2023 Clinical Update in Liver Transplantation.

Liver transplantation continues to provide life-saving treatment for patients with end-stage liver disease. Advances in the field of transplant anesthesia continue to support the care of more complex patients. The use of extracorporeal membrane oxygenation has been described in critical care settings and cardiac surgery but may be a valuable option for specific conditions for patients undergoing liver transplantation. Changes to the allocation process for liver grafts now focus on acuity circles to reduce regional disparities. As the number of life-saving transplant surgeries increases, so does the need for specialty knowledge in the anesthetic considerations of these procedures. The specialty of transplant anesthesia continues to grow and develop to meet the demands of complex patients and the increased number of transplants performed. Liver transplantation can be a resource-demanding procedure, and predicting the need for massive transfusion can aid in planning and preparing for significant blood loss.

2021 Clinical Update in Liver Transplantation.

In 2021, the United States performed 9,236 liver transplantations, an increase of 3.7% from 2020. As the specialty of transplant anesthesiologist continues to grow, so does the body of evidence-based research to improve patient care. New technology in organ preservation offers the possibility of preserving marginal organs for transplant or improving the graft for transplantation. The sequalae of end-stage liver disease have wide-ranging consequences that affect neurologic outcomes of patients both during and after transplantation that anesthesiologists should monitor. Obesity presents several challenges for anesthesiologists. As an increasing number of patients with nonalcoholic steatohepatitis are listed for transplant, managing their multiple comorbidities can be challenging. Finally, the rebalanced hemostasis of end-stage liver disease can cause both bleeding and thrombus. Often, bleeding risks predominate as a concern, but anesthesiologists should be aware of risks of intracardiac thrombus and review therapeutic options for prevention and treatment.

2020 Clinical Update in Liver Transplantation.

The gold standard treatment of end-stage liver disease continues to be liver transplantation (LT). The challenges of LT require skilled anesthesiologists to anticipate physiologic changes associated with end-stage liver disease and surgical considerations that affect multiple organ systems. While on the waiting list, patients may be placed on new anticoagulation medications that can confound already complex coagulopathy in LT patients. Pain management often is an afterthought for such a complex procedure, but appropriate medications can help control pain while limiting opioid medications. Surgical stress and medications for immunosuppression can affect perioperative glucose management in ways that have implications for patient and graft survival. The coronavirus disease 2019 pandemic in 2020 provided a new challenge for anesthesiologists. The uncertainty of the novel respiratory virus challenged providers beyond just LT patients.

A review of the impact of preoperative chemoradiotherapy on outcome and postoperative complications in esophageal cancer patients.

Preoperative chemoradiotherapy has emerged in the treatment of esophageal cancer as a means to down-stage tumors, improve local control, and possibly improve overall survival. However, there are concerns that postoperative complications may be increased by preoperative chemoradiotherapy. We review the rationale for preoperative chemoradiotherapy. We review the literature to identify the potential postoperative complications, the risk of complications, and the risk factors for complications. Although individual and previous studies have shown an increased risk of postoperative complications, the 4 most recent randomized trials published after the year 2000 have not shown an increase in postoperative complications and mortality rates in patients treated with preoperative chemoradiation compared with patients treated with surgery alone. Pulmonary complications are frequently reported, and we focus on dosimetric factors that can be used to minimize lung toxicity. Several dose-volume-histogram parameters, including V10≥40%, V15≥30%, V20≥20%, have been shown to correlate with 32% to 35% of pulmonary complications including pneumonia and acute respiratory distress syndrome. More recent evidence has suggested that an absolute volume of lung spared doses of > 5 Gy (VS5) correlates with pulmonary complications. As these data show, low-dose volume may be more important in the prevention of pulmonary complications than high-dose volume. These dosimetric constraints can be used by physicians to prevent postoperative pulmonary complications in patients treated with preoperative chemoradiotherapy.