Anesthesia for Hepatico-Pancreatic-Biliary Surgery and Transplantation

Contents
Part I Anatomy and Physiology of the Liver
Chapter 1 Anatomy of Hepato-Pancreato-Biliary Surgery and Liver Transplantation
	Introduction
	Arteries
	Veins
	Anatomical Variations
		Arteries
	Veins
	Portosystemic Shunts
	Liver
	Biliary Tree
	Pancreas
	References
Chapter 2 Anatomy and Physiology of the Liver
	Introduction
	Macroscopic Anatomy
	Structural Anatomy
	Functional Anatomy
	Blood Supply to the Liver
		Portal Vein
		Hepatic Artery
		Vascular Segments
	Drainage from the Liver
		Venous Drainage
		Bile Drainage
		Lymphatic Drainage
	Nerve Supply of the Liver
	Microscopic Anatomy
	Liver Lobules
	Liver Acinus
	Cells Within the Liver
		Hepatocytes
		Sinusoidal Cells
	Liver Function
	Nutritional Modulation by the Liver
		Metabolism of Carbohydrates
		Lactate Metabolism
		Protein Synthesis and Metabolism
		Inflammatory Proteins and Protease Inhibitors
		Synthesis and Regulation of Coagulation Factors
		Amino Acid Metabolism and Nitrogen Balance
		Lipid Metabolism
		Ketone Body Production
		Synthesis of Bile
	Metabolism and Clearance of Drugs
		Phase 1
		Oxidation Reactions
		Reduction
		Hydrolysis
		Phase 2
		Hepatic Clearance of Drugs
		Age and Nutritional Status
	Storage and Homeostasis of Iron
	Storage and Regulation of Vitamins
		Vitamin D Metabolism
	Regulation of Hormones
	Summary
	References
Part II Liver Transplantation
Chapter 3 Pathophysiology Behind Cardiopulmonary Complications of Cirrhosis and Portal Hypertension
	Abbreviations
	Introduction
	Pathophysiology of Haemodynamic Alterations in Cirrhosis
		Abnormal Haemodynamic Homeostasis
	Cardiovascular Complications of Cirrhosis
		Hyperdynamic Circulation
	Cirrhotic Cardiomyopathy
		Pathophysiology
		The Cirrhotic Heart
		Coronary Artery Disease
		Definition of Cirrhotic Cardiomyopathy (CCM)
		Systolic Dysfunction
		Diastolic Dysfunction
		Prolonged QT Interval
		Treatment and Evaluation of Cardiac Function in Liver Disease
	Respiratory Complications in Patients with Liver Disease
	Hepatopulmonary Syndrome
		Pathophysiology of the Hepatopulmonary Syndrome
		Diagnosis of the Hepatopulmonary Syndrome
		Prognosis
		Intrapulmonary Vascular Dilatation
		Treatment of Hepatopulmonary Syndrome
			Porto-Pulmonary Hypertension
		Clinical Signs and Diagnosis
		Pathophysiology of Porto-Pulmonary Hypertension
		Treatment of Portopulmonary Hypertension
			Hepatic Hydrothorax
	Conclusive Remarks
	References
Chapter 4 Liver Transplantation: Graft Variables
	Graft Types
		Donor After Brain Stem Death (DBD)
		Donor After Cardiac Death (DCD)
		Partial Liver Grafts (Reduced, Split and Living Related)
		Auxiliary Partial Liver Transplantation (APOLT)
		Domino
	Ischemic Times of Note
		Cold Ischemic Time
		Warm Ischemic Time (WIT)
	The Marginal Graft
	Donor Recipient Matching
	Liver Preservation
		Cold Static Storage (CSS)
		Machine Perfusion: Normothermic/Hypothermic
	References
Chapter 5 Surgical Aspects of Liver Transplantation
	Introduction
	Basic Liver Pathophysiology and Haemodynamics
	Cadaveric Liver Graft Anatomy
	Liver Tranplantation
	Temporary Porto-Caval Shunt (TPCS)
	Piggyback Liver Transplantion–Types of Outflow Anastomosis
	Technical Considerations
	Post-transplant Complications
	Vascular Complications
	References
Chapter 6 Pre-assessment for Hepato-Pancreato-Biliary and Liver Transplant Surgery
	Preoperative Assessment of Liver Transplant Candidates
	Assessment of the Severity of ESLD
		Child-Turcotte-Pugh (CTP) Classification
		Model for End-Stage Liver Disease (MELD) Score
		Modifications of the MELD Score
		Future Improvements in Severity Scoring
	Neurological Disorders of ESLD
		Hepatic Encephalopathy
		Cerebral Edema
	Cardiovascular Diseases in ESLD
		Hyperdynamic Circulation and Cirrhotic Cardiomyopathy
		Coronary Artery Disease
		Heart Failure
		Valvular Diseases
		Infiltrative Cardiomyopathies
		Atrial Fibrillation
		Comprehensive Assessment of Cardiovascular Risk in Liver Transplant Candidates
	Pulmonary Disorders of ESLD
		Hepatopulmonary Syndrome
		Portopulmonary Hypertension
	Gastrointestinal Disorders of ESLD
		Gastrointestinal Hemorrhage
		Ascites
	Renal Disorders of ESLD
		Hepatorenal Syndrome (HRS)
		Acute Kidney Injury (AKI)
	Coagulation Disorders of ESLD
		Pathophysiology
		Diagnostic Laboratory Tests
	Metabolic Disorders of ESLD
		Obesity
		Non-alcoholic Fatty Liver Disease (NAFLD)
	Malnutrition, Sarcopenia and Frailty in ESLD
		Malnutrition
		Sarcopenia
		Frailty
	Substance Abuse in ESLD
		Alcohol Abuse
		Tobacco Abuse
		Illicit Drug Abuse
	Preoperative Assessment of Patients for Non-transplant, Hepatico-Pancreatic-Biliary Surgery
		Assessment of Cardiovascular Status
		Assessment of Liver Function
	References
Chapter 7 The Role of Cardiopulmonary Exercise Testing (CPET) in the Preoperative Assessment of Patients for Hepatico-Pancreatic-Biliary (HPB) Surgery and Liver Transplantation (LT)
	Introduction
	The Physiology of Exercise
	Conducting the Cardiopulmonary Exercise Test
	Nine Panel Plot and Interpretation
	Evidence Base for Risk Prediction of Mortality and Morbidity
	Pre-operative Optimisation
	Post-operative Resource Allocation
	Interpreting CPET in Patients with Liver Failure Awaiting LT
	Interpreting CPET in HPB Patients
	Practical Use of CPET at King’s College Hospital
	Summary
	References
Chapter 8 Anaesthesia for Liver Transplantation
	Introduction
	Anaesthetic Management
	Induction and Maintenance of Anaesthesia
		Intraoperative Fluids Administration Management
	Phases of LT
	Neo-Hepatic Phase
	References
Chapter 9 How Does the Aetiology of Primary Liver Disease Affect Anaesthesia for Liver Transplantation
	Introduction
	Acute Liver Failure
	Clinical Picture of ALF
	Treatment of ALF
	Complications
	Recommendations for Anaesthesia in Patients with Acute Liver Disease
	Viral Hepatitis
	Alcohol Related Liver Disease
	Multi-organ Failure in Alcohol Related Liver Disease
	Non-alcoholic Fatty Liver Disease
	Autoimmune Hepatitis
	Cholestatic Disorders
	ɑ1-Antitrysin Deficiency
	Wilson’s Disease
	Haemochromatosis
	Vascular Conditions
	Polycystic Liver Disease
	Cystic Fibrosis
	Pregnancy-Related Liver Disease
	References
Chapter 10 Haemodynamic Monitoring During Liver Transplant Surgery
	Introduction
	Invasive Blood Pressure (IBP) Measurement
	Central Venous Pressure
	Pulmonary Artery Catheter (PAC)
	Transoesophageal Echocardiography
		Assessment of Ventricular Function
		Assessment of Volume
	Pulse Contour Continuous Cardiac Output Devices
		PiCCO System Monitoring During LT
		Initial Transaortic (Transpulmonary) Thermodilution Bolus
		LiDCO Haemodynamic Monitoring During LT
		LiDCO Plus Ltd., Cambridge, UK
		FloTrac/Vigileo Haemodynamic Monitoring During LT
	References
Chapter 11 Point of Care Viscoelastic Haemostasis Monitoring During Liver Transplant Surgery
	Introduction
	‘What Laboratory Tests Should We Use to Guide Coagulation and Transfusion Management During Liver Transplantation?’
	Viscoelastic Tests
		Thromboelastography
		Thromboelastometry
	‘How Do We Use POC Laboratory Tests to Support Coagulation and Transfusion Management During Liver Transplantation?’
	‘Can POC Laboratory Testing Improve Patient Outcomes and Reduces Costs During LT?’
	Conclusion
	References
Chapter 12 How to Reduce Bleeding and Blood Transfusion During Liver Transplantation
	How to Decrease Bleeding and the Need for Transfusion
		Management of Coagulopathy
		Monitoring
		Transfusion Threshold
		Physical Measures
	Conclusion
	References
Chapter 13 Fast Tracking in a Liver Transplant Programme
	Introduction
	History
	Anesthesia for Fast Track
	Implementing a Fast Track Program—The Mayo Clinic Florida Model
	References
Chapter 14 Acute Kidney Injury in Hepatico-Pancreatic-Biliary Surgery and Liver Transplantation
	Abbreviations
	Introduction
	Definitions
	Biomarker for Early Detection and Guidance for Management
	Risk Factors of Acute Kidney Injury After HPB Surgery
	Risk Factors of AKI After Liver Transplantation
		Recipient and Donor Characteristics
		Surgical and Intraoperative Factors
		Postoperative Factors
	Strategies to Prevent AKI After HPB Surgery
	Strategies to Prevent AKI After Liver Transplantation
		Preoperative Preventions
		Intraoperative Prevention and Management
		Postoperative Management of Immunosuppressive Agent
	Summary
	References
Chapter 15 Use of Extracorporeal Membrane Oxygenation During Liver Transplantation
	Introduction
	Principles of ECMO
	Circuit Configuration
	Indications and Contraindications for ECMO in LT Patients
	ECMO and Liver Transplant
	Coagulopathy
	Vascular Anastomosis
	Conclusions
	References
Chapter 16 Liver Preservation with Extracorporeal Perfusion
	Abbreviations
	Donor Liver Preservation Injury
	Organ Preservation Modalities
		Ex Situ Machine Perfusion
			Normothermic Oxygenated Machine Perfusion
			Hypothermic Oxygenated Machine Perfusion
		In Situ Machine Perfusion
	Conclusions
	References
Chapter 17 Veno-Venous Bypass in Liver Transplantation
	Introduction and Brief History
		Principle of VVB in LT Surgery
		Cannulation Technique
		Haemodynamic Effects of IVC and Portal Vein Clamp, and Role of VVB
		Effects of VVB on Renal Function
		Reasons for the Gradual Decrease in the Use of VVB
		Complications
		Clinical Outcomes
		Does the Surgical Approach Influence VVB Use?
		Is Routine VVB Use Still Necessary?
	References
Part III Liver Resection
Chapter 18 Biology of Liver Tumors and Outcomes of Liver Surgery
	Introduction
	Liver Malignancies
	Primary Liver Tumors
		Hepatocellular Carcinoma (HCC)
		Cholangiocarcinoma (CCA)
	Metastatic Liver Tumors
		Colorectal Liver Metastases (CRLM)
		Neuroendocrine Liver Metastases (NLMs)
		Non-colorectal, Non-neuroendocrine Liver Metastases
	References
Chapter 19 Anaesthesia for Live Donor Hepatectomy
	Donation Criteria and Pre-assessment
	Risk of Thromboembolism in Donors
	Body Weight and Obesity
	Evaluation of Graft and Remnant Donor Liver Volume
	Anaesthetic Management
	Intraoperative Monitoring
	Other Alternatives to CVP Monitoring
	Postoperative Pain Management
	Intensive Care Unit Management for Donors
	Donor Morbidity and Mortality
	Laparoscopic Live Donor Hepatotomy
	References
Chapter 20 Strategies for Low Central Venous Pressure in Liver Resection Surgery
	Rationale for Low Central Venous Pressure Anaesthesia for Liver Resection
	Strategies for Achieving Low CVP
	Fluid Management
	Pharmacological
	Thoracic Epidural
	Physical Manoeuvres
	Surgical Strategies
	Laparoscopic Liver Resection Surgery and Low CVP
	Safety of Low CVP Anaesthesia in Liver Resection
	Low CVP Anaesthesia Without CVP Monitoring?
	Summary
	References
Chapter 21 Enhanced Recovery After HPB Surgery
	Introduction
	Improvements in Perioperative Care
	Liver Surgery
	Pancreatic Surgery
	ERAS
	The ERAS Society (http://www.erassociety.org)
	ERAS and Liver Surgery
	ERAS and Pancreatic Surgery
	Future Developments
	Areas of Controversy
	Conclusion
	References
Chapter 22 Postoperative Analgesia in Liver Resection Surgery
	Introduction
	Basic Principles of Postoperative Analgesia
	Simple Analgesics
		Paracetamol
	NSAIDs
	Opioids
	IV Lidocaine
	Ketamine
	Regional Anaesthesia
		Safety
	Coagulopathy
	Epidural Anaesthesia
	Intrathecal Opioids
	Transversus Abdominis Plane Block and Quadratus Lumborum Blocks
	Transversus Abdominis Plane Catheter
	Erector Spinae Plane Blocks
	Rectus Sheath Catheter
	Wound Catheter
	Conclusion
	References
Part IV Pancreas
Chapter 23 Surgical Aspects of Hepato-Pancreato-Biliary Surgery
	Introduction
	Liver Surgery
	Indications of Liver Surgery and Outcomes
	Primary Liver Cancers
	Cholangiocarcinoma (CCA)
	Hepatocellular Carcinoma (HCC)
	Metastatic Liver Disease
	Gallbladder Cancer (GBC)
	Types of Liver Resection
	The Liver Resection
	Extended Liver Resections
	Post Hepatectomy Liver Failure (PHLF) and Small-for-Size Syndrome (SFSS)
	Pancreatic Surgery
	Pancreatic Surgery for Tumors Located in the Head of the Pancreas
	Distal Pancreatectomy and Splenectomy
	Total Pancreatectomy
	Biliary Surgery
	References
Chapter 24 Perioperative Anaesthetic Considerations for the Whipple Procedure and Other Pancreatic Surgeries
	Pancreatic Surgery
		Introduction
		Anatomy and Physiology
		Pancreatic Conditions Requiring Surgery
	Neoplasms
		Adenocarcinoma
			Epidemiology
		Clinical Features
		Management
		Intraductal Papillary Mucinous Neoplasm (IPMN)
		Pancreatic Neuroendocrine Tumours (PNETS)
			Epidemiology
		Clinical Features
		Management
	Pancreatitis
		Acute Pancreatitis
		Chronic Pancreatitis
	Emergency Surgery
		Trauma
	Surgical Techniques
		Resections
			Pancreaticoduodenectomy—The Whipple Procedure
		Pylorus–Preserving Pancreaticoduodenectomy
		Distal Pancreatectomy
		Central Pancreatectomy
		Total Pancreatectomy
		Enucleation
		Debridement
		Lateral Pancreato-Jejunostomy (LPJ) and Frey Procedure
		Laparoscopic Surgery
	Perioperative Management
		Preoperative
		Assessment
		Risk Scoring
		Investigations
		Cardiovascular Risk Assessment
		Functional Capacity and Frailty
	Optimisation
		Enhanced Recovery After Surgery (ERAS)
		Anaemia
		Nutrition
		Optimisation of Co-morbidities
		Exercise Prehabilitation
	Intraoperative Strategies
		Analgesia
		Goal Directed Fluid Therapy (GDT)
		Ventilation
		Prevention of Infection
		Other Considerations
		Specific Considerations for PNETs
	Postoperative Strategies
	Postoperative Complications
		Pancreatic Fistula
		Delayed Gastric Emptying
		Haemorrhage
		Exocrine Insufficiency
		Management of Diabetes
	Summary
	References
Chapter 25 Anaesthetic Management for Patients Undergoing Pancreas Transplantation
	Abbreviations
	Introduction
	Indications and Types of Pancreatic Transplantation
	Indication of Patients for Pancreas and Kidney Transplantation
	Preoperative Evaluation
		Cardiac Testing for Pancreas with/without Kidney Transplantation
		Evaluation of Other Systems
	Pre-anaesthetic Management
	Surgical Procedure
		Pancreatic Graft Implant
	Kidney Graft Implant
	Anaesthesia and Intraoperative Management
		Patient Position and General Care
		Anaesthetic Agents
		Invasive Lines
		Haemodynamic Monitoring
		Anaesthetic Management of Blood Sugars and Metabolic Abnormalities During Surgery
	Metabolic Abnormalities
		Fluids in Pancreas Transplant Surgery
		Postoperative Care
	Anaesthetic Management of Islet Transplantation (ITx) Patients
	Complications and Outcomes of PTx
	Complications Following ITx
	Conclusions
	References
Part V Paediatric
Chapter 26 Anaesthesia for Paediatric HPB Surgery
	Introduction
	Kasai Portoenterostomy for Biliary Atresia
	Choledochal Cyst Resections and Other Hepatico-Entero Anastomosis Surgeries
	Liver Tumour Resection
	Anaesthesia for Complex HPB Procedures
	Anaesthesia for Vascular Radiological Procedures
	Anaesthesia for Vascular Surgical Procedures
	Anaesthesia for Paediatric Pancreatic Surgery
	Postoperative Analgesia for Paediatric HPB Surgery
	References
Chapter 27 Anaesthesia for Paediatric Liver Transplantation
	Background
	General Indications for Transplantation
	Contraindications
	Preoperative Assessment for Liver Transplantation
	Systemic Manifestations of End-Stage Liver Disease
	Cardiovascular Function
	Respiratory Function
	Renal Function
	Neurological Function
	Haematological Function
	Metabolic Function
	Acute Liver Failure
	Surgical Technique
		Dissection Phase
		Anhepatic Phase
		Reperfusion Phase
		Early Post-operative Phase
		Anaesthetic Management
		Pre-operative Assessment
		Intraoperative Care
		Post-operative Care
	Graft Reduction and Split-Liver Transplantation
	References
Chapter 28 Communication Between HPB Anaesthetists: Meetings, Websites and Forums
	Anaesthesia and Critical Care Societies
		Liver Intensive Care Group of Europe (LICAGE)
		Liver Transplant Anaesthesia and Critical Care Forum (LiTAC)
		Enhanced Recovery After Surgery Society (ERAS)
		Enhanced Recovery After Surgery, United Kingdom (ERAS UK)
		Evidence Based Perioperative Medicine (EBPOM)
	Transplant Societies
		International Liver Transplantation Society (ILTS)
		British Transplant Society (BTS)
		The Herrick Society
		Solid Organ Transplant Pharmacy Association (SOTPA)
		British Liver Transplant Group (BLTG)
		European Society for Organ Transplantation (ESOT)
		European Liver and Intestine Transplantation (ELITA)
		The European Liver Transplant Registry (ELTR)
		The Transplantation Society (TTS)
	Surgical Societies
		International Hepato-Pancreato-Biliary Association (IHPBA)
		European-African Hepato-Pancreato-Biliary Association (EAHPBA)
		Association of Upper Gastro- Intestinal Surgery of Great Britain and Ireland (AUGIS)
	Medical Societies
		British Association for the Study of the Liver (BASL)
		European Association for the Study of the Liver (EASL)
	Cancer Based Organisations
		Pancreatic Cancer UK
		Macmillan Cancer Support
	References
Index