Semicontinuous intra-abdominal pressure measurement using an intragastric Compliance catheter

OBJECTIVE: To compare intra-abdominal pressure (IAP) measurements obtained from an intragastric Compliance catheter with the pressure measured directly in the abdominal cavity. DESIGN AND SETTING: Prospective cohort study in an operating room of the Ghent University Hospital PATIENTS: Seven patients undergoing elective laparoscopic cholecystectomy. INTERVENTIONS: IAP was obtained from both an intragastric catheter and directly from the peritoneal cavity at 1-minute intervals in patients undergoing elective cholecystectomy and compared using Bland-Altman analysis. MEASUREMENTS AND RESULTS: In 156 paired measurements obtained from 7 patients the mean difference between IAPgastric and IAPref was 0.12+/-0.70 mmHg (95% CI 0.01-0.23). CONCLUSIONS: IAP measured using an intragastric Compliance catheter reliably reflects the reference IAP in patients undergoing laparoscopic cholecystectomy

Anesthesia for combined liver-thoracic transplantation

The combined transplantation of a thoracic organ and the liver is performed in patients with dual-organ failure in whom survival is not expected with single-organ transplantation alone. Although uncommonly performed, the number of combined liver-lung and liver-heart transplants is increasing. Anesthetic management of this complex procedure is challenging. Major blood loss, prolonged operation time, difficult weaning of cardiopulmonary bypass and coagulation disturbances are common. Despite the complexity of surgery, the outcome is comparable to single-organ transplant

Hepatic artery flow and cardiac output: correlation between systemic and liver hemodynamics

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Successful Thrombectomy via a Surgically Reopened Umbilical Vein for Extended Portal Vein Thrombosis Caused by Portal Vein Embolization prior to Extended Liver Resection

Selective portal vein embolization (PVE) before extended liver surgery is an accepted method to stimulate growth of the future liver remnant. Portal vein thrombosis (PVT) of the main stem and the non-targeted branches to the future liver remnant is a rare but major complication of PVE, requiring immediate revascularization. Without revascularization, curative liver surgery is not possible, resulting in a potentially life-threatening situation. We here present a new surgical technique to revascularize the portal vein after PVT by combining a surgical thrombectomy with catheter-based thrombolysis via the surgically reopened umbilical vein. This technique was successfully applied in a patient who developed thrombosis of the portal vein main stem, as well as the left portal vein and its branches to the left lateral segments after selective right-sided PVE in preparation for an extended right hemihepatectomy. The advantage of this technique is the avoidance of an exploration of hepatoduodenal ligament and a venotomy of the portal vein. The minimal surgical trauma facilitates additional intravascular thrombolytic therapy as well as the future right extended hemihepatectomy. We recommend this technique in patients with extensive PVT in which percutaneous less invasive therapies have been proven unsuccessful

Prolonged dual hypothermic oxygenated machine preservation (DHOPE-PRO) in liver transplantation:study protocol for a stage 2, prospective, dual-arm, safety and feasibility clinical trial

INTRODUCTION: End-ischaemic preservation of a donor liver by dual hypothermic oxygenated machine perfusion (DHOPE) for 2 hours prior to transplantation is sufficient to mitigate ischaemia-reperfusion damage and fully restore cellular energy levels. Clinical studies have shown beneficial outcomes after transplantation of liver grafts preserved by DHOPE compared with static cold storage. In addition to graft reconditioning, DHOPE may also be used to prolong preservation time, which could facilitate logistics for allocation and transplantation globally. METHODS AND ANALYSIS: This is a prospective, pseudo-randomised, dual-arm, IDEAL-D (Idea, Development, Exploration, Assessment, Long term study-Framework for Devices) stage 2 clinical device trial designed to determine safety and feasibility of prolonged DHOPE (DHOPE-PRO). The end-time of the donor hepatectomy will determine whether the graft will be assigned to the intervention (16:00–3:59 hour) or to the control arm (4:00–15:59 hour). In total, 36 livers will be included in the study. Livers in the intervention group (n=18) will undergo DHOPE-PRO (≥4 hours) until implantation the following morning, whereas livers in the control group (n=18) will undergo regular DHOPE (2 hours) prior to implantation. The primary endpoint of this study is a composite of the occurrence of all (serious) adverse events during DHOPE and up to 30 days after liver transplantation. ETHICS AND DISSEMINATION: The protocol was approved by the Medical Ethical Committee of Groningen, METc2020.126 in June 2020, and the study was registered in the Netherlands National Trial Registry (https://www.trialregister.nl/) prior to initiation. TRIAL REGISTRATION NUMBER: NL8740

Evidence for a rebalanced hemostatic system in pediatric liver transplantation:A prospective cohort study

In adults with end-stage liver disease concurrent changes in pro- and antihemostatic pathways result in a rebalanced hemostasis. Children though, have a developing hemostatic system, different disease etiologies, and increased risk of thrombosis. This study aimed to assess the hemostatic state of children during and after liver transplantation. Serial blood samples were obtained from 20 children (≤16 years) undergoing primary liver transplantation (September 2017-October 2018). Routine hemostasis tests, thrombomodulin-modified thrombin generation, clot lysis times, and hemostatic proteins were measured. Reference values were established using an age-matched control group of 30 children. Thrombocytopenia was present in study patients. Von Willebrand factors were doubled and ADAMTS13 levels decreased during and after transplantation up until day 30, when platelet count had normalized. Whereas prothrombin time and activated partial thromboplastin time were prolonged during transplantation, thrombin generation was within normal ranges, except during perioperative heparin administration. Fibrinogen, factor VIII levels, and clot lysis time were elevated up until day 30. In conclusion, children with end-stage liver disease are in tight hemostatic balance. During transplantation a temporary heparin-dependent hypocoagulable state is present, which rapidly converts to a hemostatic balance with distinct hypercoagulable features that persist until at least day 30. This hypercoagulable state may contribute to the risk of posttransplant thrombosis

Controlled DCD Liver Transplantation Is Not Associated With Increased Hyperfibrinolysis and Blood Loss After Graft Reperfusion

BACKGROUND: The specific effect of donation after circulatory death (DCD) liver grafts on fibrinolysis, blood loss, and transfusion requirements after graft reperfusion is not well known. The aim of this study was to determine whether transplantation of controlled DCD livers is associated with an elevated risk of hyper-fibrinolysis, increased blood loss and higher transfusion requirements upon graft reperfusion, compared to livers donated after brain death (DBD). METHODS: A retrospective single-center analysis of all adult recipients of a primary liver transplantation between 2000 and 2019 was performed (total cohort n= 628). Propensity score matching (PSM) was used to balance baseline characteristics for DCD and DBD liver recipients (PSM cohort n= 218). Intra- and postoperative hemostatic variables between DCD and DBD liver recipients were subsequently compared. Additionally, in vitro plasma analyses were performed to compare the intraoperative fibrinolytic state upon reperfusion. RESULTS: No significant differences in median (interquartile range) postreperfusion blood loss (1.2 L [0.5-2.2] vs 1.3 L (0.6-2.2); P= 0.62), RBC transfusion (2 units [0-4) vs 1.1 units [0-3], P= 0.21), or FFP transfusion requirements (0 units [0-2.2] vs 0 units (0-0.9); P= 0.11) were seen in DCD compared to DBD recipients, respectively. Furthermore, plasma fibrinolytic potential was similar in both groups. CONCLUSIONS: Transplantation of controlled DCD liver grafts does not result in higher intraoperative blood loss or more transfusion requirements, compared to DBD liver transplantation. In accordance to this, no evidence for increased hyper-fibrinolysis upon reperfusion in DCD compared to DBD liver grafts, was found