Impact of liver-directed therapy in colorectal cancer liver metastases

Background

There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy.

Methods

We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001–2007). LDT was defined as liver resection and/or ablation-embolization.

Results

We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93–0.99), age >85 y (OR = 0.61, 95% CI 0.45–0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64–0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P < 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005–2007) period.

Conclusions

Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.     

The impact of Aldehyde dehydrogenase 1 expression on prognosis for metastatic colon cancer

Background

Cancer stem cells may be associated with tumor progression and prognosis for colon cancer. We hypothesized that expression of Aldehyde dehydrogenase 1 (ALDH1) would increase with tumor progression and be associated with survival.

Methods

Tissue was obtained from resection specimens for isolation of cancer stem cells. In addition, paraffin blocks from resected colon cancers with normal colon, primary tumor, and lymph node and liver metastasis from 2000 to 2010 were identified and stained with ALDH1.

Results

In in vitro models (adherent and tumor spheres) ALHD1+ cells grew more efficiently than ALDH1− cells. ALDH1 expression was highest in peritumoral crypt cells (0.137 μm², 95% confidence interval [CI] 0.125–0.356) and normal crypts (median 0.091 μm², 95% CI 0.064–0.299) followed by lymph node metastasis (median 0.025 μm², 95% CI 0–0.131) and the primary cancers (median 0.014 μm², 95% CI 0.0123–0.154). Samples were divided into high and low ALDH1 expression. Survival was associated with expression in the primary tumor (9 versus 23 mo, P = 0.0016) expression but not peritumoral tissue (21 versus 20.5 mo, P = 0.32), normal colon (19 versus 27 mo, P = 0.289), or lymph node metastasis (23 versus 21 mo, P = 0.69). On univariate analysis, ALDH1 expression and grade were associated with survival but ages, number of lymph node metastasis, race, or grade were not associated. On multivariate analysis, only ALDH1 status continued to be associated with survival, odds ratio 4.4, and P = 0.011.

Conclusions

ALDH1 is indicative of stemness and is a biomarker marker in colon cancer. Expression did not increase with progression from normal colon to primary tumors and metastasis.     

Hernia repair in the presence of ascites

Background

The model for end-stage liver disease (MELD) has been validated as a prediction tool for postoperative mortality, but its role in predicting morbidity has not been well studied. We sought to determine the role of MELD, among other factors, in predicting morbidity and mortality in patients with nonmalignant ascites undergoing hernia repair.

Methods

All patients undergoing hernia repair in the American College of Surgeons National Surgical Quality Improvement database (2009–11) were identified. Those with nonmalignant ascites were compared with patients without ascites. A subset analysis of patients with nonmalignant ascites was performed to evaluate the association between MELD and morbidity and mortality with adjustment for potential confounders. The association of significant factors with the rate of morbidity was displayed using a best-fit polynomial regression.

Results

Of 138,366 hernia repairs, 778 (0.56%) were performed on patients with nonmalignant ascites. Thirty-day morbidity (4% versus 19%) and mortality (0.2% versus 5.3%) were significantly more frequent in patients with ascites (P < 0.001). In univariate analysis of the 636 patients with a calculable MELD, MELD was associated with both morbidity and mortality (P < 0.001 each). In multivariate analysis, MELD remained significantly associated with morbidity (odds ratio [OR] = 1.11). Ventral hernia repair (OR = 2.9), dependent functional status (OR = 2.3), alcohol use (OR = 2.3), emergent operation (OR = 2.0) white blood count (OR = 1.1), and age (OR = 1.02) were also significantly associated with morbidity (P < 0.05).

Conclusions

Before hernia repair, the MELD score can be used to risk-stratify patients with nonmalignant ascites not only for mortality but also morbidity. Morbidity rates increase rapidly with MELD above 15, but other factors should additionally be accounted for when counseling patients on their perioperative risk.     

Liver Resection in Transplanted Patients: A Single-Center Western Experience

Background

Liver resection (LR) in liver transplant (OLT) recipients, an extremely rare situation, who performed on 8 recipients.

Methods

This retrospective analysis of prospectively collected data concerned 8 (0.66%) 1198 LR cases among OLT performed from 1997 to 2011. We analyzed demographic data, surgical indications, and postoperative courses.

Results

The indications were resectable recurrent hepatocellular carcinomas (HCC, n = 3), persistent fistula from a posterior sectorial duct (n = 1), recurrent cholangitis due to anastomotic stricture on the posterior sectorial duct (n = l), hydatid cyst (n = l), left arterial hepatic thrombosis with secondary ischemic cholangitis (n = 1), and a large symptomatic biliary cyst (n = 1). The mean interval time to liver resection was 23.7 months (range, 5–47). LR included right hepatectomy (n = 1), right posterior hepatectomy (n = 1), left lobectomy (n = 4), pericystectomy (n = 1), or biliary fenestration (n = 1). Which there was no postoperative mortality, the global morbidity rate was 62% (5/8). The mean follow-up after LR was 92 months (range, 11–156). No patients required retransplantation. None of the 3 patients who underwent LR for HCC showed a recurrence.

Conclusions

LR in OLT recipients is safe, but associated with a high morbidity rate. This procedure can avoid retransplantation in highly selected patients, presenting a possible option particularly for transplanted patients with a resectable, recurrent HCC.     

Morbidity related to concomitant adhesions in abdominal surgery

Background

We sought to assess the independent effect of concomitant adhesions (CAs) on patient outcome in abdominal surgery.

Materials and methods

Using the American College of Surgeons National Surgical Quality Improvement Program data, we created a uniform data set of all gastrectomies, enterectomies, hepatectomies, and pancreatectomies performed between 2007 and 2012 at our tertiary academic center. American College of Surgeons National Surgical Quality Improvement Program data were supplemented with additional variables (e.g., procedure complexity–relative value unit). The presence of CAs was detected using the Current Procedural Terminology codes for adhesiolysis (44005, 44180, 50715, 58660, and 58740). Cases where adhesiolysis was the primary procedure (e.g., bowel obstruction) were excluded. Multivariable logistic regression analyses were performed to assess the independent effect of CAs on 30-d morbidity and mortality, while controlling for age, comorbidities and the type/complexity/approach/emergency nature of surgery.

Results

Adhesiolysis was performed in 875 of 5940 operations (14.7%). Operations with CAs were longer (median duration 3.2 versus 2.7 h, P < 0.001), more complex (median relative value unit 37.5 versus 33.4, P < 0.001), performed in sicker patients (American Society for Anesthesiologists class ≥3 in 49.9% versus 41.2%, P < 0.001), and harbored higher risk for inadvertent enterotomies (3.0% versus 0.9%, P < 0.001). In multivariable analyses, CAs independently predicted higher morbidity (adjusted odds ratio [OR], 1.35; 95% confidence interval, 1.13–1.61, P = 0.001). Specifically, CAs independently correlated with superficial and deep or organ-space surgical site infections (OR = 1.42 (1.02–1.86), P = 0.036; OR = 1.47 (1.09–1.99), P = 0.013, respectively), and prolonged postoperative hospital stay (≥7 d, OR = 1.34 [1.11–1.61], P = 0.002). No difference in 30-d mortality was detected.

Conclusions

CAs significantly increase morbidity in abdominal surgery. Risk adjusting for the presence of adhesions is crucial in any efforts aimed at quality assessment and/or benchmarking of abdominal surgery.     

Radiofrequency-assisted versus clamp-crush liver resection: a systematic review and meta-analysis

Background

Conflicting results were found between radiofrequency-assisted liver resection (RF-LR) and clamp-crush liver resection (CC-LR) during liver surgery. We conducted a systematic review and meta-analysis that included randomized controlled trials (RCTs) and non-RCTs to compare the effectiveness and safety of RF-LR versus CC-LR during liver surgery.

Methods

Articles comparing RF-LR and CC-LR that were published before December 2012 were retrieved and subjected to a systematic review and meta-analysis. Data synthesis and statistical analysis were carried out by Review Manager Version 5.2 software.

Results

In all, four RCTs and five nonrandomized studies evaluating 728 patients were included. Compared with CC-LR, the RF-LR group had significantly reduced total intraoperative blood loss (weighted mean difference [WMD] = −187 mL; 95% confidence interval [CI] = −312, −62; data on 628 patients), and blood loss during liver transection (WMD = −143.7 mL; 95% CI = −200, −87; data on 190 patients). However, RF-LR is associated with a higher rate of intra-abdominal abscess than the clamp-crushing method (odds ratio = 3.61; 95% CI = 1.26, 10.32; data on 366 patients). No significant difference was observed between both the groups for the incidence of both blood transfusion and bile leak.

Conclusions

There is currently not sufficient evidence to support or refute the use of RF-LR in liver surgery. RF-LR has advantages in terms of reducing blood loss. However, RF-LR may increase the rates of both bile leak and abdominal abscess. So, the safety of RF-LR has not been established. Future well-designed RCTs are awaited to further investigate the efficacy and safety of RF devices in liver resection.     

Abdominal ultrasound versus hepato-imino diacetic acid scan in diagnosing acute cholecystitis—what is the real benefit?

Background

Acute cholecystitis is one of the most common surgical problems, yet substantial debate remains over the utility of simple examination, abdominal ultrasound (AUS), or advanced imaging such as hepato-imino diacetic acid (HIDA) scan to support the diagnosis.

Materials and methods

The preoperative diagnostic workup of patients who underwent cholecystectomy with histologically confirmed acute cholecystitis was reviewed to calculate the sensitivity of AUS, HIDA scan, or both. In addition, the sensitivity of the commonly described ultrasonographic findings was assessed.

Results

From 2010 through 2012, 406 patients among 9087 reviewed charts presented to the emergency department with acute upper abdominal pain and met inclusion criteria. 32.5% (N = 132) of patients underwent AUS only, 11.3% (N = 46) underwent HIDA scan only, and 56.2% (N = 228) had both studies performed for workup. 52.7% (N = 214) of patients had histopathologically confirmed acute cholecystitis. The sensitivities of AUS, HIDA, and AUS combined with HIDA for acute cholecystitis were 73.3% (95% confidence interval [CI] = 66.3%–79.5%), 91.7% (95% CI = 86.2%–95.5%), and 97.7% (95% CI = 93.4%–99.5%), respectively. Although of limited sensitivity, AUS findings of sonographic Murphy sign, gallbladder distension, and gallbladder wall thickening were associated with a diagnosis of acute cholecystitis.

Conclusions

The sensitivity of AUS for diagnosing acute cholecystitis in patients with acute upper abdominal pain is limited. The addition of a HIDA scan in the diagnostic workup significantly improves sensitivity and can add valuable information in the appropriate clinical setting.     

Identifying predictors of a difficult thyroidectomy

Background

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

Methods

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P < 0.05) variables from a univariate analysis.

Results

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P = 0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P = 0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P = 0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23–15.36, P = 0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28–9.66, P = 0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06–6.42, P = 0.037) were independently associated with DT.

Conclusions

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.     

Clinical outcomes following bowel resection versus reduction of intussusception

Background

Intussusception is most commonly managed with air-contrast reduction. However, when this fails, emergent operation with resection or manual reduction is indicated. It is not known if there are advantages to resection compared with manual reduction.

Methods

A retrospective review of all patients receiving operative care for intussusception from February 2000 to December 2011. Patients undergoing intestinal resection were compared with those treated with manual reduction alone.

Results

Of 111 patients, 49 underwent resection and 62 underwent manual reduction. Mean (±SD) time to oral intake favored manual reduction (2.1 ± 1.2 versus 2.6 ± 1.2 d, respectively, P = 0.05). Manual reduction was associated with a greater need for repeat imaging (47% versus 18%, P = 0.002) and the only recurrences were with manual reduction (8% versus 0%, P = 0.1). Mean duration of stay was no different (P = 0.36), nor was the need for reoperation (P = 0.9).

Conclusions

Patients undergoing manual reduction have an increased number of radiographic imaging procedures. The surgeon should have a low threshold for resection for intussusceptions requiring operative management.     

Le Smur meilleur vecteur pour une analgésie des patients traumatisés à l’arrivée aux urgences

Objectives

To find out prehospital factors linked with low pain on arrival into a traumatic emergency unit.

Methods

A 4-month monocentric prospective study, including patients recruited at their arrival into a traumatic emergency unit. Pain (with a numerical rating scale [NRS]), anxiety, prehospital care including the type of transportation (Physician staffed ambulances Smur, emergency medical technicians or firemen ambulances), immobilization and analgesics used were evaluated. These data were collected on arrival at the hospital by the ED orientation nurse. Uni- and multivariate analysis were performed to identify low pain's predictive factors (e.g. with a NRS ≤ 3).

Results

Three hundred and four patients were recruited, mean age = 51 ± 25, sex ratio = 1.8, mean pain/10 = 5.8 ± 2.9, 64% with a moderate or severe pain on arrival (NRS > 3). For one third of patients, immobilizations hadn’t been performed during the prehospital phase. Medical management by Smur is a low pain predictive factor (OR = 5.8; CI 95% = 1.4–24.16), anxiety is a pejorative factor (OR = 0.53 CI 95% = 0.38–0.75).

Conclusion

Our study highlights the physician staffed ambulances’ effectiveness in prehospital trauma victim's management and raises the question of anxiolysis as an adjuvant for traumatic pain management.     

The impact of pregnancy on surgical Crohn disease: an analysis of the Nationwide Inpatient Sample

Background

The impact of pregnancy on the course of Crohn disease is largely unknown. Retrospective surveys have suggested a variable effect, but there are limited population-based clinical data. We hypothesized pregnant women with Crohn disease will have similar rates of surgical disease as a nonpregnant Crohn disease cohort.

Material and methods

International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify female Crohn patients from all patients admitted using the Nationwide Inpatient Sample (1998–2009). Women were stratified as either pregnant or nonpregnant. We defined Crohn-related surgical disease as peritonitis, gastrointestinal hemorrhage, intra-abdominal abscess, toxic colitis, anorectal suppuration, intestinal–intestinal fistulas, intestinal–genitourinary fistulas, obstruction and/or stricture, or perforation (excluding appendicitis).

Results

Of the 92,335 women admitted with a primary Crohn-related diagnosis, 265 (0.3%) were pregnant. Pregnant patients were younger (29 versus 44 y; P < 0.001) and had lower rates of tobacco use (6% versus 13%; P < 0.001). Pregnant women with Crohn disease had higher rates of intestinal–genitourinary fistulas (23.4% versus 3.0%; P < 0.001), anorectal suppuration (21.1% versus 4.1%; P < 0.001), and overall surgical disease (59.6% versus 39.2%; P < 0.001). On multivariate logistic regression analysis controlling for malnutrition, smoking, age, and prednisone use, pregnancy was independently associated with higher rates of anorectal suppuration (odds ratio [OR], 5.2; 95% confidence interval [CI], 3.8–7.0; P < 0.001), intestinal–genitourinary fistulas (OR, 10.4; 95% CI, 7.8–13.8; P < 0.001), and overall surgical disease (OR, 2.9; 95% CI, 2.3–3.7; P < 0.001).

Conclusions

Pregnancy in women with Crohn disease is a significant risk factor for Crohn-related surgical disease, in particular, anorectal suppuration and intestinal–genitourinary fistulas.     

Predictors of appendiceal perforation in an equal access system

Background

Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis.

Materials and methods

All patients undergoing appendectomy for acute appendicitis (November 2004–October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis.

Results

A total of 680 patients (mean age 30 ± 16 y; 37% female) were included. The majority were Caucasian (56.4% [n = 384]; African Americans 5.6% [n = 38]; Asians 1.9% [n = 13]; and other 48.9% [n = 245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P = 0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P = 0.273; 6.60% junior versus 5.50% senior enlisted, P = 0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P = 0.7). Only age had a correlation, with individuals aged 66–75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02–1.05; P < 0.001).

Conclusions

In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.     

The role of clinical care pathways: an experience with distal pancreatectomy

Background

Previous studies have indicated that clinical pathways may shorten hospital length of stay (HLOS) among patients undergoing distal pancreatectomy (DP). Here, we evaluate an institutional standardized care pathway (SCP) for patients undergoing DP.

Materials and methods

A retrospective review of patients undergoing DP from November 2006 to November 2012 was completed. Patients treated before and after implementation of the SCP were compared. Multivariable linear regression was then performed to identify independent predictors of HLOS.

Results

There were no differences in patient characteristics between SCP (n = 50) and pre-SCP patients (n = 100). Laparoscopic technique (62% versus 13%, P < 0.001), splenectomy (52% versus 38%, P = 0.117), and concomitant major organ resection (24% versus 13%, P = 0.106) were more common among SCP patients. Overall, important complication rates were similar (24% versus 26%, P = 0.842). SCP patients resumed a normal diet earlier (4 versus 5 d, P = 0.025) and had shorter HLOS (6 versus 7 d, P = 0.026). There was no increase in 30-d resurgery or readmission. In univariate comparison, SCP, cancer diagnoses, intraductal papillary mucinous neoplasm diagnoses, neoadjuvant therapy, operative technique, major organ resection, and feeding tube placement were associated with HLOS; however, after multivariable adjustment, only laparoscopic technique (−33%, P = 0.001), concomitant major organ resection (+38%, P < 0.001), and feeding tube placement (+68%, P < 0.001) were independent predictors of HLOS.

Conclusions

Implementation of a clinical pathway did not improve HLOS at our institution. The increasing use of laparoscopy likely accounts for shorter HLOS in the SCP cohort. In the future, it will be important to identify clinical scenarios most likely to benefit from implementation of a clinical pathway.     

Prognostic Value of Oxygen Consumption and Ventilatory Equivalent Slope in Female Candidates Referred for Heart Transplantation—Experience of a Single Asian Center

Background

Ventilatory equivalent (ventilation/CO₂ production, Ve/Vco₂) slope has been suggested to be a much more accurate predicator than peak oxygen consumption (Vo₂) during exercise for prognosis in patients with heart failure. However, patients tested were predominately male.

Methods

To investigate whether peak Vo₂ and Ve/Vco₂ slope predict the prognosis of female patients with heart failure, we retrospectively collected data of 39 female candidates referred for heart transplantation (HTx) from 2004 to 2011. Both peak Vo₂ and Ve/Vco₂ slope were obtained from the results of an exercise pulmonary function test. The outcome was death or mechanical devices implantation or HTx. Logistic regression was used for data analysis.

Results

Mean age and heart failure survival score were 55.8 ± 13.7 years and 7.3 ± 0.7, respectively. Each increment of Ve/Vco₂ slope decreased 2-year event-free rate (odds ratio [OR] = 0.88, 95% confidence interval [CI] = 0.79 to 0.98) in the female group. The predictions of Ve/Vco₂ slope for 1-year event-free survival did not reach statistical significance (OR = 0.92, 95% CI = 0.84 to 1.00). On the other hand, peak Vo₂ was not a strong predictor for 1- and 2-year event-free survival (OR = 1.22 and 1.16, 95% CI = 0.96 to 1.55 and 0.94 to 1.44, respectively).

Conclusions

Impairment in exercise ventilation holds a clinical and long-term prognostic impact in female patients with heart failure. The role of peak Vo₂ during exercise in prognostic prediction among the cohort should be further investigated.     

Age and gender differences in substance screening may underestimate injury severity: a study of 9793 patients at level 1 trauma center from 2006 to 2010

Background

Although the relationship between psychoactive substance use and injury is known, evidence remains conflicting on the impact of substance use on clinical outcomes after injury. We hypothesized that preinjury substance use would negatively impact clinical outcomes.

Methods

National Trauma Registry American College of Surgeons identified patients (n = 9793) presenting to Duke Hospital from 2006 to 2010. Logistic regression models assessed potential predictors of receiving substance screening, mortality, length of stay, ventilator requirement, intensive care admission, or emergency department disposition.

Results

Forty-seven percent (4607/9793) of patients received blood alcohol screen (BAS) and 31% (3017/9793) received urine drug screen (UDS). Men were more likely to receive both BASs (P < 0.001) and UDSs (P = 0.001) than women after controlling for potential confounders. There was no significant difference between men and women over the legal limit for alcohol (OLLA; 27.2%, 95% confidence interval [CI]: 25.7%–28.8% versus 24.8%, 95% CI: 22.3%–27.5%). Similarly, younger patients more likely received both BASs (P < 0.001) and UDSs (P < 0.001) compared with older patients. The proportion of patients aged ≤45 y OLLA (26.5 %, 95% CI: 24.9%–28.2%) was similar to those aged >45 y OLLA (26.8%, 95% CI: 24.5%–29.3%). After controlling for potential confounders neither alcohol, nor tetrahydrocannabinol, nor cocaine was predictive of mortality, ventilator requirement, length of stay, or emergency department disposition, but a higher alcohol level (P = 0.0174) predicted intensive care admission.

Conclusions

Females and those aged >45 y are less likely to receive BASs and UDSs. Differential screening that is biased may place patients at risk for receiving inadequate care.     

Elevated Preoperative Recipient Neutrophil-Lymphocyte Ratio Is Associated With Delayed Graft Function Following Kidney Transplantation

Introduction

The neutrophil-lymphocyte ratio (NLR) is an indicator of inflammatory status. We studied the effect of preoperative elevated NLR in the recipient in relation to the risk of developing delayed graft function (DGF) after kidney transplantation.

Methods

We retrospectively analysed the preoperative white blood cell count of renal transplant recipients between 2003 and 2005. An NLR >3.5 was considered elevated. There were 398 kidney transplant recipients of whom 249 received organs from donors after brain death (DBD), 61 from donors after circulatory death (DCD), and 88 from living donors.

Results

One hundred three patients (26%) developed DGF, of which 67 (65%) had NLRs >3.5. Of 295 recipients with primary graft function, only 44 (15%) had elevated NLR. Univariate analysis revealed three factors that significantly influenced graft function: NLR >3.5, cold ischemic time (CIT) >15 hours, and donor type. On multivariate analysis, both donor type (DCD: hazard ratio [HR] = 2.421, confidence interval [CI] = 1.195–4.905, P = .014; LD: HR = 0.289, CI = 0.099–0.846, P = .024) and NLR (HR = 10.673, CI = 6.151–18.518, P < .0001) remained significant.

Conclusions

Elevated recipient preoperative NLR could contribute to increase the risk of developing DGF, which appears to be more pronounced in patients receiving grafts from living donors.     

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

Impact of oxygen free radicals in rat partial liver transplantation

Background

Due to the shortage of suitable organs, the demand for partial liver transplantation from living donors has increased worldwide. N-acetylcysteine (NAC) has shown protective effects as a free radical scavenger during hypothermic preservation and warm ischemia–reperfusion liver injury; however, no study has reported the effects in partial liver transplantation. The aim of this study was to analyze the impact of NAC on liver graft microcirculation and graft function after partial liver transplantation in rats.

Methods

Orthotopic partial liver transplantations were performed in 40 rats following cold storage in histidine-tryptophan-ketoglutarate solution for 3 h with 20 mM NAC (NAC group, n = 20) or without (control group, n = 20). We assessed portal circulation, graft microcirculation, and biochemical analyses of plasma at 1, 3, 24, and 168 h after portal reperfusion.

Results

(Control versus NAC, median and range): Portal venous pressure was significantly lower with NAC (P = 0.03). Microcirculation measured by laser Doppler was significantly improved with NAC throughout the time course (P = 0.003). Alanine aminotransferase levels were significantly lower in the NAC group (P < 0.05). Total antioxidative capacity was significantly higher in the NAC group at 1 h after reperfusion (Trolox equivalents: median, 3 μM; range, 2.9–6.7 versus median, 16.45 μM; range, 10.4–18.8). Lipid peroxidation was significantly abrogated in the NAC group (median, 177.6 nmol/mL; range, 75.9–398.1 versus median, 71.5 nmol/mL; range, 58.5–79 at 3 h).

Conclusions

This study showed that NAC treatment during cold storage resulted in improved microcirculation and preservation quality of partial liver graft likely because of enhanced antioxidant capacity and reduced lipid peroxidation.     

Racial disparity in early graft failure after infrainguinal bypass

Background

Racial disparities have been shown to be associated with increasing health-care costs. We sought to identify racial disparities in 30-d graft failure rates after infrainguinal bypass in an effort to define targets for improved health care among minorities.

Methods

The 2005–2011 National Surgical Quality Improvement Program database was queried for patients with peripheral arterial disease who underwent infrainguinal bypass as their primary procedure. A bivariate analysis was done to assess pre and intraoperative risk factors across race (whites, blacks, and Hispanics). Multivariate logistic regression was performed to assess the independent association of race with 30-d graft failure.

Results

Of a total of 16,276 patients, 12,536 (77.0%) were whites, 2940 (18.1%) blacks, and 800 (4.9%) Hispanics. Black patients were more likely to be younger, female, current smokers, and on dialysis (P < 0.001, all). In addition, whites were less likely to present with critical limb ischemia compared with blacks and Hispanics (44.2 versus 55.4 versus 52.8%, respectively; P < 0.001). Similarly, fewer whites underwent femoral-tibial (31.4 vs. 34.7 vs. 38.6% respectively) or popliteal-tibial level bypasses (8.9 versus 13.4 versus 16.1%, respectively) than blacks and Hispanics (P < 0.001, all). There was no difference in the use of autogenous conduit across the groups (P = 0.266). Proportionally more blacks than whites developed early graft failure (6.7 versus 4.5%; P < 0.001) but there was no difference comparing Hispanics to whites (6.0 versus 4.5%; P = 0.057). On multivariable analysis, black race remained independently associated with early graft failure (adjusted odds ratio = 1.26, 95% confidence interval 1.05–1.51; P = 0.011).

Conclusions

More blacks and Hispanics present with critical limb ischemia, requiring distal revascularization. Even when controlling for anatomic differences and degree of peripheral arterial disease, black race remained independently associated with early graft failure after infrainguinal bypass. These results identify a target for improved outcomes.