Amer Aldouri

Correlation between postoperative infective complications and long-term outcomes after hepatic resection for colorectal liver metastasis.

Background:The impact of postoperative morbidity, and in particular infective complications on long-term outcomes, following hepatic resection for colorectal liver metastasis (CRLM) is not widely published. Objective:To evaluate the effect of postoperative complications on disease recurrence and overall survival in patients undergoing hepatic resection for CRLM. Methods:All patients undergoing hepatic resection for CRLM from January 1993 and March 2007 were identified, and postoperative complications analyzed. Patients who died of postoperative complications within 30 days of surgery were excluded form the study. Postoperative complications were graded using a validated system of classification. Complications were further classified into infective and noninfective complication groups and the primary end points of the study were disease free survival (DFS) and overall survival (OS) at 5 years. Result:A total of 705 patients underwent hepatic resection in the study period. Median follow-up was 38 months. Operative morbidity and mortality were 28% and 3.6%, respectively. The total number of patients was 197 (28%) with complications, and 508 (72%) without complications. The 5 year DFS and OS for those with and without complications were: 13% versus 26% (P < 0.001) and 24% versus 37% (P < 0.001), respectively. Multivariate analysis showed inflammatory response to tumor score, blood transfusion, tumor number >8, and postoperative sepsis to be independent factors associated with DFS, and inflammatory response to tumor, tumor number >8, and postoperative sepsis to be independent predictors for OS. Intra-abdominal and respiratory infection but not wound infections were associated with poorer long-term outcomes. Conclusions:Postoperative complications influence long-term outcomes in hepatic resection for CRLM. Specifically, postoperative sepsis is an independent predictor of disease free and overall survival. Thorough preoperative optimization, meticulous surgical technique and careful management in the postoperative period may reduce the incidence of these complications and influence long-term outcomes.

Liver transplantation following donation after cardiac death: An analysis using matched pairs

Grafts from donation after cardiac death (DCD) donors are used to increase the number of organs available for liver transplantation. There is concern that warm ischemia may impair graft function. We compared our DCD recipients with a case‐matched group of donation after brain death (DBD) recipients. Between January 2002 and April 2008, 39 DCD grafts were transplanted. These were matched with 39 DBD recipients on the basis of identified variables that had a significant impact on mortality. These were used to individually match DCD and DBD patients with similar predictive mortality. We compared patient/graft survival, primary non‐function (PNF), and rates of complications. Of all liver transplants, 6.1% were DCD grafts. PNF occurred twice in the DCD group. The incidence of nonanastomotic biliary strictures (NABS; 20.5% versus 0%, P = 0.005) and hepatic artery stenosis (HAS; 12.8% versus 0%, P = 0.027) in the DCD group was higher. One‐year (79.5% versus 97.4%, P = 0.029) and 3‐year (63.6% versus 97.4%, P = 0.001) graft survival was lower in the DCD group. Three‐year patient survival was also lower (68.2% versus 100%, P < 0.0001). Our study is the first to use case‐matched patients and compare groups with similar predictive mortality. There was a higher incidence of NABS and HAS in the DCD group. NABS were likely a result of warm ischemia. HAS may have been due to ischemia or arterial injury during retrieval. The DCD group had significantly poorer outcomes, but DCD grafts remain a valuable resource. With careful donor/recipient selection, minimization of ischemia, and good postoperative care, acceptable results can be achieved. Liver Transpl 15:1072–1082, 2009.

Acceptable Outcome After Kidney Transplantation Using Expanded Criteria Donor Grafts

Introduction. With the worldwide shortage of donors, extra lengths are ongoing to enlarge the donor pool. One means has been a greater use of “expanded criteria donor” (ECD) grafts. A major concern regarding ECD kidneys is poor long-term graft survival. The aims of this study were to determine whether ECD grafts, as defined by the United Network for Organ Sharing, had a negative impact on graft survival and to identify the principle donor and recipient factors that influenced graft survival in our patient cohort. Methods. We analyzed all deceased donor renal transplants in our unit from January 1995 to October 2005, in total 1053 transplants. Results. ECD grafts (United Network for Organ Sharing criteria) demonstrated higher rates of delayed graft function and higher early mean creatinine levels. However, there was no significant difference in 5-year graft survival. Multivariate analysis of our patient group identified donor hypertension and ischemic heart disease (IHD) as independent predictors of poor graft survival. Recipient age was significant on univariate but not on multivariate analysis. However, although younger recipients maintained acceptable 5-year graft survival despite donor hypertension, IHD, or a combination of both, these factors significantly reduced graft survival in older recipients. Conclusion. Although ECD grafts had slightly worse function, 5-year survival was comparable with standard grafts in all recipients. Donor hypertension, IHD, or a combination of both significantly reduced graft survival in older recipients, not evident in younger patients. We discuss the possible factors for improved outcome with ECD grafts in our patients and the implications of our patient analysis.

Right hepatic trisectionectomy for hepatobiliary diseases: results and an appraisal of its current role.

Objective:To assess the results of 275 patients undergoing right hepatic trisectionectomy and to clarify its current role. Summary Background Data:Right hepatic trisectionectomy is considered one of the most extensive liver resections, and few reports have described the long-term results of the procedure. Methods:Short- and long-term outcomes of 275 consecutive patients who underwent right hepatic trisectionectomy from January 1993 to January 2006 were analyzed. Results:Of the 275 patients, 160 had colorectal metastases, 49 had biliary tract cancers, 20 had hepatocellular carcinomas, 20 had other metastatic tumors, and 12 had benign diseases. Fourteen of the 275 patients underwent right hepatic trisectionectomy as part of auxiliary liver transplantation for acute liver failure and were excluded. Concomitant procedures were carried out in 192 patients: caudate lobectomy in 45 patients, resection of tumors from the liver remnant in 57 patients, resection of the extrahepatic biliary tree in 45 patients, and lymphadenectomy in 45 patients. One-, 3-, 5-, and 10-year survivals were 74%, 54%, 43%, and 36%, respectively. Overall hospital morbidity and 30-day and in-hospital mortalities were 41%, 7%, and 8%, respectively. Survivals for individual tumor types were acceptable, with 5-year survivals for colorectal metastasis and cholangiocarcinoma being 38% and 32%, respectively. Multivariate analysis disclosed the amount of intraoperative blood transfusion to be the sole independent predictor for the development of hospital morbidity. Age over 70 years, preoperative bilirubin levels, and the development of postoperative renal failure were found to be independent predictors of long-term survival. Conclusion:Right hepatic trisectionectomy remains a challenging procedure. The outcome is not influenced by additional concomitant resection of tumors from the planned liver remnant. Caution must be taken when considering patients older than 70 years for such resections.

Results of pancreatic surgery in the elderly: is age a barrier?

BACKGROUND By 2033, the number of people aged 85 years and over in the UK is projected to double, accounting for 5% of the total population. It is important to understand the surgical outcome after a pancreatic resection in the elderly to assist decision making. METHODS Over a 9-year period (from January 2000 to August 2009), 428 consecutive patients who underwent a pancreatic resection were reviewed. Data were collected on mortality, complications, length of stay and survival. Patients were divided into two groups (younger than 70 and older than 70 years old) and outcomes were analysed. RESULTS In all, 119 (27.8%) patients were ≥ 70 years and 309 (72.2%) patients were < 70 years. The median length of stay for the older and younger group was 15 days (range 3-91) and 14 days (range 3-144), respectively. The overall mortality was 3.4% in the older group and 2.6% in the younger group (P = 0.75). The older cohort had a cumulative median survival of 57.3 months (range 0-119), compared with 78.7 months (range 0-126) in the younger cohort (P < 0.0001). In patients undergoing a pancreatic resection for ductal adenocarcinoma and cholangiocarcinoma there was a significant difference in survival with P-values of 0.043 and 0.003, respectively. For ampullary adenocarcinoma, the older group had a median survival of 47.1 months compared with 68.3 months (P = 0.194). CONCLUSION Results from this study suggest that while elderly patients can safely undergo a pancreatic resection and that age alone should not preclude a pancreatic resection, there is still significant morbidity and mortality in the octogenarian subgroup with poor long-term survival with the need for quality-of-life assessment.

Outcomes in right liver lobe transplantation: a matched pair analysis.

Split liver transplantation (SLT) has proven to be an effective technique of increasing the donor pool and thereby reducing adult and paediatric waiting list mortality. There remains concern regarding complications in adult recipients. Here, we compare SLT with matched whole liver grafts. Adult recipients of primary extended right lobe grafts (ERL) were matched to recipients of whole liver transplantations (WLTs) according to the following criteria: model of end‐stage liver disease (MELD) score, recipient age, indication for liver transplantation and year of transplantation. Twenty‐seven pairs of recipients were transplanted for chronic liver disease. The overall 30‐day patient survival rates after ERL and WLT were 88.9% and 92.5% and 3‐year survival rates after SLT and WLT were 77.8% and 85.2% respectively (log‐rank = 0.38). Two patients with SLTs had hepatic artery thromboses and were retransplanted with none from the WLT group. The prevalence of a biliary leak was higher among the SLT group (n = 4) compared with none in the WLT group (P = 0.05). Patients with preoperative hyponatraemia showed a trend towards poorer survival after SLT compared with WLT. Our data suggest that SLT with extended right liver lobes, although not significantly different, shows a trend towards a poorer outcome.

A matched-pair analysis of laparoscopic versus open pancreaticoduodenectomy: oncological outcomes using Leeds Pathology Protocol

BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is a safe procedure. Oncological safety of LPD is still a matter for debate. This study aimed to compare the oncological outcomes, in terms of adequacy of resection and recurrence rate following LPD and open pancreaticoduodenectomy (OPD). METHODS Between November 2005 and April 2009, 12 LPDs (9 ampullary and 3 distal common bile duct tumors) were performed. A cohort of 12 OPDs were matched for age, gender, body mass index (BMI) and American Society of Anesthesiologists (ASA) score and tumor site. RESULTS Mean tumor size LPD vs OPD (19.8 vs 19.2 mm, P=0.870). R0 resection was achieved in 9 LPD vs 8 OPD (P=1.000). The mean number of metastatic lymph nodes and total number resected for LPD vs OPD were 1.1 vs 2.1 (P=0.140) and 20.7 vs 18.5 (P=0.534) respectively. Clavien complications grade I/II (5 vs 8), III/IV (2 vs 6) and pancreatic leak (2 vs 1) were statistically not significant (LPD vs OPD). The mean high dependency unit (HDU) stay was longer in OPD (3.7 vs 1.4 days, P<0.001). There were 2 recurrences each in LPD and OPD (log-rank, P=0.983). Overall mortality for LPD vs OPD was 3 vs 6 (log-rank, P=0.283) and recurrence-related mortality was 2 vs 1. There was one death within 30 days in the OPD group secondary to severe sepsis and none in the LPD group. CONCLUSIONS Compared to open procedure, LPD achieved a similar rate of R0 resection, lymph node harvest and long-term recurrence for tumors less than 2 cm. Though technically challenging, LPD is safe and does not compromise oncological outcome.

The role of 99mtechnetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain

OBJECTIVE To assess the outcome of laparoscopic cholecystectomy on the basis of an abnormal provocative (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan for patients with typical biliary pain and normal trans-abdominal ultrasound (TUS) scan. PATIENTS AND METHODS Prospective data were collected for 1201 consecutive patients with typical biliary symptoms. Patients who were found to have a normal TUS and upper GI endoscopy subsequently underwent cholescintigraphy (HIDA scan). Patients with an abnormal HIDA scan, i.e.<40% ejection fraction with Sincalide (cholecystokinin octapeptide)--were offered cholecystectomy. Symptoms and histology were reviewed postoperatively. RESULTS In all, 48/1201 (4%) patients with typical biliary symptoms had a normal ultrasound and endoscopy; 35/48 patients had an abnormal provocative HIDA scan and all underwent laparoscopic cholecystectomy. Histology in all cases revealed chronic cholecystitis and 18 patients had sludge or microlithiasis within the gallbladder. At 6-week follow-up, 31 of the 35 patients were completely asymptomatic or improved. Furthermore, 79% of patients remained symptom-free or improved at a median follow-up of 28.5 months (range 4-70). CONCLUSIONS HIDA scan is a useful clinical tool as an adjunct to the diagnosis and management of patients who present with typical biliary pain and a normal TUS scan.

Enteral nutrition in acute pancreatitis: Nasogastric or nasojejunal?

(p<0.0001). Conclusion: Nasogastric feeding is well tolerated in the majority (73.7%) of patients with severe AP. NG feeding should be first line, but if failing a rapid change to the NJ route instituted. Take-home message: Need for nutritional support is a poor prognostic indicator and although nasogastric feed is well tolerated but over 20% of patients still require nasojejunal feeding