Introduction
Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive ...fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results.
Patients and methods
Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.
Results
A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (
n
= 136) and HCV (
n
= 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7%
p
=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years.
Conclusion
Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care
The initial management of patients with acute pancreatitis impacts both morbidity and mortality. Point-of-care decisions have been reported to differ from clinical guideline recommendations.
An ...online anonymous questionnaire was distributed through scientific associations and social media using REDCap. Multivariable logistic regression was used to identify the characteristics of participants associated with compliance with the recommendations.
A total of 1054 participants from 94 countries completed the questionnaire; median age (IQR) was 39 (32-47) years; 30.7% were women. Among the participants, 37% opted for nonmoderate flow of i.v. fluid, 31% for fluid type other than Ringer's lactate; 73.4% were in favor of nil per os to patients who could eat, 75.5% for other than enteral feeding to patients with oral intolerance; 15.5% used prophylactic antibiotic in patients with severe acute pancreatitis, 34.1% in necrotizing acute pancreatitis, and 27.4% in patients with systemic inflammatory response syndrome; 27.8% delayed cholecystectomy after biliary acute pancreatitis. Participants with publications in PubMed on acute pancreatitis showed better compliance (OR, 1.62; 95% CI: 1.15-2.32; P = .007) with recommendations of the clinical guidelines.
Feeding and nutrition require the greatest improvement efforts, but also the use of prophylactic antibiotics and timing of cholecystectomy should be improved.
Background:
Morbidly obese patients show several common comorbidities associated with immunological alterations such as a sustained low-level proinflammatory profile. Bacterial product translocation ...is frequent in inflammation-related diseases and may aggravate patients' clinical outcome.
Design:
Consecutively admitted morbidly obese patients who presented indications for bariatric surgery were studied. Before surgery, patients were subjected to a modified fasting diet. Patients underwent surgery by sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Clinical and analytical parameters were recorded. Blood samples were collected at baseline, at the end of a 3-month modified fasting period, and 3, 6, and 12 months after surgery. Serum cytokine and endotoxin levels were evaluated by flow cytometry and ELISA, respectively. Bacterial DNA was identified in blood by broad-range PCR of prokaryote 16SrRNA gene and partial sequencing analysis.
Results:
Fifty-eight patients were included in the study. All patients showed a significantly reduced weight and body mass index at each time-point. Postoperative mortality was null. Bacterial DNA translocation rate was 32.8% (19 of 58) at baseline; 13.8% (8 of 58) after the modified fasting period; and 13.8% (8 of 58), 1.8% (1 of 58), and 5.2% (3 of 58) at 3, 6, and 12 months after surgery. Proinflammatory cytokines, serum endotoxin levels, and insulin resistance remained increased in patients with bacterial DNA despite weight loss and were individually affected by the appearance/clearance of bacterial DNA in blood. Multivariate analyses revealed bacterial DNA as an independent significant factor, explaining the systemic cytokine response and the insulin resistance levels in the studied population.
Conclusion:
Bacterial DNA translocation holds increased insulin resistance and systemic inflammatory levels in morbidly obese patients despite significant weight loss.
The population of Latin America harbors the highest incidence of gallstones and acute biliary pancreatitis, yet little is known about the initial management of acute pancreatitis in this large ...geographic region.
We performed a post hoc analysis of responses from physicians based in Latin America to the international multidisciplinary survey on the initial management of acute pancreatitis. The questionnaire asked about management of patients during the first 72h after admission, related to fluid therapy, prescription of prophylactic antibiotics, feeding and nutrition, and timing of cholecystectomy. Adherence to clinical guidelines in this region was compared with the rest of the world.
The survey was completed by 358 participants from 19 Latin American countries (median age, 39 years 33–47; women, 27.1%). The proportion of participants in Latin America vs. the rest of the world who chose non-compliant options with clinical guidelines were: prescription of fluid therapy rate other than moderate (42.2% vs 34.3%, P=.02); prescription of prophylactic antibiotics for severe (10.6% vs 18.0%, P=.002), necrotizing (28.5% vs 36.9%, P=.008), or systemic inflammatory response syndrome-associated (21.2% vs 30.6%, P=.002) acute pancreatitis; not starting an oral diet to patients with oral tolerance (77.9% vs 71.1%, P=.02); and delayed cholecystectomy (16.2% vs 33.8%, P<.001).
Surveyed physicians in Latin America are less likely to prescribe antibiotics and to delay cholecystectomy when managing patients in the initial phase of acute pancreatitis compared to physicians in the rest of the world. Feeding and nutrition appear to require the greatest improvement.
La población de América Latina alberga la mayor incidencia de cálculos biliares y pancreatitis biliar aguda, sin embargo, poco se sabe sobre el manejo inicial de la pancreatitis aguda en esta extensa región geográfica.
Se realizó un análisis post hoc de las respuestas de los médicos de América Latina a la encuesta internacional multidisciplinar sobre el tratamiento inicial de la pancreatitis aguda. En el cuestionario se preguntaba por el manejo de los pacientes durante las primeras 72 h tras el ingreso, en relación con la fluidoterapia, la prescripción de antibióticos profilácticos, la alimentación y nutrición y el momento de la colecistectomía. La adherencia a las guías clínicas en esta región se comparó con la del resto del mundo.
La encuesta fue completada por 358 participantes de 19 países latinoamericanos (mediana de edad, 39 años 33-47; mujeres, 27,1%). La proporción de participantes de América Latina frente al resto del mundo que eligieron opciones no conformes con las guías clínicas fueron: prescripción de fluidoterapia en casos distintos de los moderados (42,2 vs. 34,3%, p = 0,02); prescripción de antibióticos profilácticos en casos graves (10,6 vs. 18%, p = 0,002); necrotizante (28,5 vs. 36,9%, p = 0,008) o asociada al síndrome de respuesta inflamatoria sistémica (21,2 vs. 30,6%, p = 0,002); no inicio de dieta oral en pacientes con tolerancia oral (77,9 vs. 71,1%, p = 0,02); y retraso de la colecistectomía (16,2 vs. 33,8%, p < 0,001).
Los médicos encuestados en América Latina son menos propensos a prescribir antibióticos y a retrasar la colecistectomía cuando tratan a pacientes en la fase inicial de la pancreatitis aguda, en comparación con los médicos del resto del mundo. La alimentación y la nutrición parecen requerir las mayores mejoras.
Previous studies indicated that laparoscopic surgery could improve postoperative outcomes in acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, or acute diverticulitis, but ...some reported opposite results or differences in the magnitude of improvement. A contemporary analysis using propensity score matching that compares outcomes is lacking.
Over a 6-month period, 38 centres (5% of all public hospitals) attending emergency general surgery patients on a 24 h, 7 days a week basis, enroled all consecutive adult patients who underwent laparoscopic surgery or open approach.
The study included 2 645 patients with acute appendicitis 32 years (22-51), 44.3% women, 1 182 with acute cholecystitis 65 years (48-76); 46.7% women, and 470 with gastrointestinal tract perforation 65 years (50-76); 34% women. After propensity score matching, hospital stays decreased in acute appendicitis open, 2 days (2-4); lap, 2 days (1-4); P <0.001, acute cholecystitis open, 7 days (4-12); lap, 4 days (3-6); P <0.001, and gastrointestinal tract perforation open, 11 days (7-17); lap, 6 days (5-8.5); P <0.001. A decrease in 30-day morbidity was observed in acute appendicitis (open, 15.7%; lap, 9.7%; P <0.001), acute cholecystitis (open, 41%; lap, 21.7%; P <0.001), and gastrointestinal tract perforation (open, 45.2%; lap, 23.5%; P <0.001). A decrease in 30-day mortality was found in acute cholecystitis (open, 8.8%; lap, 2.8%; P =0.013) and gastrointestinal tract perforation (open, 10.4%; lap, 1.7%; P =0.013).
This clinically based, multicentre study suggests that an initial laparoscopic approach could be considered not only in patients with acute appendicitis or acute cholecystitis but also in patients with a perforation of the gastrointestinal tract.
Bacterial (bact)DNA is an immunogenic product that frequently translocates into the blood in cirrhosis. We evaluated bactDNA clearance in patients undergoing liver transplantation (LT) and its ...association with inflammation and clinically relevant complications. We prospectively included patients consecutively admitted for LT in a one-year follow-up study. We evaluated bactDNA before and during the first month after LT, quantifying cytokine response at 30 days. One hundred patients were included. BactDNA was present in the blood of twenty-six patients undergoing LT. Twenty-four of these showed bactDNA in the portal vein, matching peripheral blood-identified bactDNA in 18 cases. Thirty-four patients showed bactDNA in blood during the first month after LT. Median TNF-α and IL-6 levels one month after LT were significantly increased in patients with versus without bactDNA. Serum TNF-α at baseline was an independent risk factor for bactDNA translocation during the first month after LT in the multivariate analysis (Odds ratio (OR) 1.14 1.04 to 1.29, P = 0.015). One-year readmission was independently associated with the presence of bactDNA during the first month after LT (Hazard ratio (HR) 2.75 1.39 to 5.45, P = 0.004). The presence of bactDNA in the blood of LT recipients was not shown to have any impact on complications such as death, graft rejection, bacterial or CMV infections. The rate of bactDNA translocation persists during the first month after LT and contributes to sustained inflammation. This is associated with an increased rate of readmissions in the one-year clinical outcome after LT.
While there is increasing interest in its use, definitive evidence demonstrating superiority of normothermic regional perfusion in controlled donation after circulatory death liver transplantation ...has not been presented. Unlike the rest of the Western world, where use of NRP has been anecdotal, 25% of all cDCD donors that have been performed in Spain since 2012 have included post-mortem NRP.
AIMAnalyze the first years of the Spanish experience with cDCD liver transplantation, in particular regarding the impact post-mortem NRP has had on organ utilization rates and transplant outcomes.
METHODSData was collected regarding potential cDCD liver donors and transplants that resulted between 2012 and 2016. All transplants had at least 6 mos of follow-up. Each donor hospital determined the process by which organs were recoveredNRP with pre-mortem cannulation, NRP with post-mortem cannulation, or super rapid recovery.
RESULTSFrom 2012 to 2016, 370 potential cDCD liver donors were evaluated152 with NRP and 218 with SRR. Ultimately, rates of liver transplantation were 64% NRP and 57% SRR (P=0.102). Among livers that were transplanted, median donor age was 57 (46-65 IQR). While there were no differences in terms of relevant donor or recipient characteristics when analyzed according to recovery method, the functional warm ischemia time was shorter when NRP was applied – 12 (10-16) NRP vs. 15 (11-20) SRR – given that in most cases femoral cannulae were placed prior to withdrawal of care. While rates of early allograft dysfunction (22% NRP vs. 29% SRR) and PNF (2% NRP vs. 4% SRR) did not vary, rates of overall biliary complications (9% NRP vs. 24% SRR, P=0.006) and ITBL (2% NRP vs. 12% SRR, P=0.01) were significantly improved among recipients of livers recovered with NRP. One-year graft survival was 87% NRP vs. 78% SRR (P=0.110). On multivariate analysis analyzing risk factors for ITBL (including fWIT), the only significant factor was the organ recovery method used.
CONCLUSIONSThis is the first large series describing the application of NRP in cDCD liver transplantation. While results with SRR were acceptable, results using NRP were superior and comparable to those achieved using standard-quality livers, even in spite of advanced donor age.
OBJECTIVE:To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery.
BACKGROUND:EPI is a common complication after pancreatic ...surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients.
METHODS:Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement.
RESULTS:These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were providedone (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement.
CONCLUSIONS:EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.
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