Preoperative Bilirubin Level Research Articles

Mo1355 - Surgical Outcomes and Prognostic Factors in Patients with Hilar Cholangiocarcinoma' Radical Resection and Preoperative Bilirubin Level were Independent Prognostic Factors of Tumor Recurrence and Overall Survival Rate

Mo1355 - Surgical Outcomes and Prognostic Factors in Patients with Hilar Cholangiocarcinoma' Radical Resection and Preoperative Bilirubin Level were Independent Prognostic Factors of Tumor Recurrence and Overall Survival Rate

Use of a pancreatic fistula risk score system for patients with clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy

Objective To study the use of a preoperative predictive scoring system established by the Beth Israel Deaconess Medical Center, Washington University School of Medicine and Hospital of the University of Pennsylvania for patients with clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy. Methods The clinical data of 394 patients who underwent pancreaticoduodenectomy at the Provincial Hospital Affiliated to Anhui Medical University from September 2007 to December 2015 were retrospectively analyzed. The four indexes including the gland texture, pathology, pancreatic duct diameter and intraoperative blood loss were calculated for the predictive score system using the logistic regression test. The factors associated with CR-POPF were analyzed. The sensitivity and specificity of the predictive scoring system were determined by the receiver operating characteristic (ROC) curve analysis. Results Of the 70 patients who were diagnosed to have postoperative pancreatic fistula (POPF), 34 were CR-POPF, which included 36 with grade A, 23 with grade B and 11 with grade C. Univariate analysis showed that male, preoperative serum total bilirubin level ≥170 mmol/L, pancreatitis or pancreatic cancer, portal vein invasion, soft pancreatic texture, main pancreatic duct diameter ≤3 mm, and pancreaticojejunostomy were significantly related to POPF after pancreaticoduodenectomy (P<0.05). Portal vein invasion, pancreatic texture and main pancreatic duct diameter were the risk factors of CR-POPF after pancreaticoduodenectomy (P<0.05). Multivariate analysis showed the independent risk factors associated with POPF were male, preoperative serum total bilirubin level ≥170 mmol/L, soft pancreatic texture and main pancreatic duct diameter ≤3 mm (P<0.05), while soft pancreatic texture and main pancreatic duct diameter ≤3 mm were the independent risk factors of CR-POPF (P<0.05). There were significant differences in the clinical relevant postoperative pancreatic fistula rates among the negligible risk, low risk, intermediate risk, and high risk patients with CR-POPF (P<0.05). The results of ROC curve analysis showed that the sensitivity and specificity of the Fistula Risk Scoring system were 76.5% and 95.8%, respectively. The nomogram showed the area under the curve was 0.913 (95%CI: 0.858~0.968). Conclusion The preoperative predictive scoring system accurately predicted the occurrence of CR-POPF. Key words: Pancreatic fistula risk score; Pancreaticoduodenectomy; Pancreatic fistula; Prediction

Does Hyperbilirubinemia Contribute to Adverse Patient Outcomes Following Pancreatoduodenectomy?

BackgroundJaundice due to biliary obstruction leads to multiple physiologic derangements and a decline in performance status that may result in unfavorable intra- and postoperative outcomes following a Whipple procedure. While preoperative biliary decompression may improve synthetic function, this strategy has been reported to increase the incidence of infectious complications following surgery. We hypothesized that hyperbilirubinemia at the time of pancreatoduodenectomy (PD) would be a risk factor for increased morbidity and mortality postoperatively. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pancreatectomy Demonstration Project and the 2014 Procedure Targeted Pancreatectomy databases were queried for patients with a bilirubin level obtained within 7 days of PD. Results were compared among patients with bilirubin level percentiles <80th (0–2.9 mg/dL), 80–90th (3–7.3 mg/dL), and >90th (>7.3 mg/dL). Data were further evaluated between those with a bilirubin ≥10 mg/dL and those with a normal level and by utilizing bilirubin as a continuous variable. Outcomes included 30-day mortality and overall and serious morbidity as previously defined by ACS-NSQIP. Categorical variables were compared using chi-squared, Fisher’s exact, Kruskal-Wallis, or Wilcoxon rank sum tests with a p = 0.05 considered significant. ResultsThe combined databases yielded 2556 patients who had PD and a preoperative bilirubin level for analysis. When comparing patients with bilirubin levels at the 80th (n = 2055), 80–90th (n = 273), and >90th percentiles (n = 228), no difference was observed among groups with respect to overall and serious morbidity or mortality. Similarly, no difference in postoperative outcomes was observed between the 147 patients who had a bilirubin ≥10 mg/dL and those with normal levels or when bilirubin increased when levels were analyzed as a continuous variable. ConclusionModest degrees of hyperbilirubinemia were not shown to affect morbidity and mortality following pancreatoduodenectomy. The indication and need for preoperative biliary decompression should be reserved, and utilized selectively, only for those with symptomatic, elevated bilirubin levels.

Value of preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy: A case–control study

The potential benefit of preoperative biliary drainage (PBD) on postoperative outcomes remains controversial. The aim of this study was to elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with PBD and to show the impact of bilirubin level. We retrospectively studied all patients who underwent PD in our center between January 2003 and June 2015. Patients were divided into: Group A (PBD) and Group B (no PBD). The primary outcome was the rate of postoperative complication. A total of 588 cases underwent PD. Group A included 314 (53.4%) patients while Group B included 274 (46.6%) patients. The overall incidence of complications and its severity were higher in Group A (p=0.03 and p=0.02). There was significant difference in the incidence of postoperative pancreatic fistula (p=0.002), delayed gastric emptying (p=0.005), biliary leakage (p=0.04), abdominal collection (p=0.04), and wound infection (p=0.04) in Group A. The mean length of hospital stay was significantly longer in Group A than in Group B (12.86±7.65days vs. 11.05±7.98days, p=0.01). No significant impact of preoperative bilirubin level on surgical outcome was detected. PBD before PD was associated with major postoperative complications and stent-related complications.

Meta-analysis of risk factors of delayed gastric emptying after pancreaticoduodenectomy

Objective To investigate the risk factors of delayed gastric emptying (DGE) after pancreaticoduodenectomy, in order to provide a theoretical basis for prevention and treatment of this complication. Methods The term DGE was searched in Pubmed, Medline, EMBASE, Cochrane Library, CNKI, Wanfang, and published literatures were collected to determine the risk factors of DGE after pancreaticoduodenectomy. The Review Manager 5.3 software was used in the analysis. Results A total of 52 articles were included. The results of Meta-analysis showed that age and preoperative bilirubin levels did not significantly influence the incidence of DGE. Preoperative cholangitis (OR=3.39, 95%CI 1.97~5.82), hypoalbuminemia (OR=2.53, 95%CI 1.59~4.02), and intraoperative blood loss of more than 1L (OR=1.98, 95%CI 1.18~3.33) significantly increased the incidence of DGE. Pyloric resection (RR=2.06, 95% CI 1.05~4.05), antecolic reconstruction (RR=0.74, 95%CI 0.56~0.99) and Braun enteroenterostomy (OR=0.36, 95%CI 0.17~0.77) significantly decreased the risk of DGE. When compared with Roux-en-Y enteroenterostomy, Billroth Ⅱ enteroenterostomy reduced the incidence of clinically relevant DGE (RR=0.30, 95%CI 0.11~0.79). Postoperative pancreatic fistula (OR=3.84, 95%CI 2.71~5.44) and intra-abdominal infection/abscess (OR=3.95, 95%CI 2.87~5.43) were significantly associated with a high incidence of DGE. Conclusions Hypoalbuminemia, cholangitis, large blood loss, and postoperative abdominal complications were the risk factors of DGE. Pyloric resection, antecolic reconstruction, Billroth Ⅱ enteroenterostomy, and Braun enteroenterostomy significantly reduced the incidence of DGE. Subgroup analysis showed that differences on DGE definition in studies might be an important cause for the heterogeneity in the results of the different studies. Key words: Pancreaticoduodenectomy; Delayed gastric emptying; Meta-analysis

Predictive Risk Factors in the Development of Intraoperative Hyperkalemia in Adult Living Donor Liver Transplantation

BackgroundHyperkalemia, defined as a serum potassium level higher than 5 mEq/L, is common in the liver transplantation setting. Severe hyperkalemia may induce fatal cardiac arrhythmias; therefore, it should be monitored and treated accordingly. The aim of the current retrospective study is to evaluate and indentify the predictive risk factors of hyperkalemia during living-donor liver transplantation (LDLT). Methods and PatientsFour hundred eighty-seven adult LDLT patients were included in the study. Intraoperative serum potassium levels were monitored at least five times during LDLT; patients with a potassium level higher than 5 mEq/L were included in group 1, and the others with normokalemia in group 2. Patients' categorical characteristics and intraoperative numeric variables with a P value <.1 were selected into a multiple binary logistic regression model. In multivariate analysis, a P value of <.05 is regarded as a risk factor in the development of hyperkalemia. ResultsFifty-one of 487 (10.4%) patients had hyperkalemia with a serum potassium level higher than 5.0 mEq/L during LDLT. Predictive factors with P < .1 in univariate analysis (Table 1), such as anesthesia time, preoperative albumin level, Model for End-stage Liver Disease score, preoperative bilirubin level, amount of blood loss, red blood cell (RBC) and fresh frozen plasma transfused, 5% albumin administered, hemoglobin at the end of surgery, and the amount of furosemide used, were further analyzed by multivariate binary regression. Results show that the anesthesia time, preoperative serum albumin level, and RBC count are determinant risk factors in the development of the hyperkalemia in our LDLT serials. ConclusionProlonged anesthesia time, preoperative serum albumin level, and intraoperative RBC transfusion are three determinant factors in the development of intraoperative hyperkalemia, and close monitoring of serum potassium levels in patients with abovementioned risk factors are recommended.

Value of Preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy: a case-control study

Introduction: The potential benefit of the preoperative biliary drainage (PBD) on postoperative outcomes remains controversial. The aim of this study was to elucidate surgical outcomes of pancreatoduodenectomy (PD) in patients with PBD and to show the impact of preoperative bilirubin level. Method: We retrospectively studied all patients who underwent PD in our center between January 2000 and June 2014. Group A (patients with PBD) and Group B (patients with non-PBD). The primary outcome was the rate of postoperative complications and their severity. Results: A total number of 588 cases underwent PD. Group A included 314 (53.4%) patients while group B included 274 (46.6%) patients. The overall incidence of complications and its severity were higher in PBD group (P = 0.03 and 0.02). There was significant difference in the incidence of postoperative pancreatic fistula (P = 0.002), delayed gastric emptying (P = 0.005), biliary leakage (P = 0.04), abdominal collection (P = 0.04) and wound infection (P = 0.04) in PBD group. The mean length of hospital stay was significantly longer in PBD group than in non PBD group (12.86 ± 7.65 days vs 11.05 ± 7.98 days, P = 0.01). No significant impact of preoperative bilirubin level on surgical outcome. Conclusions: PBD before PD was associated with major postoperative complications and stent related complications.

Gallbladder cancer presenting with jaundice: Uniformly fatal or still potentially curable?

336 Background: The prognosis of patients with gallbladder cancer (GBC) who present with jaundice has historically been considered dismal, however recent Eastern literature has demonstrated that surgical resection can be associated with long-term survival. The objective of this study was to utilize a contemporary, Western, multi-institutional dataset to examine the prognostic significance of preoperative jaundice on short- and long-term outcomes after GBC resection. Methods: Patients with GBC managed surgically from 2000 to 2015 in 10 academic institutions participating in the U.S. Extrahepatic Biliary Malignancy Consortium were stratified based on the presence of preoperative jaundice (bilirubin &gt; 3 mg/ml or requiring preoperative biliary drainage). Postoperative morbidity, mortality, and overall survival were compared. Results: Of 449 patients with GBC evaluated for resection, 301 (67%) eventually underwent curative-intent resection. Resectability for cure was much lower in patients with preoperative jaundice (48% vs. 79%, p &lt; 0.001). Of 273 patients who underwent curative-intent resection and had available preoperative bilirubin levels, 53 (19%) had preoperative jaundice and were noted to have tumors of T3/4 stage (63% vs 42%, P = 0.008), with lymph node metastasis (63% vs. 41%; p = 0.014), lymphovascular invasion (68% vs 39%; p = 0.003), and R1 margins (37 vs. 9%; p &lt; 0.001). Patients with jaundice more commonly required CBD (55% vs 32%, P = 0.004), major liver (25% vs. 7%; p &lt; 0.001) and portal vein resection (8% vs. 0.5%; p = 0.006), as well as intraoperative blood transfusion (29 % vs. 11%; p = 0.002). Overall morbidity (57% vs. 38%; p = 0.031) and in-hospital mortality (7.5% vs. 1.4%; p = 0.029) rates were higher in patients with jaundice. Overall survival after curative-intent resection was worse in patients with jaundice (median 12 vs 33 months; p &lt; 0.001). Conclusions: Half of GBC patients presenting with jaundice are not resectable for cure and when they are, their 5-year survival is 12%. These patients should not be excluded from multidisciplinary treatment strategies that include surgery, however expectations should be clearly set and selection should be cautious.

Effect of preoperative bilirubin on outcomes of completely resected hilar cholangiocarcinoma: A multi-institutional analysis.

326 Background: Perioperative and long-term outcomes of patients with Hilar cholangiocarcinoma (HC) and preoperative hyperbilirubinemia have not been clearly defined. Methods: Patients with HC undergoing hepatectomy with a complete (R0/R1) resection between 2000 and 2014 were identified within a 10-institution prospectively maintained database. Using receiver operating characteristic curves from logistic regression models, a peak bilirubin cutoff point that minimized the difference between the sensitivity and specificity, was determined. Factors affecting perioperative complications were estimated using logistic regression. Results: 191 of 328 (58.2%) patients who underwent complete resection with a hepatectomy, with available preoperative bilirubin data were analyzed. 37.2% (n = 71) had bilirubin &gt; 7.9. Patients with higher preoperative bilirubin were more likely to have a higher CA 19-9 (1776±3721.5 vs 302.1±518.6, p = 0.0006), more comorbidities (1.6±0.8 vs 1.4±0.9; p = 0.002), preoperative biliary drainage (PBD) (91.4% vs 75.6%, p = 0.007), positive lymph nodes (48.5% vs 31.5%, p = 0.025) and perioperative death (14.5% vs 5.2%, p = 0.0292). Multivariate analysis identified PBD (OR 3.2, CI 1.4-7.5; p = 0.008) and smoking (OR 2.3, CI 1.2-4.4; p = 0.016) to be independent predictors of any and major complications. Peak bilirubin &gt; 7.9 (OR 3.1, CI 1.1-8.9; p = 0.04) and preoperative systemic sepsis (PSS) (OR 5.0, CI 1.2-21.5; p = 0.03) were associated with increased risk of postoperative mortality. However, on multivariate analysis only PSS was significant (OR 14.4, CI 2.2-93.9; p = 0.005); 5/13 (23.1%) of patients with PSS died within 30 days after surgery. Conclusions: PSS portends increased operative mortality in HC patients undergoing hepatectomy, independent of preoperative peak bilirubin levels. Prevention and aggressive treatment of PSS should be the priority in the preoperative optimization of these patients.

Risk factors of morbidity and predictors of long-term survival after hepatopancreatoduodenectomy for biliary cancer.

Hepatopancreatoduodenectomy (HPD) is performed to achieve radical resection of malignant biliary tumors. We reviewed clinical outcomes to evaluate the utility of HPD in terms of morbidity and mortality. A retrospective analysis was conducted on 17 patients underwent HPD between August 1991 and May 2013; 9 bile duct cancer, 5 advanced gallbladder and 3 pancreatic tumor with liver metastasis. The morbidity and mortality rates were 88.3% and 0%, respectively. Univariate analysis showed that a body mass index of ≥22 and preoperative total bilirubin level ≥0.8 mg/dl were significantly associated with severe complications. One-, 3- and 5-year survival rate were 73.3%, 60.0% and 30.0%. In 14 patients with biliary carcinoma, univariate analysis showed that a histological grade of G1 was significantly associated with survival. Patients without pancreatic invasion or portal vein invasion tended to survive longer than patients with these types of invasion, although the difference was not significant. HPD can be performed with no mortality and provides a survival benefit for some patients with biliary carcinoma undergoing curative resection. In patients with grade G1 biliary carcinoma without pancreatic or portal vein invasion in particular, this aggressive surgery might offer a chance of long-term survival.

Clinical study on acute pancreatitis associated with pancreatectomy in 10 cases

Studies reporting on function after pancreatic surgery are frequently based on diabetes history, fasting glycemia or random glycemia. The aim of this study was to investigate prospectively the evolution of pancreatic function in patients undergoing pancreaticoduodenectomy based on proper pre- and postoperative function tests. It was hypothesised that pancreatic function deteriorates after pancreaticoduodenectomy.Between 2013 and 2016, 78 patients undergoing pancreaticoduodenectomy for oncologic indications had a prospective evaluation of their endocrine and exocrine pancreatic function. Endocrine function was evaluated with the 75 g oral glucose tolerance test (OGTT) and the 1 mg intravenous glucagon test. Exocrine function was evaluated with a 13C-labelled mixed-triglyceride breath test. Tests were performed pre- and postoperatively.In 90.5% (19/21) of patients with preoperatively known diabetes, no change in endocrine function was observed. In contrast, endocrine function improved in 68.1% (15/22) of patients with newly diagnosed diabetes. 40% (14/35) of patients with a preoperative normal OGTT or prediabetes experienced deterioration in function. In multivariate analysis, improvement of newly diagnosed diabetes was correlated with preoperative bilirubin levels (p = 0.045), while progression towards diabetes was correlated with preoperative C-peptidogenic index T30 (p = 0.037).A total of 20.5% (16/78) of patients had pancreatic exocrine insufficiency preoperatively. Another 51.3% (40/78) of patients deteriorated on exocrine level. In total, 64.1% (50/78) of patients required pancreatic enzyme-replacement therapy postoperatively.Although deterioration of endocrine function was expected after pancreatic resection, improvement is frequently observed in patients with newly diagnosed diabetes. Exocrine function deteriorates after pancreaticoduodenectomy.

The functional state of the pancreas in patients with type 2 diabetes mellitus

Studies reporting on function after pancreatic surgery are frequently based on diabetes history, fasting glycemia or random glycemia. The aim of this study was to investigate prospectively the evolution of pancreatic function in patients undergoing pancreaticoduodenectomy based on proper pre- and postoperative function tests. It was hypothesised that pancreatic function deteriorates after pancreaticoduodenectomy.Between 2013 and 2016, 78 patients undergoing pancreaticoduodenectomy for oncologic indications had a prospective evaluation of their endocrine and exocrine pancreatic function. Endocrine function was evaluated with the 75 g oral glucose tolerance test (OGTT) and the 1 mg intravenous glucagon test. Exocrine function was evaluated with a 13C-labelled mixed-triglyceride breath test. Tests were performed pre- and postoperatively.In 90.5% (19/21) of patients with preoperatively known diabetes, no change in endocrine function was observed. In contrast, endocrine function improved in 68.1% (15/22) of patients with newly diagnosed diabetes. 40% (14/35) of patients with a preoperative normal OGTT or prediabetes experienced deterioration in function. In multivariate analysis, improvement of newly diagnosed diabetes was correlated with preoperative bilirubin levels (p = 0.045), while progression towards diabetes was correlated with preoperative C-peptidogenic index T30 (p = 0.037).A total of 20.5% (16/78) of patients had pancreatic exocrine insufficiency preoperatively. Another 51.3% (40/78) of patients deteriorated on exocrine level. In total, 64.1% (50/78) of patients required pancreatic enzyme-replacement therapy postoperatively.Although deterioration of endocrine function was expected after pancreatic resection, improvement is frequently observed in patients with newly diagnosed diabetes. Exocrine function deteriorates after pancreaticoduodenectomy.

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.

Hyperbilirubinemia after cardiac surgery: An observational study.

We aimed to assess the incidence and perioperative risk factors for hyperbilirubinemia after cardiac surgery, and determine its influence on early operative outcome. This prospective observational study was conducted on 476 patients who underwent cardiac surgical procedures from January 2014 to March 2014. Postoperative hyperbilirubinemia was defined as serum total bilirubin >2.0 mg dL(-1). The overall incidence of postoperative hyperbilirubinemia was 25% (119 patients). Patients undergoing valve repair or replacement had the highest incidence of hyperbilirubinemia (36.2%), followed by coronary artery bypass grafting with concomitant valve surgery (34.1%), congenital heart surgery (23.1%), and coronary artery bypass alone (12.7%). Postoperative hyperbilirubinemia was associated with increased duration of inotropic support (p = 0.0001), mechanical ventilation (p = 0.0001), intensive care unit stay (p = 0.001), hospital stay (p = 0.006), and mortality (p = 0.014). The perioperative factors associated with postoperative hyperbilirubinemia were increased preoperative bilirubin level (p < 0.0001), preoperative prothrombin time (p < 0.0001), cardiopulmonary bypass time (p = 0.028), aortic crossclamp time (p = 0.004), and blood transfusion units (p = 0.0001). Postoperative hyperbilirubinemia is common in patients undergoing cardiopulmonary bypass and is associated with high hospital mortality. The factors associated with its occurrence are increased preoperative bilirubin level, preoperative prothrombin time, cardiopulmonary bypass time, aortic crossclamp time, and blood transfusion units. Persistent hyperbilirubinemia is associated with a worse outcome than early transient hyperbilirubinemia.

Preoperative predictors and outcomes of right ventricular assist device implantation after continuous-flow left ventricular assist device implantation

ObjectiveThe outcomes of ventricular assist device therapy remain limited by right ventricular failure. We sought to define the predictors and evaluate the outcomes of right ventricular failure requiring right ventricular assist device support after long-term continuous-flow left ventricular assist device implantation. MethodsRecords of all continuous-flow left ventricular assist device recipients for the last 10 years were analyzed, including patients on preoperative intra-aortic balloon pump, extracorporeal membrane oxygenation, and short-term ventricular assist device support. Perioperative clinical, echocardiographic, hemodynamic, and laboratory data of continuous-flow left ventricular assist device recipients requiring right ventricular assist device support (right ventricular assist device group) were compared with the rest of the patient cohort (control group). ResultsBetween July 2003 and June 2013, 152 patients underwent continuous-flow left ventricular assist device implantation as a bridge to transplantation. The overall postoperative incidence of right ventricular assist device support was 23.02% (n = 35). Right ventricular assist device implantation did not significantly affect eventual transplantation (P = .784) or longer-term survival (P = .870). Preoperative right ventricular diameter (P < .001), tricuspid annular plane systolic excursion (P < .001), previous sternotomy (P = .002), preoperative short-term mechanical support (P = .005), left atrial diameter (P = .014), female gender (P = .020), age (P = .027), and preoperative bilirubin levels (P = .031) were univariate predictors of right ventricular assist device implantation. Multivariate analysis revealed lesser tricuspid annular plane systolic excursion (P = .013; odds ratio, 0.613; 95% confidence interval, 0.417-0.901) and smaller left atrial diameter (P = .007; odds ratio, 0.818; 95% confidence interval, 0.707-0.947) as independent predictors of right ventricular assist device implantation. Receiver operating characteristic curve of tricuspid annular plane systolic excursion yielded an area under the curve of 0.85 (95% confidence interval, 0.781-0.923), with cutoff tricuspid annular plane systolic excursion less than 12.5 mm having 84% sensitivity and 75% specificity. ConclusionsLesser tricuspid annular plane systolic excursion and smaller left atrial diameter are independent predictors of the need for right ventricular assist device support after continuous-flow left ventricular assist device implantation. Right ventricular assist device implantation does not adversely affect eventual transplantation or survival after continuous-flow left ventricular assist device implantation.

High preoperative bilirubin values protect against reperfusion injury after live donor liver transplantation.

Heme Oxygenase-1 and its product biliverdin/bilirubin have been demonstrated to protect against ischemia/reperfusion injury (IRI). We investigated whether increased preoperative bilirubin values of transplant recipients decrease IRI. Preoperative bilirubin levels of live donor liver recipients were correlated to postoperative liver transaminase as a marker of IRI. Additionally, two recipient groups with pretransplant bilirubin levels >24μmol/l (n=348) and ≤24μmol/l (n=118) were compared. Post-transplant liver function, complications, length of hospital stay, and patient and graft survival were assessed. Preoperative bilirubin levels were negatively correlated to the postoperative increase in transaminases suggesting a protective effect against IRI. The maximal rise of ALT after transplantation in high versus low bilirubin patients was 288 (-210-2457) U/l vs. 375 (-11-2102) U/l, P=0.006. Bilirubin remained a significant determining factor in a multivariate linear regression analysis. The MELD score and its individual components as a marker of severity of chronic liver disease were significantly higher in the high versus low bilirubin group (P<0.001). Despite this, overall complication rate (21.0% vs. 21.2%, P=0.88), hospital stay [13 (4-260) vs. 14 (6-313) days, P=0.93), and 1-year graft survival (90.8% vs. 89.0%, P=0.62) were similar in both groups. High bilirubin levels of liver recipients before live donor transplantation is associated with decreased postoperative IRI.

Hyperbilirubinaemia in appendicitis: the diagnostic value for prediction of appendicitis and appendiceal perforation.

The aim of this study is to evaluate the diagnostic value of pre-operative bilirubin levels in the diagnosis of acute appendicitis and appendiceal perforation. A retrospective analysis of 557 patients undergoing emergency appendicectomy over a 24-month period at a large teaching hospital. Hyperbilirubinaemia was defined as >25µmol/L. Data were analysed using descriptive statistics. 484 of the 557 (86.9%) operated cases were found histologically to be appendicitis. 116 cases of the 484 were perforated (24%). Bilirubin levels were significantly higher in the group with appendicitis versus the group found to have a normal appendix at histology, [median (IQR) 12.0µmol/L (9.00) vs. 8.0µmol/L (7.00) respectively, p<0.001], despite being within normal serum bilirubin range. Sensitivity of hyperbilirubinaemia for acute appendicitis was only 8%, however specificity was 94%. PPV was 85% and NPV was 26%. Whilst bilirubin was higher in patients with a perforated appendix versus acute appendicitis [median (IQR) 13.0µmol/L (9.00) vs. 11.0µmol/L (9.00), respectively], statistically, there was no significant difference in pre-operative bilirubin levels between the perforated appendicitis cases and the non-perforated appendicitis cases (p=0.326). However, the specificity of hyperbilirubinaemia for perforated appendicitis was 93%, sensitivity 9.4%, PPV 24% and NPV 82%. Bilirubin levels may be high, but remain within normal range, in cases of appendicitis. Therefore, bilirubin levels may be a useful measurement when investigating a patient with suspected appendicitis. Hyperbilirubinaemia is highly specific with regards to perforation, a finding supported by other studies. However, possibly because of the few perforated cases in this study, we cannot recommend that hyperbilirubinaemia be used to predict perforation.

Postoperative hyperbilirubinemia suggests the occurrence of complications after esophagectomy for esophageal cancer.

Serum bilirubin levels frequently increase after esophagectomy for esophageal cancer. Several studies have reported hyperbilirubinemia in patients with postoperative complications. We aimed to perform a detailed large-scale analysis to clarify this association. We compared postoperative serum bilirubin levels of 200 patients with esophageal cancer who underwent esophagectomy, with and without postoperative complications, from January 2008 to July 2013 at Keio University Hospital, Tokyo, Japan. We also analyzed other risk factors for postoperative hyperbilirubinemia by univariate and multivariate analyses in an attempt to determine the mechanism of postoperative hyperbilirubinemia. Hyperbilirubinemia (total bilirubin >2.0 mg/dL) occurred in 71 patients (35.5 %). The mean total bilirubin peak level was 1.5 mg/dL in patients without complications, 2.0 mg/dL in those with at least one complication, 2.1 mg/dL in those with pneumonia, and 2.3 mg/dL in those with anastomotic leakage. Bilirubin levels were significantly higher in each complication group than in the non-complication group (p < 0.05 for all). Risk factors of postoperative hyperbilirubinemia by univariate analysis were the preoperative bilirubin level, video-assisted thoracoscopic surgery, three-field lymph node dissection, thoracic duct resection, prolonged surgical duration, severe complications (Clavien-Dindo grade ≥3), and severe anastomotic leakage (Clavien-Dindo grade ≥3). In contrast, the pT factor and postoperative enteral nutrition were negatively associated with postoperative hyperbilirubinemia. Risk factors by multivariate analysis were the preoperative bilirubin level, prolonged surgical duration, severe complications, and postoperative enteral nutrition. Although various factors impact postoperative hyperbilirubinemia, postoperative complications were most significantly associated with postoperative hyperbilirubinemia. Patients with postoperative hyperbilirubinemia after esophagectomy must be managed more carefully because unnoticed complications may be associated with hyperbilirubinemia.

0326: Prediction of right ventricular failure after cardiac transplantation: a recipient transcriptomic study

Right ventricle failure (RVF) is a frequent and severe complication after cardiac transplantation. However, risk stratification for RVF is poorly achieved. Development of transcriptomic biomarkers for outcome prediction in cardio-vascular diseases is promising. To identify right ventricular gene expression signature associated to RVF and to define a transcriptomic biomarker that could predict post-transplantation RVF. Recipient RV myocardial samples of 44 patients transplanted from February 1998 to November 2002 in our center were collected. We retrospectively identified patients with (RVF group) and without (CTL group) post-transplantation RVF. A 4035-gene expression profile was obtained for all patients. Differentially expressed genes between RVF and CTL groups were identified and a molecular RVF predictor was used to determine for each patient a RVF prediction score (RVFs). 9 (20%) and 18 (41%) patients were classified in RVF and CTL groups respectively. As compared to CTL group, RVF patients showed higher pre-operative bilirubin level and higher post-operative death rate. Molecular RVF predictor included 75 differentially expressed genes. Using this predictor, risk for post-transplantation RVF was 2.8-fold greater if RVFs was >0.5 (CI 95%: 1.243-6.305). Sensitivity and specificity of RVFs were 0.778 and 0.889, respectively. Using receiver operating characteristic analysis, RVFs area under curve (AUC) was significantly greater than AUC of commonly used RVF predictors (pulmonary vascular resistance, trans-pulmonary gradient). Gene expression profiling of recipient right ventricle could be used to predict post-transplantation RVF. Transcriptomic biomarkers should be further investigated as a new tool for selection of cardiac transplant candidates.

Abstract 19792: Prediction of Right Ventricular Failure After Cardiac Transplantation : A Recipient Transcriptomic Study

Introduction: Right ventricle failure (RVF) is a frequent and severe complication after cardiac transplantation. However, risk stratification for RVF is poorly achieved. Development of transcriptomic biomarkers for outcome prediction in cardio-vascular diseases is promising. Hypothesis: Our aim was to identify right ventricular gene expression signature associated to RVF and to define a transcriptomic biomarker that could predict post-transplantation RVF. Methods: Recipient RV myocardial samples of 44 patients transplanted from February 1998 to November 2002 in our center were collected. We retrospectively identified patients with (RVF group) and without (CTL group) post-transplantation RVF. A 4035-gene expression profile was obtained for all patients. Differentially expressed genes between RVF and CTL groups were identified and a molecular RVF predictor was used to determine for each patient a RVF prediction score (RVFs). Results: 9 (20%) and 18 (41%) patients were classified in RVF and CTL groups respectively. As compared to CTL group, RVF patients showed higher pre-operative bilirubin level and higher post-operative death rate. Molecular RVF predictor included 75 differentially expressed genes. Using this predictor, risk for post-transplantation RVF was 2.8-fold greater if RVFs was &gt;0.5 (CI 95%: 1.243-6.305). Sensitivity and specificity of RVFs were 0.778 and 0.889, respectively. Using receiver operating characteristic analysis, RVFs area under curve (AUC) was significantly greater than AUC of commonly used RVF predictors (pulmonary vascular resistance, trans-pulmonary gradient). Conclusions: Gene expression profiling of recipient right ventricle could be used to predict post-transplantation RVF. Transcriptomic biomarkers should be further investigated as a new tool for selection of cardiac transplant candidates.