n = 24) or liver transplantation (n = 8). Preoperative imaging and pathologic reports were retrospectively reviewed and correlated. Survival and recurrence rates were then analyzed. RESULTS: Twelve patients with more than 50% CC component showed typical CC enhancement, whereas 17 patients with less than 50% CC component exhibited typical HCC enhancement. Those with equivocal imaging findings resulted near equal tumor component. The majority demonstrated either heterogeneous or peripheral enhancement. Considering the major tumor component, 66% of the images were consistent with histopathology. The over-all 3-year recurrent rate was 59%, with a mean time to recurrence of about 7 months. The 3-year survival rate of combined tumor after hepatectomy was 76% and after transplant was 75%, regardless of major tumor component. However, patients with more than 50% CC component showed a decrease in 3-year survival rate to 50% when transplantation was performed. CONCLUSION: The overall survival rate for combined tumor after either hepatectomy or transplantation seems to be satisfactory but carries a high risk of recurrent when compared to pure HCC. On the other hand, a major CC component tumor after transplantation is associated with poor survival outcome; thus, liver transplantation has no role and is not a good management option.

Sonographic Evaluation of Post-transplantation Portal Vein Stenosis in Pediatric Living-donor Liver Transplant Recipients With Left-liver Grafts.

INTRODUCTION: Portal vein (PV) stenosis is not uncommon in post-transplantation pediatric living-donor liver transplant (PLDLT) recipients. The purpose of this study was to identify specific ultrasound criteria that may be used to detect PV stenosis in PLDLT with left-liver grafts. PATIENTS AND METHODS: From January 2010 to October 2014, 87 pediatric recipients underwent PLDLT with left lobes or left lateral segments at our hospital. All patients underwent routine liver Doppler ultrasound (DUS) as follow-up protocol. The morphologic narrowing and mean time averaged velocity (TAV) at the PV anastomotic site, change in anastomotic/pre-anastomotic TAV (ΔTAV), and the umbilical portal width were evaluated and analyzed. Ultrasound findings were correlated with computed tomography angiography where PV stenosis was suspected. RESULTS: In the liver graft follow-up study, 80.4% (70 of 87 patients) of PV anastomosis was well visualized and measured by Doppler ultrasound. The optimal threshold values for TAV and ΔTAV were 49.6 cm/s and 30 cm/s, respectively, for significant PV anastomosis stenosis. In the other 19.5% (17/87), the PV anastomosis could not be identified properly. The PV anastomosis was not always visible with ultrasound; however, the optimal dilated umbilical portion of the PV indicating possible PV anastomosis narrowing threshold was umbilical portal width >1.5 cm. CONCLUSIONS: Increased anastomotic TAV and ΔTAV are useful features for diagnosing PV stenosis. The identification of a dilated umbilical portion of the left PV helps in detection of PV stenosis in PLDLT recipients especially when the anastomotic narrowed region cannot be visualized.

Portal venous pressure in adult living donor liver transplantation.

OBJECTIVE: The relationship between portal pressure and small-for-size syndrome (SFSS) is unsettled. The purpose of this study was to evaluate the role of portal pressure in predicting SFSS. METHODS: Thirty-four patients with end-stage liver disease who received adult-to-adult living-donor liver transplantation (ALDLT) were included. Recipients were grouped based on whether they received portal flow modulation or not. The intraoperative portal vein flow volume (PVFV) and portal venous pressure (PVP) between the 2 groups were compared. The relationship of PVP to PVFV, graft weight-to-recipient weight ratio (GRWR), and graft weight-to-recipient spleen size ratio (GRSSR) were analyzed. RESULTS: Persistent portal hypertension was found after ALDLT. The PVP was linearly correlated with PVFV but not with GRWR or GRSSR. With the use of the following criteria, (1) PVFV >250 mL/min/100 g graft weight, (2) GRWR <0.8%, and (3) GRSSR <0.6, modulation of the portal flow was performed in 3 cases. The receiver operating characteristic analysis showed that 23 mm Hg was the cutoff point for PVP, with a sensitivity of 83% and specificity of 43%. CONCLUSIONS: PVP is a weak parameter to use for portal flow modulation after ALDLT. It is sensitive but not specific to predict SFSS.

The 4-week serum creatinine level predicts long-term renal dysfunction after adult living donor liver transplantation.

OBJECTIVES: Recipients after liver transplantation. (OLT) often experience renal dysfunction. Acute kidney injury (AKI) and chronic kidney disease (CKD) after OLT occur among 20% to 50% and 30% to 90% of recipients, respectively; 2% to 5% of them deteriorate into end-stage renal disease each year. Since the predictable factors for CKD have not been well identified. We sought to investigate the incidence and predictors of CKD at 5 years after OLT. PATIENTS AND METHODS: Between August 2002 and December 2005, we enrolled 77 patients who underwent adult living donor OLT with over 2 years of follow-up. The strategies to prevent renal dysfunction included induction with basiliximab to delay the use of tacrolimus: addition of mycophenolate mofetil to reduce the tacrolimus dosage; avoidance of the calcineurin inhibitor using sirolimus or administration of an angiotensin II receptor antagonist. The clinical variables were reviewed for analysis. RESULTS: The mean follow-up was 76 ± 14 months. The incidence of AKI (over 50% increase level of creatinine) was 29%. Ten (13.0%) patients developed CKD (creatinine > 2 mg/dL). One (1.3%) subject developed end-stage renal disease requiring hemodialysis. Upon multivariate analysis the development of CKD was significantly associated with the posttransplant 4-week creatinine level: 0.92 ± 0.23 versus 1.37 ± 0.93 mg/dL (P = .008). CONCLUSION: The 4-week creatinine value was predictive of the occurence of CKD over 5 years after OLT.

Comparison of postoperative morphine requirements in healthy living liver donors, patients with hepatocellular carcinoma undergoing partial hepatectomy, and liver transplant recipients.

OBJECTIVE: To retrospectively evaluate postoperative morphine requirements in healthy living donors undergoing partial hepatectomy and patients with end-stage hepatocellular carcinoma or end-stage liver disease undergoing liver transplantation. PATIENTS AND METHODS: The study included all patients who received intravenous patient-controlled analgesia after partial hepatectomy or liver transplantation from May 2008 to February 2009. Patients were divided into 3 groups according to type of surgery: group 1, healthy living liver donors undergoing graft procurement; group 2, patients with liver cirrhosis due to chronic hepatitis B virus or hepatitis C virus infection and hepatocellular carcinoma undergoing hepatectomy; and group 3, patients with end-stage liver disease undergoing living-donor liver transplantation. Data including patient age, morphine use, and visual analog scale score on postoperative days (PODs) 1, 2, and 3 were compared between groups using 2-way analysis of variance. P<.05 was considered significant. Values are given as mean (SD). RESULTS: Morphine requirement was significantly lower only in group 3 on POD 1. No difference in visual analog scale score between groups was observed postoperatively. CONCLUSION: Although others have reported decreased morphine requirements on PODs 1, 2, and 3, our results indicated that morphine requirements were significantly less only on POD 1.

Decreased fresh gas flow cannot compensate for an increased operating room temperature in maintaining body temperature during donor hepatectomy for living liver donor hepatectomy.

BACKGROUND: The purpose of this study was to compare the effect of various combinations of fresh gas flow (FGF) of anesthesia and different ambient operation room temperatures (ORT) on changes in nasopharyngeal temperature (NT) among living donors undergoing partial hepatectomy. METHODS: The anesthesia records of 167 patients were reviewed retrospectively. The patients were allocated into 4 groups: GI (n=37): isoflurane in 2 L FGF and at typical ambient ORT (19 degrees C-21 degrees C); GII (n=11) isoflurane in 1 L FGF and 1 L air at typical ORT; GIII (n=31) isoflurane in 0.5 L FGF at typical ORT; and GIV (n=88) isoflurane in 0.5 L FGF at ORT of 24 degrees C. The changes in NT were compared using a two-way repeated measure analysis of variance (ANOVA) followed by Bonferroni post hoc tests. RESULTS: Changes of NTs of GIV were significantly higher compared with the other 3 groups, whereas the changes of NTs were the same among GI, GII, and GIII. CONCLUSION: FGF of different volumes seemed to have no significant effect on intraoperative changes of NT in regular ORT. Low-flow anesthesia combined with ORT of 24 degrees C provided significantly higher NTs at all measured points compared with GI, GII, and GIII.

Doppler ultrasound evaluation of postoperative portal vein stenosis in adult living donor liver transplantation.

AIM: To evaluate the postoperative portal vein stenosis (PVS) and the diagnostic efficiency of Doppler ultrasound (DUS) in adult living donor liver transplantation (ALDLT). MATERIALS AND METHOD: From January 2007 to December 2008, 103 ALDLTs were performed and postoperatively followed by routine DUS. The morphologic narrowing at the anastomotic site (AS) of the PVS was analyzed. We calculated the PV stenotic ratio (SR) using the following formula: SR (%)=PRE-AS/PRE (PRE=pre-stenotic caliber). An SR>50% was defined as the critical point for PVS. We also calculated the velocity ratio (VR) between the AS and PRE, and set the significant VR as >3:1. Statistical analyses were carried out to determine clinical significance. RESULTS: Using the definition of morphologic PVS by DUS, there were total 20 cases (19.4%) in this series with SR>50%, which included 17 cases with VR>3:1. Eight cases of severe PVS had a stenotic AS>5 mm and subsequently underwent interventional management. Doppler criteria of SR and VR values were elevated up to 75.8% and 7.5:1, respectively, in these treated cases. Two cases of severe PVS subsequently developed PV thrombosis. Intervention by balloon dilation and/or stenting was performed successfully in this PVS case. CONCLUSION: DUS is the most convenient and efficient imaging modality to detect and follow postoperative PVS in ALDLT. The Doppler criteria of SR and VR are both sensitive but less specific. Cases of AS<5 mm require interventional management for good long-term graft survival.

Effects of hemorrhagic shock in early and late partial posthepatectomy rats.

INTRODUCTION: The purpose of the study was to determine the compensatory function of the remnant liver as a blood reservoir after 70% hepatectomy in rats to counteract hemorrhagic shock and reperfusion. METHODS AND MATERIALS: One hour of hemorrhagic shock followed by 1 hour of resuscitation induced in normal rats (group I) was compared with animals that had undergone 70% hepatectomy at postoperative day 3 (group II) and day 7 (group III). We compared the total blood loss, the blood pressure before hemorrhagic shock, hemoglobin, hemotocrit, and mortality. Liver function such as aspartate transferase (AST), alanine transferase, and lactate dehydrogenase (LDH) were also compared among groups by one-way analysis of variance with post hoc correction. A P value less than .05 was regarded as significant. RESULTS: The results showed a lower volume of drawn blood induced hemorrhagic shock in group II compared with group I or group III hosts. The blood loss was 15.6+/-1.0, 5.68+/-2.5, and 13.2+/-1.6 mL for groups I, II, and III, respectively. The mortality due to hemorrhagic shock was significantly higher in group II compared with group I or group III. Liver function tests showed that the AST and LDH were significantly higher after resuscitation in group II. CONCLUSION: In the early postoperative period (day 3) after 70% hepatectomy, rats were more vulnerable to a high mortality after hemorrhagic shock compared with hosts in the late postoperative period (day 7). Significantly higher AST and LDH in group II indicated that the remnant liver was more injured after hemorrhagic shock in the early postoperative period.

Effects of different operating room temperatures on the body temperature undergoing live liver donor hepatectomy.

OBJECTIVE: We sought to compare the effects of operation room temperature (ORT) at typical ambient environment (19-21 degrees C) and ORT at 24 degrees C on the core temperature of patients undergoing living donor hepatectomy. METHODS AND PATIENTS: Sixty-two patients undergoing living donor hepatectomy were divided into 2 groups. In group I (n = 31), surgery was performed at typical ambient ORT, and in group II (n = 31) in ORT at 24 degrees C. Anesthesia and measures to prevent heat loss, except ORT, were all the same. Nasopharyngeal temperature (NT) was recorded after anesthesia induction, then hourly until completion of the operation. Changes in NTs were analyzed as well as patient age, weight, anesthetic duration, blood loss, intravenous fluids, total urine output, and pre- and postoperative hemoglobin and hematocrit values. The Mann-Whitney U test was used for comparisons between groups. RESULTS: The patient's characteristics between groups were not statistically different. However, a significantly higher core temperature was noted in group II compared with group I. Increased ORT from 19 to 21 degrees C to 24 degrees C resulted in an increased core temperature of at least 0.5 degrees C during living donor hepatectomy.

Preoperative vascular evaluation in living donor liver transplantation for biliary atresia.

BACKGROUND: Liver transplantation is an important treatment option in the management of end-stage liver disease. Preoperative vascular evaluation plays an important role for a safe and successful operation, especially in pediatric patients undergoing living donor liver transplantation (LDLT). PURPOSE: The purpose of this study is to assess the usefulness and accuracy of Doppler ultrasound (US), computed tomographic angiography (CTA), and magnetic resonance angiography (MRA) in evaluating vascular anomalies in patients with biliary atresia (BA) undergoing LDLT. METHODS AND MATERIALS: Images of Doppler US, CTA, and MRA for preoperative vascular evaluation in 55 patients with BA undergoing LDLT were reviewed with the operative findings. RESULTS: All patients underwent preoperative US, CTA, and MRA. Pathologic portal vein (n = 18), interruption of the retrohepatic vena cava (n = 1), and aberrant right hepatic artery from the superior mesenteric artery (n = 2) were confirmed during the transplantation. The success rates of CTA and MRA in identifying vascular anomalies were 96% and 82%, respectively (P = .01). The sensitivity, specificity, and accuracy of Doppler US were 89%, 94%, and 92%, respectively. For CTA, it was 94%, 97%, and 96%, respectively; for MRA (including technical failure), it was 75%, 97%, and 89%, respectively. CONCLUSION: Doppler US serves as an initial assessment for vascular evaluation and has the advantage in determining vascular flow quantities. CTA and MRA are used for precise surgical planning. However, MRA has lower success and accuracy rates when compared with CTA (P = .01). Doppler US with CTA can provide accurate preoperative vascular imaging in patients with BA undergoing LDLT.

Correlation between hepatic steatosis, hepatic volume, and spleen volume in live liver donors.

INTRODUCTION: The purpose of this study was to evaluate the changes in liver fatty content and the volumes of liver and spleen after body weight reduction in potential living liver donors. MATERIALS AND METHODS: Twenty-three potential living donors had fatty livers at pretransplantation sonography and computed tomography (CT). All were advised to undergo body weight reduction by exercise and diet control. A percutaneous core liver biopsy was performed in segment 5 of the liver in 22 donors to evaluate the hepatic fat content before and after body weight reduction. We compared the changes in the liver CT attenuation values and volume changes in the left and right lobes of the liver and the spleen before and after body weight reduction. RESULTS: The mean (SD) body weight, body mass index, and fatty content of the liver biopsy specimens were 73 (17) kg, 26.8 (4.4), and 16.9% (12.7%), respectively, before body weight reduction and 70 (15) kg, 25.3 (3.8), and 6.6% (3.7%), respectively, thereafter. These changes were significant. The CT attenuation values of the left and right lobes of the liver and spleen were 54 (11), 51 (11), and 52 (5) HU, respectively, before body weight reduction and 60 (8), 58 (6), and 53 (5) HU, respectively, thereafter. The mean CT attenuation value of the left lateral segment was greater than that of the right lobe both before and after body weight reduction. The volume of the left and right lobes and spleen changed from 497 (129) cm3 to 452 (99) cm3, 927 (237) cm3 to 846 (173) cm3, and 185 (65) cm3 to 186 (63) cm3, respectively, thereafter. The right and left lobe volume change ratios were 7.0% (10.6%) and 7.6% (11.1%), respectively, but showed no significant difference. Twenty of the 23 candidates were able to donate part of their liver. CONCLUSION: Body weight reduction by exercise and diet control in potential living liver donors is effective to reduce the fatty content of the liver. Reversed percentage of the fatty content and volume of the liver was observed in these donors. The volumes of the right and left lobes of liver decreased significantly after body weight reduction. The volume changes were proportional.

Bispectral index monitoring in healthy, cirrhotic, and end-stage liver disease patients undergoing hepatic operation.

The purpose of this study was to assess factors influencing the end-tidal concentrations of isoflurane within a bispectral index (BIS) range of 45-55 among healthy live liver donors (n = 11), chronic hepatitis B patients undergoing hepatectomy hepatocellular carcinoma (n = 10), and end-stage liver disease patients undergoing liver transplantation (n = 7). Patients data collected prospectively were compared among the groups using one-way analysis of variance as well as univariate and multivariate techniques. The results showed that end-stage liver disease patients required the least end-tidal isoflurane concentration. Patients with hepatocellular carcinoma with cirrhosis required intermediate end-tidal isoflurane concentrations; healthy live liver donors required the highest end-tidal isoflurane concentrations to provide sufficient anesthetic depth, as monitored by a target BIS (range, 45-55). Upon multivariate analysis, liver function was the only significant factor influencing the likelihood of lowering the end-tidal isoflurane concentration by 4 hours after anesthesia induction (P = .026). In conclusion, we recommend a preset target BIS within the range of 45-55 to monitor the depth of anesthesia during partial hepatectomy and liver transplantation because end-tidal isoflurane concentration requirements are different for patients with various liver status. This strategy may protect the patients from intraoperative recall or anesthesia over-depth as a consequence of insufficient or overdose of anesthesia, respectively.

Retransplantation for end-stage liver disease: a single-center Asian experience.

Liver retransplantation carries a significantly higher morbidity and mortality compared with patients after single transplantations. The aim of this study was to review our outcomes in liver retransplantations. From February 1984 to February 2007, 409 liver transplantations were performed on 396 patients, including 13 retransplantations (3.2%) in 12 patients. The mean follow-up was 1.6 +/- 0.4 years (range, 0.1-5.2). The mean duration between the first and the second transplantation was 2.8 +/- 1.0 years (range, 15 days-11.6 years). The indications for the first liver transplantation included biliary atresia (n = 3), hepatitis B virus (HBV)-related cirrhosis with hepatoma (n = 3), fulminant hepatic failure (n = 2), HBV-related end-stage liver disease (n = 1), hepatitis C virus (HCV)-related end-stage liver disease (n = 1), neonatal hepatitis (n = 1), and glycogen storage disease (n = 1). The indications for retransplantations were secondary biliary cirrhosis (n = 3), veno-occlusive disease-related liver failure (n = 2), hepatic arterial occlusion and graft failure (n = 2), chronic rejection with hepatic graft failure (n = 2), recurrent HBV (n = 1) and de novo HBV-related decompensated cirrhosis (n = 1), and idiopathic graft failure (n = 1). There were 4 living donor and 9 deceased donor liver retransplantations. The cumulative survival rate was 71.4 +/- 14.4%, with an estimated mean survival time of 3.9 +/- 0.7 years. Our results showed that minimizing the rate of retransplantation was critical to enhance overall patient survival. Moreover, living donor liver retransplantation is another option within the short, yet critical, waiting period, after failure of the first graft. Provided that a suitable living donor is available, we recommend early retransplantation to minimize the risk of morbidity and mortality.

Fate of atrial septal defect in children with end-stage liver disease undergoing living donor liver transplantation.

BACKGROUND AND OBJECTIVE: The course of atrial septal defects (ASD) in children undergoing liver transplantation is poorly described. Our objective was to present our experience in living donor liver transplantation (LDLT) in children with type II ASD. PATIENTS AND METHODS: Between June 1994 and December 2006, 18/140 (12.8%) pediatric LDLT were diagnosed to have both type II ASD and end-stage liver disease. We reviewed the records of these patients. The median follow-up was 48.7 months. Data were analyzed using descriptive statistics. RESULTS: There were 8 male and 10 female patients whose overall mean age was 12 months. There were 15 biliary atresia and 3 neonatal hepatitis patients. The median Child score was 9. The mean Pediatric Model End-stage Liver Disease score was 14. There were 13 with small (< or =4 mm), 4 with medium (5 to 9 mm), and 1 large (>10 mm) ASD. Six small ASD closed spontaneously pretransplant. Seven small ASD closed posttransplant. The medium and large ASD persisted or increased in size posttransplant. Only one patient showed hemodynamically significant ASD based on cardiac echocardiography and catheterization. This patient underwent Amplatzer closure of the ASD at 10 months posttransplant. All patients are surviving with their original grafts to date. There were no perioperative cardiac or neurologic complications. CONCLUSION: This series demonstrated that LDLT can be safely performed in hemodynamically stable patients with small- to large-sized ASD. Small ASD may close pre- or posttransplant.

Diagnosis and interventional radiological treatment of vascular and biliary complications after liver transplantation in children with biliary atresia.

OBJECTIVE: Early diagnosis and appropriate management of vascular and biliary complications after living donor liver transplantation (LDLT) result in longer survival. We report our institutional experience regarding radiological management of these complications among patients with biliary atresia (BA) who underwent LDLT. METHODS: We analyzed the records of 116 children. All patients underwent Doppler ultrasound (US) at operation, daily for the first 2 postoperative weeks, and when necessary thereafter. After primary evaluation using US, the definite diagnosis of postoperative complication was confirmed using computed tomography, magnetic resonance imaging, and/or operation. RESULTS: There were 61 boys and 55 girls. The overall mean age was 2.69 years. The overall mean preoperative weight and height were 13.06 kg and 83.79 cm, respectively. There were 28 (24.13%) biliary and vascular complications. These were cases of biliary stricture (n = 5), bile leakage (n = 3), hepatic artery stenosis (n = 6), hepatic vein stenosis (n = 4), and portal vein thrombosis (n = 17). The diagnostic accuracy of US in detecting biliary complication, hepatic artery stenosis, hepatic venous stenosis, and portal vein thrombosis was 95.69%, 97.41%, 100%, and 100%, respectively. US in combination with multiple imaging modalities and clinical suspicion resulted in 100% diagnostic accuracy. Percutaneous transhepatic cholangiography, thrombolysis, balloon angioplasty, and stent placement were performed for the complications noted. There was an early mortality due to multiple-organ failure after failed radiological invention and subsequent surgical management. CONCLUSIONS: Doppler US is accurate in detecting postoperative complications after pediatric LDLT for BA. Radiological interventions for vascular and biliary complications are effective and safe alternatives to reconstructive surgery.

Rhabdomyolysis after liver transplantation: a case report.

Our aim was to present the case of a pediatric biliary atresia patient who experienced rhabdomyolysis with severe cardiac arrhythmias associated with hyperkalemia, metabolic acidosis, and myoglobulinemia during liver transplantation. A 5-year-old girl, weighing 16.5 kg, with end-stage liver disease due to biliary atresia underwent living donor liver transplantation. A sudden onset of atrial fibrillation with rapid ventricular response was noted during the transplantation. The cardiac arrhythmia was associated with hyperkalemia, metabolic acidosis, and myoglobulinemia. Rhabdomyolysis was suspected. Hyperkalemia and metabolic acidosis were not corrected despite treatment with 10 mL of 50% glucose plus 6 U of regular insulin in 4 succeeding boluses and 110 mEq sodium bicarbonate before sending the patient to the intensive care unit. A corresponding decrease and normalization in serum potassium and correction of metabolic acidosis were noted as responses to a single dose of intravenous (20 mg) dantrolene. The patient was extubated 5 days after transplantation. The kidney function remained within normal limits during the rhabdomyolysis and the entire hospital stay. The patient was discharged 7 weeks later and is surviving with the original liver graft and satisfactory kidney function to date.

Anesthesia management in a patient with an abdominal aortic aneurysm undergoing liver transplantation: a case report.

We describe the anesthetic management in a 56-year old man with hepatocellular carcinoma and cirrhosis who underwent liver transplantation (LT). Pretransplantation workup showed a 3-cm wide by 10-cm long infrarenal abdominal aortic aneurysm (AAA) with chronic dissection. He subsequently underwent living donor LT. The total operative time was 12 hours. The systolic blood pressure was maintained at normal levels. Severe hypertension was not noted. Hypotension noted during the anhepatic phase was managed with increased volume infusion and small doses (0.1 mg) of intravenous phenylephrine. Metabolic acidosis and ionized hypocalcemia were corrected accordingly. Total blood loss was 460 mL. Blood or blood products were not given. The intravascular volume was replaced with 1400 mL of 5% albumin and 10,610 mL of crystalloid. Extubation was performed in the intensive care unit at 12 hours after the operation. The postoperative course was unremarkable. The patient is alive at 3 years after LT. Patients with AAA undergoing LT present a challenge to the anesthesiologist because among the risk factors for rupture, blood pressure is the only factor under his or her control during the operation. If blood loss can be kept to a minimum and hemodynamic stability achieved, a chronically small dissected AAA may not be a contraindication to LT.

Electroporative alpha-MSH gene transfer attenuates thioacetamide-induced murine hepatic fibrosis by MMP and TIMP modulation.

Hepatic fibrosis represents a process of healing and scarring in response to chronic liver injury. alpha-Melanocyte-stimulating hormone (alpha-MSH) is a 13-amino-acid peptide with potent anti-inflammatory effects. We have previously demonstrated that alpha-MSH gene therapy protects against thioacetamide (TAA)-induced acute liver failure. Therefore, the aim of this study is to investigate whether alpha-MSH gene therapy possesses antihepatic fibrogenic effect. Liver fibrosis was induced by long-term TAA administration in mice. alpha-Melanocyte-stimulating hormone expression plasmid was delivered via electroporation after liver fibrosis was established. Our results showed that alpha-MSH gene therapy attenuated liver fibrosis in TAA-treated mice. Reverse transcription polymerase chain reaction revealed that alpha-MSH gene therapy attenuated the liver transforming growth factor-beta1, collagen alpha1 and cell adhesion molecule mRNA upregulation. Following gene transfer, the expression of alpha-smooth muscle actin and cyclooxygenase-2 were both significantly attenuated. Further, alpha-MSH significantly increased matrix metalloproteinase (MMP), while tissue inhibitors of matrix metalloproteinase (TIMPs) were inactivated. In summary, alpha-MSH gene therapy reversed established liver fibrosis in mice and prevented the upregulated fibrogenic and pro-inflammatory gene responses after TAA administration. Its collagenolytic effect might be attributed to MMP and TIMP modulation. Hence, alpha-MSH gene therapy may be an effective therapeutic modality against liver fibrosis with potential clinical use.

Anesthetic management of a pregnant living related liver donor.

Pregnancy is often considered a contraindication to living related liver donation. There are serious medical and ethical considerations if a pregnant woman insists on undergoing partial hepatectomy to save her sick child. Herein we report a case of living related liver donation from a pregnant woman at 18 weeks of gestation to her 1-year-old child with decompensated cirrhosis due to biliary atresia. The left lateral segment of the liver was harvested for donation. Meticulous surgical technique and anesthetic management were mandatory in assuring a successful outcome. While this isolated case demonstrated that living related liver donation can be performed successfully with a pregnant donor, it should be undertaken only when there is absolutely no other donor and the recipient is in urgent need.