Preliminary Report of Major Surgery in Liver Transplant Recipients Receiving m-TOR Inhibitors without Therapeutic Discontinuation

Introduction

Mammalian target rapamycin inhibitors (m-TORi) are increasingly used in patients undergoing liver transplantation (LT). Yet, there is rising concern that they also could impair wound healing and favor the development of several surgical complications. This report was designed to evaluate both feasibility and safety of major surgery in liver transplant recipients receiving m-TORi–based immunosuppression without therapeutic discontinuation.

Methods

From 2007 to 2012, six liver transplant recipients underwent nine major abdominal or thoracic surgical procedures without m-TORi discontinuation or specific dosage adjustment. Their characteristics and postoperative outcomes were retrospectively analyzed.

Results

Indications for m-TORi were de novo or recurrent malignant disease in five patients and calcineurin inhibitors related neurologic toxicity in one patient. Abdominal procedures, thoracic procedures, and combined thoracic and abdominal procedures were performed in six, two, and one cases respectively. Emergency surgery was performed in one case and elective procedures were performed in eight cases, including five for malignant disease and three for late surgical complications following LT. No patient died postoperatively. One major complication was observed, but no patient required reoperation. No evisceration, incisional surgical site infection, or lymphocele occurred.

Conclusions

Major surgery in liver transplant recipients receiving m-TOR inhibitors appears both feasible and safe without therapeutic discontinuation or specific dosage adjustment.     

Anaesthesia for endoluminal repair of abdominal aortic aneurysms

An audit of 100 patients undergoing elective abdominal aortic surgery either by open aortic repair (OAR group 50 patients) or endovascular aortic repair (EAR group 50 patients) was undertaken to document changes in anaesthetic technique and perioperative outcome. The data for the OAR group was collected retrospectively and thatfor the EAR group prospectively. Combined general anaesthesia and thoracic epidural anaesthesia was used in 44 of the OAR group whereas lumbar central neural blockade alone was used in 47 of the EAR group. The major differences between the two groups were that intraoperative blood loss was significantly less in the EAR group (OAR 1,674 +/- 1,008 ml, EAR 459 +/- 350 ml, P<0.001) and that no patient in the EAR group required admission to the Intensive Care Unit (ICU), whereas ICU time for the OAR patients was 29 +/- 22 hours. Hospital stay was also significantly different between the two groups (OAR 13 +/- 6 days, EAR 5 +/- 3 days, P<0.001). Major complications occurred in 20patients in the OAR group but only 4patients in the EAR group (P<0.001). EAR reduces blood loss, the requirement for ICU admission, and hospital stay. Central neural blockade is a satisfactory anaesthetic technique for EAR.     

Laparoscopic assisted colectomies in kidney transplant recipients with colon cancer

BACKGROUND: Kidney transplant recipients have increased operative risks for major abdominal surgery. The purpose of this study is to present the results of laparoscopic assisted colectomies (LAC) in patients who have received a kidney transplant, and evaluate the difficulty and potential benefits or hazards inherent in this approach. PATIENTS AND METHODS: From September 1993 to March 2003, 820 patients underwent LAC in our service. We studied all patients with kidney transplant and LAC. RESULTS: Three kidney transplantation recipients were included. Two patients were female and one male. The mean age was 65 years (range, 54-73 years). The average time elapsed since transplantation was 8 years (range, 6-10 years), and no patient had experienced problems with rejection. All patients had colon cancer. All of the allografts were contralateral to the side of the colon resection. The mean operative time was 103 minutes (range, 100-105 minutes). There were no complications, renal function remained intact, and there was no need to stop immunosuppression. The average length of hospital stay was 5 days (range, 4-7 days). The mean followup time has been 17 months (range, 3-40 months). Since surgery there have been no episodes of rejection and the patients have been free of cancer. CONCLUSION: The benefits of minimal access surgery seem to be shared by kidney transplant recipients. A key feature may be to avoid stopping immunosuppression perioperatively, therefore lowering the potential risk of rejection. Also, lessening the number of wound-related problems appears important for these patients. LAC in experienced hands must be considered a safe alternative for elective colon resections in highly selected patients with kidney transplants.     

Abdominal aortic aneurysm surgery: retroperitoneal or transperitoneal approach?

AIM: Mortality and morbidity of abdominal aortic aneurysm surgery have decreased significantly in time and transperitoneal approach (TPA) still preserves its popularity although retroperitoneal approach (RPA) is known to cause lower incidence and shortened duration of ileus, shorter intensive care unit (ICU) and hospital stay, earlier oral intake and less patient discomfort or pain. METHODS: One hundred and fifty patients that underwent abdominal aortic aneurysm repair at our Cardiovascular Surgery Center between January, 1990 and March, 2000 were reviewed and analyzed based on the elective/emergent nature of the surgery and the type of the incision as either TPA or RPA. RESULTS: Significantly shorter mechanical ventilation (15.2+/-3.8 vs 10.1+/-2.3 hours) and nasogastric decompression periods (40.6+/-10.7 vs 9.1+/-2.2 hours), less need for intravenous fluid supplementation and shorter ICU stay (29.5+/-14.8 vs 18.6+/-1.9 hours) were observed with the retroperitoneal approach (P<0.001). Need for allogeneic blood transfusion was, similar (1.3+/-1.4 vs0.9+/-0.4, P>0.05). Analysis of mortality and morbidity revealed bleeding as the major cause of mortality for ruptured aneurysm. A similar comparison between TPA and RPA groups, however, revealed no significant difference (P>0.05). CONCLUSIONS:| Retroperitoneal approach is a reliable technique causing less fluid-electrolyte imbalance with rapid restoration of gastrointestinal physiology. It causes less discomfort to patients with reduced need for analgesia. A shorter weaning period from mechanical ventilation is among the benefits for patients with co-morbid states.     

Abdominal aortic aneurysm in renal transplant recipients

BACKGROUND: Abdominal aortic aneurysms (AAA) requiring surgical management are encountered more frequently in renal transplant recipients, presenting an important technical problem during the repair. The aim of the present study was to analyze the epidemiology and natural evolution of AAA among renal allograft recipients. METHODS: Three hundred ninety-four renal transplant recipients were periodically evaluated with abdominal aortic ultrasound tomography for AAA. The indication for surgery was a maximal diameter >5 cm. Renal function, graft, and patient survival were evaluated after a mean follow-up of 51 months. RESULTS: Four AAA were detected in 394 renal transplant recipients, a prevalence of 1.01%. All of the AAA were found in male recipients of mean age 59.2 +/- 5.5 years and mean time posttransplantation of 82.7 +/- 77.3 months. The mean follow-up period between diagnosis and indication for surgery was 14.2 +/- 10.8 months. Two patients underwent open repair with aneurysmectomy and conventional tube graft positioning, and 2 patients refused surgical repair. To preserve renal graft function during the aortic cross-clamping phase, cold perfusion with 4 degrees C Ringer acetate and local hypothermia with sterile ice were used. Renal function did not change after the operation (preoperative serum creatinine levels were 1.2 and 1.3 mg/dL; postoperative 1.3 and 1.5 mg/dL respectively). The 2 patients who underwent surgery are alive with excellent graft functioning after a follow-up of 1.5 and 7 years, respectively. The 2 patients who refused surgical treatment are dead. CONCLUSIONS: Yearly ultrasound screening for AAA must be recommended in renal transplant recipients as part of the routine posttransplantation follow-up. De novo AAA occurs in younger subject in the transplant population and shows a faster evolution.     

Reduced use of intensive care after liver transplantation: Influence of early extubation

Postoperative ventilation and admission to the intensive care unit (ICU) is the standard of care in liver transplantation and comprises a significant proportion of transplantation costs. Because immediate postoperative extubation has been reported previously in a selected group of liver transplant recipients, we questioned whether this protocol could be extended to a larger group of patients. We also sought to determine the proportion of patients extubated immediately after surgery that could be transferred to the surgical ward without intervening ICU care. Of 147 patients studied in a prospective trial of sequential liver transplant recipients (who were not second-transplant recipients, United Network for Organ Sharing status 1, living donor transplant recipients, or dead before the end of surgery), 13 patients did not meet postsurgical criteria for early extubation and 111 patients were successfully extubated. Eighty-three extubated patients were transferred to the surgical ward after a routine admission to the postoperative care unit. Only 3 patients who were transferred to the surgical ward experienced complications that required a greater intensity of nursing care. A learning curve detected during the 3-year study period showed that attempts to extubate increased from 73% to 96% and triage to the surgical ward increased from 52% to 82% without compromising patient safety. The use of this protocol in our institution resulted in a 1-day reduction in ICU use in 75.5% of study subjects. We therefore conclude that the majority of liver transplant recipients can be extubated safely and admitted to the surgical ward after liver transplantation surgery, thus decreasing the cost associated with ICU care. (Liver Transpl 2002;8:676-681.)     

Clopidogrel does not increase bleeding and allogenic blood transfusion in coronary artery surgery.

OBJECTIVES: Platelet dysfunction is one of the major reasons of postoperative bleeding following coronary artery surgery. The aim of this study was to evaluate the effects of clopidogrel; a specific and potent irreversible inhibitor of platelet aggregation; on bleeding and use of blood and blood products after coronary artery bypass surgery (CABG). METHODS: Preoperative patient characteristics and perioperative and postoperative data were collected prospectively in 1628 consecutive patients undergoing isolated CABG performed by the same surgical and anesthesia team. Of these, 48 were receiving clopidogrel preoperatively. Of the 1628 patients, 1456 underwent elective and 172 (10.6%) underwent non-elective operation. Thirty-six (2.5%) of the elective patients and 12 (7%) of the non-elective patients were using clopidogrel, preoperatively. Baseline characteristics, chest tube output, and the need for reexploration or for blood and blood product transfusion of clopidogrel recipients and non-recipients were compared. The clopidogrel group had higher prothrombin time level (12.6+/-1.6; 11.5+/-1.7 s, (P=0.013), however comparable aPTT level (32.6+/-4.5 vs. 31.4+/-4.5 s), and platelet count (275,000+/-98,000 vs. 280,000+/-72,000 dl(-1)). RESULTS: The need for reexploration or for blood and blood product transfusion, chest tube output, ICU length of stay (20.1+/-2.9 vs. 21.9+/-13.5 h; P=NS), and hospital length of stay (5.5+/-1.7 vs. 5.4+/-2.1 days; P=NS) were similar in clopidogrel recipients and non-recipients, respectively. Further analysis demonstrated no significant difference in use of homologous blood or fresh frozen plasma, amount of postoperative bleeding and reoperation rates for bleeding as well as length of intensive care unit and hospital stay between the clopidogrel and the control groups both in elective and non-elective patients. CONCLUSIONS: The results of this study suggest that preoperative use of clopidogrel is not associated with increased bleeding and need for surgical exploration as well as risk of blood and blood product transfusion after CABG.     

Epidural analgesia in patients with chronic obstructive pulmonary disease undergoing transperitoneal abdominal aortic aneurysmorraphy--a multi-institutional analysis

INTRODUCTION: Patients with chronic obstructive pulmonary disease (COPD) are more likely to develop pulmonary morbidity following major abdominal surgery. The purpose of this study was to examine the utility of epidural analgesia in patients with COPD who underwent elective transperitoneal abdominal aortic aneurysm (AAA) repair. METHODS: During a 7-year period, all patients diagnosed with COPD undergoing elective AAA repair (n=425) from three hospitals were reviewed. Inclusion criteria were an FEV(1)/FVC ratio <75% and/or a PaCO(2)>45 mmHg. Clinical outcomes were compared between those who received epidural analgesia (epidural group) and those who did not (control group). Primary endpoints measured were duration of intubation, ICU stay, hospital days, and pulmonary complications. RESULTS: Strict inclusion criteria were met by 131 patients, which included 86 patients in the epidural group and 45 patients in the control group. When comparing the epidural vs. control group, the mean AAA size was 6.3+/-0.9 cm vs. 6.0+/-1.5 cm (NS), FEV(1) was 57.2+/-24.7% vs. 49.0+/-10.3% (NS), and the mean FEV(1)/FVC ratio was 52.0+/-11.4% vs. 50.6+/-6.7% (NS), respectively. The epidural group had a significantly lower incidence of post-operative ventilator dependency and ICU stay (p<0.05), as well as a decreased trend in pulmonary complications when compared to the control group. The overall hospital stay remained similar between the two groups. The relative risk of developing a pulmonary complication in the absence of epidural analgesia was 2.3. CONCLUSIONS: Perioperative epidural analgesia is beneficial in patients with COPD undergoing AAA repair by reducing both the post-operative ventilator duration and ICU stay. Epidural analgesia should be considered in all COPD patients undergoing elective transperitoneal AAA repair.     

Outcome following single vs bilateral lung transplantation in recipients 60 years of age and older

AIMS: The significant shortage of donor organs in lung transplantation necessitates a careful selection of lung transplant recipients. The outcome of lung transplant recipients aged 60 years and older has not been analyzed systematically. METHODS: We retrospectively reviewed our experience with older recipients. Between January 1999 and July 2003, 248 patients underwent lung transplantation at our institution, of which 18 were aged 60 years and older (7.3%, range 60-66, mean 62 +/- 1.1). RESULTS: Eleven (61%) of the recipients 60 years and older received a single (SLTx) and seven (39%), a bilateral lung transplant. Donor age in the single transplant cohort was 30 +/- 4 years. It was 33 +/- 3 years in bilateral patients. Posttransplant ventilation time was significantly different among groups, with 282 +/- 32 hours after bilateral and 56 +/- 13 hours after transplant (P < .05). Also significantly longer was the length of the ICU stay in the bilateral group. First PaO2 in the ICU was not different among the two groups. The 1-year survival in the single transplant group was significantly better compared to the bilateral group with 73% versus 43%, respectively. CONCLUSIONS: The 1-year survival following lung transplantation in patients older than 60 years is markedly reduced compared to recipients under 60 years of age. If a lung transplant is considered in a recipient above the age of 60 years, a single transplant should be favoured. If that is not indicated, patients over 60 should be very carefully selected for bilateral transplant.     

Gallbladder disease in cardiac transplant patients: a survey study

HYPOTHESIS: Preemptive cholecystectomy in cardiac transplant patients with radiographic biliary pathology reduces the morbidity and mortality of biliary tract disease following heart transplantation compared with expectant management. DESIGN AND SETTING: Institutional survey at the University of Washington, Seattle. PATIENTS: Cardiac transplant recipients between January 1, 1992, and January 1, 2001.Main Outcome Measure Clinical course of patients who were diagnosed as having biliary tract disease following heart transplantation and were managed expectantly (observed) compared with the course of patients whose conditions were diagnosed and who underwent an operation. RESULTS: Sixty (35.7%) of 168 cardiac transplant patients were evaluated for biliary tract pathologic condition. Of the 71.7% (43 of 60 patients) who had an abnormal radiographic evaluation, 46.5% (20 patients) had surgery on their biliary tract while the other patients were observed. Nine of the 23 patients who were followed up expectantly had cholelithiasis, 7 patients had gallbladder wall thickening, 5 patients had sludge in their gallbladder, and 2 had biliary dilatation. These patients were followed up for a mean +/- SD of 3.7 +/- 1.3 years; none developed biliary tract symptoms during this period. Cholecystectomies were completed for both emergent (7) and elective (14) indications. The mean +/- SD length of stay for patients who had emergent operations was 24.3 +/- 11.2 days, compared with 3.2 +/- 2.8 days for the patients who had elective operations. Seven (33%) of the 21 patients who had an operation had a significant complication and 1 patient died. CONCLUSIONS: These data suggest that the morbidity of an elective cholecystectomy in cardiac transplant patients is significant and equivalent to the morbidity associated with emergent procedures. Expectant management of patients with radiographic evidence of biliary tract pathology discovered after transplantation was safe in this series.     

Use of the cell saver during elective abdominal aortic aneurysm surgery--influence on transfusion with bank blood. A retrospective survey.

One hundred and two patients undergoing elective abdominal aortic aneurysm repair and admitted to ICU at RPAH in 1989/90 were studied. In forty patients a cell saver was used during the operative procedure (Group CS) while in the remaining sixty-two patients intraoperative blood loss was drained and discarded conventionally (Group NCS). Preoperative ASA grade and postoperative APACHE score were similar in these two groups. The amount of bank blood transfused intraoperatively was less in Group CS than in Group NCS (0.6 +/- 0.2 vs 3.3 +/- 0.3 units) (mean +/- SEM) (P less than 0.0001). The total amount of bank blood transfused during hospital admission was also less in Group CS (1.5 +/- 0.4 vs 4.8 +/- 0.4 units, P less than 0.0001). Of Group CS, 22 patients (55%) received no bank blood compared to two patients (3%) in Group NCS. There was no difference between the groups with respect to postoperative haemoglobin and creatinine levels. ICU stay was similar in both groups. We conclude that use of the cell saver reduces perioperative bank blood transfusion in elective abdominal aortic surgery.     

Successful aortic surgery after renal transplantation without protection of the transplanted kidney

When renal transplant recipients undergo aortic surgery, blood supply to the renal graft is interrupted while the aorta is clamped. Several innovative ways of using shunts have been described to preserve blood flow to the transplanted kidney during such surgery on the assumption that temporary warm ischemia of the renal transplant is poorly tolerated. We have performed aortic surgery in four renal transplant recipients without the use of any form of graft protection. One patient underwent urgent operation to treat an expanding aortic aneurysm and the other three had elective surgery for aortoiliac occlusive disease. Ischemic times ranged from 30 to 45 minutes. Two of the four patients had a temporary rise in serum creatinine levels. No patient required hemodialysis. We conclude that in selected renal transplant recipients, aortic surgery can be safely undertaken without graft protection.     

Endovascular repair for abdominal aortic aneurysms: initial experience of an endograft programme

OBJECTIVE: To evaluate early clinical results of elective endovascular repair of abdominal aortic aneurysms during the initial phase of an aortic endograft programme and to compare them with conventional open surgery. METHODS: Between July 1999 and September 2001, all patients with infrarenal abdominal aortic aneurysms undergoing elective repair were studied. The results of endovascular repair were compared with those of conventional repair. RESULTS: Twenty-seven endovascular repairs (24 men and three women; mean age, 74 yr) and 25 conventional repairs (19 men and six women; mean age, 73 yr) for infrarenal abdominal aortic aneurysms were evaluated. The aneurysm diameters in the two groups were similar (mean, 6.1 cm in the endovascular repair group and 6.6 cm in the conventional repair group). The comorbidities of the two groups were also comparable. The duration of operation was longer in the endograft group (249 +/- 86 min vs. 206 +/- 56 min), while the blood loss was significantly less (600 +/- 486 mL vs. 1074 +/- 1220 mL). The length of stay in the Intensive Care Unit (ICU) and the overall duration of hospitalization was also significantly less in the endograft group (1 +/- 1 d vs. 3 +/- 2 d in ICU; 9 +/- 5 d vs. 13 +/- 6 d of hospitalization). There was one hospital death in each group (4%), and the complications were similar between the two groups. During a mean follow-up period of 11.6 +/- 7.5 months, there was no rupture or open conversion in the endograft group. CONCLUSIONS: In the initial phase of the aortic endograft programme, the mortality and morbidity were acceptable and comparable to that of open surgery.     

Influence of pre- and intra- operative factors on the occurrence of postoperative fatigue

Subjective feeling of fatigue was assessed before and 10, 20 and 30 days after uncomplicated abdominal surgery in 52 patients and after minor otological surgery in 15 patients. In major surgery fatigue increased from 3.0 +/- 0.2 (mean +/- s.e.m.) arbitrary units pre-operatively to 6.1 +/- 0.3, 5.3 +/- 0.3 and 4.1 +/- 0.3 on day 10, 20 and 30, respectively (P less than 0.001). In contrast, after minor surgery fatigue did not change from before surgery (2.1 +/- 0.3) to day 7 (2.9 +/- 0.5) (P greater than 0.05), day 20 (2.3 +/- 0.4) (P greater than 0.4), or day 30 after surgery (2.1 +/- 0.3) (P greater than 0.9). Differences in fatigue between groups were significant postoperatively (P less than 0.001), but not preoperatively (P greater than 0.05). Mean duration of surgery was similar in the two groups. In the abdominal group an increase in postoperative fatigue did not correlate with age, sex, pre-operative degree of fatigue, actual body weight, triceps skinfold thickness (TSF), arm muscle circumference (AMC), anthropometric index (body weight X TSF X AMC) or serum-transferrin, but did slightly with pre-operative body weight related to ideal body weight (r = -0.3, P less than 0.05). Thus, the magnitude of the trauma and not the duration of anaesthesia may be important for occurrence of postoperative fatigue. Furthermore, fatigue after elective abdominal surgery seems to be unpredictable from the pre-operative status of the patient.     

Experience with elective surgery in renal allograft recipients

Twenty-one of 180 patients who had received renal allografts during a nine and a half year period underwent twenty-four elective procedures twenty-four hours to five years after transplantation. All survived operation, but two patients died within the postoperative period of conditions that existed before surgery. Two additional patients died of unrelated causes three and ten months after surgery. The remaining seventeen patients are alive and well and have satisfactory to excellent renal function, with the exception of one patient who is on maintenance hemodialysis after transplant nephrectomy for oxalosis. Data indicate that elective surgery can be undertaken with reasonable risk in renal allograft recipients.     

Intensive care unit extubation does not preclude extrarenal organ recovery from donors after cardiac death

BACKGROUND: We have sought to increase the utilization of both renal and extrarenal organs from donors after cardiac death (DCD), including DCD donors with ICU extubation. METHODS: Extubation occurred in the intensive care unit (ICU; n=15) and operating room (OR; n=5). The charts of donors were reviewed for demographics, cause of death, time of asystole and cold perfusion. Recipient's charts were reviewed for graft function, length of hospitalization, serum creatinine (Cr) at discharge and last follow-up. Peak transaminases, amylase, and lipase for liver and pancreas recipients were also reviewed. Data are presented as means+/-SEM. RESULTS: From December 2002 until December 2004, 20 DCD donors were utilized yielding 34 kidney transplants (33 recipients), five liver (1 liver-kidney), and two pancreas (SPK) transplants. Mean follow-up overall is 260 days. ICU extubation occurred in 26/33 (78.8%) kidneys, 3/5(60%) livers and 1/2 (50%) pancreata performed. Time from extubation to asystole was 15.9+/-1.9 min and overall warm ischemia time was 12.5+/-1.0 min. Serum Cr at discharge and at last follow-up for renal grafts are 4.3+/-0.5 and 1.9+/-0.3 mg/dl, respectively. Peak AST and ALT levels after OLTx were 3620+/-951 and 1955+/-266 i.u., respectively. Peak and discharge total bilirubin were 8.1+/-0.9 and 2.5+/-0.5 mg/dl. Length of hospitalization was 9.6+/-1.0 and 15.8+/-2.3 days for kidney and liver recipients, respectively. Both pancreas recipients were insulin free after transplant. CONCLUSIONS: ICU extubation should not eliminate extrarenal organs from consideration and may be preferable to OR extubation by improving family support and eliminating OR staff concerns about their role in end-of-life care.     

Intraoperative and early postoperative gastric intramucosal pH predicts morbidity and mortality after major abdominal surgery

The present study was undertaken to investigate the correlation between the intraoperative and postoperative gastric intramucosal pH (pHi) with important perioperative variables and to explore any potential relationship of the measured pHi with the patients' postoperative course. A prospective study was carried out in a group of 48 patients who underwent major abdominal operations over an 8-month period at St. John Hospital and Medical Center. An automated air tonometer was used for gastric pHi monitoring. Twenty-eight elective and 20 emergency abdominal operations were performed in 23 men and 25 women. Twenty-six patients (54%) required postoperative hospitalization in the Intensive Care Unit (ICU). Seventeen patients (35%) developed early postoperative complications. The non-ICU and ICU mortality rates were 4.5 and 19.2 per cent respectively. The mean intraoperative pHi (pHiOR) and postoperative pHi (pHiPO) ranged between 7.03 and 7.58 (7.38+/-0.12) and 6.89 and 7.56 (7.35+/-0.12) respectively (mean +/- standard deviation). There was a significant decrease of the gastric pHi at the first hour intraoperatively compared with the pHi after induction to anesthesia (7.44 vs 7.38+/-0.14, P < 0.001). Patients who underwent emergent abdominal procedures were characterized by lower pHiOR and pHiPO values (7.43+/-0.08 vs 7.30+/-0.13 and 7.39+/-0.84 vs 7.30+/-0.15, P < 0.001 and P < 0.05). Similarly patients who required surgical ICU admission had significantly lower pHiOR and pHiPO measurements (7.3+/-0.12 and 7.28+/-0.12) compared with the rest (7.46+/-0.06 and 7.43+/-0.06; P < 0.001). Overall, lower pHiOR and pHiPO values were associated with the occurrence of postoperative complications (P < 0.001), the postoperative mortality (P < 0.001), the requirement for postoperative mechanical ventilator (P < 0.001) and its duration (P < 0.001), longer ICU stay (P < 0.001), and prolonged hospitalization (P < 0.05). Evidence of intraoperative and early postoperative gastric mucosal ischemia (pHiOR and pHiPO < or = 7.32) was observed in 12 (25%) and 15 (31%) patients respectively. The incidence of postoperative complications and the mortality rate were higher in this group of patients (P < 0.001). At a cutoff point of 7.32 gastric pHiOR gave a sensitivity of 69 per cent and specificity of 97 per cent for predicting postoperative complications as well as a sensitivity and specificity of 67 per cent and 81 per cent for predicting death. Intraoperative and early postoperative gastric pHi is a reliable predictor of patient outcome after major abdominal operations. Splanchnic ischemia may play an important role in determining early complications and survival; therapy guided by the gastric pHi might improve outcome.     

Impact of solid organ transplantation and immunosuppression on fever, leukocytosis, and physiologic response during bacterial and fungal infections

Immunosuppressed solid organ transplant patients may exhibit a blunted response to infection compared to non-transplant patients. To test this hypothesis, we prospectively identified all episodes of bacterial and fungal infection on the in-patient abdominal organ transplant service in our hospital, in 1997, and compared them to infected general surgery and trauma admissions treated simultaneously on the same wards. Eighty-two infections occurred in transplant patients versus 463 in non-transplant patients. Transplant patients demonstrated an overall greater physiologic response [Acute Physiology and Chronic Health Evaluation (APACHE II) and Acute Physiology Scores (APS) at the time of infection of 17.0+/-0.7 and 10.3+/-0.6, respectively, vs. 12.2+/-0.4 and 8.0+/-0.3 for non-transplant patients, p < 0.003], with a similar maximum temperature (38.0+/-0.1 vs. 38.2+/-0.1 degrees C, p = 0.2) and white blood cell (WBC) count (12.1+/-1.0 vs. 13.9+/-0.4 k/mL, p = 0.08). Upon further analysis of subgroups, patients receiving mycophenolate or azathioprine had significantly lower maximum temperatures (37.9+/-0.2 degrees C) and WBC counts (11.0+/-0.9 k/mL) when compared to non-transplant patients, while steroids appeared to have little effect on the systemic inflammatory response. Overall mortality was similar between groups. In general, solid organ transplant recipients exhibit a physiologic response to bacterial or fungal infection (as measured by the APS) at least as great as that seen in non-transplant surgical patients, although mycophenolate and azathioprine appear to slightly depress the ability to respond with fever and leukocytosis. None of these differences appeared to affect overall mortality.     

Neoadjuvant transjugular intrahepatic portosystemic shunt: a solution for extrahepatic abdominal operation in cirrhotic patients with severe portal hypertension.

BACKGROUND: Major abdominal surgery, although technically feasible per se, can be contraindicated in some cirrhotic patients because of severe portal hypertension. The present study reports our experience of seven such patients who were prepared for major abdominal surgery by transjugular intrahepatic portosystemic shunt (TIPS). STUDY DESIGN: There were seven cirrhotic patients (six men and one woman aged 47 to 69 years) with portal hypertension. Portal hypertension was considered severe because of the presence of at least one of the following: history of variceal bleeding (five of seven patients), varices at risk of bleeding (red signs or cardial location of varices; four of seven patients), or intractable ascites (three of seven patients). The planned operations included colon, gastroesophageal, kidney, and aortic procedures in three, two, one, and one patient, respectively. Because portal hypertension was the leading cause of surgical contraindication, the following "two-step strategy" was applied to the seven patients: first, TIPS to control portal hypertension, followed, after a delay of at least 1 month, by abdominal surgery. RESULTS: The TIPS procedure was successfully performed in all patients without complications. The hepatic venous pressure gradient decreased from 18+/-5 to 9+/-5 mm Hg (p<0.01). All patients were operated on with a delay ranging from 1 month to 5 months after TIPS (2.9+/-1.3 months; median 3 months). The planned operation was performed in six of the seven patients. One patient with cancer of the cardia did not have resection because of extensive abdominal spreading of the tumor. Intraoperative transfusion was necessary in only two patients. Operative mortality occurred in one patient, 36 days after resection of a left colon cancer. CONCLUSIONS: The minimally invasive nature of TIPS allows us to propose the following two-step management of cirrhotic patients with severe portal hypertension needing abdominal surgery: decompression of the portal system by TIPS followed by elective surgery.