Recovery of the Psoas Muscle Index in Living Donors after a Right Lobe Hepatectomy for Liver Transplantation: A Single-Center Experience

Significance of predicted future liver remnant volume on liver failure risk after major hepatectomy: a case matched comparative study

Introduction

Future liver remnant volume (FLRV), a risk factor for liver failure (PHLF) after major hepatectomy (MH), is not routinely measured. This study aimed to evaluate the association between FLRV and PHLF.

Patients and methods

All patients undergoing MH (4 + segments) between 2011 and 2018 were identified from a prospectively maintained single-centre database. Perioperative data were collected for patients with PHLF, who were matched (1:2) with non-PHLF controls. FLRV and FLRV_% (i.e., % of total liver volume) were calculated retrospectively from preoperative CT scans using Synapse-3D software, and compared between the PHLF and matched control groups.

Results

Of 711 patients undergoing MH, PHLF occurred in 27 (3.8%), of whom 24 had preoperative CT scans available. These patients were matched to 48 non-PHLF controls, 98% of whom were classified as being at high risk of PHLF on preoperative risk scoring. FLRV_% was significantly lower in the PHLF group, compared to matched controls (median: 28.7 vs. 35.2%, p = 0.010), with FLRV% < 30% in 58% and 29% of patients, respectively. Assessment of the ability of FLRV_% to differentiate between PHLF and matched controls returned an area under the ROC curve of 0.69, and an optimal cut-off value of FLRV_% < 31.5%, which yielded 79% sensitivity and 67% specificity.

Conclusions

FLRV_% is significantly predictive of PHLF after MH, with over half of patients with PHLF having FLRV_% < 30%. In light of this, we propose that all patients should undergo risk stratification prior to MH, with the high risk patients additionally being assessed with CT volumetry.

Metabolic profiling shows pre-existing mitochondrial dysfunction contributes to muscle loss in a model of ICU-acquired weakness

BACKGROUND

Surgery can lead to significant muscle loss, which increases recovery time and associates with increased mortality. Muscle loss is not uniform, with some patients losing significant muscle mass and others losing relatively little, and is likely to be accompanied by marked changes in circulating metabolites and proteins. Determining these changes may help understand the variability and identify novel therapeutic approaches or markers of muscle wasting.

METHODS

To determine the association between muscle loss and circulating metabolites, we studied 20 male patients (median age, 70.5, interquartile range, 62.5-75) undergoing aortic surgery. Muscle mass was determined before and 7 days after surgery and blood samples were taken before surgery, and 1, 3, and 7 days after surgery. The circulating metabolome and proteome were determined using commercial services (Metabolon and SomaLogic).

RESULTS

Ten patients lost more than 10% of the cross-sectional area of the rectus femoris (RF_CSA ) and were defined as wasting. Metabolomic analysis showed that 557 circulating metabolites were altered following surgery (q < 0.05) in the whole cohort and 104 differed between wasting and non-wasting patients (q < 0.05). Weighted genome co-expression network analysis, identified clusters of metabolites, both before and after surgery, that associated with muscle mass and function (r = -0.72, p = 6 × 10^-4 with RF_CSA on Day 0, P = 3 × 10^-4 with RF_CSA on Day 7 and r = -0.73, P = 5 × 10^-4 with hand-grip strength on Day 7). These clusters were mainly composed of acyl carnitines and dicarboxylates indicating that pre-existing mitochondrial dysfunction contributes to muscle loss following surgery. Surgery elevated cortisol to the same extent in wasting and non-wasting patients, but the cortisol:cortisone ratio was higher in the wasting patients (Day 3 P = 0.043 and Day 7 P = 0.016). Wasting patients also showed a greater increase in circulating nucleotides 3 days after surgery. Comparison of the metabolome with inflammatory markers identified by SOMAscan® showed that pre-surgical mitochondrial dysfunction was associated with growth differentiation factor 15 (GDF-15) (r = 0.79, P = 2 × 10^-4 ) and that GDF-15, interleukin (IL)-8), C-C motif chemokine 23 (CCL-23), and IL-15 receptor subunit alpha (IL-15RA) contributed to metabolic changes in response to surgery.

CONCLUSIONS

We show that pre-existing mitochondrial dysfunction and reduced cortisol inactivation contribute to muscle loss following surgery. The data also implicate GDF-15 and IL-15RA in mitochondrial dysfunction.

Pneumoperitoneum-induced pneumothorax during laparoscopic living donor hepatectomy: a case report

Background

We present a living donor case with an unexpected large-volume pneumothorax diagnosed using lung ultrasound during a laparoscopic hepatectomy for liver transplantation (LT).

Case presentation

A 38-year-old healthy female living donor underwent elective laparoscopic right hepatectomy. The preoperative chest radiography (CXR) and computed tomography images were normal. The surgery was uneventfully performed with tolerable CO₂ insufflation and the head-up position. SpO₂ decreased and airway peak pressure increased abruptly after beginning the surgery. There were no improvements in the SpO₂ or airway pressure despite adjusting the endotracheal tube. Eventually, lung ultrasound was performed to rule out a pneumothorax, and we verified the stratosphere sign as a marker for the pneumothorax. The surgeon was asked to temporarily hold the surgery and cease with the pneumoperitoneum. Portable CXR verified a large right pneumothorax with a small degree of left lung collapse; thus, a chest tube was inserted on the right side. The hemodynamic parameters fully recovered and were stable, and the surgery continued laparoscopically. The surgeon explored the diaphragm and surrounding structures to detect any defects or injuries, but there were no abnormal findings. The postoperative course was uneventful, and a follow-up CXR revealed complete resolution of the two-sided pneumothorax.

Conclusion

This living donor case suggests that a pneumothorax can occur during laparoscopic hepatectomy due to the escape of intraperitoneal CO₂ gas into the pleural cavity. Because missing the chance to identify a pneumothorax early significantly decreases the safety for living donors, point-of-care lung ultrasound may help attending physicians reach the final diagnosis of an intraoperative pneumothorax more rapidly and to plan the treatment more effectively.

Evaluation of Preoperative and Postoperative S100β and NSE Levels in Liver Transplantation and Right Lobe Living-Donor Hepatectomy: A Prospective Cohort Study

BACKGROUND AND AIMS

This study aimed to evaluate plasma neuron-specific enolase (NSE) and S100β levels in orthotopic liver transplantation.

MATERIALS AND METHODS

A total of 56 patients who underwent orthotopic liver transplantation were divided into 3 groups. Healthy donors (group D), end-stage liver failure (ESLF) patients (recipient, group R), and ESLF patients diagnosed with hepatic encephalopathy (HE, group HE). Prognosis, preoperative routine laboratory findings, serum NSE, and S100β in samples obtained preoperation and first and sixth months postoperation were analyzed.

RESULTS

Serum NSE and S100β levels were significantly higher in ESLF patients compared to healthy donors, particularly during the preoperative period. There was a significant decrease in serum NSE and S100β in ESLF patients during the postoperative measurement periods compared to preoperative levels. Serum NSE and S100β levels measured at 3 different time points showed no significant difference between ESLF patients and ESLF patients with HE. However, the recent Model of End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores showed a significant correlation with serum NSE and S100β in ESLF patients diagnosed with HE. Serum NSE and S100β levels in healthy donors significantly increased within the first month following hepatectomy and decreased in the sixth month following surgery.

CONCLUSION

Although serum NSE and S100β levels significantly decreased with improved liver function in recipients following liver transplantation, there was no complete recovery within 6 months after surgery. The increase in serum levels of NSE and S100β in donors measured following hepatectomy was detected to remain slightly higher in the sixth postoperative months.

Sex differences in postsurgical skeletal muscle depletion after donation of living-donor liver transplantation, although minimal, should not be ignored

Background

Donor safety is the top priority in living-donor liver transplantation. Splenic hypertrophy and platelet count decrease after donor surgery are reported to correlate with the extent of hepatectomy, but other aftereffects of donor surgeries are unclear. In this study, we evaluated the surgical effects of donor hepatectomy on skeletal muscle depletion and their potential sex differences.

Methods

Among a total of 450 consecutive donor hepatectomies performed from April 2001 through March 2017, 277 donors who completed both preoperative and postoperative (60–119 days postsurgery) evaluation by computed tomography were the subjects of this study. Donors aged 45 years or older were considered elderly donors. Postoperative skeletal muscle depletion was assessed on the basis of the cross-sectional area of the psoas major muscle. Postoperative changes in the spleen volume and platelet count ratios were also analysed to evaluate the effects of major hepatectomy.

Results

The decrease in the postoperative skeletal muscle mass in the overall donor population was slight (99.4 ± 6.3%). Of the 277 donors, 59 (21.3%) exhibited skeletal muscle depletion (i.e., < 95% of the preoperative value). Multivariate analysis revealed that elderly donor (OR:2.30, 95% C.I.: 1.27–4.24) and female donor (OR: 1.94, 95% C.I. 1.04–3.59) were independent risk factors for postoperative skeletal muscle depletion. Stratification of the subjects into four groups by age and sex revealed that the elderly female donor group had significantly less skeletal muscle mass postoperatively compared with the preoperative values (95.6 ± 6.8%), while the other three groups showed no significant decrease. Due to their smaller physical characteristics, right liver donation was significantly more prevalent in the female groups than in the male groups (112/144, 77.8% vs 65/133, 48.9%; p < 0.001). The estimated liver resection rate correlated significantly with the splenic hypertrophy ratio (r = 0.528, p < 0.001) and the extent of the platelet count decrease (r = − 0.314, p < 0.001), but donor age and sex did not affect these parameters.

Conclusion

Elderly female donors have a higher risk of postoperative skeletal muscle depletion. Additionally, female donors are more likely to donate a right liver graft, whose potential subclinical risks include postoperative splenic enlargement and a platelet count decrease.