Preoperative Ascites Research Articles

Development of a nomogram to predict outcome after liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis

Treatment allocation in patients with hepatocellular carcinoma (HCC) on a background of Child-Pugh B (CP-B) cirrhosis is controversial. Liver resection has been proposed in small series with acceptable outcomes, but data are limited. The aim of this study was to evaluate the outcomes of patients undergoing liver resection for HCC in CP-B cirrhosis, focusing on the surgical risks and survival. Patients were retrospectively pooled from 14 international referral centers from 2002 to 2017. Postoperative and oncological outcomes were investigated. Prediction models for surgical risks, disease-free survival and overall survival were constructed. A total of 253 patients were included, of whom 57.3% of patients had a preoperative platelet count <100,000/mm3, 43.5% had preoperative ascites, and 56.9% had portal hypertension. A minor hepatectomy was most commonly performed (84.6%) and 122 (48.2%) were operated on by minimally invasive surgery (MIS). Ninety-day mortality was 4.3% with 6 patients (2.3%) dying from liver failure. One hundred and eight patients (42.7%) experienced complications, of which the most common was ascites (37.5%). Patients undergoing major hepatectomies had higher 90-day mortality (10.3% vs. 3.3%; p = 0.04) and morbidity rates (69.2% vs. 37.9%; p <0.001). Patients undergoing an open hepatectomy had higher morbidity (52.7% vs. 31.9%; p = 0.001) than those undergoing MIS. A prediction model for surgical risk was constructed (https://childb.shinyapps.io/morbidity/). The 5-year overall survival rate was 47%, and 56.9% of patients experienced recurrence. Prediction models for overall survival (https://childb.shinyapps.io/survival/) and disease-free survival (https://childb.shinyapps.io/DFsurvival/) were constructed. Liver resection should be considered for patients with HCC and CP-B cirrhosis after careful selection according to patient characteristics, tumor pattern and liver function, while aiming to minimize surgical stress. An estimation of the surgical risk and survival advantage may be helpful in treatment allocation, eventually improving postoperative morbidity and achieving safe oncological outcomes. Liver resection for hepatocellular carcinoma in advanced cirrhosis (Child-Pugh B score) is associated with a high rate of postoperative complications. However, due to the limited therapeutic alternatives in this setting, recent studies have shown promising results after accurate patient selection. In our international multicenter study, we provide 3 clinical models to predict postoperative surgical risks and long-term survival following liver resection, with the aim of improving treatment allocation and eventually clinical outcomes.

Impact of Graft Quality and Fluid Overload on Postoperative Massive Ascites After Living Donor Liver Transplantation

After living donor liver transplantation, we encounter cases with massive ascites, which is difficult to manage. We analyzed the risk factors for massive ascites after living donor liver transplantation.The subjects were 100 adult recipients who underwent living donor liver transplantation at Kyoto University Hospital from 2013 to 2017. We retrospectively assessed patient, graft, operative factors, and percent fluid overload, which were defined as [(weight on the day – preoperative weight)/preoperative weight] × 100%. We defined the massive ascites group as having a14-day average ascites ≥ 2500 mL and the mild ascites group as having a 14-day average ascites < 2500 mL.Forty-seven patients were included in the massive group, and 53 patients were included in the mild group. There was no difference in short- and long-term survival. In multivariate analysis, the presence of preoperative ascites (P = .0008), 14-day average percent fluid overload ≥ 14.5% (P = .0095), graft-to-recipient weight ratio < 0.86 (P = .0253), and donors’ age ≥ 47 years (P = .0466) were identified as independent risk factors for massive ascites after living donor liver transplantation. A liver graft with a small graft-to-recipient weight ratio or from an elderly donor, which may indicate poor graft quality, presence of preoperative ascites, and postoperative fluid overload were associated with massive ascites after living donor liver transplantation.

Heart Transplantation Outcomes in Liver Cirrhosis: Influence of Ascites on Post-Transplantation Survival

Purpose Liver cirrhosis has been implicated in poor outcome after heart transplant. However, no distinct correlation has been known between pre-existing ascites and outcomes after heart transplantation. Methods From 1994 to 2018, 170 patients with advanced heart failure underwent heart transplantation. Abdominal sonography or CT was performed to assess ascites in 163 patients preoperatively. Among them, 49 patients (30.0%) had visualized ascites and enrolled in this study. We divided them into two groups [group A; mild ascites (n=35), B; moderate to massive ascites (n=14)] and compared the clinical outcomes. Results In this cohort (19 men and 30 women, mean age 41, range 12-68 years), the causes of heart failure were dilated cardiomyopathy (DCMP) in 29 patients (59.2%), ischemic CMP in 7 patients (14.3%), valvular disease in 7 patients (14.3%) and congenital heart disease in 6 patients (12.4%). There was no difference in baseline characteristics between groups, except preoperative ascites points (group A: 1.20±0.19 vs. group B: 2.29 ± 0.46; p=0.001). Calculating scoring systems related to liver disease, MELD score was 11.73 vs. 12.4 (p=0.517), MELD-XI score was 12.9 vs. 13.7 (p=0.205) and Child-pugh score was 6.2 vs. 7.3 (p=0.843). The mean duration of follow up was 38.8 ± 42.5 months. After transplantation, ascites points were significant improved in group B (2.29 ± 0.46 to 1.74 ± 0.81, p=0.003). The 1, 2, 5 and 10-year survival rates were 82.8% vs 74.3%, 78.4% vs 74.3%, 74.6% vs 74.3% and 74.6% vs 74.3%, respectively, and the survival rates was significant lower until 2 years in group B than A (p=0.035). However, there was no difference after 2 years (p=0.793). Cox-regression analysis showed a moderate to massive ascites was associated with an increased risk of all-cause death after transplantation (p Conclusion Liver cirrhosis with moderate to severe ascites affected worse overall survival until 2 years after heart transplantation.

Magnetic resonance imaging findings for discriminating clear cell carcinoma and endometrioid carcinoma of the ovary

BackgroundCommon cancerous histological types associated with endometriosis are clear cell carcinoma (CCC) and endometrioid carcinoma (EC). CCC is regarded as an aggressive, chemoresistant histological subtype. Magnetic resonance imaging (MRI) offers some potential advantages to diagnose ovarian tumors compared with ultrasonography or computed tomography. This study aimed to identify MRI features that can be used to differentiate between CCC and EC.MethodsWe searched medical records of patients with ovarian cancers who underwent surgical treatment at Nara Medical University Hospital between January 2008 and September 2018; we identified 98 patients with CCC or EC who had undergone preoperative MRI. Contrasted MRI scans were performed less than 2 months before surgery. Patients were excluded from the study if they had no pathology, other pathological subtype of epithelial ovarian cancer, and/or salvage treatment for recurrence and metastatic ovarian cancer at the time of study initiation. Clinically relevant variables that were statistically significant by univariate analysis were selected for subsequent multivariate regression analysis to identify independent factors to distinguish CCC from EC.ResultsMRI of CCC and EC showed a large cystic heterogeneous mixed mass with mural nodules protruding into the cystic space. Univariate logistic regression analysis revealed that the growth pattern (broad-based nodular structures [multifocal/concentric sign] or polypoid structures [focal/eccentric sign]), surface irregularity (a smooth/regular surface or a rough/irregular/lobulated surface), “Width” of mural nodule, “Height-to-Width” ratio (HWR), and presence of preoperative ascites were factors that significantly differed between CCC and EC. In the multivariate logistic regression analysis, the growth pattern of the mural nodule (odds ratio [OR] = 0.69, 95% confidence interval [CI]: 0.013–0.273, p = 0.0004) and the HWR (OR = 3.71, 95% CI: 1.128–13.438, p = 0.036) were independent predictors to distinguish CCC from EC.ConclusionsIn conclusion, MRI data showed that the growth pattern of mural nodules and the HWR were independent factors that could allow differentiation between CCC and EC. This finding may be helpful to predict patient prognosis before operation.

Preoperative Ascites Predicts Right Ventricular Failure post-LVAD Implantation

Introduction Preoperative cardiac ascites has been shown to be a predictor of mortality in the latest INTERMACS report. However, it has not been shown to be an independent risk factor for the development of RVF after LVAD implantation. Hypothesis Pre-operative ascites on imaging during implant admission is associated with post-operative RVF. Methods We performed a single-center retrospective study of 153 patients who received a continuous-flow durable LVAD between 1/2006 and 12/2016 and who also had preoperative abdominal ultrasound or CT aduring implant admission. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started 14 days after implant, RVAD implant, and death from RVF. The severity of ascites was extracted from the radiology reports and was graded as either none/trace, mild, moderate, or severe. A multivariate analysis of pre-operative ascites stratified by severity and post-implant RVF was performed. Results In our 153 patient cohort, 43 (28.1%) were found to have significant ascites, with 35 (22.9%) having mild ascites, 8 (5.6%) having moderate ascites, and 0 having severe ascites. Patients with ascites had higher preoperative total bilirubin, lower platelet count, higher mean RA pressure, higher mean PA pressure, lower pulmonary artery pulsatility index (PAPi), higher PCWP, and higher mortality rate, p Table 1 ). The multivariable model (which included age, INTERMACS level, creatinine, gender, and total bilirubin) found that preoperative ascites (OR 1.98, 95% CI [1.02 - 3.81], p = 0.04) and total bilirubin (OR 1.50, 95% CI [1.07 - 2.10], p = 0.018) were independent predictors of post-implant RVF. The ROC curve of ascites and post-operative RVF had a c-statistic of 0.72 ( Figure 1 ). Conclusion The preoperative presence of ascites correlates with post-operative RVF. Abdominal imaging could be useful in further risk stratifying patients for post-implant RVF.

Potential risk factors associated with prognosis of neoadjuvant chemotherapy followed by interval debulking surgery in stage IIIc-IV high-grade serous ovarian carcinoma patients.

No consensus has been achieved on the prognostic factors for patients with advanced stage epithelial ovarian cancer who underwent neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS). This study aimed to investigate the prognostic factors for the patients diagnosed as International Federation of Gynecology and Obstetrics stage IIIc-IV high-grade serous ovarian cancer (HG-SOC). A total of 200 patients histologically diagnosed as IIIc-IV stage HG-SOC were retrospectively analyzed. All patients underwent platinum-NAC followed by IDS treatment between January 2003 and December 2013. The potential predictive factors (including preoperative ascites volume, cancer antigen 125 [CA-125] and CA-125 decreasing kinetics, NAC and adjuvant chemotherapy cycle number as well as tumor characteristics) for optimal cytoreduction by IDS and for progression free survival (PFS) and overall survival (OS) were assessed. Optimal cytoreduction by IDS was achieved in 78% of HG-SOC patients who underwent NAC. The median number of NAC cycle was 3 (range 1-8). No ascites regression (P < 0.01, odds ratio [OR] = 2.28, 95% confidence interval [CI]: 1.41-3.69), and worse CA-125 decreasing kinetics (P < 0.01, OR = 2.01, 95% CI: 1.37-2.93) were independent predictive factors for suboptimal cytoreduction by IDS. Multivariate regression analysis revealed that PFS and OS were independently associated with preoperative ascites (P < 0.01, hazard ratio [HR] = 2.13, 95% CI: 1.38-3.28 and P < 0.01, HR = 2.33, 95% CI: 1.27-4.26, respectively) and CA-125 decreasing kinetics (P = 0.01, HR = 1.10, 95% CI: 1.02-1.18 and P < 0.01, HR = 1.22, 95% CI: 1.08-1.37, respectively). PFS of patients who underwent more than four NAC cycles was shorter than those of patients who received four or less number of NAC cycles; however, no difference was observed for OS. Ascites regression and CA-125 decreasing kinetics were independently associated with the optimal cytoreduction rate and survival of patients diagnosed with advanced stage HG-SOC and treated with NAC/IDS.

Intraoperative Portal Vein Flow > 123 mL/min Per 100 g Predicts a Better Survival of Patients After Liver Transplantation

ObjectiveTo assess the importance of intraoperative portal vein flow measurement during liver transplantation in relation to postoperative complications and graft and patient survival. Materials and methodsRetrospective review including 291 patients who had all the information and covering a period of 10 years (2007–2017). Using a receiver operating characteristic curve, a cut-off point that would have the greatest impact on the probability of being alive at 5 years was established. In relation to this value, 2 groups were formed (low and high flow) and demographic variables, intraoperative variables, postoperative complications, and graft and patient survival were compared. ResultsA portal flow of 123 mL/min per100 g of liver tissue was established (area under the curve = 0.58), obtaining a low-flow (n = 129) and a high-flow group (n = 162). The 2 groups were similar in their preoperative characteristics, except for a higher proportion of preoperative ascites, a higher Model for End-Stage Liver Disease score and a lower weight of donors in the high-flow group. The arterial and portal flows were significantly higher in the high-flow group. In the postoperative period, the high-flow group presented a higher rate of ascites. The 5-year survival rate of patients was significantly higher in the high-flow group (76% vs 84%, P = .03). ConclusionsPatients undergoing liver transplantation with an intraoperative portal vein flow measurement >123 mL/min per 100 g present a greater 5-year survival rate.

Ablation approach for primary liver tumors: Peri-operative outcomes.

Ablation is a common treatment modality for malignant primary liver tumors(PLTs), outcomes following laparoscopic (LA) versus open ablation (OA) are ill-defined. This project compares peri-procedural outcomes of LA versus OA for PLTs. Patients with PLTs undergoing radiofrequency ablation were queried from ACS NSQIP Database (2005-2013) using CPT codes. Patients undergoing percutaneous ablation or hepatic resection were excluded. Multivariable logistic regression analyses determined the association of ablation approach with 30-day morbidity and mortality. Of 5747 with PLTs, 655 (11.4%) ablations were identified: 177 (27.0%) underwent OA, 478 (73.0%) underwent LA. Patients undergoing LA had lower mortality (1.9% vs 5.1%, P = 0.026), lower minor morbidity (2.3% vs 5.7%, P = 0.031), and lower major morbidity (4.2% vs 17.0%, P < 0.001). Adjusting for demographics, disease-specific variables (preoperative ascites, total bilirubin, platelet count, albumin, and INR), 30-day mortality (OR 3.85, 95%CI: 1.38-10.80, P = 0.010), minor morbidity (OR 2.98, 95%CI: 1.16-7.67, P = 0.024), and major morbidity (OR 4.59 95%CI: 2.41-8.76, P < 0.001) were statistically lower in LA. OA demonstrated increased length of stay(LOS) (5 vs 2 days, P < 0.001), and longer operative time (152 vs 112 min, P < 0.001). LA offers decreased peri-procedural morbidity, mortality, and reduced LOS. LA should be the preferred method for hepatic ablation.

Early infections in the intensive care unit after liver transplantation-etiology and risk factors: A single-center experience.

Infectious complications represent one of the main causes of perioperative morbidity and mortality of liver transplant recipients. The primary objective of this retrospective observational study was to evaluate incidence and etiology of early (within 1month from surgery and occurring in the intensive care unit [ICU]) postoperative infections as well as donor- and recipient-related risk factors. The data of 280 patients undergoing 299 consecutive liver transplant procedures from January 2012 to December 2015 were extracted from the Italian ICU registry database and hospital registries. Perioperative risk factors, etiology of infections, and antibiotic susceptibility of isolated microorganisms were taken into consideration. Global incidence of postoperative infections was 21%. Pneumonia was the most frequent infection and, globally, gram-negative bacteria were the most common agents. Septic shock was present in 22% of infection cases and hospital mortality was higher in patients with postoperative infection. Preoperative chronic obstructive pulmonary disease, malnutrition, preoperative ascites, encephalopathy, and early re-transplantation were significantly associated to post orthotopic LT infections. Infections represent a major cause of early postoperative morbidity and mortality. The impact of single risk factors and the results of their preoperative management should be further investigated in order to reduce the incidence and evolution of postoperative infections.

Relationship between duration of preoperative symptoms and postoperative ileus for small bowel obstruction

BackgroundFactors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population. Materials and methodsWe performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups. ResultsSixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P < 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: −0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization. ConclusionsOur findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.

Prognostic factors for the outcome of Kasai portoenterostomy for infants with biliary atresia in Egypt

Background Biliary atresia (BA) is the most common surgically correctable liver disorder in the pediatric age group. If untreated, progressive liver cirrhosis leads to death by the age of 2 years. Aim The aim was to study the outcome of Kasai portoenterostomy for infants with BA in Egypt and identify some prognostic factors of this outcome. Patients and methods A prospective clinical and laboratory study including 20 patients with BA who underwent Kasai operation was conducted. A detailed history taking, clinical examination, liver function tests, ultrasound of the abdomen, preoperative liver biopsy, and intraoperative cholangiography were done for all patients. Patients were followed up for a period of 6 months postoperatively. The schedule and indications for liver transplantation were also evaluated. Results Overall, 55% of operated infants showed gradual reduction of serum bilirubin, which reached a level less than 2 mg/dl, as well as reduction of liver enzymes. On the contrary, the remaining 45% of infants failed to show satisfactory reduction of serum bilirubin, which continued to be greater than 2 mg/dl as well as liver enzymes. Both groups showed statistically significant differences regarding age at operation, presence of preoperative ascites, liver size, and patients’ Child–Pugh score. Moreover, preoperative total serum bilirubin and its direct fraction, liver enzymes, and cholestatic enzymes were significantly higher among infants with a bad outcome. There were no mortalities within the 6-month follow-up period. Conclusion Kasai portoenterostomy showed better results with short-term follow-up if done at an early age. Certain preoperative clinical, laboratory, radiological, and pathological factors might predict the outcome of Kasai operation.

Standardization of intensive therapy tactics for acute hepatic insufficiency in patients with liver cirrhosis after portosystem shunting

Here we analyze efficiency of the algorithm for intensive therapy of acute hepatic insufficiency in patients with cirrhosis after portosystemic shunting, based on the experience of the Republican Specialized Scientific and Practical Medical Center of Surgery named after academician V.V. Vakhidov and considering recommendations of the world's leading hepatology schools. Algorithm efficiency was analyzed based on the results of portosystemic shunting of 556 patients with cirrhosis and acute liver insufficiency. Treatment effectiveness was assessed by presence and severity of postoperative complications, such as hepatic insufficiency and hepatic encephalopathy. Initial decompensation of liver cirrhosis significantly increases the risk of postoperative complications of portosystemic shunting due to edematous ascites syndrome - liver insufficiency (13.5% vs 6.9% in patients without ascites p≥0.05) and hepatic encephalopathy (64.9% vs. 51,7%, respectively, p≥0.05). In group of patients with preoperative ascites syndrome mortality rate was 3.8% (10 patients) and in the group without ascites - 2.3% (6 patients). The main cause of early postoperative lethality was anastomotic thrombosis development with recurrence of bleeding from esophagus and stomach varicose veins. To reduce the risk of postoperative complications and lethality, a therapeutic-tactical algorithm was developed which was effective in combination with a complex of conservative and biophysical methods of treatment and aimed at eliminating the 'resolving factors' of their developmen. One of the most important components of this algorithm is pharmacotherapy with hepatoprotective drugs use in patients with liver cirrhosis in the postoperative period to maintain liver functional state. Considering the antihypoxic, detoxifying and antioxidant properties of active components of remaxol and revealed positive effect of its use in patients (decrease in bilirubin level, increase in albumin fraction of total blood protein and decrease in activity of ALAT and ASAT in 2 times), this drug can be recommended for inclusion in the postoperative pathogenetic standard therapy in this category of patients.

Immunostaining Study on the Expression of NF-κB, ER, and PR in Ovarian Serous Carcinoma.

In order to explore whether NF-κB activation correlates to the prognosis, chemoresistance, and sex hormone receptors status in ovarian serous carcinoma, we analyzed the expression of NF-κB, ER, and PR by immunohistochemistry in 72 cases of ovarian serous carcinoma, investigated the association among these markers, and evaluated their relations to clinicopathologic factors and prognosis. The positive rates were 88.9% for NF-κB cytoplasmic expression, 45.8% for NF-κB nuclear expression, 41.7% for ER, and 29.2% for PR. NF-κB nuclear expression was positively correlated with the 4th edition WHO grade (P=0.045) and tumor stage (P=0.001). NF-κB cytoplasmic expression was associated with preoperative serum CA125 level (P=0.015) and ascites (P=0.042). Neither cytoplasmic nor nuclear staining of NF-κB showed any association with survival. PR expression was correlated with tumor stage (P=0.023) and omental metastasis (P=0.022). Omental metastasis occurred more frequently in ER-/PR- tumors (P=0.009). No correlation between NF-κB expression and ER, PR expression was observed. In conclusion, in ovarian serous carcinoma, NF-κB nuclear expression correlated with the 4th edition WHO grade and PR was a favorable prognostic factor for ovarian serous carcinoma.

Behavior and clinical impact of ascites after living donor liver transplantation: risk factors associated with massive ascites.

Massive ascites after living donor liver transplantation (LDLT), defined as small-for-size graft syndrome, is a risk factor for a poor prognosis. Few studies have reported factors associated with ascites and the relevant outcome after LDLT. Data from 413 adult patients that underwent LDLT were retrospectively analyzed. Recipient age, preoperative albumin level, Child-Pugh score, preoperative ascites, graft volume, intraoperative blood loss, and duration of warm ischemic time and the anhepatic phase were significantly associated with the total amount of ascites between postoperative day (POD) 1 and POD14. Multivariate analysis identified preoperative ascites, intraoperative blood loss, and duration of anhepatic phase as factors. Massive ascites (ascitic fluid discharge >1,000ml/day on POD14 after LDLT) occurred in 200 (48.4%) patients, and mild ascites occurred in the remaining 213 patients. Daily changes in the ascites volume differed between the two groups. Nevertheless, massive ascites itself did not have a critical impact on the patient short- and long-term outcomes when properly managed with rigorous diuretics and albumin administration. Massive ascites is frequent after LDLT; however, the impact of it could be minimized with an appropriate management.

30-day mortality after elective colorectal surgery can reasonably be predicted.

The aim of the present study was to develop a clinically relevant, accurate and usable risk assessment scoring system solely for colorectal cancer patients undergoing elective resection. All colorectal resections for colorectal cancer 2006-2012 were identified from the American College of Surgeons Quality Improvement Program. Independent risk factors for 30-day mortality after elective surgery were identified using univariable and multivariable logistic regression. A points-calculator based on factors most strongly associated with mortality and accurately predicting risk of mortality was developed. Fifty-nine thousand nine hundred eighty-six patients underwent elective colorectal cancer surgery, and 1096 (1.8%) died within 30days. On multivariable analysis, the strongest risk factors for mortality were age ≥65years [odds ratio (OR) 2.17, 95% confidence interval (CI) 1.61-2.92], American Society of Anesthesiologists score ≥3 (OR 1.77, 95% CI 1.29-2.42), renal failure (OR 3.15, 95% CI 1.01-9.77), disseminated cancer (OR 2.56, 95% CI 1.96-3.35), hypoalbuminemia (OR 2.84, 95% CI 2.21-3.65), preoperative ascites (OR 3.17, 95% CI 2.07-4.87), heart failure (OR 2.08, 95% CI 1.35-3.20) and functional status (OR 2.05, 95% CI 1.56-2.70). A model that accurately predicted risk of mortality was created using forward stepwise logistic regression and externally validated (area under the curve 0.826). This allowed for development of an eight-factor predictive score; maximum points conferred mortality of 96.1% (p<0.0001). A simple preoperative scoring system predicting 30-day mortality with good capability may allow better preoperative risk assessment, optimization and decision-making.

Incidence and risk factors for early renal dysfunction after liver transplantation.

To determine renal dysfunction post liver transplantation, its incidence and risk factors in patients from a Belgian University Hospital. Orthotopic liver transplantations performed from January 2006 until September 2012 were retrospectively reviewed (n = 187). Patients with no renal replacement therapy (RRT) before transplantation were classified into four groups according to their highest creatinine plasma level during the first postoperative week. The first group had a peak creatinine level below 12 mg/L, the second group between 12 and 20 mg/L, the third group between 20 and 35 mg/L, and the fourth above 35 mg/L. In addition, patients who needed RRT during the first week after transplantation were also classified into the fourth group. Perioperative parameters were recorded as risk factors, namely age, sex, body mass index (BMI), length of preoperative hospital stay, prior bacterial infection within one month, preoperative ascites, preoperative treatment with β-blocker, angiotensin-converting enzyme inhibitor or non steroidal anti-inflammatory drugs, preoperative creatinine and bilirubin levels, donor status (cardiac death or brain death), postoperative lactate level, need for intraoperative vasopressive drugs, surgical revision, mechanical ventilation for more than 24 h, postoperative bilirubin and transaminase peak levels, postoperative hemoglobin level, amount of perioperative blood transfusions and type of immunosuppression. Univariate and multivariate analysis were performed using logistic ordinal regression method. Post hoc analysis of the hemostatic agent used was also done. There were 78 patients in group 1 (41.7%), 46 in group 2 (24.6%), 38 in group 3 (20.3%) and 25 in group 4 (13.4%). Twenty patients required RRT: 13 (7%) during the first week after transplantation. Using univariate analysis, the severity of renal dysfunction was correlated with presence of ascites and prior bacterial infection, preoperative bilirubin, urea and creatinine level, need for surgical revision, use of vasopressor, postoperative mechanical ventilation, postoperative bilirubin and urea, aspartate aminotransferase (ASAT), and hemoglobin levels and the need for transfusion. The multivariate analysis showed that BMI (OR = 1.1, P = 0.004), preoperative creatinine level (OR = 11.1, P < 0.0001), use of vasopressor (OR = 3.31, P = 0.0002), maximal postoperative bilirubin level (OR = 1.44, P = 0.044) and minimal postoperative hemoglobin level (OR = 0.059, P = 0.0005) were independent predictors of early post-liver transplantation renal dysfunction. Neither donor status nor ASAT levels had significant impact on early postoperative renal dysfunction in multivariate analysis. Absence of renal dysfunction (group 1) was also predicted by the intraoperative hemostatic agent used, independently of the extent of bleeding and of the preoperative creatinine level. More than half of receivers experienced some degree of early renal dysfunction after liver transplantation. Main predictors were preoperative renal dysfunction, postoperative anemia and vasopressor requirement.

Risk factors of postoperative ascites on hepatic resection for hepatocellular carcinoma.

Backgrounds/AimsThe aim of this study was to identify the risk factors of the development of large amounts of ascites (LA) after hepatic resection for hepatocellular carcinoma (HCC).MethodsThe medical records of 137 consecutive patients who underwent hepatic resection for HCC from January 2010 to December 2014 were retrospectively reviewed. Patients were divided into two groups: LA group, with ascites drainage >500 cc per day over 3 days (n=37) and control group (n=100). Preoperative and intraoperative clinical variables were compared between the two groups.ResultsThirty-seven (27.0%) patients developed LA. Platelet counts of <100,000/mm3, ICG-R15 >10%, CTP scores of 6 or 7 points, major resection, the presence of cirrhosis, preoperative ascites, and portal hypertension were significantly more frequent in LA group. Multivariate analysis revealed that a higher CTP score (HR=4.1), the presence of portal hypertension (HR=26.7), and major resection (HR=18.5) were independent and significant risk factors of postoperative ascites development. Persistent refractory ascites developed in 6 (16.2%) patients who succumbed to hepatic failure during follow-up.ConclusionsPatients with a 6 or 7 point CTP score, major hepatic resection and/or portal hypertension were more likely to develop LA and experience deterioration of liver function after surgery. The selection of patients for hepatic resection should be based on a balanced assessment of the benefits of HCC treatment and risk of postoperative liver failure.

Effects of ascites on outcomes of colorectal surgery in congestive heart failure patients

BackgroundThere are limited data regarding the effects of ascites on outcome of patients undergoing colorectal resection. We sought to identify complications related to ascites. MethodsThe National Surgical Quality Improvement Program database was used to evaluate congestive heart failure (CHF) patients who had ascites before colorectal resection between 2005 and 2012. Multivariate regression analysis was performed to identify affected outcomes. ResultsWe sampled a total of 2,178 patients who suffered CHF and underwent colorectal resection, of which 195 (9%) had preoperative ascites. The mortality rate of patients who had preoperative ascites was 46.2% compared to 25.7% for patients without ascites (adjusted odd ratio [AOR], 3.38; P < .01). Complications affected by ascites include (P < .05) ventilator dependency (AOR, 2.40), acute renal failure (AOR, 2.18), and wound disruption (AOR, 2.44; P < .05). There was no increase in superficial surgical site infection rate in patients with ascites (AOR, 1.01; P = .9). ConclusionsThe presence of ascites in CHF patients is associated with increased mortality in patients undergoing colorectal surgery. There is no correlation between ascites and surgical site infection but wound disruption increases in the presence of ascites.

Selection criteria for combined resection of synchronous colorectal cancer hepatic metastases: a cautionary note

Combined resection of primary colorectal cancer and synchronous hepatic metastases has been shown to be safe and associated with acceptable oncologic outcomes in selected patients. The purpose of this study was to determine if selection criteria for combined resection could be identified using major morbidity or mortality as an avoidable outcome. We queried the American College of Surgeons National Surgery Quality Improvement Program dataset from 2005 to 2010 for combined liver and colorectal resections for colorectal cancer using procedure and diagnosis codes. These patients were compared to colorectal cancer patients receiving colectomy alone and patients receiving liver-directed surgery for secondary liver cancer. During the study period, 1,641 (53.1 %) of patients underwent colectomy alone, 1,113 (36 %) underwent liver-directed surgery alone, and 334 (10.9 %) underwent combined colectomy and liver-directed surgery for colorectal cancer. The combined patient population had statistically significant increases in American Society of Anesthesiologists class, preoperative ascites, preoperative systemic inflammatory response syndrome/sepsis, weight loss, functional dependence, and decreased serum albumin compared to the other cohorts. While major hepatectomy was less frequent in the combined cohort, the rate of rectal resection was similar to the colectomy-alone cohort. These selection disparities resulted in a subsequent increase in composite major morbidity, return to operating room, infectious complications, and length of stay in combined patients. While combined resection in patients with synchronous colorectal cancer hepatic metastases may be feasible, it is associated with considerable increase in morbidity without application of stringent selection criteria. We recommend only patients without known risk factors for perioperative morbidity and infectious complications be considered for this approach.

Factors Associated with Need for Drainage of Pleural Effusion after Diaphragm Surgery

Background: Diaphragm surgery is common with advanced ovarian malignancies. The purpose of this study is to determine associated factors with the need for drainage of pleural effusion after diaphragm surgery. Methods and Materials: A retrospective chart review was undertaken in all women undergoing debulking surgery for stage IIIc/IV ovarian cancer from 2007-2009. Results: One hundred and eight patients were found to be eligible for the study, but 73 were the primary focus of this paper due to having undergone debulking surgery, including diaphragmatic surgery, from 2007-2009. All 73 had ablation with the argon beam coagulator, 7 had a full thickness resection, and 7 had extensive peritoneal peel. Five patients had preoperative effusions. Only 7 patients required chest drainage postoperatively. Pre-operative ascites correlated closely with postoperative effusion (p-value = 0.031) but not with drainage (p-value = 0.068). The mean age of patients requiring drainage was significantly older (73 years) than that of patients who did not require drainage (60 years) (p-value = 0.002). Conclusion: Older patients undergoing diaphragm surgery are more likely to require chest tube or thoracentesis due to concurrent symptoms. Pre-operative ascites correlates closely with the development of postoperative effusion after diaphragm surgery.