Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation
Tóm tắt
Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child–Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0–18.8 l) in the re-intervention group compared with 1.5 l (range 0–13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.
Tài liệu tham khảo
Starzl TE, Demetris AJ, van Thiel D. Medical progress: liver transplantation. N Engl J Med 1989; 321:1092.
Azoulay D, Samuel D, Adam R, et al. Paul Brousse liver transplantation: the first 1.500 cases. Clin Transplant 2000; 14:273.
Baligna P, Merion RM, Turcotte JG, et al. Preoperative risk factor assessment in liver transplantation. Surgery 1992; 112:704.
Smith CM, Davies DB, McBride MA. Liver transplantation in the United States: a report from the UNOS Liver Transplant Registry. Clin Transplant 1999; 13:23.
Brown RS Jr, Ascher NL, Lake JR, et al. The impact of surgical complications after liver transplantation on resource utilisation. Arch Surg 1997; 132:1098.
Lebeau G, Yanaga K, Marsh JW, et al. Analysis of surgical complications after 397 hepatic transplantations. Surg Gynecol Obstet 1990; 170:317.
Lyass S, Venturero M, Ilan Y, et al. Reoperation after liver transplantation. Transplant Proc 1999; 31:1901.
Nemec P, Ondrasec J, Studenik P, Hokl J, Cerny J. Biliary complications in liver transplantation. Ann Transplant 2001; 6:24.
Sánchez-Bueno F, Hernández Q, Ramírez P, et al. Vascular complications in a series of 300 orthotopic liver transplants. Transplant Proc 1999; 31:2409.
Testa G, Goldstein RM, Toughanipour A, et al. Guidelines for surgical procedures after liver transplantation. Ann Surg 1998; 227:590.
Azoulay D, Linhares MM, Huguet E, et al. Decision for retransplantation of the liver: an experience- and cost-based analysis. Ann Surg 2002; 236:713.
Maring JK, Klompmaker IJ, Zwaveling JH, Kranenburg K, Ten Vergert EM, Slooff MJH. Poor initial graft function after orthotopic liver transplantation: can it be predicted and does it affect outcome? An analysis of 125 adult primary transplantations. Clin Transplant 1997; 11:373.
Starzl TE, Marchioro TI, Von Kaula HN, Herman G. Homotransplantation of the liver in human. Surg Gynecol Obstet 1963; 117:659.
Shaw BW Jr, Martin DJ, Marquez JM, et al. Venous bypass in clinical liver transplantation. Ann Surg 1984; 200:524.
Slooff MJH, Bams JL, Sluiter WJ, Klompmaker IJ, Hesselink EJ, Verwer R. A modified cannulation technique for veno-venous bypass during orthotopic liver transplantation. Transplant Proc 1989; 21:2328.
Lerut JP, Gertsh P, Blumgart LH. ‘Piggy back’ adult orthotopic liver transplantation. Helv Chir Acta 1989; 56:527.
Kok T, Slooff MJH, Thijn CJ, et al. Routine Doppler ultrasound for the detection of clinically unsuspected vascular complications in the early postoperative phase after orthotopic liver transplantation. Transpl Int 1998; 11:272.
Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transsection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973; 60:646.
Grieco A, Long C. Investigation of the Karnofsky performance status as a measure of quality of life. Health Psychol 1984; 3:129.
Bennett-Guerrero E, Feierman DE, Barclay GR, et al. Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation. Arch Surg 2001; 136:1177.
Cacciarelli TV, Keeffe EB, Moore DH, et al. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg 1999; 134:25.
Mor E, Jennings L, Gonwa TA, Holman MJ, et al. The impact of operative bleeding on outcome in transplantation of the liver. Surg Gynecol Obstet 1993; 176:219.
Palamo Sanchez JC, Jimenez C, Moreno Gonzalez E, et al. Effects of intraoperative blood transfusion on postoperative complications and survival after orthotopic liver transplantation. Hepatogastroenterology 1998; 45:1026.
Taylor MC, Greig PD, Detsky AS, McLeod RS, Abdoh A, Krahn MD. Factors associated with the high cost of liver transplantation in adults. Can J Surg 2002; 45:425.
Whiting JF, Martin J, Zavala E, Hanto D. The influence of clinical variables on hospital costs after orthotopic liver transplantation. Surgery 1999; 125:217.
Vamvakas EC. Transfusion related immunomodulation: a debate over possible deleterious clinical effects of allogeneic blood transfusion. TATM 2002; 4:48.
Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999; 340:409.
Brand A. Immunological aspects of blood transfusions. Transpl Immunology 2002; 10:183.
Opelz G, Sengar DP, Mickey MR, Terasaki PI. Effect of blood transfusions on subsequent kidney transplants. Transplant Proc 1973; 5:253.
Hébert PC, Fergusson D, Blajchman MA, et al. Clinical outcomes following institution of the Canadian universal leucoreduction program for red blood cell transfusions. JAMA 2003; 289:1941.
Porte RJ, Molenaar IQ, Begliomini B, et al. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. Lancet 2000; 355:1303.
Findlay JY, Rettke SR, Ereth MH, Plevak DJ, Krom RA, Kufner RP. Aprotinin reduces red blood cell transfusion in orthotopic liver transplantation: a prospective, randomized, double-blind study. Liver Transplant 2001; 7:802.
Hendriks HGD, Meijer K, de Wolf T. et al. Reduced transfusion requirements by recombinant factor VIIa in orthotopic liver transplantation. Transplantation 2001; 71:402.
Mallet SV, Cox DJA. Thromboelastography. Br J Anaesth 1992; 69:307.
Kang Y. Thromboelastography in liver transplantation. Semin Thromb Hemost 1995; 21:34.