Anhepatic Phase Research Articles

Development and validation of a nomogram model for predicting chronic kidney disease after liver transplantation: a multi-center retrospective study

Chronic kidney disease (CKD) is a frequent complication after liver transplantation (LT) and associated with poor prognosis. In this study, we retrospectively analyzed 515 adult patients who underwent LT in our center. They were randomly divided into a training set (n = 360) and an internal test set (n = 155). Another 118 recipients in other centers served as external validation set. Univariate and multivariate COX regression analysis were used to determine risk factors. A nomogram model was developed to predict post-LT CKD. The incidence of post-LT CKD in our center was 16.9% (87/515) during a median follow-up time of 22.73 months. The overall survival of recipients with severe CKD (stage IV and V) were significantly lower than those with non or mild CKD (stage III) (p = 0.0015). A nomogram model was established based on recipient’s age, anhepatic phase, estimated glomerular filtration rate and triglyceride levels at 30 days after LT. The calibration curves for post-LT CKD prediction in the nomogram were consistent with the actual observation in both the internal and external validation set. In conclusion, severe post-LT CKD resulted in a significantly reduced survival in liver recipient. The newly established nomogram model had good predictive ability for post-LT CKD.

Administration of magnesium sulphate does not prevent post-reperfusion syndrome but is necessary during living donor liver transplantation.

Severe hemodynamic instability is observed during portal vein de-clamping in the form of post-reperfusion syndrome in liver transplantation. The protective effect of magnesium on inflammation and ischemia-reperfusion injuries of various organs is evident, but its role in the prevention of post-reperfusion syndrome in liver transplantation is not clear. We investigated the effect of magnesium sulphate on the incidence of post-reperfusion syndrome during living donor liver transplantation. The secondary outcomes were the requirement of vasopressor boluses and levels of serum magnesium, lactate and serum C-reactive protein. Seventy living donor liver transplant recipients were randomized into a magnesium (M) group (n=35) or normal saline (N) group (n=35). The patients in group M received 35mg/kg of magnesium sulphate, 30 minutes after the beginning of the anhepatic phase, and patients in group N received normal saline. The incidence of post-reperfusion syndrome in group M and group N was 34.29% and 40%, respectively, with no significant difference. The requirement for rescue vasopressor boluses and levels of C-reactive protein and lactate were also comparable between the two groups. However, the incidence of hypomagnesemia at the end of surgery was significantly higher in group N (37.1% vs. 14.28%, p=0.027). Magnesium does not appear to prevent post-reperfusion syndrome. However, hypomagnesemia is more frequently seen during liver transplantation. Hence, serum magnesium should be routinely monitored and administered during liver transplantation.

Full-Right Full-Left Split Liver Transplantation for Two Adult Recipients: A Single-Center Experience in China.

The most effective treatment for end-stage liver diseases is liver transplantation, which is impeded by the shortage of donor livers. Split liver transplantation (SLT) is important for addressing the donor liver shortage. However, full-right full-left SLT for two adult recipients is globally rarely conducted. This study aimed to investigate the clinical outcomes of this technique. We retrospectively analyzed the clinical data of 22 recipients who underwent full-right full-left SLT at Shulan (Hangzhou) Hospital between January, 2021 and September, 2022. The graft-to-recipient weight ratio (GRWR), cold ischemia time, operation time, length of the anhepatic phase, intraoperative blood loss, and red blood cell transfusion amount were all analyzed. The differences in liver function recovery after transplantation were compared between the left and right hemiliver groups. The postoperative complications and prognosis of the recipients were also analyzed. The livers of 11 donors were transplanted into 22 adult recipients. The GRWR ranged from 1.16-1.65%, the cold ischemia time was 282.86 ± 134.87 min, the operation time was 371.32 ± 75.36 min, the anhepatic phase lasted 60.73 ± 19.00 min, the intraoperative blood loss was 759.09 ± 316.84 mL, and the red blood cell transfusion amount was 695.45 ± 393.67 mL. No significant difference in the levels of liver function markers, total bilirubin, aspartate aminotransferase, or alanine aminotransferase between left and right hemiliver groups at 1, 3, 5, 7, 14, and 28 d postoperatively was observed (both p > 0.05). One recipient developed bile leakage 10 d after transplantation, which improved with endoscopic retrograde cholangiopancreatography-guided nasobiliary drainage and stent placement. Another developed portal vein thrombosis 12 d after transplantation and underwent portal vein thrombectomy and stenting to restore portal vein blood flow. A color Doppler ultrasound performed 2 d after transplantation revealed hepatic artery thrombosis in one patient, and thrombolytic therapy was administered to restore hepatic artery blood flow. The liver function of other patients recovered quickly after transplantation. Full-right full-left SLT for two adult patients is an efficient way to increase the donor pool. It is safe and feasible with careful donor and recipient selection. Transplant hospitals with highly experienced surgeons in SLT are recommended to promote using full-right full-left SLT for two adult recipients.

Effect of terlipressin on systemic and hepatic hemodynamics in patients undergoing liver transplantation

ABSTRACT Background and Aims Liver transplantation is associated with hemodynamic instability. Systemic and Splanchnic circulations interact closely. Portal hypertension is linked to vasodilatory molecules resulting in arterial vasodilatation. Terlipressin, is a synthetic vasopressin analogue causes selective vasoconstriction of splanchnic arteriols, thus decreasing splanchnic blood flow and shifting blood from the splanchnic to the systemic circulation resulting in enhanced systemic hemodynamics. This study aimed to assess the impact of intraoperative terlipressin on systemic and hepatic hemodynamics in recipients of living donor liver transplantation (LDLT). Methods The present longitudinal observational study was carried out at Ain Shams Center for Organ Transplant on 30 cases suffering from portal hypertension and chronic liver disease undergoing LDLT. Subjects were equally categorized into two groups: Group 1(control): patients did not receive intraoperative terlipressin, Group 2 (terlipressin): patients received terlipressin (1 mg intravenously over 10 min) just after exposure of the portal vein to maintain mean arterial blood pressure over 65 mmHg. Results Systolic and diastolic blood pressure were better preserved in the terlipressin group, with reduced norepinephrine requirements as well as a substantial decline in the heart rate during the anhepatic and reperfusion phases (P < 0.05). Terlipressin significantly decreases portal venous pressure with (P = 0.03) and portal vein flow (P < 0.001) without altering the hepatic artery resistivity index (HARI) (P = 0.219). Conclusion Intraoperative terlipressin during liver transplantation surgery was associated with improved systemic hemodynamics despite decreased portal venous pressure and blood flow, without affecting HARI.

Anesthesia management protocol for liver transplantation as treatment for ornithine transcarbamylase deficiency.

Ornithine transcarbamylase deficiency is an X-linked genetic disorder that induces accumulation of ammonia in the liver and is the most common urea cycle disorder. The clinical manifestation of ornithine transcarbamylase deficiency is hyperammonemia that causes irreversible neurological damage. Liver transplantation is a curative therapy for ornithine transcarbamylase deficiency. The aim of this study is to suggest, from our previous experience, an anesthesia management protocol of liver transplantation for ornithine transcarbamylase deficiency, particularly focused on liver transplantation for cases with uncontrolled hyperammonemia. We retrospectively reviewed our anesthesia-related experience in all cases of liver transplantation for ornithine transcarbamylase deficiency in our center. Twenty-nine liver transplantation cases for ornithine transcarbamylase deficiency were found between November 2005 and March 2021 in our center. Of these, 25 cases were stable through the perioperative period. However, 2 cases with carrier donor graft had hyperammonemia after liver transplantation. Another two cases had uncontrolled hyperammonemia before liver transplantation, even with continuous hemodialysis. They underwent life-saving liver transplantation. Their metabolic status stabilized after the anhepatic phase. Liver transplantation for cases with uncontrolled hyperammonemia can be performed with proper management. Second, liver transplantation with carrier donors should be avoided because of the risk of postoperative recurrence.

A Single-Center's Early Surgical Outcomes of Living Donor Liver Transplantation

Living donor liver transplantation (LDLT) has become an increasingly common surgical option because the number of cadaveric donors is insufficient to fulfill the organ needs of patients facing end-stage cirrhosis. Many centers are investigating different surgical techniques to achieve lower complication rates. We aimed to examine our complication rates in light of demographic data, graft data, and perioperative findings as a single-center experience. The study included one hundred and three patients who underwent LDLT for end-stage liver cirrhosis. Demographic data; sex; age; blood group; Model for End-Stage Liver Disease score; Child score; etiology; liver side; graft-to-recipient weight ratio; hepatic artery, portal vein, and bile anastomosis type rates; anhepatic phase; cold ischemia time; operation time; and blood product transfusion rates were analyzed. Biliary complications in patients with single or multiple biliary anastomoses, right or left liver transplants, and with or without hepatic artery thrombosis were analyzed statistically. There was no significant difference in biliary complications between patients who underwent single or multiple bile anastomosis (P=.231) or patients receiving right lobe and left lobe transplants (P=.315). Although there was no statistically significant difference in the rate of portal vein thrombosis between the regular and reconstructed portal vein anastomosis groups (P=.693), the postoperative portal vein thrombosis rate was statistically higher in patients with left lobe transplants (P=.044). Vascular and biliary complication rates can be reduced with increasing experience.

Forced-air prewarming prevents hypothermia during living donor liver transplantation: a randomized controlled trial

Despite various intraoperative thermal strategies, core heat loss is considerable during liver transplantation and hypothermia is common. We tested whether forced-air prewarming prevents hypothermia during liver transplantation. Adult patients undergoing living donor liver transplantation were randomly assigned to non-prewarming group (n = 20) or prewarming group (n = 20). Patients in prewarming group underwent 30-min forced-air warming before anesthetic induction. During surgery, core temperature was measured in the pulmonary artery. The primary outcome was intraoperative hypothermia (< 36.0 °C). The secondary outcomes included plasma lactate concentration. Intraoperative hypothermia risk was significantly lower in prewarming group than in non-prewarming group (60.0% vs. 95.0%, P = 0.020). The difference in hypothermia incidence between groups was greater in the post-induction phase (20.0% vs. 85.0%, P < 0.001) than in the anhepatic or post-reperfusion phase, suggesting that prewarming mainly acts on preventing post-induction core-to-peripheral heat redistribution. Hypothermia duration was significantly shorter in prewarming group (60 [0–221] min vs. 383 [108–426] min, P = 0.001). Lactate concentration decreased during 3 h after graft reperfusion in prewarming group, whereas it continuously increased in non-prewarming group (− 0.19 [− 0.48 to 0.13] mmol/L vs. 1.17 [3.31–0.77] mmol/L, P = 0.034). In conclusion, forced-air prewarming decreases the incidence and duration of intraoperative hypothermia with potential clinical benefit while mainly acting by preventing the core-to-peripheral heat redistribution.Clinical trial registration: Registered at the Clinical Research Information Service (https://cris.nih.go.kr, [KCT0003230]) on 01/10/2018.

Performance of the Hypotension Prediction Index in living donor liver transplant recipients.

The Hypotension Prediction Index (HPI) was recently introduced and clinically validated in different surgical conditions. This prospective observational study evaluated HPI's performance in living donor liver transplant recipients under the hypothesis that HPI would be inferior to the previously reported predictability in major surgery due to the surgical characteristics of liver transplantation. Twenty adult patients undergoing living donor liver transplantation were enrolled. HPI was monitored during the surgery with the attending anesthesiologist blinded to the HPI. The mean arterial pressure and HPI were recorded at 1-minute intervals. The area under the curve (AUC) of the receiver operating characteristic curve was calculated for the whole dataset and at each phase of liver transplantation at 5, 10, and 15 minutes to analyze HPI's performance. A total of 9173 data points were analyzed. The AUC for predicting hypotension at 5 minutes was 0.810 (95% confidence interval [CI]: 0.780-0.840). The AUCs for predicting hypotension at 10 and 15 minutes were 0.726 (95% CI: 0.681-0.772) and 0.689 (95% CI: 0.642-0.737), respectively. The AUCs for predicting hypotension at 5 minutes in the preanhepatic, anhepatic, and neohepatic phase were 0.795 (95% CI: 0.711-0.876), 0.728 (95% CI: 0.638-0.819), and 0.837 (95% CI: 0.802-0.873), respectively. The HPI's performance was inferior to that previously reported in major surgery. HPI in this observational study in living donor liver transplantation predicted hypotension with moderate-to-low accuracy, its predictive value being highest in the neohepatic phase and lowest in the anhepatic phase.

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?

A Novel Online Calculator Predicting Acute Kidney Injury After Liver Transplantation: A Retrospective Study.

Acute kidney injury (AKI) after liver transplantation (LT) is a common complication, and its development is thought to be multifactorial. We aimed to investigate potential risk factors and build a model to identify high-risk patients. A total of 199 LT patients were enrolled and each patient data was collected from the electronic medical records. Our primary outcome was postoperative AKI as diagnosed and classified by the KDIGO criteria. A least absolute shrinkage and selection operating algorithm and multivariate logistic regression were utilized to select factors and construct the model. Discrimination and calibration were used to estimate the model performance. Decision curve analysis (DCA) was applied to assess the clinical application value. Five variables were identified as independent predictors for post-LT AKI, including whole blood serum lymphocyte count, RBC count, serum sodium, insulin dosage and anhepatic phase urine volume. The nomogram model showed excellent discrimination with an AUC of 0.817 (95% CI: 0.758-0.876) in the training set. The DCA showed that at a threshold probability between 1% and 70%, using this model clinically may add more benefit. In conclusion, we developed an easy-to-use tool to calculate the risk of post-LT AKI. This model may help clinicians identify high-risk patients.

Relationship between Mean Systemic Filling Pressure, Cardiac Power Output, Myocardial Efficiency and Venous Return Gradient in Liver Transplant Patients

Introduction: The mean systemic filling pressure (PMSF) depends on volemic state, vasomotor tone and cardiovascular function. Therefore, it should be causally correlated with cardiac power, myocardial efficiency and venous return gradient. The aim of the present study was to correlate PMSF with cardiac output, myocardial efficiency and venous return gradient in the perioperative period of patients undergoing orthotopic heart transplantation. Material and methods. Retrospective, descriptive, analytical cohort study, from January 1, 2021 to January 31, 2022. Inclusion criteria included liver transplantation (ortothopic) adult patients with pulmonary artery catheter. Those with decompensated liver disease due to hemorrhage, grade III ascites or hepatic encephalopathy and those admitted to the ICU without pulmonary artery catheter were excluded. The aim was to correlate PMSF with cardiac power, myocardial efficiency and venous return gradient in the perioperative period of liver transplantation patients. Results. A strong positive correlation was reported between cardiac power and PMSF just after placement of the pulmonary artery catheter (initial) (r= 0.929, p= &lt;0.001), as well as between cardiac power output and PMSF in the preanhepatic phase (r= 0.591, p= 0.013). For myocardial efficiency strong negative correlations with significant p-value were found for initial PMSF and myocardial efficiency r= -0.659, p= 0.04; between myocardial efficiency and PMSF in the preanhepatic phase r= -0.635, p= 0. 006; myocardial efficiency and PMSF in the anhepatic phase, r= -0.593, p= 0.012; between myocardial efficiency and PMSF in the neohepatic phase r= -0.502, p= 0.040; and for myocardial efficiency and PMSF on admission of patients to the ICU r=-0.571, p= 0.017. Related to the venous return gradient (PMSF - CVP) and PMSF, the correlation was r= 0.919, p= &lt;0.001 (initial) and for the preanhepatic phase with a moderate positive correlation r= 0.490 p= 0.046. Conclusion. PMSF is useful as a marker for the diagnosis and hemodynamic management of patients undergoing liver transplantation.

Central Versus Peripheral Invasive Arterial Blood Pressure Monitoring in Liver Transplant Surgery.

Introduction Invasive blood pressure monitoring is essential in liver transplant surgery due to expected major hemodynamic shifts.The use of central versusperipheral arterial access, however, is institution-dependent, which can affect clinical decisions regarding vasopressor therapy.Although there are studies that demonstrate inconsistencies based on arterial cannulation sites, few studies have compared femoral and radial artery blood pressures in patients undergoing liver transplant surgery.To our knowledge, there are no studies investigating the differences between continuous minute-to-minute femoral and radial artery measurements during all three phases of liver transplant surgery. Objective The main objective of this study was to evaluate for any differences between central and peripheral blood pressure measurements in liver transplant surgeryand to assess for any correlation between vasopressor infusion dose and femoral-arterial pressure differences. Methods In this retrospective study, we reviewed and studied the data of 61 patientswith American Society of Anesthesiologists (ASA) grade 4who underwent liver transplant surgery at Loma Linda University Medical Center between January and December of 2019.All patients had both femoral and radial arterial lines placed for liver transplant surgery.Femoral and radial arterial blood pressure values were obtained continuously over 60 minutes in the pre-anhepatic phase, 45 minutes during the anhepatic phase, and 60 minutes into the neo-hepatic phase. Vasopressor infusion doses were also recorded for each patient during these time frames. Results This pilot study found statistically significant differences between the mean femoral and radial systolic blood pressure (SBP; p < 0.0001), diastolic blood pressure (DBP; p < 0.0001), and mean arterial pressure (MAP; p < 0.0001)during all phases of liver transplantation.The meanSBP and MAP differences between femoral and radial arteries were highest (femoral blood pressure reading higher than radial blood pressure measurements) in the late anhepatic and early neo-hepatic phases with SBP differences of 20.8 ± 0.8 mmHg and 22.8 ± 0.8 mmHg, respectively, and MAP differences of 10.0 ± 0.4 mmHg and 9.8 ± 0.4 mmHg, respectively. Higher vasopressor infusion doses were strongly associated with greater differences in femoral-radial SBP and MAP measurements (r = 0.69 for vasopressin, 0.68 for norepinephrine, and 0.68 for epinephrine; p < 0.0001) during the anhepatic phase. Conclusions Peripheral invasive blood pressure monitoring may result in underestimation of the central blood pressure, as was seen in all phases of liver transplantation. This may lead to excessive vasopressor use with potentially adverse effects. Although the cause for the difference between femoral and radial artery measurements is unclear, increasing vasopressor infusion dosages appears to contribute. Femoral artery blood pressure monitoring allows clinicians to interpret hemodynamic status and administer appropriate vasopressors more accurately.

Magnetic-assisted rapid liver transplantation blood vessel anastomosis from conception to clinical practice

The anastomotic reconstruction of liver accessory vessels is the primary surgical procedure in liver transplantation. The overall surgical outcome and long-term patient survival are related to the anastomosis speed and quality. The application of magnetic anastomosis technology based on the concept of magnetic surgery to achieve rapid reconstruction of liver accessory vessels has the unique advantages of safety and high efficiency, which greatly shorten the time of the anhepatic phase and also provide new possibilities for the development of liver transplantation under minimally invasive conditions.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Laparoscopic-assisted liver transplantation: A realistic perspective

Laparoscopic approach was rarely described in recipients for liver transplantation (LT). We report the feasibility and safety of laparoscopic-assisted LT (LA-LT) in patients with unresectable liver metastases of neuroendocrine tumors. Total hepatectomy was performed laparoscopically with graft implantation through an upper midline incision. Liver grafts were retrieved from deceased donors. From July 2019 to July 2021, six patients (4 women, 2 men) underwent LA-LT. Median age and BMI were 46 (29-54) and 24 (19-35) kg/m2 , respectively. Implanted grafts were reduced (n= 3), full (n= 2), and a right split liver (n= 1). Median surgical time was 405 min (390-450) and median blood loss was 425 ml (250-600). Median cold and warm ischemia times were 438 min (360-575) and 35 min (30-40), respectively. Median anhepatic phase was 51 min (40-67) and midline incision was 14 cm (13-20) long. On postoperative day 5, median prothrombin index and serum bilirubin levels were 95% (70-117) and 11 (10-37) μmol/L, respectively. No Clavien-Dindo > III complications were encountered. Median hospital stay was 12 days (10-14). After a median follow-up of 8 (8-32) months, all patients were alive without tumor recurrence or adverse event. This preliminary series suggests that in selected patients, LA-LT is a safe and effective option.

Evaluation of right ventricular function during liver transplantation with transesophageal echocardiography.

The pathophysiology of advanced liver cirrhosis may induce alterations in the circulatory system that may be challenging for the anesthesiologist to manage intraoperatively, and perioperative cardiovascular events are associated with worse outcomes in cirrhotic patients undergoing liver transplantation. It remains controversial whether right ventricular function is impaired during this procedure. Studies using transesophageal echocardiography for quantitative analysis of the right ventricle remain scarce in this setting, yielding conflicting results. The aim of this study was to perform a quantitative assessment of right ventricular function with two parameters derived from transesophageal echocardiography during liver transplantation. Nineteen adult patients of both genders undergoing liver transplantation were evaluated in this observational study. The exclusion criteria were age under 18 or above 65 years old, fulminant hepatic failure, hepatopulmonary syndrome, portopulmonary hypertension, cardiopulmonary disease, and contraindications to the transesophageal echocardiogram. Right ventricular function was assessed at five stages during liver transplantation: baseline, hepatectomy, anhepatic, postreperfusion, and closure by measuring tricuspid annular plane systolic excursion and right ventricular fractional area change obtained with transesophageal echocardiography. Right ventricular function was found to be normal throughout the procedure. The tricuspid annular plane systolic excursion showed a trend toward a decrease in the anhepatic phase compared to baseline (2.0 ± 0.9 cm vs. 2.4 ± 0.7 cm; P = 0.24) but with full recovery after reperfusion. Right ventricular fractional area change remained nearly constant during all stages studied (minimum: 50% ± 10 at baseline and anhepatic phase; maximum: 56% ± 12 at postreperfusion; P = 0.24). Right ventricular function was preserved during liver transplantation at the time points evaluated by two quantitative parameters derived from transesophageal echocardiogram.

Postreperfusion Syndrome in Liver Transplant: A Risk Factor for Acute Kidney Failure: A Retrospective Analysis

The maximum expression of hemodynamic instability during liver transplant is the so-called postreperfusion syndrome (PRS) that increases both overall mortality and postoperative complications. It was first defined by Aggarwal et al in 1987, but the results are still conflicting when establishing the relationship between PRS and acute kidney failure (AKF). We conducted a retrospective observational study of transplant recipients with deceased-donor liver grafts between January 2002 and December 2018. We analyzed the incidence of PRS and its potential negative impact over kidney function. A total of 551 transplants were analyzed. PRS was recorded in 130 patients (23.6%). The incidence of AKF was 61.5%. A total of 111 patients required kidney replacement therapy (32.7%). Regarding the severity of AKF, 128 patients were classified as acute kidney injury (AKI) 1 (23.2%), 76 as AKI 2 (13.8%), and 135 as AKI 3 (24.5%). In the group with PRS, 75.4% (n=98) developed AKF vs 57.2% (n=241) in the group without PRS. In the multivariate analysis we found a relationship between PRS and AKF with an odds ratio of 2.18 (95% CI, 1.30-3.64; P=.003), once adjusted by the length of the anhepatic phase, donor age, Model for End-Stage Liver Disease score, history of ascites, and need for early surgical reintervention. The incidence of AKF decreased (44.5%) ever since the implementation of delayed calcineurin inhibitors therapy and piggyback surgical technique, but a clear influence of the occurrence of PRS on the development of AKF is still observed, with an OR of 3.78 (95% CI, 1.92-7.43; P < .001), once adjusted by albumin and hemoglobin levels, Model for End-Stage Liver Disease score, and Child classification.

Anesthesia management in living-donor liver transplantation in a patient with carbamoyl phosphate synthetase deficiency: a case report

BackgroundCarbamoyl phosphate synthetase deficiency (CPS1D) is a urea-cycle disorder (UCD). We report successful perioperative management of pediatric living donor liver transplantation (LDLT) in a CPS1D patient.Case presentationA 10-year-old female patient with CPS1D underwent LDLT. Proper administration of dextrose 50% and 60 kcal/kg/day with l-arginine and l-carnitine resulted in the avoidance of intraoperative hyperammonemia induced by hypercatabolism. Serum ammonia level transiently increased to 61 mmol/L in the anhepatic phase and decreased to 44 mmol/L after reperfusion.ConclusionsWe suggest anesthesia management with administration of dextrose to avoid hyperammonemia during LDLT in patients with CPS1D.

P9.09: Peri-Hepatic Gauze Packing for the Control of Haemorrhage During Liver Transplantation: Experience of a High-Volume Center

Introduction: The use of peri-hepatic gauze packing (PHGP) has been rarely reported during liver transplantation (LT). The objective of this technique is to achieve fast control of bleeding while haemodynamic stability is restored and coagulation disorders are fixed. Conditions like baseline cirrhosis-related coagulopathy, intraoperative blood loss, prolonged surgery, anhepatic phase and initial allograft dysfunction may all contribute to persistent bleeding. In some cases, usual means of haemostasis can be ineffective and reiterate attempts at controlling bleeding can be frustrating or even detrimental. Although, PHGP use during LT raises concerns for a potentially increased risk of infection and graft related complications. The aim of our study was to assess the value of PHGP during LT. Method: We conducted a retrospective and descriptive study. We reviewed the clinical records of 13 orthotopic liver transplantation (OLT) patients undergoing PHGP between a total of 407 patients at the HPB surgery and liver transplant department of the Hospital de Alta Complejidad “El Cruce” between January 2013 and February 2022. Patients and donor’s demographics and intra/postoperative features were analyzed. Continuous data are presented as medians and means and standard deviations. Discrete data are given as counts and percentages. Chi-square test, Fisher exact test, Mann–Whitney U test and Student’s T-test were used when appropriate (for categorical and continuous data respectively). Two-sided p value equal or less than 0.05 was considered to indicate statistical significance with a confidence interval of 95%. All analyses were conducted using MedCalc version 20.027 (https://www.medcalc.org/). Results: Of 407 recipients, 13 were treated with packing for peri-hepatic bleeding (3.19%). One of them required urgent reoperation for ongoing haemorrhage after PHGP. After that, correction of haemodynamic and coagulation parameters was constantly achieved (table 1). 6 patients died (46.15%), none of them related to the PHGP. Patient survival (table 2) was associated with recipient age (p≤0.001) and intraoperative plasma transfusions (p=0.02). Conclusion: Peri-hepatic gauze packing it’s highly effective in achieving adequate haemostasis, allowing the correction of haemodynamic parameters and underlying disorders. However, it’s associated with relevant morbidity and high mortality. We believe that PHGP is a valuable strategy in the armamentarium of the liver transplant surgeon facing a life-threatening situation like the persistent bleeding during the operation.

313.9: Perfusate IL-6 Levels During Liver NMP Might Be Predictive For Hemodynamic Response and Catecholamine Demand After Reperfusion in the Recipient

Introduction: Normothermic liver preservation (NMP) has become a clinical routine at several transplant centres. Reperfusion-syndrome occurs less often in recipients of NMP-livers compared to cold stored livers. We hypothesized that perfusate interleukin (IL)-6 during liver NMP correlate with recipient hemodynamics in the post-reperfusion period. Method: Consecutive NMP-liver transplants at a single-centre were prospectively analysed. Perfusate samples were collected at 1 and 6 hours of NMP and at the end of perfusion and analysed for IL-6 levels. Median arterial pressure (MAP) and catecholamine need during surgery were recorded. The anhepatic phase was defined as baseline for MAP and catecholamine requirements. Results: Over a period of 36 months, IL-6 perfusate measurements were assessed in 77 livers undergoing NMP and transplantation; 15/77 (19.5%) were DCD organs. The median donor age was 61 (15-87) years, median recipient age was 60 (19-73) years. Median (IQR) cold ischemia time was 6.2 (2.1) hrs, NMP-time and overall preservation time were 17.6 (10.4) hrs and 23.6 (10.6) hrs. Median (IQR) IL-6 levels (ng/L) after 1, 6 hrs and NMP-end were 52 (175), 278 (674) and 174 (2171). Neither duration of CIT nor NMP correlated with IL-6 levels over time. NMP-livers were stratified for the median of the last IL-6 measurement. Recipients receiving NMP-livers with perfusate IL-6 levels above the median developed significantly lower post-reperfusion MAP (dropping 20% from baseline) and displayed a significant higher demand of catecholamines (increase of 25% from baseline) up to 30 minutes after reperfusion. Perfusate IL-6 did not correlate with the occurrence of early allograft dysfunction.Conclusion: Perfusate IL-6 levels during liver NMP are clinically relevant as they help to predict the post-reperfusion hemodynamics in recipients.