Orthotopic Liver Transplantation Procedures Research Articles

Liver Transplantation After Hepatic Artery Infusion Pump Therapy: Single-Center Experience and Technical Considerations.

Hepatic artery infusion pump (HAIP) therapy has become increasingly commonplace in the treatment of intrahepatic tumors. When combined with standard chemotherapy, HAIP therapy demonstrates a higher response rate than chemotherapy alone. Biliary sclerosis is observed in up to 22 % of patients, for whom no treatment has been standardized. This report describes orthotopic liver transplantation (OLT) both as a treatment for HAIP-induced cholangiopathy and as a possible definitive oncologic treatment after HAIP-bridging therapy. A retrospective study reviewed patients who had undergone HAIP placement followed by OLT at the authors' institution. Patient demographics, neoadjuvant treatment, and postoperative outcomes were reviewed. Seven OLTs were performed for patients with prior HAIP placement. The majority were women (n = 6), and the median age was 61 years (range, 44.5-65.5 years). Transplantation was performed for five patients due to biliary complications secondary to HAIP and two patients because of residual tumor after HAIP therapy. All the OLTs had difficult dissections due to adhesions. Because of HAIP-induced damage, atypical arterial anastomoses were required in six patients (2 patients used a recipient common hepatic artery below the gastroduodenal artery takeoff; 2 patients used recipient splenic arterial inflow; 1 patient used the junction of the celiac and splenic arteries; and 1 patient used the celiac cuff). The one patient with standard arterial reconstruction experienced an arterial thrombosis. The graft was salvaged with thrombolysis. Biliary reconstruction was duct-to-duct in five cases and Roux-en-Y in two cases. The OLT procedure is a feasible treatment option for end-stage liver disease after HAIP therapy. Technical considerations include a more challenging dissection and an atypical arterial anastomosis.

Changes in the Serum Fatty Acid Profile After Anhepatic Phase of Orthotopic Liver Transplantation Procedure.

During orthotopic liver transplantation (OLT), the patients’ body remains deprived of this organ for some time, which could cause critical changes in the levels of various metabolites in the circulation, including fatty acids. Thus, the aim of this study was to determine whether the liver transplantation procedure leads to significant changes in the FA profile in serum lipids after the anhepatic phase. Our gas chromatography–mass spectrometry analysis revealed that after transplantation, serum levels of myristic and palmitic acids significantly decreased, whereas serum levels of very long-chain FAs containing 20 or more carbons in their chains were increased. These results indicate that the anhepatic phase during liver transplantation produces significant changes in serum fatty acid levels, and emphasizes the role of the liver in the metabolism of very long-chain fatty acids.

Intraoperative management and early post-operative outcomes of patients with coronary artery disease who underwent orthotopic liver transplantation

BackgroundCoronary artery disease (CAD) is frequently observed in aging end-stage liver disease (ESLD) patients who require orthotopic liver transplantation (OLT). This situation is challenging for both the patients and the medical staff. MethodsWe retrospectively studied the case records of 26 ESLD patients with CAD who underwent OLT with total clamping of the inferior vena cava between 2014 and 2018. We analyzed the details of the pre-operative evaluation, intraoperative anesthetic management and post-operative prognosis of these patients. ResultsAll patients tolerated the anhepatic stage well. Post-reperfusion syndrome (PRS) was observed in 13 patients (50%) and 2 of them were severe but corrected well. ST-segment depression was frequently observed during the anhepatic stage and reperfusion stage. No mortality due to cardiac-related events occurred among the patients during hospitalization. OLT with the modified piggyback technique could successfully be performed in ESLD patients with mild and moderate CAD. ConclusionsA thorough evaluation and optimization of recipients, strict monitoring and optimized management of circulation, knowledge of the complicated changes during OLT procedures, and strategies to ameliorate post-reperfusion syndrome favorite the outcomes.

Effects of liver ischemia-reperfusion injury on respiratory mechanics and driving pressure during orthotopic liver transplantation.

During orthotopic liver transplantation (OLT), liver graft ischemia-reperfusion injury (IRI) triggers a cytokine-mediated systemic inflammatory response, which impairs graft function and disrupts distal organ homeostasis. The objective of this prospective, observational trial was to assess the effects of IRI on lung and chest wall mechanics in the intraoperative period of patients undergoing OLT. In 26 patients undergoing OLT, we measured elastance of the respiratory system (ERS), partitioned into lung (EL) and chest wall (ECW), hemodynamics, and fluid and blood product intake before laparotomy (T1), after portal/caval surgical clamp (T2), and immediately (T3) and, at 90 and 180 minutes post-reperfusion (T4 and T5, respectively). Interleukin-6 (IL-6), monocyte chemotactic protein-1 (MCP-1), IL-1β and tumor necrosis factor-α plasma concentrations were assessed at T1, T4 and T5. EL significantly decreased from T1 to T2 (13.5±4.4 vs 9.7±4.8 cmH2O/L, P<0.05), remained stable at T3, while at T4 (12.3±4.4 cmH2O/L, P<0.05) was well above levels recorded at T2, reaching its highest value at T5 (15±3.9 cmH2O/L, P<0.05). Variations in ERS, EL, driving pressure (∆P) and trans-pulmonary pressure (∆PL) significantly correlated with changes in IL-6 and MCP-1 plasma concentrations, but not with changes in wedge pressure, fluid amounts, and red blood cells and platelets administered. No correlation was found between changes in cytokine concentrations and ECW. We found that EL, ECW, ∆P and ∆PL underwent significant variations during the OLT procedure. Further, we documented a significant association between the respiratory mechanics changes and the inflammatory response following liver graft reperfusion.

Liver Transplantation Techniques for the Surgical Management of Renal Cell Carcinoma with Tumor Thrombus in the Inferior Vena Cava: Step-by-Step Description

BackgroundRenal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon given the operative difficulty, potential for massive hemorrhage, and possibility of tumor thromboemboli. ObjectiveTo determine the applicability of a self-developed technique based on orthotopic liver transplantation procedures for safe resection of these tumors. Design, setting, and participantsFrom August 1997 to February 2008, 68 consecutive patients underwent resection of RCC with suprahepatic and/or retrohepatic (level 3 and 4) tumor thrombus in a single referral institution. Surgical procedureA triradiate incision over the upper abdomen permits the placement of a Rochard retractor. Early vascular control of the renal artery is achieved by creating a posterior plane of dissection. Venous collateral decompression permits development of a bloodless anterior plane by mobilizing the liver in a “piggy-back” fashion and the spleen–pancreas en bloc to the midline. Thrombus extraction requires circumferential control at the renal veins, hepatic hilum, and IVC before cavotomy. The central tendon of the diaphragm may be opened for cranial control and gentle traction over the right atrium performed. Repositioning of the proximal clamp and Pringle release avoid veno-venous bypass and cardiopulmonary bypass (CPB) in most cases. MeasurementsThe extent of the tumor thrombus was retrohepatic in 56 patients and suprahepatic/intra-atrial in 12 patients. Results and limitationsMean operative time was 5h 32min. Mean estimated blood loss (EBL) was 2112±3834ml (range: 100–25 000), with a mean transfusion being 4.2±4.1 U (range: 0–30). Five patients (7.3%) required CPB. Three patients (4.4%) died in the immediate postoperative period. All had complete tumor resection. No patient developed intraoperative thromboembolism. ConclusionsThis surgical approach provides excellent exposure and control of the IVC in cases with level 3 and 4 tumor thrombus, avoiding CPB except in rare circumstances.

Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation

Michael R. Charlton, William J. Wall, Akinlolu O. Ojo, Pere Gines, Stephen Textor, Fuad S. Shihab, Paul Marotta, Marcelo Cantarovich, James D. Eason, Russell H. Wiesner, Michael A. Ramsay, Juan C. Garcia-Valdecasas, James M. Neuberger, Sandy Feng, Connie L. Davis, Thomas A. Gonwa, and the International Liver Transplantation Society Expert Panel Mayo Clinic, Rochester MN; Department of General Surgery, London Health Science Center, London, Ontario, Canada; Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI; Liver Unit, Hospital Clinic, University of Barcelona School of Medicine, Barcelona, Spain; Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT; Medical School, University of Western Ontario, London, Ontario, Canada; Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada; Transplant Institute, University of Tennessee, Memphis, TN; Baylor University Medical Center, Dallas, TX; Hospital Clinic I Provincial, Barcelona, Spain; Queen Elizabeth Hospital, Birmingham, England; Department of Transplant Surgery, University of California San Francisco Medical Center, San Francisco, CA; Department of Medicine, University of Washington Medical Center, Seattle, WA; and Mayo Clinic, Jacksonville, FL

A 20-Year Period of Orthotopic Liver Transplantation Activity in a Single Center: A Time Series Analysis Performed Using the R Statistical Software

In many Western countries a “minimum volume rule” policy has been adopted as a quality measure for complex surgical procedures. In Italy, the National Transplant Centre set the minimum number of orthotopic liver transplantation (OLT) procedures/y at 25/center. OLT procedures performed in a single center for a reasonably large period may be treated as a time series to evaluate trend, seasonal cycles, and nonsystematic fluctuations. Between January 1, 1987 and December 31, 2006, we performed 563 cadaveric donor OLTs to adult recipients. During 2007, there were another 28 procedures. The greatest numbers of OLTs/y were performed in 2001 (n = 51), 2005 (n = 50), and 2004 (n = 49). A time series analysis performed using R Statistical Software (Foundation for Statistical Computing, Vienna, Austria), a free software environment for statistical computing and graphics, showed an incremental trend after exponential smoothing as well as after seasonal decomposition. The predicted OLT/mo for 2007 calculated with the Holt-Winters exponential smoothing applied to the previous period 1987–2006 helped to identify the months where there was a major difference between predicted and performed procedures. The time series approach may be helpful to establish a minimum volume/y at a single-center level.

Postreperfusion syndrome during liver transplantation for cirrhosis: Outcome and predictors

During orthotopic liver transplantation (OLT), a marked decrease in blood pressure following unclamping of the portal vein and liver reperfusion is frequently observed and is termed postreperfusion syndrome (PRS). The predictive factors and clinical consequences of PRS are not fully understood. The goal of this study was to identify predictors of PRS and morbidity/mortality associated with its occurrence during OLT in patients with cirrhosis. During a 3-year period, all consecutive OLT procedures performed in patients with cirrhosis were studied. Exclusion criteria were OLT for acute liver failure, early retransplantation, combined liver/kidney transplantation, and living-donor related transplantation. PRS was defined as a decrease in the mean arterial pressure of more than 30% of the value observed in the anhepatic stage, for more than 1 minute during the first 5 minutes after reperfusion of the graft. Transplantation was performed with preservation of the inferior vena cava with or without temporary portocaval shunt. Associations between PRS and donor and recipient demographic data, recipient operative and postoperative outcomes were tested with bivariate statistics. Independent predictors of PRS were determined in multivariable logistic regression analysis. Of the 75 patients included in the study, 20 patients (25%) developed PRS. In a multivariable analysis, absence of a portocaval shunt [odds ratio (95% confidence interval) = 4.42 (1.18-17.6)] and duration of cold ischemia [odds ratio (95% confidence interval) = 1.34 (1.07-1.72)] were independent predictors of PRS. Patients who experienced PRS displayed more postoperative renal failure and lower early (<15 days after OLT) survival (80% versus 96%; P = 0.04). In conclusion, the absence of portocaval shunt and the duration of cold ischemia were independent predictors of intraoperative PRS. PRS was associated with significant adverse postoperative outcome. These results provide realistic clinical targets to improve patient outcome after OLT for cirrhosis.

Conversion to termino-terminal cavo-cavostomy as a rescue technique for infrahepatic obstruction after piggyback liver transplantation

Conversion to termino-terminal cavo-cavostomy as a rescue technique for infrahepatic obstruction after piggyback liver transplantation

Metabolic Issues in Liver Transplantation

Patients who undergo orthotopic liver transplantation (OLT), almost by definition, have end-stage liver disease. One cannot examine the metabolic changes observed during OLT without insight into the profound effects of preexisting liver dysfunction. Because the liver plays a central role in regulation of whole-body metabolism, its disease leads to major alterations in glucose metabolism. Most patients presenting for OLT have chronic liver disease which has gradually progressed to the point where replacement surgery is indicated. The endocrine and metabolic changes associated with chronic cirrhosis are well described. A small subset of patients presents for OLT with fulminant liver failure which may or may not have been preceded by chronic liver disease. Evidence describing metabolic alterations of patients with fulminant disease, because of its unstable nature, is much less complete than that for patients with chronic disease. Many of the underlying endocrine and metabolic alterations are exacerbated by the OLT procedure itself. After OLT, full normalization of glucose metabolism is delayed and corrects in stages. Certain primary inherited diseases (‘‘inborn errors’’) of metabolism, which can be corrected by OLT, present unique issues that are beyond the scope of this review. Patients with end-stage liver disease exhibit disturbances in lipid, amino acid, and protein metabolism; and also poor clearance of drugs whose elimination or biotransformation depends on hepatic function. However, these subjects are also outside of the scope of the present review. This review focuses on the intertwined derangements of glucose metabolism, acid-base balance, and serum electrolyte concentrations that appear in patients before OLT, then describes changes which occur intraoperatively and persist in the postoperative setting. The endocrine environment that in part mediates the metabolic response is presented first.

Preoperative risk factor analysis in orthotopic liver transplant-ation with pretransplant artificial liver support therapy

To assess the value of pre-transplant artificial liver support in reducing the pre-operative risk factors relating to early mortality after orthotopic liver transplantation (OLT). Fifty adult patients with various stages and various etiologies undergoing OLT procedures were treated with molecular adsorbent recycling system (MARS) as preoperative liver support therapy. The study included two parts, the first one is to evaluate the medical effectiveness of single MARS treatment with some clinical and laboratory parameters, which were supposed to be the therapeutical pre-transplant risk factors, the second part is to study the patients undergoing OLT using the regression analysis on preoperative risk factors relating to early mortality (30 d) after OLT. In the 50 patients, the statistically significant improvement in the biochemical parameters was observed (pre-treatment and post-treatment). Eight patients avoided the scheduled Ltx due to significant relief of clinical condition or recovery of failing liver function, 8 patients died, 34 patients were successfully bridged to Ltx, the immediate outcome of this 34 patients within 30 d observation was: 28 kept alive and 6 patients died. Pre-operative SOFA, level of creatinine, INR, TNF-alpha, IL-10 are the main preoperative risk factors that cause early death after operation, MARS treatment before transplantation can relieve these factors significantly.

Internal Jugular Versus Subclavian Vein Catheterization for Central Venous Catheterization in Orthotopic Liver Transplantation

The aim of this study was to compare incidence rates of mechanical and infectious complications associated with central venous catheterization via the internal jugular vein (IJV) versus the subclavian vein (SV) among 45 consecutive patients undergoing orthotopic liver transplantation (OLT) between January 2000 and June 2004. The subjects were divided into two groups according to the site of central venous catheterization (IJV or SV). We recorded each patient’s physical characteristics, international normalized ratio (INR), partial thromboplastin time, platelet levels, number of puncture attempts, success/failure of central venous catheterization, duration of catheter placement, occurrence of catheter tip misplacement, arterial puncture, incidence of hematoma or pneumothorax, catheter-related infection, or bacterial colonization of the catheter. Senior staff anesthesiologists performed 22 SV and 23 IJV catheterizations for the 45 OLT procedures. The SV and IVJ groups both had minor coagulation abnormalities with slightly increased INR values at the time of catheterization. There were no significant differences between the groups with respect to success of central venous catheterization (100% for both), numbers of attempted punctures, duration of catheter placement, and incidence rates of mechanical and infectious complications. Both groups showed high frequencies of catheter tip misplacement, with right atrium as the site of misplacement in all cases. Two patients in the IJV group (8.7%) developed hematomas after accidental carotid artery puncture. The results suggest that, when performed by experienced anesthesiologists, central venous catheterization via the SV is an acceptable alternative to IJV catheterization for patients undergoing OLT.

Impact of prior portosystemic shunt procedures on outcome of liver transplantation

Cirrhotic patients may require portosystemic shunts as treatment for complications of portal hypertension. The aim of this study was to asses how these procedures may influence the orthotopic liver transplantation procedure and its outcome. Forty-five patients with a previous portosystemic shunt were divided into 3 groups (group 1, 19 with a portocaval shunt; group 2, 4 with a mesocaval shunt and 5 with a distal splenorenal shunts; group 3, 17 with a transjugular intrahepatic portosystemic shunt). Forty-five patients without a shunt, matched for age, gender, pretransplant liver status, and year of transplantation, were selected as controls. Surgical time, transfusional requirement, intensive care unit and total hospital duration of stay, complications, retransplantation rate, and short- and long-term mortality were analyzed. Group 1 showed a significantly longer surgical time, higher red blood cell transfusional requirements, longer intensive care unit and hospital stay, and greater short and long-term mortality than the controls. No significant differences were observed between groups 2 and 3 and the controls. In cirrhotic patients, surgically created portosystemic shunts involving the hepatic hilum have a negative impact on liver transplantation. This operation should be avoided in potential liver transplant candidates; surgical shunts that do not compromise the hepatic hilum or transjugular intrahepatic portosystemic shunts are preferred.

Preoperation risk factor analysis in orthotopic liver transplantation with pretransplant artificial liver support therapy

Orthotopic liver transplantation (OLT) is an accepted therapy for selected patients with advanced liver diseases. However, the early mortality rate after OLT remains relatively high due to the poor selection of candidates with various serious conditions. The aim of this study is to assess the value of pretransplantation artificial liver support treatment in reducing the pre-operation risk factors relating to early mortality after OLT. 50 adult patients in various stages of different etiologies who underwent OLT procedures had been treated with molecular adsorbent recycling system (MARS) preoperatively. The study was designed in two parts: the first one was to evaluate the effectiveness of a single MARS therapy by using some clinical and laboratory parameters which were supposed to be therapeutical pretransplantation risk factors. The second part was to study the patients undergoing OLT by using the regression analysis on preoperation risk factors relating to early (within 30 d after OLT) mortality rate. Among the 50 patients, a statistically significant improvement of the biochemical parameters was observed (pretreatment vs posttreatment). 8 patients cancelled their scheduled LTXs due to significant improvements in their clinical conditions or recovery of their failing liver functions. 8 patients died and 34 patients successfully underwent LTX. The immediate outcome (within 30 postoperative days) of these 34 patients was that 28 were kept alive and 6 died. Preoperation sequential organ failure assessment (SOFA), level of creatinine, INR, TNFalpha, and IL-10 are the main preoperative risk factors relating to early death after an operation. MARS treatment before a transplant operation can relieve these factors significantly, hence improve survival rate of liver transplantation or even make the transplantation unnecessary.

Hepatic artery reconstruction prior to orthotopic liver transplantation

Background This study examines the types of arterial reconstruction for grafts prepared for orthotopic transplantation procedures. Methods Between 1993 and February 2003, 200 organs were harvested for orthotopic liver transplantation. Arterial variations were found in 28 cases (14%), among which 16 cases (8%) required vascular reconstruction with 4 cases due to accidentally damaged during liver harvesting. Results Among the 200 organs harvested for liver transplantation, arterial variations requiring reconstruction were found in 12 cases (6%); these included: replacing an accessory left hepatic artery from the left gastric artery (9/1 reconstruction); replacing an accessory left hepatic artery from the upper mesenteric artery (2/1 reconstruction), and replacing an accessory right hepatic artery from the upper mesenteric artery (10/10 reconstructions). The splenic artery was typically used for anastomosis (seven cases, 58.3%) as well as the gastroduodenal artery (two cases, 16.7%) or the right gastric artery (one case, 8.3%). In the remaining two cases, a more complex technique was required. Conclusions Reconstruction of graft vessels before an orthotopic liver transplantation procedure does not increase the risk of vascular complications.

Parenchymal liver injury in orthotopic liver transplantation.

A 35-year period of clinical development resulted in orthotopic liver transplantation (OLT) becoming a standardized surgical procedure. Despite this progress, the rate of technical complications is still high. Although the main problem in most analyses is vascular or bile duct failure, we observed a remarkable number of parenchymal liver injuries that led to intraoperative problems. Our aim, therefore, is to present an overall report on the incidence, treatment, and clinical course of parenchymal liver injuries in OLT. Five hundred seventy-two consecutive OLT procedures performed between 1988 and 1998 were analyzed in a retrospective study. Parenchymal liver injury was diagnosed by means of examination of the surgical reports. Donor- and recipient-related data followed the medical report. The lesions were classified according to the Organ Injury Scale. Parenchymal liver injury was diagnosed in 23 patients (4%). The lesions were classified as grade Ia (13.1%), grade Ib (13.1%), grade IIb (52.1%), grade IIIa (17.1%), and grade IIIb (4.3%). In 19 patients (82.6%), the lesion was detected during OLT, and in four patients (17.4%), during relaparotomy. The latter group showed significantly higher-grade injuries. Treatment was suture or fibringlue alone, 17.4%; fibringlue and hemostyptics, 26.1%, mesh wrapping 30.4%, and mesh packing 26.1%. Seven patients (30.4%) underwent relaparotomy. Further active bleeding was not found in any of them. Statistical analysis found a correlation between injury grade and relaparotomy rate. No patients died as a result of parenchymal liver injury. Parenchymal liver injuries can be treated well, with no adverse effect on patient or graft survival. An early decision concerning the surgical procedure for controlling hemorrhage is required. A basically aggressive therapeutic approach might avoid further complications relating to reperfusion edema.

7237 Bile leaks after t-tube removal in orthotopic liver transplantation patients: the role of ercp.

Background: End-to-end choledochocholedochostomy (CCS) over a T-tube has been the standard method of biliary reconstruction following orthotopic liver transplantation (OLT). Bile leaks following T-tube removal in these patients (pts) have been reported with a frequency of 8-12% in published series. Hypotheses: (1) T-tube removal in OLT pts with CCS have an unusually high incidence of post-procedure bile leaks. (2) Patients with bile leaks following Ttube extraction can be successfully treated with endoscopic therapy. Methods: The records of all pts having OLT at our center between 8/93 and 6/99 were reviewed for endoscopic management of bile leaks following T-tube removal. Pt records and a computerized database of ERCP procedures were searched. Indications for ERCP were noted, as well as the number of stent placements, the size of the stents, and length of treatment required for leak resolution. Results: 216 OLT procedures were performed in the study period. 26 (12%) pts required ERCP to assess and treat a bile leak after T-tube extraction. Most developed pain immediately after T-tube extraction; only 1 patient developed pain after 24 hours. Two patients were lost to follow-up after their index ERCP. Of the remaining 24, 20(83%) underwent 1 stent insertion and 4(17%) underwent 2 stent insertions. Initial stent sizes were 7FR (n=9; 38%); 8.5FR (n=1; 4%) and 10FR (n=14; 58%). All patients requiring two stent placements (n=4), initially received a 7FR stent. Treatment lasted an average of 49 days (ranging 21-82 days) following the initial ERCP. No pt required percutaneous biliary drainage or surgery for this type of leak. Cholangitis (n=1) was the only complication noted. Discussion: In our center, the incidence of bile leaks following T-tube extraction in OLT pts was similar to that of previously reported series. In every case endoscopic stenting resulted in resolution of the leak. Delayed closure of leaks was associated with initial use of a 7FR stent, suggesting that larger (e.g. 10FR) diameter stents should be used whenever possible. ERCP with biliary stent placement appears to be an effective way to manage bile leaks following T-tube extraction in this pt group. Recognizing that urgent ERCP may be required when T-tubes are removed, we have established a policy of fasting these patients overnight and doing the T-tube extraction early in the day.

Cost analysis of intraoperative blood salvage during orthotopic liver transplantation

Approximately 6,000 to 7,000 orthotopic liver transplantation (OLT) procedures are performed annually, which require the administration of large volumes of blood products. Thus liver transplantation can significantly strain local and regional blood resources at a time when transfusion practices are changing dramatically, in large part because of anxiety caused by the human immunodeficiency virus. Intraoperative autologous transfusion has been proposed as a means of both reducing transfusion demands and lessening the hazards of allogeneic transfusion. However, the cost effectiveness of intraoperative blood salvage has not been unequivocally determined. We retrospectively examined the cost of intraoperative autologous transfusion during OLT for a 2-year period at the University of Cincinnati Hospital. A direct comparison was made between the charge for autologous transfusion and the calculated cost of allogeneic transfusion. Seventy OLT procedures were performed during the years 1993-1994. The average charge for autologous transfusion was $1,048.73 per case. Cell-salvage volumes for all cases were added, and the calculated conservation of allogeneic packed red blood cells totaled 359.6 units, worth $30,026.60 or $428.95 per case. The break-even point is approximately 12.6 units, and most patient do not receive this volume of salvaged blood. In fact, cell salvage reached cost equivalence in only three cases (4.8%). Moreover, the cost deficit of autologous transfusion during this 2-year period averaged $586.56 per case. (Liver Transpl Surg 1997 Sep;3(5):513-7)

Cost analysis of intraoperative blood salvage during orthotopic liver transplantation.

Approximately 6,000 to 7,000 orthotopic liver transplantation (OLT) procedures are performed annually, which require the administration of large volumes of blood products. Thus liver transplantation can significantly strain local and regional blood resources at a time when transfusion practices are changing dramatically, in large part because of anxiety caused by the human immunodeficiency virus. Intraoperative autologous transfusion has been proposed as a means of both reducing transfusion demands and lessening the hazards of allogeneic transfusion. However, the cost effectiveness of intraoperative blood salvage has not been unequivocally determined. We retrospectively examined the cost of intraoperative autologous transfusion during OLT for a 2-year period at the University of Cincinnati Hospital. A direct comparison was made between the charge for autologous transfusion and the calculated cost of allogeneic transfusion. Seventy OLT procedures were performed during the years 1993-1994. The average charge for autologous transfusion was $1,048.73 per case. Cell-salvage volumes for all cases were added, and the calculated conservation of allogeneic packed red blood cells totaled 359.6 units, worth $30,026.60 or $428.95 per case. The break-even point is approximately 12.6 units, and most patient do not receive this volume of salvaged blood. In fact, cell salvage reached cost equivalence in only three cases (4.8%). Moreover, the cost deficit of autologous transfusion during this 2-year period averaged $586.56 per case.

Reperfusion damage to the bile canaliculi in transplanted human liver

In 19 patients who have undergone orthotopic liver transplantation (OLT), the trend and degree of cholestasis was statistically monitored in terms of plasma levels of L-gamma-glutamyl transferase (GGT) and total bilirubin. In addition, the ultrastructure of the bile canaliculus was examined during the entire OLT procedure, i.e., during explantation, cold ischemia, and after 60 to 90 minutes of organ reperfusion. Cholestasis was evident from the second day after surgery, with a peak after approximately 10 to 16 days. Defined, small changes in the functional state of actin filaments were noted in the bile canalicular area after prolonged ischemia. But the morphological status of the bile canaliculi changed dramatically after reperfusion. In fact, the mean area and perimeter of the canaliculi had increased significantly, and there was a marked loss in the number of bile microvilli per unit of canalicular area. The bile canaliculus appears to be one of the liver structures most susceptible to ischemia- reperfusion damage. A series of biochemical changes occurring during ischemia and after reoxygenation of the transplanted liver, especially, would provide a reason for the observed early morphological damage of the bile canaliculus, which, in turn, would explain the cholestasis of these patients in the first posttransplantation period. (Hepatology 1996 Nov;24(5):1053-7)