Increase in Operating Room Visits After Liver Transplants

To reduce operating room revisits it is advisable not to match an obese liver transplant recipient with an alcoholic donor.

Highlights:

There is a higher incidence of return to the operating room in obese patients, with an increased risk of coagulopathy, who receive a liver from an alcoholic patient
Understanding this can help clinicians to plan better for their patients during and after surgery

A few liver transplant patients have been found to have a higher risk of requiring a second surgery within 48 hours, revealed a new study.

Although a liver transplant is a necessary and life-saving procedure, there is a significant incidence of postoperative complications. Within 48 hours following their initial surgery, about to one in four liver transplant patients will return to the operating room (R-OR).

Liver Transplantation - Facts, Contraindications, Procedure, Follow up, Complications & Prognosis
Liver transplantation is a surgical option for the treatment of liver failure where the diseased liver is replaced with a healthy one.

‘The return to the operating room rate for liver transplant patients with a BMI greater than 30 with an increased risk of coagulopathy and who were matched with livers from alcoholic donors was 100%.’

The risk indicators can suggest a more probable R-OR, enabling patients, medical professionals and family members to more thoroughly prepare for this eventuality.

The R-OR rate for liver transplant patients with a body mass index (BMI) greater than 30 and who were matched with livers from donors with a history of heavy alcohol use was 80%. The trio of obesity, excessive alcohol consumption and coagulopathy- a diminished capacity to produce blood clots and stop bleeding- was also linked to a 100% R-OR.

“What this tells us is that, if possible, we should try to not match a recipient with obesity with a donor who has a history of alcohol use. If we can’t minimize the risk, then we’ll try to really manage the recipient’s coagulopathy- manage it more aggressively than if they didn’t have those risk factors,” said the principal investigator, Hunter Moore, MD, PhD.

Adult to Child Living Donor Liver Transplantation
Adult to child liver transplantation refers to removing a small segment of liver from an adult and transplanting this segment into a child.

Risks of Going Back to Operating Room

The Colorado Multi-Institutional Review Board study used liver transplant recipients who had signed up to collect blood samples prospectively during the first day after surgery.

“We noticed a much higher rate of return to the operating room in certain populations, most patients with obesity,” Moore says. “We wanted to know if obesity was a real risk factor and what additional kind of factors was associated with it, and to see if any of those were modifiable to reduce the risk of needing a second operation.”

Common Types of Liver diseases leading to Liver Transplantation
Liver disease that ends in liver failure (end stage liver disease), disrupting several important metabolic functions needs liver transplant for patient survival.

A hematoma, or pool of largely clotted blood, forming around the new liver, is one of the main reasons liver transplant recipients need a second surgery.

“During the transplant operation, the liver is a little slow and takes a while to wake up, which results in slow coagulopathic bleeding which causes blood to coagulate around it. It’s not very harmful, but when there’s a lot of it, it puts pressure on the liver and can slow its recovery," said Moore.

Living Donor Liver Transplant: What Are the Risks? - Causes, Symptoms, Diagnosis, Treatment
The risk of dying as a result of a living donor liver segment removal is between 0.2-2.0%. The risk of morbidity is anywhere between 1.3% (in highly experienced centers) to 60%.

Researchers studied data from 160 liver transplant recipients. They found that 80% of patients with a BMI of 30 or higher and who received a liver from a donor who drank two or more servings of alcohol per day returned to the operating room within 48 hours of initial surgery. Every patient with both the risk factors and an additional risk factor of coagulopathy did so within 48 hours.

Risk Factors of a Liver Transplant

“The issues with returning to the OR are not really related to any detriment to survival and function,” Moore says. “But because it happens with one in four liver transplant patients, if you can reduce that number, it’s much better for patients’ recovery and it reduces the burden on OR staff.”

The findings will help patients, their caregivers and surgical teams to plan for R-OR or possibly reduce risk before surgery.

“When I see my pre-evaluation liver transplant patients if they have a BMI that’s 30 or higher, I let them know that if they can work toward getting their BMI below 30 it may reduce their risks of returning to the OR and improve their outcomes,” Moore says. “Another way to mitigate risk is to fix coagulation in the OR aggressively. We can pre-emptively transfuse them with more hemostatic blood products if we know their coagulopathy risk before surgery.”

Risk factors more closely related to donors and donated livers will be the subject of future studies. Moore has started researching the enzyme transaminase levels in donor's livers, possibly linked to a higher risk of fluid accumulation in the abdomen after transplant surgery.

“One of our main goals is to understand risk factors so that we can anticipate outcomes and better plan for them during and after surgery,” Moore says.

Source-Medindia