Mangus R S, Kinsella S B, Nobari M M, Fridell J A, Vianna R M, Ward E S, Nobari R, Tector A J
Department of Surgery, Transplantation Section, Indiana University School of Medicine, Indianapolis, Indiana 46202-5250, USA.
Transplant Proc. 2007 Dec;39(10):3207-13. doi: 10.1016/j.transproceed.2007.09.029.
Orthotopic liver transplantation (OLT) has historically been associated with massive blood loss and hemodynamic instability related to the coexistence of varices, coagulopathy, thrombocytopenia, and portal hypertension. Piggyback hepatectomy (PGB) is a technique increasingly utilized in OLT to avoid veno-venous bypass and vena cava clamping. This study evaluated the factors associated with blood loss and blood product requirement in PGB.
This study is a retrospective review of the anesthesia preoperative and operative notes and computerized lab values for all adult cadaveric liver transplants over a 42-month period. These data were combined with the liver transplant database for analysis. Approximately 98% of the transplants were performed using a standard piggyback approach with no use of veno-venous bypass.
Data were included for all 526 transplants performed during this time period. Estimated blood loss (EBL) was 1000 cc. Median transfusion requirement was 3 units packed red blood cells, 7 units fresh frozen plasma, and 6 units platelets. Multivariate linear regression demonstrated that predictors of EBL were age, MELD score, preoperative hemoglobin, initial fibrinogen, initial central venous pressure, and total anesthesia time. Predictors of PRBC useage were age, MELD score, preoperative hemoglobin, initial fibrinogen, and anesthesia time. Postoperatively increased transfusion requirement was associated with increased length of hospital stay and lower 90-day and 1-year graft and patient survivals.
These results demonstrate that PGB can be safely accomplished in nearly all liver transplant patients without venovenous bypass or vena cava clamping and with less warm ischemia, which may ultimately be associated with less perioperative morbidity and improved outcomes.
原位肝移植（OLT）在历史上一直与大量失血以及与静脉曲张、凝血病、血小板减少症和门静脉高压并存相关的血流动力学不稳定有关。背驮式肝切除术（PGB）是一种在OLT中越来越多地被采用的技术，以避免静脉-静脉转流和腔静脉钳夹。本研究评估了与PGB中失血和血液制品需求相关的因素。
本研究是对42个月期间所有成人尸体肝移植的麻醉术前和手术记录以及计算机化实验室值的回顾性分析。这些数据与肝移植数据库相结合进行分析。大约98%的移植采用标准背驮式方法，未使用静脉-静脉转流。
纳入了该时间段内进行的所有526例移植的数据。估计失血量（EBL）为1000毫升。输血需求中位数为3单位浓缩红细胞、7单位新鲜冰冻血浆和6单位血小板。多变量线性回归表明，EBL的预测因素为年龄、终末期肝病模型（MELD）评分、术前血红蛋白、初始纤维蛋白原、初始中心静脉压和总麻醉时间。浓缩红细胞使用的预测因素为年龄、MELD评分、术前血红蛋白、初始纤维蛋白原和麻醉时间。术后输血需求增加与住院时间延长以及90天和1年移植肝和患者生存率降低相关。
这些结果表明，PGB几乎可以在所有肝移植患者中安全完成，无需静脉-静脉转流或腔静脉钳夹，且热缺血时间较短，这最终可能与围手术期发病率降低和预后改善相关。
