Shaun P. Patel

Sarcopenia and Mortality after Liver Transplantation

BACKGROUND Surgeons frequently struggle to determine patient suitability for liver transplantation. Objective and comprehensive measures of overall burden of disease, such as sarcopenia, could inform clinicians and help avoid futile transplantations. STUDY DESIGN The cross-sectional area of the psoas muscle was measured on CT scans of 163 liver transplant recipients. After controlling for donor and recipient characteristics using Cox regression models, we described the relationship between psoas area and post-transplantation mortality. RESULTS Psoas area correlated poorly with Model for End-Stage Liver Disease score and serum albumin. Cox regression revealed a strong association between psoas area and post-transplantation mortality (hazard ratio = 3.7/1,000 mm(2) decrease in psoas area; p < 0.0001). When stratified into quartiles based on psoas area (holding donor and recipient characteristics constant), 1-year survival ranged from 49.7% for the quartile with the smallest psoas area to 87.0% for the quartile with the largest. Survival at 3 years among these groups was 26.4% and 77.2%, respectively. The impact of psoas area on survival exceeded that of all other covariates in these models. CONCLUSIONS Central sarcopenia strongly correlates with mortality after liver transplantation. Such objective measures of patient frailty, such as sarcopenia, can inform clinical decision making and, potentially, allocation policy. Additional work is needed develop valid and clinically relevant measures of sarcopenia and frailty in liver transplantation.

Resident Participation Does Not Affect Surgical Outcomes, Despite Introduction of New Techniques

BACKGROUND Surgical operations at academic medical centers typically involve a resident physician performing cases together with, and/or under the supervision of, an attending physician. Although this is a widely accepted practice, recent emphasis on patient safety has led to scrutiny about this educational model. There are few studies evaluating whether complication rates, independent of patient risk factors, are affected by resident participation in operations. STUDY DESIGN We identified 295 patients (590 breasts) who had undergone bilateral reduction mammoplasty led by a single attending surgeon between October 1, 1997 and September 30, 2008 at the University of Michigan Health System. In all cases, the attending operated on the right breast and the resident operated on the left breast under the supervision of the attending, allowing each patient to act as their own control. Their charts were retrospectively reviewed and major complications were defined as those requiring either an operation or hospitalization to treat. RESULTS Twenty-three patients (7.8%) had a major complication after their breast reduction. Ten of these complications occurred in the left breast, 9 in the right breast, and 4 in both breasts. Statistical analysis revealed no differences in major complication rates between the side operated on with the primary surgeon being the resident versus the attending (4.7% versus 4.4%; p = 1.00). CONCLUSIONS In the context of this single surgical operation, resident participation does not substantially affect major complication rates. The common residency training paradigm provides clinical experience and supervision without necessarily impacting patient safety. Analysis of additional operations in different settings will be necessary.

The effect of smoking on biliary complications following liver transplantation

We sought to estimate the effect of smoking on the biliary complication rate following orthotopic liver transplantation. We retrospectively evaluated the records of liver transplant recipients at our center from July 1, 1999 to October 26, 2007. Using Cox proportional hazards models, we estimated the time to the earliest biliary complication (leak or stricture) based on smoking exposure, as active, former, or lifetime nonsmoker, adjusting for other clinical factors. Overall, 409 liver transplant recipients were evaluated. The overall biliary complication rate was 37.7% (n = 154). Biliary complications included 66 anastomotic leaks, 60 anastomotic strictures, and 28 nonanastomotic lesions. ERCP was the primary diagnostic modality (n = 112). 18.1% of liver transplant recipients were active smokers (n = 74) and 42.8% were former smokers (n = 175). Active smokers were at greatest risk for biliary complications on unadjusted analysis (P = 0.022). After multivariable adjustment, active smokers had a 92% higher rate of biliary complication rates compared with lifetime nonsmokers (HR 1.92, 95% CI 1.07–3.43), but no difference was noted in the rate of complication resolution. Smoking clearly portends a significant risk of biliary complications following liver transplantation. Smoking status should be clearly defined when evaluating transplant candidacy and in counseling patients with cirrhosis.

Portrayal of organ donation and transplantation on American primetime television

Harbaugh C, Afana M, Burdick S, East J, Kodali S, Lee J, Patel S, Rangrass G, Ranney D, Sood V, Lynch R, Sonnenday CJ, Englesbe MJ, Mathur AK. Portrayal of organ donation and transplantation on American primetime television.
Clin Transplant 2011: 25: E375–E380.

Complications after sternal reconstruction: a 16-y experience

BACKGROUND Unlike risk factors associated with sternotomy complications, those associated with sternal reconstruction have not been well elucidated. We sought to examine complication rates after sternal wound reconstruction and to identify perioperative risk factors associated with these complications. METHODS We evaluated the records of 230 consecutive patients who underwent sternal reconstruction with muscle flaps after cardiac surgery. Patient demographics, clinical comorbidities, and operative procedure types were evaluated against two outcome variables-major complications and reconstructive failure. RESULTS The mean age of our cohort was 62 y. Major complications (readmission, reoperation, or death) occurred in 76 patients (33%), including mortality rate of 3.5%. Obesity, chronic obstructive pulmonary disease, and type of reconstructive procedure correlated with an increased risk of major complications. Reconstructive failure occurred in 39 patients (17%) and was associated with female gender, obesity, previous coronary artery bypass graft procedure, and prior left internal mammary artery usage. Regression analyses demonstrated that obesity is independently associated with an increased risk of major complications and that women are at an increased risk of reconstructive failure. Reconstructions involving the rectus abdominis were correlated with an increased risk of major complications, but this difference was not significant in multiple regression analysis. CONCLUSIONS Usual risk factors for sternal wound development after cardiac surgery include diabetes, age, obesity, tobacco use, history of stroke, bilateral left internal mammary artery harvest, and significant blood transfusion. In distinction, this study found that the risks independently associated with major complications and reconstructive failures after reconstruction of sternal wounds are limited to obesity and female gender.

Normative Vertebral Hounsfield Unit Values and Correlation with Bone Mineral Density

Background: We hypothesized that vertebral bone mineral density as measured in Hounsfield units (HU) by computed tomography (CT) can correlate with values obtained by dual x-ray absorptiometry (DXA). Our study aimed to report such a correlation along with the normative HU values within a large, heterogeneous population. Methods: We identified 2,020 trauma patients with a CT scan encompassing any part of their thoracic or lumbar spine. Mean HU values within each vertebral body were reported with respect to vertebral level, sex, and age. Using linear regression analysis, our data were also compared to DXA results in patients having both CT and DXA scans. Results: Analyses of CT scans yielded 28,083 unique vertebrae (18,489 male and 9,594 female) for which HU values were obtained. There were significant correlations between lumbar vertebral body HU and both DXA bone mineral density estimates (R2 = 0.50) and T-scores (p<0.001 and p<0.01, respectively). Using DXA T-scores as the reference standard, the sensitivity, specificity, and positive and negative predictive values of CT HU were 0.93, 0.75, 0.74 and 0.94, respectively. Conclusion: CT can be used to measure vertebral bone mineral density and may aid in the diagnosis and management of osteoporosis.