1
|
Kukla A, Sahi SS, Navratil P, Benzo RP, Smith BH, Duffy D, Park WD, Shah M, Shah P, Clark MM, Fipps DC, Denic A, Schinstock CA, Dean PG, Stegall MD, Kudva YC, Diwan TS. Weight Loss Surgery Increases Kidney Transplant Rates in Patients With Renal Failure and Obesity. Mayo Clin Proc 2024; 99:705-715. [PMID: 38702124 DOI: 10.1016/j.mayocp.2024.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/23/2023] [Accepted: 01/25/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE To describe the outcomes of kidney transplant (KT) candidates with obesity undergoing sleeve gastrectomy (SG) to meet the criteria for KT. METHODS Retrospective analysis was conducted of electronic medical records of KT candidates with obesity (body mass index >35 kg/m2) who underwent SG in our institution. Weight loss, adverse health events, and the listing and transplant rates were abstracted and compared with the nonsurgical cohort. RESULTS The SG was performed in 54 patients; 50 patients did not have surgery. Baseline demographic characteristics were comparable at the time of evaluation. Mean body mass index ± SD of the SG group was 41.7±3.6 kg/m2 at baseline (vs 41.5±4.3 kg/m2 for nonsurgical controls); at 2 and 12 months after SG, it was 36.4±4.1 kg/m2 and 32.6±4.0 kg/m2 (P<.01 for both). In the median follow-up time of 15.5 months (interquartile range, 6.4 to 23.9 months), SG was followed by active listing (37/54 people), and 20 of 54 received KT during a median follow-up time of 20.9 months (interquartile range, 14.7 to 28.3 months) after SG. In contrast, 14 of 50 patients in the nonsurgical cohort were listed, and 5 received a KT (P<.01). Three patients (5.6%) experienced surgical complications. There was no difference in overall hospitalization rates and adverse health outcomes, but the SG cohort experienced a higher risk of clinically significant functional decline. CONCLUSION In KT candidates with obesity, SG appears to be effective, with 37% of patients undergoing KT during the next 18 months (P<.01). Further research is needed to confirm and to improve the safety and efficacy of SG for patients with obesity seeking a KT.
Collapse
Affiliation(s)
- Aleksandra Kukla
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN; Von Liebig Transplant Center, Mayo Clinic, Rochester, MN.
| | - Sukhdeep S Sahi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Pavel Navratil
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Urology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic; Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Roberto P Benzo
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - Byron H Smith
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dustin Duffy
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Walter D Park
- Department of Cardiovascular Surgery Research, Mayo Clinic, Rochester, MN
| | - Meera Shah
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Pankaj Shah
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Matthew M Clark
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Aleksandar Denic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Carrie A Schinstock
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN; Von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Patrick G Dean
- Von Liebig Transplant Center, Mayo Clinic, Rochester, MN; Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Mark D Stegall
- Von Liebig Transplant Center, Mayo Clinic, Rochester, MN; Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Yogish C Kudva
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Tayyab S Diwan
- Von Liebig Transplant Center, Mayo Clinic, Rochester, MN; Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| |
Collapse
|
2
|
Pencovich N, Smith BH, Attia ZI, Jimenez FL, Bentall AJ, Schinstock CA, Khamash HA, Jadlowiec CC, Jarmi T, Mao SA, Park WD, Diwan TS, Friedman PA, Stegall MD. Electrocardiography-based Artificial Intelligence Algorithms Aid in Prediction of Long-term Mortality After Kidney Transplantation. Transplantation 2024:00007890-990000000-00715. [PMID: 38557657 DOI: 10.1097/tp.0000000000005023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Predicting long-term mortality postkidney transplantation (KT) using baseline clinical data presents significant challenges. This study aims to evaluate the predictive power of artificial intelligence (AI)-enabled analysis of preoperative electrocardiograms (ECGs) in forecasting long-term mortality following KT. METHODS We analyzed preoperative ECGs from KT recipients at three Mayo Clinic sites (Minnesota, Florida, and Arizona) between January 1, 2006, and July 30, 2021. The study involved 6 validated AI algorithms, each trained to predict future development of atrial fibrillation, aortic stenosis, low ejection fraction, hypertrophic cardiomyopathy, amyloid heart disease, and biological age. These algorithms' outputs based on a single preoperative ECG were correlated with patient mortality data. RESULTS Among 6504 KT recipients included in the study, 1764 (27.1%) died within a median follow-up of 5.7 y (interquartile range: 3.00-9.29 y). All AI-ECG algorithms were independently associated with long-term all-cause mortality (P < 0.001). Notably, few patients had a clinical cardiac diagnosis at the time of transplant, indicating that AI-ECG scores were predictive even in asymptomatic patients. When adjusted for multiple clinical factors such as recipient age, diabetes, and pretransplant dialysis, AI algorithms for atrial fibrillation and aortic stenosis remained independently associated with long-term mortality. These algorithms also improved the C-statistic for predicting overall (C = 0.74) and cardiac-related deaths (C = 0.751). CONCLUSIONS The findings suggest that AI-enabled preoperative ECG analysis can be a valuable tool in predicting long-term mortality following KT and could aid in identifying patients who may benefit from enhanced cardiac monitoring because of increased risk.
Collapse
Affiliation(s)
- Niv Pencovich
- Departments of Surgery and Immunology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
- Department of General Surgery and Transplantation, Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Tel-Aviv, Israel
| | - Byron H Smith
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Andrew J Bentall
- Departments of Surgery and Immunology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Carrie A Schinstock
- Departments of Surgery and Immunology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | | | | | - Tambi Jarmi
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Shennen A Mao
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ
| | - Walter D Park
- Departments of Surgery and Immunology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Tayyab S Diwan
- Departments of Surgery and Immunology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mark D Stegall
- Departments of Surgery and Immunology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| |
Collapse
|
3
|
Kukla A, Kudva YC, Navratil P, Sahi SS, Benzo RP, Fipps DC, Erickson AE, Majorowicz RR, Clark MM, Schinstock CA, Shah P, Shah M, Diwan TS. Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach. Mayo Clin Proc 2024; 99:445-458. [PMID: 38432750 DOI: 10.1016/j.mayocp.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/17/2023] [Accepted: 11/14/2023] [Indexed: 03/05/2024]
Abstract
Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.
Collapse
Affiliation(s)
- Aleksandra Kukla
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA; Von Liebig Transplant Center, Department of Transplantation Surgery, Mayo Clinic, MN, USA.
| | - Yogish C Kudva
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, MN, USA
| | - Pavel Navratil
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA; Department of Urology, University Hospital Hradec Kralove, and Charles University, Faculty of Medicine in Hradec Kralove, Czechia
| | - Sukhdeep S Sahi
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | - Roberto P Benzo
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | - David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | - Avery E Erickson
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, MN, USA
| | - Rachael R Majorowicz
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, MN, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, MN, USA
| | - Carrie A Schinstock
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA; Von Liebig Transplant Center, Department of Transplantation Surgery, Mayo Clinic, MN, USA
| | - Pankaj Shah
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, MN, USA
| | - Meera Shah
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, MN, USA
| | - Tayyab S Diwan
- Von Liebig Transplant Center, Department of Transplantation Surgery, Mayo Clinic, MN, USA
| |
Collapse
|
4
|
Pencovich N, Long JJ, Smith BH, Kinzelman-Vesely EA, Sudhindran V, Ryan RJ, Stegall MD, Kukla A, Diwan TS. Outcomes of Kidney Transplantation in Patients That Underwent Bariatric Surgery: A Systematic Review and Meta-analysis. Transplantation 2024; 108:346-356. [PMID: 37271882 DOI: 10.1097/tp.0000000000004680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The impact of bariatric surgery (BS) on kidney transplantation (KT) outcomes in patients with obesity remains controversial. We systematically searched MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials for studies reporting outcomes of KT recipients that underwent prior BS. Common/random effects meta-analyses were performed to obtain summary ratios of the postoperative outcomes. Eighteen eligible studies involving 315 patients were identified. Sleeve gastrectomy was the most common BS type (65.7%) followed by Roux-en-Y gastric bypass (27.6%) and gastric banding (4.4%). Across studies that provided the data, the %excess weight loss from BS to KT was 62.79% (95% confidence interval [CI], 52.01-73.56; range, 46.2%-80.3%). The rates of delayed graft function and acute rejection were 16% (95% CI, 7%-28%) and 16% (95% CI, 11%-23%) in 14 and 11 studies that provided this data, respectively. The rates of wound, urinary, and vascular complications following KT were 5% (95% CI, 0%-13%),19% (95% CI, 2%-42%), and 2% (95% CI, 0%-5%), in 12, 9, and 11 studies that provided this data, respectively. Follow-up time after KT was reported in 11 studies (61.1%) and ranged from 16 mo to >5 y. Graft loss was reported in 14 studies with an average of 3% (95% CI, 1%-6%). Four studies that included a comparator group of patients with obesity who did not undergo BS before KT showed comparable outcomes between the groups. We conclude that currently there is a paucity of robust evidence to suggest that pretransplant BS has a major effect on post-KT outcomes. High-quality studies are needed to fully evaluate the impact of BS on KT outcomes.
Collapse
Affiliation(s)
- Niv Pencovich
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Jane J Long
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Byron H Smith
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | | | - Vineeth Sudhindran
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Randi J Ryan
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Mark D Stegall
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Aleksandra Kukla
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Tayyab S Diwan
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
5
|
Watt KD, Paul S, Khan MQ, Siddiqui M, Lam J, Diwan TS, Camilleri M. Obesity management for the hepatologist-What to do, how to do it and why? Hepatology 2023:01515467-990000000-00571. [PMID: 37725761 DOI: 10.1097/hep.0000000000000598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/13/2023] [Indexed: 09/21/2023]
Abstract
Obesity is highly prevalent in hepatology clinics and has a significant impact on chronic liver disease and patient management. Hepatologists and gastroenterologists need to be actively engaged in the management of obesity. This review provides a detailed approach to this challenging comorbidity.
Collapse
Affiliation(s)
- Kymberly D Watt
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sonali Paul
- Center for Liver Diseases, University of Chicago Medicine, Chicago, Illinois, USA
| | - Mohammad Qasim Khan
- Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
| | - Mohammad Siddiqui
- Division of Gastroenterology & Hepatology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jenny Lam
- Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Tayyab S Diwan
- Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
6
|
Sharma I, Nakanishi H, Hage K, Marrero K, Diwan TS, daSilva-deAbreu A, Davis SS, Clapp B, Ghanem OM. Bariatric surgery and left ventricular assist device in patients with heart failure: A systematic review and meta-analysis. Am J Surg 2023; 226:340-349. [PMID: 37355375 DOI: 10.1016/j.amjsurg.2023.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/21/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND The role of metabolic and bariatric surgery (MBS), in synergy with left ventricular assist device (LVAD) implantation, in the scope of end-stage heart failure management for patients with severe obesity is not well elucidated. METHODS We conducted a meta-analysis using Cochrane, Embase, PubMed, and Scopus databases to include articles from their inception to November 2022. RESULTS A total of 271 patients who underwent MBS during or after the LVAD implantation were included from eleven separate studies. After surgery, 67.4% of patients were listed on the heart transplant waitlist with 32.5% undergoing a successful transplant. We reported a mean listing time of 13.8 months. Finally, the pooled postoperative complication rate, 30-day readmission rate, and one-year mortality rate were 47.6%, 23.6% and 10.2% respectively. CONCLUSIONS MBS and LVAD is a safe and effective approach to bridge patients with severe obesity and end-stage heart failure for definitive heart transplantation.
Collapse
Affiliation(s)
- Ishna Sharma
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Karl Hage
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Katie Marrero
- Carle Foundation Hospital General Surgery Residency, Champaign, IL, USA
| | - Tayyab S Diwan
- Division of Transplantation, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Scott S Davis
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
7
|
Lutz AJ, Diwan TS, Hobeika MJ, Dunn T, Proffitt E, Reynolds T, Fridell JA. Revitalizing pancreas transplantation: creation of a hands-on training course for pancreas allograft procurement, backbench preparation, and transplantation. Global Surg Educ 2023; 2:61. [PMID: 38013877 PMCID: PMC10243691 DOI: 10.1007/s44186-023-00139-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/09/2023] [Accepted: 05/14/2023] [Indexed: 11/29/2023]
Abstract
Despite a steady increase in the number of organs available for transplant in the United States, over the last two decades there has been a precipitous decrease in the annual number of pancreas transplants performed. One overlooked consequence of this decline in pancreas transplant volume has been a decrease in experience in proper pancreas procurement and transplantation techniques for transplant surgeons as well as fewer trained abdominal transplant fellows entering the workforce certified for pancreas procurement and transplantation, with those achieving certification having less-developed judgment, skills, and experience. To augment current fellowship training and provide a concentrated experience in pancreas procurement and transplantation, the ASTS developed a hands-on surgical skills workshop focused on proper techniques for pancreas allograft procurement and backbench preparation.
Collapse
Affiliation(s)
- Andrew J. Lutz
- Department of Surgery, Indiana University School of Medicine, 550 N University BLVD, #4258, Indianapolis, IN 46202 USA
| | - Tayyab S. Diwan
- Division of Transplantation Surgery, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Mark J. Hobeika
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, TX USA
| | - Ty Dunn
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, PA USA
| | | | - Tracy Reynolds
- American Society of Transplant Surgeons, Arlington, VA USA
| | - Jonathan A. Fridell
- Department of Surgery, Indiana University School of Medicine, 550 N University BLVD, #4258, Indianapolis, IN 46202 USA
| |
Collapse
|
8
|
Fipps DC, Sinha S, Diwan TS, Clark MM. Psychosocial considerations in the combined bariatric surgery and organ transplantation population: a review of the overlapping pathologies and outcomes. Curr Opin Organ Transplant 2022; 27:514-522. [PMID: 36103143 DOI: 10.1097/mot.0000000000001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW This review highlights the salient data of the psychosocial concerns that influence outcomes of bariatric surgery and organ transplantation. RECENT FINDINGS Bariatric surgery has emerged as an important intervention with data supporting substantial and sustained weight loss, enhanced quality of life, remission of obesity-related medical comorbidities, and improved long-term patient and graft survival in transplant patients. Depression, suicide, anxiety, posttraumatic stress disorder, alcohol use, adherence, and psychopharmacology considerations can influence outcomes of both these surgeries. SUMMARY Obesity is increasingly prevalent among patients pursuing transplantation surgery, and it is often a factor in why a patient needs a transplant. However, obesity can be a barrier to receiving a transplant, with many centers implementing BMI criteria for surgery. Furthermore, obesity and obesity-related comorbidities after transplant can cause poor outcomes. In this context, many transplant centers have created programs that incorporate interventions (such as bariatric surgery) that target obesity in transplant candidates. A presurgery psychosocial assessment is an integral (and required) part of the process towards receiving a bariatric surgery and/or a transplantation surgery. When conducting a dual (bariatric and transplantation surgery) psychosocial assessment, it is prudent to understand the overlap and differentiation of specific psychosocial components that influence outcomes in these procedures.
Collapse
Affiliation(s)
| | - Shirshendu Sinha
- Department of Psychiatry and Psychology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Matthew M Clark
- Department of Psychiatry and Psychology
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
9
|
Diwan TS. We are transplant surgeons first, bariatric surgeons second. Am J Transplant 2021; 21:909. [PMID: 32594632 DOI: 10.1111/ajt.16165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|
10
|
Kassam AF, Cortez AR, Winer LK, Conzen KD, El-Hinnawi A, Jones CM, Matsuoka L, Watkins AC, Collins KM, Bhati C, Selzner M, Sonnenday CJ, Englesbe MJ, Diwan TS, Dick AAS, Quillin RC. Extinguishing burnout: National analysis of predictors and effects of burnout in abdominal transplant surgery fellows. Am J Transplant 2021; 21:307-313. [PMID: 32463950 DOI: 10.1111/ajt.16075] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 01/25/2023]
Abstract
Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.
Collapse
Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kendra D Conzen
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Ashraf El-Hinnawi
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | | | - Lea Matsuoka
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony C Watkins
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Kelly M Collins
- Department of Transplantation and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Chandra Bhati
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - André A S Dick
- Department of Surgery, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - Ralph C Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
11
|
Diwan TS. Comment on: Bariatric surgery before, during, and after liver transplantation: a systematic review and meta-analysis. Surg Obes Relat Dis 2020; 16:1347-1348. [PMID: 32737012 DOI: 10.1016/j.soard.2020.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, University of Cincinnati, Milford, Ohio
| |
Collapse
|
12
|
Diwan TS, Lee TC, Nagai S, Benedetti E, Posselt A, Bumgardner G, Noria S, Whitson BA, Ratner L, Mason D, Friedman J, Woodside KJ, Heimbach J. Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic. Am J Transplant 2020; 20:2143-2155. [PMID: 31965711 DOI: 10.1111/ajt.15784] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/05/2020] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplant and unique challenges in perioperative and postoperative outcomes. Because of comorbidities associated with obesity, along with the underlying end-stage organ disease leading to transplant candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplant. However, the use of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease and improve perioperative and postoperative outcomes. We review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients and explore potential interventions to address obesity in these populations.
Collapse
Affiliation(s)
| | | | | | | | - Andrew Posselt
- University of California at San Francisco, San Francisco, California, USA
| | | | | | | | - Lloyd Ratner
- Columbia University Medical Center, New York, New York, USA
| | | | | | | | | |
Collapse
|
13
|
Rice TC, Kassam AF, Lewis HV, Hobeika M, Cuffy MC, Ratner LE, Diwan TS. Changing Education Paradigms: Training Transplant Fellows for High Stake Procedures. J Surg Educ 2020; 77:830-836. [PMID: 32067900 DOI: 10.1016/j.jsurg.2020.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/23/2019] [Accepted: 01/19/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Living kidney donation is a unique operation, as healthy patients are placed at risks inherent with major surgery without physical benefit. The ethical implications associated with any morbidity make it a high-stakes procedure. Fellowships are faced with the dilemma of optimizing fellow training in this demanding procedure while providing safe outcomes to donors. The Laparoscopic Living Donor Nephrectomy (LDN) Workshop is a resource that can provide intense instruction to help bridge the training deficit. Our aim was to examine the course's effectiveness in improving fellows' skill and confidence related to implementing LDN into future practice. METHODS From 2017 to 2018, 36 abdominal transplant surgery fellows participated in a 2-day workshop consisting of live surgery observation, cadaver lab, and didactic sessions. Surveys were completed precourse, postcourse, and at 3-month postcourse follow-up. RESULTS Preworkshop, 61% of participants reported less than 50% confidence in independent performance of LDN. Following workshop completion, 95% reported improved confidence. At 3-month follow-up, there was a 30% (p < 0.05) increase in median confidence level. Immediately following the course, 67% reported improved ability to analyze kidneys prior to donation, 74% changed the way donor candidates were evaluated, and 67% reported enhanced ability to risk stratify donors. Eighty-five percent felt it strengthened operative techniques with 70% implementing new diagnostic treatments and surgical strategies. Seventy percent of participants felt it improved their communication with colleagues and 67% had enhanced communication with patients. These trends were maintained at 3-month follow-up. CONCLUSION These results indicated that the LDN Workshop improves confidence and increases fellows' skillset in a high-stakes procedure. The LDN Workshop is a useful adjunct to fellowship training to optimize successful, efficient, and safe performance of a demanding procedure in a uniquely healthy donor population.
Collapse
Affiliation(s)
- Teresa C Rice
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Hannah V Lewis
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Mark Hobeika
- J.C. Walter, Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Madison C Cuffy
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University, New York, New York
| | - Tayyab S Diwan
- Department of Surgery, Division of Transplantation, University of Cincinnati, Cincinnati, Ohio.
| |
Collapse
|
14
|
Anwar N, Kaiser TE, Bari K, Schoech M, Diwan TS, Cuffy MC, Silski L, Quillin RC, Safdar K, Shah SA. Use of Hepatitis C Nucleic Acid Test-Positive Liver Allografts in Hepatitis C Virus Seronegative Recipients. Liver Transpl 2020; 26:673-680. [PMID: 32125753 DOI: 10.1002/lt.25741] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/06/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023]
Abstract
Because of underutilization of liver allografts, our center previously showed that hepatitis C virus (HCV) antibody-positive/nucleic acid test (NAT)-negative livers when transplanted into HCV nonviremic recipients were safe with a 10% risk of HCV transmission. Herein, we present our single-center prospective experience of using HCV NAT+ liver allografts transplanted into HCV NAT- recipients. An institutional review board-approved matched cohort study was conducted examining post- liver transplantation (LT) outcomes of HCV- patients who received HCV NAT+ organs (treatment group) compared with matched recipients with HCV NAT- organs (matched comparator group) between June 2018 to October 2019. The primary endpoint was success of HCV treatment and elimination of HCV infection. The secondary outcomes included the 30-day and 1-year graft and patient survival as well as perioperative complications. There were 32 recipients enrolled into each group. Because of 1 death in the index admission, 30/31 patients (97%) were given HCV treatment at a median starting time of 47 days (18-140 days) after LT. A total of 19 (63%) patients achieved sustained virological response at week 12 (SVR12). Another 6 patients achieved end-of-treatment response, while 5 remained on therapy and 1 is yet to start treatment. No HCV treatment failure has been noted. There were no differences in 30-day and 1-year graft and patient survival, length of hospital stay, biliary or vascular complications, or cytomegalovirus viremia between the 2 groups. In this interim analysis of a matched cohort study, which is the first and largest study to date, the patients who received the HCV NAT+ organs had similar outcomes regarding graft function, patient survival, and post-LT complications.
Collapse
Affiliation(s)
- Nadeem Anwar
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tiffany E Kaiser
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Khurram Bari
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael Schoech
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Madison C Cuffy
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Latifa Silski
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ralph C Quillin
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kamran Safdar
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
15
|
Abstract
Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.
Collapse
Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Madison C Cuffy
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ivan Linares-Cervantes
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Amit Govil
- Division of Nephrology, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
16
|
Lee TC, Cortez AR, Kassam AF, Morris MC, Winer LK, Silski LS, Quillin RC, Cuffy MC, Jones CR, Diwan TS, Shah SA. Outcomes of en bloc simultaneous liver-kidney transplantation compared to the traditional technique. Am J Transplant 2020; 20:1181-1187. [PMID: 31605561 DOI: 10.1111/ajt.15655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/03/2019] [Accepted: 10/05/2019] [Indexed: 01/25/2023]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is indicated for patients with end-stage liver disease (ESLD) and concurrent renal insufficiency. En bloc SLKT is an alternative to traditional separate implantations, but studies comparing the two techniques are limited. The en bloc technique maintains renal outflow via donor infrahepatic vena cava and inflow via anastomosis of donor renal artery to donor splenic artery. Comparison of recipients of en bloc (n = 17) vs traditional (n = 17) SLKT between 2013 and 2017 was performed. Recipient demographics and comorbidities were similar. More recipients of traditional SLKT were dialysis dependent (82.4% vs 41.2%, P = .01) with lower baseline pretransplant eGFR (14 vs 18, P = .01). En bloc SLKT was associated with shorter kidney cold ischemia time (341 vs 533 minutes, P < .01) and operative time (374 vs 511 minutes, P < .01). Two en bloc patients underwent reoperation for kidney allograft inflow issues due to kinking and renal steal. Early kidney allograft dysfunction (23.5% in both groups), 1-year kidney graft survival (88.2% vs 82.4%, P = 1.0), and posttransplantation eGFR were similar between groups. In our experience, the en bloc SLKT technique is safe and feasible, with comparable outcomes to the traditional method.
Collapse
Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Latifa S Silski
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph C Quillin
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Madison C Cuffy
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
17
|
Cortez AR, Winer LK, Katsaros GD, Kassam AF, Shah SA, Diwan TS, Cutler Quillin R. Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide. J Gastrointest Surg 2020; 24:796-803. [PMID: 31012042 DOI: 10.1007/s11605-019-04226-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) requires an experience in hepatopancreatobiliary (HPB) surgery as part of general surgery residency training. The composition of this experience, however, is unclear. We set out to evaluate current trends in the HPB experience of US general surgery residents. METHODS National ACGME operative case logs from 1990 to 2016 were examined with a focus on the HPB operative domains. Time-trend analysis was performed using ANOVA and linear regression analysis. RESULTS Median biliary, liver, and pancreatic operative volumes increased by 30%, 33%, and 27% over the 27-year study period (all p < 0.05). Both core and advanced HPB cases increased, but the rate of increase for core was four times greater than that of advanced. However, when cholecystectomy was excluded, this trend reversed such that HPB core operations decreased by 11 cases over the study period. Further analysis demonstrated that laparoscopic cholecystectomy comprised 90% of all biliary cases and 77% of all HPB cases for graduates in 2016. Finally, operative volume variability-the difference in case numbers between high and low volume residents-increased by 16%, 21%, and 73% for the biliary, liver, and pancreatic domains, respectively (all p < 0.05). CONCLUSIONS Despite increases in overall HPB operative volume, the HPB experience is changing for today's surgical trainees. Moreover, the HPB experience is comprised largely of a single operation-the cholecystectomy. Awareness of these trends is important for surgical educators to facilitate adequate exposure to HPB surgery among general surgery residents.
Collapse
Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
| | - Gianna D Katsaros
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
| | - Shimul A Shah
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
18
|
Kassam AF, Cortez AR, Diwan TS, Bailey A, Mirza A, Sussman JJ, Makley AT, Quillin RC. Return to the Real World: A Novel Program to Improve Resident Readiness for the Transplant Surgery Rotation. J Surg Educ 2020; 77:242-245. [PMID: 31563426 DOI: 10.1016/j.jsurg.2019.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/05/2019] [Accepted: 09/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE We describe a novel didactic program to prepare mid-level residents for the operative complexities of the transplant surgery rotation. DESIGN A faculty led dry and wet lab experience was held for all residents returning to clinical rotations from a 2-year research experience. Residents were provided instructional video prior to the dry lab and instructed through both labs by transplant faculty and fellows. The culmination of the program entailed a porcine renal autotransplantation. SETTING The University of Cincinnati, Department of Surgery, Cincinnati, OH. PARTICIPANTS Incoming third year general surgery residents returning to clinical rotations from a 2-year research experience. RESULTS This lab was well received by residents and faculty and increased confidence in residents. CONCLUSIONS This program increased confidence in complex operations seen on the transplant surgery rotation and can be replicated in a cost-effective manner.
Collapse
Affiliation(s)
- Al-Faraaz Kassam
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, Ohio; Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, Ohio; Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amanda Bailey
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ahmad Mirza
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ralph Cutler Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, Ohio; Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| |
Collapse
|
19
|
Kassam AF, Mirza A, Kim Y, Hanseman D, Woodle ES, Quillin RC, Johnson BL, Govil A, Cardi M, Schauer DP, Smith EP, Diwan TS. Long-term outcomes in patients with obesity and renal disease after sleeve gastrectomy. Am J Transplant 2020; 20:422-429. [PMID: 31605562 DOI: 10.1111/ajt.15650] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/06/2019] [Accepted: 10/03/2019] [Indexed: 01/25/2023]
Abstract
Morbid obesity is a barrier to kidney transplant in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (SG) is an increasingly considered intervention, but the safety and long-term outcomes are uncertain. We reviewed prospectively collected data on patients with ESRD and chronic kidney disease (CKD) undergoing SG from 2011 to 2018. There were 198 patients with ESRD and 45 patients with CKD (stages 1-4) who met National Institutes of Health guidelines for bariatric surgery and underwent SG; 72% and 48% achieved a body mass index of ≤ 40 and ≤ 35 kg/m2 , respectively. The mean percentages of total weight loss and excess weight loss were 18.9 ± 10.8% and 38.2 ± 20.3%, respectively. SG reduced hypertension (85.8% vs 52.1%), decreased antihypertensive medication use (1.6 vs 1.0) (P < .01 each), and reduced incidence of diabetes (59.6% vs 32.5%, P < .01). Of the 71 patients with ESRD who achieved a body mass index of ≤ 40 kg/m2 , 45 were waitlisted and received a kidney transplant, whereas 10 remain on the waitlist. Mortality rate after SG was 1.8 per 100 patient-years, compared with 7.3 for non-SG. Patients with stage 3a or 3b CKD exhibited improved glomerular filtration rate (43.5 vs 58.4 mL/min, P = .01). In conclusion, SG safely improves transplant candidacy while providing significant, sustainable effects on weight loss, reducing medical comorbidities, and possibly improving renal function in stage 3 patients.
Collapse
Affiliation(s)
- Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ahmad Mirza
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Young Kim
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - E Steve Woodle
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ralph C Quillin
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Bobby L Johnson
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amit Govil
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael Cardi
- Department of Internal Medicine, The Christ Hospital, Cincinnati, Ohio
| | - Daniel P Schauer
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eric P Smith
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|
20
|
Kassam AF, Taylor ME, Morris MC, Watkins BM, Thompson JR, Schauer DP, Smith EP, Diwan TS. The impact of sleeve gastrectomy on renal function in patients with chronic kidney disease varies with severity of renal insufficiency. Surg Obes Relat Dis 2020; 16:607-613. [PMID: 32093996 DOI: 10.1016/j.soard.2020.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although laparoscopic sleeve gastrectomy is known, in general, to improve renal function in patients with obesity and chronic kidney disease (CKD), its effect on estimated glomerular filtration rate (eGFR) stratified by the stage of CKD is less clear. OBJECTIVES We aimed to evaluate the impact of sleeve gastrectomy on renal function in a stratified cohort of patients with CKD. SETTING University Hospital. METHODS We performed a retrospective review of 1932 patients who met National Institutes of Health's guidelines for metabolic surgery and underwent laparoscopic sleeve gastrectomy performed by 1 of 3 surgeons. One hundred sixty-four patients with CKD stages 1 through 4 were identified. RESULTS Mean follow-up period was 1.57 ± 1.0 years. Mean age was 56.4 ± 9.9 years with a preoperative body mass index of 47 ± 9 kg/m2, which decreased to 38.9 ± 8.7 kg/m2 at most recent follow-up (P < .001). In the cohort of patients with diabetes, significant decreases were observed in mean glycated hemoglobin level, daily number of oral hypoglycemics, and daily long acting insulin use (P < .001 each). Of 67 patients with diabetes, 34.3% (n = 24) achieved complete remission. In patients with hypertension, average daily number of antihypertensives decreased (P < .001) and 22.3% (n = 31) of 133 patients with hypertension discontinued all antihypertensives. Patients with CKD stages 2, 3a, and 3b showed significant improvement in eGFR. Reinforcing this evidence of improvement, patients with CKD 3a and 3b were more likely to downstage disease compared with those with CKD 4 (58.1% versus 73.1% versus 22.7%, respectively) (P < .001). CONCLUSION Renal function, as measured by eGFR, in patients with stages 1 and 4 CKD did not improve after laparoscopic sleeve gastrectomy; in contrast, eGFR in patients with CKD stages 2 and 3 significantly improved. Early surgical referral and intervention may be important in achieving the greatest improvement in eGFR and possibly delaying or reversing progression to end-stage renal disease.
Collapse
Affiliation(s)
- Al-Faraaz Kassam
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | | | | | - Brad M Watkins
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | | | - Daniel P Schauer
- University of Cincinnati, Department of Internal Medicine, Cincinnati, Ohio
| | - Eric P Smith
- University of Cincinnati, Department of Internal Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio.
| |
Collapse
|
21
|
Morris MC, Jung AD, Kim Y, Lee TC, Kaiser TE, Thompson JR, Bari K, Shah SA, Cohen RM, Schauer DP, Smith EP, Diwan TS. Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience. Liver Transpl 2019; 25:1673-1681. [PMID: 31518478 DOI: 10.1002/lt.25637] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022]
Abstract
Obesity has become an epidemic in the United States over the past decade, and recent studies have shown this trend in the liver transplantation (LT) population. These patients may be candidates for laparoscopic sleeve gastrectomy (LSG) to promote significant and sustained weight loss to prevent recurrence of nonalcoholic steatohepatitis. However, safety remains a concern, and efficacy in this setting is uncertain. A single-institution database from 2014 to 2018 was queried for patients undergoing LSG following LT. The selection criteria for surgery were consistent with National Institutes of Health guidelines, and patients were at least 6 months after LT. A total of 15 patients (median age, 59.0 years; Caucasian, 86.7%; and female, 60%) underwent LSG following LT. Median time from LT to LSG was 2.2 years with a median follow-up period of 2.6 years. The median hospital length of stay (LOS) was 2 days after LSG. Mortality and rate of liver allograft rejection was 0, and there was 1 postoperative complication (a surgical site infection). Following LSG, body mass index (BMI) decreased from 42.7 to 35.9 kg/m2 (P < 0.01), and in 12 patients with at least 1 year of follow-up, the total body weight loss was 20.6%. Following LSG in patients with diabetes, the median daily insulin requirements decreased from 98 (49-118) to 0 (0-29) units/day (P = 0.02), and 60% discontinued insulin. Post-LT patients had a similar decrease in BMI and reduction in comorbidities at 1 year compared with a matched non-LT patient cohort. In the largest patient series to date, we show that LSG following LT is safe, effective, and does not increase the incidence of liver allograft rejection. Larger longer-term studies are needed to confirm underlying metabolic changes following LSG.
Collapse
Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Andrew D Jung
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Young Kim
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany C Lee
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Jonathan R Thompson
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Khurram Bari
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Robert M Cohen
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel P Schauer
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Eric P Smith
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| |
Collapse
|
22
|
Kim Y, Bailey AJ, Morris MC, Kassam AF, Shah SA, Diwan TS. Kidney transplantation after sleeve gastrectomy in the morbidly obese candidate: results of a 2-year experience. Surg Obes Relat Dis 2019; 16:10-14. [PMID: 31668565 DOI: 10.1016/j.soard.2019.09.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/24/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Morbid obesity serves as a barrier to kidney transplantation (KT) due to potential suboptimal posttransplant outcomes. Laparoscopic sleeve gastrectomy (LSG) has previously been shown to improve transplant eligibility through weight loss. OBJECTIVES We aimed to examine the role LSG plays in improving patient outcomes postrenal transplantation, including possible impact on new-onset diabetes after transplant (NODAT). SETTING University Hospital. METHODS A single-center analysis was performed identifying all patients who underwent KT after LSG from 2011 to 2017 (n = 41). Exclusion criteria included type I diabetes and previous pancreas transplantation. NODAT was defined as a new insulin requirement after KT. Delayed graft function was defined as need for dialysis within the first week after KT. Mean posttransplant follow-up period was 22 months. RESULTS Forty-one patients underwent KT after LSG after median time of 16 months. Median age of postLSG patients undergoing KT was 56.0 years at time of KT. Average body mass index decreased by 9 from the time of LSG to KT, and no patients regained weight at 1-year follow-up. After LSG, the number of patients with hypertension (85.4% versus 48.5%) and the number of antihypertensive medications used decreased significantly (1.6 versus .6) at time of KT (P < .001 each). At 1-year follow-up, the improvement in hypertension persisted (51.2% versus 48.5%, P = nonsignificant). The average insulin regimen decreased from 33.0 ± 51.6 to 11.7 ± 21.5 units at KT (P < .001). This improvement also persisted at 1-year follow-up (11.9 versus 11.7 units, P = nonsignificant). Zero patients suffered NODAT over the follow-up period (versus institutional rate of NODAT at 15.8%). One patient developed delayed graft function (2.4%, versus institutional rate of 13.3%). After 1 year postKT, there was 1 graft loss (2.4%) and no mortality. CONCLUSION This is the largest reported series of KT after planned LSG in morbidly obese patients. Our results confirm excellent posttransplant outcomes among patients who otherwise would have been denied KT eligibility.
Collapse
Affiliation(s)
- Young Kim
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda J Bailey
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| |
Collapse
|
23
|
Dhar VK, Lee TC, Thompson JR, Diwan TS. Reducing Excess Staple Cartridge Use During Sleeve Gastrectomy. Surg Obes Relat Dis 2018. [DOI: 10.1016/j.soard.2018.09.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
24
|
Diwan TS, Rice TC, Heimbach JK, Schauer DP. Liver Transplantation and Bariatric Surgery: Timing and Outcomes. Liver Transpl 2018; 24:1280-1287. [PMID: 30080949 DOI: 10.1002/lt.25303] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
Nonalcoholic steatohepatitis (NASH) is projected to become the leading indication for liver transplantation (LT) in the next decade in the United States. Strategies to treat the underlying etiology of NASH, which is almost always obesity, are being pursued. One such strategy is the utilization of bariatric surgery (BS) in the peritransplant period. The use of BS prior to LT could prevent the progression of NASH and abrogate the need for LT. BS at the time of LT or postoperatively has the potential to not only improve obesity-associated conditions such as diabetes, but also the potential to influence the incidence of NASH in the post-LT setting. However, there continues to be no consensus on the use and timing of BS in this patient population. This review aims to discuss the current literature and possible future action.
Collapse
Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
| | - Teresa C Rice
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
| | - Julie K Heimbach
- Division of Transplantation Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Daniel P Schauer
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
| |
Collapse
|
25
|
Dhar VK, Wima K, Kim Y, Hoehn RS, Jung AD, Ertel AE, Diwan TS, Paterno F, Shah SA. Cost of achieving equivalent outcomes in sicker patients after liver transplant. HPB (Oxford) 2018; 20:268-276. [PMID: 28988703 DOI: 10.1016/j.hpb.2017.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/10/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to characterize variability in cost after straightforward orthotopic liver transplant (OLT). METHODS Using the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified patients who underwent OLT between 2011 and 2014. Patients meeting criteria for straightforward OLT, defined as length of stay < 14 days with discharge to home, were selected (n = 5763) and grouped into tertiles (low, medium, high) according to cost of perioperative stay. RESULTS Patients undergoing straightforward OLT were of similar demographics regardless of cost. High cost patients were more likely to require preoperative hemodialysis, had higher severity of illness, and higher model for end-stage liver disease (MELD) (p < 0.01). High cost patients required greater utilization of resources including lab tests, blood transfusions, and opioids (p < 0.01). Despite having higher burden of disease and requiring increased resource utilization, high cost OLT patients with a straightforward perioperative course were shown to have identical 2-year graft and overall survival compared to lower cost patients (p = 0.82 and p = 0.63), respectively. CONCLUSION Providing adequate perioperative care for OLT patients with higher severity of illness and disease burden requires increased cost and resource utilization; however, doing so provides these patients with long term survival equivalent to more routine patients.
Collapse
Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Young Kim
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard S Hoehn
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew D Jung
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Flavio Paterno
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
26
|
Kim Y, Jung AD, Dhar VK, Tadros JS, Schauer DP, Smith EP, Hanseman DJ, Cuffy MC, Alloway RR, Shields AR, Shah SA, Woodle ES, Diwan TS. Laparoscopic sleeve gastrectomy improves renal transplant candidacy and posttransplant outcomes in morbidly obese patients. Am J Transplant 2018; 18:410-416. [PMID: 28805345 DOI: 10.1111/ajt.14463] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 01/25/2023]
Abstract
Morbid obesity is a barrier to kidney transplantation due to inferior outcomes, including higher rates of new-onset diabetes after transplantation (NODAT), delayed graft function (DGF), and graft failure. Laparoscopic sleeve gastrectomy (LSG) increases transplant eligibility by reducing BMI in kidney transplant candidates, but the effect of surgical weight loss on posttransplantation outcomes is unknown. Reviewing single-center medical records, we identified all patients who underwent LSG before kidney transplantation from 2011-2016 (n = 20). Post-LSG kidney recipients were compared with similar-BMI recipients who did not undergo LSG, using 2:1 direct matching for patient factors. McNemar's test and signed-rank test were used to compare groups. Among post-LSG patients, mean BMI ± standard deviation (SD) was 41.5 ± 4.4 kg/m2 at initial encounter, which decreased to 32.3 ± 2.9 kg/m2 prior to transplantation (P < .01). No complications, readmissions, or mortality occurred following LSG. After transplantation, one patient (5%) experienced DGF, and no patients experienced NODAT. Allograft and patient survival at 1-year posttransplantation was 100%. Compared with non-LSG patients, post-LSG recipients had lower rates of DGF (5% vs 20%) and renal dysfunction-related readmissions (10% vs 27.5%) (P < .05 each). Perioperative complications, allograft survival, and patient survival were similar between groups. These data suggest that morbidly obese patients with end-stage renal disease who undergo LSG to improve transplant candidacy, achieve excellent posttransplantation outcomes.
Collapse
Affiliation(s)
- Y Kim
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - A D Jung
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - V K Dhar
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - J S Tadros
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - D P Schauer
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - E P Smith
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - D J Hanseman
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - M C Cuffy
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R R Alloway
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - A R Shields
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - S A Shah
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - E S Woodle
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - T S Diwan
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
27
|
Rice TC, Reznichenko A, Shah SA, Diwan TS. Laparoscopic repair of delayed incarcerated diaphragmatic hernia in an adult liver transplant recipient. Surgery 2017. [DOI: 10.1016/j.surg.2017.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
28
|
Diwan TS, Lichvar AB, Leino AD, Vinks AA, Christians U, Shields AR, Cardi MA, Fukuda T, Mizuno T, Kaiser T, Woodle ES, Alloway RR. Pharmacokinetic and pharmacogenetic analysis of immunosuppressive agents after laparoscopic sleeve gastrectomy. Clin Transplant 2017; 31. [PMID: 28342282 DOI: 10.1111/ctr.12975] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Severe obesity has been shown to limit access to renal transplantation in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (LSG) has been performed in the ESRD population to assist in achieving waitlist and transplant eligibility. Little is known about how LSG impacts the bioequivalence of tacrolimus products and immunosuppression pharmacokinetics. METHODS This was a prospective, open-label, single-dose, crossover, two-period pharmacokinetic (PK) study. The purpose of this study was to assess single-dose PK of immediate-release tacrolimus (IR-TAC), extended-release tacrolimus (ER-TAC), and mycophenolic acid (MPA) in adult ESRD patients post-LSG. RESULTS Twenty-three subjects were included in the 24-hour PK assessments. The ratio of geometric means between ER-TAC and IR-TAC was 103.5% (90% CI; 89.6%-119.6%) for AUC0-24 and 92.5% (90% CI; 80.4%-106.4%) for Cmax . PK parameters were similar between ER-TAC and IR-TAC, except for Cmin (P=.004) and Cmax (P=.04). MPA AUC0-24 was similar when given with either ER-TAC or IR-TAC (P=.32). Patients expressing CYP3A5*1 genotypes had lower tacrolimus AUC0-24 values vs those with CYP3A5*3/*3 (IR-TACP<.001; ER-TACP=.008). Genotype did not impact MPA PK. CONCLUSION Dose modification of immunosuppressants post-LSG may not be necessary aside from standard therapeutic drug monitoring.
Collapse
Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alicia B Lichvar
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Abbie D Leino
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Uwe Christians
- Department of Anesthesiology, iC42 Clinical Research and Development, University of Colorado Denver, Aurora, CO, USA
| | - Adele R Shields
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,The Christ Hospital, Cincinnati, OH, USA
| | | | - Tsuyoshi Fukuda
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tiffany Kaiser
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
29
|
Kim Y, Shi J, Freeman CM, Jung AD, Dhar VK, Shah SA, Woodle ES, Diwan TS. Addressing the challenges of sleeve gastrectomy in end-stage renal disease: Analysis of 100 consecutive renal failure patients. Surgery 2017; 162:358-365. [PMID: 28411866 DOI: 10.1016/j.surg.2017.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/01/2017] [Accepted: 02/24/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND While previous studies have demonstrated short-term efficacy of laparoscopic sleeve gastrectomy in candidates awaiting renal transplantation, the combination of morbid obesity and end-stage renal disease presents unique challenges to perioperative care. We demonstrate how increasing experience and the development of postoperative care guidelines can improve outcomes in this high-risk population. METHODS Single-center medical records were reviewed for renal transplantation candidates undergoing laparoscopic sleeve gastrectomy between 2011 and 2015 by a single surgeon. Postoperative care protocols were established and continually refined throughout the study period, including a multidisciplinary approach to inpatient management and hospital discharge planning. The first 100 laparoscopic sleeve gastrectomy patients were included and divided into 4 equal cohorts based on case sequence. RESULTS Compared with the first 25 patients undergoing laparoscopic sleeve gastrectomy, the last 25 patients had shorter operative times (97.8 ± 27.9 min vs 124.2 ± 33.6 min), lower estimated blood loss (6.6 ± 20.8 mL vs 34.0 ± 38.1 mL), and shorter hospital duration of stay (1.7 ± 2.1 days vs 2.9 ± 0.7 days) (P < .01 each). Readmission rates, complications, and 1-year mortality did not differ significantly. CONCLUSION Increasing experience and the development of clinical care guidelines in this high-risk population is associated with reduced health care resource utilization and improved perioperative outcomes.
Collapse
Affiliation(s)
- Young Kim
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Junzi Shi
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Christopher M Freeman
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew D Jung
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Vikrom K Dhar
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - E Steve Woodle
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH.
| |
Collapse
|
30
|
Kim Y, Chang AL, Wima K, Ertel AE, Diwan TS, Abbott DE, Shah SA. The impact of morbid obesity on resource utilization after renal transplantation. Surgery 2016; 160:1544-1550. [PMID: 27574775 DOI: 10.1016/j.surg.2016.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/15/2016] [Accepted: 07/27/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND A growing number of renal transplant recipients have a body mass index ≥40. While previous studies have shown that patient and graft survival are significantly decreased in renal transplant recipients with body mass indexes ≥40, less is known about perioperative outcomes and resource utilization in morbidly obese patients. We aimed to analyze the effects of morbid obesity on these parameters in renal transplant. METHODS Using a linkage between the Scientific Registry of Transplant Recipients and the databases of the University HealthSystem Consortium, we identified 29,728 adult renal transplant recipients and divided them into 2 cohorts based on body mass index (<40 vs ≥40 kg/m2). The body mass index ≥40 group comprised 2.5% (n = 747) of renal transplant recipients studied. RESULTS Body mass index ≥40 recipients incurred greater direct costs ($84,075 vs $79,580, P < .01), index admission costs ($91,169 vs $86,141, P < .01), readmission costs ($5,306 vs $4,596, P = .01), and combined costs ($99,590 vs $93,939, P < .001). Thirty-day readmission rates were also greater among body mass index ≥40 recipients (33.92% vs 26.9%, P < .01). Morbid obesity was not predictive of stay (odds ratio 1.01, P = .75). CONCLUSION Morbidly obese renal transplant recipients incur greater costs and readmission rates compared with nonobese patients. Recognition of increased resource utilization should be accompanied by appropriate, risk-adjustment reimbursement.
Collapse
Affiliation(s)
- Young Kim
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alex L Chang
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.
| |
Collapse
|
31
|
Tremblay S, Kaiser TE, Alloway RR, Woodle ES, Diwan TS. Absence of the Effect of Pretransplant Body Mass Index on Post Kidney Transplant Outcomes. Prog Transplant 2016; 26:183-90. [PMID: 27207408 DOI: 10.1177/1526924816640679] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CONTEXT Obesity has been reported as risk factor for reduced posttransplant graft and patient survival and increased delayed graft function (DGF). OBJECTIVE The purpose of this work is to analyze the effect of body mass index (BMI) on defined transplant outcomes in patients transplanted under defined guidelines in a kidney transplant program. DESIGN Review of a prospectively collected database in renal transplant recipients receiving rabbit antithymocyte globulin induction, mycophenolate mofetil, tacrolimus, and early corticosteroid withdrawal between 2001 and 2011. SETTING This review was conducted in a single abdominal transplant program in the United States. MAIN OUTCOME MEASURES Primary outcome was death-censored graft survival categorized by posttransplant body mass groups. Secondary outcomes included DGF as well as patient survival. RESULTS Four hundred sixty seven patients were identified. No difference was observed in graft survival or DGF between BMI groups. One-year, death-censored graft survival and patient survival rates ranged from 97.5% to 100% and 96.6% to 100%, respectively. Delayed graft function was uncommon across all BMI groups, ranging from 5.3% to 9.1%, with the lowest incidence in patients with a BMI ≥ 35 kg/m(2). Biopsy-proven acute rejection rates at 1 year were similar across all groups (10.1%-14%) as were estimated glomerular filtration rates were at 1, 3, and 5 years. CONCLUSION Our results do not show an effect of BMI on posttransplant outcomes, suggesting that relaxation of BMI criteria may be warranted for recipient selection.
Collapse
Affiliation(s)
- Simon Tremblay
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tiffany E Kaiser
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Rita R Alloway
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
32
|
Singhal A, Wilson GC, Wima K, Quillin RC, Cuffy M, Anwar N, Kaiser TE, Paterno F, Diwan TS, Woodle ES, Abbott DE, Shah SA. Impact of recipient morbid obesity on outcomes after liver transplantation. Transpl Int 2015; 28:148-55. [PMID: 25363625 DOI: 10.1111/tri.12483] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/25/2014] [Accepted: 10/24/2014] [Indexed: 12/28/2022]
Abstract
The aim of this study was to analyze the impact of morbid obesity in recipients on peritransplant resource utilization and survival outcomes. Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 12 445 patients who underwent liver transplantation (LT) between 2007 and 2011 and divided them into two cohorts based on recipient body mass index (BMI; <40 vs. ≥40 kg/m²). Recipients with BMI ≥40 comprised 3.3% (n = 416) of all LTs in the studied population. There were no significant differences in donor characteristics between two groups. Recipients with BMI ≥40 were significant for being female, diabetic, and with NASH cirrhosis. Patients with a BMI ≥40 had a higher median MELD score, limited physical capacity, and were more likely to be hospitalized at LT. BMI ≥40 recipients had higher post-LT length of stay and were less often discharged to home. With a median follow-up of 2 years, patient and graft survival were equivalent between the two groups. In conclusion, morbidly obese LT recipients appear sicker at time of LT with an increase in resource utilization but have similar short-term outcomes.
Collapse
Affiliation(s)
- Ashish Singhal
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Diwan TS, Paterno F, Shah SA. Use of Extended Criteria Deceased Donors in Adult Liver Transplantation. Curr Surg Rep 2015. [DOI: 10.1007/s40137-015-0103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
34
|
Freeman CM, Woodle ES, Shi J, Alexander JW, Leggett PL, Shah SA, Paterno F, Cuffy MC, Govil A, Mogilishetty G, Alloway RR, Hanseman D, Cardi M, Diwan TS. Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy. Am J Transplant 2015; 15:1360-8. [PMID: 25708829 DOI: 10.1111/ajt.13116] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/20/2014] [Accepted: 11/16/2014] [Indexed: 01/25/2023]
Abstract
Morbid obesity is a barrier to renal transplantation and is inadequately addressed by medical therapy. We present results of a prospective evaluation of laparoscopic sleeve gastrectomy (LSG) for patients failing to achieve significant weight loss with medical therapy. Over a 25-month period, 52 obese renal transplant candidates meeting NIH guidelines for metabolic surgery underwent LSG. Mean age was 50.0 ± 10.0 years with an average preoperative BMI of 43.0 ± 5.4 kg/m(2) (range 35.8-67.7 kg/m(2)). Follow-up after LSG was 220 ± 152 days (range 26-733 days) with last BMI of 36.3 ± 5.3 kg/m(2) (range 29.2-49.8 kg/m(2)) with 29 (55.8%) patients achieving goal BMI of <35 kg/m(2) at 92 ± 92 days (range 13-420 days). The mean percentage of excess weight loss (%EWL) was 32.1 ± 17.6% (range 6.7-93.8%). A segmented regression model was used to compare medical therapy versus LSG. This revealed a statistically significant increase in the BMI reduction rate (0.3 kg/m(2)/month versus 1.1 kg/m(2)/month, p < 0.0001). Patients also experienced a 40.9% decrease in anti-hypertensive medications (p < 0.001) and a 49.7% decrease in total daily insulin dose (p < 0.001). LSG is a safe and effective means for addressing obesity in kidney transplant candidates in the context of a multidisciplinary approach.
Collapse
Affiliation(s)
- C M Freeman
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Quillin RC, Wilson GC, Sutton JM, Hanseman DJ, Paterno F, Cuffy MC, Paquette IM, Diwan TS, Woodle ES, Abbott DE, Shah SA. Increasing prevalence of nonalcoholic steatohepatitis as an indication for liver transplantation. Surgery 2014; 156:1049-56. [PMID: 25239365 DOI: 10.1016/j.surg.2014.06.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 06/27/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND In Ohio, the obesity rate has increased from 21.5% in 2000 to 30.1% in 2012. Nonalcoholic steatohepatitis is believed to be increasing as an indication for orthotopic liver transplantation. METHODS We evaluated the diagnosis of nonalcoholic steatohepatitis as an indication for orthotopic liver transplantation and ensuing outcomes relative to other common hepatic diseases requiring orthotopic liver transplantation in Ohio. We queried 2,356 patients with nonalcoholic steatohepatitis, alcoholic cirrhosis (ETOH), and hepatitis C cirrhosis from the Ohio Solid Organ Transplantation Consortium who were listed for and/or received an orthotopic liver transplant from 2000 to 2012. RESULTS The proportion of listed patients with nonalcoholic steatohepatitis increased from 0% to 26% and the proportion of transplanted patients increased from 0% to 23.4%. Compared with patients with hepatitis C and ETOH, patients with nonalcoholic steatohepatitis were older, and more likely to be white, and have private insurance (P < .05 for each). There was no difference in median waiting time among patients with nonalcoholic steatohepatitis, hepatitis C, and ETOH (P = .18) and Model for End-Stage Liver Disease scores at orthotopic liver transplantation among patients with nonalcoholic steatohepatitis, hepatitis C (P = .48), and ETOH (P = .27). Patient and graft survival after orthotopic liver transplantation was comparable between patients with nonalcoholic steatohepatitis and ETOH (P = .79 and P = .86, respectively); however, patients with nonalcoholic steatohepatitis had better patient and graft survival compared with patients with hepatitis C after orthotopic liver transplantation (P < .01 and P = .02, respectively). Additionally, body mass index had no influence on overall or graft survival for patients with nonalcoholic steatohepatitis undergoing orthotopic liver transplantation. CONCLUSION This study reflects the growing potential for transplantation in patients with fatty liver disease and suggests the outcomes are equivalent or superior to other common indications for orthotopic liver transplantation.
Collapse
Affiliation(s)
- R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Gregory C Wilson
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Jeffrey M Sutton
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Flavio Paterno
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Madison C Cuffy
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - E Steve Woodle
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
| |
Collapse
|
36
|
Paterno F, Wilson GC, Wima K, Quillin RC, Abbott DE, Cuffy MC, Diwan TS, Kaiser T, Woodle ES, Shah SA. Hospital utilization and consequences of readmissions after liver transplantation. Surgery 2014; 156:871-8. [DOI: 10.1016/j.surg.2014.06.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 06/20/2014] [Indexed: 02/09/2023]
|
37
|
Kennedy TJ, Cassera MA, Khajanchee YS, Diwan TS, Hammill CW, Hansen PD. Laparoscopic radiofrequency ablation for the management of colorectal liver metastases: 10-year experience. J Surg Oncol 2012; 107:324-8. [PMID: 22996143 DOI: 10.1002/jso.23268] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 08/27/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Published results addressing the treatment of colorectal liver metastases (CRLM) with radiofrequency ablation (RFA) vary widely with local recurrence rates of 2-40% and 5-year survival of 14-55%. The goal of this study was to analyze our 10-year experience with laparoscopic RFA. METHODS From January 2000 to July 2010, 130 patients underwent laparoscopic RFA for CRLM. Kaplan-Meier analysis was used to assess survival. Univariate and multivariate analysis were performed to identify factors associated with survival and recurrence. RESULTS In this cohort, median survival was 40.4 months with 5-year survival of 28.8%. Overall, 9.2% of patients had a local recurrence (3.6% for tumors 3 cm or less). On univariate analysis, factors associated with decreased survival were BMI (P = 0.045), rectal primary (P = 0.005), and increased tumor size (P = 0.002). On multivariate analysis, increased tumor size (HR 1.29 [95% CI: 1.04-1.59]; P = 0.020) and bilobar disease (HR 2.06 [95% CI: 1.02-4.15]; P = 0.044) were associated with decreased survival. On univariate analysis, only BMI was found to be associated with disease recurrence (P = 0.025). CONCLUSIONS Our data demonstrate that laparoscopic RFA can achieve a median survival of 40.4 months with a low local recurrence rate. Patients with tumors 3 cm or less have a decreased risk of local recurrence.
Collapse
Affiliation(s)
- Timothy J Kennedy
- Department of Surgery, Montefiore Medical Center, New York City, NY, USA
| | | | | | | | | | | |
Collapse
|
38
|
Affiliation(s)
- Michael B. Ujiki
- University of Chicago Pritzker School of Medicine Chicago, Illinois
| | - Adam Adler
- Providence Portland Medical Center Portland, Oregon
| | | | | | - Paul D. Hansen
- Oregon Health Sciences University Providence Portland Medical Center Portland, Oregon
| |
Collapse
|
39
|
Ujiki MB, Adler A, Swanstrom LL, Diwan TS, Hansen PD. Emergent pancreaticoduodenectomy for Dieulafoy lesion of the duodenum. Am Surg 2010; 76:656-657. [PMID: 20583531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|
40
|
Diwan TS, Martinec DV, Ujiki MB, Dunst CM, Swanström LL. Video: a simplified technique for placement of biologic mesh in paraesophageal hernia repair (PEH). Surg Endosc 2009; 24:221-2. [PMID: 19517179 DOI: 10.1007/s00464-009-0542-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 03/31/2009] [Accepted: 05/01/2009] [Indexed: 12/26/2022]
Affiliation(s)
- Tayyab S Diwan
- Gastrointestinal and Minimally Invasive Surgery, Legacy Health System, Suite 560, Portland, OR 97210, USA.
| | | | | | | | | |
Collapse
|
41
|
Abstract
The placement of mesh in the crural closure of paraesophageal hiatal hernia repairs has been shown to decrease hernia recurrence rates. Typical synthetic mesh are easy to use but have high rate of erosion into the esophagus. Alternatively, biologic mesh decrease the risk of erosion, but are more difficult to manipulate, and there is currently no well-described method for securing them. Current fixation techniques of mesh are difficult, cumbersome, incur extra expense, and are not without complications. A method that requires no additional sutures or staples and achieves excellent contact and reinforcement of the crural closure is presented.
Collapse
Affiliation(s)
- T S Diwan
- Department of Gastrointestinal and Minimally Invasive Surgery, Legacy Health System, Portland, Oregon, USA
| | | | | | | |
Collapse
|