The learning curve for piggyback liver transplantation: identifying factors challenging surgery.

BACKGROUND: This study aimed to quantify the learning curve of piggyback liver transplantation and to identify factors that impact the operative time and blood transfusion during the learning curve. METHODS: A retrospective review was performed on consecutive cases of patients' first piggyback liver transplantations that were performed by a single surgeon. The learning curve for the operative time was evaluated using the cumulative sum method. RESULTS: There were 181, consecutive, first-time piggyback liver transplantations. The median operative time was 345 minutes (range: 180-745 minutes) with a median transfusion rate of 4 packed red blood cell units (range: 0-23 units). The cumulative sum learning curve identified 3 phases: an initial phase (1-70 piggyback liver transplantations), a plateau phase (71-101 piggyback liver transplantations), and a stable phase (102-181 piggyback liver transplantations). Over the 3 phases, there were significant decreases in the median duration of the surgery (388.8 vs 344.8 vs 326.9 minutes; P = .004, P = .0004, P ≤ .0001) and the number of red blood cell units transfused (6.00 vs 3.90 vs 3.71; P = .02, P = .79, P = .0006). Multivariable analysis identified that the following factors impacted the operative time: surgeon experience (P = .00006), previous upper abdominal surgery (P = .01), portocaval shunt fashioning (P = .0003), early portal section (P = .00001), multiple arterial graft reconstruction (P = .03), and the length of the retrohepatic inferior vena covered by segment 1 (P = .0006). Independent risk factors for increased blood loss were surgeon experience (P = .0001), previous upper abdominal surgery (P = .002), the retrohepatic inferior vena cava encirclement by segment 1 (P = .0001), severe portal hypertension (P = .01), early portal section (P = .001), and low prothrombin time (P = .00001). CONCLUSION: Easily identifiable factors related to recipients (segment 1 morphology, previous upper abdominal surgery, severe portal hypertension) and to surgeon (operative experience, portocaval shunt fashioning, early portal section, and multiple arterial reconstructions) impact operative time and blood loss during the learning curve of piggyback liver transplantation. These factors can be used for grading the difficulties of liver transplantation to tailor the surgical strategy.

Intraoperative management of brain-dead organ donors by anesthesiologists during an organ procurement procedure: results from a French survey.

BACKGROUND: This study aimed at describing usual anesthetic practices for brain-dead donors (BDD) during an organ procurement (OP) procedure and to assess the knowledge and self-confidence of French anesthesiologists with this practice. METHODS: An electronic and anonymous survey with closed-questions about anesthetic management of BDD was distributed to French anesthesiologists via the mailing list of the French Society of Anesthesiology and Intensive Care Medicine. RESULTS: Four hundred fifty-eight responses were analyzed. Respondents were mainly attending physicians with more than 10 years of clinical experience. 78% of them declared being cognizant of guidelines regarding management of BDD. Advanced hemodynamic monitoring and endocrine substitution were rarely considered by respondents (31 and 35% of respondents, respectively). 98% of the respondents used crystalloids for fluid resuscitation. During the procedure, use of neuromuscular blockers, opioids and sedative agents were considered by respectively 84, 61 and 27% of the respondents. A very high level of agreement (10 [8-10], on a ten-points Likert-style scale) was reported concerning the expected impact of intraoperative anesthetic management on the primary function of grafts. CONCLUSIONS: Declared anesthetic practice appeared in accordance with guidelines concerning organ donor management in the ICU. Further studies are needed to evaluate the specific impact of intraoperative management during this procedure and thus the need for specific anesthetic guidelines.

Interleukin 6 at reperfusion: A potent predictor of hepatic and extrahepatic early complications after liver transplantation.

BACKGROUND AND AIMS: Ischemia-reperfusion injury impacts early liver graft function. Interleukin 6 (IL-6) as early as at reperfusion has shown to predict in-hospital complications, but its impact on vascular complications and long-term outcomes is not ascertained. METHODS: A retrospective study was conducted on all consecutive patients transplanted during a 6-year period to define significant early systemic inflammatory response (ESIR). The main end-point was 3-year graft survival. Significant ESIR was defined according to IL-6 level at reperfusion on an exploratory set of 121 patients and validated on an independent cohort (n = 153). RESULTS: Significant ESIR was defined as IL-6 at reperfusion >1000 ng/mL in the exploratory cohort. Three-year graft and overall survival were lower in patients with ESIR in the determination set (P = 0.001 and 0.045, respectively). This was confirmed in the validation set (P = 0.045 and 0.027). In patients with high cytolysis, IL-6 identified patients at risk for arterial thrombosis. The main determinants for IL-6 level were intragraft lactate level, cold ischemia time, and anhepatic phase duration (P = 0.005). IL-6 level independently predicted graft survival (P = 0.0003). CONCLUSIONS: IL-6 at reperfusion is a valid biomarker to predict long-term survival. Furthermore, it helps the interpretation of cytolysis in the prediction of early vascular complications.

Liver transplantation in critically ill patients: Preoperative predictive factors of post-transplant mortality to avoid futility.

BACKGROUND: The allocation of liver transplants to patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) with multi-organ failure who are admitted in ICU remains controversial due to their high post-transplant mortality rate and the absence of identified mortality risk factors. METHODS: We performed a single-center retrospective cohort study to determine the post-transplant mortality rate of patients with ALF and ACLF requiring ICU care prior to liver transplant (LT) and identified pretransplant factors of post-transplant mortality. RESULTS: Eighty-four patients (29 with ALF and 55 with ACLF) received a liver transplant while they were hospitalized at the ICU. Their mean model for end-stage liver disease (MELD) score was 41, and their mean sequential organ failure assessment (SOFA) was 15 the day before transplant. The overall 1-year survival rate was 66%. In multivariate analysis, pretransplant lactate level and acute respiratory distress syndrome (ARDS) were the only two independent factors associated with post-transplant mortality. The absence of ARDS and a pretransplant lactate level< 5 mmol/L led to the identification of a subgroup of ICU patients with a good 1-year post-transplant survival (>80%). CONCLUSIONS: Low lactatemia lactate level and the absence of ARDS could be useful criteria in selecting those patients in ICU who could be eligible for liver transplant.

Skeletal Muscle and Lymphocyte Mitochondrial Dysfunctions in Septic Shock Trigger ICU-Acquired Weakness and Sepsis-Induced Immunoparalysis.

Fundamental events driving the pathological processes of septic shock-induced multiorgan failure (MOF) at the cellular and subcellular levels remain debated. Emerging data implicate mitochondrial dysfunction as a critical factor in the pathogenesis of sepsis-associated MOF. If macrocirculatory and microcirculatory dysfunctions undoubtedly participate in organ dysfunction at the early stage of septic shock, an intrinsic bioenergetic failure, sometimes called "cytopathic hypoxia," perpetuates cellular dysfunction. Short-term failure of vital organs immediately threatens patient survival but long-term recovery is also severely hindered by persistent dysfunction of organs traditionally described as nonvital, such as skeletal muscle and peripheral blood mononuclear cells (PBMCs). In this review, we will stress how and why a persistent mitochondrial dysfunction in skeletal muscles and PBMC could impair survival in patients who overcome the first acute phase of their septic episode. First, muscle wasting protracts weaning from mechanical ventilation, increases the risk of mechanical ventilator-associated pneumonia, and creates a state of ICU-acquired muscle weakness, compelling the patient to bed. Second, failure of the immune system ("immunoparalysis") translates into its inability to clear infectious foci and predisposes the patient to recurrent nosocomial infections. We will finally emphasize how mitochondrial-targeted therapies could represent a realistic strategy to promote long-term recovery after sepsis.