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Anaesthesia for Liver Transplantation

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Liver Diseases

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Abstract

Perioperative risk for patients undergoing liver transplantation is influenced by the severity of their liver disease as well as by extrahepatic complications including frailty, sarcopenia, poor exercise tolerance and cardiorespiratory pathology. Safe intraoperative care depends upon an understanding of the surgical procedure and an appreciation of the physiological changes which occur during the anhepatic stage and at reperfusion of the donor graft. Cardiovascular and respiratory dysfunction, acute kidney injury, and severe bleeding due to the surgery, portal hypertension and coagulopathy are common in the perioperative period. Robust strategies for detecting and correcting coagulopathy, as well as meticulous attention to fluid balance and electrolytes, are essential. Live donors are extensively screened and in good general health. Their intraoperative management is similar to that of patients undergoing liver resection.

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References

  1. NHS Blood and Transplant. Annual report on liver transplantation 2016/2017. Watford: NHS Blood and Transplant; 2017. Available from: https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/5007/annual_liver_transplantation_report_2017.pdf.

    Google Scholar 

  2. Chan AC, Fan ST, Lo CM, et al. Liver transplantation for acute-on-chronic liver failure. Hepatol Int. 2009;3(4):571–81. https://doi.org/10.1007/s12072-009-9148-8.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Choudhary NS, Saraf N, Saigal S, Soin AS. Liver transplantation for acute on chronic liver failure. J Clin Exp Hepatol. 2017;7(3):247–52. https://doi.org/10.1016/j.jceh.2017.08.001.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31:864–71.

    Article  CAS  PubMed  Google Scholar 

  5. Lai JC, Feng S, Terrault NA, Lizaola B, Hayssen H, Covinsky K. Frailty predicts waitlist mortality in liver transplant candidates. Am J Transplant. 2014;14(8):1870–9. https://doi.org/10.1111/ajt.12762.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526–9. https://doi.org/10.1093/ageing/afl041.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  PubMed  Google Scholar 

  8. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, et al. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl. 2012;18(10):1209–16. https://doi.org/10.1002/lt.23495.

    Article  PubMed  Google Scholar 

  9. Kaido T, Ogawa K, Fujimoto Y, Ogura Y, Hata K, Ito T, et al. Impact of sarcopenia on survival in patients undergoing living donor liver transplantation. Am J Transplant. 2013;13(6):1549–56. https://doi.org/10.1111/ajt.12221.

    Article  CAS  PubMed  Google Scholar 

  10. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on sarcopenia in older people. Age Ageing. 2010;39(4):412–23. https://doi.org/10.1093/ageing/afq034.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Carey EJ, Steidley DE, Aqel BA, Byrne TJ, Mekeel KL, Rakela J, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010;16(12):1373–8. https://doi.org/10.1002/lt.22167.

    Article  PubMed  Google Scholar 

  12. Prentis JM, Manas DM, Trenell MI, Hudson M, Jones DJ, Snowden CP. Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation. Liver Transpl. 2012;18(2):152–9. https://doi.org/10.1002/lt.22426.

    Article  PubMed  Google Scholar 

  13. Aldenkortt F, Aldenkortt M, Caviezel L, Waeber JL, Weber A, Schiffer E. Portopulmonary hypertension and hepatopulmonary syndrome. World J Gastroenterol. 2014;20(25):8072–81. https://doi.org/10.3748/wjg.v20.i25.8072.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Krowka MJ, Fallon MB, Kawut SM, Fuhrmann V, Heimbach JK, Ramsay MA, et al. International liver transplant society practice guidelines: diagnosis and management of hepatopulmonary syndrome and portopulmonary hypertension. Transplantation. 2016;100(7):1440–52. https://doi.org/10.1097/TP.0000000000001229.

    Article  PubMed  Google Scholar 

  15. Khaderi S, Khan R, Safdar Z, Stribling R, Vierling JM, Goss JA, et al. Long-term follow-up of portopulmonary hypertension patients after liver transplantation. Liver Transpl. 2014;20(6):724–7. https://doi.org/10.1002/lt.23870.

    Article  PubMed  Google Scholar 

  16. Liu H, Jayakumar S, Traboulsi M, Lee SS. Cirrhotic cardiomyopathy: implications for liver transplantation. Liver Transpl. 2017;23(6):826–35. https://doi.org/10.1002/lt.24768.

    Article  PubMed  Google Scholar 

  17. Serio S, Clements JM, Grauf D, Merchant AM. Outcomes of diabetic and nondiabetic patients undergoing general and vascular surgery. ISRN Surg. 2013;2013:963930. https://doi.org/10.1155/2013/963930.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011;365(2):147–56. https://doi.org/10.1056/NEJMra1011170.

    Article  CAS  PubMed  Google Scholar 

  19. Wax DB, Torres A, Scher C, Leibowitz AB. Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States. J Cardiothorac Vasc Anesth. 2008;22(6):811–3. https://doi.org/10.1053/j.jvca.2008.07.007.

    Article  PubMed  Google Scholar 

  20. Reeves ST, Finley AC, Skubas NJ, Swaminathan M, Whitley WS, Glas KE, Hahn RT, Shanewise JS, Adams MS, Shernan SK. Basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:443–56.

    Article  PubMed  Google Scholar 

  21. Feltracco P, Biancofiore G, Ori C, Saner FH, Della Rocca G. Limits and pitfalls of haemodynamic monitoring systems in liver transplantation surgery. Minerva Anestesiol. 2012;78(12):1372–84.

    CAS  PubMed  Google Scholar 

  22. Mallett SV. Clinical utility of viscoelastic tests of coagulation (TEG/ROTEM) in patients with liver disease and during liver transplantation. Semin Thromb Hemost. 2015;41(5):527–37. https://doi.org/10.1055/s-0035-1550434.

    Article  PubMed  Google Scholar 

  23. Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. Eur J Anaesthesiol. 2017;34(6):332–95. https://doi.org/10.1097/EJA.0000000000000630.

    Article  PubMed  Google Scholar 

  24. Schumann R, Mandell S, Michaels MD, et al. Intraoperative fluid and pharmacologic management and the anesthesiologist’s supervisory role for nontraditional technologies during liver transplantation: a survey of US Academic Centers. Transplant Proc. 2013;45(6):2258–62.

    Article  CAS  PubMed  Google Scholar 

  25. Yunos NM, Kim IB, Bellomo R, et al. The biochemical effects of restricting chloride-rich fluids in intensive care. Crit Care Med. 2011;39(pg):2419–24.

    Article  CAS  PubMed  Google Scholar 

  26. Alamo JM, León A, Mellado P, Bernal C, Marín LM, Cepeda C, Suárez G, Serrano J, Padillo J, Gómez MÁ. Is “intra-operating room” thromboelastometry useful in liver transplantation? A case-control study in 303 patients. Transplant Proc. 2013;45:3637–9.

    Article  PubMed  Google Scholar 

  27. Rana A, Petrowsky H, Hong JC, Agopian VG, Kaldas FM, Farmer D, et al. Blood transfusion requirement during liver transplantation is an important risk factor for mortality. J Am Coll Surg. 2013;216(5):902–7. https://doi.org/10.1016/j.jamcollsurg.2012.12.047.

    Article  PubMed  Google Scholar 

  28. Massicotte L, Beaulieu D, Thibeault L, Roy JD, Marleau D, Lapointe R, et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation. 2008;85(7):956–62. https://doi.org/10.1097/TP.0b013e318168fcd4.

    Article  PubMed  Google Scholar 

  29. Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl. 2006;12:117–23.

    Article  PubMed  Google Scholar 

  30. Barbas AS, Levy J, Mulvihill MS, et al. Liver transplantation without venovenous bypass: does surgical approach matter? Transplant Direct. 2018;4(5):e348. https://doi.org/10.1097/TXD.0000000000000776.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Fonouni H, Mehrabi A, Soleimani M, Müller SA, Büchler MW, Schmidt J. The need for venovenous bypass in liver transplantation. HPB. 2008;10(3):196–203. https://doi.org/10.1080/13651820801953031.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Pratschke S, Meimarakis G, Bruns CJ, Kaspar M, Prix N, Zachoval R, et al. Temporary intraoperative porto-caval shunt: useless or beneficial in piggy back liver transplantation? Transpl Int. 2013;26(1):90–8. https://doi.org/10.1111/tri.12007.

    Article  PubMed  Google Scholar 

  33. Matsusaki T, Hilmi IA, Planinsic RM, Humar A, Sakai T. Cardiac arrest during adult liver transplantation: a single institution’s experience with 1238 deceased donor transplants. Liver Transpl. 2013;19(11):1262–71. https://doi.org/10.1002/lt.23723.

    Article  PubMed  Google Scholar 

  34. Koelzow H, Gedney JA, Baumann J, et al. The effect of methylene blue on the hemodynamic changes during ischemia reperfusion injury in orthotopic liver transplantation. Anesth Analg. 2002;94(4):824–9. Table of contents.

    Article  CAS  PubMed  Google Scholar 

  35. Mandell MS, Stoner TJ, Barnett R, Shaked A, Bellamy M, Biancofiore G, et al. A multicenter evaluation of safety of early extubation in liver transplant recipients. Liver Transpl. 2007;13(11):1557–63.

    Article  PubMed  Google Scholar 

  36. Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: consequences, prediction and management. World J Transplant. 2016;6(2):291–305. https://doi.org/10.5500/wjt.v6.i2.291.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Byram SW, Gupta RA, Ander M, Edelstein S, Andreatta B. Effects of continuous octreotide infusion on intraoperative transfusion requirements during orthotopic liver transplantation. Transplant Proc. 2015;47(9):2712–4. https://doi.org/10.1016/j.transproceed.2015.07.036.

    Article  CAS  PubMed  Google Scholar 

  38. Badenoch A, Sharma A, Gower S, Selzner M, Srinivas C, Wąsowicz M, et al. The effectiveness and safety of tranexamic acid in orthotopic liver transplantation clinical practice: a propensity score matched cohort study. Transplantation. 2017;101(7):1658–65. https://doi.org/10.1097/TP.0000000000001682.

    Article  CAS  PubMed  Google Scholar 

  39. Lewandowska L, Matuszkiewicz-Rowinska J. Acute kidney injury after procedures of orthotopic liver transplantation. Ann Transplant. 2011;16(2):103–8.

    Article  PubMed  Google Scholar 

  40. Sahmeddini MA, Amini A, Naderi N. The effect of octreotide on urine output during orthotopic liver transplantation and early postoperative renal function; a randomized, double-blind, placebo-controlled trial. Hepat Mon. 2013;13(9):e12787. https://doi.org/10.5812/hepatmon.12787.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Kim WR, Lake JR, Smith JM, Schladt DP, Skeans MA, Harper AM, et al. OPTN/SRTR 2016 Annual data report: liver. Am J Transplant. 2018;18(Suppl 1):172–253. https://doi.org/10.1111/ajt.14559.

    Article  PubMed  Google Scholar 

  42. de Villa VH, Lo CM, Chen CL. Ethics and rationale of living-donor liver transplantation in Asia. Transplantation. 2003;75(3 Suppl):S2–5.

    Article  PubMed  Google Scholar 

  43. Lee SG, Hwang S, Moon DB, Ahn CS, Kim KH, Sung KB. Expanded indication criteria of living donor liver transplantation for hepatocellular carcinoma at one large-volume center. Liver Transpl. 2008;14(7):935–45. https://doi.org/10.1002/lt.21445.

    Article  PubMed  Google Scholar 

  44. Akamatsu N, Sugawara Y, Kokudo N. Living-donor vs deceased-donor liver transplantation for patients with hepatocellular carcinoma. World J Hepatol. 2014;6(9):626–31. https://doi.org/10.4254/wjh.v6.i9.626.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Lee SG. A complete treatment of adult living donor liver transplantation: a review of surgical technique and current challenges to expand indication of patients. Am J Transplant. 2015;15(1):17–38. https://doi.org/10.1111/ajt.12907.

    Article  PubMed  Google Scholar 

  46. Walter J, Burdelski M, Bröring DC. Chances and risks in living donor liver transplantation. Dtsch Arztebl Int. 2008;105(6):101–7. https://doi.org/10.3238/arztebl.2008.0101.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Lu Q, Wu H, Yan L-N, Chen Z-Y, Fan Y-T, Luo Y. Living donor liver transplantation using dual grafts: ultrasonographic evaluation. World J Gastroenterol. 2010;16(31):3979–83. https://doi.org/10.3748/wjg.v16.i31.3979.

    Article  PubMed  PubMed Central  Google Scholar 

  48. British Transplantation Society. BTS UK guidelines: living donor liver transplantation. Macclesfield: BTS; 2015. Available from: https://bts.org.uk/wp-content/uploads/2016/09/03_BTS_LivingDonorLiver-1.pdf.

    Google Scholar 

  49. Clarke H, Chandy T, Srinivas C, et al. Epidural analgesia provides better pain management after live liver donation: a retrospective study. Liver Transpl. 2011;17(3):315–23.

    Article  PubMed  Google Scholar 

  50. Choi SJ, Gwak MS, Ko JS, et al. The changes in coagulation profile and epidural catheter safety for living liver donors: a report on 6 years of our experience. Liver Transpl. 2007;13(1):62–70.

    Article  PubMed  Google Scholar 

  51. Ko JS, Choi SJ, Gwak MS, Kim GS, Ahn HJ, Kim JA, et al. Intrathecal morphine combined with intravenous patient-controlled analgesia is an effective and safe method for immediate postoperative pain control in live liver donors. Liver Transpl. 2009;15(4):381–9. https://doi.org/10.1002/lt.21625.

    Article  PubMed  Google Scholar 

  52. Maeda A, Shibata SC, Wada H, Marubashi S, Kamibayashi T, Eguchi H, et al. The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study. J Anesth. 2016;30(1):39–46. https://doi.org/10.1007/s00540-015-2085-x.

    Article  PubMed  Google Scholar 

  53. Choi S-S, Kim S-H, Kim Y-K. Fluid management in living donor hepatectomy: recent issues and perspectives. World J Gastroenterol. 2015;21(45):12757–66. https://doi.org/10.3748/wjg.v21.i45.12757.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Yaprak O, Dayangac M, Akyildiz M, et al. Biliary complications after right lobe living donor liver transplantation: a single-centre experience. HPB (Oxford). 2012;14(1):49–53. https://doi.org/10.1111/j.1477-2574.2011.00401.x.

    Article  Google Scholar 

  55. Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Harada N, Ijichi H, et al. Biliary strictures in living donor liver transplantation: incidence, management, and technical evolution. Liver Transpl. 2006;12(6):979–86.

    Article  PubMed  Google Scholar 

  56. Lee SH, Jeong JS, Ha HS, No MJ, Hong JJ, Kwon JS, et al. Decision-related factors and attitudes toward donation in living related liver transplantation: ten-year experience. Transplant Proc. 2005;37(2):1081–4.

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Royal Free Perioperative Research, London, UK

    Donald M. Milliken & Michael D. Spiro

  2. Liver Transplant and HPB Anaesthesia, The Royal Free London NHS Foundation Trust, London, UK

    Donald M. Milliken & Michael D. Spiro

  3. Department of Hepato-pancreatico-biliary Surgery, Royal Free Hospital, London, UK

    Brian R. Davidson

  4. The Royal Free London NHS Foundation Trust, University College London, London, UK

    Michael D. Spiro

Authors
  1. Donald M. Milliken
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Editor information

Editors and Affiliations

  1. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Florentina Radu-Ionita

  2. New Jersey Medical School, Rutgers University New Jersey Medical School, Newark, NJ, USA

    Nikolaos T. Pyrsopoulos

  3. Carol Davila University of Medicine and Pharmacy, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Mariana Jinga

  4. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Ion C. Tintoiu

  5. Medical Radiation Sciences, Curtin University, Perth, WA, Australia

    Zhonghua Sun

  6. “Prof. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Bucharest, Romania

    Ecaterina Bontas

Self Study

Self Study

1.1 Questions

  1. 1.

    Which of the following statements is true?

    1. (a)

      Candidates are prioritised for liver transplant based primarily on an assessment of their frailty.

    2. (b)

      Any degree of portopulmonary hypertension is generally considered a contraindication to liver transplantation.

    3. (c)

      At the time of transplant, patients may be at increased risk of haemorrhage, thrombosis, or both.

    4. (d)

      Preoperative correction of laboratory coagulation tests is important to reduce the risk of intraoperative haemorrhage.

  2. 2.

    Which of the following statements is true?

    1. (a)

      European Society of Anaesthesiology guidelines recommend against the use of point-of-care viscoelastic testing in liver transplantation.

    2. (b)

      Intraoperative cardiac arrest during orthotopic liver transplantation is very rare.

    3. (c)

      The severity of bleeding during surgery does not predict transplant outcomes.

    4. (d)

      Living donation may allow candidates to undergo transplantation who would not qualify to receive a deceased donor liver.

1.2 Answers

  1. 1.

    Which of the following statements is true?

    1. (a)

      Prioritisation is usually based on liver disease severity, and the most commonly used measure is the MELD score.

    2. (b)

      Mild portopulmonary hypertension increases perioperative risk only slightly and is not generally considered a contraindication to transplant. Severe portopulmonary hypertension is generally considered a contraindication.

    3. (c)

      CORRECT ANSWER. The cell-based model of coagulation explains that while coagulation in chronic liver disease is ‘rebalanced’, there is an increased vulnerability to stressors that may increase the tendency to thrombosis, haemorrhage, or both.

    4. (d)

      Laboratory coagulation tests are poor predictors of surgical bleeding and are not normally corrected preoperatively.

  2. 2.

    Which of the following statements is true?

    1. (a)

      ESA guidelines support the use of an algorithmic approach with predefined viscoelastic triggers for the treatment of perioperative bleeding. They also state that there is some evidence to suggest that viscoelastic testing reduces bleeding during liver transplantation.

    2. (b)

      The rate of cardiac arrest within minutes of donor organ reperfusion is around 3% in some series.

    3. (c)

      Massive haemorrhage during liver transplant surgery predicts worse graft and patient survival.

    4. (d)

      CORRECT ANSWER. Candidates with hepatocellular carcinoma falling outside of standard transplantation criteria, and those with liver disease of insufficient severity to prioritise them for deceased donor transplant, may undergo living donor transplant.

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Milliken, D.M., Davidson, B.R., Spiro, M.D. (2020). Anaesthesia for Liver Transplantation. In: Radu-Ionita, F., Pyrsopoulos, N., Jinga, M., Tintoiu, I., Sun, Z., Bontas, E. (eds) Liver Diseases. Springer, Cham. https://doi.org/10.1007/978-3-030-24432-3_70

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