The impact of consecutive operations on survival after liver transplantation

Accepting multiple simultaneous liver offers does not negatively impact transplant outcomes

Impact of performing multiple liver transplants (LT) in a short period of time is unknown. Consecutively performed LT potentially increase complication rates through team fatigue and overutilization of resources and increase ischemia time. We analyzed the impact of undertaking consecutive LT (Consecutive liver transplant, CLT; LT preceded by another transplant performed not more than 12 h before, both transplants grouped together) on outcomes. Of 1702 LT performed, 314 (18.4%) were CLT. Outcome data was compared with solitary LT (SLT; not more than one LT in 12-h period). Recipient, donor, and graft characteristics were evenly matched between SLT and CLT; second LT of CLT group utilized younger donors grafts with longer cold ischemic times (P = 0.015). Implantation and operative time were significantly lower in CLT recipients on intergroup analysis (P = 0.0001 and 0.002, respectively). Early hepatic artery thrombosis (E-HAT) was higher in CLT versus SLT (P = 0.038), despite absolute number of E-HAT being low in all groups. Intragroup analysis demonstrated a trend toward more frequent E-HAT in first LT, compared to subsequent transplants; however, difference did not reach statistical significance (P = 0.135). In era of organ scarcity, CLT performed at high-volume center is safe and allows pragmatic utilization of organs, potentially reducing number of discarded grafts and reducing waiting list mortality.

Division of surgeon workload in pancreaticoduodenectomy: striving to decrease post-operative pancreatic fistula

BACKGROUND

Many studies have reported factors affecting pancreatic leakage after pancreaticoduodenectomy (PD), but there have been few reports on surgeon workload and post-operative pancreatic fistula (POPF). This study was conducted to explore whether a surgeon's workload during PD impacts the occurrence of POPF.

METHODS

We retrospectively analysed 270 consecutive patients who underwent PD between January 2008 and June 2013 by a single experienced surgeon. These patients were divided into those who underwent PD entirely by a single operator (group 1) and those who received reconstructions by other operators (group 2). Duct-to-mucosa pancreaticojejunostomy was performed on all patients. The International Study Group on Pancreatic Fistula criteria were used to define POPF.

RESULTS

There were 157 patients (58.1%) in group 1 and 113 patients (41.9%) in group 2. The post-operative morbidity rate was comparable between the two groups (55.4% versus 52.2%; P = 0.603), but the clinical pancreatic fistula (grade B/C) rate was significantly different (10.8% versus 2.7%; P = 0.011). The overall post-operative mortality was one patient (0.4%). Significant associations were found between clinical pancreatic fistulas and soft pancreas texture (P = 0.021), preoperative serum albumin level ≤3.5 g/dL (P = 0.012), other pathology besides pancreatic cancer (P = 0.027) and a single-operator procedure (P = 0.019). A multivariate logistic regression analysis revealed that a single operator (odds ratio: 4.2, P = 0.029) was a significant predictive risk factor for clinically relevant POPF.

CONCLUSION

Dividing the surgeon's workload in PD is associated with lower rates of POPF.

Impact of the center on graft failure after liver transplantation

The hospital at which liver transplantation (LT) is performed has a substantial impact on post-LT outcomes. Center-specific outcome data are closely monitored not only by the centers themselves but also by patients and government regulatory agencies. However, the true magnitude of this center effect, apart from the effects of the region and donor service area (DSA) as well as recipient and donor determinants of graft survival, has not been examined. We analyzed data submitted to the Organ Procurement and Transplantation Network for all adult (age ≥ 18 years) primary LT recipients (2005-2008). Using a mixed effects, proportional hazards regression analysis, we modeled graft failure within 1 year after LT on the basis of center (de-identified), region, DSA, and donor and recipient characteristics. At 115 unique centers, 14,654 recipients underwent transplantation. Rates of graft loss within a year varied from 5.9% for the lowest quartile of centers to 20.2% for the highest quartile. Gauged by a comparison of the 75th and 25th percentiles of the data, the magnitude of the center effect on graft survival (1.49-fold change) was similar to that of the recipient Model for End-Stage Liver Disease (MELD) score (1.47) and the donor risk index (DRI; 1.45). The center effect was similar across the DRI and MELD score quartiles and was not associated with a center's annual LT volume. After stratification by region and DSA, the magnitude of the center effect, though decreased, remained significant and substantial (1.30-fold interquartile difference). In conclusion, the LT center is a significant predictor of graft failure that is independent of region and DSA as well as donor and recipient characteristics.

Surgeon fatigue: impact of case order on perioperative parameters and patient outcomes

PURPOSE

We tested the hypothesis that surgeon fatigue results in worse outcomes for laparoscopic and robot-assisted laparoscopic prostatectomy, and percutaneous nephrolithotomy by comparing outcomes of sequentially scheduled procedures.

MATERIALS AND METHODS

We identified days when 2 procedures of the same type were performed by the same surgeon, including 72 laparoscopic and 340 robot-assisted laparoscopic prostatectomies, and 110 percutaneous nephrolithotomies. Clinical data and outcomes were compared.

RESULTS

For percutaneous nephrolithotomy multiple access (16% vs 9%, p = 0.2), transfusion (3.6% vs 5.4%, p = 0.5), complication (20% vs 18%, p = 0.5), residual fragment (53% vs 45%, p = 0.3), second look (38% vs 35% p = 0.4) and stone-free (86% vs 89% p = 0.3) rates did not differ for the first and second procedures. For laparoscopic prostatectomy nerve sparing (100% vs 97.1%, p = 0.5), operative complications (0% vs 0%, p = 0.7), drain requirement (36% vs 42%, p = 0.6) and lymphadenectomy (13.5% vs 25.7%, p = 0.16) rates were comparable. Positive margins (19.4% vs 36.1% p = 0.08), continence (66.7% vs 66.7%, p = 0.9), potency (58.3% vs 52.8%, p = 0.76) and prostate specific antigen recurrence (10.8% vs 20%, p = 0.45) did not significantly differ for the first and second procedures. For robot-assisted laparoscopic prostatectomy operative complications (3% vs 3.5%, p = 0.8), drain requirement (7.7% vs 9.8%, p = 0.5), positive margins (41.7% vs 39.3%, p = 0.37), continence (78.6% vs 84.4%, p = 0.12), potency (51% vs 50%, p = 0.15) and prostate specific antigen recurrence (9.5% vs 11.6%, p = 0.2) did not significantly differ. Nerve sparing was more common in the second case cohort (86.9% vs 75.7%, p = 0.03).

CONCLUSIONS

Despite concern that surgeon fatigue may impact outcomes, our data suggests that performing several complex urological procedures consecutively is not associated with worse outcomes.

Does surgeon workload per day affect outcomes after pulmonary lobectomies?

BACKGROUND

Our aim was to evaluate whether the workload of a surgeon, including number of operations, operative time, or number of rooms per day, influenced patient morbidity or mortality after pulmonary lobectomy.

METHODS

The records of all patients who underwent pulmonary lobectomy at our institution during 2 years (2007-2009) by 6 surgeons were retrospectively reviewed. Surgeon workload per day and individual patient variables were evaluated. Both univariate and multivariate analyses were performed to identify risk factors for patient morbidity and mortality.

RESULTS

We analyzed 481 patients (269 men, 112 women) whose median age was 68 years (range, 20 to 94 years). Operative mortality occurred in 6 patients (1.25%), and morbidity occurred in 198 patients (41%). On univariate analysis, the total number of hours a surgeon operated per day was a significant predictor of complications (odds ratio, 1.032; p=0. 048) and length of stay (average increase of 0.17 days for each additional hour; p=0.004). There were multiple patient variables that were significant predictors of outcome. On multivariate analysis, which adjusted for patient variables, the total number of hours a surgeon operated per day remained a significant predictor of complications (odds ratio, 1.036; p=0.03) and increased length of stay (average increase of 0.16 days for each additional hour; p=0.006). On multivariate analysis, patient variables of age, forced expiratory volume In 1 second, and renal failure were significant predictors of outcome.

CONCLUSIONS

The total number of hours a surgeon operates per day is independently associated with an increased risk of complications when performing pulmonary lobectomies. This could be related to surgeon fatigue associated with longer operative days. However, other patient variables are also associated with outcome. The relationship among these factors needs to be better understood with larger-scale models on a multiinstitutional level.

Impact of nighttime and weekend liver transplants on graft and patient outcomes

Safety concerns have been raised about nighttime and weekend patient care, but it is unknown whether these issues affect liver transplantation. We sought to identify the impact of nighttime and weekend liver transplants on graft and patient survival. We used the United Network for Organ Sharing database to review adult liver transplants from 1987 to 2010. Comparisons were made between nighttime and daytime operations and between weekday and weekend operations. Cox proportional hazard ratios (HRs) were determined 30, 90, and 365 days after transplantation after we controlled for relevant factors; 94,768 transplants were included in the analysis. The patient survival rates at 30, 90, and 365 days for nighttime operations were 96%, 93%, and 86%, respectively. The patient survival rates at 30, 90, and 365 days for weekend operations were 95%, 92%, and 86%, respectively. These rates did not significantly differ from those for daytime and weekday operations, respectively. The graft failure rate was unchanged at 30 and 90 days for weekend transplants but was modestly increased at 365 days [HR = 1.05 (95% confidence interval = 1.01-1.11)]. Graft survival was unaffected by nighttime transplantation. Nighttime and weekend operations for liver transplantation do not affect patient or graft survival, and this testifies to the patient safety measures in place.

Impact of operative start time on surgical outcomes in patients undergoing primary cytoreduction for advanced ovarian cancer

OBJECTIVES

To evaluate the impact of operative start time (OST) on surgical outcomes in patients with advanced ovarian cancer.

METHODS

All stage IIIB-IV serous ovarian cancer patients who underwent primary surgery at our institution from 1/01 to 1/10 were identified. Fourteen factors were evaluated for an association with surgical outcomes including OST and OR tumor index (1 point each for carcinomatosis and/or bulky [≥ 1 cm] upper abdominal disease). Univariate logistic regression considering within-surgeon clustering was performed for cytoreduction to ≤ 1 cm versus >1cm residual disease. In patients with ≤ 1 cm residual disease, univariate logistic regression considering within-surgeon clustering was performed for 1-10mm residual disease versus complete gross resection (CGR, 0mm residual). A multivariate logistic model was developed based on univariate analysis results in the ≤ 1 cm residual disease cohort.

RESULTS

Of 422 patients, residual disease was: 0mm, 144 (34.1%); 1-10mm, 175 (41.5%); >10mm, 103 (23.3%). OST was not associated with cytoreduction to ≤ 1 cm residual disease on univariate analysis. In the ≤ 1 cm residual disease cohort, albumin, CA-125, ascites, ASA score, stage, OR tumor index, and OST were associated with CGR on univariate analysis. Earlier OSTs were associated with increased rates of CGR. On multivariate analysis, CA-125 was independently associated with CGR. OST was associated with CGR in patients with an OR tumor index of 2 but not an OR tumor index<2.

CONCLUSIONS

OST was not associated with cytoreduction to ≤ 1 cm residual disease in patients with advanced serous ovarian cancer. In the cohort of patients with ≤ 1 cm residual disease, later OSTs were associated with reduced rates of CGR in patients with greater tumor burden.