Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist.

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Nutritional Status and Circulating Levels of Fat-Soluble Vitamins in Cystic Fibrosis Patients: A Cohort Study and Evaluation of the Effect of CFTR Modulators.

BACKGROUND: Improved therapy in CF has led to an overall improvement in nutritional status. The objectives of our study are: to cross-sectionally assess nutritional status and serum levels of fat-soluble vitamins; to retrospectively evaluate the efficacy of modulators on nutritional status and fat-soluble vitamin levels. METHODS: In patients younger than 2 years of age, we evaluated growth, in patients aged 2-18 years, we assessed BMI z-scores, and in adults, we assessed absolute BMI values. Levels of 25(OH)D, vitamins A, and E were measured. RESULTS: A cross-sectional analysis was conducted on 318 patients, 109 (34.3%) with pancreatic sufficiency. Only three patients were under 2 years old. In 135 patients aged 2-18 years, the median BMI z-score was 0.11, and 5 (3.7%) patients had malnutrition (z-score ≤ 2SD). In 180 adults, the median BMI was 21.8 kg/m2. Overall, 15 (13.7%) males (M) and 18 (25.3%) females (F) were underweight (18 < BMI > 20); 3 (2.7%) M and 5 (7.0%) F had a BMI < 18. Suboptimal 25(OH)D levels were found in patients with pancreatic insufficiency. The prevalence of deficiency of vitamins A and E is low. After one year of treatment with modulators, the increase in BMI was more consistent (M: 1.58 ± 1.25 kg/m2 F: 1.77 ± 1.21 kg/m2) in elexacaftor/tezacaftor/ivacaftor (ETI)-treated patients compared with other modulators, with a significant increase in levels of all fat-soluble vitamins. CONCLUSIONS: Malnutrition is present in a limited number of subjects. The prevalence of subjects with suboptimal 25(OH)D levels is high. ETI showed a beneficial effect on nutritional status and circulating levels of fat-soluble vitamins.

Suicidality in adolescents with onset of anorexia nervosa.

OBJECTIVES: The mortality rate in patients with anorexia nervosa (AN) is 5 to 10 times higher than in general population and, suicide is one of the main causes of death. We evaluated the prevalence of suicidality (ideation, self-injurious behaviour, suicidal attempts) in 100 adolescents with onset of AN and we explored the correlation between suicidality, severity of AN symptoms and psychiatric comorbidity. METHODS: We subdivided AN patients into restrictive (R-AN; n = 66) and restrictive atypical (A-AN; n = 34), according to the European Guidelines criteria. Assessment was performed using the eating disorder inventory 3rd version, the schedule for affective disorders and schizophrenia for school-age children-present and lifetime version interview, and the Columbia-suicide severity rating scale. Fisher's exact test and Mann-Whitney test (with correction for multiple testing) were used to compare the distribution of categorical and continuous variables between R-AN and A-AN patients, and between patients with vs. without suicidal behaviours. RESULTS: Twenty-seven patients (27%) presented suicidality as clinical feature, expressed as at least one of the following: suicidal ideation (24%), self-cutting (19%), and suicidal attempt (6%). Patients with suicidality showed greater severity of psychiatric symptoms related to AN psychopathology and presented psychiatric comorbidity, especially depression, more often than patients who did not reported suicidality (70,4% vs 29,6%). No significant differences in terms of suicidal behaviours and AN-specific psychopathology were found between R-AN and A-AN. CONCLUSIONS: Suicidality in adolescent patients with R-AN and A-AN seems to be related to ED symptoms. These data highlight the importance of screening for suicidality among adolescents at onset of AN, and confirms that A-AN should not be considered a milder disease. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia.

TIPS is a percutaneous procedure which diverts blood from the portal to the systemic circulation preventing rebleeding from varices and stopping or reducing the formation of ascites. The choice of the anaesthetic technique is still a matter of debate. Since January 2003, 150 consecutive TIPS were performed using total intravenous anesthesia (TIVA), (propofol/fentanyl or remifentanil), endotracheal intubation and mechanical ventilation. Sixty-one patients were classified as ASA 2, 73 ASA 3, and 16 ASA 4. According to CHILD classification, 96 patients were in Class A, 48 in Class B, 6 in Class C. Mean duration f the procedure was 100+/-62 min. After TIPS placement Portal vein pressure decreased from 30+/-10 to 14+/-4 mmHg while RAP increased from 8+/-4 to 12+/-6 mmHg. Intraoperative fluid management included mainly crystalloids (750+/-200 ml, 5.4+/-1.5 ml/kg/h). Fresh frozen plasma (median 2 units, range 1-3) was given in 20 patients (13%) if PT INR was >2. Packed red cells (median 2 units, range 1-5) were transfused in 35 patients (23%) to keep haematocrit >25%; platelets were administered before the procedure if platelet count was <50,000x10(-9) (20 patients, 13%). Urine output was kept above 4 ml/kg/h with loops diuretics (mean diuresis 700+/-200 ml, 5+/-1.5 ml/kg/h). Ten patients (6.6%) required ICU after the procedure, because of intraoperative hemodynamic instability. Three patients (2%) died in the early postoperative period because of multiple organ failure associated with the acute deterioration of an already marginal hepatic function.