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CHIERICI A, ALROMAYAN M, DEFATICO S, DRAI C, VINCI D, ANTY R, SCHIAVO L, IANNELLI A. Is bariatric surgery safer before, during, or after liver transplantation? A systematic review and meta-analysis. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2023.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Clinical and Economic Impact of Bariatric Surgery Post Liver Transplantation: a Nationwide, Population-Based Retrospective Study. Obes Surg 2022; 32:2548-2555. [PMID: 35668279 DOI: 10.1007/s11695-022-06120-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Prevalence of obesity in liver transplant recipients is increasing with the overall epidemic augmentation of severe obesity, the effects of immunosuppressive drugs, and lifestyle changes which are responsible for de novo obesity development or aggravation of pre-existing obesity. The aim of this study is to analyze the differences in overall mortality, re-hospitalization rate, and hospitalization-related costs between patients undergoing bariatric surgery after liver transplantation and patients undergoing bariatric surgery alone. MATERIALS AND METHODS Twenty patients with history of liver transplantation who underwent bariatric surgery were analyzed from the French National Hospital Discharge Database. Overall mortality, re-hospitalization rate, length of stay for bariatric procedure, and the costs of bariatric surgery hospitalization and eventual re-hospitalizations were compared to a group of 360,846 patients who underwent bariatric surgery alone from 2010 to 2019. Furthermore, a 1:1 propensity score matching analysis was conducted. RESULTS Patients with a history of liver transplantation showed an increased risk of overall mortality (HR: 7.66, p = 0.0047) and increased costs of hospitalization for bariatric surgery (8250 ± 4822€ vs 5583 ± 3398€, p = 0.0005). No differences in length of stay, re-hospitalization rate, and costs were found after multivariate analysis. After propensity score matching analysis, a significant increased cost of hospitalization (8250 ± 4822€ vs 6086 ± 1813€, p = 0.0195) still resulted for the liver transplantation group. CONCLUSION Bariatric surgery represents the best treatment for obesity and its related associated medical problems. Our study highlights an increased risk of overall all-cause mortality and increased costs of hospitalization in this population compared to patients undergoing bariatric surgery alone.
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Bagheri Lankarani K, Honarvar B, Akbari M, Bozorgnia N, Rabiey Faradonbeh M, Bagherpour M, Nikeghbalian S, Shamsaeefar A, Malekhosseini SA. Quality of Life and Its Determinants in Liver Transplantation Candidates: A Missed Link in Liver Care Program during the Waiting Time for Liver Transplantation. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:227-235. [PMID: 35634527 PMCID: PMC9126895 DOI: 10.30476/ijms.2021.88302.1895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/08/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
Background The health-related quality of life (HRQOL) in the before liver transplantation (LT) stage has not been studied as much as that after the LT stage. We aimed to assess HRQOL and its determinants before the LT stage. Methods As a cross-sectional study, HRQOL of all adult patients (n=632) referred to the LT center of Shiraz, Iran in 2018-2019 were assessed. Demographic, socioeconomic, medical, and paraclinical data were requested. Physical (PCS) and mental (MCS) aspects of HRQOL were assessed using the SF36 questionnaire. Univariable, multivariable (linear regression), and confirmatory factor analysis were performed utilizing SPSS 20 and Mplus 6.1 software. P<0.05 was considered to be significant. Results The mean age of the patients was 47.6±12.3 years, while 414 (65.6%) were men, and the mean, score of the model for end-stage liver disease (MELD) was 18.36±5.58. The mean score of QOL, PCS, and MCS was 50.01±21.73, 46.23±23.23, and 53.78±23.91 (out of 100), respectively. Vitality had the most association with HRQOL, while role limitations had the lowest. The multivariable analysis revealed that unemployment (P<0.001), anemia (P=0.005), weight loss (P=0.005), diabetes mellitus (DM) (P=0.009), low MELD score (P=0.027), and drug use (P=0.03) were the significant determinants of HRQOL, respectively. Conclusion The present study showed that HRQOL in the LT candidates was at the intermediate level, while their PCS and MCS are at the low and moderate levels, respectively. Furthermore, physical performance, job status, anemia, weight loss, MELD score, DM, and drug use should be considered as the significant determinants of HRQOL in the LT candidates.
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Affiliation(s)
- Kamran Bagheri Lankarani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Behnam Honarvar
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Akbari
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naghmeh Bozorgnia
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Rabiey Faradonbeh
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Morteza Bagherpour
- Department of Industrial Engineering, Iran University of Science and Technology, Tehran, Iran
| | - Saman Nikeghbalian
- Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Shamsaeefar
- Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Yemini R, Nesher E, Braun M, Cohen M, Carmeli I, Mor E, Keidar A. Long-term outcomes of Roux-en-Y gastric bypass or sleeve gastrectomy in patients with cirrhosis; before, during or after liver transplantation: A single center's experience. Clin Transplant 2021; 35:e14374. [PMID: 34043840 DOI: 10.1111/ctr.14374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/18/2021] [Accepted: 05/16/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The increasing prevalence of morbid obesity (MO) results in parallel growth of obesity-associated liver diseases necessitating liver transplantation (LT). OBJECTIVE To examine the feasibility and safety of Roux-en-Y gastric bypass or sleeve gastrectomy in the setting of LT. METHODS This retrospective chart review included the data on all the MO candidates before and after LT who underwent bariatric surgery (BS) in our institution between 04/2013-09/2016. The reported outcomes were weight change and early and late postoperative complications (mean follow-up: 43 ± 11.1 months). RESULTS Eighteen MO peri-LT patients (10 females, 8 males, average age 48 years) were included in the study. Ten had cirrhosis (mean Model of End-stage Liver Disease [MELD] score of 12.5 ± 6.42), three underwent concurrent LT and BS (mean MELD score 23.7 ± 0.58), and five had LT (mean of 56 months from LT). The mean percentage of total and excess weight loss was 31% and 81%, respectively. Six of the eight patients with type 2 diabetes mellitus became normoglycemic after BS. Three patients sustained perioperative complications. Two cirrhotic patients died 1 and 4.5 years after BS with decompensation. CONCLUSIONS Bariatric surgery appears to effectively address obesity in cirrhotic and LT patients. The surgical risk is higher than that of the regular BS population.
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Affiliation(s)
- Renana Yemini
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eviatar Nesher
- Department of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Marius Braun
- Liver Diseases Institute, Beilinson Medical Center, Petach-Tikva, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Cohen
- Liver Diseases Institute, Beilinson Medical Center, Petach-Tikva, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Idan Carmeli
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eytan Mor
- Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery B, Transplant Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Andrei Keidar
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Åberg F. Quality of life after liver transplantation. Best Pract Res Clin Gastroenterol 2020; 46-47:101684. [PMID: 33158471 DOI: 10.1016/j.bpg.2020.101684] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/31/2020] [Indexed: 01/31/2023]
Abstract
Liver transplantation (LT) enables rapid transition from critical illness and poor prognosis back to health. After LT, health-related quality of life (HRQoL) generally becomes comparable to that of the general population, although some deficits in mainly physical domains are frequent. However, recipients continue to have symptoms related to immunosuppression, complications, and other things, which impact HRQoL and the recipient's ability to regain independence and re-establish function in everyday life. Less than half of LT recipients return to work. Reportedly, HRQoL seems to deteriorate slightly over the long-term, but still remains satisfactory. Physical fatigue is common, but recent studies show that structured exercise programs improve both fatigue and HRQoL. Emerging evidence also suggests that continued patient information, structured psychosocial support systems, and caregiver involvement might further help improve long-term HRQoL. More research is needed to gain better understanding of the factors affecting long-term HRQoL, and how to best improve HRQoL.
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Affiliation(s)
- Fredrik Åberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki University, Helsinki, Finland; The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Beyond Survival in Solid Organ Transplantation: A Summary of Expert Presentations from the Sandoz 6th Standalone Transplantation Meeting, 2018. Transplantation 2020; 103:S1-S13. [PMID: 31449167 DOI: 10.1097/tp.0000000000002846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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van Son J, Stam SP, Gomes-Neto AW, Osté MCJ, Blokzijl H, van den Berg AP, Porte RJ, Bakker SJL, de Meijer VE. Post-transplant obesity impacts long-term survival after liver transplantation. Metabolism 2020; 106:154204. [PMID: 32173406 DOI: 10.1016/j.metabol.2020.154204] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/22/2020] [Accepted: 03/11/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Short-term survival after orthotopic liver transplantation (OLT) has improved over the past decades, but long-term survival remains impaired. The effects of obesity on long-term survival after OLT are controversial. Because pre-transplant body mass index (BMI) can be confounded by ascites, we hypothesized that post-transplant BMI at 1 year could predict long-term survival. METHODS A post-hoc analysis was performed of an observational cohort study consisting of adult recipients of a first OLT between 1993 and 2010. Baseline BMI was measured at 1-year post-transplantation to represent a stable condition. Recipients were stratified into normal weight (BMI < 25 kg/m2), overweight (25 ≤ BMI ≤ 30 kg/m2), and obese (BMI > 30 kg/m2). Kaplan-Meier survival analyses were performed with log-rank testing, followed by multivariable Cox proportional hazards regression analysis. RESULTS Out of 370 included recipients, 184 had normal weight, 136 were overweight, and 50 were obese at 1-year post-transplantation. After median follow-up for 12.3 years, 107 recipients had died, of whom 46 (25%) had normal weight, 39 (29%) were overweight, and 22 (44%) were obese (log-rank P = 0.020). Obese recipients had a significantly increased mortality risk compared to normal weight recipients (HR 2.00, 95% CI 1.08-3.68, P = 0.027). BMI was inversely associated with 15 years patient survival (HR 1.08, 95% CI 1.03-1.14, P = 0.001 per kg/m2), independent of age, gender, muscle mass, transplant characteristics, cardiovascular risk factors, kidney- and liver function. CONCLUSION Obesity at 1-year post-transplantation conveys a 2-fold increased mortality risk, which may offer potential for interventional strategies (i.e. dietary advice, lifestyle modification, or bariatric surgery) to improve long-term survival after OLT.
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Affiliation(s)
- Jeffrey van Son
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Suzanne P Stam
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Antonio W Gomes-Neto
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Maryse C J Osté
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Obesity in the Liver Transplant Setting. Nutrients 2019; 11:nu11112552. [PMID: 31652761 PMCID: PMC6893648 DOI: 10.3390/nu11112552] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022] Open
Abstract
The obesity epidemic has resulted in an increased prevalence of obesity in liver transplant (LT) candidates and in non-alcoholic fatty liver disease (NAFLD) becoming the fastest growing indication for LT. LT teams will be dealing with obesity in the coming years, and it is necessary for them to recognize some key aspects surrounding the LT in obese patients. Obesity by itself should not be considered a contraindication for LT, but it should make LT teams pay special attention to cardiovascular risk assessment, in order to properly select candidates for LT. Obese patients may be at increased risk of perioperative respiratory and infectious complications, and it is necessary to establish preventive strategies. Data on patient and graft survival after LT are controversial and scarce, especially for long-term outcomes, but morbid obesity may adversely affect these outcomes, particularly in NAFLD. The backbone of obesity treatment should be diet and exercise, whilst being careful not to precipitate or worsen frailty and sarcopenia. Bariatric surgery is an alternative for treatment of obesity, and the ideal timing regarding LT is still unknown. Sleeve gastrectomy is probably the procedure that has the best evidence in LT because it offers a good balance between safety and efficacy.
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Yemini R, Keidar A, Nesher E, Mor E. Commentary: Peri-Transplant Bariatric Surgery. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kardashian AA, Dodge JL, Roberts J, Brandman D. Weighing the risks: Morbid obesity and diabetes are associated with increased risk of death on the liver transplant waiting list. Liver Int 2018; 38:553-563. [PMID: 28727287 DOI: 10.1111/liv.13523] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 07/07/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Obesity is a growing problem in liver transplant (LT) candidates, paralleling the US obesity epidemic and increase in LT for non-alcoholic steatohepatitis (NASH). While post-LT survival appears to be similar in obese and non-obese patients, data are scarce regarding risk of waitlist dropout in patients with morbid obesity (BMI ≥ 40 kg/m2 ). We examined the impact of obesity on waitlist mortality and evaluated predictors of dropout in LT candidates with morbid obesity or NASH. METHODS Competing risk analyses were performed in candidates listed between 3/2002-12/2013 to evaluate predictors of waitlist removal or death. Variables with P-value <.05 in univariable models or clinically relevant were included in multivariable models. RESULTS Eighty-four thousand two hundred and fifty-four patients (34% female, median age 55, 15% Hispanic) were included. Compared to those with BMI 25-29.9 kg/m2 , candidates with BMI ≥ 40 kg/m2 were more likely to be female (46% vs 28%), diabetic (25% vs 18%) and have NASH (35% vs 13%); all P < .001. After adjusting for well-recognized predictors of waitlist dropout, including ascites severity, morbid obesity (HR = 1.27, CI 1.20-1.36) and diabetes (HR = 1.14, CI 1.11-1.17) were independent predictors of dropout. Morbid obesity remained a predictor (HR = 1.27, CI 1.10-1.47) of dropout in patients without ascites (24%). In NASH patients, morbid obesity (HR = 1.21, CI 1.07-1.37) and diabetes (HR = 1.15, CI 1.06-1.23) were also associated with a higher dropout risk. In patients with morbid obesity, diabetes trended towards a higher dropout risk but was not significant (HR = 1.12, CI 0.995-1.26). CONCLUSIONS Morbid obesity and diabetes are independent predictors of death in LT candidates.
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Affiliation(s)
- Ani A Kardashian
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Jennifer L Dodge
- Department of Surgery, University of California, San Francisco, CA, USA
| | - John Roberts
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Danielle Brandman
- Department of Medicine, University of California, San Francisco, CA, USA
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Maurizi G, Della Guardia L, Maurizi A, Poloni A. Adipocytes properties and crosstalk with immune system in obesity-related inflammation. J Cell Physiol 2017; 233:88-97. [PMID: 28181253 DOI: 10.1002/jcp.25855] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 12/11/2022]
Abstract
Obesity is a condition likely associated with several dysmetabolic conditions or worsening of cardiovascular and other chronic disturbances. A key role in this mechanism seem to be played by the onset of low-grade systemic inflammation, highlighting the importance of the interplay between adipocytes and immune system cells. Adipocytes express a complex and highly adaptive biological profile being capable to selectively activate different metabolic pathways in order to respond to environmental stimuli. It has been demonstrated how adipocytes, under appropriate stimulation, can easily differentiate and de-differentiate thereby converting themselves into different phenotypes according to metabolic necessities. Although underlying mechanisms are not fully understood, growing in adipocyte size and the inability of storing triglycerides under overfeeding conditions seem to be crucial for the switching to a dysfunctional metabolic profile, which is characterized by inflammatory and apoptotic pathways activation, and by the shifting to pro-inflammatory adipokines secretion. In obesity, changes in adipokines secretion along with adipocyte deregulation and fatty acids release into circulation contribute to maintain immune cells activation as well as their infiltration into regulatory organs. Over the well-established role of macrophages, recent findings suggest the involvement of new classes of immune cells such as T regulatory lymphocytes and neutrophils in the development inflammation and multi systemic worsening. Deeply understanding the pathways of adipocyte regulation and the de-differentiation process could be extremely useful for developing novel strategies aimed at curbing obesity-related inflammation and related metabolic disorders.
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Affiliation(s)
- Giulia Maurizi
- Clinica di Ematologia, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Ancona, Italy
| | - Lucio Della Guardia
- Dipartimento di Sanità Pubblica, Medicina Sperimentale e Forense, Unità di Scienza dell'Alimentazione, Università degli studi di Pavia, Pavia, Italy
| | - Angela Maurizi
- Chirurgia d'Urgenza e del Trauma, Azienda Ospedaliera Universitaria-Ospedali Riuniti di Ancona, Ancona, Italy
| | - Antonella Poloni
- Clinica di Ematologia, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Ancona, Italy
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Abstract
Obesity has become increasingly prevalent, and the number of obese patients in need of liver transplant is expected to continue to increase. In addition, liver disease due to nonalcoholic fatty liver disease is expected to become the leading cause of liver transplantation in the near future. However, obesity remains a relative contraindication in liver transplant. New strategies in managing this patient population are clearly needed. To this end, the authors review the current literature on the efficacy of bariatric surgery in the setting of liver transplantation in obese patients.
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Affiliation(s)
- Duminda Suraweera
- Department of Medicine, Olive-View Medical Center, 14445 Olive View Drive, 2B-182, Sylmar, CA 91342, USA
| | - Erik Dutson
- Department of Surgery, University of California at Los Angeles, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA
| | - Sammy Saab
- Department of Surgery, University of California at Los Angeles, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA; Department of Medicine, University of California at Los Angeles, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA.
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GUERRA TS, HOEHR NF, BOIN IDFSF, STUCCHI RSB. TRACE ELEMENTS IN PLASMA AND NUTRITIONAL ASSESSMENT IN PATIENTS WITH COMPENSATED CIRRHOSIS ON A LIVER TRANSPLANT LIST. ARQUIVOS DE GASTROENTEROLOGIA 2016; 53:84-8. [DOI: 10.1590/s0004-28032016000200006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/18/2016] [Indexed: 12/13/2022]
Abstract
ABSTRACT Background - In chronic liver disease, trace element levels in plasma are usually low. However, the specific cause and functional implications of this abnormality are yet not well understood. These element levels may decrease as a result of abnormal liver function in patients with cirrhosis and/or malnutrition. Objective - To evaluate the nutritional status and the profile of trace elements in plasma of patients with cirrhosis on a liver transplant list and to correlate them with disease severity. Methods - This cross-sectional study evaluated 31 male patients diagnosed with compensated liver cirrhosis on a waiting list for liver transplant. Nutritional status was objectively evaluated through anthropometry using Mendenhall score and Blackburn classification, subjectively through the Detsky questionnaire and severity of the disease by MELD and CTP score. Trace elements (Zn, Se, Cu, Ca, Fe, Mg and Mn) in plasma were analyzed by inductively coupled plasma mass spectrometry (ICP-MS). Statistical analysis was performed using Mann-Whitney test. Results - According to the nutritional assessment 19 (61.3%) were malnourished and 12 (38.7%) were overweight. Regarding disease severity 12 (39%) were classified as Child A, 17 (55%), Child B and 2 (6%) Child C, with 46.9% of patients with MELD score >17. The trace element analysis indicated that 31 (100%) had Mn levels above the reference range, 23 (74.2%) low levels of Cu, 29 (93.5%) with deficiency of Se, and 31 (100%) low levels of Ca and Mg. Disease severity did not show statistical difference between the studied trace elements, in contrast to the nutritional status, in which the malnourished group showed higher levels of Mn (P=0.01) and Fe (P=0.01) and low levels of Zn (P=0.03) when compared to the overweight group. Conclusion - The results showed that the trace elements in plasma are altered in chronic liver disease; without significant correlation to disease severity, but correlated to nutritional status. Malnutrition is present in the patients studied, nonetheless a new scenario with an increase in the prevalence of overweight was verified regardless of the degree of hepatic decompensation.
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Terjimanian MN, Harbaugh CM, Hussain A, Olugbade KO, Waits SA, Wang SC, Sonnenday CJ, Englesbe MJ. Abdominal adiposity, body composition and survival after liver transplantation. Clin Transplant 2016; 30:289-94. [PMID: 26717257 DOI: 10.1111/ctr.12688] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Current measures of obesity do not accurately describe body composition. Using cross-sectional imaging, objective measures of musculature and adiposity are possible and may inform efforts to optimize liver transplantation outcomes. METHODS Abdominal visceral fat area and psoas muscle cross-sectional area were measured on CT scans for 348 liver transplant recipients. After controlling for donor and recipient characteristics, survival analysis was performed using Cox regression. RESULTS Visceral fat area was significantly associated with post-transplant mortality (p < 0.001; HR = 1.06 per 10 cm(2) , 95% CI: 1.04-1.09), as were positive hepatitis C status (p = 0.004; HR = 1.78, 95% CI: 1.21-2.61) and total psoas area (TPA) (p < 0.001; HR = 0.91 per cm(2) , 95% CI: 0.88-0.94). Among patients with smaller TPA, the patients with high visceral fat area had 71.8% one-yr survival compared to 81.8% for those with low visceral fat area (p = 0.15). At five yr, the smaller muscle patients with high visceral fat area had 36.9% survival compared to 58.2% for those with low visceral fat area (p = 0.023). CONCLUSIONS Abdominal adiposity is associated with survival after liver transplantation, especially in patients with small trunk muscle size. When coupled with trunk musculature, abdominal adiposity offers direct characterization of body composition that can aid preoperative risk evaluation and inform transplant decision-making.
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Affiliation(s)
- Michael N Terjimanian
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Calista M Harbaugh
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Adnan Hussain
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Kola O Olugbade
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Seth A Waits
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Stewart C Wang
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christopher J Sonnenday
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael J Englesbe
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Diabetes mellitus, and not obesity, is associated with lower survival following liver transplantation. Dig Dis Sci 2015; 60:1036-44. [PMID: 25596720 DOI: 10.1007/s10620-014-3469-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 11/26/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS The impact of obesity on survival following liver transplantation is unclear, and existing studies report conflicting results. Our current study aims to further delineate the impact of obesity using population-based registry data from the USA. METHODS All US adult liver transplant recipients from 2003 to 2012 were evaluated using the United Network for Organ Sharing registry. The impact of obesity on survival following liver transplantation was further stratified into class I obesity [body mass index (BMI) 30.0-34.9 kg/m(2)], class II obesity (BMI 35.0-39.9 kg/m(2)), and class III obesity (BMI ≥ 40 kg/m(2)) and evaluated using Kaplan-Meier methods and multivariate Cox proportional hazards models. RESULTS Overall, 57,255 patients with chronic liver disease underwent liver transplantation, among which 32.9 % had BMI ≥ 30 kg/m(2). While patients in all obesity classes had similar survival to patients with BMI 18.0-24.9 kg/m(2), the presence of concurrent diabetes mellitus resulted in significantly lower post-transplant survival. After multivariate regression, post-transplant survival in patients with class II obesity (HR 0.97; 95 % CI 0.89-1.05) or class III obesity (HR 0.99; 95 % CI 0.90-1.09) was not significantly lower than patients with BMI 18.0-24.9 kg/m(2), but diabetes mellitus was independently associated with lower post-transplant survival (HR 1.29; 95 % CI 1.21-1.36). CONCLUSION In conclusion, obesity alone was not associated with lower post-transplant survival. However, DM, either alone or comorbid with obesity, is associated with significantly greater post-transplant mortality.
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Saab S, Lalezari D, Pruthi P, Alper T, Tong MJ. The impact of obesity on patient survival in liver transplant recipients: a meta-analysis. Liver Int 2015; 35:164-70. [PMID: 24313970 DOI: 10.1111/liv.12431] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 12/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS It is controversial if obesity has an impact on overall survival after liver transplantation (LT). The goal of this study was to determine if obesity impacts liver transplant recipient survival. Through subgroup analysis, we also evaluated different body mass index (BMI) thresholds and the confounding effect of ascites on survival. METHODS A systematic literature search from 1990 until July 2013. The main outcome was to evaluate the impact of obesity on survival in adult LT recipients. Dochotomous outcomes were reported as relative risk (RR) with 95% confidence intervals (CI). RESULTS Thirteen studies with a total 2275 obese and 72 212 non obese patients were included in the analysis. The combined analysis showed no difference in mortality between control and increased weight patients (RR = 0.97, 95% CI [0.82, 1.13], P = 0.66) at last follow-up. Moreover, no differences in mortality were noted in subgroup analysis comparing different BMI thresholds. There was also no differences in survival when BMI was adjusted for ascites or in studies where the liver disease severity was similar. Obese patients had worse survival than nonobese patients in pooled analysis of studies which had similar causes of liver disease (RR = 0.69, 95% CI [0.52, 0.92], P = 0.01). CONCLUSION The results of our pools analysis suggest that BMI does not specifically impact patient survival. However, obese patients have worse survival when analysis was performed in studies whose cohorts of obese and nonobese patients had similar causes of liver disease.
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Affiliation(s)
- Sammy Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA; Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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Hakeem AR, Cockbain AJ, Raza SS, Pollard SG, Toogood GJ, Attia MA, Ahmad N, Hidalgo EL, Prasad KR, Menon KV. Increased morbidity in overweight and obese liver transplant recipients: a single-center experience of 1325 patients from the United Kingdom. Liver Transpl 2013; 19:551-62. [PMID: 23408499 DOI: 10.1002/lt.23618] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 01/11/2013] [Indexed: 12/13/2022]
Abstract
Obesity levels in the United Kingdom have risen over the years. Studies from the United States and elsewhere have reported variable outcomes for obese liver transplant recipients in terms of post-liver transplant morbidity, mortality, and graft survival. This study was designed to analyze the impact of the body mass index (BMI) on outcomes following adult liver transplantation. Data from 1994 to 2009 were retrieved from a prospectively maintained database. Patients were stratified into 5 World Health Organization BMI categories: underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), obese (30.0-34.9 kg/m(2)), and morbidly obese (≥35.0 kg/m(2)). The primary outcome was an evaluation of graft and patient survival, and the secondary outcome was an assessment of postoperative morbidity. Bonferroni correction was applied with statistical significance set at P < 0.012. Kaplan-Meier curves were used to study the effects of BMI on graft and patient survival. A total of 1325 patients were included in the study: underweight (n = 47 or 3.5%), normal-weight (n = 643 or 48.5%), overweight (n = 417 or 31.5%), obese (n = 145 or 10.9%), and morbidly obese patients (n = 73 or 5.5%). The rate of postoperative infective complications was significantly higher in the overweight (60.7%, P < 0.01) and obese recipients (65.5%, P < 0.01) versus the normal-weight recipients (50.4%). The morbidly obese patients had a longer mean intensive care unit (ICU) stay than the normal-weight patients (4.7 versus 3.2 days, P = 0.03). The mean hospital stay was longer for the overweight (22.4 days, P < 0.001), obese (21.3 days, P = 0.04), and morbidly obese recipients (22.4 days, P = 0.047) versus the normal-weight recipients (18.0 days). There was no difference in death-censored graft survival or patient survival between the groups. In conclusion, this is the largest and only reported UK series on BMI and outcomes following liver transplantation. Overweight and obese patients have significantly increased morbidity in terms of infective complications after liver transplantation and, consequently, longer ICU and hospital stays.
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Affiliation(s)
- Abdul R Hakeem
- Department of Hepatopancreatobiliary and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom
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Lin MYC, Tavakol MM, Sarin A, Amirkiai SM, Rogers SJ, Carter JT, Posselt AM. Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates. Surg Obes Relat Dis 2013; 9:653-8. [PMID: 23701857 DOI: 10.1016/j.soard.2013.02.013] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 12/28/2012] [Accepted: 02/16/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Morbid obesity is a relative contraindication for organ transplant because it is associated with higher postoperative morbidity and mortality. The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a weight loss method for patients awaiting transplant has not been examined. METHODS A retrospective review was performed on morbidly obese patients awaiting liver or kidney transplant who underwent LSG from 2006 to 2012. Data included patient demographic characteristics, operative details, 30-day complications, percentage of excess weight loss, postoperative laboratory data, and status of transplant candidacy. RESULTS Twenty-six pretransplant patients underwent LSG. The mean age was 57 years, and 17 (65%) were women. Six patients had end-stage renal disease, and 20 patients had end-stage liver disease. The preoperative mean body mass index was 48.3 kg/m(2) (range 38-60.4 kg/m(2)). There were no deaths, and there were 6 postoperative complications: 2 superficial wound infections, 1 staple line leak, 1 postoperative bleed requiring blood transfusion, 1 transient encephalopathy, and 1 temporary renal insufficiency. The mean percentage of excess weight loss at 1, 3, and 12 months was 17% (n = 24/26), 26% (n = 23/26), and 50% (n = 18/20), respectively. All patients met our institution's body mass index cutoffs for transplantation by 12 months after the procedure. One patient's renal function stabilized, and he was taken off the transplant list. Eight patients eventually underwent solid organ transplant. Six received liver transplants, 1 patient received a combined liver and kidney transplant, and 1 received a kidney transplant. The mean time between LSG and transplant was 16.6 months. CONCLUSIONS This is the largest case series involving LSG in patients awaiting solid organ transplantation. LSG is well tolerated, is technically feasible, and improves candidacy for transplantation.
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Affiliation(s)
- Matthew Y C Lin
- Department of Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
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Hoy HM, Feurer ID, Alexander S, Loyd J, Wells N, Pinson CW. Negative Effects of Pretransplant Body Mass Index on Physical Health—Related Quality of Life after Lung Transplant. Prog Transplant 2012. [DOI: 10.7182/pit2012582] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Although current national data show improved graft and patient survival following lung transplant, the effects of several modifiable preexisting comorbid conditions on health-related quality of life after transplant have not been evaluated. This study examines the effects of 3 comorbid conditions present before lung transplant (reduced bone density, diabetes mellitus, and elevated body mass index) on health-related quality of life after lung transplant. Methods The Short Form 36 Health Survey was completed by 92 adult recipients at various times after lung transplant (mean, 41 months; range, 1–127 months). Multiple linear regression models that controlled for underlying disease, chronic rejection, and time after transplant tested the independent effects of the 3 pretransplant conditions on posttransplant health-related quality of life. Results The effects of pretransplant reduced bone density and diabetes mellitus were not statistically significant in these models. However, pretransplant body mass index had a significant negative effect (β = −.29, P = .007) on posttransplant physical health–related quality of life. Additionally, overweight status and obesity exerted comparable independent negative effects ( P = .01 and P = .03, respectively) on the physical function scale of the Short-Form 36 Health Survey compared with persons who were underweight or normal weight before transplant. Conclusions Reevaluation of elevated body mass index before transplant as a risk for reduced physical quality of life after lung transplant should be considered.
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Affiliation(s)
- Haley M. Hoy
- Vanderbilt Transplant Center, Nashville, Tennessee (HMH, IDF, JL, NW, CWP), University of Alabama, Huntsville (HMH, SA), Vanderbilt University Medical Center, Nashville, Tennessee (IDF, CWP)
| | - Irene D. Feurer
- Vanderbilt Transplant Center, Nashville, Tennessee (HMH, IDF, JL, NW, CWP), University of Alabama, Huntsville (HMH, SA), Vanderbilt University Medical Center, Nashville, Tennessee (IDF, CWP)
| | - Susan Alexander
- Vanderbilt Transplant Center, Nashville, Tennessee (HMH, IDF, JL, NW, CWP), University of Alabama, Huntsville (HMH, SA), Vanderbilt University Medical Center, Nashville, Tennessee (IDF, CWP)
| | - Jim Loyd
- Vanderbilt Transplant Center, Nashville, Tennessee (HMH, IDF, JL, NW, CWP), University of Alabama, Huntsville (HMH, SA), Vanderbilt University Medical Center, Nashville, Tennessee (IDF, CWP)
| | - Nancy Wells
- Vanderbilt Transplant Center, Nashville, Tennessee (HMH, IDF, JL, NW, CWP), University of Alabama, Huntsville (HMH, SA), Vanderbilt University Medical Center, Nashville, Tennessee (IDF, CWP)
| | - C. Wright Pinson
- Vanderbilt Transplant Center, Nashville, Tennessee (HMH, IDF, JL, NW, CWP), University of Alabama, Huntsville (HMH, SA), Vanderbilt University Medical Center, Nashville, Tennessee (IDF, CWP)
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Safety and feasibility of sleeve gastrectomy in morbidly obese patients following liver transplantation. Surg Endosc 2012; 27:81-5. [PMID: 22752278 DOI: 10.1007/s00464-012-2410-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 05/17/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND Obesity, steroid-induced diabetes, hypercholesterolemia, and steatohepatitis can occur after liver transplantation and may respond to bariatric surgery. The safety and feasibility of bariatric surgery after liver transplantation is unknown. METHODS Nine morbidly obese patients with prior liver transplants underwent sleeve gastrectomy in a pilot program. Sleeve gastrectomy was chosen over gastric banding to avoid foreign body implantation, and over gastric bypass to maintain endoscopic access to the biliary system and reduce surgical complexity. We reviewed patient demographics, operative details, 30-day complications, weight loss, postoperative hepatic and renal functions, and resolution of comorbidities. RESULTS Sleeve gastrectomy was performed laparoscopically in eight patients and as an open procedure in one patient. The mean operative time was 165 min and mean postoperative length of stay was 5 days. Follow-up ranged from 3 to 36 months. In the first 30 days, there were three complications in three patients: mesh dehiscence after a synchronous incisional hernia repair, bile leak from the liver surface requiring laparoscopic drainage, and postoperative dysphagia that required reoperation. Calcineurin inhibitor levels and hepatic and renal functions remained stable. There were no episodes of graft rejection. At 3 months liver function tests remained stable. Excess weight loss averaged 55.5% at 6 months. CONCLUSION Sleeve gastrectomy is technically feasible after liver transplantation and resulted in weight loss without adversely affecting graft function and immunosuppression. Early complications may be more frequent as a result of adhesions of the left upper quadrant. Late complications were rare.
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Ferreira LG, Anastácio LR, Correia MI. The impact of nutrition on cirrhotic patients awaiting liver transplantation. Curr Opin Clin Nutr Metab Care 2010; 13:554-61. [PMID: 20531175 DOI: 10.1097/mco.0b013e32833b64d2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To review the most recent aspects of nutrition therapy of cirrhotic patients on the waiting list for liver transplantation. RECENT FINDINGS Undernutrition has been widely reported among these patients, despite the lack of consensus on the best nutritional assessment tools in this population. Nutrition therapy has been marked by controversy. Nonetheless, recent findings have pointed out to the important role of the nutrition status and of some specific nutrients on the outcome of these patients. SUMMARY We report the latest findings on nutrition care of patients with end-stage liver disease on the waiting list for liver transplantation such as the impact of the nutritional status on outcome, probiotic and branched-chain amino acid supplementation, as well as the use of immunomodulating formula. Another important strategy that has been shown to improve these patients' nutritional care is the offering of nocturnal meals and micronutrient supplementation.
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Affiliation(s)
- Lívia G Ferreira
- Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Zaydfudim V, Feurer ID, Moore DR, Moore DE, Pinson CW, Shaffer D. Pre-transplant Overweight and Obesity Do Not Affect Physical Quality of Life after Kidney Transplantation. J Am Coll Surg 2010; 210:336-44. [DOI: 10.1016/j.jamcollsurg.2009.11.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 11/18/2009] [Accepted: 11/18/2009] [Indexed: 12/19/2022]
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