Preoperative Bilirubin Research Articles

Postoperative Liver Failure Risk Score: Identifying Patients with Resectable Perihilar Cholangiocarcinoma Who Can Benefit from Portal Vein Embolization

Major liver resection for perihilar cholangiocarcinoma (PHC) is associated with a 22% to 33% postoperative liver failure incidence. The aim of this study was analyze the predictive value of future liver remnant (FLR) volume for postoperative liver failure after resection for PHC and to develop a risk score to improve patient selection for portal vein embolization. A consecutive series of 217 patients underwent major liver resection for PHC between 1997 and 2014 at 2 Western centers; FLR volumes were calculated with CT volumetry; other variables included jaundice at presentation, immediate preoperative bilirubin, and preoperative cholangitis. The FLR volume was categorized as <30%, 30% to 45%, or >45%. A risk score for postoperative liver failure (grade B/C according to the International Study Group of Liver Surgery criteria) was developed using multivariable logistic regression with 5 predefined variables. Postoperative liver failure incidence was 24% and liver failure-related mortality was 12%. Risk factors for liver failure were FLR volume <30% (odds ratio 4.2; 95% CI 1.77 to 10.3) and FLR volume 30% to 45% (odds ratio 1.4; 95% CI 10.6 to 3.4). In addition, jaundice at presentation (odds ratio 3.1; 95% CI 1.1 to 9.0), immediate preoperative bilirubin >50 μmol/L (>2.9 mg/dL) (odds ratio 4.3; 95% CI 1.7 to 10.7), and preoperative cholangitis (odds ratio 3.4; 95% CI 1.6 to 7.4) were risk factors for liver failure. These variables were included in a risk score that showed good discrimination (area under the curve 0.79; 95% CI 0.72 to 0.86) and ranking patients in 3 risk sub-groups with predicted liver failure incidence of 4%, 14%, and 44%. The selection of patients for portal vein embolization using only liver volume is insufficient, considering the other predictors of liver failure in PHC patients. The proposed risk score can be used for selection of patients for portal vein embolization, for adequate patient counseling, and identification of other modifiable risk factors besides liver volume.

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

Percutaneous transhepatic cholangiographic endobiliary forceps biopsy versus endoscopic ultrasound fine needle aspiration for proximal biliary strictures: a single-centre experience

BackgroundEndoscopic ultrasound fine needle aspiration (EUS-FNA) and percutaneous transhepatic cholangiographic endobiliary forceps biopsy (PTC-EFB) are valid procedures for histological assessment of proximal biliary strictures (PBS), but their performances have never been compared. This study aimed to compare the diagnostic performance of these two techniques. MethodThe diagnostic performances of EUS-FNA and PTC-EFB were compared in a retrospective cohort of patients assessed for PBS from 2011 to 2015 at a single tertiary centre. An inverse probability of treatment weighting (IPTW) was performed to adjust for covariate imbalance. ResultsA total of 102 EUS-FNAs and 75 PTC-EFBs (performed in 137 patients) were compared. Patients in the PTC-EFB group had higher preoperative bilirubin (243 versus 169 μmol/l, p = 0.005) and a higher incidence of malignancy (87% versus 67%, p = 0.008). Both techniques showed specificity and positive predictive value of 100%, and similar sensitivity (69% versus 75%, p = 0.45), negative predictive value (58% versus 38%, p = 0.15) and accuracy (78% versus 79%, p = 1.00). After IPTW, the diagnostic performance of the two techniques remained similar. ConclusionCompared to EUS-FNA, PTC-EFB provides similar sensitivity, negative predictive value and accuracy. It should therefore be considered as the preferred tissue-sampling procedure, if biliary drainage is indicated.

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.

Patterns of Early Allograft Dysfunction in Adult Live Donor Liver Transplantation: The A2ALL Experience.

Early allograft dysfunction (EAD) after living donor liver transplantation (LDLT) has often been attributed to inadequate graft size, and termed small-for-size syndrome. Early allograft dysfunction definitions include a variable constellation of findings, including hyperbilirubinemia, coagulopathy, encephalopathy, and ascites formation. Among putative causes of EAD after LDLT are excessive portal pressure and/or flow. Our objective was to evaluate patterns of EAD after LDLT. In this study, 631 LDLT recipients were monitored for complications, EAD (defined by postoperative day 7 bilirubin >10 mg/dL or international normalized ratio >1.6), and graft failure. Approximately 200 had portal venous and arterial pressure and flow measurements before and after LDLT. Portal inflow modification (splenic artery ligation, hemiportocaval shunt, or splenectomy) was performed at the discretion of the operating surgeon. Associations between EAD and recipient, donor, and transplant factors were examined using multivariable logistic regression. Risk of EAD was associated with left lobe grafts, lower graft weight among left lobes, higher preoperative bilirubin, higher portal reperfusion pressure, higher donor age, and higher donor body mass index. The risk of graft loss within the first 90 days was 5.2 times higher for recipients with EAD versus those without EAD (P < 0.001). Early allograft dysfunction can be defined using postoperative day 7 laboratory values that are highly predictive of early graft failure within 90 days. Risk factors associated with EAD after LDLT include: graft type and size, preoperative bilirubin, portal reperfusion pressure, donor age, and donor body mass index.

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.

Surgery for benign histology is associated with worse perioperative outcomes compared to malignant histology in patients undergoing Whipple's pancreaticoduodenectomy for pancreatic head mass

Aims: To evaluate whether the histology of the pancreatic head mass has a direct impact on perioperative outcomes in patients undergoing Whipple's Pancreaticoduodenectomy. Methods: A case matched-control study was undertaken from a prospectively collected database over a 9 years period (01/01/2006 - 31/12/2014). 465 patients underwent a Whipple's procedure of which 42 had benign histology. Gastrointestinal Stromal and Neuroendocrine Tumours were excluded. Of the 42 cases identified, the histology of 34 patients was unknown prior to commencement of surgery and to avoid bias were included in this study. Each case was independently matched to a case with confirmed malignant histology using pre-set criteria which included standardization of the procedure, type of pancreatic reconstruction, preoperative bilirubin, ERCP/PTC stenting as well as patient demographics and physiological scoring. Outcomes included 30 and 90 day mortality and morbidity measured using the Clavien-Dindo classification. Results: 68 patients were included in the study. Matched characteristics demonstrated no significant difference between the two groups. No significant difference was noted between the groups for 30 day mortality (Benign 4, Malignant 1; p = 0.166) and length of stay (Median length of stay: 16 (range 6 – 49) vs 12 (range 6 – 28; p = 0.186). However, significant differences were noted between the groups for major complications (Clavien IIIa – V) (16 vs 7; p = 0.020) although minor complications (Clavien I – II) demonstrated no significant differences (22 vs 25; p = 0.324). Independently pancreatic fistula rates were significantly higher in the benign group (9 vs 1; p = 0.02). Conclusions: Surgery for a benign pancreatic head mass confers a higher incidence of major complications. The most notable is the rate of pancreatic fistulas.

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.

Predicting Individual Survival After Hepatectomy for Hepatocellular Carcinoma: a Novel Nomogram from the “HCC East & West Study Group”

IntroductionsDifferent staging systems have been devised for patients undergoing resection for hepatocellular carcinoma (HCC) with disparate results. The aim of this study was to create a new nomogram to predict individual survival after hepatectomy for HCC. MethodsBased on the “Hepatocellular Carcinoma: Eastern & Western Experiences Network,” data from 2046 patients who underwent HCC resections at ten centers were reviewed. Patient survival was analyzed with Cox-regression analysis to construct a unique nomogram and contour plots to predict survival. ResultsThe nomograms built on the multivariate analyses, which showed that the independent predictors were tumor size, tumor number, vascular invasion, cirrhosis, preoperative bilirubin value, and esophageal varices, showed good calibration and discriminatory abilities with C-index value of 0.62 (95 % CI, 0.59–0.69) and 0.61 (95 % CI, 0.56–0.64) for overall and disease-free survival, respectively. The 5-year survival contour plots showed that the presence of vascular invasion was associated with decreased survival, regardless of the tumor number or size. Cirrhosis and varices were equally associated with decreased survival, according to the tumor number or size. ConclusionsThese nomograms accurately predict individual prognosis after HCC resection and support an expansion of the selection criteria for resection. They offer useful guidance to clinicians for individual survival prediction.

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.

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.

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.

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.

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.

Recipient Hyperbilirubinemia May Reduce Ischemia-Reperfusion Injury but Fails to Improve Outcome in Clinical Liver Transplantation.

Background. Exogenous bilirubin may reduce experimental ischemia-reperfusion injury (IRI) due to its antioxidant properties. We studied if early graft exposure to high bilirubin levels in the recipient affects the early IRI and outcomes after liver transplantation (LTx). Methods. In 427 LTx patients, the AUROC curve based on bilirubin and AST at day 1 identified a cutoff of 2.04 mg/dL for the recipient pretransplant bilirubin. Recipients were grouped as having low (group L, n = 152) or high (group H, n = 275) bilirubin. Both groups had similar donor-related variables (age, preservation time, donor BMI > 28, and donor risk index (DRI)). Results. Alanine (ALT) and aspartate (AST) aminotransferase levels were higher in group L at day 1; ALT levels remained higher at day 2 in group L. LTx from high risk donors (DRI > 2) revealed a trend towards lower transaminases during the first two days after transplantation in group H. One month and 1-year patient survival were similar in groups L and H. High preoperative bilirubin did not affect the risk for early graft dysfunction (EGD), death, or graft loss during the first year after transplantation nor the incidence of acute rejection. LTx using donors with DRI > 2 resulted in similar rates of EGD in both groups. Conclusion. Increased bilirubin appears to reduce the early IRI after LTx yet this improvement was insufficient to improve the clinical outcome.

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.