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Linda Sher

Publications and source records attributed to Linda Sher.

10 recordsLinked to original sources
PubMed2005

Transfusion free surgery: single institution experience of 27 consecutive liver transplants in Jehovah's Witnesses.

BACKGROUND: Despite the risks associated with transfusion, the medical community continues to view blood as a safe and abundant product. In this article, we provide an effective strategy to accomplish orthotopic liver transplantation without transfusion. STUDY DESIGN: From June 1999 through July 2004, 27 liver transplantations were performed in Jehovah's Witness patients at the USC-University Hospital (24 adults, 3 children). Nineteen of these were living donor (LD) and eight were deceased donor (DD) liver transplants. Preoperative blood augmentation with erythropoietin and iron was achieved. At induction, all LD and six of eight DD recipients underwent acute normovolemic hemodilution (ANH), and the operation was conducted under conditions of moderate anemia. Cell scavenging techniques were used. Acute normovolemic hemodilution and salvaged blood were returned as needed during bleeding or on completion of transplantation. RESULTS: The preoperative liver disease severity score was higher in the deceased donor group. We had 100% graft and patient survivals in the LD group, and 75% in the DD recipients. Two DD recipients died. The remaining are all alive and well, with a mean followup of 965 days (range 266 to 1,979 days) in the LD group and 624 days (range 119 to 1,132 days) in the DD group. CONCLUSIONS: Preoperative blood augmentation and acute normovolemic hemodilution provide a safe cushion against operative blood loss. Elective living donor liver transplantation allows full implementation of a transfusion-free strategy in the setting of early hepatic failure, portal hypertension, and anemia. This feat is an important step toward global standardization of transfusion-free surgical practice and an important response to widespread blood shortages and transfusion risks.

Blood Loss, Surgical↗
PubMed2004

Comparison of a new fibrin sealant with standard topical hemostatic agents.

BACKGROUND: Bleeding following liver resection continues to be a significant morbidity of the procedure. Fibrin sealants represent an improvement over conventional topical hemostatic agents, because they contain components that actively form clot. However, most available agents contain nonhuman protein, which represents an immunologic risk. HYPOTHESIS: An investigational surgical fibrin sealant (Crosseal; American Red Cross, Washington, DC) composed of human clottable proteins and human thrombin is more effective than standard topical hemostatic agents in reducing the time required to achieve hemostasis after liver resection. DESIGN: Prospective, randomized, controlled trial. SETTING: Fifteen major referral centers in the United States and the United Kingdom. METHODS: After liver resection using standard surgical techniques, 121 patients seen between May 1999 and May 2000 were randomized to treatment with a 2-component fibrin sealant (n=58) or to standard topical hemostatic agents, used singly or in combination (n=63). Up to 10 mL of Crosseal was administered by a spray applicator, as recommended by the manufacturer, whereas agents used in the control group were applied according to their instructions for use. MAIN OUTCOME MEASURES: The primary outcome measured was time to hemostasis. Secondary outcomes measured included blood loss between application of the hemostatic agent and closure of the abdomen, duration of postoperative biliary drainage, and the occurrence of complications, defined a priori as reoperation for any reason, development of abdominal fluid collections, or bilious appearance of drained fluid for at least 1 day postoperatively. RESULTS: The mean time to hemostasis was 282 seconds with Crosseal, compared with 468 seconds with standard agents (2-sided; P =.06), for the 116 efficacy-evaluable patients. Hemostasis was achieved within 10 minutes in 53 patients (91.4%) treated with the study fibrin sealant and in 44 control patients (69.8%) (2-sided; P =.003). Intraoperative blood loss was similar in the 2 groups. In the Crosseal group, the percentage of patients developing postoperative complications was 17.2%, compared with 36.5% in the control group (2-sided; P =.02). CONCLUSIONS: Compared with the use of standard topical hemostatic agents, Crosseal fibrin sealant significantly reduced the time to achieve hemostasis following liver resection. Patients treated with the new fibrin sealant also experienced significantly fewer postoperative complications.

Adult↗
PubMed2004

Live donor liver transplantation: staging hepatectomy in a Jehovah's Witness recipient.

Orthotopic liver transplantation (OLT) is usually associated with significant blood loss and frequently requires the usage of blood products. OLT has been offered sparingly in Jehovah's Witness (JW) patients because of their refusal to accept blood products for religious reasons. Several innovations have made surgery safer in these patients. These include the pre-operative use of erythropoietin to increase red cell mass, the use of intraoperative cell salvage and acute normovolemic hemodilution, and judicious postoperative blood testing. Thoughtful perioperative decision-making and careful surgical techniques remain the cornerstone to a successful outcome. We report our experience in a two-stage hepatectomy done for a JW patient who underwent live donor liver transplant from his mother, also a JW, without blood transfusion. The recipient had an unusually enlarged left lateral segment of the liver which was densely adherent to the spleen. Removing these adhesions in the presence of significant portal hypertension would have resulted in considerable blood loss. This was successfully avoided by leaving this portion of the liver attached to the spleen while proceeding with the hepatectomy. The right lobe of the liver from the donor was then implanted uneventfully. Two weeks later the remaining segment of the recipient liver was removed without incident. The two-stage procedure was life-saving in this JW patient.

Adult↗
PubMed2004

Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application.

OBJECTIVE: Developing strategies for transfusion-free live donor liver transplantation in Jehovah's Witness patients. SUMMARY BACKGROUND DATA: Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovah's Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovah's Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients. METHODS: From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovah's Witness patients (transfusion-free group) and 30 in non-Jehovah's Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed. RESULTS: Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/- 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients. CONCLUSIONS: Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.

Blood Transfusion↗
PubMed2003

Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service.

BACKGROUND/AIMS: There remains a critical shortage of cadaveric organs. At a large inner city level one trauma centre, several strategies were devised and combined to (a). optimize the physiologic status of potential donors, (b). promote awareness of the donation process among health care professionals and (c). perform quality control on the organ donation system - all in an effort to improve organ donation rates. Resuscitative and maintenance protocols were devised and implemented through a multidisciplinary team approach for patients diagnosed with brain death. We report the effect this approach has had on organ donation in a single centre. METHOD: A death record review (DRR) by the local organ procurement agency (OPO) was used to identify the number of patients diagnosed with brain death at Los Angeles County Hospital each year from 1995 through 2001. Data were collected to determine the number of these potential donors that eventually underwent organ donation. Data were collected for two time intervals: Phase I (1995-98) and Phase II (1999-2001). During Phase I, there was no focused institutional programme for the approach to potential donors. During Phase II, an institutional programme including the following characteristics was implemented: 1). donor resuscitation protocol, 2). assignment of a dedicated OPO coordinator liaison to interact with families, hospital personnel and the coroner's office, 3). assignment of the primary role of stabilization and care of potential donors and the integration of all medical services to the trauma service, and 4). biweekly conferences to review policies, protocols, and outcomes of donor management strategies. RESULTS: From 1995 to 2001 there was a large increase in patient referrals for donor evaluation from 86 (Phase I) to 124 (Phase II). There was a smaller increase in the number of suitable donors: Phase I (mean: 51/year) and Phase II (mean: 63/year). There was, however, an increase in the mean number of actual organ donors from 14.2/year to 25.7/year from Phase I to Phase II and an increase in organs donated from 29 to 49. Organ donor declines decreased from 53% (Phase I) to 39% (Phase II). CONCLUSIONS: Strategies to increase the number of cadaveric organs available for organ transplantation are crucial. A strategy combining prompt identification of potential organ donors, institution of resuscitative protocols, a multidisciplinary team approach, educational activities and utilization of personnel expert in organ procurement led to a marked increase in the number of organ donors and the number of organs donated at a single institution. Wider application of this approach should prove successful in increasing organ donation in a similar fashion in other institutions.

Cadaver↗
PubMed2003

Comparison of outcomes in noncomplicated and in higher-risk donors after standard versus hand-assisted laparoscopic nephrectomy.

Hand-assisted techniques facilitated dissemination of the laparoscopic approach in live kidney donors and addressed concerns regarding potential procedural complications. We report our experience with both standard and hand-assisted laparoscopic nephrectomy in routine, complicated, and higher-risk donors. From July 1999 to September 2002, 47 donors underwent standard laparoscopic donor nephrectomy (SLDN; n = 29) or hand-assisted laparoscopic donor nephrectomy (HALDN; n = 18). Donors were "complicated" if they were > 60 years of age, obese, refused blood-product transfusion, had multiple renal arteries or veins, or had right nephrectomies. "Higher-risk" donors had two or more risk factors. Results for SLDN and HALDN were compared for the overall groups and for the "complicated" and "higher-risk" groups. No donor required blood transfusion or reoperation. Warm-ischemia times were shorter in left nephrectomies (191 +/- 72 seconds vs. 337 +/- 95 seconds, P = 0.005), and blood loss was greater in patients with a body mass index > or = 30 kg/m2 (296 +/- 232 mL vs. 170 +/- 139 mL, P = 0.03). Higher-risk donors had an increased operative blood loss and longer hospital stay than low-risk donors. Mean donor creatinine at discharge was 1.19 +/- 0.2 mg/dL. Comparison of SLDN versus HALDN revealed shorter operating times for the latter, which approached statistical significance. Warm-ischemia time, operative blood loss, length of hospitalization, and donor and recipient discharge creatinines were similar for both groups. Laparoscopic donor nephrectomy can be applied to selected higher-risk donors with outcomes comparable to uncomplicated donors. Hand-assisted techniques facilitate the procedure during the learning curve, with advantages similar to standard laparoscopic techniques.

Adult↗
PubMed2003

Characteristics and management of splenic artery aneurysm in liver transplant candidates and recipients.

The incidence of splenic artery aneurysm (SAA) in patients with cirrhosis ranges from 7 per cent to 17 per cent. SAA rupture after liver transplantation (LT) is reported to result in significant morbidity and mortality. We report our experience with SAA in LT candidates. From September 1995 through August 2002, 14 LT candidates were diagnosed with SAA. Twenty SAA occurred in 14 patients with an average diameter of 20 mm. Eleven patients qualified for LT; to date, seven have been transplanted. No intervention for SAA occurred prior to LT. Of the seven patients transplanted, four had SAA identified prior to LT. Three were treated at LT and are alive; the fourth had postoperative splenic artery embolization followed by splenectomy and expired on day 109 from duodenal ulcer complications. Three of seven patients had undiagnosed SAA at LT. One required emergency splenectomy for SAA rupture and is alive at 44 months. The remaining two received no treatment; one suffered a late septic death and one is alive at 15 months. No ruptures occurred in our pre-LT population, suggesting that definitive management can await LT. We recommend that all patients undergo four-phase computed tomography or magnetic resonance angiography (MRA) as part of the LT evaluation and that identified SAA be resected at transplantation.

Adult↗