Amr M. Yassen

Biliary complications in living donor right hepatectomy are affected by the method of bile duct division

The bile duct division is a crucial step in the donor hepatectomy. Multiple small ducts will make the biliary reconstruction more difficult and may influence the outcome of the recipient. Biliary leakage, bilomas and biliary strictures are well recognized donor complications that may be directly linked to bile duct division. Biliary division still needs more standardization. This work aims to analyze our experience with two different methods of bile duct division in relation to the development of intraoperative and postoperative biliary complications. Between April 2004 and March 2013, 216 liver donors underwent right hepatectomy, in Gastro‐Enterology Surgical Center, Mansoura University, Egypt. According to the method of bile duct division, the study population was divided into 2 groups; 1‐ extrahepatic dissection group (EDG) and 2‐ fluoroscopy guided transection group (FGG), each comprised 108 patients. Data were collected from a prospectively registered database, with special emphasis on the occurrence of biliary complications. Complications were classified according to the latest version of Clavien classification. Intraoperative biliary complications did not differ between both groups, p = 0.313. The commonest postoperative complication was biliary leak/biloma accounting for 32.5% of all donor complications, followed by non‐biliary fluid collections. 24 (11.1%) donors developed 27 biliary complications. The FGG showed significantly less biliary complications (5.6%, 6 donors), when compared to EDG (15.7%, 18 donors), p = 0.015. Grade 3 complications were significantly higher in EDG, p = 0.024. On multivariate analysis, the only significant factor predicting the occurrence of biliary complications was the use of fluoroscopy guided bile duct division, p = 0.009. In conclusion, we believe that the proposed method of biliary division is safe, simple and reproducible. Liver Transpl 20:1393‐1401, 2014.

Problem of living liver donation in the absence of deceased liver transplantation program: Mansoura experience

We report our experience with potential donors for living donor liver transplantation (LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors (n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion (n = 792). Most of the transplant candidates (82.3%) had an experience with more than one excluded donor (median = 3). Some recipients travelled abroad for a deceased donor transplant (n = 12) and some died before finding a suitable donor (n = 14). The evaluation of an excluded donor is a time-consuming process (median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD (range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.

The impact of portopulmonary hypertension on intraoperative right ventricular function of living donor liver transplant recipients.

BACKGROUND: Portopulmonary hypertension (PPH) burdens a right ventricle (RV) already exposed to physiologic stress during liver transplantation. The magnitude of the impact of PPH on RV function, especially early reperfusion, has not been evaluated adequately by prospective controlled trials. In this study, we prospectively quantified the impact of PPH on the RV function in living donor liver transplant recipients. METHODS: Twenty patients undergoing living donor liver transplant were stratified based on mean pulmonary artery pressure (mPAP) into a control group (mPAP <25 mm Hg) and a PPH group (mPAP ≥25 mm Hg). Standard anesthetic technique and monitoring were used. Fiberoptic pulmonary artery catheters enabled to measure RV ejection fraction (RVEF) were used. Hemodynamics were recorded after induction of anesthesia, the end of hepatectomy, before portal unclamping, 5 and 30 minutes after reperfusion, and at skin closure. RESULTS: The PPH group had significantly lower RVEF, stroke volume, and higher central venous pressure and RV end-diastolic volume index after portal unclamping versus the controls. Pulmonary vascular resistance index and mPAP were significantly higher throughout the operation in the PPH group, but RV stroke work index did not differ significantly between groups. RVEF was significantly reduced in the PPH group after reperfusion compared with baseline, but the control group did not experience such a reduction. CONCLUSIONS: Mild to moderate PPH was associated with reduced RVEF during liver transplantation, especially after reperfusion, likely because of a reduced RV contractile reserve in PPH patients. This reduction in RVEF was clinically well tolerated by patients with mild to moderate PPH.

Hematological profile and transfusion requirement during hysteroscopic myomectomy: A comparative study between oxytocin and tranexamic acid infusion

Abstract Background Oxytocin is uterotonic drug reducing uterine blood loss. Tranexamic acid reduce blood loss in various settings. Data on their efficacy are limited in gynecological hysteroscopy. This study was conducted to compare the effect of oxytocin versus tranexamic acid on hematological profile and transfusion requirement during hysteroscopic myomectomy (HM). Methods Fifty women scheduled for HM were randomly assigned into two groups. Ttranexamic acid (TXA) or oxytocin (OXY). TXA was injected with 15 mg kg−1 of tranexamic acid, followed by infusion of 10 mg kg−1 h−1. In OXY, 10 Unites of oxytocin were added to 500 mL saline (400 mU/min) during surgery. Spinal anesthesia was induced for all patients. Hemodynamics, hematological data, number of transfusions, serum sodium and central venous pressure were measured. Results TXA showed significant decrease of heart rate 30 and 45 min and 1 and 2 h when compared with OXY. Post operative Hb and Hct showed significant decrease (p < 0.001) in TXA compared with OXY. CVP in TXA displayed significant increase (p < 0.001) 15 min after spinal blockade and 30 min, 45 min, 1 h and 2 h. Serum sodium showed significant decrease in TXA (p < 0.001) compared with OXY nearly throughout study period. Conclusion Use of oxytocin during HM was accompanied with stable hemodynamics, hematological profile and less transfusion requirement compared with the use of tranexamic acid.

Hepatic venous outflow obstruction after living donor liver transplantation managed with ectopic placement of a foley catheter: A case report.

Highlights • Hepatic venous outflow obstruction is a rare serious complication after liver transplantation.• Hepatic venous outflow obstruction may result in graft loss and recipient death.• We report the use of the foley catheter to temporary fix the graft and correct the hepatic venous outflow obstruction.• It is a simple, cheap and safe device to correct the hepatic venous outflow obstruction.• It could be easily monitored and removed under Doppler US without any device related complications.

Automated control of end-tidal sevoflurane in living donor hepatectomy, a prospective, randomized, controlled study

Abstract Background Reduction of anesthesia cost has become a necessity, especially in developing countries. Recently, automated control of end-tidal sevoflurane concentration (EtSev) has been proposed as a new technique with both cost-effectiveness and safety profiles. In this study, sevoflurane consumption (primary outcome variable) was evaluated during living donor hepatectomy using automated control of EtSev (EtC) at fresh gas flow (FGF) of 0.5 and 2 L/min compared to manual control (MC) technique at FGF of 2 L/min. Materials and methods Prospective, randomized, controlled trial including 60 Potential donors scheduled for living donor right hepatectomy. patients were randomized into 3 equal groups (according to target control of sevoflurane), MC group, EtC-2L group, and EtC-0.5L group. In MC group: FGF was set to 2 L/min, inspired concentration of Sevoflurane (FiSev) was set to 1.5–2% in 0.4 fractional inspired oxygen concentration (FiO2), while in EtC-2L group: FGF was set to 2 L/min, EtSev was set to 1–1.5% with end tidal oxygen concentration (EtO2) target of 0.35. In EtC-0.5L group, FGF was set to minimal flow and EtSev target to 1–1.5% and EtO2 target of 0.35. Anesthetic gases consumption (sevoflurane ml, Oxygen L, and air consumption L) per anesthesia hour were recorded at the end of surgery. Other recorded data included intraoperative hemodynamics, the number of user adjustments, and extubation time. Results Significant reduction in sevoflurane consumption when EtC-0.5L is used (4.2 ± 1.3 ml/h, 12.6 ± 2.6 ml/h, and 15 ± 2.9 ml/h respectively, p. 0.001). Also, a significant decrease in overall numbers of user adjustments between the three groups (8 times for EtC-0.5L group, 7 times in EtC-2L group, 22 times for MC group, p. 0.008) was observed. Conclusion automated control of EtSev during anesthesia of living donor hepatectomy significantly lowers sevoflurane consumption and decreases required user interventions without deleterious effect on patient safety.

Low dose ketorolac infusion improves postoperative analgesia combined with patient controlled fentanyl analgesia after living donor hepatectomy – Randomized controlled trial

Abstract Background Hepatectomy elaborates significant post-operative pain. Opioids represent cornerstone for post-operative analgesia in such cases. This study examined the therapeutic effect and outcome of adding low dose ketorolac tromethamine infusion to PO intravenous patient controlled fentanyl analgesia IV-PCA. Patients and methods Sixty right lobe donors were randomized into either fentanyl or ketorolac groups (30 patients each). Patients in both groups received fentanyl (2 μg/ml) solution in normal saline as IV-PCA with background infusion in a rate adjusted to deliver 0.25 μg kg h−1 and boluses of 10 ml with a lock-out time of 20 min. They received 15 mg ketorolac IV bolus in ketorolac group and similar placebo injection in the control. Patients in both groups received a continuous intravenous infusion of 240 ml normal saline solution that is either free in the FENT group or containing 60 mg ketorolac in ketorolac group, adjusted to a rate of 0.2 ml kg h−1. Visual analogue score (VAS) and hemodynamic profile were recorded at 1, 6, 12, 24, 36 and 48 h while laboratory results were recorded after 48 h and 7 days post-operatively. Results VAS was significantly lower in ketorolac group compared to fentanyl group from 6 to 36 h post-operatively while sedation score was significantly higher in fentanyl group compared to fentanyl–ketorolac group between 12 and 36 h post-operatively. Fentanyl consumption was significantly lower in ketorolac group at 24 (318.7 ± 66 vs 468.3 ± 79) and 48 (211.5 ± 59 vs 369.1 ± 68) h. Hemodynamic data and laboratory parameters were comparable in both groups. Nausea had a significantly higher incidence in FENT compared to KETR groups while other complications (vomiting and blood loss) were homogenous in both groups. Conclusion Adding ketorolac to IV PCA fentanyl improved the analgesic state and reduced the dose of fentanyl used without adding any side effects or risks to donors subjected to right lobe hepatectomy.

Pressure versus volume indices to guide fluid infusion early after living donor liver transplantation: A prospective randomized controlled trial

Abstract Background Fluid resuscitation in early post-operative (PO) period after liver transplantation (LT) can be very detrimental for both graft and patients outcome. Central venous pressure (CVP) was commonly used to guide fluid resuscitation after LT; yet, volumetric indices like stroke volume (SV) or right ventricular end diastolic volume (RVEDV) have gained more support recently. We tested the hypothesis that use of any of the three parameters to guide fluid therapy in the early PO period after living donor liver transplantation (LDLT) will not elaborate any changes in fluid volumes infused or graft and patient outcome. Patients and methods Sixty patients undergoing LDLT allocated based on the parameter guiding the fluid therapy in the first 72 h in ICU into one of three groups, G-CVP (control), G-SV and G-RV groups 20 patients each using CVP, SVI and RVEDVI respectively to guide fluid therapy. Based on the guiding parameter assessed every 4 h, fluid therapy was administered as 500 ml boluses followed by reassessment of the guiding parameter for further fluid infusion. Fluids infused over three days in the ICU were used as a primary outcome. Hemodynamics, graft and renal functions, and graft and patient outcome were recorded as secondary objectives. Results CVP and PCWP were significantly higher in G-SV and G-RV compared to the CVP group while other hemodynamic parameters did not show significant differences between the groups. Fluid volume infused and urine output were significantly higher in G-SV and G-RV compared to G-CVP group. Laboratory and survival data did not differ among the studied groups. Conclusion The use of the CVP to guide fluid infusion after LT is a safe and effective alternative to more logistically demanding techniques as SV and RVEDVI without any negative impact on patient hemodynamic or metabolic homeostasis.

Dexmedetomidine in a surgically inserted catheter for transversus abdominis plane block in donor hepatectomy: A prospective randomized controlled study

Background: Transversus abdominis plane (TAP) block is a promising technique for analgesia after abdominal surgery. This prospective, randomized controlled trial assessed the effect of adding dexmedetomidine to bupivacaine in TAP block for donor hepatectomy. We hypothesized that this would improve postoperative morphine consumption and reduce analgesia related complication and inflammation. Methods: A total of 50 donor hepatectomy were enrolled in this study. Patients divided into two equal groups according to drugs used for TAP block. Group (B) received 20 ml of bupivacaine hydrochloride 0.25%, Group (BD) received 20 ml of bupivacaine hydrochloride 0.25% and 0.3 μg/kg dexmedetomidine, on both sides at the end of surgery and every 8 h for 48 h at right side only through inserted catheter. Primary outcome objective was morphine consumption at first 72 h. Secondary outcome objectives were morphine requirement, numbers of intake, time to first intake, pain score numerical analog scale (NAS), postoperative analgesia related complications, recovery of intestinal motility, and inflammatory markers. Results: Data were analyzed, rescue morphine analgesia was significantly lower in (BD) group compared with (B) groups as considering total morphine consumption (B 4 ± 1.9, BD 1.5 ± 0.5, P = 0.03), numbers of morphine intake (P = 0.04), morphine requirement (P = 0.03), and first time of analgesia intake (P = 0.04). NAS was significantly lower in group (BD) compared with group (B) group in the first 12 h (NAS 0 - P = 0.001, NAS 1 - P = 0.03). Adding dexmedetomidine improved gut motility, first oral intake without detectable anti-inflammatory effect. Conclusion: Adding dexmedetomidine to bupivacine in a surgically inserted catheter for TAP block in donor hepatectomy reduced morphine consumption without detectable anti-inflammatory effect.

Outcomes of Living Donor Liver Transplantation for Patients with Preoperative Portal Vein Problems

BackgroundPortal vein thrombosis (PVT) is a common complication for patients with end-stage liver disease. The presence of PVT used to be a contraindication to living donor liver transplantation (LDLT). The aim of this study is to evaluate the influence of preoperative PVT on perioperative and long-term outcomes of the recipients after LDLT.MethodsWe reviewed the data of patients who underwent LDLT during the period between 2004 till 2017.ResultsDuring the study period, 500 cases underwent LDLT. Patients were divided into three groups. Group I included non-PVT, 446 patients (89.2%); group II included attenuated PV, 26 patients (5.2%); and group III included PVT, 28 patients (5.6%). Higher incidence of hematemesis and encephalopathy was detected in PVT (p = 0.001). Longer anhepatic phase was found in PVT (p = 0.013). There were no significant differences between regarding operation time, blood loss, transfusion requirements, ICU, and hospital stay. The 1-, 3-, and 5-year overall survival (OS) rates of non-PVT were 80.5%, 77.7%, and 75%, and for attenuated PV were 84.6%, 79.6%, and 73.5%, and for PVT were 88.3%, 64.4%, and 64.4%, respectively. There was no significant difference between the groups regarding OS rates (logrank 0.793).ConclusionPreoperative PVT increases the complexity of LDLT operation, but it does not reduce the OS rates of such patients.