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LIVER TRANSPLANT STATISTICS

  • Nearly 6000 liver transplants are performed annually in the United States.

  • As available figures show, the waiting list for liver transplant has nearly 16,000 patients, and the numbers continue to grow.

HISTORICAL DEVELOPMENTS AND CHALLENGES

  • Surgical techniques evolved from canine models dating from 1955 by Stuart Welch in Albany and Jack Cannon at the UCLA.

  • Pioneer preservation solutions formulated at the University of Wisconsin allow liver preservation up to 18 to 24 hours.

  • In 1944 Medawar recognized the role of immunity in transplant rejection.

  • Immunosuppression was a major challenge, and experiences from renal transplant (synergistic use of azathioprine + prednisone) formed the basis of the present immunotherapy regimen.

  • Initial attempts at liver transplants (since 1963) were plagued by immediate surgical failures and intractable bleeds.

  • Eventually the first successful transplant was achieved by Starzl et al. in 1967 in a 1-year-old child with hepatoblastoma.

  • Survival rates were significantly enhanced by the introduction of antithymocyte globulin (1967) and tacrolimus (1989).

PREOPERATIVE CONCERNS WITH LIVER TRANSPLANTS

Preanesthetic evaluation:

  • A 2-stage evaluation is preferred, the first at the time of reporting the need for a transplantation and the second as a re-evaluation after donor identification, just prior to the actual transplantation.

  • The gap between these 2 evaluations can be used to improve nutritional status, treat any active infections, and manage associated coagulopathies and reversible organ system damages.

COMMON SYSTEMS INVOLVED AND ANESTHETIC-RELEVANT EVALUATIONS

Cardiopulmonary system (Fig. 56-1 and Table 56-1):

  • Conventional noninvasive functional status evaluation – 6-minute walk test.

  • Any suspicion of coronary artery disease must be evaluated – Improves long-term outcomes posttransplant.1

  • If significant coronary artery stenosis (>70% stenosis) is detected, revascularization may be attempted prior to transplant.

  • Pulmonary hypertension should be ruled out, and patients with right ventricular systolic pressure >45 mm Hg should undergo further evaluation (e.g., cardiac catheterization).

  • Dobutamine stress test

    • Preferred in patients with poor/limited functional status, as it quantifies the risk.

    • Rationalized as simulation of cardiovascular stress comparable to surgical stages of liver transplant.

    • High negative predictive value (75% to 100%).

    • Poor positive predictive value (0% to 33%).

  • Cardiopulmonary exercise testing (CPET)

    • Physiologically superior in evaluating cardiac and respiratory system reserves in coordination.

    • Some centers have included CPET in the routine evaluation.

    • Patients with an anaerobic threshold >9.0 mL/min/kg predicts complications, with sensitivity and specificity 90.7% and 83.3%, respectively.2

  • Hepatopulmonary syndrome (HPS)

    • Intrapulmonary vasodilation leading to blood shunting and hypoxemia.

    • Routine evaluation using room air. Arterial blood gas analysis with PO2values below 80 mm Hg need further investigation.

    • Transthoracic echocardiography visualizing transpulmonary air bubble appearance into the left heart is fairly sensitive.

    • HPS has high predictive value for need for prolonged postoperative mechanical ventilation.

  • Portopulmonary hypertension

    • Portopulmonary hypertension is characterized by a mean pulmonary artery pressure greater than 25 mm Hg ...

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