The effect of preoperative renal insufficiency on postoperative outcomes after major hepatectomy: a multi-institutional analysis of 1,170 patients

The clinical outcome of minor changes in serum creatinine for patients after curative gastrectomy: a prospective study

Introduction

Patients with renal insufficiency are more prone to postoperative complications (PCs). Studies have shown that minor changes in serum creatinine (SCr), immediately post-surgery, can aid in assessing patients' renal function. This study aimed to explore the relationship between the changes in SCr and PCs in patients with gastric cancer (GC).

Materials and methods

We prospectively collected data regarding the SCr of 530 GC patients, within 2 weeks before surgery and within 24 hours after surgery in our hospital (2014-2016). The patients were divided into three groups according to the level of SCr change after surgery: reduced (<10%), normal (10%), and elevated (>10%) creatinine groups. Univariate and multivariate logistic analysis were performed to evaluate its correlation with short-term PCs in the patients. The R language was used to construct a nomogram.

Results

83, 217, and 230 patients were assigned to the elevated, reduced, and normal SCr groups, respectively. Multivariate analysis showed that the reduced and elevated SCr groups were independently associated with the occurrence of PCs and severe postoperative complications (SPCs), respectively. Additionally, postsurgical SCr change, age, hypoalbuminemia, total gastrectomy, combined resection, and laparoscopy, were independently related to PCs. Combining the above influential factors, the predictive model can distinguish patients with PCs more reliably (c-index is 0.715).

Conclusion

Post-surgery, reduced SCr is a protective factor for PCs, while elevated serum creatinine is an independent risk factor for SPCs. Our nomogram can identify GC patients with high risks of PCs.

The influence of propofol-based total intravenous anesthesia on postoperative outcomes in end-stage renal disease patients: A retrospective observation study

Background

To determine whether the anesthetic method of propofol total intravenous anesthesia (TIVA) is associated with postoperative outcome in ESRD patients, we evaluated the incidence of postoperative major adverse cardiac events (MACE), comparing propofol TIVA versus anesthesia with volatile anesthesia in ESRD patients.

Methods

Retrospectively, we identified cases with ESRD patients who underwent surgery under general anesthesia. Patients were divided into those who received only volatile anesthesia (volatile group) and those who received only propofol TIVA (TIVA group). The incidence of MACE and potential confounding variables were compared separately in a univariate logistic model and subsequently by multivariate logistic regression.

Results

Among the 2576 cases in ESRD patients, 1374 were in the TIVA group and 1202 were in the volatile group. The multivariate analysis included 12 factors, including the anesthesia method, of which five factors were significant. Factors that were associated with a significantly lower MACE risk included preoperative chloride concentration (OR: 0.96; 95% CI, 0.92–0.99), baseline SBP (OR: 0.98; 95% CI, 0.98–0.99), and propofol TIVA (OR: 0.37; 95% CI, 0.22–0.60).

Conclusions

We inferred that the anesthetic method associated with the postoperative outcome in patients with ESRD.

Impact of pretreatment asymptomatic renal dysfunction on clinical course after esophagectomy

PURPOSE

Recent large-scale clinical studies have shown that preoperative renal insufficiency is associated with an increased risk of postoperative complications after esophagectomy; however, it remains unclear whether asymptomatic renal dysfunction affects the postoperative course after esophagectomy.

METHODS

The subjects of this retrospective study were 177 patients who underwent esophagectomy between May, 2009 and December, 2018. Renal function was evaluated based on the pretreatment estimated glomerular filtration rate (eGFR). Patients were divided into two groups according to the eGFR cut-off value of 55 ml/min per 1.73 m².

RESULTS

There were 17 patients in the low eGFR group and 160 patients in the normal group eGFR group. The rate of severe complications was significantly higher in the low eGFR than in the normal eGFR group. A low eGFR was the only significant complication risk factor identified; however, there were no marked differences in mortality or survival between the low and normal eGFR groups.

CONCLUSION

Our findings demonstrate that pretreatment asymptomatic renal dysfunction may be a significant risk factor for severe morbidity after esophagectomy.

Obesity is an Independent Risk Factor for Mortality in Otherwise Healthy Patients After Hepatectomy

BACKGROUND

Obesity is often associated with comorbidities that limit remnant liver recovery after hepatectomy. The extent to which obesity, in the absence of comorbidities, impacts surgical risk after hepatectomy is unknown. We hypothesized that an obese population without major comorbidities would not be at increased risk of adverse outcomes after hepatectomies.

METHODS

We performed a retrospective analysis identifying patients who underwent hepatectomies from the American College of Surgeons National Surgical Quality Improvement Program data set 2005-2017. Outcomes of interest included the following: mortality, any morbidity, critical care complications, and failure to discharge home. Body mass index (BMI) was the primary variable of interest, grouped as ≥35 and <35 based on bivariate tests of associations with candidate cut-off points. In attempt to isolate the effect of obesity on outcomes among patients "without major comorbidities" (WOC), we included patients without diabetes, chronic obstructive pulmonary disease, renal insufficiency, and nonsmokers; remaining patients were grouped as "with major comorbidities" (WC). Multivariable logistic regression was used to test whether obesity is independently associated with the outcomes of interest after adjustment for other covariates.

RESULTS

A total of 36,396 patients were included. There were 13,754 patients in the WOC group and 22,642 in the WC group. Among patients in the WOC group, the adjusted odds of mortality were 2.2 times higher for patients with a BMI ≥35 versus a BMI <35. Among the patients in the WC group, a BMI ≥35 was not a statistically significant predictor of mortality after adjustment for other covariates. Obese patients had increased odds of each outcome among the WOC group.

CONCLUSIONS

Our hypothesis was refuted by these data. In fact, the adverse effect of obesity was more evident among healthy patients.

Relevance of Preoperative Hyperbilirubinemia in Patients Undergoing Hepatobiliary Resection for Hilar Cholangiocarcinoma

Preoperative hyperbilirubinemia is known to increase the risk of mortality and morbidity in patients undergoing resection for hilar cholangiocarcinoma. The aim of this study was to characterize the associations between the preoperative bilirubin concentration and the risk of postoperative mortality and severe complications to guide decision-making regarding preoperative biliary drainage. Eighty-one patients undergoing liver and bile duct resection for hilar cholangiocarcinoma between 2005 and 2015 were analyzed retrospectively. Postoperative mortality and severe complications, defined as a Clavien⁻Dindo grade of ≥III, were the primary and secondary outcome measures, respectively. The severe postoperative complications and mortality rates were 28.4% (23/81) and 11.1% (9/81), respectively. Patients with preoperative biliary drainage had significantly lower bilirubin concentrations (p = 0.028) than did those without. The preoperative bilirubin concentration was a risk factor of postoperative mortality (p = 0.003), with an optimal cut-off of 6.20 mg/dL (c-statistic = 0.829). The preoperative bilirubin concentration was a risk factor of severe morbidity (p = 0.018), with an optimal cut-off of 2.48 mg/dL (c-statistic = 0.662). These results indicate that preoperative hyperbilirubinemia is a major risk factor of negative early postoperative outcomes of patients who undergo surgical treatment for hilar cholangiocarcinoma and may aid in decision-making with respect to preoperative biliary drainage.

Liver Resection for Hepatocellular Carcinoma in Patients with Renal Dysfunction

BACKGROUND

The aim of this study was to evaluate the feasibility of liver resection in hepatocellular carcinoma (HCC) patients with preoperative renal dysfunction (RD).

METHODS

Data from 735 patients undergoing primary liver resection for HCC between 2002 and 2014 were analyzed. Short- and long-term outcomes were compared between the RD group, defined by a preoperative estimated glomerular filtration rate of <45 mL/min/1.73 m², and the non-RD group.

RESULTS

Sixty-two patients had RD. The incidence of postoperative pleural effusion (24 vs. 11%; P = 0.007) and major complications (Clavien-Dindo III-V; 31 vs. 15%; P = 0.003) were significantly higher in RD patients. In RD patients with Child-Pugh A, 90-day mortality rate (1.9%) and median survival time (6.11 years) were comparable to that of non-RD patients. In contrast, RD patients with Child-Pugh B had a very high 90-day mortality rate (22.2%), and a significant shorter median survival time compared to non-RD patients (1.19 vs. 4.84 years; P = 0.001).

CONCLUSIONS

Liver resection for Child-Pugh A patients with RD is safe and has comparable oncological outcomes compared to non-RD patients. However, selection of liver resection candidates from Child-Pugh B patients with RD should be stricter.

Severe acute kidney injury following major liver resection without portal clamping: incidence, risk factors, and impact on short-term outcomes

BACKGROUND

Acute kidney injury (AKI) following major hepatectomy (MH) remains inadequately investigated. This retrospective study aimed to assess the risk factors and prognostic value of AKI on short-term outcomes following MH without portal pedicle clamping.

METHODS

From January 2014 through June 2017, 111 consecutive patients underwent MH without portal pedicle clamping, but with intraoperative low-crystalloid infusion. Kidney Disease Improving Global Outcomes stages II and III were classified as severe AKI.

RESULTS

A total of 102 patients did not develop AKI or only AKI stage I (92%, control group), whereas 9 patients developed severe AKI (8%, severe AKI group). Hepatectomy (P = 0.002) and surgery (P = 0.011) durations were longer in the severe AKI group. Clavien-Dindo grades 3 to 5 morbidity (55% versus 9%, P = 0.001), liver failure (P = 0.017), and 90-day mortality (33% versus 2%, P = 0.003) were significantly higher in the severe AKI group. After a multivariate analysis, the duration of hepatectomy (cut-off: 250 min; P = 0.029) and urea serum levels on postoperative day 3 (P = 0.006) were identified as independent predictors of severe AKI.

DISCUSSION

Severe AKI, is common with increased duration of hepatectomy, was associated with poor short-term outcomes, and can be predicted by operative duration greater than 250 minutes.

Application of the Revised Cardiac Risk Index to the Model for End-Stage Liver Disease Score Improves the Prediction of Cardiac Events in Patients Undergoing Liver Transplantation

INTRODUCTION

Although the revised cardiac risk index (RCRI) is a useful tool for estimating the risk of postoperative cardiac events, whether it improves the prediction of cardiac events in patients undergoing liver transplantation (LT) has not been sufficiently demonstrated.

METHODS

We retrospectively analyzed 1429 patients who underwent LT. Cardiac events were defined as myocardial infarction, death, or combined events within 30 days after surgery. The RCRI was defined as the number of independent predictors including high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin treatment, and creatinine level >2 mg/dL. Multivariate logistic regression analysis was performed to identify factors independently associated with cardiac events. The additive predictability of RCRI for the Model for End-Stage Liver Disease (MELD) score was assessed using receiver operating characteristic curve analysis.

RESULTS

Forty-four (3.1%) cardiac events occurred within 30 days after surgery. Both the MELD score (adjusted odds ratio [aOR], 1.05; P = .005) and RCRI (aOR, 4.35; P < .001 for RCRI score 2; aOR, 6.27; P = .009 for RCRI score 3 compared with RCRI score 1) independently predicted postoperative 30-day cardiac events. The model with MELD score plus RCRI was significantly more predictive for postoperative 30-day cardiac events than the model with MELD score alone (C-statistics 0.800 vs 0.757; P = .030).

CONCLUSIONS

For preoperative risk stratification, RCRI showed additive value to MELD score in predicting postoperative 30-day cardiac events after LT.

Self-reported functional status predicts post-operative outcomes in non-cardiac surgery patients with pulmonary hypertension

Background

Pulmonary hypertension (PHTN) is associated with increased post-procedure morbidity and mortality. Pre-procedure echocardiography (ECHO) is a widely used tool for evaluation of these patients, but its accuracy in predicting post-procedure outcomes is unproven. Self-reported exercise tolerance has not been evaluated for operative risk stratification of PHTN patients.

Objective

We analyzed whether self-reported exercise tolerance predicts outcomes (hospital length-of-stay [LOS], mortality and morbidity) in PHTN patients (WHO Class I–V) undergoing anesthesia and surgery.

Methods and findings

We reviewed 550 non-cardiac, non-obstetric procedures performed on 370 PHTN patients at a single institution between 2007 and 2013. All patients had cardiac ECHO documented within 1 year prior to the procedure. Pre-procedure comorbidities and ECHO data were collected. Functional status (< or ≥ 4 metabolic equivalents of task [METs]) was assigned based on responses to standard patient interview questions during the pre-anesthesia clinic visit. Multiple logistic regression was used to develop a risk score model (Pulmonary Hypertension Outcome Risk Score; PHORS) and determine its value in predicting post-procedure outcomes. In an adjusted model, functional status <4 METs was independently associated with a LOS >7 days (p < .003), as were higher ASA class (p < .002), open surgical approach (p < .002), procedure duration > 2 hours (p < .001), and the absence of systemic hypertension (p = .012). PHORS Score ≥2 was associated with an increased 30-day major complication rate (28.7% vs. 19.2%; p < 0.001) and ICU admission rate (8.6% s 2.8%; p = .007), but no statistical difference in hospital readmissions rate (17.6% vs. 14.0%; p = .29), or mortality (3.5% vs. 1.4%; p = .75). Similar ECHO findings did not further improve outcome prediction.

Conclusions

Poor functional status is associated with severe PHTN and predicts increased LOS and post-procedure complications in patients with moderate to severe pulmonary hypertension with different etiologies. A risk assessment model predicts increased LOS with fair accuracy. A thorough evaluation of underlying etiologies of PHTN should be undertaken in every patient.

Pretransplant serum procalcitonin level for prediction of early post-transplant sepsis in living donor liver transplantation

AIM

Infection is a frequent cause of in-hospital mortality after liver transplantation (LT). Elimination of possible risks in the pretransplant period, early diagnosis of post-transplant sepsis, and prompt treatment with antimicrobial agents are important. The objectives of this study were to analyze the impact of early post-transplant sepsis on outcomes and to clarify the value of predictive factors for early post-transplant sepsis.

METHODS

The study included 136 patients who underwent initial living donor LT (LDLT) at our institute between April 2009 and December 2016. Sepsis was defined using the third international consensus criteria. The results of biochemical tests at the introduction of anesthesia before LDLT were collected for pretransplant evaluation.

RESULTS

Post-transplant sepsis was found in 37 patients (27.2%). More patients had a pre-transplant serum procalcitonin (PCT) level >0.5 ng/mL in the sepsis group than in the non-sepsis group (11 [29.7%] vs 10 [10.1%]; P = 0.007). The 1-year survival rate in the sepsis group was significantly lower than in the non-sepsis group (53.8% vs 87.2%; P < 0.001). Multivariate analysis identified pretransplant serum PCT >0.5 ng/mL (odds ratio, 3.8; 95% confidence interval, 1.3-10.9; P = 0.01) as the only independent risk factor for post-transplant sepsis.

CONCLUSIONS

Survival of patients with early post-transplant sepsis was poor and the incidence of sepsis was associated with the pretransplant serum PCT level. Re-evaluation of the general condition and rescheduling of LT should be considered in a patient with pretransplant serum PCT >0.5 ng/mL.

Outcomes of Living Donor Liver Transplantation Alone for Patients on Maintenance Renal Replacement Therapy in Japan: Results of a Nationwide Survey

BACKGROUND

Because simultaneous liver and kidney transplantation has been limited as a standard practice because of a severe shortage of deceased donors in Japan, living donor (LD) liver transplantation alone (LTA) is indicated in most recipients with maintenance renal replacement therapy (MRRT).

METHODS

A retrospective nationwide survey of LD LTA was performed for liver transplant patients on MRRT. The characteristics of donors and recipients, postoperative complications, survival rate, and causes of death were analyzed.

RESULTS

In the adult cases (n = 28), the overall survival rate at 1 year and 5 years were 66.1% and 57.3%, respectively. When compared with those adults without MRRT (n = 237), it was significantly worse. In the 7 pediatric cases, the overall survival rate at 1 and 5 years were both 83.3%. Three adult recipients died of nonaneurysm cerebral hemorrhage after 1 year and 1 adult recipient died of acute heart failure after 7 months. In adult recipients with MRRT, graft weight versus standard liver volume, and duration and blood loss in LTA surgery were associated with poor outcomes after LD LTA. Multivariate analysis revealed that MRRT was highest hazard ratio on patient survival after LD LTA.

CONCLUSIONS

Early post-LD LTA mortality was higher in patients with MRRT than in those without MRRT with characteristic causes. Smaller grafts for size and a complicated surgery were associated with poor outcome after LD LTA. Thus, LD LTA in adult patients on MRRT should be carefully treated with meticulous postoperative management and follow-up.

Acute kidney injury following hepatectomy for hepatocellular carcinoma: incidence, risk factors and prognostic value

BACKGROUND

Acute kidney injury (AKI) following hepatectomy remains understudied in terms of diagnosis, severity, recovery and prognostic value. The aim of this study was to assess the risk factors and prognostic value of AKI on short- and long-term outcomes following hepatectomy for hepatocellular carcinoma (HCC).

METHOD

This is a retrospective analysis of a single-center cohort of 457 consecutive patients who underwent hepatectomy for HCC. The KDIGO criteria were used for AKI diagnosis. The incidence, risk factors, and prognostic value of AKI were investigated.

RESULTS

AKI occurred in 67 patients (15%). The mortality and major morbidity rates were significantly higher in patients with AKI (37% and 69%) than in those without (6% and 22%; p < 0.001). Renal recovery was complete in 35 (52%), partial in 25 (37%), and absent in 7 (11%) patients. Advanced age, an increased MELD score, major hepatectomy and prolonged duration of operation were identified as independent predictors of AKI. AKI was identified as the strongest independent predictor of postoperative mortality but did not impact survival.

CONCLUSION

AKI is a common complication after hepatectomy for HCC. Although its development is associated with poor short-term outcomes, it does not appear to be predictive of impaired long-term survival.

A preoperative personalized risk assessment calculator for elderly ovarian cancer patients undergoing primary cytoreductive surgery

OBJECTIVE

Cytoreductive surgery for ovarian cancer has higher rates of postoperative complication than neoadjuvant chemotherapy followed by surgery. If patients at high risk of postoperative complication were identified preoperatively, primary therapy could be tailored. Our objective was to develop a predictive model to estimate the risk of major postoperative complication after primary cytoreductive surgery among elderly ovarian cancer patients.

METHODS

Patients who underwent primary surgery for ovarian cancer between 2005 and 2013 were identified from the National Surgical Quality Improvement Project. Patients were selected using primary procedure CPT codes. Major complications were defined as grade 3 or higher complications on the validated Claviden-Dindo scale. Using logistic regression, we identified demographic and clinical characteristics predictive of postoperative complication.

RESULTS

We identified 2101 ovarian cancer patients of whom 35.9% were older than 65. Among women older than 65, the rate of major postoperative complication was 16.4%. Complications were directly associated with preoperative laboratory values (serum creatinine, platelets, white blood cell count, hematocrit), ascites, white race, and smoking status, and indirectly associated with albumin. Our predictive model had an area under receiver operating characteristic curve of 0.725. In order to not deny patients necessary surgery, we chose a 50% population rate of postoperative complication which produced model sensitivity of 9.8% and specificity of 98%.

DISCUSSION

Our predictive model uses easily and routinely obtained objective preoperative factors to estimate the risk of postoperative complication among elderly ovarian cancer patients. This information can be used to assess risk, manage postoperative expectations, and make decisions regarding initial treatment.

mTOR-Dependent Suppression of Remnant Liver Regeneration in Liver Failure After Massive Liver Resection in Rats

BACKGROUND AND AIMS

Massive hepatectomy often leads to fatal liver failure because of a small remnant liver volume. The aim of this study was to investigate the potential mechanisms leading to liver failure.

METHODS

Sprague-Dawley rats had performed a sham operation, 85 % partial hepatectomy (PH) or 90 % PH, and all had free access to water with or without supplemented glucose. Liver function and survival were evaluated. Liver parenchymal injury was assessed by evaluating hepatic pathology, blood biochemistry, and apoptotic and necrotic alterations. The regeneration response was assessed by the weight gain of the remnant liver, hepatocyte proliferation markers, and regeneration-related molecules.

RESULTS

The 90 % hepatectomy resulted in a significantly lower survival rate and impaired liver function; however, no significant more serious liver parenchymal injuries were detected. TNF-α, HGF, myc and IL-6 were either similarly expressed or overexpressed; however, the increase in remnant liver weight, mitotic index, and the presence of Ki-67 and PCNA were significantly lower in the 90 %-hepatectomized rats. mTOR, p70S6K and 4EBP1 were not activated in the remnant liver after a 90 % hepatectomy as obviously as those after an 85 % hepatectomy, which was concomitant with the higher expression of phospho-AMPK and a lower intrahepatic ATP level. Glucose treatment significantly improved the survival rate of 90 %-hepatectomized rats.

CONCLUSIONS

Suppression of remnant liver regeneration was observed in the 90 % PH and contributed to fatal liver failure. This suppressed liver regenerative capacity was related to the inhibited activation of mTOR signaling.