Carol A. Hirshman, M.D., Editor
Edited by R. Park and Y. Kang. Boston, Butterworth-Heinemann, 1995. Pages: 270. Price: $85.00.
This monograph on the perioperative care of the patient with liver disease is divided into 4 sections and contains 18 chapters. The first section deals with the assessment of patients with liver disease. The second deals with the pharmacology of commonly used drugs in the setting of liver disease. Anesthetic considerations are covered in the third, and the last section deals with the perioperative intensive care often required for patients with hepatic dysfunction.
The chapters are written by 28 recognized hepatologists, anesthesiologists, and intensivists from the United States, the United Kingdom, and Germany. The expressed intent of this volume is to approach the perioperative care of the hepatic patient from the perspective of the many specialties involved before, during, and after surgery.
After a review of anatomy, histology, and hepatic hemodynamics, section 1 examines the causes of liver disease and the assessment of the various liver function tests, including new metabolic tests, such as the monoethylglycinexylidide. Section 2 considers the varied effects of volatile anesthetics on the liver and the effects and pharmacokinetics of intravenous sedative, analgesic, anesthetic, and muscle-relaxant drugs in patients with impaired liver function.
Because the general focus of the text is toward the patient with liver disease undergoing diagnostic and surgical procedures, a number of procedures are covered. Section 3 reviews diagnostic endoscopies, sclerotherapy, and biliary procedures; major hepatic procedures, including porto-systemic shunts; and liver transplantation. The discussion of disordered coagulation of severe liver disease and the effects of massive blood transfusion is excellent. Pediatric hepatic surgery is included, as is hepatic dysfunction during pregnancy.
The perioperative care of severe liver disease includes those patients who require preoperative intensive care as well as those who require short- or long-term intensive care after anesthesia and surgery. Section 4 deals with these areas. Acute liver failure is discussed, including a brief but well written discussion of the management of hepatic encephalopathy and intracranial hypertension. Important postoperative intensive care issues are covered, such as postoperative bleeding and coagulation, fluid balance, ventilator weaning, renal protection, perioperative nutrition, and infection risks.
This book was written to address the multidisciplinary continuum of care required for many hepatic patients. It is well focused on these issues, whether relatively minor diagnostic interventions or hepatic transplantation. References are up-to-date, well chosen, and numerous (mean 78, range 33-154).
Whenever an attempt is made to minimize the length of a text, there is room to second guess about items left out. Some areas could be improved in a later edition. A dynamically malignant form of pulmonary hypertension is seen in a small number of liver transplant patients and complicates the decision-making process, i.e., whether to transplant or to include a pulmonary transplant. These issues are not covered, although this group has a high degree of perioperative mortality. These patients may benefit from the availability of newer drugs, such as nitric oxide, which also is not discussed. The chapters on hepatic procedures do not mention transjugular intrahepatic portosystemic shunting, an increasingly common procedure for non-emergency portal decompression. The controversy over the perioperative management of the liver transplant patient with hepatitis B surface antigen positive disease also is not covered. There are advocates of aggressive intravenous and/or intramuscular hepatitis B immunoglobulin therapy, which represents a commitment of resources to suppress an infection that often does not resolve. Similarly, there is no discussion of cost issues of liver transplantation. Enormous resources are brought to bear for every transplant recipient. Many of the costs are drug, surgery-, and intensive care unit-related; discussion is needed based on as much objective data as is available on areas where expenses can be trimmed. Multiple system organ failure, a devastating development in the liver patient, especially after liver transplantation, is not adequately mentioned. Lastly, the pediatric chapter deals with hepatic surgery but not transplantation. Because there can be significant differences in the management of pediatric liver transplantation in relation to adults, this is unfortunate.
The above limitations notwithstanding, this text represents a reasonable value, especially for those desiring a fairly comprehensive overview of the subjects. Residents and fellows especially will find the book a worthwhile springboard to further reading.
William T. Merritt, M.D., Associate Professor, Head, Liver Transplantation Anesthesia, Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Hospital, 600 North Wolfe Street, Tower 711, Baltimore, Maryland 21287-8711.
© 1995 American Society of Anesthesiologists, Inc.