Marianne Carlier

Size reduction of the donor liver is a safe way to alleviate the shortage of size-matched organs in pediatric liver transplantation.

The development of pediatric liver transplantation is considerably hampered by the dire shortage of small donor organs. This is a very sad situation because in most experienced centers, liver replacement can offer a long-term hope of survival of more than 70% in a growing variety of pediatric liver disorders. The reported experience with 54 reduced-size grafts on a total of 141 transplants performed in 117 children between 1984 and 1988 demonstrates that the technique of reduced-size liver transplantation not only allows long-term survival but, in fact, offers the same survival hope with the same quality of liver function, regardless of the childs age and clinical condition. The prominent feature of our experience with the reduced liver concerns its deliberate use for elective cases. Seventy-seven per cent of the 30 children who electively received a reduced liver were alive 1 year after transplantation, as were 85% of the 62 children who received a full-size graft. There is no difference in the long-term survival rate of patients who received elective grafts, which is in the range of 75% with both techniques.

Pediatric liver transplantation: from the full-size liver graft to reduced, split, and living related liver transplantation

Abstract Between 1984 and 1996, the authors performed 499 liver transplants in 416 children less than 15 years old. The overall patient survival at 10 years was 76.5%. It was 71.3% for the 209 children grafted in 1984–1990; 78.5% for biliary atresia (n = 286), 87.3% for metabolic diseases (n = 59), and 72.7% for acute liver failure (n = 22). The 5-year survival was 73.6% for the 209 children grafted in 1984–1990 and 85% for the 206 grafted in 1991–1996. Scarcity of size-matched donors led to the development of innovative techniques: 174 children who electively received a reduced liver as a first graft in our center had a 5-year survival of 76% while 168 who received a full-size graft had a survival of 85% (NS). Results of the European Split Liver Registry showed 6-month graft survival similar to results obtained with full-size grafts collected by the European Liver Transplant Registry. Extensive use of these techniques allowed the mortality while waiting to be reduced from 16.5% in 1984–1990 to 10% in 1991–1992. It rose again to 17% in 1993, leading the authors to develop a program of living related liver transplantation (LRLT). The legal and ethical aspects are analyzed. Between July 1993 and October 1997, the authors performed 53 LRLTs with 90% survival. In elective cases, a detailed analysis was made of the 45 children listed for LRLT between July 1993 and March 1997 and the 79 registered on the cadaveric waiting list during the same period. Mortality while waiting was 2% and 14.5% for the LRLT and cadaveric lists, respectively. The retransplantation rate was 4.6% and 16.1% for LRLT and cadaveric transplants, respectively. Overall post-transplant survival was 88% and 82% for children who received a LRLT or a cadaveric graft, respectively. Overall survival from the date of registration was 86% and 70% (P < 0.05) for LRLT or cadaveric LT respectively. The 2-year post-transplant survival in children less than 1 year of age at transplantation was 88.8% and 80.3% with a LRLT or cadaveric graft, respectively; patient survival after 3 months post-transplant was 95.8% and 91.9% for stable children waiting at home, 93.7% and 93.7% in children hospitalized for complications of their disease, and 89.5% and 77.7% for children hospitalized in an intensive care unit at the time of transplantation for children who received a LRLT or cadaveric graft, respectively. It is concluded that LRLT seems to be justified for multidisciplinary teams having a large experience with reduced and split liver grafting.

Maximal Hydration During Anesthesia Increases Pulmonary Arterial Pressures and Improves Early Function of Human Renal-transplants

The recipients hemodynamic condition during anesthesia for renal transplantation has a major influence on the early diuresis of the graft. The effect of maximal hydration during operation was studied in a series of 120 primary human cadaver kidney transplantations performed under peroperative monitoring of the pulmonary arterial pressures (PAPs). The PAPs levels before and at the time of clamp release were correlated with the frequency of postoperative acute tubular necrosis (ATN). The 120 patients were divided in two groups according to the PAPs levels before release of the vascular clamps: group 1 (22 patients) with a mean PAP (PAP) of ≤ 20 mm Hg and a diastolic PAP (DPAP) of > 15 mm Hg was compared with group 2 (98 patients) with a PAP of > 20 mm Hg and a DPAP of > 15 mm Hg. Both groups were comparable with regard to the donors data and the quantity of peroperative fluids. The frequency of ATN was 36% in group 1 versus only 6% in group 2. This difference is attributed to the different hemodynamic conditions in both groups: at the beginning of the transplant procedure, PAP, DPAP, and central venous pressure (CVP) were higher in group 2; at the time of clamp release, PAP, DPAP, CVP, and systolic blood pressure (SBP) were also higher in group 2. This study emphasizes the importance of the PAPs levels at the time of release of vascular clamps to avoid postoperative ATN of a kidney transplant.

Liver transplantation in children less than 1 year of age.

Of 139 children who received an orthotopic liver transplant in our center between March 1984 and July 1989, a total of 17 patients (12%) had transplants before their first birthday (mean age 10.3 months; range 8 to 11). The mean weight was 7.3 kg (range 5.2 to 13). Nine retransplantations were performed in five children because of primary nonfunction (three children), hepatic artery thrombosis (four), or rejection (two). A reduced donor liver was used for 11 of 26 transplants. Baseline immunosuppression included cyclosporine, prednisone, and azathioprine with OKT3 or anti-thymocyte globulin for steroid-resistant rejection episodes. Survivors were discharged after a mean hospital stay of 47 days (range 22 to 87), and nonsurvivors died within a mean of 40 days (range 0 to 120). The 1 year actuarial survival rate was 64.7%, in comparison with 75.8% in the whole series. One patient died perioperatively, two died from primary nonfunction, one from adenovirus infection, two from rejection, and one from bone marrow aplasia. Eighteen rejection episodes, of which 11 were steroid resistant, occurred in 11 patients. Our series shows that liver transplantation can be successful in this age group.

The analgesic efficacy of bilateral combined superficial and deep cervical plexus block administered before thyroid surgery under general anesthesia.

In this study we evaluated the analgesic efficacy of combined deep and superficial cervical plexus block in patients undergoing thyroidectomy under general anesthesia. For this purpose, 39 patients undergoing elective thyroid surgery were randomized to receive a bilateral combined deep and superficial cervical block (14 mL per side) with saline (Group 1;n = 13), ropivacaine 0.5% (Group 2;n = 13), or ropivacaine 0.5% plus clonidine 7.5 &mgr;g/mL (Group 3;n = 13). Deep cervical plexus block was performed with a single injection (8 mL) at the C3 level. Superficial cervical plexus block consisted of a subcutaneous injection (6 mL) behind the lateral border of the sternocleidomastoid muscle. During surgery, the number of additional alfentanil boluses was significantly reduced in Groups 2 and 3 compared with Group 1 (1.3 ± 1.0 and 1.1 ± 1.0 vs 2.6 ± 1.0;P < 0.05). After surgery, the opioid and non-opioid analgesic requirements were also significantly reduced in Groups 2 and 3 (P < 0.05) during the first 24 h. Except for one patient in Group 3, who experienced transient anesthesia of the brachial plexus, no side effect was noted in any group. We conclude that combined deep and superficial cervical plexus block is an effective technique to alleviate pain during and immediately after thyroidectomy.

Prospective Evaluation of Thoracic-duct Drainage in the Treatment of Respiratory-failure Complicating Severe Acute-pancreatitis

Thoracic duct drainage (TDD) may be of value for removing toxic substances released by the inflamed pancreas and which are responsible for lung damage. We have prospectively assessed the efficacy of TDD in improving pulmonary gas exchange in 12 patients with severe acute pancreatitis (SAP) complicated by persistent respiratory failure despite standard conservative treatment including peritoneal dialysis in 8 patients. In group A were 6 patients (mean Ranson score=7.3) with adult respiratory distress syndrome (ARDS) and in group B were 6 hypoxemic patients (mean Ranson score=6.6) judged to be at risk of developing ARDS. The duration of TDD ranged from 3 to 10 days and the total amount of drained lymph (L) varied from 770 to 15 600 ml. Immunoreactive trypsin levels were significantly higher in L when compared to blood in both groups. Leukocyte myeloperoxidases in L (normal value < than 332±82 ng/ml in plasma) were increased in 5 of 5 group A patients (830±317 ng/ml) and in 3 of 6 patients in group B (671±467 ng/ml). After TDD pulmonary gas exchange as measured by median PaO2/FiO2 (mmHg) improved from 148±60 to 285±42 in group A and from 192±37 to 330±42 in group B (p<0.05). All patients were weaned after ventilation for a mean of 8 days in group A and 4 days in group B. All patients survived apart from 1 group B patient who died of sepsis on day 34. These data suggest that TDD, by allowing removal of potential mediators of lung injury is of major therapeutic value in ARDS complicating SAP. This approach may also prevent further respiratory impairment in susceptible patients.

Hemodynamic changes in patients with Alagille's syndrome during orthotopic liver transplantation.

UNLABELLED Children with Alagilles syndrome are at increased perioperative risk during orthotopic liver transplantation due to the cardiopulmonary abnormalities and the hemodynamic changes associated with this procedure. We studied 16 children with Alagilles syndrome who underwent 21 orthotopic liver transplantations. Peripheral pulmonary stenosis was present in all subjects. Right ventricular pressures were increased in 15 cases. Caval clamping resulted in a mean decrease of 15 +/-9 mm Hg in systolic blood pressure, 5 +/- 3 mm Hg in mean pulmonary artery pressure, and 4 +/- 3 mm Hg in central venous pressure. Systolic blood pressure decreased by 16 +/- 13 mm Hg, whereas mean pulmonary artery pressure and central venous pressure increased by 3 +/- 4 mm Hg and 1 +/- 4 mm Hg, respectively, at portal vein unclamping. There was no correlation between severity of pulmonary artery stenosis and hemodynamic changes. Veno-venous bypass used in four cases resulted in smaller hemodynamic changes. Time to extubation and duration of intensive care unit stay were unrelated to severity of pulmonary artery stenosis. IMPLICATIONS Some children with Alagilles syndrome require liver transplantation. In our study, associated pulmonary artery stenosis did not dramatically increase perioperative risk. Veno-venous bypass decreased intraoperative hemodynamic changes in these patients.

Cardiac tamponade early after thrombolysis for acute myocardial infarction: a rare but not reported hemorrhagic complication.

Among 392 consecutive patients admitted for acute myocardial infarction and treated with thrombolytic drugs, 4 patients (1%) developed an early hemorrhagic pericardial effusion (without ventricular wall rupture) evolving within 24 h to cardiogenic shock consequent to cardiac tamponade. They all suffered from a large anterior myocardial infarction treated within 4 h after onset of symptoms with intravenous anisoylated plasminogen streptokinase activator complex (one case), recombinant tissue-type plasminogen activator (rt-PA) (two cases) or streptokinase (one case), anticoagulation with heparin (all cases) and aspirin (three cases). As soon as pericardial effusion was established by echocardiography, emergency percutaneous pericardiocentesis was performed at the bedside 20 +/- 6 h after thrombolytic therapy was started. This corrected immediately the clinical and hemodynamic status of each patient and a catheter was left in the pericardial space for 34 +/- 18 h. Thus, in the presence of unexplained clinical and hemodynamic deterioration occurring during the first 24 h after thrombolytic treatment of a large myocardial infarction, cardiac tamponade should be suspected. Immediate percutaneous pericardiocentesis followed by continuous drainage is a simple and definitive treatment for this complication.

Arterialization of the portal vein in conjunction with a therapeutic portacaval shunt. Hemodynamic investigations and results in 75 patients.

Seventy-five cirrhotic patients were submitted to peroperative hemodynamic investigations including flow and pressure studies. Sixty-two patients with a hepatopedal portal flow underwent a therapeutic end-to-side portacaval shunt (PC) in conjunction with arterialization of the portal vein and 13 with a stagnant flow a PC shunt alone. Thirty-five patients were operated on in emergency and 40 electively. In 61 patients portal flow was correlated with maximum perfusion pressure (r = 0.66), and in 33 patients with the reduction of corrected sinusoidal pressure induced by the occlusion of the portal vein (r = 0.72). Operative mortality, which was 3.5% for 57 class A and B patients and 55.5% for 18 class C patients, differed significantly (p < 0.05) in emergency between arterialized (14.8%) and nonarterialized patients (62.5%). At the time this study was ended on July 15, 1981, the follow-up was over two years for all the patients. The five-year actuarial survival rate of the arterialized patients was 48% for the whole group and 56% for class A and B patients; the overall incidence of chronic encephalopathy was 20%. It is concluded that arterialization is a safe surgical procedure that could be beneficial in respect with operative mortality in emergency, late survival, and toierance to portacaval shunt. However, a prospective randomized study such as the one undertaken in December 1979 is the only method to prove clearly that arterialization is really able to minimize the risk of encephalopathy and to prolong the long-term survival after portacaval shunt.

The effects of intraoperative intravenous clonidine on fluid requirements, hemodynamic variables, and support during liver transplantation: a prospective, randomized study.

In this prospective, nonblind study, we report the use of clonidine during orthotopic liver transplantation (OLT).Twenty adult patients in a stable medical condition were studied. General anesthesia consisted of isoflurane in air/oxygen and sufentanil. Patients in the clonidine group received a slow IV infusion (15 min) of 4 [micro sign]g/kg clonidine during induction. The other patients were used as controls. IV fluid requirements were determined as follows: albumin (4% solution) was administered to maintain filling pressures to a pulmonary capillary wedge pressure (PCWP) of more than 12 mm Hg. Packed red blood cells were transfused to maintain a hemoglobin level of 8-9 g/dL. Circulatory stability was evaluated using: systolic and diastolic arterial blood pressure and heart rate recorded at 2-min intervals; and the vasopressor/inotropic support required to maintain adequate hemodynamic variables after reperfusion. Intraoperative albumin and packed red blood cell requirements were significantly reduced in patients in the clonidine group (1644 +/- 140 and 50 +/- 50 mL vs 2867 +/- 226 mL and 1350 +/- 443 mL; P < 0.05). Heart rate was significantly slower in patients of the clonidine group. There were no differences in systolic arterial blood pressure. After reperfusion, patients in the control group showed significantly lower diastolic arterial blood pressure, required more vasopressor/inotropic support, and were more acidotic than patients in the clonidine group. We conclude that the administration of 4 [micro sign]g/kg clonidine during induction of OLT significantly reduced the intraoperative requirements of IV fluids and blood products without compromising circulatory stability. Improvement in immediate reperfusion-induced disturbances was observed. Implications: The administration of 4 [micro sign]g/kg clonidine during induction of liver transplantation significantly reduced the intraoperative requirements for IV fluids and blood products without compromising the circulatory stability. Improvement in immediate reperfusion-induced disturbances was also observed. (Anesth Analg 1998;86:468-76)