Gerardo Martinelli

Liver Transplantation from Donors Aged 80 Years and Over: Pushing the Limit

Older donors are a growing part of the total donor pool but no definite consensus exists on the limit of age for their acceptance. From November 1998 to January 2003, in a retrospective case–control multicenter study, we compared the outcome of 30 orthotopic liver transplantations (OLTs) with octogenarian donors and of 60 chronologically correlated OLTs performed with donors <40 years. The percentage of refusal was greater among older than younger donors (48.2 vs. 14.3%; p < 0.001). Cold ischemia was significantly shorter in the older than younger groups. Recipients with hepatocarcinoma and older age received octogenarian grafts more frequently. No differences were seen in post‐operative complications and 6‐month graft and patient survival. However, long‐term survival was lower in patients transplanted with octogenarian donors (p = 0.04). Interestingly, the mortality related to hepatitis C recurrence was greater in patients with octogenarian donors. Accordingly, the long‐term survival of HCV‐positive patients who received older grafts was lower than those receiving younger grafts (p = 0.05). Octogenarian livers can be used safely but a careful donor evaluation and a short cold ischemia are required to prevent additional risk factors. However, hepatitis C recurrence is associated with a greater mortality in patients who received octogenarian grafts raising concerns whether to allocate these livers to HCV‐positive recipients.

First Report of Cryopreserved Human Hepatocytes Based Bioartificial Liver Successfully Used as a Bridge to Liver Transplantation

Cryopreserved human hepatocytes could be the best type of cells to be used in a bioartificial liver (BAL) device due to reduced biosafety and biocompatibility risks. Banking of primary human hepatocytes, obtained from livers unwanted for transplantation at harvesting, could be used as a source of human liver cells for BAL treatment. We describe herein for the first time the case of a patient affected by fulminant hepatic failure (FHF) due to acute HBV infection that was successfully bridged to emergency liver transplantation by BAL treatment using cryopreserved primary human hepatocytes. The use of cryopreserved primary human hepatocytes as the biological part of the BAL device has never been described before and might be considered as a possible alternative to xenogenic material or human tumoral cell lines due to reduced biosafety and biocompatibility risks.

Opioid-induced hyperalgesia and rapid opioid detoxification after tacrolimus administration.

Opioids can induce central sensitization and hyperalgesia, referred to as opioid-induced hyperalgesia. Our report describes a patient who underwent intestinal transplant followed by immunosuppressant-related neuropathic pain. Her pain was treated with limited success over the course of 3 yr with different therapies, including i.v. morphine. She developed opioid-induced hyperalgesia, which was successfully treated with rapid detoxification under general anesthesia. Detoxification improved her quality of life, including the ability to resume physiotherapy. Six months after treatment, she remained opioid free. Our experience suggests that rapid detoxification under general anesthesia may be an effective treatment for opioid-induced hyperalgesia and merits comparison to traditional detoxification methods.

Hypothermia and respiratory care.

In the adult respiratory distress syndrome (ARDS) maintaining a normal program of respiratory assistance can worsen the lung disease, and consequently, a breathing assistance technique has been developed (3). This technique consists in combining low-frequency positive-pressure ventilation with extracorporeal CO 2 removal (LFPPV-ECC02R) (1). It entails an extracorporeal flow of 1000-1500 ml/min, which creates considerable problems in terms of control and applicability. We analyzed the possibility of associating LFPPV with controlled hypothermia (HC), in order to take advantage of the resulting decrease in the CO2 production, thus obtaining a reduced extracorporeal flow (4). We used five pigs weighing between 35 and 45 kg. Each animal received general anaesthesia using keta-

Anesthesia and psychology in the elderly patient

Summary As the aging of population is increasing everywhere in the world, the elderly frequently becomes surgical patient. The anesthetist must always face both the psychological and physiological status of the elderly patient. The concerns about impending surgery depend on some stressfull sensations, such as the separation from family, the impact of a new environment, the possibility of loss of independence, the possibility of death. The elderly people employ two types of coping when facing surgery: the “vigilance” and the “avoidance”; these seem to produce different postoperative effects. The vigilant patient has a longer hospitalization and a more negative psychological reaction after surgery. The avoidant patient has a better recovery. The anesthetist has a great choice among different anesthetic techniques. Actually we know that no significant difference in outcome can be attributed to the use of any specific anesthetic agent. A recent study of us indicates that the combined anesthesia (narcosis with peridural analgesia), allows a better recovery of psychophysical functions in the earlier postoperative phases. Postoperatively the elderly often presents disorientation and acute brain syndrome that may persist for a long time, apart from anesthetic technique. The problem is that many factors influence the mental status of the elderly. It appears that the biological age of the brain rather than its chronological age may be correlated with the vulnerability by anesthesia.