Perioperative Management of the Patient With Liver Disease Publications (65)


Perioperative Management of the Patient With Liver Disease Publications

Anesthesiol Clin
Anesthesiol Clin 2016 Dec;34(4):645-658
Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street-PH 5, New York, NY 10032, USA.

Hepatic and renal disease are common comorbidities in patients presenting for intermediate- and high-risk surgery. With the evolution of perioperative medicine, anesthesiologists are encountering more patients who have significant hepatic and renal disease, both acute and chronic in nature. It is important that anesthesiologists have an in-depth understanding of the physiologic derangements seen with hepatic and renal disease to evaluate and manage these patients appropriately. Read More

Perioperative management requires an understanding of the physiologic perturbations associated with each disease process. This article elucidates the goals in the management and treatment of this complex patient population.

Paediatr Anaesth
Paediatr Anaesth 2016 Oct 12;26(10):976-86. Epub 2016 Jul 12.
Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, CA, USA.

Combined heart and liver transplantation (CHLT) in the pediatric population involves a complex group of patients, many of whom have palliated congenital heart disease (CHD) involving single ventricle physiology.
The purpose of this study was to describe the perioperative management of pediatric patients undergoing CHLT at a single institution and to identify management strategies that may be used to optimize perioperative care.
We did a retrospective database review of all patients receiving CHLT at a children's hospital between 2006 and 2014. Read More

Information collected included preoperative characteristics, intraoperative management, blood transfusions, and postoperative morbidity and mortality.
Five pediatric CHLTs were performed over an 8-year period. All patients had a history of complex CHD with multiple sternotomies, three of whom had failing Fontan physiology. Patient age ranged from 7 to 23 years and weight from 29.5 to 68.5 kg. All CHLTs were performed using an en-bloc technique where both the donor heart and liver were implanted together on cardiopulmonary bypass (CPB). The median operating room time was 14.25 h, median CPB time was 3.58 h, and median donor ischemia time was 4.13 h. Patients separated from CPB on dopamine, epinephrine, and milrinone infusions and two required inhaled nitric oxide. All patients received a massive intraoperative blood transfusion post CPB with amounts ranging from one to three times the patient's estimated blood volume. The patient who required the most transfusions was in decompensated heart and liver failure preoperatively. Four of the five patients received an antifibrinolytic agent as well as a procoagulant (prothrombin complex concentrate or recombinant activated Factor VII) to assist with hemostasis. There were no 30-day thromboembolic events detected. Postoperatively the median length of mechanical ventilation, ICU stay and stay to hospital discharge was 4, 8, and 37 days, respectively. All patients are alive and free from allograft rejection at this time.
Combined heart and liver transplantation in the pediatric population involves a complex group of patients with unique perioperative challenges. Successful management starts with thorough preoperative planning and communication and involves strategies to deal with massive intraoperative hemorrhage and coagulopathy in addition to protecting and supporting the transplanted heart and liver and meticulous surgical technique. An integrated multidisciplinary team approach is the cornerstone for successful outcomes.

A A Case Rep
A A Case Rep 2016 Apr;6(7):189-92
From the *Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and †Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

We report the perioperative management of a patient with melanoma. Surgical intervention was withheld at multiple institutions because of the presence of metastases; the patient was undergoing experimental immunotherapy and had responded everywhere except in the liver. She underwent hepatic right trisegmentectomy to improve her quality of life and to allow resumption of immunotherapy. Read More

Dyspnea because of heart compression, pleural effusion, lung collapse, and pulmonary emboli improved. She died of late complications. This case highlights physiologic and ethical considerations.

Reg Anesth Pain Med
Reg Anesth Pain Med 2015 Nov-Dec;40(6):718-9
From the Department of Anesthesiology, National Hospital Organization Osaka National Hospital, Osaka, Japan.
Medicine (Baltimore)
Medicine (Baltimore) 2015 Sep;94(35):e1426
From the Hepatobiliary Surgery Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, P.R. China (J-HZ, X-MY, S-DL, Y-YW, B-DX, LM, F-XW, W-PY, L-QL); Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Nanning, PR China (J-HZ, X-MY, S-DL, Y-YW, B-DX, LM, F-XW, W-PY, L-QL); and Disease Classification Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, P.R. China (YC).

The present study compared the efficacy of hepatic resection (HR) in patients with large hepatocellular carcinoma (HCC) and those with multinodular tumor and examined how that efficacy has changed over time in a large medical center.The intermediate stage of HCC comprises a highly heterogeneous patient population. Moreover, official guidelines have different views on the suitability of HR to treat such patients. Read More

A consecutive sample of 927 patients with preserved liver function and large and/or multinodular HCC who were treated by initial HR were divided into 3 groups: those with a single tumor ≥5 cm in diameter (n = 588), 2 to 3 tumors with a maximum diameter >3 cm (n  = 225), or >3 tumors of any diameter (n = 114). Hospital mortality and overall survival (OS) in each group were compared for the years 2000 to 2007 and 2008 to 2013.Patients with >3 tumors showed the highest incidence of hospital mortality of all groups (P < 0.05). Kaplan-Meier survival analysis showed that OS varied across the 3 groups as follows: single tumor > 2 to 3 tumors > 3+ tumors (all P < 0.05). OS at 5 years ranged from 24% to 41% in all 3 groups for the period 2000 to 2007, and from 35% to 46% for the period 2008 to 2013. OS was significantly higher during the more recent 6-year period in the entire patient population, those with single tumor, and those with 3+ tumors (all P < 0.05). However, in patients with 2 to 3 tumors, OS was only slightly higher during the more recent 6-year period (P = 0.084).Prognosis can vary substantially for these 3 types of HCC. Patients with >3 tumors show the highest hospital mortality and lowest OS after HR. OS has been improving for all 3 types of HCC at our medical center as a consequence of improvements in surgical technique and perioperative management.

Cancer Chemother. Pharmacol.
Cancer Chemother Pharmacol 2015 Oct 26;76(4):659-77. Epub 2015 Jun 26.
Medical Oncology Department, Biomedical Research Institute INIBIC, A Coruña University Hospital, A Coruña, Spain.
BMC Surg
BMC Surg 2015 May 21;15:65. Epub 2015 May 21.
Starzl Unit of Abdominal Transplantation, University Hospital of Saint Luc, Université Catholique of Louvain, Brussels, Belgium.

Patients with cirrhosis have a high incidence of abdominal wall hernias and carry an elevated perioperative morbidity and mortality. The optimal surgical management strategy as well as timing of abdominal hernia repair remains controversial.
A cohort study of 67 cirrhotic patients who underwent hernia repair during the period of January 1998-December 2009 at the University Hospital of Sao Paulo were included. Read More

After meeting study criteria, a total of 56 patients who underwent 61 surgeries were included in the final analysis. Patient characteristics, morbidity (Clavien score), mortality, Child-Turcotte-Pugh score, MELD score, use of prosthetic material, and elective or emergency surgery have been analysed with regards to morbidity and 30-day mortality.
The median MELD score of the patient population was 14 (range: 6 to 24). Emergency surgery was performed in 34 patients because of ruptured hernia (n = 13), incarceration (n = 10), strangulation (n = 4), and skin necrosis or ulceration (n = 7). Elective surgery was performed in 27 cases. After a multivariable analysis, emergency surgery (OR 7.31; p 0.017) and Child-Pugh C (OR 4.54; p 0.037) were risk factors for major complications. Moreover, emergency surgery was a unique independent risk factor for 30-day mortality (OR 10.83; p 0.028).
Higher morbidity and mortality are associated with emergency surgery in advanced cirrhotic patients. Therefore, using cirrhosis as a contraindication for hernia repair in all patients may be reconsidered in the future, especially after controlling ascites and in those patients with hernias that are becoming symptomatic or show signs of possible skin necrosis and rupture. Future prospective randomized studies are needed to confirm this surgical strategy.

Reg Anesth Pain Med
Reg Anesth Pain Med 2015 Mar-Apr;40(2):139-49
From the *Department of Anesthesiology, Virginia Mason Medical Center; †Axio Research; and ‡Department of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA.

Esophageal cancer is a leading cause of cancer death worldwide, and esophageal resection is associated with extremely high perioperative morbidity and mortality. A perioperative clinical pathway for esophagectomy patients in which anesthetic care is both integral and standardized has not been described previously.
A continuously refined clinical pathway for perioperative care of the esophagectomy patient has been developed at the Virginia Mason Medical Center over the past 22 years. Read More

Ongoing data collection records patient demographics, comorbidities, tumor stage, and various outcomes including intensive care unit and hospital length of stay, surgical complications, and morbidity and mortality rates.
Over time, patients presenting for surgical treatment of esophageal cancer have had significantly higher Charlson comorbidity scores and a higher incidence of diabetes mellitus, hypertension, liver disease, and history of deep vein thrombosis or pulmonary embolism. During the same period, intensive care unit and hospital length of stays have decreased, whereas most complication rates have remained stable despite more advanced tumor stage and increased use of neoadjuvant chemoradiotherapy. In-hospital and 30-day mortality rates are well below national averages at 0.5% each.
We present a detailed anesthetic and surgical perioperative pathway for esophageal resection, along with evidence of improved or stable patient outcomes despite an increase in comorbidity burden and increasingly advanced tumor stage.

A A Case Rep
A A Case Rep 2013 Dec;1(5):72-4
From the *Department of Anesthesiology and Perioperative Care, Division of Pain Medicine, University of California-San Francisco, San Francisco, California; and †Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington.

We present the case of a 25-year-old woman with acute fatty liver of pregnancy, a rare mitochondrial disorder that manifests during pregnancy and has a significant mortality rate. Postoperative pain management is challenging for myriad reasons. With the increasing application of transversus abdominis plane blocks for postcesarean delivery analgesia, we describe the real and potential complications of this method of regional analgesia in patients with this disease. Read More