Sezgin Ulukaya

Causes of postreperfusion syndrome in living or cadaveric donor liver transplantations

OBJECTIVE The postreperfusion syndrome (PRS) occurrence was evaluated in patients undergoing liver transplantation in our institution to determine the relationship between PRS and associated variables. METHODS Of the 185 consecutive liver transplants, pediatric patients, patients with uncompleted data or retransplantations were excluded. The remaining 145 adult patients having 77 cadaveric and 68 living donor right lobe liver transplantations were studied. PRS was defined as a decrease in mean arterial pressure >30% below the baseline value. Logistic regression was used for statistical analyses. A P value <.05 was considered as significant. RESULTS Total rate of PRS occurrence was 48.9% (71 patients) for the 145 patients. Logistic regression analyses revealed a significant relationship between the PRS and four of the variables: shorter duration of the anhepatic period, higher mean calcium requirement, higher mean heart rate difference from anhepatic to reperfusion period and lower central venous pressure at the dissection period during operations (P <.05). We could not demonstrate any significant effect of the operation type-surgical technique and duration of operations, blood and fresh frozen plasma volume transfused, demographic variables of the recipients, donor liver factors, other haemodynamic and metabolic variables at specific time periods (P >.05). CONCLUSIONS In conclusion, it is important that PRS does not seem to occur in a predictable manner in this study except for the increased calcium requirements during the operations in PRS experienced patients. The clinical parameters as graft ischemia time, the type of the operation, demographic variables of the recipient, hemodynamic or metabolic variables and transfusion needs during the operations seemed to have no contribution to PRS occurrence.

Effects of cardiac valve dysfunction on perioperative management of liver transplantation.

OBJECTIVE Our aim was to investigate the effects of cardiac valve dysfunction on perioperative management of orthotopic liver transplantation (OLT) among a retrospective cohort. PATIENTS AND METHODS Three hundred forty-six patients underwent echocardiographic (ECHO) examination prior to OLT. Data of patients with valvular dysfunctions were compared to subjects with normal ECHO. We evaluated patient characteristics, operation variables, hemodynamic course, blood products, fluid and drug requirements, extubation, and mortality rates. RESULTS Ninety-five patients (27.5%) with cardiac valve dysfunction were classified as mitral valve insufficiency (MVI; n = 32), tricuspid valve insufficiency (TVI; n = 23), or both MVI and TVI (n = 40). One hundred fifty-two patients displayed normal ECHO examinations (control). Ninety-nine patients with other pathologies were excluded from the study. Systemic vascular resistance was significantly lower among the MVI group, and cardiac output (CO) significantly higher in the MVI and both MVI and TVI groups compared with controls. More MVI and both MVI and TVI patients required epinephrine compared with controls. The number of patients who required blood transfusion was higher in the MVI than the control group (P < .05). Patient characteristics, end-stage liver failure scores, duration of operations, hemodynamic variables, incidence of postreperfusion syndrome, mean doses of ephedrine and epinephrine, red blood cells, fresh frozen plasma and fluid requirements, number of patients extubated immediately after surgery, and mortality rates were not different between the groups. CONCLUSIONS Our study demonstrated that cardiac valve dysfunction may be associated with end-stage liver disease among patients undergoing OLT. Patients with MVI or both MVI and TVI required more care in perioperative management.

Effects of ropivacaine on pain after laparoscopic cholecystectomy: A prospective, randomized study

Postoperative pain after laparoscopic cholecystectomy is an ongoing problem. To relieve this pain, practitioners have used many anesthetic and analgesic drugs. This study was undertaken to assess the effects of incisional and intraperitoneal administration of ropivacaine on postoperative pain and stress response in patients undergoing laparoscopic cholecystectomy. In this prospective, singleblinded, randomized study, 45 patients with ASA (American Society of Anesthesiologists) scores I and II who were about to undergo laparoscopic cholecystectomy were divided into 3 groups. After cholecystectomy, a total of 40 mL of 3.75% ropivacaine was administered preincisionally and intraperitoneally to patients in group 1 (n=14); preincisionally and intraperitoneally to patients in group 2 (n=17); and intraperitoneally and locally at incision sites to patients in group 3 (n=14). Blood levels of epinephrine and norepinephrine were examined preoperatively, 15 min after insufflation, and at the end of the operation. Visual analog pain scale scores and analgesic requirements were used for 24-h postoperative follow-up of pain levels reported by patients. No statistically significant difference was found among the 3 groups with respect to visual analog pain scale scores, total analgesic requirements, and accompanying pain, nausea, and vomiting. The earliest analgesic requirements were seen in group 2 (P < .005), and less shoulder pain was noted in group 3 (P < .005). Norepinephrine and epinephrine levels showed no statistically significant differences between the 3 groups. Administration of ropivacaine preoperatively and postoperatively for laparoscopic cholecystectomy has similar effects on postoperative pain and the stress response of patients.

Cytokine Gene Polymorphism and Postreperfusion Syndrome During Orthotopic Liver Transplantation

UNLABELLED The molecular basis underlying the clinical response to acute liver stress remains to be clarified. Postreperfusion syndrome (PRS) occurring after the meeting of grafted liver with the recipient blood is characterized by hemodynamic instability that develops immediately after reperfusion of an orthotopic liver transplantation (OLT). Cytokines have a role during PRS. The aim of this study was to evaluate the role of some cytokine gene polymorphisms on PRS in patients. MATERIALS AND METHODS Forty-six patients who underwent OLT were divided into two groups: with versus without PRS. Cytokine genotyping using patient blood was determined by the PCR-SSP method. RESULTS Liver transplant patients as a whole are usually characterized as low producers of tumor necrosis factor (TNF)-alpha and interleukin (IL)-10, high producers of transforming growth factor (TGF)-beta1 and IL-6 and intermediate producers of interferon (IFN)-gamma. However no significant relationship was shown between the development of PRS and cytokine gene polymorphisms of TNF-alpha (-308 G/A), TGF-beta1 (C/T codon 10, C/G codon 25), IL-10 (-1082 G/A, -819 T/C, -592 A/C), IL-6 (-174 G/C), or IFN-gamma (+874 A/T). CONCLUSION It seemed that our limited data did not substantiate a role of certain cytokine gene polymorphisms on PRS occurence during OLT. A larger study population may be required to examine this relationship.

Right‐sided diaphragmatic hernia after orthotopic liver transplantation: Report of two cases

Kazimi M, İbis C, Alper I, Ulas M, Baran M, Arikan C, Aydogdu S, Ulukaya S, Zeytunlu M, Kilic M. Right‐sided diaphragmatic hernia after orthotopic liver transplantation: Report of two cases.
Pediatr Transplantation 2010: 14:e62–e64.

Live donor liver transplantation for Budd-Chiari syndrome: anastomosis of the right hepatic vein to the right atrium.

A 29-year-old male patient with the diagnosis of endstage liver disease due to Budd-Chiari syndrome was referred to our hospital for liver transplantation. The patient had been diagnosed 4 years earlier and initially was managed with anticoagulant therapy and diuretics. Later, he developed end-stage liver disease, and anticoagulant therapy was withdrawn. He was admitted with massive ascites, jaundice, and fatigue complaints, and his Child and Model for End-Stage Liver Disease scores were 12 and 23, respectively. The workup for the etiology of Budd-Chiari syndrome, including bone marrow biopsy, autoantibodies, and mutations for thrombosis, did not demonstrate a specific cause. Multislice computed tomography of the abdomen and chest and vena cavography were performed, revealing total thrombosis of the inferior vena cava ascending from the renal vein orifices to the diaphragm (Fig. 1). His 22-year-old brother volunteered for right lobe liver donation, and his workup to be a live donor did not show any abnormalities. The donor and the recipient simultaneously underwent surgery for regular live donor liver transplantation. Technically, in these kind of cases, the mobilization of the liver and the piggyback maneuver are not easy because of diffuse fibrotic reactions in the retroperitoneum, which also involves the inferior vena cava. The recipient liver was removed, and the vena cava was observed to be fibrotic and totally thrombosed from the renal vein orifices to the right atrium. The pericardium was cut, and the supradiaphragmatic vena cava was encircled (Fig. 2). As the vena cava was totally obstructed and there was no place to perform an anastomosis on the vena cava, the right atrium was used for the outflow reconstruction. The diaphragm surrounding the vena cava was excised with electrocautery, and the pericardial space was widely exposed (Fig. 3). The suprahepatic vena cava was also fibrotic and did not have enough distance to allow an anastomosis; thus, a Satinsky clamp was placed diagonally on the right atrium without causing any arrhythmia, and the bottom of the atrium was cut 2 cm wide so that anastomosis could be performed (Fig. 4). The fibrotic native vena cava was removed, and anastomosis between the right atrium and right hepatic vein was performed with 5/0 polypropylene sutures in a continuous fashion (Figs. 5 and 6). The pericardium was left open at the end of the procedure. The portal vein, hepatic artery, and bile duct anastomoses were performed in the usual fashion. The patient was hemodynamically stable during the operation, and the postoperative period was uneventful. Mild sinus tachycardia occurring after surgery resolved in 5 days, and the patient did not develop any further arrhythmias. He was taken out of the intensive care unit on postoperative day 4, and he was discharged home on postoperative day 20. His liver function tests recovered gradually after the transplant, and his control echocardiogram

Soluble cytokeratin 18 biomarkers may provide information on the type of cell death during early ischemia and reperfusion periods of liver transplantation.

Ulukaya S, Ulukaya E, Alper I, Yilmaztepe‐Oral A, Kilic M. Soluble cytokeratin 18 biomarkers may provide information of the type of cell death during early ischemia and reperfusion periods of liver transplantation. 
Clin Transplant 2010: 24: 848–854.

Transfusion requirements during cadaveric and living donor pediatric liver transplantation

Abstract:  Surgical techniques that have been used during liver transplantation (LT) together with patients coagulation profile and institutional practices are reported to have an effect on transfusion requirements. The aim of this study is to evaluate the transfusion requirement in both cadaveric (CDLT, n = 22) and living donor (LDLT, n = 24) pediatric LT performed in our institution. Balanced general anesthesia was used for all patients. Transfusion requirements were met to maintain a hemoglobin concentration of 8–10 g/dL, platelet level >50 × 103/mL, prothrombin time <20 s and hemodynamic course with observing heart rate, arterial and central venous blood pressures and hourly urine output. Blood loss was replaced by using whole blood. Both groups’ perioperative total blood and fresh‐frozen plasma (FFP) volumes transfused, fluid requirements and hemodynamic courses, standard coagulation profile and metabolic variables determined in time periods of operations, patients’ preoperative characteristics, operative features and postoperative events were compared. The mean transfusion requirements were 37.1 ± 33.4 and 74.8 ± 90.8 mL/kg of whole blood (p = 0.059) and 34.5 ± 24.9 and 51.5 ± 59.7 mL/kg of FFP for CDLT and LDLT, respectively (p = 0.519). The mean ages and mean body weights of the CDLT patients were higher than LDLT patients (9.7 ± 5.3 vs. 6.6 ± 4.4 yr, p = 0.015 and 32.4 ± 17.7 vs. 21.0 ± 14.8 kg, p = 0.032, respectively) while the mean operation time (493 ± 135 vs. 323  ± 93 min, p = 0.0001) and PELD score (13.1 ± 11.2 vs. 20.1 ± 11.8, p = 0.036) were higher for LDLT. In the entire population, multiple regression analysis showed that age, body weight and operation time have a significant combined effect on blood consumption (r2 = 0.29, p = 0.003) meanwhile operation time was found to be an effective single variable (p = 0.002). None of the single or combined variables was found to have a significant effect on FFP consumption (r2 = 0.17, p = 0.63) and crystalloid use (r2 = 0.19, p = 0.11). Hemodynamic courses of both groups were similar. The incidences of metabolic acidosis and hypothermia during the anhepatic periods were higher in the CDLT group (p < 0.05). However, transfusion requirement in the ICU were higher in LDLT group [6.9 ± 2.2 (n = 6) vs. 18.6 ± 19 (n = 11) mL/kg, p < 0.05] after LT. As a result of this study in a pediatric patient population, no statistical significance was found in whole blood transfusion and FFP requirements between CDLT and LDLT. Duration of the operation was the primary factor effecting transfusion volume showing the importance of continued small volume losses during uncomplicated LT in this small sized patient population. Transfusion need for pediatric LT should be individualized for each patient based on the intraoperative conditions including surgical and patient features.

Reabsorption of ascites and the factors that affect this process in cirrhosis.

Ascites is one of the main features of liver decompensation in cirrhosis, and it is considered to be a dynamic process. In this study, we aimed to (1) measure the reabsorption rate of ascites; (2) evaluate whether these findings were related to features of ascites, hemodynamics, and serum measurements; and (3) examine morphologic changes in the diaphragm of cirrhotic patients. In all, 42 cirrhotic patients with ascites were enrolled in the study to comprise our study group. Using the dextran 70 test, patient ascites volumes and reabsorption rates were measured. Biopsies from the peritoneal side of the diaphragm were also processed for scanning electron microscopy and lymphatic immunohistochemical studies from the cirrhotic patients and control cadavers. The mean ascites reabsorption rate was 4.5 +/- 4.5 (0.18-14.6) mL/min, which correlated significantly with the calculated ascites volume (r = 0.75, P < 0.001). The mean ascites viscosity was 1.07 +/- 0.07 (0.99-1.17) centipoise, which demonstrated a high degree of negative correlation with the ascites reabsorption rate (r = -0.77, P < 0.001). Patients with a history of spontaneous bacterial peritonitis had significantly lesser ascites reabsorption rates than patients without this particular history. The size of lymphatic stomata in scanning electron microscopy depictions was increased, and lymphatic lacunae were dilated in immunohistochemical studies in the cirrhotic patients with ascites. However, these findings were not uniform in every cirrhotic patient with ascites. The volume and viscosity of ascites seem to influence its reabsorption rate. Additionally, previous episodes of spontaneous bacterial peritonitis may be responsible for the decreased ascites reabsorption rates observed in certain patient populations.

Laparoscopic cholecystectomy pain: effects of the combination of incisional and intraperitoneal levobupivacaine before or after surgery.

OBJECTIVES We aimed to investigate whether the timing of administration, using a combination of incisional and intraperitoneal levobupivacaine (0.25%), has an effect on the postoperative pain after laparoscopic cholecystectomy in a prospective, randomized, and controlled study. METHODS Sixty six patients were allocated to one of the three groups. Group BS received levobupivacaine before trocar site incision and intraperitoneal levobupivacaine immediately after pneumoperitoneum. Group AS received intraperitoneal levobupivacaine before trocars were withdrawn and incisional levobupivacaine administered at the end of surgery. Group C received no treatment. Data of intraoperative variables, postoperative pain relief, rescue analgesic consumption, and patient satisfaction were compared. RESULTS The intraoperative fentanyl consumption was found lower in Group BS, compared to Groups AS and C (p<0.05). VAS scores were lower in both Groups BS and AS, compared to Group C immediately after the operation (p<0.05). VAS scores were significantly decreased during the first two hours in Group AS, compared to Group C. The mean doses and number of patients needing rescue meperidine were lower in Group AS, compared to the Groups BS and C (p<0.05). CONCLUSION The combination of incisional and intraperitoneal levobupivacaine administered before or after surgery can reduce postoperative pain and analgesic and antiemetic consumption together with improved patient satisfaction. However, administering levobupivacaine before surgery might be advantageous for less intraoperative fentanyl consumption, while levobupivacaine after surgery is advantageous for less postoperative rescue analgesic requirement.