|Year : 2017 | Volume
| Issue : 4 | Page : 181-183
A focused survey of immediate postoperative practices in liver transplantation in India
Zubair Umer Mohamed1, Rajesh Keshavan1, Fazil Muhammed1, Drisya Santosh2, Sudhindran Surendran2
1 Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Web Publication||28-Dec-2017|
Zubair Umer Mohamed
Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwavidyapeetham, Ponekkara, Kochi - 682 041, Kerala
Source of Support: None, Conflict of Interest: None
Aim: Over the last decade, the number of liver transplantations and centers that provide this service in India have grown exponentially. However, not all practices relevant to liver transplantation are uniform across the country. We decided to get the opinion from living donor liver transplant (LDLT) centers across the country on four specific aspects relating to LDLT. Methods: We formulated four specific questions that were carefully worded to incorporate aspects of “routine practice” and also answerable in the negative or affirmative, so as to make comparison possible. We collected the data of LDLT centers in India from popular resources such as MOHAN Foundation, from our institutional memory, and also by inquiring with respondents. The following questions were asked: (1) Do you routinely use N-acetyl cysteine for LDLT donors? (2) Do you use routinely use prostaglandin E1 (alprostadil) to facilitate hepatic artery flow in recipients? (3) Do you routinely use antiplatelets to prevent hepatic artery thrombosis in adult LDLT recipients? (4) Do you routinely use low molecular weight heparin for deep vein thrombosis prophylaxis after donor hepatectomy? Results: We received a total of 38 responses, of which 34 were complete. Conclusions: There is no consensus among practitioners regarding the studied aspects of the practice pertinent to immediate postoperative care in liver transplantation. This is primarily because there is neither evidence nor clear guidance from learned societies regarding these issues.
Keywords: Liver transplantations, living donor liver transplant, survey
|How to cite this article:|
Mohamed ZU, Keshavan R, Muhammed F, Santosh D, Surendran S. A focused survey of immediate postoperative practices in liver transplantation in India. Indian J Transplant 2017;11:181-3
|How to cite this URL:|
Mohamed ZU, Keshavan R, Muhammed F, Santosh D, Surendran S. A focused survey of immediate postoperative practices in liver transplantation in India. Indian J Transplant [serial online] 2017 [cited 2018 Jun 23];11:181-3. Available from: http://www.ijtonline.in/text.asp?2017/11/4/181/221850
| Introduction|| |
Liver transplantation is the only definitive treatment for end-stage liver disease. The number of liver transplantations and the centers that provide this service have increased significantly over the last decade in India. Due to the shortage of deceased donors, the sources of liver grafts for transplantation in India are mostly live donors – living donor liver transplantation (LDLT). The morbidity and mortality after liver transplantation have steadily decreased over the years. Since the inception of the LDLT program at Amrita Institute of Medical Sciences, we have been following certain immediate postoperative management practices based on best available evidence and guidance from learned societies. However, not all are based on guidelines, as guidelines do not cover all aspects.
Experimental evidence suggests that N-acetyl cysteine (NAC) may ameliorate reactive oxygen species-mediated liver injury. Experimental animal models have shown a potential positive impact of glutathione or its precursor, NAC infusions in decreasing ischemia-reperfusion injury of the liver. NAC is commonly used as a mucolytic agent for respiratory illnesses, as an antidote for hepatotoxicity due to paracetamol overdose, and as prophylaxis against renal injury due to radiocontrast agent. However, there is no evidence to support or refute the use of NAC in donor hepatectomy. Bleeding and thrombotic risks exist in the immediate postoperative period for the donor, and there is no guideline regarding the timing of the decision to commence deep vein thrombosis prophylaxis in the postoperative period. A similar paucity of guideline or consensus exists regarding pharmacological techniques to improve hepatic artery flow and prevent hepatic artery thrombosis in the immediate postoperative period in the recipients of LDLT.,
| Methods|| |
We decided to get the opinion from LDLT centers across the country on four specific aspects relating to LDLT. We formulated four specific questions pertaining to immediate postoperative practices in LDLT. The questions were carefully worded to incorporate aspects of “routine practice” and also answerable in the negative or affirmative way so as to make comparison possible. We collected the data of LDLT centers in India from popular resources such as MOHAN Foundation, from our institutional memory, and also by inquiring with subsequent respondents. Individual centers were contacted through E-mail or telephone and informed about the study. Decision to participate was solely voluntary and we did not specify clinician of which specialty (intensive/intensive care/surgery/hepatology) to be interviewed as the questions pertained to routine practice.
| Results|| |
We were able to locate 38 centers of which 34 sent complete responses. The distribution of responders based on state is provided in [Table 1]. Maximum respondents were from Delhi and surrounding areas.
|Table 1: Distribution of respondents (with percentage), in decreasing order of frequency|
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- Question 1
Do you routinely use NAC for LDLT donors?
Of the 37 responses received, 19 (51.35%) replied in the affirmative.
- Question 2
Do you use routinely use prostaglandin E1 (alprostadil) to facilitate hepatic artery flow in recipient?
Of the 36 responses received, only 3 (8.33%) replied in the affirmative.
- Question 3
Do you routinely use antiplatelets to prevent HAT in adult LDLT recipients?
Of the 37 responses received, 13 (35.13%) replied in the affirmative.
Among the people who use it, 12/13 (92.30%) use aspirin 75 mg once daily. One center use heparin 5000 mg BD. Most were noncommittal to the duration of therapy.
- Question 4
Do you routinely use low molecular weight heparin as DVT prophylaxis postdonor hepatectomy?
Of the 34 responses received, 19 (55.88%) replied in the affirmative.
- Question 4a
If yes, if INR >2 on day 2, will you give LMWH?
Four hospitals replied in the affirmative.
| Discussion|| |
As far as we know, this is the first study looking at these specific practices among the various LDLT centers in India. We were able to achieve responses from 38 doctors who treat liver transplant patients. As the questions were clearly framed as “routinely,” we did not insist on the specialty of doctors. However, majority were anesthetists or intensive care physicians, and a few were surgeons and hepatologists.
NAC is routinely administered in nearly 50% of the liver transplant centers. Recent data from Grendar et al. showed that NAC administration is associated with increased incidence of delirium. Our institutional data showed only a 0.5% incidence. However, the patient population was different in both these studies as one group had healthy donors while the other had patients with malignancy.
Only 3 centers (8.33%) use prostaglandins to facilitate hepatic artery flow. A recent Cochrane review found no evidence to recommend the use of prostaglandin in adult liver transplantation. A recent publication by Bharathan et al. confirmed this finding in the LDLT's setting. However, they did find that it reduces the incidence of posttransplant renal dysfunction.
Approximately, a third of the centers routinely use antiplatelets to prevent hepatic artery thrombosis. Although the questionnaire was worded as “antiplatelet,” one person replied in the affirmative and stated that they use heparin. This was calculated as affirmative for the purpose of analysis as the question was intended to find out about pharmacological intervention to prevent hepatic artery thrombosis. Published literature does not support the use of antiplatelets to prevent hepatic artery thrombosis, including a recent one from India., Although the use of heparin in this setting is described in literature, the evidence for this practice is mainly derived from small individual centres and retrospective studies., It is possible that large multicenter studies might be able to shed more light into this topic.
Deep vein thrombosis is a known complication after hepatectomy. Although only around 50% of the centers replied to using low molecular weight heparin to prevent deep vein thrombosis, other centers use thromboelastic deterrent stockings or sequential compression devices. Patients are known to become prothrombotic after hepatectomy. It is known that the usual markers of coagulation, namely, prothrombin time and activated partial thromboplastin time are not useful markers to assess clotting in these patients. Even the utility of thromboelastogram has been questioned in a recent article by Hilmi and Planinsic  More advanced assays of coagulation such as protein C, soluble P-selectin, antithrombin III, thrombin–antithrombin complex, and thrombin generation complex have been suggested as potentially more useful in this setting. However, they are neither extensively studied nor routinely available.
Our study has a number of drawbacks. It is a questionnaire survey and has the inherent disadvantages of a questionnaire survey such as recall bias, reliability of response, and thought input. Usually, the operating surgeon takes decision on most of these practices. Although majority of our response were from anesthetists, since the questions were framed as “routine,” we hope that it would not significantly alter the answers. Another possible drawback is that the percentage provided is based on number of centers and not weighted to the number of cases per centre. The information on the transplant centers was obtained from MOHAN Foundation, web search, and word of mouth. It is possible that we could have missed some of the liver transplant centers in the country. Although it was intended to capture information regarding deep vein thrombosis prevention practices, the question on the use of low molecular weight heparin was possibly too specific and introduced an element of researcher imposition. It did not include use of thromboelastic deterrent stockings or sequential compression devices. Furthermore, the centers that use heparin in the immediate postoperative period to prevent hepatic artery thrombosis do not need to use low molecular weight heparin to prevent deep vein thrombosis.
A striking feature of the results is that although these are situation faced by almost every liver transplantation program, there is no clear consensus. This is primarily because there is a paucity of evidence to most of these questions and evidently, we have differing approaches to deal with them.
| Conclusion|| |
Many of the routine practices pertaining to liver transplantation are varied across India and clear guidance from learned societies and evidence from literature is lacking. A multicentric study comparing some of these practices to outcome measures may provide clinically meaningful answers and help clinicians make more informed decisions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Selzner M, Kashfi A, Cattral MS, Selzner N, McGilvray ID, Greig PD, et al.
Live donor liver transplantation in high MELD score recipients. Ann Surg 2010;251:153-7.
Sener G, Tosun O, Sehirli AO, Kaçmaz A, Arbak S, Ersoy Y, et al.
Melatonin and N-acetylcysteine have beneficial effects during hepatic ischemia and reperfusion. Life Sci 2003;72:2707-18.
Aitio ML. N-acetylcysteine - passe-partout or much ado about nothing? Br J Clin Pharmacol 2006;61:5-15.
Warner P, Fusai G, Glantzounis GK, Sabin CA, Rolando N, Patch D, et al.
Risk factors associated with early hepatic artery thrombosis after orthotopic liver transplantation - Univariable and multivariable analysis. Transpl Int 2011;24:401-8.
Mourad MM, Liossis C, Gunson BK, Mergental H, Isaac J, Muiesan P, et al.
Etiology and management of hepatic artery thrombosis after adult liver transplantation. Liver Transpl 2014;20:713-23.
Mohamed ZU, Kumar L, Surendran S. Effect of N-acetylcysteine on liver recovery after resection: A randomized clinical trial. J Surg Oncol 2016;114:446-50.
Cavalcanti AB, De Vasconcelos CP, de Oliveira MP, Rother ET, Ferraz LJ. Prostaglandins for adult liver transplanted patients. Cochrane Database of Systematic Reviews 2011:CD006006. DOI: 10.1002/14651858.CD006006.pub2.
Bharathan VK, Chandran B, Gopalakrishnan U, Varghese CT, Menon RN, Balakrishnan D, et al.
Perioperative prostaglandin e1 infusion in living donor liver transplantation: A double-blind, placebo-controlled randomized trial. Liver Transpl 2016;22:1067-74.
Algarni AA, Mourad MM, Bramhall SR. Anticoagulation and antiplatelets as prophylaxis for hepatic artery thrombosis after liver transplantation. World J Hepatol 2015;7:1238-43.
Selvakumar N, Gupta S, Goyal N. Hepatic artery thrombosis versus neurological complications-Role of antiplatelet medications in adult living donor liver transplantation. Indian J Transplantant 2016;10:5-8.
Hashikura Y, Kawasaki S, Okumura N, Ishikawa S, Matsunami H, Ikegami T, et al.
Prevention of hepatic artery thrombosis in pediatric liver transplantation. Transplantation 1995;60:1109-12.
Abou Ella KA, Al Sebayel MI, Ramirez CB, Rabea HM. Hepatic artery thrombosis after orthotopic liver transplantation. Saudi Med J 2001;22:211-4.
Hilmi IA, Planinsic RM. Live liver donors: Are they at a higher risk for post-operative thrombotic complications? World J Transplant 2012;2:1-4.