Michael A. Fink

Complications and mortality in older surgical patients in Australia and New Zealand (the REASON study): a multicentre, prospective, observational study*

We conducted a prospective study of non‐cardiac surgical patients aged 70 years or more in 23 hospitals in Australia and New Zealand. We studied 4158 consecutive patients of whom 2845 (68%) had pre‐existing comorbidities. By day 30, 216 (5%) patients had died, and 835 (20%) suffered complications; 390 (9.4%) patients were admitted to the Intensive Care Unit. Pre‐operative factors associated with mortality included: increasing age (80–89 years: OR 2.1 (95% CI 1.6–2.8), p < 0.001; 90+ years: OR 4.0 (95% CI 2.6–6.2), p < 0.001); worsening ASA physical status (ASA 3: OR 3.1 (95% CI 1.8–5.5), p < 0.001; ASA 4: OR 12.4 (95% CI 6.9–22.2), p < 0.001); a pre‐operative plasma albumin < 30 g.l−1 (OR: 2.5 (95% CI 1.8–3.5), p < 0.001); and non‐scheduled surgery (OR 1.8 (95% CI 1.3–2.5), p < 0.001). Complications associated with mortality included: acute renal impairment (OR 3.3 (95% CI 2.1–5.0), p < 0.001); unplanned Intensive Care Unit admission (OR 3.1 (95% CI 1.9–4.9), p < 0.001); and systemic inflammation (OR 2.5 (95% CI 1.7–3.7), p < 0.001). Patient factors often had a stronger association with mortality than the type of surgery. Strategies are needed to reduce complications and mortality in older surgical patients.

Liver transplant recipient selection: MELD vs. clinical judgment

Minimization of death while waiting for liver transplantation involves accurate prioritization according to clinical status and appropriate allocation of donor livers. Clinical judgment in the Liver Transplant Unit Victoria (LTUV) was compared with Model for End‐Stage Liver Disease (MELD) in a retrospective analysis of the LTUV database over the 2‐year period August 1, 2002, through July 31, 2004. A total of 1,118 prioritization decisions occurred. Decisions were concordant in 758 (68%), comparing priorities assigned by clinical judgment with those assigned by MELD, P < 0.01. A total of 263 allocation decisions occurred. Decisions were concordant in 190 (72%) and 203 (77%) of the cases, comparing donor liver allocation with prioritization by MELD and clinical judgment, respectively. Of the 52 patients allocated a liver, only 23 would have been allocated on the basis of MELD while 29 had been prioritized on the waiting list in the week prior to transplantation. A total of 10 patients died on the waiting list in the 2‐year period (annual adult waiting list mortality is 9.3%). Patients who subsequently died waiting were 3 times as likely to be prioritized by MELD as clinical judgment (29% vs. 9%, respectively). One half (3 of 6) of the patients who could have received a donor liver but who died waiting would have been allocated the organ on the basis of MELD. In conclusion, an allocation process based on MELD rather than clinical judgment would significantly alter organ allocation in Australia and may reduce waiting list mortality. (Liver Transpl 2005;11:621–626.)

Risk factors for liver transplantation waiting list mortality

Background and Aim:  The gap between the demand for liver transplantation and organ donation rates has a major impact on waiting list mortality. Understanding the risk factors that predict liver transplant waiting list death may help optimize organ allocation policy and reduce waiting list deaths.

Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis.

BACKGROUND Gangrenous cholecystitis (GC) is considered a more severe form of acute cholecystitis. The risk factors associated with this condition and its impact on morbidity and mortality compared with those of non-gangrenous acute cholecystitis (NGAC) are poorly defined and based largely on findings from older studies. METHODS Patients with histologically confirmed acute cholecystitis treated in specialized units in a tertiary hospital between 2005 and 2010 were identified from a prospectively maintained database. Data were reviewed retrospectively and patients with GC were compared with those with NGAC. RESULTS A total of 184 patients with NGAC and 106 with GC were identified. The risk factors associated with GC included older age (69 years vs. 57 years; P= 0.001), diabetes (19% vs. 10%; P= 0.049), temperature of >38 °C (36% vs. 16%; P < 0.001), tachycardia (31% vs. 15%; P= 0.002), detection of muscle rigidity on examination (27% vs. 12%; P= 0.01) and greater elevations in white cell count (WCC) (13.4 × 10⁹/l vs. 10.7 × 10⁹/l; P < 0.001), C-reactive protein (CRP) (94 mg/l vs. 17 mg/l; P= 0.001), bilirubin (19 µmol/l vs. 17 µmol/l; P= 0.029), urea (5.3 mmol/l vs. 4.7 mmol/l; P= 0.016) and creatinine (82 µmol/l vs. 74 µmol/l; P= 0.001). The time from admission to operation in days was greater in the GC group (median = 1 day, range: 0-14 days vs. median = 1 day, range: 0-10 days; P= 0.029). There was no overall difference in complication rates between the GC and NGAC groups (22% vs. 14%; P= 0.102). There was a lower incidence of common bile duct stones in the GC group (5% vs. 13%; P= 0.017). Gangrenous cholecystitis was associated with increased mortality (4% vs. 0%; P= 0.017), but this was not an independent risk factor on multivariate analysis. CONCLUSIONS Gangrenous cholecystitis has certain clinical features and associated laboratory findings that may help to differentiate it from NGAC. It is not associated with an overall increase in complications when treated in a specialized unit.

A Fast Track Recovery Program Significantly Reduces Hospital Length of Stay Following Uncomplicated Pancreaticoduodenectomy

CONTEXT Factors affecting length of hospital stay after uncomplicated pancreaticoduodenectomy have not been reported. We hypothesized that patients undergoing uncomplicated pancreaticoduodenectomy treated by fast track recovery program would have a shorter length of hospital stay compared to those managed by a standard program. METHODS Patients without surgical or medical complications following pancreaticoduodenectomy managed by fast track or standard protocols, between 2005 and 2011, were identified and prognostic predictors for length of hospital stay determined. RESULTS Forty-one patients treated by pancreaticoduodenectomy had no medical or surgical complications during this period. Of these patients, 20 underwent fast track recovery program compared to 21 who underwent standard care. Patients in the standard group were more likely to have a feeding jejunostomy tube (P<0.001), pylorus preserving procedure (P=0.001) and a nasogastric tube in place longer than 24 hours postoperatively (P<0.001). The median postoperative length of stay was shorter in the fast track recovery program group (8 days, range: 7-16 days) versus 14 days, range: 8-29 days; P<0.001). There were three readmissions in the fast track recovery program related to abdominal pain and none in the standard group. The overall length of stay, accounting for readmissions, still remained significantly shorter in the fast track recovery program group (median 9 days, range: 7-17 days versus median14 days, range: 8-29 days ; P<0.001). There were no significant differences in discharge destination between groups. On multivariate analysis, the only factor independently associated with postoperative discharge by day 8 was fast track recovery program (OR: 37.1, 95% CI: 4.08-338; P<0.001). CONCLUSION Fast track recovery program achieved significantly shorter length of stay following uncomplicated pancreaticoduodenectomy.

A fatal case of emphysematous gastritis and esophagitis

&NA; Emphysematous gastritis is a rare form of infectious gastritis characterized by intramural gas production by gas forming organisms. We report a fatal case of this disorder with involvement of both stomach and esophagus in a 76 yr old man who had a past history of alcohol abuse, and whose recent therapy included nonsteroidal anti‐inflammatory agents.

Novel population-based study finding higher than reported hepatocellular carcinoma incidence suggests an updated approach is needed

Hepatocellular carcinoma (HCC) incidence is rising rapidly in many developed countries. Primary epidemiological data have invariably been derived from cancer registries that are heterogeneous in data quality and registration methodology; many registries have not adopted current clinical diagnostic criteria for HCC and still rely on histology for classification. We performed the first population‐based study in Australia using current diagnostic criteria, hypothesizing that HCC incidence may be higher than reported. Incident cases of HCC (defined by American Association for the Study of Liver Diseases diagnostic criteria or histology) were prospectively identified over a 12‐month period (2012‐2013) from the population of Melbourne, Australia. Cases were captured from multiple sources: admissions to any of Melbournes seven tertiary hospitals; attendances at outpatients; and radiology, pathology, and pharmacy services. Our cohort was compared to the Victorian Cancer Registry (VCR) cohort (mandatory notified cases) for the same population and period, and incidence rates were compared for both cohorts. There were 272 incident cases (79% male; median age: 65 years) identified. Cirrhosis was present in 83% of patients, with hepatitis C virus infection (41%), alcohol (39%), and hepatitis B virus infection (22%) the commonest etiologies present. Age‐standardized HCC incidence (per 100,000, Australian Standard Population) was 10.3 (95% confidence interval [CI]: 9.0‐11.7) for males and 2.3 (95% CI: 1.8 to 3.0) for females. The VCR reported significantly lower rates of HCC: 5.3 (95% CI: 4.4 to 6.4) and 1.0 (95% CI: 0.7 to 1.5) per 100,000 males and females respectively (P < 0.0001). Conclusions: HCC incidence in Melbourne is 2‐fold higher than reported by cancer registry data owing to under‐reporting of clinical diagnoses. Adoption of current diagnostic criteria and additional capture sources will improve registry completeness. Chronic viral hepatitis and alcohol remain leading causes of cirrhosis and HCC. (Hepatology 2016;63:1205–1212)

Outcomes of cholecystectomy for treatment of acute cholecystitis in octogenarians

The independent influence of advanced age on outcomes in contemporary series treated by early cholecystectomy is undetermined.

Early-onset versus late-onset nonanastomotic biliary strictures post liver transplantation: risk factors reflect different pathogenesis

Nonanastomotic biliary strictures (NAS) cause significant morbidity post liver transplantation. Timing of stricture development varies considerably, but the relationship between timing of stricture onset and aetiology has not been fully elucidated. Database analysis was performed on all adult patients undergoing liver transplantation between 1st January 1990 and 31st May 2008. Diagnosis of NAS required demonstration on at least two radiological studies. Early NAS were defined as developing <1 year post transplant (minimum 1‐year follow‐up) and late NAS developing >1 year post transplant (minimum 10‐year follow‐up). Ninety‐six of 397 patients developed NAS (24%); 54 were early‐onset NAS (56%) and 42 late‐onset NAS (44%). Primary sclerosing cholangitis (PSC) was the only risk factor for NAS overall (P = 0.001). However, when patients with PSC were excluded, older donor age was a significant risk for NAS (P = 0.003). Early‐onset NAS were associated with advanced donor age (P = 0.02), high MELD score (P = 0.001) and ABO‐identical grafts (P = 0.02), whereas late‐onset NAS were associated with PSC (P = 0.0008), bilio‐enteric anastomosis (P = 0.006) and tacrolimus (P = 0.0001). Advanced donor age is a significant risk for NAS in patients without PSC. Importantly, aetiology of NAS varies depending on time to stricture development, suggesting early‐onset and late‐onset NAS may have different pathogenesis.

Experimental folic acid nephropathy

&NA; In rats, single intravenous doses of folic acid induce damage to renal tubular epithelium, deposition of folic acid in tubular lumens, increase in wet kidney weight, oliguria and interstitial connective tissue proliferation. Separation of the nephrotoxic and obstructive effects of folic acid was attempted by pretreatment with NH4Cl or NaHCO3. These effects of folic acid were unaltered by pretreatment with NH4Cl and there was, in addition, accumulation of eosinophilic droplets in papillary collecting duct epithelium. After pretreatment with NaHCO3, folic acid deposition is decreased or absent; there is a smaller increase in wet kidney weight; the rats are polyuric rather than oliguric; interstitial connective tissue proliferation is reduced; and no droplets form in papillary collecting ducts, but lesions are still present in proximal convoluted tubule epithelial cells. These findings indicate that folic acid has direct nephrotoxic effects independent of intraluminal folic acid deposition, and that damage to renal epithelium, unlike that induced by many nephrotoxins, occurs at several levels of the nephron.