Charles M Miller

Publications (50)178.31 Total impact

• Article: Right hepatectomy for living donation: Role of remnant liver volume in predicting hepatic dysfunction and complications.

  Marcelo Facciuto, Alan Contreras-Saldivar, Manoj K Singh, Juan P Rocca, Bachir Taouli, Irina Oyfe, Dianne Lapointe Rudow, Gabriel E Gondolesi, Thomas D Schiano, Leona Kim-Schluger, Myron E Schwartz, Charles M Miller, Sander Florman
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  ABSTRACT: BACKGROUND: Extensive attention has been placed on remnant liver volume (RLV) above other factors to ensure donor safety. METHODS: We performed a retrospective review of 137 right hepatectomies in live donors between June 1999 and November 2010. RESULTS: Median right lobe volume was 1,029 cm(3), which correlated with its actual weight (r = 0.63, P < .01); median RLV was 548 cm(3). Of the donors, 32 (24%) developed postoperative hepatic dysfunction (bilirubin >3 mg/dL or prothrombin time >18 s on postoperative day 4). RLV did not predict postoperative hepatic dysfunction (P = .9), but it was associated with peak international normalized ratio (INR) (P = .04). Donor age and male gender were predictors of increased bilirubin at postoperative day 4 (age, P = .03; gender, P = .02). Of the donors, 45 (33%) experienced complications, and 24 donors had RLVs <30%; 42% experienced complications compared to 31% of donors whose RLVs were greater than 30% (P = .3). Cell-saver utilization and aspartate-aminotransferase (AST) levels (OR = 3) were associated with complications. Volumetric assessment can predict RLV accurately. CONCLUSION: Although no demonstrable association between RLV <30% and complications was found, an RLV of 30% should remain the threshold for donor safety. Age and gender should be balanced in donors with a near threshold RLV of 30%. Surgical complexity, suggested by the need for intraoperative autoinfusion of blood and postoperative levels of AST, remained the independent predictor of complications.
  Surgery 02/2013; · 3.10 Impact Factor
• Article: Combined Heart and Liver Transplantation: The Cleveland Clinic Experience.

  A Dave Nagpal, Themistokles Chamogeorgakis, Alexis E Shafii, Mazen Hanna, Charles M Miller, John Fung, Gonzalo V Gonzalez-Stawinski
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  ABSTRACT: BACKGROUND: Combined heart-liver transplantation (CHLT) has been utilized as a life-saving procedure in those with end-stage cardiac and hepatic pathology. Techniques and outcomes of this procedure are varied. We sought to review the Cleveland Clinic experience with CHLT. METHODS: This study is a retrospective chart review of patients who received simultaneous heart and liver transplantation between January 2006 and December 2012. RESULTS: Five patients received CHLT. The mean age was 49 (± 20) years. All cardiac pathology was nonischemic cardiomyopathy, with a mean ejection fraction of 0.36 (± 0.13). Three of the 5 were on preoperative inotropic support, 1 of which required placement of a total artificial heart for support pretransplant. Liver pathology was amyloid in 1 patient and hepatitis C in the remaining 4. Mean Model for End-Stage Liver Disease score was 17 (± 5), and mean Childs-Pugh score was 8 (± 1). Survival, now at a mean of 38 (± 20) months remains 100%, with no cardiac or hepatic graft dysfunction or episodes of rejection. One hospital readmission was required for gastroenteritis at 15 months posttransplant. CONCLUSIONS: These results suggest that excellent outcomes can be achieved in this extremely sick cohort of patients, and add to the growing literature of perioperative management of CHLT recipients.
  The Annals of thoracic surgery 11/2012; · 3.74 Impact Factor
• Article: Living donor liver transplantation: ethical considerations.

  Charles M Miller, Martin L Smith, Teresa Diago Uso
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  ABSTRACT: Most solid-organ transplants performed in the Western world are from deceased donors. In the last decade, deceased donation rates have reached a plateau as the number of patients with end-stage organ disease has steadily increased, resulting in a large discrepancy between organ supply and demand. Living donor transplantation is one way to decrease this discrepancy. However, living donation is not universally accepted. For instance, living donation rates vary geographically (eg, living donation is more accepted in Asia than in the Western world) and depend on the organ donated (eg, kidney versus liver donation). In this article we will review the ethical principles guiding living donor liver transplantation, with emphasis on justification and safeguards that support the practice of adult-to-adult living donor liver transplantation, the most clinically and ethically challenging type of living organ donation. Our ethical justification will include a presentation of triangular or tripartite equipoise, a framework that aims to balance donor safety, expected recipient outcomes, and need.
  Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine 03/2012; 79(2):214-22. · 2.00 Impact Factor
• Article: Outcomes of simultaneous liver transplantation and elective cardiac surgical procedures.

  Brian Lima, Edward R Nowicki, Charles M Miller, Koji Hashimoto, Nicholas G Smedira, Gonzalo V Gonzalez-Stawinski
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  ABSTRACT: Many centers are reticent to list patients for liver transplantation until coexistent cardiac disease is surgically corrected. Previous studies have documented considerable morbidity and mortality in liver failure patients undergoing cardiac operations. This study examined whether elective cardiac operations at the time of hepatic transplantation would yield enhanced outcomes. Between July 1999 and June 2010, 10 patients underwent simultaneous liver transplantation and elective cardiac operations at a single institution. Postoperative outcomes were analyzed using a prospectively maintained database. The 10 patients were men (mean age, 59.8 ± 8.3 years): 7 were in Child-Pugh class B and 3 were in class C. Mean Model for End-Stage Liver Disease score was 17.0 ± 5.8. Cardiac operations included coronary artery bypass grafting in 1, aortic valve replacement in 4, coronary artery bypass grafting and aortic valve replacement in 3, coronary artery bypass grafting and mitral valve repair in 1, and tricuspid valve repair in 1. In-hospital mortality was 20%. Mean postoperative length of stay was 23 ± 8 days. Actuarial survival at 3 years was 70%. Survival was modestly improved relative to that observed in previous studies of advanced liver failure patients undergoing heart operations without concomitant hepatic replacement. Moreover, the medium-term survival outcomes approach those documented with liver transplant alone. Further studies are warranted with this combined surgical strategy to determine if such an approach would be routinely preferable to staged repair of cardiac pathology and liver transplant.
  The Annals of thoracic surgery 09/2011; 92(5):1580-4. · 3.74 Impact Factor
• Article: Splenic artery embolization for the treatment of refractory ascites after liver transplantation.

  Cristiano Quintini, Giuseppe D'Amico, Chase Brown, Federico Aucejo, Koji Hashimoto, Dympna M Kelly, Bijan Eghtesad, Mark Sands, John J Fung, Charles M Miller
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  ABSTRACT: Refractory ascites (RA) is a challenging complication after orthotopic liver transplantation. Its treatment consists of the removal of the precipitating factors. When the etiology is unknown, supportive treatment can be attempted. In severe cases, transjugular intrahepatic portosystemic shunts, portocaval shunts, and liver retransplantation have been used with marginal results. Recently, splenic artery embolization (SAE) has been described as an effective procedure for reducing portal hyperperfusion in patients undergoing partial or whole liver transplantation. Here we describe our experience with SAE for the treatment of RA. Between June 2004 and June 2010, 6 patients underwent proximal SAE for RA. Intraoperative flow measurements, graft characteristics, embolization portal vein (PV) velocities before and after SAE, and spleen/liver volume ratios were collected and analyzed. The response to treatment was assessed with imaging (ultrasound/computed tomography) and on the basis of clinical outcomes (weight changes, diuretic requirements, and the time to ascites resolution). The PV velocity decreased significantly for each patient after the embolization (median = 66.5 cm/second before SAE and median = 27.5 cm/second after SAE, P < 0.01). All patients experienced a significant postprocedural weight loss (mean = 88.1 ± 28.4 kg before SAE and mean = 75.8 ± 28.4 kg after SAE, P < 0.01) and a dramatic decrease in their diuretic requirements. All but 1 of the patients experienced a complete resolution of ascites after a median time of 49.5 days (range = 12-295 days). No patient presented with postembolization complications. In conclusion, SAE was effective in reducing the PV velocity immediately after the procedure. Clinically, this translated into a dramatic weight loss, a reduction of diuretic use, and a resolution of ascites. SAE appears to be a safe and effective treatment for RA.
  Liver Transplantation 06/2011; 17(6):668-73. · 3.39 Impact Factor
• Article: Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients?

  Koji Hashimoto, Charles M Miller, Cristiano Quintini, Federico N Aucejo, Kenzo Hirose, Teresa Diago Uso, Loris Trenti, Dympna M Kelly, Charles G Winans, David P Vogt, Bijan Eghtesad, John J Fung
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  ABSTRACT: Blood flow to the liver is partly maintained by the hepatic arterial buffer response (HABR), which is an intrinsic autoregulatory mechanism. Temporary clamping of the portal vein (PV) results in augmentation in hepatic artery flow (augHAF). Portal hyperperfusion impairs HAF due to the HABR in liver transplantation (LT). The aim of this study is to examine the effect of the HABR on biliary anastomotic stricture (BAS). In 234 cadaveric whole LTs, PV flow (PVF), basal HAF, and augHAF were measured intra-operatively after allograft implantation. All recipients with a vascular complication were excluded. Buffer capacity (BC) was calculated as (augHAF - basal HAF)/PVF to quantify the HABR. Recipients were divided into 2 groups based on their BC: low BC (<0.074; n = 117) or high BC (> or =0.074; n = 117). Of the 234 recipients, 23 (9.8%) had early BAS (< or =60 days after LT) and 18 (7.7%) had late BAS (>60 days after LT). The incidence of late BAS and bile leakage was similar between the groups; however, the incidence of early BAS in the low BC group was greater than that in the high BC group (15% vs 5.1%; P = .0168). In the multivariate analysis, low BC (P = .0325) and bile leakage (P = .0002) were found to be independent risk factors affecting early BAS. Recipients with low BC who may have impaired HABR are at greater risk of early BAS after LT. Intraoperative measurements of blood flow help predict the risk of BAS.
  Surgery 03/2010; 148(3):582-8. · 3.10 Impact Factor
• Article: Side-to-side cavocavostomy with an endovascular stapler: Rescue technique for severe hepatic vein and/or inferior vena cava outflow obstruction after liver transplantation using the piggyback technique.

  Cristiano Quintini, Charles M Miller, Koji Hashimoto, Ding Philip, Teresa Diago Uso, Federico Aucejo, Dympna Kelly, Charles Winans, Bijan Eghtesad, David Vogt, John Fung
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  ABSTRACT: Venous outflow obstruction is a rare but potentially lethal complication after orthotopic liver transplantation (OLT) with the "piggyback" technique. Therapeutic options include angioplasty with or without stent placement, surgical reconstruction of the venous anastomosis, and retransplantation. Surgical options are technically very challenging and the outcomes discouraging. We describe here two cases of venous outflow obstruction in recipients of piggyback liver grafts, one involving both the vena cava and hepatic veins and the other affecting only hepatic vein outflow. Both patients were treated successfully with side-to-side cavo-cavostomy using an endovascular (endo-GIA) stapler. This novel technique is fast and effective in resolving the outflow obstruction.
  Liver Transplantation 02/2009; 15(1):49-53. · 3.39 Impact Factor
• Article: Aggressive surgical resection for hilar cholangiocarcinoma: is it justified? Audit of a single center's experience.

  Manousos M Konstadoulakis, Sasan Roayaie, Ilias P Gomatos, Daniel Labow, Maria-Isabell Fiel, Charles M Miller, Myron E Schwartz
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  ABSTRACT: The current study presents our experience with resectional surgery for patients with hilar cholangiocarcinoma (HC). Medical records of 73 HC patients who were referred to our department between 1988 and 2006 were reviewed. Resectability rate, surgical mortality, and factors contributing to survival were investigated. Resectional surgery was performed in 59 patients (80.8%), 51 of whom (86.4%) underwent major hepatic resection. Negative margins were obtained in 35 of 51 patients (68.6%) and were associated with right-sided hepatectomy (80% vs 20%, P = .049). In-hospital mortality and morbidity were 6.8% and 25.4%, respectively. One-, 3- and 5-year survival rates after liver resection were 86%, 48.9%, and 34.9%, respectively. Histologic differentiation, left-sided hepatectomy, and inferior vena cava resection independently predicted survival. Patients undergoing R1 hepatectomy had significantly improved 5-year survival rates compared with patients who were unresectable (P <.01). Major hepatic resections with concomitant vascular resection and reconstruction, when needed, are justified for patients with Bismuth type III and IV hilar cholangiocarcinoma with negative nodes. Reluctance to incorporate segments V and/or VIII into a left lobectomy often results in tumor-positive margins and unfavorable prognosis. Resections for hilar lesions less than stage IVB, even when resulting in microscopically positive margins, confer prolonged survival compared with untreated patients. The results are further improved for patients with well-differentiated HC.
  American journal of surgery 09/2008; 196(2):160-9. · 2.36 Impact Factor
• Article: Split liver transplantation: Will it ever yield grafts for two adults?

  Cristiano Quintini, Federico Aucejo, Charles M Miller
  Liver Transplantation 08/2008; 14(7):919-22. · 3.39 Impact Factor
• Article: Ethical dimensions of living donation: experience with living liver donation.

  Charles M Miller
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  ABSTRACT: Whereas distributive justice is the most important principle in most aspects of transplantation and the allocation of scarce resources, it is far less of a central principle in directed living liver donation. For living donation, the ethical principals include (1) respect for the donor's autonomy through full, voluntary, informed consent; (2) beneficence; and (3) nonmaleficence. But how do we put these principles into practice? Practical decision making in living liver donation involves 3 fundamental ethical dimensions: (1) need, (2) probability of donor safety, and (3) the chance for good short- and long-term recipient outcomes. These same dimensions exist everywhere, but the size and shape of the "triangle" can vary greatly depending on societal beliefs. Ultimately, the proper balance of ethical equipoise is affected by the dynamics of these 3 dimensions.
  Transplantation reviews (Orlando, Fla.) 07/2008; 22(3):206-9.
• Article: "Splenic artery steal syndrome" is a misnomer: the cause is portal hyperperfusion, not arterial siphon.

  Cristiano Quintini, Kenzo Hirose, Koji Hashimoto, Teresa Diago, Federico Aucejo, Bijan Eghtesad, David Vogt, Gregory Pierce, Mark Baker, Dympna Kelly, Charles M Miller
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  ABSTRACT: Splenic artery embolization (SAE) improves hepatic artery (HA) flow in liver transplant (OLT) recipients with so-called splenic artery steal syndrome. We propose that SAE actually improves HA flow by reducing the HA buffer response (HABR). Patient 1: On postoperative day (POD) 1, Doppler ultrasonography (US) showed patent vasculature with HA resistive index (RI) of 0.8. On POD 4, aminotransferases rose dramatically; his RI was 1.0 with no diastolic flow. Octreotide was begun, but on POD 5 US showed reverse diastolic HA flow with no signal in distal HA branches. After SAE, US showed markedly improved flow, RI was 0.6, diastolic flow in the main artery, and complete visualization of all distal branches. By POD 6, liver function had normalized. RI in the main HA is 0.76 at 2 months postsurgery. Patient 2: On POD 1, RI was 1.0. US showed worsening intrahepatic signal, with no signal in the intrahepatic branches and reversed diastolic flow despite good graft function. On POD 7, SAE improved the intrahepatic waveform and RI (from 1.0 to 0.72). Patient 3: Intraoperative reverse diastolic arterial flow persisted on PODs 1, 2, and 3, with progressive loss of US signal in peripheral HA branches. SAE on POD 4 improved the RI (0.86) and peripheral arterial branch signals. Patient 4: US on POD 1 showed good HA flow with a normal RI (0.7). A sudden waveform change on POD 2 with increasing RI (0.83) prompted SAE, after which the wave form normalized, with reconstitution of a normal diastolic flow (RI 0.68). In conclusion, these reports confirm the usefulness of SAE for poor HA flow but suggest that inflow steal was not the problem. Rather than producing an increase in arterial inflow, SAE worked by reducing portal flow and HABR, thereby reducing end-organ outflow resistance. Evidence of this effect is the marked reduction of the RI after the SAE to 0.6, 0.72, 0.86, and 0.68, in patients 1-4, respectively. SAE reduces excessive portal vein flow and thereby ameliorates an overactive HABR that can cause graft dysfunction and ultimately HA thrombosis.
  Liver Transplantation 04/2008; 14(3):374-9. · 3.39 Impact Factor
• Article: Fifteen-year, single-center experience with the surgical management of intrahepatic cholangiocarcinoma: operative results and long-term outcome.

  Manousos M Konstadoulakis, Sasan Roayaie, Ilias P Gomatos, Daniel Labow, Maria-Isabell Fiel, Charles M Miller, Myron E Schwartz
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  ABSTRACT: Limited data exist regarding the role of extended liver resection for the management of intrahepatic cholangiocarcinoma (ICC), most of which derive from small single-center or larger multicenter series. In the current report, we present our experience with the surgical management of ICC, analyze operative results, and investigate prognostic factors in resected patients. A total of 72 patients underwent operative exploration for ICC between 1991 and 2005; 54 patients were resected, and 18 patients were deemed unresectable based on intraoperative findings. Demographics, pathology, anatomic characteristics, operative results, and survival were analyzed. The resectability rate was 71%, with negative margins achieved in 78% of the resected patients. Extended liver resections were performed in 24 (44%) of the 72 patients. Perioperative mortality after resection was 7%, with 11% morbidity. The 1-, 3- and 5-year survival rates after resection were 80%, 49% and 25%, respectively, and were significantly greater than for patients with unresectable disease (P < .001). R1 liver resections conferred increased 5-year survival compared with patients deemed unresectable (P = .03). None of the factors evaluated proved to be independent prognostic factors on multivariate analysis. R0 resection of ICC provides the best chance for prolonged survival, whereas R1 resection appears to be superior to nonoperative treatment. Declining operative mortality as a result of improved intraoperative and perioperative care justifies the performance of extended liver resections in these patients, although benefit has to be evaluated with respect to nodal involvement.
  Surgery 03/2008; 143(3):366-74. · 3.10 Impact Factor
• Article: Successful liver transplantation using a severely injured graft.

  Fabrizio Di Benedetto, Cristiano Quintini, Nicola De Ruvo, Michele Masetti, Nicola Cautero, Augusto Lauro, Teresa Diago Uso, Gianpiero Guerrini, Stefano Di Sandro, Charles M Miller, Antonio D Pinna, Giorgio E Gerunda
  The Journal of trauma 08/2007; 63(1):217-20. · 2.48 Impact Factor
• Article: Isolated right hepatic vein obstruction after piggyback liver transplantation.

  Federico Aucejo, Charles Winans, J Michael Henderson, David Vogt, Bijan Eghtesad, John J Fung, Mark Sands, Charles M Miller
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  ABSTRACT: The "piggyback" technique for liver transplantation has gained worldwide acceptance. Still, complications such as outflow obstruction have been observed, usually attributable to technical errors such as small-caliber anastomosis of the suprahepatic vena cava, twisting, or kinking. Iatrogenic Budd-Chiari syndrome after piggyback liver transplantation has been reported as a consequence of obstruction involving the entire anastomosis (usually the 3 hepatic veins). Here we describe technical issues, clinical presentation, diagnosis, and treatment of 3 cases in which outflow obstruction affected only the right hepatic vein. In conclusion, all 3 patients developed recurrent ascites requiring angioplasty and/or stent placement across the right hepatic vein to alleviate the symptoms.
  Liver Transplantation 06/2006; 12(5):808-12. · 3.39 Impact Factor
• Article: Expanding the donor pool: safe transplantation of a cadaveric liver allograft with a 10 cm cavernous hemangioma--a case report.

  Federico N Aucejo, Werner Andrade Ortiz, Dympna Kelly, Charles Winans, David Vogt, Bijan Eghtesad, John J Fung, Charles M Miller
  Liver Transplantation 05/2006; 12(4):687-9. · 3.39 Impact Factor
• Article: Live donor liver transplantation.

  Sander Florman, Charles M Miller
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  ABSTRACT: With ever-increasing demand for liver replacement, supply of organs is the limiting factor and a significant number of patients die while waiting. Live donor liver transplantation has emerged as an important option for many patients, particularly small pediatric patients and those adults that are disadvantaged by the current deceased donor allocation system. Ideally there would be no need to subject perfectly healthy people in the prime of their lives to a potentially life-threatening operation to procure transplantable organs. Donor safety is imperative and cannot be compromised regardless of the implication for the intended recipient. The evolution of split liver transplantation is the basis upon which live donor transplantation has become possible. The live donor procedures are considerably more complex than whole organ decreased donor transplantation and there are unique considerations involved in the assessment of any specific recipient and donor. Donor selection and evaluation have become highly specialized. The critical issue of size matching is determined by both the actual size of the donor graft and the recipient as well as the degree of recipient portal hypertension. The outcomes after live donor liver transplantation have been at least comparable to those of deceased donor transplantation. Nevertheless, all efforts should be made to improve deceased donor donation so as to minimize the need for live donors. Transplant physicians, particularly surgeons, must take responsibility for regulating and overseeing these procedures.
  Liver Transplantation 05/2006; 12(4):499-510. · 3.39 Impact Factor
• Article: Extended follow-up of extended right lobe living donors: when is enough enough?

  Bijan Eghtesad, Charles M Miller
  Liver Transplantation 03/2006; 12(2):199-200. · 3.39 Impact Factor
• Article: Hepatocellular proliferation and changes in microarchitecture of right lobe allografts in adult transplant recipients.

  Ruoqing Huang, Thomas D Schiano, May Jennifer Amolat, Charles M Miller, Swan N Thung, Romil Saxena
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  ABSTRACT: Imaging studies show complete restoration of liver volume in adult recipients of right lobe allografts within 2-3 weeks of living donor transplantation (LDLT). However, it is not known if this growth is associated with restoration of hepatic microarchitecture. We compared 21 biopsies without significant pathology from LDLT recipients with 23 biopsies from adult recipients of cadaveric donor liver transplantation (CDLT) performed within 3 months of transplantation. The difference in the number of portal tracts per cm was statistically significant (P < .0001) between CDLT (9.08 +/- 1.74) and LDLT recipients within 3 months (6.26 +/- 1.62), as well as after 3 months following transplantation (6.56 +/- 1.44). The coefficient of correlation between length of biopsy specimens and the number of portal tracts in these 3 groups was .94, .93, and .85, respectively. Proliferative activity demonstrated by immunohistochemical staining for MIB-1 was seen predominantly in hepatocytes in both groups; bile ducts only occasionally stained positive. The difference between labeling indices of hepatocytes was statistically significant (P = .00056) between CDLT and LDLT recipients within 3 months of transplantation (.82 +/- .63 and 4.53 +/- 3.72), and between LDLT recipients within 3 weeks and after 3 weeks of transplantation (5.97 +/- 3.78 and 1.80 +/- 1.37, P = .0074). In conclusion, restoration of liver volume following LDLT occurs by proliferation of hepatocytes in the immediate posttransplant period. There is a decrease in number of portal tracts in these volume-restored allografts. Volume restoration is therefore, not accompanied by restoration of hepatic microarchitecture.
  Liver Transplantation 12/2004; 10(12):1461-7. · 3.39 Impact Factor
• Article: Living donor liver transplantation with left liver graft.

  Michele Masetti, Antonio Siniscalchi, Lesley De Pietri, Vanessa Braglia, Fabrizio Benedetto, Nicola Di Cautero, Bruno Begliomini, Antonio Romano, Charles M Miller, Giovanni Ramacciato, Antonio D Pinna
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  ABSTRACT: Small-for-size syndrome in LDLT is associated with graft exposure to excessive portal perfusion. Prevention of graft overperfusion in LDLT can be achieved through intraoperative modulation of portal graft inflow. We report a successful LDLT utilising the left lobe with a GV/SLV of only 20%. A 43 year-old patient underwent to LDLT at our institution. During the anhepatic phase a porto-systemic shunt utilizing an interposition vein graft anastomosed between the right portal branch and the right hepatic vein was performed. After graft reperfusion splenectomy was also performed. Portal vein pressure, portal vein flow and hepatic artery flow were recorded. A decrease of portal vein pressure and flow was achieved, and the shunt was left in place. The recipient post-operative course was characterized by good graft function. Small-for-size syndrome by graft overperfusion can be successfully prevented by utilizing inflow modulation of the transplanted graft. This strategy can permit the use of left lobe in adult-to-adult living donor liver transplantation.
  American Journal of Transplantation 11/2004; 4(10):1713-6. · 6.39 Impact Factor
• Article: Increased prothrombin time and platelet counts in living donor right hepatectomy: implications for epidural anesthesia.

  Antonio Siniscalchi, Bruno Begliomini, Lesley De Pietri, Vanessa Braglia, Matteo Gazzi, Michele Masetti, Fabrizio Di Benedetto, Antonio D Pinna, Charles M Miller, Alberto Pasetto
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  ABSTRACT: The risks and benefits of adult-to-adult living donor liver transplantation need to be carefully evaluated. Anesthetic management includes postoperative epidural pain relief; however, even patients with a normal preoperative coagulation profile may suffer transient postoperative coagulation derangement. This study explores the possible causes of postoperative coagulation derangement after donor hepatectomy and the possible implications on epidural analgesia. Thirty donors, American Society of Anesthesiology I, with no history of liver disease were considered suitable for the study. A thoracic epidural catheter was inserted before induction and removed when laboratory values were as follows: prothrombin time (PT) > 60%, activated partial thromboplastin time < 1.24 (sec), and platelet count > 100,000 mmf pound sterling (mm3). Standard blood tests were evaluated before surgery, on admission to the recovery room, and daily until postoperative day (POD) 5. The volumes of blood loss and of intraoperative fluids administered were recorded. Coagulation abnormalities observed immediately after surgery may be related mostly to blood loss and to the diluting effect of the intraoperative infused fluids, although the extent of the resection appears to be the most important factor in the extension of the PT observed from POD 1. In conclusion, significant alterations in PT and platelet values were observed in our patients who underwent uncomplicated major liver resection for living donor liver transplantation. Because the potential benefits of epidural analgesia for liver resection are undefined according to available data, additional prospective randomized studies comparing the effectiveness and safety of intravenous versus epidural analgesia in this patient population should be performed.
  Liver Transplantation 09/2004; 10(9):1144-9. · 3.39 Impact Factor