Postoperative Aspartate Aminotransferase Levels Research Articles

Does the Absence of Contrast Passage Into the Duodenum During Intraoperative Cholangiogram Truly Predict Choledocholithiasis?

Background and AimsThe absence of contrast passage to the duodenum is frequently encountered during an intraoperative cholangiogram (IOC), and patients with this finding are suspected of having choledocholithiasis. This study was conducted to determine the positive predictive value (PPV) of the absence of contrast passage during IOC and identify predictors, if any, that increase the pretest probability of choledocholithiasis in these patients. MethodsAll laparoscopic cholecystectomies with IOCs between September 1, 2019, and September 1, 2021, at a tertiary medical center were reviewed to identify those with abnormal cholangiograms due to only the lack of contrast passage to the duodenum. Patient demographic information, pre- and postoperative laboratory results, and radiographic studies were recorded. Postprocedural clinical outcomes including endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) findings were tabulated to determine the presence of choledocholithiasis. Patient factors and outcomes were compared between a cohort that was found to have choledocholithiasis vs those who were not. Finally, multiple logistic regression was performed to identify predictors of choledocholithiasis. ResultsOf 320 IOCs, 31(9.7% of all abnormal IOCs) showed the lack of contrast passage in the duodenum as the only abnormality. The PPV of an IOC with the lack of contrast in the duodenum was 29%. Preoperative bilirubin levels, postoperative aspartate aminotransferase levels, and postoperative alanine transaminase levels were significant predictors of choledocholithiasis in this group of patients. ConclusionsThe lack of contrast passage to the duodenum as the sole finding of an abnormal IOC has poor PPV for choledocholithiasis. Thus, it is reasonable to consider using less invasive modalities such as EUS and/or magnetic resonance cholangiopancreatography before ERCP in these patients.

Meta-analysis of ischemic preconditioning (IP) on postoperative outcomes after liver resections.

Background:The protective role (decrease ischemia-reperfusion injury) of ischemic preconditioning (IP) before continuous vascular occlusion in liver resection is controversial. This meta-analysis aimed to compare the advantages and any potential disadvantages of IP maneuver.Methods:A systematic search in the Embase, Medline, PubMed databases, and the Cochrane Library was performed using both medical subject headings (MeSH) and truncated word searches to identify all randomized controlled trials (RCTs) published on this topic. The primary outcomes were postoperative morbidity, mortality, postoperative aspartate aminotransferase (AST) level, alanine aminotransferase (ALT) level, and total bilirubin (TB) level. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the random effects model or fixed effects model.Results:Thirteen RCTs involving 918 patients were analyzed to achieve a summated outcome. The patients have been divided into IP group (n = 455) and no IP group (n = 463) before continuous vascular occlusion. No significant difference was found in postoperative mortality between both groups (P = .30). Subgroup analysis revealed that the postoperative morbidity in the cirrhosis subgroup was significantly less for the IP group compared with the control group (P = .01). In the cirrhosis subgroup, the result was stable (P = .04), without heterogeneity (P = .59; I2 = 0%). Meta-analysis of AST level on postoperative day (POD) 1 indicated lower postoperative AST level in the IP group (P = .04). The analysis of ALT level showed lower ALT level in the IP group versus control group (P = .02). However, there was no difference in postoperative AST and ALT level after excluding 1 study with statistical heterogeneity (all P > .05). With respect to postoperative TB level, there was no significant difference between 2 groups.Conclusion:IP cannot decrease the hospital mortality for patients undergoing hepatectomy. IP may be beneficial for patients with cirrhosis due to less morbidity in patients with liver cirrhosis. However, we cannot conclude that IP can decrease ischemia-reperfusion injury because it did not significantly decrease postoperative AST, ALT, and TB levels.

Micro-RNA-208a, -208b, and -499 as Biomarkers for Myocardial Damage After Cardiac Surgery in Children.

To test the hypothesis that cardiac-enriched micro-RNAs can serve as accurate biomarkers that reflect myocardial injury and to predict the postoperative course following pediatric cardiac surgery. Micro-RNAs have emerged as plasma biomarkers for many pathologic states. We aimed to quantify preoperative and postoperative plasma levels of cardiac-enriched micro-RNA-208a, -208b, and -499 in children undergoing cardiac surgery and to evaluate correlations between their levels, the extent of myocardial damage, and the postoperative clinical course. PICU. Thirty pediatric patients that underwent open heart surgery for the correction of congenital heart defects between January 2012 to July 2013. None. At 12 hours post surgery, the plasma levels of the micro-RNAs increased by 300- to 4,000-fold. At 24 hours, their levels decreased but remained significantly higher than before surgery. Micro-RNA levels were associated with troponin levels, longer cardiopulmonary bypass and aortic crossclamp times, maximal postoperative aspartate aminotransferase levels, and delayed hospital discharge. Circulating micro-RNA-208a, -208b, and -499 are detectable in the plasma of children undergoing cardiac surgery and may serve as novel biomarkers for monitoring and forecasting postoperative myocardial injury and recovery.

Post-operative aspartate aminotransferase levels independently predict mortality after isolated coronary artery bypass grafting

BackgroundSince troponins have become widely available, the roles of other less specific biomarkers for myocardial necrosis following coronary artery bypass grafting (CABG) have been seldom studied. Aspartate aminotransferase (AST) may not only be released from the heart but also from the liver or skeletal muscle. We assessed whether post-operative AST levels were associated with mortality and morbidity after contemporary (CABG). MethodPatients undergoing isolated CABG during July 2010–June 2012 at Auckland City Hospital were included if they had a post-operative AST measurement within 48h (n=804 of 818). The prognostic utility of 2× upper limit of normal of AST (>90U/L) pre-specified for adverse outcomes was assessed. ResultsMedian post-operative AST level was 37U/L (lower quartile 30, upper quartile 48). In multivariable analysis, including baseline characteristics, AST >90U/L was independently associated with 30-day mortality (OR 12.0, 95% CI 2.99–47.9, P<0.001), long-term mortality (OR 12.0, 95% CI 1.69–34.8, P<0.001) and composite morbidity (OR 3.31, 95% CI 1.56–7.02, P=0.002). AST as a continuous parameter remained an independent predictor for 30-day and long-term mortality when hs-TnT was adjusted for but not for composite morbidity. Independent predictors of AST >90U/L included female sex, unstable angina and operation time. ConclusionIncrease in AST levels within 48 hours of CABG was a strong independent predictor of 30 day mortality. Although AST increase is not specific to myocardial necrosis, it remains useful for prognosis in cardiac surgery.

Prognostic value of post-operative aspartate aminotransferase levels after isolated coronary artery bypass grafting and isolated isolated aortic valve replacement

Prognostic value of post-operative aspartate aminotransferase levels after isolated coronary artery bypass grafting and isolated isolated aortic valve replacement

Selection and outcomes of living donors with a remnant volume less than 30% after right hepatectomy

The evidence for defining a safe minimal remnant volume after living donor hepatectomy is insufficient. The aim of this study was to evaluate the outcomes of living donors with a remnant/total volume ratio (RTVR) < 30% after right hepatectomy according to the following selection criteria: the preservation of the middle hepatic vein (MHV), an age < 50 years, and no or mild fatty changes in healthy adults. All living donors who underwent right hepatectomy preserving the MHV at our institution between January 2005 and September 2011 were divided into 2 groups: group A with an RTVR < 30% and group B with an RTVR ≥ 30%. Perioperative data, complications by the Clavien classification, and outcomes with at least 15.1 months' follow-up were compared. Twenty-eight donors were enrolled in group A, and 260 were enrolled in group B. The estimated liver volume was strongly correlated with the actual graft weight (R(2) = 0.608, P < 0.001). The calculated donation liver volume and the RTVR were significantly different between the 2 groups (P = 0.03 and P < 0.001, respectively). The peak postoperative aspartate aminotransferase levels, alanine aminotransferase levels, and international normalized ratios did not differ between the 2 groups. The peak total bilirubin level was higher for group A versus group B (P = 0.04). The hospital stay was longer for group A versus group B (P < 0.001). All donors recovered completely, and there were no significant differences in overall complications between the 2 groups. In conclusion, right hepatectomy preserving the MHV with an RTVR < 30% can be safely indicated for carefully selected living donors less than 50 years old with no or mild fatty changes.

Invited Commentary

Perioperative myocardial infarction (PMI) is an important determinant of mortality after coronary artery bypass grafting (CABG). By universal definitions, PMI is defined by an elevation of serum biomarker value more than fivefold the 99th percentile of the normal reference range in the first 72 hours following CABG along with electrocardiograph changes or angiographic evidence of native vessel or graft occlusion [1Thygesen K. Alpert J.S. White H.D. et al.Universal definition of myocardial infarction.Circulation. 2007; 116: 2634-2653Crossref PubMed Scopus (2110) Google Scholar]. Diagnostic criteria of PMI remain controversial in reported studies; the answer to which serum biomarker is most predictive of death after CABG, and the magnitude of rise of such a marker in blood, is a matter of debate. In this issue of The Annals of Thoracic Surgery, Dr van Boxtel and associates attempt to answer whether a noncardiac specific serum biomarker, aspartate aminotransferase (AST), can be regarded as a predictor of perioperative and late mortality in a retrospective study of 13,505 patients that have undergone isolated CABG in a single centre from January 1998 to December 2010 [2van Boxtel A.G.M. Bramer S. Hamad M.A.S. van Straten A.H.M. Perioperative serum aspartate aminotransferase level as a predictor of survival after coronary artery bypass grafting.Ann Thorac Surg. 2012; 94: 1492-1499Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. They arbitrarily divided postoperative AST levels into five incremental groups and obtained greater than 91% follow-up at a mean of 5.9 years. Their main findings were that AST was an independent predictor of all-cause early and late mortality, with a graded increase in the odds ratio of mortality amongst the five AST groups (unadjusted and adjusted). For late mortality, AST > 300 resulted in an adjusted hazard ratio (HR) equivalent to the HR of having severe preoperative left ventricular dysfunction (HR = 2.5). Furthermore, incremental increases in AST were associated with higher rates of PMI. The clinical significance in elevation of serum biomarkers after CABG is reflected by important publications in this topic over the past 40 years. Much focus has been on cardiac-specific biomarkers such as creatinine kinase myocardial band (CK-MB) and troponin. A recent metaanalysis (one of the largest to date) of 18,908 CABG patients showed a strong, graded independent association between elevation of CK-MB or troponin within the first 24 hours and early and intermediate mortality after CABG [3Domanski M.J. Mahaffey K. Hasselblad V. et al.Association of myocardial enzyme elevation and survival following coronary artery bypass graft surgery.JAMA. 2011; 305: 585-591Crossref PubMed Scopus (202) Google Scholar]. The metaanalysis showed that mortality rate doubles at a CK-MB ratio of 4.4. Another large metaanalysis of 29,483 patients showed that CK-MB release of fivefold to eightfold the upper limit of normal was associated with an increase risk of death for the next 40 months after CABG [4Petaja L. Salmenpera M. Pulkki K. et al.Biochemical injury markers and mortality after coronary artery bypass grafting: a systematic review.Ann Thorac Surg. 2009; 87: 1981-1992Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. These studies highlight the fact that such enzyme elevation perioperatively is prognostically important for early and longer-term mortality. Elevation in these biomarkers after CABG can occur in the absence of graft occlusion; such elevations may be due to regional or global myocardial ischemia from a variety of causes or from direct myocardial injury. Regardless of the cause, myocardial necrosis depicted by cardiac-specific enzymes is associated with worse prognosis. In this milieu, Dr van Boxtel and his team's investigation with serum AST, which is a noncardiac specific biomarker, speaks to the fact that a rise in AST, regardless of the presence of myocardial necrosis or infarction, is associated with worse outcomes after CABG. This study does not, however, answer two highly relevant questions, namely the comparative value of AST or the added value of AST in conjunction with other cardiac-specific biomarkers. Nonetheless, the authors should be congratulated for their rigorous work in bringing the spotlight back on this important yet understudied marker in cardiac surgery. Perioperative Serum Aspartate Aminotransferase Level as a Predictor of Survival After Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryVol. 94Issue 5PreviewElevated cardiac enzymes after coronary artery bypass grafting (CABG) surgery have been identified as a risk factor for worse postoperative outcome. Cardiac enzymes play an important role in the diagnosis of perioperative myocardial infarction. This study aims to investigate the predictive value of aspartate aminotransferase (AST) with respect to early and late mortality after CABG. Full-Text PDF

Postoperative Liver Dysfunction in Living Donors After Left-Sided Graft Hepatectomy: Portal Venous Occlusion of the Medial Segment After Lateral Segmentectomy and Hepatic Venous Congestion After Left Lobe Hepatectomy

BackgroundThe aim of this study was to evaluate how sacrifice of the portal vein and/or hepatic vein affects remnant liver dysfunction after lateral segmentectomy or left lobe hepatectomy. Materials and methodsAmong 130 patients who underwent donor hepatectomy between March 2002 and July 2011, we enrolled lateral segment (n = 15) and left lobe donors (n = 40). We evaluated the postoperative courses and the territory of venous obstruction or congestion based on the sacrificed portal vein or hepatic vein after the donor operation: lateral segment grafts (P4a, P4b, LV4) and left lobe grafts (MV5, MV8) according to the results analyzed by MeVis Distant Service. ResultsAmong lateral segment donors, the predicted sacrificed territory of portal vein and hepatic vein was 14.3% (7.3%–19.4%) in P4a + 4b: (P4a: 8.6%, P4b: 5.8%) and 2.9% (0%–8.4%) in LV4, respectively. On the other hand, in left lobe donors, the predicted congestive territory of the hepatic vein was 17.6% (2.8%–33.0%) in MV5 + 8 (7.8% in MV5 and 9.8% in MV8, respectively). The incidence of patients whose postoperative peak aspartate aminotransferase (AST) or alanine aminotransferase levels were higher than 500 IU/L was 20% in the lateral segment donors and 5% in the left lobe donors. The peak postoperative AST levels and territory of MV5 + 8 showed a significant positive correlation (R = 0.569, P < .05) among left lobe donors. ConclusionTerritories of P4 in lateral segment donors and MV5 + 8 in left lobe donors impacted postoperative liver dysfunction. It is important to recognize the precise territory of the portal vein and the hepatic vein before the donor operation.

Association between donor-recipient serum sodium differences and orthotopic liver transplant graft function

Previous studies have shown that donor hypernatremia and possibly recipient hyponatremia negatively impact graft function after orthotopic liver transplant (OLT). The purpose of this retrospective investigation was to determine whether measured differences in serum sodium values between cadaveric donors and OLT recipients (DeltaNa(+)) influence immediate postoperative allograft function and short-term patient outcomes. Two hundred and fifty patients that underwent OLT from January 2001 to December 2005 were included in this study. The DeltaNa(+) for each donor recipient pair was correlated with standard postoperative liver function tests as well as recipient length of intensive care unit stay (LOICUS), length of hospital stay (LOHS) and recipient survival. The relationship between donor hypernatremia (serum sodium >or= 155 mEq/mL), recipient hyponatremia (serum sodium level <or= 130 mEq/mL), and postoperative outcomes were analyzed as well. Adjustments were made for baseline potential confounders, including model for end-stage liver disease (MELD) score, preservation solution used (HTK vs. UW), recipient and donor demographics and cold ischemia time (CIT). DeltaNa(+) as well as donor hypernatremia and recipient hyponatremia were not found to be associated with immediate postoperative allograft function, intraoperative blood product usage, LOICUS, LOHS or short-term patient survival. However, both the preoperative MELD score and HTK preservation solution used were significantly associated with several patient outcomes. A higher MELD score was associated with both increased red blood cell (RBC) (P < 0.001) and fresh frozen plasma (FFP) usage (P = 0.002), elevated postoperative total bilirubin levels (P < 0.001), increased LOHS (P = 0.04), and a higher 30-day post transplant mortality (P = 0.02). The use of HTK preservation solution was associated with higher mean postoperative aspartate aminotransferase levels (P = 0.02) and decreased mean RBC (P < 0.001) and FFP usage (P = 0.009) compared to UW preservation solution use.

Complement activation after ischemia-reperfusion in human liver allografts: Incidence and pathophysiological relevance

BACKGROUND & AIMS: Little is known about the occurrence and possible consequences of local complement activation in human liver transplantation. The aim of this study was to search for signs of complement activation in human liver allografts and evaluate their relationship to cell injury and leukocyte sequestration.METHODS: In 33 postreperfusion biopsy specimens, 9 preoperative specimens, and 10 intraoperative specimens, the cytolytic membrane attack complex of complement was localized, expression of complement inhibitors was evaluated, and intragraft accumulation of leukocytes and platelets was quantitated.RESULTS: In control samples and preoperative biopsy specimens, the membrane attack complex was detected only in extracellular deposits, associated with its soluble inhibitors clusterin and vitronectin. Comparable observations were performed in 14 postoperative specimens. In the remaining 19 postoperative specimens, membrane attack complex decorated a variable proportion of hepatocytes. The extent of membrane attack complex deposition correlated with the increase in postoperative aspartate aminotransferase levels in serum (P = 0.002) and the decrease in postoperative factor V levels in serum (P = 0.002). It also correlated with the number of leukocytes and platelets accumulating within the graft (P < or = 0.001).CONCLUSIONS: Local complement activation is frequent during human liver transplantation and probably contributes to cell injury and leukocyte sequestration in the allograft.(Gastroenterology 1997 Mar;112(3):908-18)