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Transplantation Division, Hospital Israelita Albert Einstein, São Paulo, Brazil, takaoka@einstein.br or ytakaoka@uol.com.br
To the Editor:
We have read with interest the article by Lutz et al. (1) on living donor liver transplantation (LDLT). They point out that "anesthetic perioperative management is crucial for minimizing risks," "In most of the donors, a thoracic epidural catheter was inserted preoperatively," and "during surgery, the patients received epidurally bupivacaine 0.5%."
Have the authors considered that liver dysfunction is present in the majority of adult patients after right hepatectomy? (2). If so, how to justify a technique that has a specific risk for perioperative epidural hematoma (3)?
Thoracic epidural anesthesia with 0.5% bupivacaine in patients who have a blood loss of more than 2.000 mL (4 donors) presents some serious concerns for intraoperative hemodynamic stability. This is of paramount importance to preserve hepatic function perioperatively.
At our institution, we performed 33 LDLTs under general anesthesia since January 2002. In the donor group, there was no need for intraoperative blood transfusion or blood salvage techniques; no epidural catheters were placed in the last 31 patients.
Advancement of LDLT will be mostly related to our ability to minimize risks to the donors. Although minimal, epidural anesthesia or analgesia involves recognized risks. There are other safe and effective alternatives we can offer to our patients.
References
Klinik für Anästhesiologie und Intensivmedizin Klinik für Allgemein und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Germany
In Response:
We appreciate the interest in our article (1). Obviously, as in any patient undergoing central neuraxis blockade, benefits (2,3) and risks have to be considered carefully. Thoracic epidural anesthesia has been shown to minimize pulmonary complications after surgery (3). We offered epidural pain therapy to living liver donors for the same reasons as for other patients undergoing liver resections. In a study of 4185 patients, some of them with abnormal coagulation, we did not find a single epidural hematoma (4) and have extensive experience with this technique. Data from patients with previously inserted thoracic epidural catheters undergoing cardiopulmonary bypass while being fully heparinized suggest that epidural anesthesia can be safe even under these conditions (5).
Finally, coagulation tests in our donors confirm that this management is feasible, considering that epidural catheters were exclusively inserted in donors with normal preanesthesia coagulation tests and pulled postoperatively while coagulation tests were within normal limits (see Figure1).
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Needless to say that we are used to administer epidural bupivacaine with respect to hemodynamic stability and perfusion pressures.
We congratulate the authors for not even being dependent on blood salvage techniques but have not seen these data published. However, considering that maximum safety of the donor clearly is the goal we do not understand why these techniques are not used by Takaoka et al.
References
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