Citations

Portopulmonary hypertension is a relatively common pathologic condition in patients with end-stage liver disease. Traditionally, severe pulmonary hypertension is regarded as a contraindication to liver transplantation (LT) due to a high perioperative mortality rate. Recently, extracorporeal membrane oxygenation (ECMO) has been utilized for intraoperative management of LT. As venoarterial (VA) ECMO may benefit certain high-risk LT patients by reducing the ventricular workload by the equivalent of the programmed flow rate, its usage requires multidisciplinary planning with considerations of the associated complications. We highlighted two cases at our single-center institution as examples of high-risk pulmonary hypertension patients undergoing LT on planned VA ECMO. These patients both survived the intraoperative period; however, they had drastically different postoperative outcomes, generating discussions on the importance of judicious patient selection. Since ECMO has removed the barrier of intraoperative survivability, the patient selection process may need to put weight on the patient’s potential for postoperative recovery and rehabilitation. Considerations on LT recipients undergoing preemptive ECMO need to expand from the ability of the patients to withstand the demands of the surgery during the immediate perioperative period to the long-term postoperative recovery course.

AbstractThe coronavirus disease 2019 (COVID‐19) pandemic created unprecedented challenges for anesthesiologists both at work and home. This study examined whether the pandemic affected academic productivity and career satisfaction among anesthesiologists practicing in the United States during the early stages of the pandemic and whether these effects differed by gender. A survey was emailed to 25,473 members of the American Society of Anesthesiologists to learn about their experiences during the beginning of the pandemic. The survey directed respondents to rate their change in academic productivity, clinical care hours, scholarly and leadership opportunities, income, childcare duties, and household responsibilities during the first 5 months of the pandemic (March 1–July 31, 2020). The primary variable was gender, academic productivity was the primary outcome, and data were analyzed by multivariable proportional odds logistic regression models and correlations. Female anesthesiologists reported lower academic productivity and career satisfaction relative to male anesthesiologists during the study period. Career satisfaction positively correlated with academic productivity. Compared to male anesthesiologists, female anesthesiologists also had more household responsibilities before and during the pandemic. Being a female parent reduced academic productivity relative to that reported by nonparents of either gender. In conclusion, the early months of the COVID‐19 pandemic had a greater adverse professional impact on female anesthesiologists than on their male counterparts. Efforts to support and retain female anesthesiologists, particularly those early in their careers and those with children, are essential for the specialty to maintain its workforce and promote gender equity in promotion and leadership.

Background. The International Liver Transplantation Society (ILTS) has placed a strong focus on achieving gender equality and equity in liver transplant (LT). We aimed to understand gender distribution in leadership positions among LT physicians around the world and within ILTS. Methods. In 2019, the ILTS Equality, Diversity, and Inclusion Committee distributed a survey to obtain granular data on gender and characteristics of transplant physicians as well as those in leadership positions in each center. Additionally, data were collected on the gender composition of the ILTS membership, council, chairpersons, and committees and from the United Network for Organ Sharing. Results. Data were collected from 243 transplant centers. Thirty-two (13.2%) had at least 1 woman as the director of LT, chief of transplant surgery, or chief of transplant hepatology. Of the 243 centers, 133 reported the age and gender of the leadership personnel. Women physicians comprised 152 of the 833 transplant surgeons (18.2%) and 298 of the 935 hepatologists (31.9%). Among the 1331 ILTS physician members, 588 (44.2%) provided gender information in their member profiles, and 155 (26.3%) identified themselves as women. Of the 26 ILTS leadership positions, 7 (26.9%) were held by women. Conclusions. This analysis of worldwide gender distribution in the LT physician workforce showed notable gender disparity in LT leadership around the globe and within the ILTS. These data provide a launching point for promoting and achieving gender equality and equity in LT.

AbstractBackgroundThe optimal analgesic strategy for patients undergoing donor hepatectomy is not known and the potential short‐ and long‐term physical and psychological consequences of complications are significant.ObjectivesTo identify whether a multimodal approach to pain of the donor intraoperatively enhances immediate and short‐term outcomes after living liver donation, and to provide international expert panel recommendations.Data sourcesOvid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.MethodsSystematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO 2021 CRD42021260699.ResultsNine studies assessing multi‐modal analgesia strategies were included in a qualitative assessment. Interventions included local, regional, and neuro‐axial anesthetic techniques, pharmacological intervention (NSAIDs, COX‐2 inhibitors, ketamine, dexmedetomidine, and lidocaine), and acupuncture. Overall, there was a significant (40%) reduction in opioid requirement on day 1 and a significant reduction in pain scores in the intervention vs control groups. Significant reductions in either length of stay or post‐operative complications were demonstrated in four of nine studies.ConclusionsOpioid use for patients undergoing donor hepatectomy is likely to impact both their short‐ and long‐term outcomes. To reduce post‐operative pain scores, shorten length of hospital stay, and promote earlier post‐operative return of bowel function, we recommend that multi‐modal analgesia be offered to patients undergoing living donor hepatectomy. Further research is required to confirm which multi‐modal techniques are most associated with enhanced recovery in living liver donors.

AbstractBackgroundHypertrophic cardiomyopathy (HCM) presents with a hypertrophied left ventricle (LV). It is often associated with LV outflow tract obstruction (LVOTO) and a risk for sudden death. This study aimed to describe outcomes of patients with HCM who underwent liver transplant (LT).MethodsA retrospective review was conducted for patients diagnosed with HCM undergoing LT. Patient characteristics, preoperative echocardiography results, HCM risk of sudden cardiac death prediction model score, and 5‐year mortality were examined. A univariable Cox proportional hazards model was used to evaluate the association between risk factors and 5‐year mortality. All tests were two‐sided with the alpha level set at .05.ResultsTwenty‐nine patients were included in the analysis. Six patients (21%) had a perioperative cardiopulmonary complication. The 5‐year survival rate was 61% (95% CI, 45–82). The analyzed risk factors showed that 5‐year post‐LT survival was significantly predicted by maximal LV outflow tract gradient at rest > 60 mmHg (hazard ratio, 1.04 [95% CI, 1.01‐1.06]).ConclusionsPreoperative LV outflow tract resting gradient > 60 mmHg was associated with 5‐year post‐LT mortality. The results suggest the severity of LVOTO identified by echocardiography is a prognostic tool for patients with HCM after LT.