Post-Reperfusion Syndrome in Liver Transplantation: Does a Caval Blood Flush Vent Help?

BACKGROUND Post-reperfusion syndrome (PRS) during liver transplantation can range from a benign event to a profound hemodynamic excursion from baseline with significant morbidity. Multiple variables can be responsible for the diverse presentations. Over time, our group noticed that a blood flush of the liver graft via a caval vent (in addition to a standard chilled flush via the portal vein) appeared to result in a milder reperfusion effect. Attenuation of PRS via caval vent seemed to minimize hemodynamic instability and reduce metabolic derangements associated with reperfusion. MATERIAL AND METHODS This was a prospective observational pilot study of standard practice with the addition of lab values and hemodynamic evaluations. We methodically observed normal clinical flow in 20 adult orthotopic liver transplant recipients. We analyzed blood and fluid samples at set time intervals during the peri-reperfusion phase. RESULTS Sixteen out of 20 patients received a blood flush via caval venting. Mean arterial pressure (MAP) and heart rate were better preserved in the patient population that received a caval blood flush vent. Elevations in central venous pressure (CVP) were similar between the 2 groups. Lab values (blood gas, electrolyte, and hemoglobin) of the patients' blood were similar, with no notable differences. Analysis of the initial blood flushed through the liver graft proved to be hypothermic, acidotic, and hyperkalemic. CONCLUSIONS Pre-reperfusion caval venting in liver transplantation (in addition to a portal vent and a chilled LR/albumin portal flush solution) appears to have favorable hemodynamic effects. The literature on this technique is sparse and larger studies are needed.

Thoracolumbar interfascial plane (TLIP) block: a pilot study in volunteers.

PURPOSE: Regional anesthesia has been shown to improve outcomes in several recent studies. The transversus abdominis plane (TAP) block provides anesthesia to the abdominal wall by introducing local anesthetic to the ventral rami of the thoracolumbar nerves. This work quantifies the area of anesthesia obtained after performing the novel thoracolumbar interfascial plane block (analogous to the TAP block but intended for the back) which targets the sensory component of the dorsal rami of the thoracolumbar nerves. METHODS: Ten participants underwent bilateral ultrasound-guided injections of 0.2% ropivacaine 20 mL into the fascial plane between the multifidus and longissimus muscles. After five and 20 min, respectively, the area of anesthesia was plotted on the participant's back. Anesthesia was defined as loss of point discrimination to pinprick. RESULTS: Participants reported a mean (SD) area of anesthesia surrounding the needle injection site of 137.4 (71.0) cm(2) and 217.0 (84.7) cm(2) at five and 20 min after injection, respectively. The mean (SD) cephalad and caudal spread of local anesthetic from the site of injection was 6.5 (1.8) cm and 3.9 (1.2) cm, respectively. There were no complications or adverse events reported. CONCLUSION: This report shows that a reproducible area of anesthesia can be obtained by ultrasound-guided injection of local anesthetic in the fascial plane between the multifidus and longissimus muscles of the thoracolumbar spine. The area of anesthesia consistently covered the midline and had a predictable spread. This project was registered with clinicaltrials.gov (NCT02297191).

Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile?

BACKGROUND: Because survival after pancreaticoduodenectomy for cancer is limited, it is difficult to assess longterm pancreaticojejunal anastomotic patency. However, in patients with benign disease, pancreaticojejunal anastomotic stenosis may become problematic. What happens when pancreaticojejunal anastomosis revision is undertaken? METHODS: Patients undergoing pancreatic anastomotic revision after pancreatic head resection for benign disease between 1997 and 2007 at the Medical University of South Carolina were identified. A retrospective chart review and analysis were undertaken with the approval of the Institutional Review Board for the Evaluation of Human Subjects. Longterm follow-up was obtained by patient survey at a clinic visit or by telephone. RESULTS: During the study period, 237 patients underwent pancreatic head resection. Of these, 27 patients (17 women; median age 42 years) underwent revision of pancreaticojejunal anastomosis. Six patients (22%) had a pancreatic leak or abscess at the time of the index pancreatic head resection. The indication for revision of anastomosis was intractable pain. All patients underwent preoperative magnetic resonance cholangiopancreatography (MRCP), which indicated anastomotic stricture in 18 patients (63%). Nine other patients underwent exploration based on clinical suspicion caused by recurrent pancreatitis and stenosis was confirmed at the time of surgery. Six patients (22%) had perioperative complications after revision. The median length of stay was 12 days. There were no perioperative deaths; however, late mortality occurred in four patients (15%). Six of 23 survivors (26%) at the time of follow-up (median 56 months) reported longterm pain relief. CONCLUSIONS: Stricture of the pancreaticojejunal anastomosis after pancreatic head resection presents with recurrent pancreatitis and pancreatic pain. MRCP has good specificity in the diagnosis of anastomotic obstruction, but lacks sensitivity. Pancreaticojejunal revision is safe, but rarely effective, as a means of pain relief in patients with the pain syndrome associated with chronic pancreatitis.