Successful Liver Transplantation in a Patient With Quadriparesis: A Case Report W. Taesombat, B. Nonthasoot, B. Sirichindakul, J. Supaphol, and S. Nivatwongs ABSTRACT Major abdominal surgeries, including liver transplantation, are considered high-risk procedures for patients with respiratory muscle dysfunction, such as patients with quadriparesis, due to possible fatal postoperative pulmonary complications. We report on a 57-year-old male patient with longstanding quadriparesis due to fifth cervical spine injury from a traffic accident who suffered from decompensated liver cirrhosis related to hepatitis C infection and hepatocellular carcinoma. A preoperative pulmonary function test showed forced expiratory volume in 1 minute (FEV1) 1.06 L, which was a risk for pulmonary complications. The patient required respiratory training. Cadaveric liver transplantation was performed successfully without surgical complications. The patient was extubated on the fourth day after surgery and initially did well. However, on the eighth postoperative day, an episode of status epilepticus from metabolic derangement developed. After controlling seizure with anticonvulsive medication and sedation, the patient was reintubated due to hypoventilation. Chest radiograph showed upper lung atelectasis. Due to this complication, tracheostomy was performed. The patient’s condition gradually improved. He was ultimately discharged on the 45th postoperative day. Two months after the transplantation, liver functions were normal and the patient could breathe spontaneously without tracheostomy and had good quality of life. In conclusion, this is, to our knowledge, the first report of liver transplantation in a patient with quadriparesis. It shows that even with a very high risk for postoperative pulmonary complications, liver transplantation can be performed successfully with careful patient selection and effective respiratory care.
L
IVER transplantation is the best treatment for patients with early hepatocellular carcinoma associated with decompensated liver cirrhosis [1]. However, this procedure is considered a high-risk major abdominal surgery, with reported perioperative morbidity of 20% to 35% [2,3] and mortality of 5% to 8% [4]. Postoperative pulmonary complication is one of the common complications after major abdominal surgeries, including liver transplantation [5]. Patients with respiratory muscle dysfunction such as quadriparesis or an abnormal preoperative pulmonary function test result are at risk for this complication [6,7], and are considered to have a relative contraindication for liver transplantation.
CASE REPORT The patient was a 57-year old man with longstanding, at least 25 years, quadriparesis due to a fifth cervical spine injury from a traffic accident. After this, his daily life was limited to an automatic
wheelchair and he could breathe spontaneously without respiratory support. He was able to conduct business with a computer-assisted device controlled with his finger. He suffered from decompensated liver cirrhosis related to hepatitis C infection and hepatocellular carcinoma. Preoperative dobutamine stress echocardiography showed normal left ventricular function (ejection fraction 75%) and no stress -induced regional wall movement abnormality. Preoperative spirometry showed forced expiratory volume in 1 minute (FEV1) 1.06 L (Table 1). The patient required respiratory training, controlling ascites, and encouraging enteral nutrition before the surgery. The patient underwent cadaveric liver transplantation by piggyback technique with temporary portocaval shunt. Immediately after From the Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand. Address reprint requests to Wipusit Taesombat, Department of Surgery, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand 10300. E-mail: t.wipusit@gmail. com
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.131
Transplantation Proceedings, 46, 1001e1002 (2014)
1001
1002
TAESOMBAT, NONTHASOOT, SIRICHINDAKUL ET AL
Table 1. Spirometry (Patient Body Weight 72 kg, Height 167 cm)
FVC FEV0.5 FEV1.0 FEV3.0 FEV0.5/FVC FEV1.0/FVC
Measurement (L)
Prediction (L)
Prediction, %
1.06 0.92 1.06 1.06 86.79 100.00
4.11 2.14 2.97
25.8 43.0 35.7
Abbreviations: FVC, forced vital capacity; FEV, forced expiratory volume.
the surgery, the patient was monitored closely in the surgical intensive care unit and on controlled mechanical ventilation. The postoperative immunosuppressive regimen was prednisolone, tacrolimus, and mycophenolate. After the liver graft function gradually improved, the patient was weaned off of mechanical ventilation and extubated on fourth postoperative day. Initially his general condition was good, without surgical complications. However, on the eighth postoperative day, an episode of status epilepticus developed due to metabolic derangement. The patient required combined anticonvulsive medication and sedation. Unfortunately, he was reintubated due to hypoventilation. A chest radiograph revealed upper lung atelectasis. After that, pneumonia and pleural effusion necessitating percutaneous drainage developed. Due to this complication, tracheostomy was performed. After controlling seizure and lung infection, the patient’s condition gradually improved. He was ultimately discharged on 45th postoperative day. Two months after the transplantation, liver functions were normal and the patient could breathe spontaneously without tracheostomy and had a good quality of life.
DISCUSSION
Liver transplantation is one of the major abdominal surgeries that carries the risk of postoperative complications, such as pulmonary complications. Postoperative pulmonary complications are an important cause of perioperative morbidity and mortality [7]. Cirrhotic patients may show a pattern of lung restriction [5] due to massive ascites and also may have decreased muscle mass, including respiratory muscle, due to malnutrition, which increases the risk of postoperative
pulmonary complications in liver transplantation. Therefore, ascites must be controlled, nutritional status should be improved, and muscle mass and function should be maintained during the waiting period before transplantation. Patients with fifth cervical spine injury can breathe spontaneously, but with low tidal volume, forced vital capacity, and FEV1. If these patients are scheduled to undergo abdominal surgery, they should have respiratory training that includes cough maneuver, deep breathing, and a chest physiotherapy consultation. Early tracheostomy should be considered in this group of patients to facilitate pulmonary toilet and ventilator weaning [8]. In conclusion, liver transplantation in a patient with quadriparesis who is at very high risk for postoperative pulmonary complications can be performed successfully with careful patient selection and effective respiratory care. REFERENCES [1] Mazzafero V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, et al. Liver transplantation for the treatment of small hepatocellular carcinoma in patients with cirrhosis. N Engl J Med 1996;334:693e9. [2] Prashant B, Eric V, Pietro M, et al. Intention-to-treat analysis of liver transplantation for hepatocellular carcinoma: living versus deceased donor transplantation. Hepatology 2011;53:1570e9. [3] Lo CM, Fan ST, Liu CL, et al. Living donor versus deceased donor liver transplantation for early irresectable hepatocellular carcinoma. Br J Surg 2007;94:78e86. [4] Moon DB, Lee SG. Liver transplantation. Gut Liver 2009;3: 145e65. [5] Levesque E, Hoti E, Azoulay D, et al. Pulmonary complications after elective liver transplantationdincidence, risk factors, and outcome. Transplantation 2012;94:532e8. [6] Bozbas SS, Yılmaz EB, Dogrul I, et al. Preoperative pulmonary evaluation of liver transplant candidates: results from 341 adult patients. Ann Transplant 2011;16:88e96. [7] Kocabas A, Karat K, SiiNmzt H, et al. Value of preoperative spirometry to predict postoperative pulmonary complication. Resp Med 1996;90:25e33. [8] Harrop JS, Sharan AD, Scheid EH Jr, et al. Tracheostomy placement in patient with complete cervical spinal cord injuries. J Neurosurg 2004;100(Suppl Spine1):20e3.
L
IVER transplantation is the best treatment for patients with early hepatocellular carcinoma associated with decompensated liver cirrhosis [1]. However, this procedure is considered a high-risk major abdominal surgery, with reported perioperative morbidity of 20% to 35% [2,3] and mortality of 5% to 8% [4]. Postoperative pulmonary complication is one of the common complications after major abdominal surgeries, including liver transplantation [5]. Patients with respiratory muscle dysfunction such as quadriparesis or an abnormal preoperative pulmonary function test result are at risk for this complication [6,7], and are considered to have a relative contraindication for liver transplantation.
CASE REPORT The patient was a 57-year old man with longstanding, at least 25 years, quadriparesis due to a fifth cervical spine injury from a traffic accident. After this, his daily life was limited to an automatic
wheelchair and he could breathe spontaneously without respiratory support. He was able to conduct business with a computer-assisted device controlled with his finger. He suffered from decompensated liver cirrhosis related to hepatitis C infection and hepatocellular carcinoma. Preoperative dobutamine stress echocardiography showed normal left ventricular function (ejection fraction 75%) and no stress -induced regional wall movement abnormality. Preoperative spirometry showed forced expiratory volume in 1 minute (FEV1) 1.06 L (Table 1). The patient required respiratory training, controlling ascites, and encouraging enteral nutrition before the surgery. The patient underwent cadaveric liver transplantation by piggyback technique with temporary portocaval shunt. Immediately after From the Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand. Address reprint requests to Wipusit Taesombat, Department of Surgery, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand 10300. E-mail: t.wipusit@gmail. com
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.131
Transplantation Proceedings, 46, 1001e1002 (2014)
1001
1002
TAESOMBAT, NONTHASOOT, SIRICHINDAKUL ET AL
Table 1. Spirometry (Patient Body Weight 72 kg, Height 167 cm)
FVC FEV0.5 FEV1.0 FEV3.0 FEV0.5/FVC FEV1.0/FVC
Measurement (L)
Prediction (L)
Prediction, %
1.06 0.92 1.06 1.06 86.79 100.00
4.11 2.14 2.97
25.8 43.0 35.7
Abbreviations: FVC, forced vital capacity; FEV, forced expiratory volume.
the surgery, the patient was monitored closely in the surgical intensive care unit and on controlled mechanical ventilation. The postoperative immunosuppressive regimen was prednisolone, tacrolimus, and mycophenolate. After the liver graft function gradually improved, the patient was weaned off of mechanical ventilation and extubated on fourth postoperative day. Initially his general condition was good, without surgical complications. However, on the eighth postoperative day, an episode of status epilepticus developed due to metabolic derangement. The patient required combined anticonvulsive medication and sedation. Unfortunately, he was reintubated due to hypoventilation. A chest radiograph revealed upper lung atelectasis. After that, pneumonia and pleural effusion necessitating percutaneous drainage developed. Due to this complication, tracheostomy was performed. After controlling seizure and lung infection, the patient’s condition gradually improved. He was ultimately discharged on 45th postoperative day. Two months after the transplantation, liver functions were normal and the patient could breathe spontaneously without tracheostomy and had a good quality of life.
DISCUSSION
Liver transplantation is one of the major abdominal surgeries that carries the risk of postoperative complications, such as pulmonary complications. Postoperative pulmonary complications are an important cause of perioperative morbidity and mortality [7]. Cirrhotic patients may show a pattern of lung restriction [5] due to massive ascites and also may have decreased muscle mass, including respiratory muscle, due to malnutrition, which increases the risk of postoperative
pulmonary complications in liver transplantation. Therefore, ascites must be controlled, nutritional status should be improved, and muscle mass and function should be maintained during the waiting period before transplantation. Patients with fifth cervical spine injury can breathe spontaneously, but with low tidal volume, forced vital capacity, and FEV1. If these patients are scheduled to undergo abdominal surgery, they should have respiratory training that includes cough maneuver, deep breathing, and a chest physiotherapy consultation. Early tracheostomy should be considered in this group of patients to facilitate pulmonary toilet and ventilator weaning [8]. In conclusion, liver transplantation in a patient with quadriparesis who is at very high risk for postoperative pulmonary complications can be performed successfully with careful patient selection and effective respiratory care. REFERENCES [1] Mazzafero V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, et al. Liver transplantation for the treatment of small hepatocellular carcinoma in patients with cirrhosis. N Engl J Med 1996;334:693e9. [2] Prashant B, Eric V, Pietro M, et al. Intention-to-treat analysis of liver transplantation for hepatocellular carcinoma: living versus deceased donor transplantation. Hepatology 2011;53:1570e9. [3] Lo CM, Fan ST, Liu CL, et al. Living donor versus deceased donor liver transplantation for early irresectable hepatocellular carcinoma. Br J Surg 2007;94:78e86. [4] Moon DB, Lee SG. Liver transplantation. Gut Liver 2009;3: 145e65. [5] Levesque E, Hoti E, Azoulay D, et al. Pulmonary complications after elective liver transplantationdincidence, risk factors, and outcome. Transplantation 2012;94:532e8. [6] Bozbas SS, Yılmaz EB, Dogrul I, et al. Preoperative pulmonary evaluation of liver transplant candidates: results from 341 adult patients. Ann Transplant 2011;16:88e96. [7] Kocabas A, Karat K, SiiNmzt H, et al. Value of preoperative spirometry to predict postoperative pulmonary complication. Resp Med 1996;90:25e33. [8] Harrop JS, Sharan AD, Scheid EH Jr, et al. Tracheostomy placement in patient with complete cervical spinal cord injuries. J Neurosurg 2004;100(Suppl Spine1):20e3.
