Anesth Analg 2004;98:935-936
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000105873.06811.90
CARDIOVASCULAR ANESTHESIA
Massive Gastrointestinal Bleeding Complicating Portal Vein Cross-Clamping During Liver Transplantation
Dominic A. Cave, MB, BS, FRCPC, and
Barry A. Finegan, MB, FFARCSI, FRCPC
Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
Address correspondence and reprint requests to B. A. Finegan, MB, FFARCSI, FRCPC, Department of Anesthesiology and Pain Medicine, 3B2.32 W. C. Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada, T6G 2B7. Address e-mail to bfinegan{at}ualberta.ca
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Abstract
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This case report describes the occurrence of massive upper gastrointestinal hemorrhage immediately after cross-clamping of the inferior vena cava and hepatic portal vein. This case suggests that acute intraoperative hemorrhage from a varix should always be a consideration before liver transplantation in patients who have a history of upper gastrointestinal bleeding.
IMPLICATIONS: A case of severe bleeding during liver transplantation is described in a patient who had a history of bleeding from the stomach before surgery. The importance of understanding surgical options and the ability to provide rapid massive transfusion in the management of this complication are discussed.
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Introduction
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Recurrent life-threatening variceal hemorrhage secondary to portal hypertension is an indication for liver transplantation (1). The vascular isolation of the liver during the transplantation procedure is associated with increases of inferior vena caval and portal venous pressures (2). One method of decompressing the cross-clamped inferior vena cava and hepatic portal veins is to institute venovenous bypass, in which blood is shunted from the portal vein and the inferior vena cava to the superior vena cava via the antecubital, axillary, subclavian, or jugular veins (3). However, the establishment and use of venovenous bypass is not without complications, and it is not used routinely in some centers (4). We describe the previously unreported occurrence of sudden massive bleeding during liver transplantation because of the rupture of a large gastric varix that occurred when the vena cava and hepatic portal veins were cross-clamped in the absence of venovenous bypass.
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Case Report
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A 13-yr-old 50-kg girl who had undergone a previous Kasai procedure (portoenterostomy) in infancy because of biliary atresia presented for emergency liver transplantation because of severe encephalopathy (Grade 3) after multiple massive esophageal variceal bleeding episodes over the previous 5 days. The patient had received transfusions in excess of one blood volume and required inotropic support to maintain her systemic arterial blood pressure during the periods of acute hemorrhage. Before surgery, attempts to sclerose her gastric varices had been unsuccessful. An octreotide infusion was initiated and continued during surgery. A transjugular intrahepatic portal systemic shunt procedure was not performed, because her rapidly worsening encephalopathy precipitated her listing for liver transplantation, and an organ quickly became available. Transfer from intensive care and the induction of anesthesia were achieved uneventfully. A double-lumen 12F dialysis catheter was inserted into the right internal jugular vein, and 8.5F single-lumen and 7F triple-lumen catheters were inserted into the left internal jugular vein. The radial and femoral arteries were also cannulated. Initial blood gas and chemistry measurements were within the normal range. The platelet count was 68,000/mm3, international normalized ratio was 1.3, partial thromboplastin time was 41 s, fibrinogen was 1.9 g/L, and D-dimer was >4.0 mg/L.
The preanhepatic phase proceeded uneventfully, with stable systemic blood pressures and central venous pressure (CVP) remaining at 8–10 mm Hg. However, on test clamping, within 1 min of occlusion of the inferior vena cava and hepatic portal vein, sudden gastric distension was reported by the surgeon. This was accompanied by a precipitous reduction in arterial blood pressure and hemorrhage from the mouth and nares. CVP at this time was 0–1 mm Hg. Rapid transfusion was commenced, the cross-clamps were removed, and the circulation was supported pharmacologically, necessitating bolus phenylephrine (1 mg total) and a norepinephrine infusion at 0.2 µg · kg-1 · min-1 to maintain systolic blood pressure >60 mm Hg. The stomach was incised in an attempt to control the bleeding under direct vision, which prompted further hemorrhage that necessitated further pharmacologic support. Temporary hemostasis required direct pressure applied to the bleeding varix. This was achieved within 5 min. The varix was oversewn in stages by intermittently releasing the applied pressure and allowing time for blood volume to be restored. The resuscitation involved the transfusion of 9 U of blood, 12 U of cryoprecipitate, 8 U of platelets, 2 U of fresh frozen plasma, 750 mL of cell saved blood, 5 L of plasmalyte, and 1 L of Pentaspan and the administration of 100 mEq of NaHCO3 and 4 g of CaCl2 in a 10-min period. At this point, with a CVP of 12 mm Hg and a systolic blood pressure of 116 mm Hg on norepinephrine 0.1 µg · kg-1 · min-1, the patient tolerated subsequent portal and systemic venous isolation and donor liver implantation without incident. The patient was discharged from the intensive care unit on the fourth postoperative day with excellent liver function.
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Discussion
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Venovenous bypass reduces systemic venous congestion and may protect the recipient from the effects of reduced cardiac output, altered systemic vascular resistance, and possible renal damage with cross-clamping (5). Venovenous bypass is associated with major vascular injury and death in approximately 1% of patients and has minor complication rates in the 10%–30% range, with no clear benefit in preservation of renal function (6). The use of venovenous bypass has decreased (6), whereas the "piggyback" technique of explantation/implantation has become more popular, whereby the caudate lobe is dissected free by dividing the short hepatic veins individually, leaving the recipient’s vena cava in place, applying a side clamp to the main hepatic vena cava to facilitate hepatic removal, and attaching the common cuff so formed to the donor liver’s suprahepatic cava. The latter technique may be combined with a portocaval shunt, but only a few patients require this intervention (7). No significant increase in mortality or morbidity is reported in case series in which transplantation has been performed without the aid of venovenous bypass (8,9). Venovenous bypass may still be indicated in patients who display marked cardiovascular instability during hepatic dissection or who on trial of cross-clamping display a reduction in systemic blood pressure to <100 mm Hg and/or a marked reduction in cardiac output at that time (10). In our center, we institute venovenous bypass only as a last resort in the presence of marked hemodynamic instability, but we do ensure that groin access is available should the need for venovenous bypass occur.
Both the piggyback technique and the establishment of a portocaval shunt require temporary restriction of flow through the portal system, which evokes an increase in portal pressure. Although this pressure alteration is brief, variceal rupture at the time of flow restriction remains a real hazard. The rapid occurrence of massive hemorrhage in our case after test clamping suggests that hemorrhage may have occurred even if the aforementioned techniques had been attempted. Recent gastrointestinal hemorrhage in association with documented large varices represents an indication for the consideration of venovenous bypass or portocaval shunting, but neither may be a definitive preventive measure against acute variceal rupture. We are unaware of any case reports of intraoperative gastric variceal rupture after the institution of venous isolation, although such an event has been reported after liver transplantation (11). Our patient bled more than two blood volumes in a matter of minutes. In an era of improved anesthetic and surgical techniques, it is easy to forget that massive blood loss is always a possibility during liver transplantation. The importance of having blood products immediately available cannot be overstated. We suggest that venovenous bypass or portocaval shunt should be considered in patients undergoing emergency liver transplantation consequent to severe hemorrhage due to esophageal or gastric varices. However, we also caution that these patients will remain at high risk for this potentially catastrophic complication whatever procedure the surgeon performs.
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References
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- Gow PJ, Chapman RW. Modern management of oesophageal varices. Postgrad Med J 2001; 77: 75–81.[Abstract/Free Full Text]
- Peachey T, Eason J, Potter D, Ginsburg R. Observations on abdominal venous pressures during orthotopic liver transplantation in man. Transplant Proc 1989; 21: 3526–7.[Medline]
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- Stock PG, Payne WD, Ascher NL, et al. Rapid infusion technique as a safe alternative to veno-venous bypass in orthotopic liver transplant (TX). Transplant Proc 1989; 21: 2322–5.[Medline]
- Kaufman RD, Khoury GF. Hemodynamic changes with initiation of veno-venous bypass in orthotopic liver transplant patients. Am J Anesthesiol 1995; 22: 184–8.[Medline]
- Chari RS, Gan TJ, Robertson KM, et al. Venovenous bypass in adult orthotopic liver transplantation: routine or selective use? J Am Coll Surg 1998; 186: 683–90.[Medline]
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- Chari RS, Gan TJ, Robertson KM, et al. Venovenous bypass in adult orthotopic liver transplantation: routine or selective use? J Am Coll Surg 1998; 186: 683–90.
- Hirata M, Harihara Y, Hisatomi S, et al. A case of esophageal variceal rupture following acute portal vein thrombosis three days after living-related liver transplantation. Transplant Proc 2000; 32: 2266–8.[Medline]
Accepted for publication October 23, 2003.
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Abstract
Introduction
