The impact of peri‐operative blood transfusions on post‐pancreatectomy short‐term outcomes: an analysis from the American College of Surgeons National Surgical Quality Improvement Program

BackgroundPeri‐operative red blood cell transfusions (RBCT) may induce transfusion‐related immunomodulation and impact post‐operative recovery. This study examined the association between RBCT and post‐pancreatectomy morbidity.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP) registry, patients undergoing an elective pancreatectomy (2007–2012) were identified. Patients with missing data on key variables were excluded. Primary outcomes were 30‐day post‐operative major morbidity, mortality, and length of stay (LOS). Unadjusted and adjusted relative risks (RR) with a 95% confidence interval (95%CI) were computed using modified Poisson, logistic, or negative binomial regression, to estimate the association between RBCT and outcomes.ResultsThe database included 21 132 patients who had a pancreatectomy during the study period. Seventeen thousand five hundred and twenty‐three patients were included, and 4672 (26.7%) received RBCT. After adjustment for baseline and clinical characteristics, including comorbidities, malignant diagnosis, procedure and operative time, RBCT was independently associated with increased major morbidity (RR 1.49; 95% CI: 1.39–1.60), mortality (RR 2.19; 95%CI: 1.76–2.73) and LOS (RR 1.27; 95%CI 1.24–1.29).ConclusionPeri‐operative RBCT for a pancreatectomy was independently associated with worse short‐term outcomes and prolonged LOS. Future studies should focus on the impact of interventions to minimize the use of RBCT after an elective pancreatectomy.     

Early post‐operative prediction of morbidity and mortality after a major liver resection for colorectal metastases

BackgroundAn early prediction of poor outcomes is essential in the management of patients after a liver resection. The aim of this study was to evaluate the role of selected biochemical parameters on post‐operative day 1 (POD 1) in the prediction of morbidity and mortality after a liver resection for colorectal metastases.MethodThis retrospective study was based on 236 major liver resections for colorectal metastases performed between 2006 and 2011. Results of biochemical tests of blood samples obtained on POD 1 were assessed as predictors of primary outcome measures (hepatic and overall morbidity, 90‐day mortality) using multiple regression and receiver‐operating characteristics (ROC).ResultsHepatic morbidity, overall morbidity and 90‐day mortality rates were 18.6%, 28.0% and 4.7%, respectively. On the basis of multiple regression analysis and comparisons of the prediction models, serum bilirubin was selected for the prediction of hepatic (>2.05 mg/dl, sensitivity 69.2%, specificity 71.2%) and overall (>2.05 mg/dl, sensitivity 61.1% and specificity 71.2%) morbidity, and aspartate aminotransferase (AST) was selected for the prediction of 90‐day mortality (>798 U/l, sensitivity 62.5% and specificity 90.4%).DiscussionBiochemical analyses of blood on POD1 enables stratification of patients into low‐ and high‐risk groups for negative outcomes, with serum bilirubin associated with overall and hepatic morbidity and AST associated with mortality.     

The inhomogeneous distribution of liver function: possible impact on the prediction of post‐operative remnant liver function

BackgroundPrevious studies have shown that liver function is inhomogeneously distributed in diseased livers, and this uneven distribution cannot be compensated for if a global liver function test is used for the prediction of post‐operative remnant liver function. Dynamic Gd‐EOB‐DTPA‐enhanced magnetic resonance imaging (MRI) can assess segmental liver function, thus offering the possibility to overcome this problem.MethodsIn 10 patients with liver cirrhosis and 10 normal volunteers, the contribution of individual liver segments to total liver function and volume was calculated using dynamic Gd‐EOB‐DTPA‐enhanced MRI. Remnant liver function predictions using a segmental method and global assessment were compared for a simulated left hemihepatectomy. For the prediction based on segmental functional MRI assessment, the estimated function of the remnant liver segments was added.ResultsGlobal liver function assessment overestimated the remnant liver function in 9 out of 10 patients by as much as 9.3% [median −3.5% (−9.3–3.5%)]. In the normal volunteers there was a slight underestimation of remnant function in 9 out of 10 cases [median 1.07% (−0.7–2.5%)].DiscussionThe present study underlines the necessity of a segmental liver function test able to compensate for the non‐homogeneous nature of liver function, if the prediction of post‐operative remnant liver function is to be improved.     

Präoperative Risikobeurteilung bei Herzinsuffizienz

The primary target in preoperative risk evaluation is not to classify patients as operable or inoperable but rather to reduce perioperative morbidity and mortality. Indications for perioperative diagnostic and therapeutic procedures are mostly the same as for patients without subsequent non-cardiac surgery. However, the time schedule often depends on cofactors such as urgency and severity of surgical interventions. Perioperative risk management requires exceedingly good communication and collaboration between surgeons, anesthesiologists and internists and offers the chance to diagnose and treat perioperative risk factors in a justifiable time and cost context.     

Effect of D,L‐threo‐1‐phenyl‐2‐decanoylamino‐3‐morpholino‐1‐propanol and tetrandrine on the reversion of multidrug resistance in K562/A02 cells

Abstract

We studied the clinical impact of CD38 expression in 226 chronic lymphocytic leukemia patients (CLL) at disease presentation and during follow up to determine its prognostic significance, progression free survival (PFS) and overall survival (OS), and to verify whether this parameter changed over time. Various patients' characteristics were studied including gender, Rai and Binet stages, immunoglobulin light chain expression, lymphocyte doubling time and CD38 expression. After a median follow up of 53 months (range 6–282), 62% CD38 positive(+) patients required therapy. PFS and OS at 84 months were significantly lower for CD38(+) patients: 20 and 71% respectively, compared to CD38 negative(?): 70 and 96%. At multivariate analysis CD38(+) showed to be the best factor for predicting progression: HR 3·3, 95%CI 2·10–5·14, p = 0·000. Its expression did not change in 98% re-evaluated patients. We confirm that CD38(+) is a stable parameter for the identification of CLL patients with a more aggressive disease course.     

Does the placement of a cystic duct tube after a hepatic resection help reduce the incidence of post‐operative bile leak?

Background

In this retrospective study, the effects of cystic duct (C) tube use on the incidence of post-hepatectomy bile leak were assessed.

Methods

The subjects were 550 patients who underwent a hepatectomy during 1990–2011, with (n = 83) and without (n = 467) C tube drainage. The use of a C tube was based on the surgeon''s choice.

Results

Bile leakage was observed in 44 (8%) patients, and its incidence post-operatively correlated with intrahepatic cholangiocarcinoma, parenchymal transection with forceps fracture and tie, a major hepatectomy, prolonged surgery and excessive blood loss (P < 0.050) but not with the use of a C tube. The incidence of an intra-abdominal infection was higher and the hospital stay was longer in the leak (49 days) than non-leak group (21 days, P < 0.001). ISGLS grade B and C bile leak post-hemi-hepatectomy and extended-hepatectomy were more frequent in the non-C than C tube group (P = 0.016). The duration of hospitalization was not different between the two groups; however, 7 patients in the non-C tube group had prolonged hospitalization (> 60 days) compared with none in the C tube group (P = 0.454).

Conclusion

The usefulness of the C tube in preventing post-hepatectomy bile leak could not be confirmed; however, both bile leak requiring clinical management and long hospitalization after a major hepatectomy could be reduced with C tube use.     

Präoperative Kurzzeitbestrahlung beim tief sitzenden Rektumkarzinom

Background: Although some trials have shown a lower rate of local recurrences after preoperative irradiation rectal carcinoma, the indication for preoperative irradiation in resectable low rectal cancer, is discussed controversely. Patients and Methods: In this study a differentiated concept is demonstrated: patients with uT2-tumor received no preoperative adjuvant therapy, whereas patients with uT3-carcinoma received preoperative short-time irradiation with 25 Gy on 5 days. We present the results of 85 patients who underwent total mesorectal excision and colonic J-pouch-anal anastomosis between 01.07.1999 and 30.06.2001. Forty-seven patients with uT2-cancer underwent surgery alone and 38 had preoperative short-time irradiation. Primary stoma was constructed in 42 patients (surgery alone: 18 [39%], preoperative irradiation: 24 [63%]). In the surgery alone group two patients underwent relaparotomy and secondary stoma construction due to anastomotic dehiscence. Three female patients needed secondary stoma for rectovaginal fistulas. In the irradiation group two female patients received secondary stoma construction for rectovaginal fistulas. The overall rate of anastomotic complications with required reoperation was 9.9%. It was not higher in the patients with preoperative irradiation than in the surgery alone group. Results: The early functional results were slightly worse after preoperative irradiation. In follow-up only one anastomotic recurrence occurred in a patient without preoperative irradiation. Another patient developed a pT1-carcinoma in the pouch, which could be treated by transanal excision. Conclusion: From our point of view preoperative short-time irradiation is a good supplement in the therapy of uT3-tumors of the lower rectum. We did not observe negative influences on anastomotic healing or functional results. Because of the short follow-up time with a median of 23 months definitive statements concerning the rate of local recurrences have to be evaluated by former studies.     

Krebsbekämpfung,allgemeine und operative Therapie

Ohne Zusammenfassung     

Krebsbekämpfung,allgemeine und operative herapie

Ohne Zusammenfassung     

N‐Acetylcysteine Treatment Protects Against VEGF‐Receptor Blockade‐Related Emphysema

Administration of the VEGF receptor blocker SU5416 to rats causes alveolar septal cell apoptosis and emphysema; both can be prevented by a superoxide dismutase mimetic. Here we show that SU5416 induces the expression of heme oxygenase‐1 in the lung tissue and that administration of antioxidant N‐acetyl‐l‐cysteine protects alveolar septal cells against apoptosis, as demonstrated by caspase‐3 lung immunohistochemistry, and against emphysema.     

A Cost‐Effectiveness Analysis of a Peak Flow‐Based Asthma Education and Self‐Management Plan in a High‐Cost Population

Background. Asthma education and action plans (AP) have been recognized as important components in the optimal management of asthma. Studies have differed on the importance of a peak flow‐based self‐management plans in reducing health care costs and use due to asthma exacerbation. Objective. To analyze the cost‐effectiveness of peak flow‐based action plans in reducing costs associated with ER visits and hospitalizations due to acute asthma exacerbation in a population of high‐risk and high‐cost patients, defined as patients with moderate to severe asthma with a history of recent urgent treatment in the ER or hospitalization due to asthma. Methods. A literature review of randomized clinical trials comparing peak flow‐based (PFB) action plans, symptom‐based (SB) action plans, and usual care/no action plan (NAP) was performed. Probability values regarding the effectiveness of each alternative (as measured by increase/decrease in ER visits and hospitalizations over a 6‐month period) were derived. Incremental cost‐effectiveness and cost‐benefit ratios were calculated for each alternative. Sensitivity analyses were performed. Results. For high‐risk and high‐cost asthma patients, our analysis revealed that the most cost‐effective alternative for reducing ER visits was a peak flow‐based self‐management plan. The peak flow‐based self‐management program had an incremental cost‐effectiveness (C/E) ratio of $ 60.57 per ER visit averted compared to usual care/NAP and a C/E ratio of $31.46 compared to the SB‐AP. The PFB‐AP was also the most cost‐effective in reducing asthma hospitalization costs with an incremental C/E ratio of $300 per hospitalization prevented, compared with usual care and a C/E ratio of $311, compared to a SB‐AP. Analysis yielded a cost‐benefit ratio of 13.79 for the PFB‐AP compared to NAP; the SB‐AP had a cost‐benefit ratio of 11.53 compared to NAP. Conclusion. Cost‐effectiveness and cost‐benefit analyses reveal that for high‐cost patients, a peak flow‐based asthma education and self‐management plan program is the most cost‐effective alternative in reducing costs associated with ER visits and hospitalizations due to asthma exacerbation. Further refinements to this cost‐effectiveness analysis including measuring changes in drug use and costs and patients' productivity losses need to be pursued and may demonstrate additional cost‐savings due to peak flow‐based asthma education plans.     

Kinetics of liver function tests after a hepatectomy for colorectal liver metastases predict post‐operative liver failure as defined by the International Study Group for Liver Surgery

BackgroundPost‐hepatectomy liver failure (PHLF) has been defined by the International Study Group for Liver Surgery (ISGLS). The purpose of the present study was to examine the kinetics of conventional liver function tests (LFT) after a major liver resection and is the first to examine their utility in predicting PHLF in groups defined by the ISGLS.MethodsConsecutive patients undergoing a major liver resection for colorectal liver metastases were stratified into ISGLS groups and their LFT up to 1 year after surgery compared. Receiving‐operating characteristic (ROC) analysis of LFT identified optimal thresholds in predicting category C liver failure.ResultsIn total, 32, 22 and 19 patients belonged to ISGLS groups A, B and C, respectively. The median international normalized ratio (INR) and bilirubin values on post‐operative days 1, 3, 5 and 7 were significantly different among the groups (all P‐values <0.05). ROC analysis of day 1 INR (AUC 0.813) and day 5 bilirubin (AUC 0.798) revealed thresholds of 1.35 and 52 μmol/l to have sensitivities of 85% and 81% and specificities of 63% and 73%, respectively, to predict group C liver failure.DiscussionPost‐operative LFT after a major liver resection differs significantly among the three ISGLS groups. Thresholds of bilirubin and INR can be used to identify patients who are at a maximum risk of complications.     

The Short‐Term Effects and Unintended Long‐Term Consequences of Binge Drinking in College: A 10‐Year Follow‐Up Study

This study addresses binge drinking in college as a risk factor for heavy drinking and alcohol dependence after college. A national probability sample of 1972 college students from the National Longitudinal Surveys of Youth (NLSY79) was interviewed in 1984 and reinterviewed again as adults in 1994. The short‐term effects of binge drinking in college were assessed as well as the extent to which experiences of negative effects in college predicted patterns of alcohol use across the transition from college into postcollege years. As expected, college binge drinkers were comparatively more likely than nonbinge drinkers to experience one or more alcohol‐related problems while in college. In addition, weighted estimates of DSM‐IV‐defined diagnostic criteria in logistic regression models indicated that the binge drinking patterns exhibited during the college years, for some former college students of both genders, posed significant risk factors for alcohol dependence and abuse 10 years after the initial interview, in conjunction with evidence of academic attrition, early departure from college and less favorable labor market outcomes.     

What affects mortality after the operative management of hepatic abscess?

Background. Historically, the operative mortality associated with hepatic abscess was >50%. More recently, patients have been treated with percutaneous drainage; however, those failing conservative management are treated operatively. Our aim was to evaluate the outcome of operation for hepatic abscess in those failing conservative treatment or in those presenting as a surgical emergency. Patients and methods. This was a retrospective review of patients undergoing operation for hepatic abscess at the Mayo Clinic, Rochester, Minnesota from 1990 to 2003. Results. Of 288 patients diagnosed with hepatic abscesses, 32 required operation. Percutaneous drainage was the initial treatment in 15 (47%). The remaining 17 were initially managed with operation. Operative indication was septic shock (41%), failed nonoperative management (31%), and failure to make a diagnosis (28%). Operation was drainage (62%) or resection (38%). The morbidity and mortality rates were 41% and 15.6%, respectively. Factors associated with increased operative mortality were shock (p=0.04), INR > 1.5 (p=0.03), WBC >15 000 (p=0.04), AST > 150 U/L (p=0.01), alkaline phosphatase >500 U/L (p=0.03), positive blood cultures (p=0.03), total bilirubin >2.0 mg/dl (p<0.01), multiple abscesses (p=0.01), and second operation (p<0.001). Factors not associated were extent of resection (p>0.10), peritonitis (p>0.10), intensive care admission (p>0.10), polymicrobial infection (p>0.10), and blood transfusion (p>0.10). Conclusion. Operative intervention is avoided in 89% of patients with hepatic abscess. Septic shock is the most common reason for operation. Patients with septic shock, INR>1.5, WBC>15 000, AST>150 U/L, total bilirubin >2.0 mg/dl, positive blood cultures, or alkaline phosphatase >500 U/L have increased mortality when undergoing operation for hepatic abscess.     

Do preoperative pancreatic stents increase operative morbidity for chronic pancreatitis?

BACKGROUND/AIMS: Recent studies suggest that preoperative placement of bile duct stents increases morbidity after pancreatic surgery. The influence of pancreatic duct stenting on outcome after pancreatic surgery is unknown. METHODOLOGY: The records of 264 consecutive patients who underwent lateral pancreaticojejunostomy, pancreaticoduodenectomy, or distal pancreatectomy for chronic pancreatitis were retrospectively reviewed and analyzed. RESULTS: There were 137 patients who received preoperative endoscopic pancreatic stents. The remainder underwent preoperative ERCP without stent placement. Both groups had a similar stage of disease measured by endoscopic, clinical, and histological findings. The overall postoperative morbidity was higher in the stent group (19.7% vs. 42.3%, p<0.001, odds ratio 3.0). Intra-abdominal complications occurred more frequently in the stent group (10.2% vs. 32.8%, p<0.001), including a difference in pancreatic leaks. There was no difference in extra-abdominal complications (10.2% vs. 13.1%) and mortality (1.6% vs. 1.5%). CONCLUSIONS: Patients who undergo pancreatic duct stenting and require surgical drainage at a later point have a threefold increased risk for peri-operative complications. An increase in intra-abdominal complications might be related to stent associated pancreatic duct injuries, stent occlusion, and bacterial colonization of the stent.     

Pr?operative Evaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen

Medizin aktuell

Pr?operative Evaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen     

Präoperative Evaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen

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Pr?operative Evaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen     

Intravenous n‐acetylcysteine,ascorbic acid and selenium‐based anti‐oxidant therapy in severe acute pancreatitis

Background: To observe outcome in a cohort of patients with severe acute pancreatitis receiving multiple anti‐oxidant therapy. Methods: An observational study was carried out in 46 consecutive patients with acute pancreatitis fulfilling current Atlanta consensus criteria for severe disease. All patients received multiple anti‐oxidant therapy based on intravenous selenium, N‐acetylcysteine and ascorbic acid plus β‐carotene and α‐tocopherol delivered via nasogastric tube. Principal outcomes were the effect of anti‐oxidant supplementation on anti‐oxidant levels, morbidity and mortality in patients on anti‐oxidant therapy, case‐control analysis of observed survival compared to predicted survival derived from logistic organ dysfunction score (LODS), logistic regression analysis of factors influencing outcome and side effect profile of anti‐oxidant therapy. Results: Paired baseline and post‐supplementation data were available for 25 patients and revealed that anti‐oxidant supplementation restored vitamin C (P?=?0.003) and selenium (P?=?0.028) toward normal. In univariate survival analysis, patient survival to discharge was best predicted by admission APACHE‐II score with relative risk of death increasing 12.6% for each unit increase (95% CI 6.0% to 19.6%). The mean LODS calculated on admission to hospital was 3.7 (standard error of the mean 4.1) giving a predicted mortality for the cohort of 21%. The observed in‐hospital mortality was 43%. Conclusions: Case‐control analyses do not appear to demonstrate any benefit from the multiple anti‐oxidant combination of selenium, N‐acetylcysteine and ascorbic acid in severe acute pancreatitis.