Abernethy Sendromlu Pediatrik Hastada Anestezi Yönetimi
Özet
Abernethy sendromu portal kanın akımının, konjenital olarak karaciğerden sapması ile karakterize, çoğunlukla çocukluk döneminde tanı alan nadir bir sendromdur (1). Portal venin yokluğu veya küçük portal ven dallarının varlığı olarak sınıflandırılan iki alt tipi vardır. Dalak ve bağırsaklardan gelen kan, karaciğeri dışarıda bırakan bir şant aracılığıyla inferior vena kavaya (İVK) geçer ve pulmoner vazoaktif maddelerin metabolizmasında değişikliğe; pulmoner vazodilatasyona, difüzyon-perfüzyon bozukluğuna ve arteriyel hipoksemiye neden olur. Abernethy sendromu hepato-pulmoner sendromun etiyolojilerinden biri olarak kabul edilir (2). Preoperatif dönemde sendromun sebep olduğu portal akım anomalileri sonucu gelişen karaciğer hastalığı ve bu karaciğer hastalığının diğer organ sistemleri üzerine etkileri değerlendirilmelidir. Özellikle karaciğer yetmezliği mevcutsa kapsamlı bir değerlendirme yapılmalı, zaman varsa sistemsel sorunlar ameliyat öncesinde optimize edilmelidir. Postoperatif dönemde dekompansasyon açısından riskler unutulmamalı, hasta yakın takip edilmelidir.
Abernethy syndrome is a rare disorder, typically diagnosed in childhood, characterized by the congenital diversion of portal blood flow from the liver (1). There are two subtypes of this syndrome: the absence of the portal vein and the presence of small portal vein branches. In this condition, blood from the spleen and intestines bypasses the liver via a shunt and flows directly into the inferior vena cava (IVC). This bypass alters the metabolism of pulmonary vasoactive substances, leading to pulmonary vasodilation, diffusion-perfusion mismatch, and arterial hypoxemia. Abernethy syndrome is recognized as one of the etiologies of hepatopulmonary syndrome (2).
In the preoperative period, it is crucial to evaluate the liver disease caused by portal flow anomalies and the impact of this liver disease on other organ systems. A thorough assessment is particularly necessary if liver failure is present; systemic issues should be optimized before surgery if time permits. In the postoperative period, the risks of decompensation must not be overlooked, and the patient should be closely monitored.
Referanslar
Howard ER, Davenport M. Congenital extrahepatic portocaval shunts—the Abernethy malformation. Journal of pediatric surgery. 1997;32(3): 494-97. doi: 10.1016/s0022-3468(97)90614-x
Alvarez AE, Ribeiro AnF, Hessel G, et al. Abernethy malformation: one of the etiologies of hepatopulmonary syndrome. Pediatric pulmonology. 2002;34(5): 391-404. doi: 10.1002/ppul.10182
Gilbert-Kawai N, Hogan B, Milan Z. Perioperative management of patients with liver disease. BJA education. 2022;22(3): 111. doi: 10.1016/j.amsu.2022.103397
Haq MM, Faisal N, Khalil A, et al. Midazolam for sedation during diagnostic or therapeutic upper gastrointestinal endoscopy in cirrhotic patients. European journal of gastroenterology & hepatology. 2012;24(10): 1214-18. doi: 10.1097/MEG.0b013e328356ae49
Mindikoglu AL, Pappas SC. New developments in hepatorenal syndrome. Clinical Gastroenterology and Hepatology. 2018;16(2): 162-77. doi: 10.1016/j.cgh.2017.05.041
Giannini EG, Testa R, Savarino V. Liver enzyme alteration: a guide for clinicians. Cmaj. 2005;172(3): 367-79. doi: 10.1503/cmaj.1040752
Redelmeier DA. New thinking about postoperative hypoalbuminemia: a hypothesis of occult protein-losing enteropathy. Open Medicine. 2009;3(4): e215.
Ruiz-del-Árbol L, Serradilla R. Cirrhotic cardiomyopathy. World journal of gastroenterology. 2015;21(41): 11502. doi: 10.3748/wjg.v21.i41.11502
Rudzinski W, Waller AH, Prasad A, et al. New index for assessing the chronotropic response in patients with end-stage liver disease who are undergoing dobutamine stress echocardiography. Liver Transplantation. 2012;18(3): 355-60. doi: 10.1002/lt.22476
Mandras SA, Mehta HS, Vaidya A. Pulmonary hypertension: a brief guide for clinicians. Mayo Clinic Proceedings. 2020;95(9): 1978-88 doi: 10.1016/j.mayocp.2020.04.039
Safdar Z, Bartolome S, Sussman N. Portopulmonary hypertension: an update. Liver Transplantation. 2012;18(8): 881-91. doi: 10.1002/lt.23485
Fauconnet P, Klopfenstein CE, Schiffer E. Hepatopulmonary syndrome: the anaesthetic considerations. European Journal of Anaesthesiology| EJA. 2013;30(12): 721-30. doi: 10.1097/EJA.0b013e328365bb6f
Sharma AK, Kaufman DC. TIPS performed in a patient with complete portal vein thrombosis. Radiology Case Reports. 2017;12(2): 327-30. doi: 10.1016/j.radcr.2017.01.013
Suk KT. Hepatic venous pressure gradient: clinical use in chronic liver disease. Clinical and molecular hepatology. 2014;20(1): 6. doi: 10.3350/cmh.2014.20.1.6
Albillos A, Lario M, Álvarez-Mon M. Cirrhosis-associated immune dysfunction: distinctive features and clinical relevance. Journal of hepatology. 2014;61(6): 1385-96. doi: 10.1016/j.jhep.2014.08.010
Sonsuz A. Asit ve komplikasyonlarının tedavisi. In. 8. Ulusal İç Hastalıkları Kongresi, 13-17 Eylül 2006, Antalya, Türkiye, (pp. 97-99).
Jain D, Mahmood E, Maria V, et al. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Annals of gastroenterology. 2018;31(3): 330. doi: 0.20524/aog.2018.0249
Rosemurgy A, Statman R, Murphy C, et al. Postoperative ascitic leaks: the ongoing challenge. Surgery. 1992;111(6): 623-25.
Tsiaousi ET, Hatzitolios AI, Trygonis SK, et al. Malnutrition in end stage liver disease: recommendations and nutritional support. Journal of gastroenterology and hepatology. 2008;23(4): 527-33. doi: 10.1111/j.1440-1746.2008.05369.x
Norman K, Haß U, Pirlich M. Malnutrition in older adults—recent advances and remaining challenges. Nutrients. 2021;13(8): 2764. doi: 10.3390/nu13082764
Serón-Arbeloa C, Labarta-Monzón L, Puzo-Foncillas J, et al. Malnutrition screening and assessment. Nutrients. 2022;14(12): 2392. doi: 10.3390/nu14122392
Mukhtar A, Masry AE, Moniem A, et al. The impact of maintaining normal serum albumin level following living related liver transplantation: does serum albumin level affect the course? A pilot study. Transplantation proceedings; 2007;39(10): 3214-18. doi: 10.1016/j.transproceed.2007.06.084
Tufoni M, Zaccherini G, Caraceni P, et al. Albumin: indications in chronic liver disease. United European Gastroenterology Journal. 2020;8(5): 528-35. doi: 10.1177/2050640620910339
Kappus MR. Acute hepatic failure and nutrition. Nutrition in Clinical Practice. 2020;35(1): 30-35. doi: 10.1002/ncp.10462
Amodio P, Bemeur C, Butterworth R, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58(1): 325-36. doi: 10.1002/hep.26370
Morkane CM, Kearney O, Bruce DA, et al. An outpatient hospital-based exercise training program for patients with cirrhotic liver disease awaiting transplantation: a feasibility trial. Transplantation. 2020;104(1): 97-103. doi: 10.1097/TP.0000000000002803
Kaibori M, Ishizaki M, Matsui K, et al. Perioperative exercise for chronic liver injury patients with hepatocellular carcinoma undergoing hepatectomy. The American Journal of Surgery. 2013;206(2): 202-09. doi: 10.1016/j.amjsurg.2012.07.035
Williams FR, Milliken D, Lai JC, et al. Assessment of the frail patient with end‐stage liver disease: a practical overview of sarcopenia, physical function, and disability. Hepatology communications. 2021;5(6): 923-37. doi: 10.1002/hep4.1688
Kim HY, Jang JW. Sarcopenia in the prognosis of cirrhosis: going beyond the MELD score. World journal of gastroenterology: WJG. 2015;21(25): 7637. doi: 10.3748/wjg.v21.i25.7637
Laube R, Wang H, Park L, et al. Frailty in advanced liver disease. Liver International. 2018;38(12): 2117-28. doi: 10.1111/liv.13917
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness?: a systematic review of the literature and the tale of seven mares. Chest. 2008;134(1): 172-78. doi: 10.1378/chest.07-2331
Markin NW, Sharma A, Grant W, et al. The Safety of Transesophageal Echocardiography in Patients Undergoing Orthotopic Liver Transplantation. Journal of Cardiothoracic and Vascular Anesthesia. 2015;29(3): 588-93. doi: 10.1053/j.jvca.2014.10.012
Servin F, Desmonts JM, Haberer JP, et al. Pharmacokinetics and protein binding of propofol in patients with cirrhosis. Anesthesiology. 1988;69(6): 887-91. doi: 10.1097/00000542-198812000-00014
Bosilkovska M, Walder B, Besson M, et al. Analgesics in patients with hepatic impairment: pharmacology and clinical implications. Drugs. 2012;72: 1645-69. doi: 10.2165/11635500-000000000-00000
Hayward KL, Powell EE, Irvine KM, et al. Can paracetamol (acetaminophen) be administered to patients with liver impairment? British journal of clinical pharmacology. 2016;81(2): 210-22. doi: 10.1111/bcp.12802
Antman EM, Bennett JS, Daugherty A, et al. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007;115(12): 1634-42. doi: 10.1161/CIRCULATIONAHA.106.181424
Mcclain RL, Ramakrishna H, Aniskevich III S, et al. Anesthetic pharmacology and perioperative considerations for the end stage liver disease patient. Current Clinical Pharmacology. 2015;10(1): 35-46. doi: 10.2174/1574884709666140212110036
Craig R, Hunter J. Neuromuscular blocking drugs and their antagonists in patients with organ disease. Anaesthesia. 2009;64: 55-65. doi: 10.1111/j.1365-2044.2008.05871.x
Alvarellos ML, McDonagh EM, Patel S, et al. PharmGKB summary: succinylcholine pathway, pharmacokinetics/pharmacodynamics. Pharmacogenetics and genomics. 2015;25(12): 622-30. doi: 10.1097/FPC.0000000000000170
Kharasch ED. Biotransformation of sevoflurane. Anesthesia & Analgesia. 1995;81(6S): 27-38. doi: 10.1097/00000539-199512001-00005
Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood. 2010;116(6): 878-85. doi: 10.1182/blood-2010-02-261891
Verbeek TA, Stine JG, Saner FH, et al. Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management. Transplantation Direct. 2018;4(11): e403. doi: 10.1097/TXD.0000000000000843
T.C. Sağlık Bakanlığı, Sağlık Hizmetleri Genel Müdürlüğü. Hasta kan yönetimi rehberi: Modül 2 Perioperatif. (19/05/2024 tarihinde https://dosyamerkez.saglik.gov.tr/Eklenti/44847/0/2-hasta-kan-yonetimi-rehberi-modul-2---perioperatifpdf.pdf adresinden ulaşılmıştır).
Northup PG, Caldwell SH. Coagulation in Liver Disease: A Guide for the Clinician. Clinical Gastroenterology and Hepatology. 2013;11(9): 1064-74. doi: 10.1016/j.cgh.2013.02.026
Siniscalchi A, Gamberini L, Bardi T, et al. Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients - results after three years of practice. World J Hepatol. 2016;8(26): 1097-104. doi: 10.4254/wjh.v8.i26.1097
Gao Y, Liu L, Cui Y, et al. Postoperative analgesia efficacy of erector spinae plane block in adult abdominal surgery: A systematic review and meta-analysis of randomized trials. Frontiers in Medicine. 2022;9: 934866. doi: 10.3389/fmed.2022.934866
Canillas L, Pelegrina A, Álvarez J, et al. Clinical guideline on perioperative management of patients with advanced chronic liver disease. Life. 2023;13(1): 132. doi: 10.3390/life13010132
Weeder PD, Porte RJ, Lisman T. Hemostasis in liver disease: implications of new concepts for perioperative management. Transfusion medicine reviews. 2014;28(3): 107-13. doi: 10.1016/j.tmrv.2014.03.002
Zhou S, Deng F, Zhang J, et al. Incidence and risk factors for postoperative delirium after liver transplantation: a systematic review and meta-analysis. European Review for Medical & Pharmacological Sciences. 2021;25(8): 3246-53. doi: 10.26355/eurrev_202104_25733
Campos-Varela I, Blumberg E, Giorgio P, et al. What is the optimal antimicrobial prophylaxis to prevent postoperative infectious complications after liver transplantation? A systematic review of the literature and expert panel recommendations. Clin Transplant. 2022;36: e14631. doi: 10.1111/ctr.14631
Referanslar
Howard ER, Davenport M. Congenital extrahepatic portocaval shunts—the Abernethy malformation. Journal of pediatric surgery. 1997;32(3): 494-97. doi: 10.1016/s0022-3468(97)90614-x
Alvarez AE, Ribeiro AnF, Hessel G, et al. Abernethy malformation: one of the etiologies of hepatopulmonary syndrome. Pediatric pulmonology. 2002;34(5): 391-404. doi: 10.1002/ppul.10182
Gilbert-Kawai N, Hogan B, Milan Z. Perioperative management of patients with liver disease. BJA education. 2022;22(3): 111. doi: 10.1016/j.amsu.2022.103397
Haq MM, Faisal N, Khalil A, et al. Midazolam for sedation during diagnostic or therapeutic upper gastrointestinal endoscopy in cirrhotic patients. European journal of gastroenterology & hepatology. 2012;24(10): 1214-18. doi: 10.1097/MEG.0b013e328356ae49
Mindikoglu AL, Pappas SC. New developments in hepatorenal syndrome. Clinical Gastroenterology and Hepatology. 2018;16(2): 162-77. doi: 10.1016/j.cgh.2017.05.041
Giannini EG, Testa R, Savarino V. Liver enzyme alteration: a guide for clinicians. Cmaj. 2005;172(3): 367-79. doi: 10.1503/cmaj.1040752
Redelmeier DA. New thinking about postoperative hypoalbuminemia: a hypothesis of occult protein-losing enteropathy. Open Medicine. 2009;3(4): e215.
Ruiz-del-Árbol L, Serradilla R. Cirrhotic cardiomyopathy. World journal of gastroenterology. 2015;21(41): 11502. doi: 10.3748/wjg.v21.i41.11502
Rudzinski W, Waller AH, Prasad A, et al. New index for assessing the chronotropic response in patients with end-stage liver disease who are undergoing dobutamine stress echocardiography. Liver Transplantation. 2012;18(3): 355-60. doi: 10.1002/lt.22476
Mandras SA, Mehta HS, Vaidya A. Pulmonary hypertension: a brief guide for clinicians. Mayo Clinic Proceedings. 2020;95(9): 1978-88 doi: 10.1016/j.mayocp.2020.04.039
Safdar Z, Bartolome S, Sussman N. Portopulmonary hypertension: an update. Liver Transplantation. 2012;18(8): 881-91. doi: 10.1002/lt.23485
Fauconnet P, Klopfenstein CE, Schiffer E. Hepatopulmonary syndrome: the anaesthetic considerations. European Journal of Anaesthesiology| EJA. 2013;30(12): 721-30. doi: 10.1097/EJA.0b013e328365bb6f
Sharma AK, Kaufman DC. TIPS performed in a patient with complete portal vein thrombosis. Radiology Case Reports. 2017;12(2): 327-30. doi: 10.1016/j.radcr.2017.01.013
Suk KT. Hepatic venous pressure gradient: clinical use in chronic liver disease. Clinical and molecular hepatology. 2014;20(1): 6. doi: 10.3350/cmh.2014.20.1.6
Albillos A, Lario M, Álvarez-Mon M. Cirrhosis-associated immune dysfunction: distinctive features and clinical relevance. Journal of hepatology. 2014;61(6): 1385-96. doi: 10.1016/j.jhep.2014.08.010
Sonsuz A. Asit ve komplikasyonlarının tedavisi. In. 8. Ulusal İç Hastalıkları Kongresi, 13-17 Eylül 2006, Antalya, Türkiye, (pp. 97-99).
Jain D, Mahmood E, Maria V, et al. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Annals of gastroenterology. 2018;31(3): 330. doi: 0.20524/aog.2018.0249
Rosemurgy A, Statman R, Murphy C, et al. Postoperative ascitic leaks: the ongoing challenge. Surgery. 1992;111(6): 623-25.
Tsiaousi ET, Hatzitolios AI, Trygonis SK, et al. Malnutrition in end stage liver disease: recommendations and nutritional support. Journal of gastroenterology and hepatology. 2008;23(4): 527-33. doi: 10.1111/j.1440-1746.2008.05369.x
Norman K, Haß U, Pirlich M. Malnutrition in older adults—recent advances and remaining challenges. Nutrients. 2021;13(8): 2764. doi: 10.3390/nu13082764
Serón-Arbeloa C, Labarta-Monzón L, Puzo-Foncillas J, et al. Malnutrition screening and assessment. Nutrients. 2022;14(12): 2392. doi: 10.3390/nu14122392
Mukhtar A, Masry AE, Moniem A, et al. The impact of maintaining normal serum albumin level following living related liver transplantation: does serum albumin level affect the course? A pilot study. Transplantation proceedings; 2007;39(10): 3214-18. doi: 10.1016/j.transproceed.2007.06.084
Tufoni M, Zaccherini G, Caraceni P, et al. Albumin: indications in chronic liver disease. United European Gastroenterology Journal. 2020;8(5): 528-35. doi: 10.1177/2050640620910339
Kappus MR. Acute hepatic failure and nutrition. Nutrition in Clinical Practice. 2020;35(1): 30-35. doi: 10.1002/ncp.10462
Amodio P, Bemeur C, Butterworth R, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58(1): 325-36. doi: 10.1002/hep.26370
Morkane CM, Kearney O, Bruce DA, et al. An outpatient hospital-based exercise training program for patients with cirrhotic liver disease awaiting transplantation: a feasibility trial. Transplantation. 2020;104(1): 97-103. doi: 10.1097/TP.0000000000002803
Kaibori M, Ishizaki M, Matsui K, et al. Perioperative exercise for chronic liver injury patients with hepatocellular carcinoma undergoing hepatectomy. The American Journal of Surgery. 2013;206(2): 202-09. doi: 10.1016/j.amjsurg.2012.07.035
Williams FR, Milliken D, Lai JC, et al. Assessment of the frail patient with end‐stage liver disease: a practical overview of sarcopenia, physical function, and disability. Hepatology communications. 2021;5(6): 923-37. doi: 10.1002/hep4.1688
Kim HY, Jang JW. Sarcopenia in the prognosis of cirrhosis: going beyond the MELD score. World journal of gastroenterology: WJG. 2015;21(25): 7637. doi: 10.3748/wjg.v21.i25.7637
Laube R, Wang H, Park L, et al. Frailty in advanced liver disease. Liver International. 2018;38(12): 2117-28. doi: 10.1111/liv.13917
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness?: a systematic review of the literature and the tale of seven mares. Chest. 2008;134(1): 172-78. doi: 10.1378/chest.07-2331
Markin NW, Sharma A, Grant W, et al. The Safety of Transesophageal Echocardiography in Patients Undergoing Orthotopic Liver Transplantation. Journal of Cardiothoracic and Vascular Anesthesia. 2015;29(3): 588-93. doi: 10.1053/j.jvca.2014.10.012
Servin F, Desmonts JM, Haberer JP, et al. Pharmacokinetics and protein binding of propofol in patients with cirrhosis. Anesthesiology. 1988;69(6): 887-91. doi: 10.1097/00000542-198812000-00014
Bosilkovska M, Walder B, Besson M, et al. Analgesics in patients with hepatic impairment: pharmacology and clinical implications. Drugs. 2012;72: 1645-69. doi: 10.2165/11635500-000000000-00000
Hayward KL, Powell EE, Irvine KM, et al. Can paracetamol (acetaminophen) be administered to patients with liver impairment? British journal of clinical pharmacology. 2016;81(2): 210-22. doi: 10.1111/bcp.12802
Antman EM, Bennett JS, Daugherty A, et al. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007;115(12): 1634-42. doi: 10.1161/CIRCULATIONAHA.106.181424
Mcclain RL, Ramakrishna H, Aniskevich III S, et al. Anesthetic pharmacology and perioperative considerations for the end stage liver disease patient. Current Clinical Pharmacology. 2015;10(1): 35-46. doi: 10.2174/1574884709666140212110036
Craig R, Hunter J. Neuromuscular blocking drugs and their antagonists in patients with organ disease. Anaesthesia. 2009;64: 55-65. doi: 10.1111/j.1365-2044.2008.05871.x
Alvarellos ML, McDonagh EM, Patel S, et al. PharmGKB summary: succinylcholine pathway, pharmacokinetics/pharmacodynamics. Pharmacogenetics and genomics. 2015;25(12): 622-30. doi: 10.1097/FPC.0000000000000170
Kharasch ED. Biotransformation of sevoflurane. Anesthesia & Analgesia. 1995;81(6S): 27-38. doi: 10.1097/00000539-199512001-00005
Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood. 2010;116(6): 878-85. doi: 10.1182/blood-2010-02-261891
Verbeek TA, Stine JG, Saner FH, et al. Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management. Transplantation Direct. 2018;4(11): e403. doi: 10.1097/TXD.0000000000000843
T.C. Sağlık Bakanlığı, Sağlık Hizmetleri Genel Müdürlüğü. Hasta kan yönetimi rehberi: Modül 2 Perioperatif. (19/05/2024 tarihinde https://dosyamerkez.saglik.gov.tr/Eklenti/44847/0/2-hasta-kan-yonetimi-rehberi-modul-2---perioperatifpdf.pdf adresinden ulaşılmıştır).
Northup PG, Caldwell SH. Coagulation in Liver Disease: A Guide for the Clinician. Clinical Gastroenterology and Hepatology. 2013;11(9): 1064-74. doi: 10.1016/j.cgh.2013.02.026
Siniscalchi A, Gamberini L, Bardi T, et al. Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients - results after three years of practice. World J Hepatol. 2016;8(26): 1097-104. doi: 10.4254/wjh.v8.i26.1097
Gao Y, Liu L, Cui Y, et al. Postoperative analgesia efficacy of erector spinae plane block in adult abdominal surgery: A systematic review and meta-analysis of randomized trials. Frontiers in Medicine. 2022;9: 934866. doi: 10.3389/fmed.2022.934866
Canillas L, Pelegrina A, Álvarez J, et al. Clinical guideline on perioperative management of patients with advanced chronic liver disease. Life. 2023;13(1): 132. doi: 10.3390/life13010132
Weeder PD, Porte RJ, Lisman T. Hemostasis in liver disease: implications of new concepts for perioperative management. Transfusion medicine reviews. 2014;28(3): 107-13. doi: 10.1016/j.tmrv.2014.03.002
Zhou S, Deng F, Zhang J, et al. Incidence and risk factors for postoperative delirium after liver transplantation: a systematic review and meta-analysis. European Review for Medical & Pharmacological Sciences. 2021;25(8): 3246-53. doi: 10.26355/eurrev_202104_25733
Campos-Varela I, Blumberg E, Giorgio P, et al. What is the optimal antimicrobial prophylaxis to prevent postoperative infectious complications after liver transplantation? A systematic review of the literature and expert panel recommendations. Clin Transplant. 2022;36: e14631. doi: 10.1111/ctr.14631
