The Anaesthesiologist and Liver Transplantation. Should We Mind the West-East Gap?

The Anaesthesiologist and Liver Transplantation. Should We Mind the West-East Gap?

  • Issue 71

Dana Tomescu
danatomescu@gmail.com

Solid organ transplantation has been one of the most dynamic and researched topics in medicine during the last decades. With the introduction of new immunosuppressant drugs and different surgical techniques, both surgeons and anaesthesiologists have pushed the limits of liver transplantation (LT) beyond what was imagined two or three decades ago. This is why we can safely say that LT represents one of the most successful stories in modern medicine as it provides a definitive cure for patients with End-Stage Liver Disease, and a quality of life beyond expectations. What was thought to be unimaginable in the 1960s is now common practice: people who undergo LT have near normal life expectancies, return to their everyday lives and jobs, get married, and have children. The first LT[1] was performed by Starzl in 1963 in Denver, USA. Immediately after that, in 1967, the first liver transplant in Europe was performed by Roy Calne in the UK.[2] The first liver transplant in Romania was performed by Irinel Popescu almost 30 years later, in 1997, at Fundeni Clinical Institute in Bucharest, but the successful LT programme started in 2000. Since then, the number of patients who underwent LT exponentially increased[3] each year, and since 2010 Fundeni Clinical Institute has become a high volume centre with a maximum of 122 patients (in a single centre in 2015). Two small volume centres have recently begun performing LT in Bucharest and Iași. Although the history of LT in Romania is just beginning in comparison with Western Europe, we have managed to overcome this time gap and bring the standards of care for the transplanted patient alongside any other major centre in Europe. This was accomplished by a small team of anaesthesiologist and surgeons who “broke the record” with 6 LTs performed over 48 hours.

Along with LT with cadaveric graft, the gap between the need and supply of organs in our country was reduced by developing alternative techniques, so living related liver transplant (LRLT) from adult to adult or children, split liver, dual grafts, domino LT, and ABO incompatible transplants are successfully performed.

The way we look at anaesthesia in LT has changed dramatically in the last decade. Now more and more centres have adopted and implemented fast-track protocols that allow early extubation (in the operating room) and fast discharge from the ICU with no increase in the rate of complications. With the introduction of viscoelastic testing and patient blood management policies, targeted transfusion therapy is administered, allowing LT to be safely performed without blood product transfusion. Also, minimally invasive hemodynamic monitoring though pulmonary artery catheters has mostly been replaced by transpulmonary thermodilution techniques or transoesophageal echocardiography.

In Romania, fast track was implemented in 2013 with more than 80% of patients currently being extubated[4] in the operating theatre. Viscoelastic testing has become routine in our centre, and transfusion was reduced in the perioperative setting for LT procedures. Short duration of surgery time, adoption of fast-track, allowed a faster discharge from the Post Anaesthesia Care Unit with a decrease of the length of stay to 2–3 days. Hepatic dialysis, renal replacement therapy, and plasma exchange are routinely used for the management of graft dysfunction and associated organ failure in order to improve outcome and extend patient and graft survival.[5]

One of the most important challenges in LT is the management of patients with acute liver failure (ALF). The role of the intensivist is crucial and includes intensive care management and bridging techniques, anaesthesia for emergency surgery, and care of the liver transplant recipient in the intensive care unit. Nevertheless, we have managed to improve outcome of patients with ALF and decrease mortality from over 80% before the introduction of LT to less than 30%, with a decrease of the time between the inclusion on the waiting list and LT to less than 24 hours, with good results using LRLT.

Recently, in 2013, a team of anaesthesiologist and surgeons went to the Republic of Moldova and performed the first liver transplants. This led to a solid and well-defined cooperation between the two countries that led to an international exchange programme with the main purpose of creating the framework for a national stand-alone LT programme in Moldova. As educating the future generation of anaesthesiologists represents one of the most ambitious goals of any leader, the joined teams of anaesthesiologists and surgeons have accessed funds through two European Framework Programmes aimed at teaching the future generation about organ donation and transplantation medicine.

Now Romania, as well as most countries in Europe and the United States, faces a new challenge: the increase in number of patients included on the waiting list. This unfortunately was paralleled by a significant decrease in deceased organ donors due to either decreased acceptance of donation by families (as in the case of Romania) or to increasing age and co-morbidities in the general population that makes finding suitable organ grafts harder. This will probably lead to an increase in utilisation of marginal liver grafts and/or an increase in number of patients undergoing living-donor LT or split LT.[6] This will present new challenges for the anaesthesiologist in order to keep the living donation safe and optimise early postoperative patient care. All of this translates into the need to create highly skilled anaesthesia teams able to contribute substantially to the success of LT programs.

To answer our initial question, we consider that, at the present time, there is no gap between Eastern Europe, especially Romania, and the Western World. Although local policies, funding, and some limited resources are different, joining the worldwide network in order to improve organ donation rates and to promote safe anaesthesia for organ transplantation is mandatory.

References
1. Starzl TE, Marchioro TL, Porter KA, Brettschneider L. Transplantation 1967;5:790–803.
2. Calne RY, Williams R. Br Med J 1968;4(5630):535–40.
3. Popescu I, Ionescu M, Brasoveanu V, et al. Chirurgia (Bucur) 2017;112(3):229-43.
4. Tomescu D, Popescu M. Ann Fundeni Hosp 2013;18 (1-4):11-21.
5. Tomescu DR, Olimpia DS, Ungureanu D, et al. Int J Artif Organs 2016;39(3):136-40.
6. Orman ES, Mayorga ME, Wheeler SB, et al. Liver Transpl 2015;21(8):1040-50.