Pulmonary and metabolic responses to hepatic excision in liver transplant recipients with hepatocellular carcinoma (HCC)

Background: Liver transplantation for HCC is a complex procedure that imposes significant physiological stress, especially during hepatic excision. This phase is associated with marked alterations in pulmonary function (PF) and arterial blood gases (ABG), influenced by surgical manipulation, anesthesia, and comorbidities. Transplantation includes 3 phases: dissection (removal of native liver), anhepatic (no liver function), and reperfusion (graft blood flow restoration). Method: In this retrospective study, 126 HCC patients who underwent liver transplantation at Atakent Acibadem Hospital (2015–2024) were analyzed. Alongside PF tests and ABG parameters, perioperative variables were evaluated, including MELD score, liver and kidney function tests, tumor characteristics, donor-recipient serology, operative details, immunosuppression, complications, graft/recipient weight ratio, and post-transplant outcomes. Result: The cohort was predominantly male (80%), mean age 60±7 years, with 10% having chronic lung disease. Mean FVC 3371±761mL, FEV1 2590±634mL, and FEV1/FVC 77±9%. During hepatic excision and the anhepatic phase, ABG analysis showed mild acid-base disturbances: mean pH 7.34–7.41, PaO2 85–218mmHg, PaCO2 33–41mmHg, SO2 92–99%, HCO3 20–26mmol/L, and lactate 1.5–5.2mmol/L. The highest lactate and most pronounced acid-base shifts occurred during the reperfusion phase. Pulmonary complications occurred in up to 32% of cases, often linked to intraoperative instability and fluid shifts. Conclusion: Careful perioperative monitoring of ABG and individualized fluid strategies are essential to minimize pulmonary complications and optimize outcomes in this high-risk population.