Werner Pothmann

In Situ Splitting Of The Liver In The Heart-beating Cadaveric Organ Donor For Transplantation In Two Recipients

SLT presents an interesting concept to alleviate the organ shortage for children with end-stage liver disease. The procedure has, however, not gained wide acceptance. This is not only related to the complexity of the procedure, but also to the poorer results and the complications reported on the right side graft. We report on a first case in which we applied a new concept for splitting. The liver was split in situ in the heart-beating cadaveric donor with the aim of reducing the problems with the right side graft. This procedure makes splitting of the liver possible without submitting the recipient of the right side to increased risk. Therefore, in situ splitting of the liver has the potential of making splitting of liver grafts the rule rather than the exception, thus increasing the organ pool for small children presently carrying a high risk of dying on the waiting list.

Living donor for liver transplantation

Since living related liver transplantation was first performed in 1989, more than 150 cases have been performed worldwide, mostly in the United States and Japan. This paper reports the first series of living related liver transplantation in Europe. Twenty living related liver transplantation surgeries were performed over a 13‐mo period, with an overall patient survival of 85%. For patients who underwent elective transplantation (n=13), the survival rate was 100%. Technical complications included one arterial thrombosis necessitating retransplantation and five bile leaks requiring surgical revision. The technical improvements that permit avoidance of these complications are discussed. A detailed description of the living related liver procurement is given. All procurements yielded grafts of excellent quality. No intraoperative complications occurred, and no reoperations were necessary. No heterologous blood transfusion was needed. In two patients, incisional hernias developed after wound infection. Living related liver transplantation does not absolve the transplant community of efforts to promote cadaveric organ procurement. Nevertheless, living related liver transplantation does have the advantage of a readily available graft of excellent quality, permitting transplantation with optimal timing under elective conditions. Several centers are now preparing living related segmental liver transplants, following the model of our protocol, for three reasons: (a) to obtain superior results compared with cadaveric liver transplantation; (b) to overcome cadaveric organ shortage and further reduce pretransplantation mortality and (c) to provide viable organs in countries where cadaveric organ procurement is not established. When performed by a team experienced in pediatric liver transplantation and in adult liver resection, living related liver transplantation is an excellent modality for the treatment of end‐stage liver disease in children. (Hepatology 1994;20:49S‐55S.)

Selection of the living liver donor.

Living related liver transplantation offers several advantages in comparison to transplantation of cadaver organs. To achieve maximal donor safety evaluation, selection criteria and complications of the donor operation were retrospectively analyzed in living donors of segmental liver transplants. Seventy-three liver donor candidates were evaluated between October 1991 and June 1994. The median age of 42 mothers and 31 fathers was 31 years (range, 19-50 years). The median volume of the left lateral liver lobe comprised 230 ml (100-350 ml). Twenty-four of 73 (33%) donor candidates were not accepted for living donation. Rejection was due to unsuitability of the donors liver as a graft (n = 13) or due to an increased risk for living donation (n = 11). Of 35 living donations performed so far, one was a full left hemihepatectomy and 34 were left lateral segmentectomies. The length of the donor operation was, on average, 4.3 hr. No heterologous blood was needed. Postoperative complications included death due to pulmonary embolism (n = 1), seizure due to a previously undiagnosed ependymoma (n = 1), bile duct injury (n = 1), incisional hernia necessitating late revision (n = 2), and duodenal ulcer (n = 2). Long-term follow-up revealed no persistent complications. Using our standardized protocol, 33% of young, presumably healthy donor candidates were rejected for living donation.

One Hundred Thirty-Two Consecutive Pediatric Liver Transplants Without Hospital Mortality: Lessons Learned and Outlook for the Future

Objective:Orthotopic liver transplantation (OLT) has become an established procedure for the treatment of pediatric patients with end-stage liver disease. Since starting our program in 1989, 422 pediatric OLTs have been performed using all techniques presently available. Analyzing our series, we have concluded that the year of transplantation is the most important prognostic factor in patient and graft survival in a multivariate analysis. Methods:From April 2001 to December 1, 2003, 18 whole organs (14%), 17 reduced-size organs (13%), 53 split organs (42%; 46 ex situ, 7 in situ), and 44 organs from living donors (33%) were transplanted into 115 patients (62 male and 53 female). One hundred twelve were primary liver transplants, 18 were retransplants, one third and one fourth liver transplants. Of the 132 OLTs, 26 were highly urgent (19.7%). The outcome of these 132 OLTs was retrospectively analyzed. Results:Of 132 consecutive pediatric liver transplants, no patients died within the 6 months posttransplantation. Overall, 3 recipients (2%) died during further follow-up, 1 child because of severe pneumonia 13 months after transplantation and the second recipient with unknown cause 7 months postoperatively, both with good functioning grafts after uneventful transplantation. The third had a recurrence of an unknown liver disease 9 months after transplantation. The 3-month and actual graft survival rates are 92% and 86%, respectively. Sixteen children (12%) had to undergo retransplantation, the causes of which were chronic rejection (3.8%), primary nonfunction (3.8%), primary poor function (PPF; 1.5%), and arterial thrombosis (3%). The biliary complication rate was 6%; arterial complications occurred in 8.3%; intestinal perforation was observed in 3%; and in 5%, postoperative bleeding required reoperation. The portal vein complication rate was 2%. Conclusions:Progress during the past 15 years has enabled us to perform pediatric liver transplantation with near perfect patient survival. Advances in posttransplant care of the recipients, technical refinements, standardization of surgery and monitoring, and adequate choice of the donor organ and transplantation technique enable these results, which mark a turning point at which immediate survival after transplantation will be considered the norm. The long-term treatment of the transplanted patient, with the aim of avoiding late graft loss and achieving optimal quality of life, will become the center of debate.

One year of experience with extended application and modified techniques of split liver transplantation.

As organ donation rates decreased in Europe, the authors started a systematic approach of liver splitting in their center in 1994. During this 1-year experience, 73 cadaveric liver transplantations were performed in 66 patients. Sixteen of these transplantations were the result of split-liver transplantation (21.9% of grafts, 24.2% of patients). Patient and graft survival rates at 3 months were 81.2% and 75%, compared with 89.1% and 76.9 % for whole organs. Two modified techniques were developed, based on the technique of living related liver procurement, and applied in 10 cases. With these new techniques, patient and graft survival rates were 90% and 90%. This systematic approach allowed the total number of transplantations in our program to be maintained, despite the decrease in organ availability.

Split liver transplantation and risk to the adult recipient: analysis using matched pairs

BACKGROUND The technique of liver splitting is an effective way of increasing the donor pool and reducing pediatric waiting list mortality. But the procedure is still not fully accepted because of concerns that it may cause complications in adult recipients. STUDY DESIGN Fifty-nine adult recipients of primary extended right split liver transplantations (SLTs) were matched to recipients of whole liver transplantations (WLTs) according to the following criteria: 1) United Network for Organ Sharing (UNOS) status, 2) donor age, 3) recipient age, 4) total cold ischemic time, 5) indication for liver transplantation, 6) Child-Pugh class, and 7) year of transplantation. A WLT-recipient match was identified in 40 adult recipients of primary SLT. RESULTS Fifteen percent of the recipients in our study were highly urgent cases (UNOS 1), and 85% were UNOS status 3-4. The 3- and 12-month patient survival rates after SLT and WLT were 82.5% and 77.1%, and 92.5% and 87.5%, respectively (log rank p = 0.358). The 3- and 12-month graft survival rates showed no significant difference in either group (80% and 74% in SLT and 87.5% and 77.4% in WLT [log rank p = 0.887]). The rates of primary nonfunction, primary poor function, biliary and vascular complications, intra- and postoperative blood transfusion, and intensive care stay were comparable for SLT and WLT. CONCLUSIONS SLT, using the extended right hepatic lobe, does not notably differ from WLT with regard to initial graft function, postoperative complications, or patient and graft survival. Based on this, the liver can be considered a paired organ, and mandatory splitting of good-quality livers can be recommended.

The laryngeal mask airway: Anesthetic gas leakage and fiberoptic control of positioning

STUDY OBJECTIVE To examine the anesthetic gas leakage and prelaryngeal position of the laryngeal mask airway (LMA). DESIGN Clinical trial evaluating LMA ventilation conditions. SETTING Lithotripsy room of a urology clinic at a university hospital. PATIENTS 100 adult ASA physical status I and II patients undergoing general anesthesia for kidney stone lithotripsy. INTERVENTIONS Anesthesia was induced with propofol 1.5 to 2.5 mg/kg intravenously (IV) and fentanyl 1 to 1.5 micrograms/kg IV and maintained with isoflurane plus nitrous oxide in oxygen. MEASUREMENTS AND MAIN RESULTS Waste anesthetic gas concentration, an indicator of mask tightness during intermittent positive-pressure ventilation, was measured using an infrared oxide analyzer. LMA position in relation to laryngeal skeleton was assessed using fiberoptic laryngoscopy. The LMA was found to be gastight in 62% of patients, with a peak airway pressure up to 25 cmH2O. During peak airway pressure ventilation less than 10 cmH2O and during spontaneous ventilation, waste anesthetic gas contamination in the anesthesiologists breathing zone was within legal limits in every case. During peak airway pressure ventilation up to 30 cmH2O, contamination was found within legal limits in 78% of all cases. Fiberoptic control showed a central position in 59% of cases, lateral deviations to the left or right in 29%, dorsal positions in 8%, and ventral positions in 4%. Incorrect ventral or dorsal positioning was related to forced reclining or forced flexion of the patients head. There was no correlation between LMA position and tightness. The esophageal entrance was visible in 15 patients using high peak airway pressure greater than 25 cmH2O. CONCLUSIONS The LMA is a new airway management technique with good qualities of tightness and ventilation conditions. However, contraindications such as patients with a full stomach, intra-abdominal surgery, high peak airway pressure, prolonged operation, and an inexperienced anesthesiologist apply.

Cortical arousal in critically ill patients: an evoked response study

Abstract Objective: Assessing the level of sedation in critically ill patients remains a challenge for the intensivist in order to avoid over or under-sedation. Clinical scoring systems may fail in patients with concomitant neurological disorders or requiring muscle relaxants. We evaluated auditory (AER) and median nerve somatosensory evoked responses (MnSSER) in critically ill patients sedated with sufentanil and propofol, in order to quantify the level of sedation during therapeutic interventions. Design: Prospective clinical study. Setting: Anaesthesiological intensive care unit (ICU) in a university hospital. Patients and participants: Thirty-two patients following major abdominal or thoracic surgery requiring sedation during their stay on the ICU. Interventions: During physiotherapy and following nursing care (tracheal suctioning) AER and MnSSER were recorded. The level of sedation was evaluated clinically in relation to vital parameters. Data were analysed by multivariate analyses of variance (Hotellings T2), Friedman test. Measurements and results: In comparison to baseline levels the AER latency Nb decreased, while the amplitude NaPa increased during physiotherapy and after tracheal suctioning (p<0.001). In contrast, the MnSSER latency P25 decreased and the amplitude P25N35 increased after tracheal suctioning only (p≤0.001). Clinical sedation scores decreased and mean arterial blood pressure increased during physiotherapy and nursing care. Conclusions: Changes of AER or MnSSER waves indicated cortical arousal in ICU patients during nursing care and physiotherapy. Further studies with evoked responses are recommended to evaluate whether bolus injections of sedatives and/or analgesics reduce cortical arousal and thereby minimise the patient’s stress during nursing care.