Objectives: Pulmonary complications are a leading problem after a liver transplant. This study sought to predict postoperative early complications by a chest radiograph performed after a transplant among adult orthotopic liver transplant recipients.

Materials and Methods: One hundred thirty-five patients (43 women, 92 men; mean age, 40 y; range, 16-66 y) were included and their medical data reviewed retrospectively. A postoperative chest radiograph of each patient was evaluated to check for pulmonary complications.

Results: Smoking history was noted in 61 patients (45.2%). Postoperative first chest radiograph evaluation showed normal findings in 56 patients (41.5%). Right pleural effusion was found in 25 patients (18.5%), and atelectasis was found in 25 (18.5%). Bilateral pleural effusion was the second most-frequent finding on postoperative radiograph (14.8%). Effusion accompanied by atelectasis was found in 3 patients (2.2%). Other postoperative chest radiograph findings were consolidation (n=2, 1.5%), left pleural effusion (n=2, 1.5%), and bronchiectasis (n=2, 1.5%).

Conclusions: We investigated the reflection of the first chest radiograph after liver transplant on postoperative early complications. Postoperative first chest radiograph can be an inexpensive and accessible diagnostic tool for predicting postoperative problems.

Key words : Chest radiograph, Pleural effusion, Postoperative

Introduction

Liver transplant is a successful treatment for patients with acute liver failure and end-stage liver cirrhosis. Postoperative complications of a transplant require unique and intensive management approach. Early detection and management of complications can reduce the risk of morbidity and mortality. In the first month course after transplant, surgical complications, graft dysfunction, and infections are the most common problems.^1,2 Pulmonary complications also are one of the leading problems after a liver transplant. Complications and their results vary depending on the time after a transplant. However, in every stage of the transplant, infections remain a common life-threatening complication despite prophylactic strategies.^3,4 Infectious and noninfectious pulmonary complications can cause prolonged ventilatory support. Pleural effusion, acute respiratory failure, pulmonary edema, alveolar hemorrhage, and acute respiratory distress syndrome are pulmonary complications that can be encountered after liver transplant. This study sought to predict postoperative early complications by first chest radiograph performed after transplant among adult orthotopic liver transplant recipients.

Materials and Methods

Study population
One hundred thirty-five patients (43 women, 92 men; mean age, 40 y; range, 16-66 y) were included and their medical data reviewed retrospectively. The smoking status, other demographics, mortality, and rejection within a month after transplant were noted. Preoperative pulmonary clinical status also was determined by assessing the preoperative chest radiograph and the patient’s medical history. The postoperative first chest radiograph of each patient was checked for pulmonary complications. Findings of pleural effusion, atelectasis, consolidation, and normal chest radiograph were noted. Pleural effusion was evaluated in 4 groups as right-sided, left-sided, bilateral, and concomitant atelectasis. We also checked for whether thoracentesis was performed in patients with pleural effusion, and the results that evaluation were obtained from the medical records. The relation between findings on the first chest radiograph, and development of postoperative complications within the first month after transplant, was examined.

Statistical analyses
Statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 20.0, IBM Corporation, Armonk, NY, USA). Continuous variables are expressed as means ± standard deviation. Chi-square test was used to compare the qualitative variables. All P values are 2-sided, and values for P less than .05 were considered statistically significant.

Results

One hundred thirty-five patients (43 women, 92 men; mean age, 40 y; range, 16-66 y) were included and their medical data reviewed retrospectively; their characteristics are shown in Table 1. Pulmonary disease, diagnosed before transplant, was detected in 11 patients (8.1%). Sixteen patients (11.9%) had respiratory symptoms before the transplant; the most frequent respiratory symptom was a cough (7.4%). Preoperative chest radiograph was abnormal in 49 patients (36.3%). Right diaphragma elevation, itself or accompanied by other findings, was the most common abnormality on preoperative chest radiograph (23.7%). The other findings included atelectasis (16.3%), pleural effusion (16.3%), left diaphragma elevation (6.7%). The results of a postoperative first chest radiograph were normal in 56 patients (41.5%). Right pleural effusion was found in 25 patients (18.5%), and atelectasis was found in 25 patients (18.5%).

Bilateral pleural effusion was the second most frequent finding on postoperative radiographs (14.8%). Effusion accompanied by atelectasis was found in 3 patients (2.2%) . Other postoperative chest radiograph findings were consolidation (n=2, 1.5%), left pleural effusion (n=2, 1.5%), and bronchiectasis (n=2, 1.5%). Postoperative pulmonary complications within 1 month after transplant were also noted. Sixty-three patients (46.6%) had one of the following pulmonary complications: on-going pleural effusion (23.0%), pneumonia (20.7%), acute respiratory distress syndrome (0.7%), alveolar hemorrhage (0.7%), right heart failure (0.7%), respiratory failure (0.7%), and atelectasis (0.7%). Postoperative pulmonary complications were significantly higher in patients with a postoperative pleural effusion than patients without postoperative pleural effusion (P < .05). Smoking status also correlated with postoperative pulmonary complications (P < .05). Postoperative mortality was investigated among patients with abnormal findings on their postoperative chest radiographs (Figure 1). Mortality was higher in those with abnormal findings on their first chest radiograph after transplant than patients with a normal postoperative chest radiograph. (P = .0). Postoperative pleural effusion was evaluated also and it had a significant relation with postoperative mortality. However, rejection within a month it did not correlate with either postoperative pleural effusion or any other postoperative abnormal findings on chest radiograph (P > .05).

Discussion

Chest radiograph is an inexpensive and easily accessible diagnostic tool used since its discovery in 1895 by Wilhelm Konrad Roentgen. The radiation dose of a chest radiograph is small (~0.2 mSv).⁵ In our study, we investigated reflection of the first chest radiograph after liver transplant on postoperative early complications. Pleural effusion was detected on 50 patients’ (37.0%) postoperative first chest radiographs, 25 were right-sided, 20 were bilateral, 3 were right-sided and accompanied by atelectasis, and 2 were left-sided. Preoperative pleural effusion in liver transplant candidates did not correlate with postoperative pleural effusion (P > .05). Disruption of diaphragmatic lymphatics during hepatectomy is thought to be the principle mechanism of fluid accumulation, especially on the operation side. Intraoperative high fluid input, low protein levels of blood because of insufficient liver function also are reasons for pleural effusion.³ Isolated left-sided effusions are sampled to rule out other causes.⁶ In our study, both of patients with isolated left-sided effusion developed pulmonary complications, one developed pneumonia and the other had pleural effusion that persists more than 3 weeks.

Postoperative pulmonary complications within 1 month after a liver transplant were significantly higher in those with right-sided or bilateral postoperative pulmonary effusion than in patients with other postoperative abnormal findings on their chest radiograph or a normal postoperative chest radiograph (P < .05). Persistent pleural effusion (effusion that does not resolve within 3 weeks or persists or enlarges within 3 weeks) was the most common, and pneumonia was the second most common pulmonary complication in patients with pleural effusion. Previous studies have identified pleural effusion as the most frequent respiratory complication after orthotopic liver transplant.^4,7 After intra-abdominal operations, pleural effusions may enlarge over the first postoperative week but typically resolve by the third week.⁸ The effusion, if allowed stand for a long time, may get infected leading to empyema, and this will be mortal in patients with immunodeficiency. Therefore, follow-up and treatment are important. In our study, thoracentesis was performed in 40 patients because of postoperative pleural effusion (29.6%), and effusion was exudative in 18 patients (13.3%), 7 of them had positive bacterial culture results.

Abnormal findings on the first chest radiograph after transplant were not predictive of transplant rejection within 1 month. However, an extended scan of records that involves a longer time could change the result. New and larger studies can answer this question. When early mortality rates were analyzed, we found that an abnormal chest radiograph was associated with significantly higher early postoperative mortality. Postoperative early pleural effusion alone was associated with early postoperative mortality. Among patients with early postoperative pleural effusion, 13 patients (26.0%) died because of sepsis in the first month after transplant; this was the most frequent cause of death.

Patients undergoing a liver transplant require early diagnosis and intensive treatment to diminish morbidity and mortality associated with postoperative complications. A postoperative first chest radiograph can be an accessible diagnostic tool for predicting postoperative problems. To the best of our knowledge, this is the first study that examines a chest radiograph as a quick predictive method. Larger studies are needed.

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