Comparison of Patients With and Without Anterior Sector Venous Drainage in Right Lobe Liver Transplantation From Live Donors in Terms of Complications, Rejections, and Graft Survival: Single-Center Experience.

AIM: The issue of performing an anastomosis of the anterior sector veins to the vena cava in living donor liver transplantation is still controversial. We aimed to research whether there was any difference in terms of complications, rejections, and graft survival between patients with and without anterior sector venous drainage to the vena cava. PATIENTS AND METHODS: Patients were retrospectively investigated for demographic data and ratio of graft needed to available graft weight. Donors had volumetric calculations and middle hepatic vein anterior sector drainage documented in detail. RESULTS: Seventy-three donors with middle hepatic vein drainage were included. Thirty-five had anterior sector venous drainage performed and 38 patients did not have drainage procedures performed. The incidence of general complications was higher in the group without anterior sector drainage (78.3% and P = .002). Biloma linked to bile leaks were observed in 8 patients without drainage (72.8%) and 3 patients with drainage (27.2%). Late acute rejection occurring during follow up after transplantation was identified in 28 patients (11.6%). Of these, 1 (14.3%) had anterior sector drainage and 6 (85.7%) were in the patient group without drainage (P = .067). CONCLUSION: As a result of this study, for patients with grafts at the volume limit (graft weight to receiver weight ratio <0.8) and with congestion observed in the anterior sector after liver implantation and for patients with outflow problems identified on Doppler ultrasonography, anterior sector veins >5 mm should definitely be drained into the vena cava. Hence, both complication and rejection rates will reduce, and we can lengthen the graft, and thus patient, survival.

Hepatic Artery Reconstruction With Autologous Inferior Mesenteric Artery Graft in Living Donor Liver Transplant Recipients.

INTRODUCTION: In living donor liver transplantation (LDLT), hepatic arterial continuity is crucial to avoid biliary leakage, biliary stricture, cholangitis, and graft and patient loss. Sometimes there exist factors making anastomosis difficult or even impossible. In these cases, a vascular graft may be needed to bridge the two arteries for revascularization. METHOD: Medical records of 297 patients who underwent LDLT between June 2000 and July 2016 at the Hepatopancreatobiliary Surgery and Liver Transplantation Unit of Dokuz Eylul University Hospital were reviewed retrospectively. Twenty-eight (9%) patients younger than the age of 18 were excluded from the study. The remaining 269 patients were included in the study. We analyzed data of patients who developed hepatic arterial complications during or after LDLT and underwent revascularization using autologous interposed inferior mesenteric artery (IMA) grafts. RESULTS: In 8 (2.9%) of the 269 patients who underwent LDLT and were included in the study, autologous interposed IMA grafts were used for the hepatic artery revascularization. All of the patients were males. Their mean age was 42 (range, 25-57). The mean duration of follow-up was 83.25 months (range, 3-144 months). One patient developed intraoperative hepatic arterial thrombosis (HAT) after autologus IMA reconstruction and this patient needed retransplantation. No arterial complications developed in the other 7 patients. CONCLUSION: Autologous interposed IMA graft could be used as an alternative vascular graft in hepatic artery revascularization to provide tension-free hepatic arterial continuity.

Complications in Donors Using Right Liver Graft: Analysis of 280 Consecutive Cases.

INTRODUCTION: Living donor liver transplantation (LDLT) is performed with increasing frequency worldwide due to the shortage of donated organs. It is a life-saving procedure for the recipient, but, on the other hand, a major surgical procedure for healthy donors and it may cause morbidity and even mortality. PATIENTS AND METHODS: This research was completed at Dokuz Eylül University Faculty of Medicine Hospital General Surgery Department Liver Transplant Unit and included 280 cases (4 with simultaneous liver and kidney transplants from living donors) who underwent donor right hepatectomy for LDLT from June 2000 to June 2016. We analyzed the data of patients retrospectively. RESULTS: Of 280 donor right hepatectomies for LDLT, 181 were male (M; 64.6%) and 99 were female (F; 35.4%) (M/F: 1.82). Mean donor age was 31.2 ± 0.9 years (range, 18-56). Mean donor monitoring duration was 45 ± 2.4 months (range, 3-192 months). Mean body mass index (BMI) was 24.28 ± 2.96 kg/m2 (range, 18.1-32.42 kg/m2). In our study 72 cases (25.7%) developed postoperative complications. There were 17 Clavien grade 3A, 1 grade 3B, and 5 grade 4A complications and also 1 death due to pulmonary embolism. CONCLUSION: Together with the increase in living donor surgery, the morbidity and mortality of these cases are becoming controversial. Full donor safety is only possible with appropriate donor choice requiring very detailed studies, a problem-free hepatectomy process, and close postoperative donor monitoring.

Comparison of the RIFLE, AKIN, and KDIGO Diagnostic Classifications for Acute Renal Injury in Patients Undergoing Liver Transplantation.

BACKGROUND: The aim of this study was to determine the incidence and peri-operative risk factors for acute renal injury (ARI) and their relationship with mortality rate through the use of 3 different ARI diagnostic classifications in patients after liver transplantation (LT). METHODS: We retrospectively investigated the medical records of adult LT recipients. Post-operative ARI was determined with the Risk, Injury, Failure, Loss, and End-Stage Renal Failure (RIFLE), Acute Kidney Injury Network (AKIN), and Kidney Disease: Improving Global Outcomes (KDIGO) classifications. RESULTS: We analyzed 440 adult patients. The post-operative incidence of ARI was 8.0% by the RIFLE classification, 14.31% by the AKIN classification, and 14.54% by the KDIGO classification. Significant risk factors for ARI were pre-operative albumin (odds ratio [OR], 0.776; 95% confidence interval [CI], 0.473-1.273 for AKIN; and OR, 0.724; 95% CI, 0.444-1.182 for KDIGO) and hemoglobin levels (OR, 2.830; 95% CI, 1.157-6.9261 by RIFLE), intra-operative red blood cell transfusion (OR, 1.072; 95% CI, 1.004-1.143 by AKIN; and OR, 1.077; 95% CI, 1.011-1.147 by KDIGO), and blood loss (OR, 1.00; 95% CI, 0.999-1.000 by RIFLE). The early mortality rate was 7.9% in our series. CONCLUSIONS: The RIFLE, AKIN, and KDIGO ARI classifications classify the severity of renal dysfunction in patients who have undergone LT. Direct associations were found between higher mortality rates and severity of renal disease.

Effect of magnesium sulfate on renal ischemia-reperfusion injury in streptozotocin-induced diabetic rats.

OBJECTIVE: Ischemia/reperfusion (I/R) injury is a major cause of acute organ dysfunction and I/R related acute renal failure is a common clinical problem. Diabetes mellitus is defined as a risk factor for the development of acute renal injury as diabetic nephropathy compromises the renal tolerance to ischemia. The aim of this study was to investigate the protective effect of magnesium sulfate in a diabetic rat renal I/R injury model. MATERIALS AND METHODS: Diabetes mellitus was induced using streptozotocin. Thirty-five rats were divided into five groups: Group I: Nondiabetic sham group; Group II: Diabetic sham group; Group III: Diabetic I/R group; Group IV: Diabetic I/R + prophylactic (preischemic) MgSO4; and Group V: Diabetic I/R + therapeutic (following reperfusion) MgSO4 group. MgSO4 was administered 200 mg/kg intraperitoneally. Renal I/R (45 min ischemia + 4 h reperfusion) was induced in both kidneys. Histomorphological, immunohistochemical (caspase-3 and iNOS) and biochemical (BUN, Creatinine) methods were performed to assess the blood and tissue samples. RESULTS: Histomorphological injury scores and immunostaining intensities (for both caspase-3 and iNOS) were significantly lower in the MgSO4 administered groups (prophylactic and therapeutic) than in the Diabetic IR group. There were no significant differences in biochemical parameters (BUN, Cr) between the MgSO4 administered groups and the Diabetic IR group. CONCLUSIONS: In the present study, it was demonstrated by histomorphological and immunohistochemical methods that magnesium sulfate administration before ischemia or following reperfusion significantly reduced renal I/R injury in a diabetic rat model.

Incidence of Late Acute Rejection in Living Donor Liver Transplant Patients, Risk Factors, and the Role of Immunosuppressive Drugs.

INTRODUCTION: Late acute rejection (LAR) is a clinical manifestation that occurs 6 months after liver transplantation, shows histopathologic features different from those of acute rejection, and is the cause of a high prevalence of morbidity and mortality. METHODS: In this study, hospital records of 211 living donor liver transplantation (LDLT) patients who underwent surgery in our clinic between June 2000 and February 2014 were reviewed retrospectively. The patients were ≥ 18 years old and were followed for ≥ 6 months. RESULTS: Of the 211 patients, 21 (9.9%; 16 males, 5 females) developed LAR. The mean age of the patients was 46 years (range, 33-58). The mean follow-up period was 61.2 months (range, 6-152) and the median time to development of LAR was 26.4 months (range, 7-77). In our study, patients who received cyclosporine and mycophenolate mofetil (MMF) treatment developed more LAR than did patients who received tacrolimus and MMF therapy (P = .05). In addition, the incidence of LAR in patients who underwent LDLT was significantly greater in the ABO-matched groups than in the ABO identical group (P = .028). CONCLUSIONS: Development of LAR and serious complications related to it can be avoided if liver transplant recipients are followed regularly and closely in outpatient clinics after transplantation.

Acute Renal Injury Evaluation After Liver Transplantation: With RIFLE Criteria.

BACKGROUND: The aim of this study was to identify acute renal injury (ARI) through the use of RIFLE (risk, injury, failure, loss, end-stage kidney disease) criteria and to investigate perioperative risk factors for ARI in liver transplantation (LT). METHODS: We reviewed medical records of adult LT patients retrospectively. Postoperative ARI was staged with RIFLE criteria by the 1st and 7th days of the surgery. RESULTS: We analyzed 440 adult LT patients, categorized as risk (R), injury (I), or failure (F) according to the RIFLE criteria. In this study, in the first postoperative day, incidence of ARI was 7.95%; all of them were R-class, and, on the 7th day, the incidence of ARI was 7.27%, as R-class 6.59% and I-class 0.68%. Significant risk factors were detected within the first postoperative day including pre-operative hemoglobin levels <9 g/dL (P = .019), intra-operative transfusion of red blood cells (RBCs) (P = .049) and fresh-frozen plasma (FFP) (P = .049), blood loss (P = .011), and post-reperfusion syndrome (P = .023). Multivariate analysis revealed risk factors for ARI as RBCs (odds ratio [OR], 1.049; P = .247) and FFP (OR, 1.017; P = .627) transfusion and blood loss (OR, 1.000; P = .021) (blood loss OR: 0.9996952300184; 95% confidence interval: 0.9994356774026 to 0.999548500399). The only significant risk factor for the 7th postoperative day was the Model for End-Stage Liver Disease (MELD) score (>20) (P = .002). CONCLUSIONS: This study showed that RBC and FFP transfusion, perioperative blood loss, and MELD score >20 are risk factors for LT-related ARI. Also normalization of hemoglobin levels with non-blood products in patients with preoperative low hemoglobin levels can diminish the need for RBC and that can prevent ARI.

Risk factors for early bacterial infections in liver transplantation.

OBJECTIVE: Our aim was to determine perioperative risk factors for early bacterial infection after liver transplantation. METHODS: Retrospectively examining medical records using Centers for Disease Control and Prevention (CDC) definitions to identify nosocomial infections, we analyzed data on 367 adult patients. RESULTS: The incidence of infection was 37.3% (n = 137): namely, surgical site (n = 74; 20.2%) [corrected], blood stream (n = 64; 17.4%), pulmonary (n = 49; 13.4%), urinary system (n = 26; 7.1%). Significant risk factors within the first 30 days were as follows: deceased donor, Model for End-Stage Liver Disease (MELD) >20, albumin level <2.8 g/dL, intraoperative erythrocyte transfusion >6 U, intraoperative fresh frozen plasma >12 U, bilioenteric anastomosis, postoperative intensive care unit stay >6 days, and postoperative length of stay >21 days. Significant risk factors detected within the first 90 days were as follows: MELD >20, preoperative length of stay >7 days, reoperation, postoperative length of intensive care unit stay >6 days, and postoperative length of stay >21 days. Variability was observed in risk factors according to localization of infection. As a result, except for MELD, type of donor, and biliary anastomosis, the others are preventable factors for early bacterial infection. In addition, the same risk factors showed variability according to the site of infection.

Anesthesia-related complications in living liver donors: the experience from one center and the reporting of one death.

Living donor liver transplantation has become an alternative therapy for patients with end-stage liver disease. Donors are healthy individuals and donor safety is the primary concern. The objective of this study was to evaluate the anesthetic complications and outcomes for our donor cases; we report one death. The charts of the patients who underwent donor hepatectomy from February 1997 to June 2007 were retrospectively reviewed. Right hepatectomy (resection of segments 5-8) was done in 101 donors, left lobectomy (resection of segments 2-3) in 11 donors, and left hepatectomy (resection of segments 2-4) in one donor. Minor anesthetic complications were shoulder pain, pruritus and urinary retention related to epidural morphine, and major morbidity included central venous catheter-induced thrombosis of the brachial and subclavian vein, neuropraxia, foot drop and prolonged postdural puncture headache. One of 113 donors died from pulmonary embolism on the 11th postoperative day. This procedure has some major risks related to anesthesia and surgery. Although careful attention will lower complication rate, we have to keep in mind that the risks of donor surgery will not be completely eliminated.

Comparison of effects of preoperatively administered lornoxicam and tenoxicam on morphine consumption after laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVE: The efficacy, tolerability and the morphine-sparing effects of lornoxicam were compared with those of tenoxicam when used preoperatively in patients undergoing laparoscopic cholecystectomy. METHODS: In this prospective, double-blind study, 60 ASA I-II patients undergoing laparoscopic cholecystectomy were randomized equally to receive intravenous tenoxicam 40 mg (Group T) or lornoxicam 16 mg (Group L), preemptively. Three patients withdrew from the study, so 57 patients were included in the analysis. In the postoperative period, the first morphine demand times, pain scores, side-effects and cumulative morphine consumptions were evaluated during the first 24 h. RESULTS: The patient characteristics data and the duration of surgery were similar between two groups, except for body weights (P = 0.002). The first morphine demand time was significantly longer in Group L (P = 0.037), but the pain levels did not differ. The mean pain scores were higher in Group T in the 15 min (P = 0.036), 1 h (P = 0.020), 2 h (P = 0.001) and 4 h (P = 0.0042) after extubation. A statistically significant difference between two groups was found in calculated cumulative morphine consumptions per kilogram in the 15 min (P = 0.037), 30 min (P = 0.016), and 1 h (P = 0.004) and 2 h (P = 0.013) between two groups. There was no difference in the severity of nausea but 13 patients in Group T and five patients in Group L had vomiting (P = 0.018). Patient satisfaction was similar in the two groups. CONCLUSIONS: Preoperatively administered lornoxicam 16 mg significantly prolonged the first morphine demand time, reduced postoperative morphine consumption during the first 4 h and caused significantly fewer adverse effects when compared with tenoxicam after laparoscopic cholecystectomy.

Efficacy of right anterior sector drainage reconstruction in right-lobe live-donor transplantation.

BACKGROUND: Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial. METHODS: Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 +/- 6, 16 +/- 4, 18 +/- 7), graft weight (817 +/- 181, 838 +/- 152, and 855 +/- 159 g), and graft/ideal liver weight ratio (0.54 +/- 0.12, 0.57 +/- 0.13, and 0.57 +/- 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21. RESULTS: Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 +/- 8.14) was significantly higher than in the minor ligatation group (29.6 +/- 8.6) but not in the major reconstruction group (33.7 +/- 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 +/- 0.18), which was significantly better than the major reconstruction (2.7 +/- 0.1) but not the major ligation (3.1 +/- 0.14) cohorts (P = .02 and P = .13). CONCLUSIONS: In this study of a limited number of cases, right-lobe liver grafts with GRWR of > or =1.1% displayed optimal graft function without additional venous reconstruction to the AS.

Prophylactic use of low-dose, on-demand, intramuscular hepatitis B immunoglobulin and lamivudine after liver transplantation.

The combination of hepatitis B immunoglobulin (HBIG) and antivirals (nucleos[t]ide analogs) has extended the applicability of orthotopic liver transplantation (OLT) for patients with hepatitis B virus (HBV)-related liver disease. However, HBIG administrations have an extremely high cost. Herein, we evaluated our results with low-dose, on-demand, intramuscular HBIG plus lamivudine (LAM) prophylaxis after OLT. The HBV DNA status in 40 patients at the time of OLT determined the treatment: group A (n = 22), HBV DNA (-), no antiviral pretreatment; group B (n = 11), HBV DNA (-), after LAM; group C (n = 3), HBV DNA (+) after LAM (LAM resistance/Adefovir [ADV] unavailable); group D (n = 2), HBV DNA (+), no antiviral pretreatment; and group E (n = 2), HBV DNA (-) after LAM + ADV (LAM resistance/ADV available). Five patients died within 12 months after OLT unrelated to HBV infection. The remaining 35 patients were followed for a median duration of 16 months (range, 6-93 months). Only two recipients from group C, who were transplanted despite LAM resistance + no ADV pretreatment, revealed recurrent HBV infections at 14 and 16 months posttransplantation; they were then treated successfully with ADV as it became available. The third group C recipient had undetectable HBV DNA at 18 months after OLT. The mean cumulative doses of HBIG administered within the first, second, and third years were 34,014, 5258, and 5090 IU, respectively. In conclusion, low-dose, on-demand, intramuscular HBIG plus (LAM +/- ADV) prophylaxis is a safe, efficient, and cost-effective regimen to prevent recurrent HBV infection following OLT. OLT despite untreated LAM resistance may require sustained higher serum HBsAb levels after surgery.

Effect of analgesia administration timing on early post-operative period characteristics: a randomized, double-blind, controlled study.

This study investigated the effect of time of analgesia administration in 64 patients undergoing total abdominal hysterectomy. Patients received standard general anaesthesia and were divided randomly into two equal groups. At the time of fascia closure, patients in the intra-operative (Iop) group received 0.5 mg/kg pethidine intravenously. On arrival in the post-anaesthesia care unit, the same dose of pethidine was given to patients in the post-operative (Pop) group. All patients then used a patient-controlled analgesia pump to administer pethidine analgesia as required. Times to extubation, response to verbal stimulation and orientation, post-operative pain scores and analgesic consumption were recorded. Times to extubation and response to verbal stimulation were significantly longer in the Iop group. Pain scores, analgesic consumption and additional analgesic requirements were significantly higher in the Pop group in the first 2 h post-operatively. In conclusion, intra-operative administration of pethidine provided better pain management than post-operative administration.

Antithrombin III pretreatment reduces neutrophil recruitment into the lung in a rat model of abdominal sepsis.

BACKGROUND: Antithrombin III (AT III) is a serine protease inhibitor and the mechanism of its anti-inflammatory action is still not understood. In the present study, we aimed to investigate the anti-inflammatory action of AT III on lung injury in a rat model of sepsis. METHODS: Three groups of animals were used in this controlled study: the sham-operated group (sham, n = 3) which only underwent a laparotomy; the control group (control, n = 7) which underwent cecal ligation and perforation (CLP); and the AT III-treated group (AT III, n = 6) which underwent CLP and received intravenous (i.v.) 250 U/kg AT III 30 min before induction of sepsis. Rats were killed 24 h after induction of sepsis by needle aspiration of the right ventricle after a sternotomy, and the lungs and trachea were removed en bloc under ether anesthesia. RESULTS: Pulmonary accumulation of polymorphonuclear leukocytes (PMN) was assessed by measuring lung tissue myeloperoxidase (MPO) activity. Lipid peroxidation in lung tissue was assessed by tissue thiobarbituric acid reactive substance (TBARS) levels. The plasma prostacyclin level was assessed by the plasma 6-keto prostaglandin F(1alpha)(6-keto-PGF(1alpha)) level, which is a stable derivative of prostacyclin. Histopathological changes in lung tissue were assessed by PMN count in the capillaries and alveolar spaces. The lung tissue TBARS level, MPO activity and PMN count in the control group were significantly higher than in the AT III group (P < 0.05). The change in plasma 6-keto-PGF(1alpha) level in the AT III group was insignificant compared with the control group (P = 0.15). CONCLUSIONS: AT III prevented pulmonary infiltration of PMN and subsequent injury by the endothelial release of prostacyclin in CLP-induced sepsis.

Comparison of the haemodynamic effects of interscalene block combined with general anaesthesia and interscalene block alone for shoulder surgery.

Interscalene brachial plexus block (ISB) anaesthesia is widely used with or without general anaesthesia in patients undergoing shoulder surgery, which is generally done with the patient in a sitting position. This position affects haemodynamics, and supplementing ISB with general anaesthesia can exaggerate these haemodynamic changes. This study compared ISB combined with general anaesthesia, with ISB alone, in 29 patients undergoing elective shoulder surgery. Heart rate and oxygen saturation remained stable throughout the study in both groups. Mean arterial pressure was significantly decreased when the patient moved into the sitting position in those given combined anaesthesia, whereas in those given ISB alone mean arterial pressure did not change significantly. Neither pain scores nor patient satisfaction scores differed significantly between the two groups. All of the patients were either satisfied or entirely satisfied with their anaesthesia/analgesia. There were no significant differences in side-effects and no severe complications in either group. We advocate using ISB alone for patients undergoing shoulder surgery, but further larger studies are needed to confirm the present results.