Probiotics and Synbiotics Decrease Postoperative Sepsis in Elective Gastrointestinal Surgical Patients: a Meta-Analysis

Background

The health benefits of probiotics and synbiotics are well established in healthy adults, but their role in preventing postoperative sepsis remains controversial. This meta-analysis assesses the impact of probiotics and synbiotics on the incidence of postoperative sepsis in gastrointestinal (GI) surgical patients.

Methods

A comprehensive literature search of all published randomized control trials (RCTs) was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966–2015). Inclusion criteria included RCTs comparing the use of any strain or dose of a specified probiotic/synbiotic with placebo or a “no treatment” control group. The incidence of postoperative sepsis (within 1 month of surgery) and postoperative mortality were analyzed.

Results

Fifteen RCTs involving 1201 patients (192 receiving probiotics, 413 receiving synbiotics, and 596 receiving placebo) were analyzed. Overall, probiotic and synbiotic uses significantly reduced the risk of developing postoperative sepsis by 38 % (relative risk (RR)?=?0.62, 95 % confidence interval (CI) 0.52–0.74, p?<?0.001).

Conclusions

The use of probiotic/synbiotic supplementation is associated with a significant reduction in the risk of developing postoperative sepsis in patients undergoing elective GI surgery. Probiotic/synbiotic supplementation is a valuable adjunct in the care of patients undergoing GI surgery. Additional studies are required to determine the optimal dose and strain of probiotic/synbiotic.

     

Hepatic arterial buffer response after pediatric living donor liver transplantation: report of a case

Background

Excessive portal pressure at an early stage after living-donor liver transplantation (LDLT) can damage sinusoidal endothelial cells and hepatocytes through shear stress leading to graft failure, or hepatic arterial complications due to low hepatic artery flow from a hepatic arterial buffer response. We encountered a case in which excessive portal vein flow was observed from an early stage after pediatric LDLT. The hepatic artery flow decreased due to a hepatic arterial buffer response.

Case report

A 6-month-old boy with biliary atresia showed excessive portal vein flow early after LDLT with a decreasing hepatic artery flow without anastomotic stenosis from postoperative day 3. The PV flow gradually exhibited a decrease at approximately postoperative day 8 and, similtaneously, hepatic artery flow exhibited improvement.

Conclusion

Because excessive portal pressure after LDLT is reversible, it has been suggested that it may be possible to prevent the progress of hepatic arterial complications if temporary portal pressure modulation can be performed for cases among the high-risk group for hepatic arterial complications.     

Risk factors associated with relapse or infectious complications in Japanese patients with microscopic polyangiitis

Background

The prevention of relapse and infection complications during remission maintenance therapy is required to improve the prognosis of patients with microscopic polyangiitis (MPA) showing rapidly progressive glomerulonephritis (RPGN). The clinicopathological characteristics of patients with ANCA-positive MPA were examined to determine the risk factors for relapse or infectious complications after remission induction therapy.

Patients and methods

The study population consisted of 52 patients diagnosed as ANCA-positive MPA showing RPGN from 2002 to 2012, after publication of the Japanese guideline for RPGN. The clinicopathological findings were examined between the presence and absence of relapse or infectious complications.

Results

The value of vasculitis damage index (VDI) was high for the relapse group and VDI value was identified as the leading factor associated with relapse [hazard ratio (HR) 3.36, 95 % confidence interval (CI) 1.58–7.12, P < 0.01]. On the other hand, the values of Birmingham Vasculitis Activity Score, clinical grade category of RPGN at diagnosis, and VDI at remission were high in the infectious group. Furthermore, clinical grade category of RPGN was the leading factor associated with infectious complications (HR 5.30, 95 % CI 1.41–19.9, P = 0.01).

Conclusion

The disease activity at diagnosis and severity of organ damage at remission were associated with relapse and infectious complications during remission maintenance therapy and infectious complication affected kidney survival and all-cause mortality in patients with ANCA-positive MPA exhibiting RPGN.

     

Embolisation for Vascular Injuries Complicating Elective Orthopaedic Surgery

Objectives

The study aims to present the indications and emphasise the role of embolisation for vascular injuries in orthopaedic surgery.

Methods

Thirty-one patients with vascular injuries complicating elective orthopaedic surgery had embolisation from 2003 to 2010. N-2-butyl cyano-acrylate (NBCA) was used as embolic agent in 28 patients, gelatin sponge in three and coil embolisation in addition to NBCA or gelatin sponge in two patients. The mean follow-up period was 37 months (range, 4–96 months).

Results

The most common orthopaedic operations associated with vascular injuries amenable to embolisation were hip-joint procedures; and the most common injuries were arterial tears of branch vessels or non-critical axial vessels, most commonly of the superior glutaeal artery. In all cases, angiography showed the bleeding point, and a single embolisation session effectively stopped bleeding. Embolisation-related complications were not observed.

Conclusions

Embolisation should be considered the treatment of choice for vascular injuries of branch vessels or non-critical axial vessels following elective orthopaedic surgery because of the advantages of minimally invasive therapy and the lack of complications.     

Infection Complications and Pattern of Bacterial Resistance in Living-Donor Liver Transplantation: A Multicenter Epidemiologic Study in Egypt

Introduction

Data on the prevalence and pattern of infection after living-donor liver transplantation (LDLT) are scarce in Egypt. We therefore conducted this study to quantify the incidence, risk factors, and pattern of bacterial resistance post-LDLT in 3 hospitals in Egypt.

Patients and Methods

We conducted a retrospective, multicenter study of the medical records of 246 patients who underwent LDLT between January 2006 and April 2011 at 3 transplant centers in Egypt.

Results

Of 246 patients enrolled in this study, 127 (52%) developed infectious complications after LDLT, with 416 episodes of infection occurring within 3 months of transplantation. Biliary tract infection was the most common, occurring in 169 (40.6%) patients. The rate of infection with Gram-negative bacteria was higher than that of infection with Gram-positive bacteria (310 [74%] vs 87 [21%]; P < .001). Overall, 75% of Gram-negative isolates were multidrug resistant. Significant independent risk factors for infection were portal vein thrombosis (odds ratio, 2.4; P = .037) and biliary complications (odds ratio, 5.4; P < .001).

Conclusions

Our data showed a high-resistance pattern of bacterial infection after LDLT in Egypt. Early biliary complications were an independent risk factor for bacterial infection.     

Primary Living-donor Liver Transplantation Is Not the Optimal Treatment Choice in Patients With Early Hepatocellular Carcinoma With Poor Tumor Biology

Objective

Liver resection (LR) and living-donor liver transplantation (LDLT) are considered the two potentially curative treatments for hepatocellular carcinoma (HCC). The aim of this study was to investigate whether there is a difference in the oncologic outcomes between LR and LDLT according to tumor biology.

Omitting perioperative urinary catheterization in laparoscopic cholecystectomy: a single-institution experience

Purpose

In 2009, the Centers for Disease Control and Prevention published Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections, which limited the indications for perioperative urinary catheter use. We conducted this study to evaluate the safety of elective laparoscopic cholecystectomy (LC) without urinary catheter placement and to investigate whether it reduces the incidence of urinary complications.

Methods

Of 244 patients who underwent elective LC between March, 2010 and April 2011, 192 patients fulfilled the eligibility criteria and underwent surgery without urinary catheterization (non-catheterized group). We compared the clinical features and surgical outcomes of the non-catheterized group with those of an historical control of 90 patients who underwent LC with routine urinary catheterization.

Results

The operating times were similar in the two groups and there was no case of conversion to open surgery. The postoperative hospital stay was slightly shorter and the incidence of urinary complications was significantly lower in the non-catheterized group. Three patients in the non-catheterized group suffered urinary retention, which resolved after temporary catheterization.

Conclusion

Our study demonstrated that elective LC without urinary catheter placement is feasible for most patients and might reduce the incidence of perioperative urinary complications.

     

A Significant Expansion of CD8 CD28 T-Suppressor Cells in Adult-to-Adult Living Donor Liver Transplant Recipients

Background

The appearance of human regulatory CD8⁺ CD28⁻ T-suppressor (Ts) cells has been associated with a reduced need for maintenance immunosuppression in cadaveric heart- kidney transplant recipients and pediatric liver-intestine transplant recipients. However, few data are available in adult-to-adult living donor liver transplantation (A-A LDLT).

Materials and Methods

To study the population of CD8⁺ CD28⁻ Ts cells in A-A LDLT, we performed flow cytometry on whole blood specimens obtained from 20 transplant recipients, 18 end-stage liver disease patients, and 20 normal controls. Meanwhile, we measured the trough levels of immunosuppressants and monitored graft function in transplant recipients. We retrospectively reviewed the clinical data of the 20 recipients.

Results

A significant expansion of CD8⁺ CD28⁻ Ts cells was observed among recipients of A-A LDLT as compared with a disease control group (P = .000) or healthy individuals (P = .000). All recipients were free of acute cellular rejection episodes. During the follow-up period, no grafts were lost due to acute or chronic rejection.

Conclusion

Expansion of CD8⁺ CD28⁻ Ts cells in A-A LDLT seemed to be associated with a decreased occurrence of acute or chronic rejection and sustained good graft function. Based on our low dosages of immunosuppressants for recipients of A-A LDLT, we suggest that this strategy may promote expansion of CD8⁺ CD28⁻ Ts cells, which can conversely maintain the low immunosuppressant dosages.     

Right lobe living-donor liver transplantation with or without middle hepatic vein: a meta-analysis

Objective

The purpose of this meta-analysis was to compare outcomes after right-lobe living-donor liver transplantation (LDLT) with or without the middle hepatic vein (MHV).

Methods

Studies were identified through a computerized search of Pubmed, Embase, Ovid, the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials, the Cochrane Library database, and the Web of Science. Two reviewers independently assessed the quality of each study and abstracted outcome data. We extracted data for liver functional recovery in donors, donor hospital stay, donor complications and liver functional recovery in recipients. We synthesized published data using random-effects and fixed-effect models, expressing results as weighted mean differences (WMD) or relative risk (RR).

Results

The 11 included eligible studies came from medical centers worldwide. Significant differences between “with MHV” versus “without MHV” groups were not observed for liver functional recovery (P = .08; WMD = −2.88), donor hospital stay (P = .00; WMD = 0.00), or donor complications (P = .90; RR = 1.02). However, our meta-analysis showed a significant benefit for recipients liver functional recovery favoring the MHV group (P = .02; WMD = −33.06).

Conclusions

Our meta-analysis discovered that right lobes with MHV not only experienced better liver functional recovery in recipients, but also caused no greater harm or risk to donors.     

Duct-to-Duct Biliary Reconstructions and Complications in 100 Living Donor Liver Transplantations

Objective

We evaluated the risk factors for biliary complications and surgical procedures for duct-to-duct reconstructions in adult living donor liver transplantation (LDLT).

Patients and Methods

From February 2005 to March 2008, we performed 100 cases of adult LDLT with duct-to-duct biliary reconstruction, using 64 right lobe grafts, 33 left lobe grafts, and 3 right lateral grafts. We employed 4 types of duct-to-duct procedures: all interrupted 6-0 Prolene suture (group 1, n = 9); continuous posterior and interrupted anterior wall 6-0 Prolene suture (group 2, n = 49); all continuous 7-0 Prolene suture (group 3, n = 26); and all continuous 7-0 Prolene suture with external stent (group 4, n = 16). Biliary complications were defined as an anastomosis stricture or a leakage.

Results

Thirty-four patients experienced biliary complications during the follow-up period (median, 27 months). The incidence of stricture was 27% and that of leakage, 8%. There were no perioperative, intraoperative, or anatomic risk factors for biliary complications, except the type of duct-to-duct procedure. Group 1 and 2 patients showed higher incidences of biliary strictures than groups 3 and 4 (43.1% vs 4.7%; P = .00). Group 3 patients experienced a higher incidence of bile leakage than the other groups (23.1% vs 2.7%; P = .004).

Conclusions

The type of biliary reconstruction is a factor affecting biliary complications following duct-to-duct anastomosis in LDLT. Duct-to-duct biliary anastomosis with 7-0 monofilament suture and a small external stent is a feasible procedure in LDLT that significantly reduces the incidence of biliary complications.     

Noncompliance with medications in pediatric patients after living-donor liver transplantation

Introduction

Noncompliance with immunosuppressant therapy is a serious problem that leads to the possibility of graft rejection, even in the long term after liver transplantation. The objectives of the present study were to review and describe features of patient noncompliance after living-donor liver transplantation (LDLT).

Patients and Methods

Among pediatric patients (age <18 years) surviving more than 5 years after LDLT, noncompliant patients were identified, and their clinicopathologic characteristics were studied retrospectively.

Results

Of 108 pediatric recipients who survived more than 5 years after LDLT, 6 female patients (5.6%) were noncompliant. Median (range) age at transplantation was 5 (2–15) years, and at noncompliance was 18 (9–21) years. Median time to noncompliance after transplantation was 8 (5–16) years. The 6 noncompliant patients received increased immunosuppression therapy, and liver function test results improved. Noncompliance was improved via intervention with medication, but recurred in 2 patients (33%). Noncompliance did not result in graft or patient loss.

Conclusion

The prevalence of noncompliance was not so high in LDLT recipients. Liver dysfunction secondary to noncompliance improved with increased immunosuppression therapy.     

Elective intestinal operations in infants and children without mechanical bowel preparation: a pilot study

Background/Purpose

Preoperative mechanical bowel preparation (MBP) for elective intestinal operations has been a long accepted practice. However, MBP is often unpleasant and time-consuming for patients, and clinical trials in adults have not shown improved outcomes. We conducted this pilot study to test whether omitting MBP before elective intestinal operations in infants and children would increase the risk of infectious or anastomotic complications.

Methods

Retrospective review was performed of 143 patients who had an elective colon or distal small bowel procedure performed at our children's hospital between 1990 and 2003.

Results

Thirty-three patients (No PREP) were managed by a single surgeon who routinely omitted MBP, whereas another 110 patients (PREP) were prepared with enemas, laxatives, or both. Both groups received 24 hours of preoperative dietary restriction to clear liquids and perioperative parenteral antibiotics. The No PREP group had one anastomotic leak and no wound infections, whereas the PREP group had 2 anastomotic leaks and 1 wound infection (P = .58). These results occurred despite greater duration of antibiotic therapy and incidence of delayed wound closures in the PREP group.

Conclusion

The results of this pilot study suggest that omitting MBP before elective intestinal operations in infants and children carries no increased risk of infectious or anastomotic complications. Eliminating MBP may reduce health care costs and inconvenience to patients. These findings warrant a large, prospective, randomized clinical trial to validate our findings and to investigate further the necessity of MBP in the pediatric population.     

Splenectomy for Severe Intestinal Bleeding Caused by Portal Hypertensive Enteropathy After Pediatric Living-Donor Liver Transplantation: A Report of Three Cases

Background

The incidence of portal vein thrombosis after pediatric living-donor liver transplantation (LDLT) is reported to be higher than that after deceased-donor or adult liver transplantation. Portal vein thrombosis can cause portal hypertension and related complications, including portal hypertensive gastropathy or portal hypertensive enteropathy (PHE). PHE, in particular, can lead to severe intestinal bleeding, which is extremely difficult to treat. However, the pathogenesis of and appropriate treatment for PHE are not clearly defined, especially after pediatric LDLT.

Evaluation of morbidity and mortality after anastomotic leakage following elective colorectal surgery in patients treated with or without mechanical bowel preparation

Background

A previous multicenter randomized trial demonstrated that mechanical bowel preparation (MBP) does not guard against anastomotic leakage in elective colorectal surgery. The aim of this complementary study was to evaluate the effects of MBP on morbidity and mortality after anastomotic leakage in elective colorectal surgery.

Methods

A subgroup analysis was performed of a randomized trial comparing the incidence of anastomotic leakage and septic complications with and without MBP in patients undergoing elective colorectal surgery.

Results

Elective colorectal surgery was performed in 1,433 patients with primary anastomoses, of whom 63 patients developed anastomotic leakage. Twenty-eight patients (44%) received MBP and 35 patients (56%) did not. Mortality rate, initial need for surgical reintervention, and extent of bowel contamination did not differ between groups (29% vs 40%; P = .497, P = .667, and P = .998, respectively).

Conclusions

No benefit of MBP was found regarding morbidity and mortality after anastomotic leakage in elective colorectal surgery.     

Usefulness of PIVKA-II After Living-donor Liver Transplantation for Hepatocellular Carcinoma

Objective

Prothrombin induced by the absence of vitamin K or antagonist-II (PIVKA-II) is a useful tumor marker for hepatocellular carcinoma (HCC). However, the usefulness of post-transplantation surveillance with PIVKA-II is not clear. We evaluated the clinical value of PIVKA-II in monitoring HCC recurrence after living-donor liver transplantation (LDLT).

Hepatic Artery Reconstruction With Autologous Inferior Mesenteric Artery Graft in Living Donor Liver Transplant Recipients

Introduction

In living donor liver transplantation (LDLT), hepatic arterial continuity is crucial to avoid biliary leakage, biliary stricture, cholangitis, and graft and patient loss. Sometimes there exist factors making anastomosis difficult or even impossible. In these cases, a vascular graft may be needed to bridge the two arteries for revascularization.

Cost Analysis and Determinants of Living Donor Liver Transplantation in Taiwan

Background

Liver transplantation (LT) has become established therapy for end-stage liver disease and small-cell hepatocellular carcinoma (HCC), relying mainly on living donor LT (LDLT) in Taiwan. The cost of LDLT varies in different countries depending on the insurance system, the costs of the facility, and staff. In this study we aimed to investigate cost outcomes and determinants of LDLT in Taiwan.

Clinical Outcomes of Living Liver Transplantation According to the Presence of Sarcopenia as Defined by Skeletal Muscle Mass,Hand Grip,and Gait Speed

Background

Sarcopenia is an independent predictor of death after living-donor liver transplantation (LDLT). However, the ability of the Asian Working Group for Sarcopenia criteria for sarcopenia (defined as reduced skeletal muscle mass plus low muscle strength) to predict surgical outcomes in patients who have undergone LDLT has not been determined.

Improved Results of a Surgical Resection for the Recurrence of Hepatocellular Carcinoma After Living Donor Liver Transplantation

Purpose

This study was designed to analyze the clinical outcomes of the recurrence of hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) and to evaluate the efficacy of a surgical resection in treating such a recurrence.

Methods

A total of 101 adult LDLT recipients with HCC between 1996 and 2007, including 17 who had recurrent HCC, were reviewed. The endpoints analyzed were survival from time of transplant and survival from time of recurrence. Recipient demographics, laboratory valuables, and tumor characteristics were analyzed. Any medical or surgical treatments that had been administered for any recurrence also were considered.

Results

The mean duration until the initial recurrence after LDLT and the mean duration until death after the initial recurrence were 12.9 months and 12.0 months, respectively. A univariate analysis showed that gender, interferon therapy, early posttransplant tumor recurrence, and eligibility for a surgical resection all had a beneficial impact on survival from tumor recurrence. A surgical resection of tumor relapse was the most important variable in our study, and therefore the patients were divided into two groups: surgical therapy group (n = 9), and nonsurgical therapy group (n = 7). Interestingly, the overall survival rates of the surgical group were significantly better than those of the nonsurgical group and were similar to that of the patients without HCC recurrence.

Conclusions

Surgical therapy might be useful for patients who experience a recurrence of HCC after LDLT to improve their outcome, when such treatment is available.     

Vascular Complications After Deceased and Living Donor Liver Transplantation: A Single-Center Experience

Introduction

Vascular complications (VC) after liver transplantation (OLT) are one of the most feared problems that frequently result in graft and patient loss. Herein we have reported our experience with VC after either deceased donor liver transplantation (DDLT) or living donor liver transplantation (LDLT).

Patients and Methods

Between April 2001 and September 2009, we performed 224 OLT: 155 DDLT and 69 LDLT. The overall male/female ratio was 136/88 and the adult/pediatric ratio was 208/16. We retrospectively identified and analyzed vascular complications in both groups.

Results

In the DDLT group, 11/155 recipients (7%) suffered vascular complications; hepatic artery thrombosis (HAT; n = 5; 3.2%), portal vein thrombosis occurred (n = 4; 2.6%); hepatic vein stenosis (n = 1; 0.6%), and severe postoperative bleeding due to a slipped splenic artery ligature (n = 1, 0.6%). In the DDLT group, 4/11 (36.4%) patients died as a direct result of the vascular complications. In the LDLT group, 9/69 recipients (13%) suffered vascular complications: HAT (n = 3; 4.3%), portal vein problems (n = 5; 7.2%), and hepatic vein stenosis (n = 1; 1.5%). Among LDLT, 3/9 (33.3%) patients died as a direct result of the vascular complications. In both groups vascular complications were associated with poorer patient and graft survival.

Conclusions

In our experience, the incidence of vascular complications was significantly higher among the LDLT group compared with the DDLT group. Vascular complications were associated with poorer graft and patient survival rates in both groups.