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Perioperative anaphylaxis is relatively rare but can be life-threatening. The incidence in China is unknown and may differ from other global geographic regions. This study was therefore designed to understand the incidence of perioperative anaphylaxis in China.We enrolled 112 tertiary care hospitals from seven distinct geographic areas in mainland China. We collected information about Ring and Messmer III and IV reactions from September 2018 to August 2019. A collaborative educational learning network was used to reduce diagnostic errors. Information about patient characteristics, clinical features, treatment, and clinical outcomes were recorded and analysed.A total of 447 cases of 5 078 118 surgical procedures met inclusion criteria. The incidence of suspected perioperative anaphylaxis throughout China was one in 11 360 anaesthetics (95% confidence interval [CI], with a range of 1:12 521 to 1:10 397). The incidence in South China was higher (one in 6050; 95% CI, from 1:8013 to 1:4859) than in Northeast China (one in 19 262; 95% CI, from 1:33 088 to 1:13 585) (P0.01) with an increasing trend from the north to the south. The most common clinical manifestations were hypotension (91.1%) and tachycardia (65.3%). The majority of patients (83.4%) were given epinephrine. A total of 27 patients (6.0%) required cardiopulmonary resuscitation. Ultimately, nine patients died (2.0%).This nationwide survey showed an incidence of perioperative anaphylaxis of one in 11 360, but this varied significantly by region. The underlying reason for this pattern remains unknown and could be attributable to environmental or genetic influences, which requires further investigation.ChiCTR1900025956.

BACKGROUND Conflicting evidence underlies the controversial role of allogenic blood transfusion in recurrence of non-small cell lung cancer (NSCLC). Insufficient sample size and failure to measure effects of important confounders in previous studies contribute to the conflicting findings. To overcome these limitations, we applied robust statistics and weighted covariates in a large study cohort. METHODS Cox regression analyses were used to estimate the recurrence and survival in patients with NSCLC disease stages I through III who were transfused for a haemoglobin level less than 8.0 g/dL within seven days after surgical resection. Inverse probability of treatment weighting (IPTW) was used to balance covariates in the sequential cohort of patients receiving an incremental amount of blood. We applied restricted cubic spline functions to characterise dose-response effects of transfusion amount on recurrence and mortality. RESULTS A total of 209 (11.6%) of 1803 patients received transfusions. Over a median of 42 months after surgery (interquartile range 24.9-71.9), patients who received blood had a greater risk of early recurrence (IPTW-adjusted HR: 1.81, 95% CI: 1.59-2.06, P

There is conflicting evidence whether allogeneic blood transfusion influences survival or cancer recurrence after resection of hepatocellular cancer. We followed up 1469 patients who had undergone hepatocellular resection for a median (IQR [range]) of 45 (21-78 [0-162]) months, of whom 626 (43%) had had blood transfusion within 7 days of surgery. Both disease-free survival and patient survival were measured using a proportional hazards regression model and inverse probability of treatment weighting. We used restricted cubic splines for the association of the number of packed red blood cell units transfused with cancer recurrence and survival. We found that peri-operative blood transfusion was independently associated with survival and cancer recurrence after resection of hepatocellular carcinoma. Adjusted hazard ratios (95%CI) for the association of blood transfusion with cancer recurrence and all-cause mortality were 1.3 (1.1-1.4) and 1.9 (1.6-2.3), p < 0.001 for both. With more units transfused cancer recurrence was more likely and survival was shorter. The association of the number of transfused units was non-linear for cancer recurrence and linear response for all-cause mortality.

Little is known about living liver donors' perceptions of their physical well-being following the procedure. We collected data on donor fatigue, pain, and other relevant physical outcomes as part of the prospective, multicenter Adult-to-Adult Living Donor Liver Transplantation Cohort Study consortium. A total of 271 (91%) of 297 eligible donors were interviewed at least once before donation and 3, 6, 12, and 24 months after donation using validated measures when available. Repeated measures regression models were used to identify potential predictors of worse physical outcomes. We found that donors reported more fatigue immediately after surgery that improved by 2 years after donation, but not to predonation levels. A similar pattern was seen across a number of other physical outcomes. Abdominal or back pain and interference from their pain were rated relatively low on average at all study points. However, 21% of donors did report clinically significant pain at some point during postdonation study follow-up. Across multiple outcomes, female donors, donors whose recipients died, donors with longer hospital stays after surgery, and those whose families discouraged donation were at risk for worse physical well-being outcomes. In conclusion, although not readily modifiable, we have identified risk factors that may help identify donors at risk for worse physical outcomes for targeted intervention. Liver Transplantation 00 000-000 2018 AASLD.

Ischemia and reperfusion significantly contributes to the morbidity and mortality of liver surgery and transplantation. Based on studies showing a critical role for adenosine signaling in mediating tissue adaptation during hypoxia, we hypothesized that signaling events through adenosine receptors (ADORA1, ADORA2A, ADORA2B, or ADORA3) attenuates hepatic ischemia and reperfusion injury. Initial screening studies of human liver biopsies obtained during hepatic transplantation demonstrated a selective and robust induction of ADORA2B transcript and protein following ischemia and reperfusion. Subsequent exposure of gene-targeted mice for each individual adenosine receptor to liver ischemia and reperfusion revealed a selective role for the Adora2b in liver protection. Moreover, treatment of wild-type mice with an Adora2b-selective antagonist resulted in enhanced liver injury, whereas Adora2b-agonist treatment was associated with attenuated hepatic injury in wild-type, but not in Adora2b −/− mice. Subsequent studies in mice with Adora2b deletion in different tissues—including vascular endothelia, myeloid cells, and hepatocytes—revealed a surprising role for hepatocellular-specific Adora2b signaling in attenuating nuclear factor NF-κB activation and thereby mediating liver protection from ischemia and reperfusion injury. These studies provide a unique role for hepatocellular-specific Adora2b signaling in liver protection during ischemia and reperfusion injury.

Because results from single-center (mostly kidney) donor studies demonstrate interpersonal relationship and financial strains for some donors, we conducted a liver donor study involving nine centers within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2) consortium. Among other initiatives, A2ALL-2 examined the nature of these outcomes following donation. Using validated measures, donors were prospectively surveyed before donation and at 3, 6, 12, and 24 mo after donation. Repeated-measures regression models were used to examine social relationship and financial outcomes over time and to identify relevant predictors. Of 297 eligible donors, 271 (91%) consented and were interviewed at least once. Relationship changes were positive overall across postdonation time points, with nearly one-third reporting improved donor family and spousal or partner relationships and >50% reporting improved recipient relationships. The majority of donors, however, reported cumulative out-of-pocket medical and nonmedical expenses, which were judged burdensome by 44% of donors. Lower income predicted burdensome donation costs. Those who anticipated financial concerns and who held nonprofessional positions before donation were more likely to experience adverse financial outcomes. These data support the need for initiatives to reduce financial burden.

Background. Incorrect placement of epidural catheters causes medical complications. We used linear discriminant analysis (LDA) to develop an intelligent recognition system (i-RS) in order to guide epidural placement and reduce physician error. Methods. We analysed real-time dual-wavelength fibreoptic data recorded from the end of an epidural needle in a live porcine model. Two categories of tissue layers were necessary for correct placement of catheter: epidural space and ligamentum flavum. The data were tested using linear, quadratic and logistic parametric analysis to identify which method could distinguish the two anatomical structures. Results. LDA was the best fit for our model. There was 80% sensitivity and specificity for correct anatomical identification. Error rates based on cross-validation were 17.0% for the epidural space and 18.6% for ligamentum flavum. Error rates were greater with the 532 nm compared with 650 nm wavelength. Conclusions. The sensitivity and specificity of LDA for identifying the correct anatomical structure was similar to a physician who is an expert in epidural placement. Overall performance of an i-RS could be improved by expanding the database for decision-making and adding a category of uncertainty. This would reduce complications caused by incorrect epidural placement.

Purpose of review This review aims to identify specific criteria for cirrhotic cardiomyopathy, examine the correlation with perioperative adverse outcomes and explore options for hemodynamic monitoring. Recent findings Cirrhotic cardiomyopathy is characterized by an increase in cardiac output, blunted systolic contractile response to stress, diastolic dysfunction and electrophysiological abnormalities. Adverse events due to cirrhotic cardiomyopathy are not as well characterized, but evidence suggests that some cardiovascular complications during surgery and in the postoperative period are caused by an impaired response to physiological stress. New developments in hemodynamic monitoring using not only thermodilution technology provide more reliable information about cardiac performance than pressure-derived measures. Transesophogeal echocardiography also offers the physician new information including the ability to visualize heart structures, shape, and function. Summary To detect cirrhotic cardiomyopathy, physicians must conduct a systematic examination of the patient. Overt manifestations of cirrhotic cardiomyopathy often only become evident after a patient is exposed to physiological or drug-induced stress. Appropriate hemodynamic monitoring is a cornerstone in the perioperative management of cirrhotic patients.

Background Previous studies using linear regression analysis have shown that age, weight, gender, and the site of operation affect intravenous patient-controlled analgesia (IVPCA) narcotic use. However, there are inconsistent observations in the literature. The authors postulate that patient variables could have different effects at various doses of narcotics. To test this hypothesis, the authors analyzed the effect of patient variables on increasing doses of IVPCA narcotic with quantile regression. Methods The authors collected retrospective data from 1,782 patients who received IVPCA for a minimum of 3 days after surgery. The authors used stepwise linear regression model to identify variables that significantly affected the total IVPCA requirements. Quantile regression model was further applied to assess the effects of selected variables on the ascending percentile of IVPCA narcotic use. Results Gender, age, body weight, cancer, and surgical site were identified as significant predictors for IVPCA demand. Body weight had the most and cancer had the least significant effects on total IVPCA demands. The results of quantile regression model revealed that the determinants under consideration varied with different percentiles of IVPCA demand. The patient variables correlated with IVPCA narcotic use differently when the dose exceeded the seventieth to eightieth percentiles compared with other percentiles of narcotic use. Conclusions The authors' findings highlight the heterogeneous postoperative pain requirements among patients and the consequent complex process of efficiently managing postoperative pain.

The trend to extubate patients as soon as possible following large and complex surgery is supported by a large body of evidence showing early extubation is safe and saves money. However, the use of early extubation in liver transplant recipients is still debated. This review will explore the reasons why there is still resistance to the use of early extubation in liver transplantation.Studies show the majority of liver transplant recipients can be extubated immediately after surgery. A multiinstitutional study addressed the safety of immediate postoperative intubation and confirmed that the rate of complications and reintubation was similar to the very low rate observed in recovery room patients. Investigators, however, cannot agree on what patient or donor factors predict successful extubation. These variables seem to differ between institutions.There is robust evidence to support the use of immediate postoperative ventilation in liver transplant recipients. There is no evidence, however, to show that routine ventilation of all transplant recipients provides outcomes that are as good as those documented in extubated patients. It is probably time to turn the evidentiary tables around and ask proponents of routine ventilation to prove that they have done no harm and that they meet the new minimal performance standards established by immediate postoperative extubation.

Campsen J, Zimmerman MA, Narkewicz MR, Sokol RJ, Mandell MS, Kam I, Dovel D, Karrer FM. Choledochoduodenostomy in pediatric liver transplantation. Pediatr Transplantation 2011: 15: 237–239. © 2011 John Wiley & Sons A/S. Abstract: Reconstruction of the bile ducts during pediatric liver transplantation is generally performed by a Roux-en-Y CDJ because direct duct-to-duct anastomosis CC is often not possible. Anastomosis of the donor liver bile duct to the duodenum CDD provides another option. We provide preliminary evidence that CDD is an alternative technique for biliary reconstruction when CC is not possible in pediatric liver transplant recipients that have a hostile abdomen or to preserve bowel length. Methods: From 2007 to 2008, a total of 19 pediatric cadaveric liver transplants were performed at our center. Four of the 19 had a bile duct reconstruction by CDD. Results: CDD reconstruction was used in patients who received a liver transplant for a diagnosis of PSC, congenital hepatic fibrosis, biliary atresia, and Alagille syndrome. The ages of the patients were 17 and 10 yr and 10 and 17 months. Three grafts were whole cadaveric livers, and one was a reduced left lobe. CDD was used to revise a prior anastomosis in one patient who had a previous Roux-en-Y that was unusable during the retransplant, and another to repair a stricture in a second patient with a CC. We also performed a CDD in a patient with a hostile abdomen from previous surgery, and another patient to avoid short gut syndrome that a Roux-en-Y may have created. All patients are alive with functioning grafts with a follow-up of at least one yr. None of the patients developed clinically significant biliary complications (leak, stricture, cholangitis). Conclusion: Our preliminary experience suggests that CDD is an option for biliary reconstruction in pediatric transplant patients with hostile abdomens or to preserve bowel length.

Background Living donor liver transplantation has gained wide acceptance as an alternative for children with end-stage liver disease. The standard left lateral segment used in this operation does not provide adequate parenchymal mass to broaden its application to larger children or adults. Methods We report two cases of adult to adult living donor liver transplantation using a right hepatic lobe in patients with chronic liver disease. Results Both recipients experienced excellent initial graft function and have normal liver function 4 and 9 months postoperatively. Both donors are alive and well and returned to normal life 4 weeks postoperatively. Conclusions Our initial experience suggests that this technique is a safe and reliable option for adults with chronic end-stage liver disease. A conservative application of this procedure in the adult population could significantly reduce the mortality on the adult waiting list.

Liver disease affects the function of all other organ systems, and cirrhosis can be thought of as a systemic disease that produces multisystem organ failure as a principal cause of death. The lung is particularly sensitive to changes in hepatic function and respiratory failure is a common complication of advanced liver disease. Historically, while physicians recognized an association between lung and liver disease, this association was considered to be rare. But more recent studies have shown that symptoms such as hypoxemia at rest occur in at least 27–33 % of liver transplant candidates [1]. Hypoxemia is caused by a wide variety of diseases. Some pulmonary diseases occur more commonly in patients with liver disease than in the general population. These pulmonary defects can affect the perioperative management of patients and may influence the decision to proceed with transplantation. This chapter will present an overview of the changes in lung mechanics and gas exchange that occur in patients with liver disease and cover some of the more common causes of pulmonary disease in cirrhotic patients.

PURPOSE OF REVIEW Cardiovascular disease has emerged as a leading cause of perioperative morbidity and mortality in renal and liver transplant patients. There is no consensus on how to diagnose cardiac disease in transplant patients. Further, there is significant disagreement in the literature regarding the use of routine screening methods to detect disease. This review will explore published observations on cardiac complications in renal and liver transplant patients to try and determine why investigators hold such divergent opinions. RECENT FINDINGS The prevalence of cardiac disease is greater in renal and liver transplant patients than in the general public. Complications of cardiac disease play a large role in early mortality and graft loss in the postoperative period. While the presence of risk factors seems to predict coronary disease in renal disease, these factors do not perform as well in liver disease. Noninvasive stress testing for coronary artery disease seems to have low sensitivity in both transplant populations. However, the measurement of cardiac troponin seems to be of some value in predicting early mortality. SUMMARY Physicians have not identified an effective yet cost-effective way to screen transplant patients for cardiac disease. Therefore, the first step in creating widely accepted protocols demand that physicians decide what predictive power that screening tests should have in this unique population.

Introduction. A Roux-en-Y hepaticojejunostomy (HJ) is usually performed during live donor liver transplantation (LDLT) when a duct-to-duct reconstruction is not possible. However, direct anastomosis of the bile duct to the duodenum (hepaticoduodenostomy [HD]) is an alternative technique for biliary repair that has been previously used for conventional biliary surgery and at our center for cadaveric liver transplant. We provide the first evidence that HD is an alternative technique for biliary reconstruction in LDLT. Methods. We performed a total of 71 LDLT between 2002 and 2008. An end-to-end anastomosis was used in 30 patients. Forty-one patients had a biliary enteric anastomosis in which seven were reconstructed with an HD. Accessory ducts were fashioned into a common duct or implanted into the duodenum separately. Results. There were no patient deaths or retransplants in a follow-up period that ranged from 90 to 771 days after surgery. One patient was diagnosed with cholangitis that responded to intravenous antibiotics and removal of the stent by endoscopy. Conclusions. This preliminary case series suggests that that HD is a feasible alternative to HJ biliary anastomosis when a duct-to-duct anastomosis cannot be performed. HD offers the possible advantage of simple postoperative access to the biliary system by endoscopy and avoids complications caused by HJ bowel anastomosis.

Bile duct reconstruction during liver transplantation is usually performed by a duct-to-duct anastomosis or a Roux-en-Y choledochojejunostomy (CDJ). Direct anastomosis of the bile duct to the duodenum (choledochoduodenostomy-CDD) is another option for biliary reconstruction. This technique has been used with good outcome for the treatment of choledochal cysts, ampullary stenosis, and major bile duct injuries; however, there is little published experience with CDD in liver transplantation. We provide preliminary evidence that CDD is a safe technique for biliary anastomosis in liver transplant recipients.From September 2000 to August 2007 a total of 619 adult first-time cadaveric or living donor liver transplants were performed at the University of Colorado Health and Science Center. Bile duct repair was performed by direct end-to-end anastomosis in 466 patients and by choledocoenterostomy in the remaining 153 patients, 82 of whom were cadaveric recipients. The cadaveric choledocoenterostomy patients were divided into two groups: CDD in 25 and CDJ in 57 recipients.There were no significant differences in the 1-year patient or graft survival between the cadaveric groups. The 1-year patient survival was 100% in the CDD group and 97.1% in the CDJ group. The CDD group did not experience more surgical complications compared to the CDJ group.Choledochoduodenostomy is a safe alternative to CDJ biliary anastomosis when a duct-to-duct anastomosis cannot be performed. There is no significant difference in mortality, graft survival, or biliary complications. In addition, CDD offers the advantage of postoperative access to the billiary system by endoscopy and avoids complications associated with the CDJ bowel anastomosis.

Physicians previously thought that heart disease was rare in patients with end stage liver disease. However, recent evidence shows that the prevalence of ischemic heart disease and cardiomyopathy is increased in transplant candidates compared to most other surgical candidates. Investigators estimate that up to 26% of all liver transplant candidates have at least one critical coronary artery stenosis and that at least half of these patients will die perioperatively of cardiac complications. Cardiomyopathy also occurs in greater frequency. While all patients with advanced cardiac disease have defects in cardiac performance, a larger than expected number of patients have classical findings of dilated, restrictive and hypertrophic cardiomyopathy. This may explain why up to 56% of patients suffer from hypoxemia due to pulmonary edema following transplant surgery. There is considerable controversy on how to screen transplant candidates for the presence of heart disease. Questions focus upon, which patients should be screened and what tests should be used. This review examines screening strategies for transplant candidates and details the prognostic value of common tests used to identify ischemic heart disease. We also review the physiological consequences of cardiomyopathy in transplant candidates and explore the specific syndrome of “cirrhotic cardiomyopathy”.