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Chaurasiya K, Kireeva E, Yadgarov M, Akhaladze D, Likar Y. Role of Preoperative Hepatobiliary Scintigraphy in Children Requiring Liver Resection. Clin Nucl Med 2023; 48:581-585. [PMID: 37272978 DOI: 10.1097/rlu.0000000000004660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE The risk of posthepatectomy liver failure (PHLF) remains an important concern following major liver resection. Assessment of future remnant liver function (FRLF) by hepatobiliary scintigraphy has shown its significance to prevent PHLF after major liver resection in adults with a threshold value of FRLF greater than 2.7%/min per m2. However, such data for pediatric patients were not published. METHODS A total of 77 pediatric patients with liver tumors who underwent 1-stage liver resection were included in this study. Assessment of FRLF, future remnant liver volume (FRLV), and the ratio of remnant liver volume to body weight (RLV-BWR) was performed before the surgery. RESULTS All patients had RLV-BWR values of more than 0.5%/kg. Future remnant liver volume values ranged from 19% to 89%, and FRLF values ranged from 1.8% to 31.8%/min per m2. Only 7 of 77 patients had FRLV values less than 25%, but their FRLF values exceeded 2.7%/min per m2. Two patients developed grade A and grade B PHLF. CONCLUSION Future remnant liver volume and the RLV-BWR can be used in most pediatric patients for the assessment of liver before hepatectomy. According to our data, implementation of FRLF assessment using hepatobiliary scintigraphy can be most beneficial for children with FRLV of less than 25%. The cutoff value of FRLV greater than 25% can be slightly decreased with minimal risk of developing PHLF. However, to establish a new cutoff value for FRLV in children, further prospective studies including larger numbers of patients with FRLV of less than 25% are needed.
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Affiliation(s)
- Kailash Chaurasiya
- From the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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Panagiotakis E, Selzer T, Böhm G, Schrem H, Vondran FWR, Qu Z, Ockenga J, Hertenstein B, Winterhalter M, Bektas H. Preoperative hemoglobin levels, extended resections and the body mass index influence survival after pancreaticoduodenectomy. Langenbecks Arch Surg 2023; 408:124. [PMID: 36935457 DOI: 10.1007/s00423-023-02863-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 03/09/2023] [Indexed: 03/21/2023]
Abstract
PURPOSE The negative influence of perioperative transfusion of packed red blood cells on the prognosis of various malignancies is the focus of recent research interest. The development of a propensity score for the prediction of perioperative transfusion of packed red blood cells (pRBCs) and the identification of independent risk factors for survival, that can either be known prior to or during surgery in patients undergoing pancreaticoduodenectomy for pancreatic head cancer are the two objectives of this study. METHODS Logistic regression analyses and Cox regression modeling were used to identify independent risk factors for perioperative transfusion of pRBCs and to determine individual risk factors for patient survival. A total of 101 adult patients who underwent surgery between 01/01/2016 and 12/31/2020 were investigated in a single-center retrospective analysis. RESULTS Preoperative hemoglobin levels (OR: 0.472, 95%-CI: 0.312-0.663, p < 0.001) and extended resections (OR: 4.720, 95%-CI: 1.819-13.296, p = 0.001) were identified as independent risk factors for perioperative transfusion of pRBCs, enabling the prediction of pRBC transfusion with high sensitivity and specificity (AUROC: 0.790). The logit of the derived propensity model for the transfusion of pRBCs (HR: 9.231, 95%CI: 3.083-28.118, p < 0.001) and preoperative Body Mass Index (BMI) (HR, 0.925; 95%-CI: 0.870-0.981, p = 0.008) were independent risk factors for survival. CONCLUSIONS Low preoperative hemoglobin levels, low BMI values, and extended resections are significant risk factors for survival that can be known and thus potentially be influenced prior to or during surgery. Patient blood management programs and prehabilitation programs should strive to increase preoperative hemoglobin levels and improve preoperative malnutrition.
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Affiliation(s)
- Emmanouil Panagiotakis
- General, Visceral and Oncologic Surgery, Gesundheit Nord, Klinikum Bremen Mitte, Bremen, Germany
| | - Tabea Selzer
- General, Visceral and Oncologic Surgery, Gesundheit Nord, Klinikum Bremen Mitte, Bremen, Germany
| | - Gabriele Böhm
- General, Visceral and Oncologic Surgery, Gesundheit Nord, Klinikum Bremen Mitte, Bremen, Germany
| | - Harald Schrem
- General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Florian W R Vondran
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Zhi Qu
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Bernd Hertenstein
- Department of Internal Medicine I, Klinikum Bremen Mitte, Bremen, Germany
| | | | - Hüseyin Bektas
- General, Visceral, and Oncologic Surgery, Gesundheit Nord, Klinikum Bremen Mitte, Sankt Jürgen Str. 1, 28177, Bremen, Germany.
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Schardey J, Zehl S, Kappenberger AS, Zimmermann P, Beigel F, Schiergens TS, Kasparek MS, Kühn F, Werner J, Wirth U. It is not NOD2 - genetic and clinical risk factors for postoperative complications following ileocolic resection in Crohn's disease. Int J Colorectal Dis 2022; 37:1901-1908. [PMID: 35913516 PMCID: PMC9388399 DOI: 10.1007/s00384-022-04223-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the role of the nucleotide oligomerization domain 2 (NOD2) mutation status and other risk factors for the incidence of postoperative complications after ileocolic resection for Crohn's disease (CD). METHODS Data of 138 patients consecutively undergoing ileocolic resection for CD at a tertiary academic referral center were retrospectively analyzed including single nucleotide polymorphism (SNP) data of the NOD2 gene. Uni- and multivariate regression analysis was performed to identify factors associated with increased risk of severe postoperative complications. RESULTS From 114 patients (83%), the NOD2 mutation status was available. Of these, 60 (53%) had a NOD2 wildtype, whereas eleven (10%) were homozygous for the high risk p.Leu1007fsX1008 (rs2066847) variant. Major postoperative complications occurred in 28 patients (20%). Twenty-seven of these (96%) were intraabdominal septic complications such as anastomotic leakage or abscess. Male gender (P = 0.029; OR 3.052, the duration of CD (time [months] from initial diagnosis of CD to surgery; P = 0.001; OR 1.009), previous abdominal surgery for CD (P = 0.017; OR 3.49), and the presence of enteric fistulas (P = 0.023; OR 3.21) were identified as independent risk factors for major postoperative complications. Homozygosity for the NOD2 high-risk variant p.Leu1007fsX1008 did not show increased postoperative morbidity in the short and long-term outcome. CONCLUSIONS We could detect independent risk factors for major postoperative complications after ileocolic resection for Crohn's disease. However, patients with the high-risk variant p.Leu1007fsX1008 of the NOD2 gene did not show increased postoperative morbidity.
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Affiliation(s)
- Josefine Schardey
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Sophie Zehl
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Alina S. Kappenberger
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Petra Zimmermann
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Florian Beigel
- grid.5252.00000 0004 1936 973XDepartment of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Tobias S. Schiergens
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Michael S. Kasparek
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany ,Department of Visceral Surgery, Josephinum, Munich, Germany
| | - Florian Kühn
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Jens Werner
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Ulrich Wirth
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
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4
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Bulte CS, Boer C, Hemmes SN, Neto AS, Binnekade JM, Hedenstierna G, Jaber S, Hiesmayr M, Hollmann MW, Mills GH, Melo MFV, Pearse RM, Putensen C, Schmid W, Severgnini P, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ. The effects of preoperative moderate to severe anaemia on length of hospital stay: A propensity score-matched analysis in non-cardiac surgery patients. Eur J Anaesthesiol 2021; 38:571-581. [PMID: 33399375 PMCID: PMC9867571 DOI: 10.1097/eja.0000000000001412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anaemia is frequently recorded during preoperative screening and has been suggested to affect outcomes after surgery negatively. OBJECTIVES The objectives were to assess the frequency of moderate to severe anaemia and its association with length of hospital stay. DESIGN Post hoc analysis of the international observational prospective 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study. PATIENTS AND SETTING The current analysis included adult patients requiring general anaesthesia for non-cardiac surgery. Preoperative anaemia was defined as a haemoglobin concentration of 11 g dl-1 or lower, thus including moderate and severe anaemia according to World Health Organisation criteria. MAIN OUTCOME MEASURES The primary outcome was length of hospital stay. Secondary outcomes included hospital mortality, intra-operative adverse events and postoperative pulmonary complications (PPCs). RESULTS Haemoglobin concentrations were available for 8264 of 9864 patients. Preoperative moderate to severe anaemia was present in 7.7% of patients. Multivariable analysis showed that preoperative moderate to severe anaemia was associated with an increased length of hospital stay with a mean difference of 1.3 ((95% CI 0.8 to 1.8) days; P < .001). In the propensity-matched analysis, this association remained present, median 4.0 [IQR 1.0 to 5.0] vs. 2.0 [IQR 0.0 to 5.0] days, P = .001. Multivariable analysis showed an increased in-hospital mortality (OR 2.9 (95% CI 1.1 to 7.5); P = .029), and higher incidences of intra-operative hypotension (36.3 vs. 25.3%; P < .001) and PPCs (17.1 vs. 10.5%; P = .001) in moderately to severely anaemic patients. However, this was not confirmed in the propensity score-matched analysis. CONCLUSIONS In this international cohort of non-cardiac surgical patients, preoperative moderate to severe anaemia was associated with a longer duration of hospital stay but not increased intra-operative complications, PPCs or in-hospital mortality. TRIAL REGISTRATION The LAS VEGAS study was registered at Clinicaltrials.gov, NCT01601223.
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Affiliation(s)
- Carolien S.E. Bulte
- Department of Anaesthesiology, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Sabrine N.T. Hemmes
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paolo, Brazil
| | - Jan M. Binnekade
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Goran Hedenstierna
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Samir Jaber
- Montpellier University Hospital, Saint Eloi Intensive Care Unit and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gary H. Mills
- Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK
| | - Marcos F. Vidal Melo
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Bostan, MA, USA
| | | | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, ASST Sette Laghi Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Universitá degli Studi di Genova, Genova, Italy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marcus J. Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Mahidol Oxford Tropical Medicine Research Unit (MORU), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, Mahidol University, Bangkok, Thailand, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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5
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Sneidere M, Schrem HH, Mahlmann JC, Beetz O, Cammann S, Oldhafer F, Kleine M, Klempnauer J, Kaltenborn A, Zwirner U, Kulik U. Proposal of a Multivariable Prediction Model for Graded Morbidity after Liver Resection for Colorectal Metastases. Zentralbl Chir 2020; 148:147-155. [PMID: 33091938 DOI: 10.1055/a-1243-0746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Prognostic models to predict individual early postoperative morbidity after liver resection for colorectal liver metastases (CLM) are not available but could enable optimized preoperative patient selection and postoperative surveillance for patients at greater risk of complications. The aim of this study was to establish a prognostic model for the prediction of morbidity after liver resection graded according to Dindo. METHODS N = 679 cases of primary liver resection for CLM were retrospectively analyzed using univariable and multivariable ordinal regression analyses. Receiver operating characteristics curve (ROC) analysis was utilised to assess the sensitivity and specificity of predictions and their potential usefulness as prognostic models. Internal validation of the score was performed using data derived from 129 patients. RESULTS The final multivariable regression model revealed lower preoperative levels, a greater number of units of intraoperatively transfused packed red blood cells (pRBCs), longer duration of surgery, and larger metastases to independently influence postoperatively graded morbidity. ROC curve analysis demonstrated that the multivariable regression model is able to predict each individual grade of postoperative morbidity with high sensitivity and specificity. The areas under the receiver operating curves (AUROC) for all of these predictions of individual grades of morbidity were > 0.700, indicating potential usefulness as a predictive model. Moreover, a consistent concordance in Grades I, II, IV, and V according to the classification proposed by Dindo et al. was observed in the internal validation. CONCLUSION This study proposes a prognostic model for the prediction of each grade of postoperative morbidity after liver resection for CLM with high sensitivity and specificity using pre- and intraoperatively available variables.
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Affiliation(s)
- Mara Sneidere
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
| | | | | | - Oliver Beetz
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
| | - Sebastian Cammann
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
| | - Felix Oldhafer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
| | - Moritz Kleine
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
| | - Juergen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
| | | | - Ulrich Zwirner
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
| | - Ulf Kulik
- General, Visceral and Transplantation Surgery, Hannover Medical School, Germany
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6
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Gordon V, Chowdhury A, Keim S. Etiology and Comorbidity Diagnoses Effect on Outcomes for Patients Undergoing Endoscopic Retrograde Cholangiopancreatography. Cureus 2020; 12:e10209. [PMID: 33042658 PMCID: PMC7534508 DOI: 10.7759/cureus.10209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is now the first-line approach to treating choledocholithiasis. As a minimally invasive procedure, it is considered relatively safe but still entails a higher risk than other routine endoscopic procedures. This study aims to look at possible patient etiologies and comorbidities that may affect patient outcomes. Methods This study used the Nationwide Inpatient Sample (NIS) from the years 2012 - 2015 to collect anonymous patient data through the use of International Classification of Diseases, Ninth Revision (ICD-9) codes. Specific codes were used to determine the top five etiologies (or presenting diagnosis) for patients who had this surgery and to separate outpatients with specific comorbidity diagnoses. The IBM Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY) was then used to compare patients with these diagnoses or etiologies to those without to measure differences in patient outcomes, such as mortality, length of stay, and total charges. Results Patients who had an etiological diagnosis of acute kidney failure had worse outcomes than patients who were admitted for ERCP without that etiological diagnosis. There were also specific comorbidity diagnoses that were noted to have worse patient outcomes, including congestive heart failure, diabetes mellitus with complications, a coagulopathy disorder, anemia, or chronic liver disease. Additionally, patients who had both acute kidney disease and chronic liver disease had the worst outcomes. Conclusions This study highlights the need to understand all patient risk factors before having them undergo ERCP, especially in the setting of scheduled surgery. Working to control these factors before surgery can increase the possibility of avoiding negative outcomes like mortality, increased patient costs, and increased length of stay.
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Affiliation(s)
- Victoria Gordon
- Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, USA
| | - Anni Chowdhury
- Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, USA
| | - Sarah Keim
- General Surgery, The University of Kansas Medical Center, Kansas City, USA
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Zwiep TM, Gilbert RWD, Moloo H, Touchie D, Martel G, Wallace T, Bertens KA. Improving the treatment of pre-operative anemia in hepato-pancreato-biliary patients: a quality improvement initiative. Patient Saf Surg 2020; 14:18. [PMID: 32346397 PMCID: PMC7181477 DOI: 10.1186/s13037-020-00239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022] Open
Abstract
Background Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery. Methods This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin. Results A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%. Conclusions This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated.
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Affiliation(s)
- Terry M Zwiep
- 1Department of Surgery, London Health Sciences Centre, London, Canada
| | - Richard W D Gilbert
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Husein Moloo
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Donna Touchie
- 3Surgical Blood Management Program, The Ottawa Hospital, Ottawa, Canada
| | - Guillaume Martel
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Tom Wallace
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Kimberly A Bertens
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
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Liu J, Zhang Y, Zhu H, Qiu L, Guo C. Prediction of perioperative outcome after hepatic resection for pediatric patients. BMC Gastroenterol 2019; 19:201. [PMID: 31775648 PMCID: PMC6882044 DOI: 10.1186/s12876-019-1109-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/05/2019] [Indexed: 02/08/2023] Open
Abstract
Background Hepatic resection is associated with significant risk of morbidity and mortality. Optimising the surgical techniques and perioperative management may improve in operative morbidity and mortality. However, perioperative variables involved in the improvement for postoperative outcomes in pediatric hepatectomy have not been defined. Methods We retrospectively reviewed 156 consecutive pediatric patients who underwent hepatectomy at our center (an academic tertiary care hospital) between 2006 and 2016. Baseline demographic variables, intraoperative variables, complications, and hospital stay were explored. The patients were further investigated using univariate and multivariate analysis for the factors involved in the postoperative outcomes. Results Of the conditions requiring resections, malignant and benign liver diseases accounted for 47.4% (74/156) and 52.6% (82/156), respectively. The overall hospital mortality was 1.9% (3/156) and the overall postoperative complication rate was 44.2% (69/156). Anatomical resections were performed in 128 patients (82.1%), including 14(9.0%) extended hepatectomies. Eighty percent of patients had three or more segments resected. The median operative time was 167.7 (65–600) minutes and median estimated blood loss was 320.1(10–1600) mL. On multivariate analysis, the estimated blood loss (EBL) (mL) (OR, 2.19; 95CI, 1.18–3.13; p = 0.016), extent of hepatectomy (OR, 1.81; 95CI, 1.06–2.69; p = 0.001) and pringle maneuver (OR, 1.38; 95CI, 1.02–1.88; p = 0.038) were the independent predictors of postoperative complications. Conclusions Extent of hepatectomy and estimated blood loss are largely responsible for the perioperative complications. With the surgical devices and management amelioration, like pringle maneuver, the treatment planning may be optimize in pediatric liver resection.
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Affiliation(s)
- Jianxia Liu
- Department of Anesthesiology, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China
| | - Yunfei Zhang
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China
| | - Hai Zhu
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China
| | - Lin Qiu
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China.
| | - Chunbao Guo
- Department of Anesthesiology, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China. .,Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China. .,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China. .,Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China.
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9
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Wronka KM, Grąt M, Stypułkowski J, Bik E, Patkowski W, Krawczyk M, Zieniewicz K. Relevance of Preoperative Hyperbilirubinemia in Patients Undergoing Hepatobiliary Resection for Hilar Cholangiocarcinoma. J Clin Med 2019; 8:jcm8040458. [PMID: 30959757 PMCID: PMC6517893 DOI: 10.3390/jcm8040458] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 03/22/2019] [Accepted: 04/02/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Karolina Maria Wronka
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097 Warsaw, Poland.
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097 Warsaw, Poland.
| | - Jan Stypułkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097 Warsaw, Poland.
| | - Emil Bik
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097 Warsaw, Poland.
| | - Waldemar Patkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097 Warsaw, Poland.
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097 Warsaw, Poland.
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097 Warsaw, Poland.
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10
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Mueller MM, Van Remoortel H, Meybohm P, Aranko K, Aubron C, Burger R, Carson JL, Cichutek K, De Buck E, Devine D, Fergusson D, Folléa G, French C, Frey KP, Gammon R, Levy JH, Murphy MF, Ozier Y, Pavenski K, So-Osman C, Tiberghien P, Volmink J, Waters JH, Wood EM, Seifried E. Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference. JAMA 2019; 321:983-997. [PMID: 30860564 DOI: 10.1001/jama.2019.0554] [Citation(s) in RCA: 345] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEW The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018. FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCE The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.
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Affiliation(s)
- Markus M Mueller
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Kari Aranko
- European Blood Alliance (EBA), Amsterdam, the Netherlands
| | - Cécile Aubron
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Jeffrey L Carson
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | | | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Departments of Medicine, Surgery, Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gilles Folléa
- Société Française de Transfusion Sanguine (SFTS), Paris, France
| | - Craig French
- Intensive Care, Western Health, Melbourne, Australia
| | | | | | - Jerrold H Levy
- Department of Cardiothoracic Intensive Care Medicine, Duke University Medical Centre, Durham, North Carolina
| | - Michael F Murphy
- National Health Service Blood and Transplant and University of Oxford, Oxford, United Kingdom
| | - Yves Ozier
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Cynthia So-Osman
- Sanquin Blood Bank, Leiden and Department of Haematology, Groene Hart Hospital, Gouda, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
| | | | - Jimmy Volmink
- Department of Clinical Epidemiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jonathan H Waters
- Departments of Anesthesiology and Bioengineering, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania
| | - Erica M Wood
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erhard Seifried
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
- European Blood Alliance (EBA), Amsterdam, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
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11
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Abstract
PURPOSE OF REVIEW Anemia remains a global health issue. This review addresses the recent findings on anemia in surgical patients and its significance in perioperative setting. RECENT FINDINGS The prevalence of anemia in surgical populations is high, ranging from one-third of population to nearly 100%. Anemia is an independent, modifiable risk factor for a growing list of unfavorable events, complications and diminished functional outcomes (lasting for months following discharge), as well as a major predisposing factor for allogeneic blood transfusions. Therefore, timely screening and diagnosis of anemia prior to elective surgeries is of great importance. Nonetheless, studies suggest that many opportunities to properly manage anemia in perioperative setting are lost. Patient blood management provides a framework of evidence-based strategies to effectively reduce the risk of occurrence of anemia and treat it with the ultimate goal of improving patient outcomes. Studies on the clinical impact of patient blood management strategies are emerging. SUMMARY Active screening for anemia and proper management of it in perioperative setting is essential. Several strategies to prevent anemia - including elimination of unnecessary diagnostic blood draws - are effective and reasonable approaches.
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12
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Lu Q, Lu JW, Wu Z, Liu XM, Li JH, Dong J, Yin GZ, Lv Y, Zhang XF. Perioperative outcome of elderly versus younger patients undergoing major hepatic or pancreatic surgery. Clin Interv Aging 2018; 13:133-141. [PMID: 29416321 PMCID: PMC5790074 DOI: 10.2147/cia.s153058] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective The aim of this study was to determine the safety of elderly cancer patients (≥70 years) undergoing hepatic resection (HR) or pancreaticoduodenectomy (PD) in comparison with younger adults (<70 years). Methods A total of 1,012 consecutive patients undergoing HR or PD were included. The incidence and severity of morbidity were documented within 30 days postoperatively and compared between elderly and younger groups. Risk factors associated with postoperative morbidity were investigated by multivariate logistic regression analysis. Results Elderly patients (n=111, 11.0%) had more comorbidities and worse preoperative general condition and liver function versus younger patients (n=901, 89.0%), and thus were more likely to develop infectious (eg, systemic sepsis and urinary tract infection, both p<0.01) and technical-associated complications (intraperitoneal bleeding and biliary/pancreatic fistula, p=0.029 and p=0.074, respectively). However, the incidence and severity of complications were comparable between elderly and younger patients in the whole cohort, and also in HR and PD surgery groups separately. Preoperative hemoglobin (odds ratio [OR] 1.4, p=0.007) and intraoperative blood transfusion (OR 1.9, p=0.002), rather than age, were independently associated with postoperative morbidity. Hepatitis (OR 2.9, p=0.001), preoperative hemoglobin (OR 1.6, p=0.036), and pancreatic versus hepatic surgery (OR 2.3, p=0.005) were independently associated with postoperative infectious. For elderly patients only, American Society of Anesthesiologists (ASA) score III (OR 2.1, p=0.033) and intraoperative blood transfusion (OR 3.2, p=0.030) were independently associated with postoperative morbidity. Conclusion HR and PD can be safely performed in selected elderly patients versus younger patients. Elderly patients with ASA score III or above should be cautiously selected for major surgeries.
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Affiliation(s)
- Qiang Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Jian-Wen Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Xue-Min Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Jian-Hui Li
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China.,Department of Surgical Oncology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Jian Dong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Guo-Zhi Yin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
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13
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Oliveira RA, Turrini RNT, Poveda VDB. Risk factors for development of surgical site infections among liver transplantation recipients: An integrative literature review. Am J Infect Control 2018; 46:88-93. [PMID: 28689978 DOI: 10.1016/j.ajic.2017.05.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Surgical site infection (SSI) is an important complication in the postoperative period of recipients of liver transplantation. The purpose of this integrative literature review is to summarize the knowledge available about the risk factors contributing to the development SSI among adults undergoing liver transplantation. METHODS We reviewed the Medical Literature Analysis and Retrieval System Online/PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature, Scopus, and Web of Science databases. RESULTS Two hundred sixteen articles were identified and the final sample of 9 articles was analyzed in full length. The SSI rate found in the investigations ranged between 9.6% and 35.5%. Risk factors for SSI were grouped into categories related to the preoperative period, such as Model for End-Stage Renal Disease score > 35 and ventilated support on day of transplant; to the intraoperative period activity, such as transfusion of packed red blood cells, extended surgical time, hyperglycemia >200 mg/dL, use of vasopressor drugs, and ascites flow >1 L; and to the donor/recipient relationship, such as age differences >10 years, ratio of donor liver mass to recipient body mass < 0.01. Additionally, centers that annually perform <50 transplants appear to have higher rates of SSI. CONCLUSIONS Few studies have addressed the subject of SSI in relation to liver transplantation in the scientific literature. Risk factors for SSI in patients who underwent liver transplantation vary between institutions.
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14
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Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection An international audit by ESCP and S-ECCO. Colorectal Dis 2017; 20:219-227. [PMID: 28913968 DOI: 10.1111/codi.13889] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/30/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patient and disease-related factors, as well as operation technique all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results. AIM To investigate the effect of pre- and intra-operative risk factors on 30-day postoperative outcome in patients undergoing surgery for Crohn's disease. METHOD International prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. This study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien-Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, re-operation, surgical site infection and length of stay at hospital. Multivariable binary logistic regression analyses were used to produce odds ratios (OR) and 95% confidence intervals (CI). RESULTS Three hundred and seventy five resections in 375 patients were included. The median age was 37 and 57.1% were female. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36 95% CI 1.10-4.97)], urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13-3.55) and unplanned intraoperative adverse events (OR 2.30, 95% CI 1.20-4.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, CI [1.08-1.61]) and those who had urgent/expedited operations (OR 1.21, CI [1.07-1.37]). CONCLUSION Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intraoperative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients. This article is protected by copyright. All rights reserved.
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15
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Kagedan DJ, Goyert N, Li Q, Paszat L, Kiss A, Earle CC, Karanicolas PJ, Wei AC, Mittmann N, Coburn NG. The Impact of Increasing Hospital Volume on 90-Day Postoperative Outcomes Following Pancreaticoduodenectomy. J Gastrointest Surg 2017; 21:506-515. [PMID: 28058617 DOI: 10.1007/s11605-016-3346-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/20/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system. METHODS A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases. RESULTS Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers. CONCLUSION Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.
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Affiliation(s)
- Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nik Goyert
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Lawrence Paszat
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alexander Kiss
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada
| | - Craig C Earle
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada
| | - Alice C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Natalie G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. .,Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada. .,, 2075 Bayview Ave., Rm. T2-11, Toronto, ON, M4N 3M5, Canada.
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16
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Lemke M, Law CHL, Li J, Dixon E, Tun Abraham M, Hernandez Alejandro R, Bennett S, Martel G, Karanicolas PJ. Three-point transfusion risk score in hepatectomy. Br J Surg 2017; 104:434-442. [PMID: 28079259 DOI: 10.1002/bjs.10416] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/27/2016] [Accepted: 09/30/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score. METHODS A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated. RESULTS There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66. CONCLUSION The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.
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Affiliation(s)
- M Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - C H L Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - J Li
- Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - E Dixon
- Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - M Tun Abraham
- Hepatobiliary Surgery, Division of General Surgery, London Health Sciences Centre, University of Western Ontario, London, Canada
| | - R Hernandez Alejandro
- Hepatobiliary Surgery, Division of General Surgery, London Health Sciences Centre, University of Western Ontario, London, Canada
| | - S Bennett
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - G Martel
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - P J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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17
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Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy. J Surg Res 2016; 206:106-112. [PMID: 27916348 DOI: 10.1016/j.jss.2016.07.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/26/2016] [Accepted: 07/07/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy. MATERIALS AND METHODS Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality. RESULTS Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm (n = 229, 44%), primary hepatic neoplasm (n = 108, 21%), primary extra-hepatic biliary neoplasm (n = 23, 4%), and nonmalignant indications (n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870). CONCLUSIONS Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.
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