INTRAOPERATIVE MANAGEMENT AND OPERATIVE TECHNIQUE
Cold ischemia was kept to a minimum. Only local donors were used. The operating room was kept warm to avoid hypothermia and resultant coagulopathy.12
All intraoperative blood sampling was also kept to a minimum. Laboratory evaluations included testing for arterial blood gas, electrolyte, and hematocrit levels and thromboelastography. The thromboelastograph (Haemoscope, Hellige, Germany) was used as the primary monitor of coagulation status.13 Plateletpheresis was performed after induction by phlebotomizing 5 to 7 L of blood at a flow rate of 60 mL/min and processing through the plateletpheresis unit (Hemonetics, Braintree, Mass).14 We estimated that one pheresis product of 250 to 300 mL contained a platelet count of 3× 109/L to 8× 109L, to be infused after reperfusion.
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Filling pressures were optimized during the pheresis procedure with albumin, crystalloid solutions, and hydroxyethyl starch. Isovolemic hemodilution was therefore achieved in conjunction with the phlebotomy for the plateletpheresis.15 Phlebotomized, platelet-poor blood was reinfused slowly to maintain oxygen-carrying capacity.
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All incisions were made using electrocautery with a coagulation mode. The use of laparotomy sponges was kept to a minimum to allow for the collection of as many red blood cells as possible before stable clots could form. When used, the sponges were drained into the field, and the drained blood was collected with the cell-saver suction. The cell saver 4 (Hemonetics) and the Rapid Infusion System (Hemonetics) were used for the salvage of red blood cells.16
The native liver was removed in all patients, with the piggyback technique used in three patients to avoid dissection of the retroperitoneal and retrocaval areas.17 An argon beam coagulator (Birtcher, Irvine, Calif) was used liberally to cauterize raw surfaces. Venovenous bypass, either portal, systemic, or combined, was used in all cases.
On reperfusion of the liver and termination of the venovenous bypass, platelet-rich plasma was slowly returned to the patient. The blood from the venovenous bypass tubing was drained directly into the patient. This process returned between 200 and 250 mL of blood per patient.
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All anastomoses were performed in standard fashion. Extra care was taken to use smaller than usual sutures and smaller spacing to minimize bleeding from the anastomotic sites. Jackson Pratt drains were left as monitors for bleeding. These drains proved useful in identifying postoperative bleeding in one patient.
Immunosuppression was induced intraoperatively with tacrolimus (Prograft), 0.05 mg/kg over 24 hours in a continuous intravenous infusion, and methylprednisolone, 1 g. Maintenance corticosteroid therapy consisted of 20 mg of methylprednisolone every 24 hours. An intravenous infusion of tacrolimus, 0.05 mg/kg, was continued until gastrointestinal function returned.
In the immediate postoperative period, hemodynamic monitoring and fluid management were performed in the standard way. All blood drawing was limited. Coagulation was monitored by thromboelastography, prothrombin time, and platelet count. Any fibrinolysis was corrected with ∊-aminocaproic acid.18
Minimal blood drawing guidelines were observed throughout the hospital stay. All patients again received erythropoietin and ferrous sulfate Fe 59 until their hematocrit levels rose to more than 0.35.
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