Ex-situ machine perfusion in clinical liver transplantation: Current practices and future directions.

Ex-situ machine perfusion of the liver has surmounted traditional limitations associated with static cold storage in the context of organ preservation. This innovative technology has changed the landscape of liver transplantation by mitigating ischemia perfusion injury, offering a platform for continuous assessment of organ quality, and providing an avenue for optimizing use of traditionally marginal allografts. This review summarizes the contemporary clinical applications of machine perfusion devices, and discusses potential future strategies for real-time viability assessment, therapeutic interventions, and modulation of organ function after recovery.

"Early" and "Late" Hospital readmissions in the first year after kidney transplant at a single center.

BACKGROUND: Hospital readmission (HR) after surgery is considered a quality metric. METHODS: Data on 2371 first-time adult kidney transplant (KT) recipients were collected to analyze the "early" (≤30 days) and "late" (31-365 days) HR patterns after KT at a single center over a 12-year time span (2002-2013). RESULTS: 30-day, 90-day, and 1-year HR were 31%, 41%, and 53%, respectively. Risk factors for HR included age >50, female sex, black race, BMI >30, transplant LOS >5 days, and pre-transplant time on dialysis >765 days. Indications for early (n = 749) and late (n = 508) HR were similar. Early HR (OR: 3.80, P = .007) and black race (OR: 2.38, P = .009) were associated with higher odds of 1-year graft failure while frequency (1-2, 3-4, 5+) of HR (ORs: 4.68, 8.36, 9.44, P < .001) and age > 50 (OR: 2.11, P = .007) were associated with higher odds of 1-year mortality. Transplant LOS > 5 days increased both odds of 1-year graft failure (OR: 3.51, P = .001) and mortality (OR: 2.05, P = .006). One-year graft and recipient survival were 96.7% and 94.8%, respectively. CONCLUSIONS: Hospital readmission was associated with reduced graft and patient survival; however, despite a relatively high and consistent HR rate after KT, overall 1-year graft and patient survival was high.

Interventions to Reduce Burnout and Improve Resilience: Impact on a Health System's Outcomes.

With the continuously changing health care environment and dramatic shift in patient demographics, institutions have the responsibility of identifying and dedicating resources for maintaining and improving wellness and resilience among front line providers to assure the quality of patient care. Our institution, the Ohio State University Wexner Medical Center (OSUWMC), has addressed the goal to decrease burnout for providers in a multistep, multiprofessional, and multiyear program starting firstly with institutional cultural change then focused provider interventions, and lastly, proactive resilience engagement. We describe herein our approach and outcomes as measured by provider wellness and health system outcomes. In addition, we address the overall feasibility and effectiveness of these programs in promoting provider compassion and mindfulness while reducing burnout and improving resilience. Institutional culture change and readiness were initiated in 2010 with the introduction of Crew Resource Management training for all providers across the OSUWMC. This multiyear program was implemented and has been sustained to the current day. Focused interventions to improve mindfulness were undertaken in the form of both Mindfulness in Motion (MIM) training for intensive care unit personnel and a "flipped classroom" mindfulness training for faculty and residents. Lastly, sustainable changes were introduced in the form of the Gabbe Health and Wellness program which consists of interprofessional MIM training and other wellness offerings for staff, faculty, and residents embedded across the entire medical center. The introduction of Crew Resource Management in 2010 continues to be endorsed and supported throughout OSUWMC for all providers, including residents and students. The improvements seen have not only improved patient satisfaction but also reduced patient safety events and improved national reputation for the institution as a whole. Subsequently, MIM training for intensive care unit providers has resulted in improved resilience as well as decreased patient safety events. In addition, the "flipped classroom" mindfulness training for residents and faculty has resulted in improvements in providing calm and compassionate care, improvements in physician wellbeing, and reductions in emotional exhaustion and depersonalization. Lastly, implementing the Gabbe Health and Wellness program inclusive of interprofessional MIM training for staff, faculty, and residents has resulted in significant reductions in burnout while significantly increasing resilience postintervention. The engagement from staff and enthusiasm to continue this program have escalated and been positively accepted across OSUWMC. To reduce the incidence of burnout, improve resilience, and ultimately improve patient outcomes, a health system must identify and prioritize a commitment and dedication of resources to develop and sustain a multimodal and interprofessional approach to change. These initiatives at OSU originated with cultural transformation allowing the acceptance of change in the form of mindfulness training, resilience building, and the engagement of organizational science, so as to demonstrate the outcomes and impact to the health system and academic peers. Herein we describe the work that has been done thus far, both published and in progress, to understand our journey.

Changes in the burnout profile of chairs of academic departments of obstetrics and gynecology over the past 15 years.

BACKGROUND: While many studies have documented the high prevalence of burnout in practicing physicians and medical trainees, fewer reports describe burnout in academic leaders. In 2002, we observed a moderate-high to high level of burnout in 41.4% of chairs of academic departments of obstetrics and gynecology. OBJECTIVE: The purpose of this study was to identify trends in burnout and associated factors in today's obstetrics and gynecology chairs as they face complex changes to the current health care environment. STUDY DESIGN: This was a cross-sectional study. A survey was developed based on the questionnaire used in our first investigation and sent electronically to all members of the Council of University Chairs of Obstetrics and Gynecology. Burnout was measured using an abbreviated Maslach Burnout Inventory-Human Sciences Survey. In addition to demographic data, we assessed perceived stressors, job satisfaction, spousal/partner support, self-efficacy, depression, suicidal ideation, and stress management. RESULTS: The response rate was 60% (84/139). Almost 30% of chairs were women, increased from 7.6% in 2002. Hospital and department budget deficits and loss of key faculty remain major stressors noted by participants. The Maslach Burnout Inventory results have changed dramatically over the past 15 years. Today's chairs demonstrated less burnout but with an "ineffective" profile. Subscale scores for emotional exhaustion and depersonalization were reduced but >50% reported low personal accomplishment. Spousal support remained important in preventing burnout. CONCLUSION: Chairs of academic departments of obstetrics and gynecology continue to face significant job-related stress. Burnout has decreased; however, personal accomplishment scores have also declined most likely due to administrative factors that are beyond the chairs' perceived control.

The Adrenal Gland as a Sanctuary Site of Metastases After Pembrolizumab Treatment: A Case Series.

Therapeutic agents targeting the PD-1/PD-L1 axis have shown durable clinical responses in patients with various cancer types. Although objective responses are common, intrapatient heterogeneous responses have been described, and the mechanism for the different organ responses remains unknown. We present a series of patients in whom a lack of response was noted solely in the adrenal glands. This is the first case series describing 3 patients with heterogeneous patterns of response to pembrolizumab with progression of adrenal metastatic disease despite objective response (complete or partial response) in all other sites of metastatic disease. Two patients, one with melanoma and one with uterine carcinosarcoma, underwent robotic adrenalectomy for enlarging adrenal metastases. An additional patient with melanoma underwent laparotomy with attempted resection, but infiltration of the adrenal tumor into the inferior vena cava prohibited safe excision. This report provides additional insight into the heterogeneous patterns of disease response to anti-PD-1 therapy, highlighting the adrenal gland as a potential sanctuary site for this immunotherapy. These cases display the potential benefit of early surgical resection in this scenario and the pitfalls of delaying referral to a surgeon for assessment of operative intervention.

A retrospective comparison of robotic cholecystectomy versus laparoscopic cholecystectomy: operative outcomes and cost analysis.

INTRODUCTION: Robotic-assisted surgery is gaining popularity in general surgery. Our objective was to evaluate and compare operative outcomes and total costs for robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC). METHODS AND PROCEDURES: A retrospective review was performed for all patients who underwent single-procedure RC and LC from January 2011 to July 2015 by a single surgeon at a large academic medical center. Demographics, diagnosis, perioperative variables, postoperative complications, 30-day readmissions, and operative and hospital costs were collected and analyzed between those patient groups. RESULTS: A total of 237 patients underwent RC or LC, and comprised the study population. Ninety-seven patients (40.9 %) underwent LC, and 140 patients (50.1 %) underwent RC. Patients who underwent RC had a higher body mass index (p = 0.03), lower rates of coronary artery disease (p < 0.01), and higher rates of chronic cholecystitis (p < 0.01). There were lower rates of intraoperative cholangiography (p < 0.01) and conversion to an open procedure (p < 0.01), however longer operative times (p < 0.01) for patients in the RC group. There were no bile duct injuries in either group, no difference in bile leak rates (p = 0.65), or need for reoperation (p = 1.000). Cost analysis of outpatient-only procedures, excluding cases with conversion to open or use of intraoperative cholangiography, demonstrated higher total charges (p < 0.01) and cost (p < 0.01) and lower revenue (p < 0.01) for RC compared to LC, with no difference in total payments (p = 0.34). CONCLUSIONS: Robotic cholecystectomy appears to be safe although costlier in comparison with laparoscopic cholecystectomy. Further studies are needed to understand the long-term implications of robotic technology, the cost to the health care system, and its role in minimally invasive surgery.

Development of a Prehospital Tranexamic Acid Administration Protocol.

OBJECTIVE: Early administration of tranexamic acid (TXA) has been shown to reduce all-cause mortality and death secondary to trauma. Our objective was to develop a collaborative prehospital TXA administration protocol between a ground EMS and academic medical center. METHODS: Physicians, pharmacists, and EMS and fire department personnel developed a prehospital TXA administration protocol between a local fire and EMS center with a Midwest tertiary care health system based on results from the CRASH-2 Trial. The protocol was initiated March 27, 2013 and the first dose of TXA was administered in September 2013. RESULTS: Since September 2013, nineteen trauma patients received TXA. Survival rate was 89% (17/19); 2 patients expired immediately following arrival to the trauma bay. Seven patients did not receive the in-hospital maintenance dose due to the following: 3/7 (43%) due to miscommunication of pre-TXA administration; 2/7 (29%) did not meet inclusion criteria for TXA protocol; 1/7 (14%) due to protocol noncompliance; 1/7 (14%) due to a chaotic situation with an unstable patient. CONCLUSIONS: Prehospital TXA protocol based on the CRASH-2 trial is safe and feasible. The first dose of TXA administered under this protocol marks the first ground EMS administration in the USA. Conceivably, this will pose as a model to other trauma centers that receive patients from outlying areas without immediate access to care. Large multi-institutional analyses need to be performed to evaluate survival benefits of prehospital TXA administration protocol.

Reproductive planning and infertility: Training the next generation of surgeons.

BACKGROUND: Female surgeons face increased rates of fertility challenges compared to the general population. We aim to understand surgical trainees' understanding and perspectives on family planning. METHODS: A 35-question survey was emailed to program directors at all US surgical residency programs for distribution to residents. Descriptive analyses were performed to evaluate resident understanding and perspectives on family planning and fertility treatments. RESULTS: A total of 121 residents responded to the survey. Most were female (n â€‹= â€‹78; 65 â€‹%). Responders indicated the need to postpone pregnancy during training (female: n â€‹= â€‹48, 64 â€‹% vs male n â€‹= â€‹18, 45 â€‹%; p â€‹= â€‹0.09). Potential negative career consequences (n â€‹= â€‹50; 42 â€‹%), limited leave benefits (n â€‹= â€‹47; 39 â€‹%), and lack of childcare (n â€‹= â€‹45; 38 â€‹%) were primary reasons for postponing pregnancy. Only nine responders (8 â€‹%) received fertility-preservation education. CONCLUSION: Surgical trainees delay pregnancy for career and social support concerns and are interested in reproductive preservation. Fertility education could provide needed support for trainees.

Declining Medicare reimbursement in abdominal transplantation from 2000 to 2021.

BACKGROUND: The Centers for Medicare and Medicaid Services is a major payer for abdominal transplant services. Reimbursement reductions could have a major impact on the transplant surgical workforce and hospitals. Yet government reimbursement trends in abdominal transplantation have not been fully characterized. METHODS: We performed an economic analysis to characterize changes in inflation-adjusted trends in Medicare surgical reimbursement for abdominal transplant procedures. Using the Medicare Fee Schedule Look-Up Tool, we performed a procedure code-based surgical reimbursement rate analysis. Reimbursement rates were adjusted for inflation to calculate overall changes in reimbursement, overall year-over-year, 5-year year-over-year, and compound annual growth rate from 2000 to 2021. RESULTS: We observed declines in adjusted reimbursement of common abdominal transplant procedures, including liver (-32.4%), kidney with and without nephrectomy (-24.2% and -24.1%, respectively), and pancreas transplant (-15.2%) (all, P < .05). Overall, the yearly average change for liver, kidney with and without nephrectomy, and pancreas transplant were -1.54%, -1.15%, -1.15%, and -0.72%. Five-year annual change averaged -2.69%, -2.35%, -2.64%, and -2.43%, respectively. The overall average compound annual growth rate was -1.27%. CONCLUSION: This analysis depicts a worrisome reimbursement pattern for abdominal transplant procedures. Transplant surgeons, centers, and professional organizations should note these trends to advocate sustainable reimbursement policy and to preserve continued access to transplant services.

Case report: Emphysematous pyelonephritis associated with kidney allograft abscess formation.

Emphysematous pyelonephritis (EPN) is a severe, acute necrotizing infection that is defined by the presence of gas in the kidney parenchyma. Multiple case reports have described the radiological findings and clinical course of EPN. Herein, we report on EPN including the histopathological findings in a kidney transplant recipient. Our patient presented with EPN complicated by multiorgan failure and was successfully managed with transplant nephrectomy.

Robotic Full Lobe Hepatectomy With Natural Orifice Extraction: Case Series Describing the Novel Technique of Robotic Major Hepatectomy and Transvaginal Specimen Extraction.

MINI-ABSTRACT: A minimally invasive approach to partial hepatectomy with transvaginal specimen extraction is safe and feasible with the potential to improve the cosmetic outcome, minimize postoperative narcotic utilization, and shorten hospital length of stay. This series describes the initial experience using this novel technique.

Left Renal Vein Ligation for Spontaneous Splenorenal Shunts During Deceased-Donor Orthotopic Liver Transplant Is Safe and Can Mitigate Complications from Portal Steal: A Case Series.

OBJECTIVES: Large spontaneous splenorenal shunts can result in portal vein steal syndrome and is a risk factor for portal vein thrombosis after orthotopic liver transplant. Disconnection of these shunts by left renal vein ligation has been suggested as a potential technique for improving portal venous flow and mitigating risk of portal vein thrombus, thus improving graft perfusion. We present a series of 6 patients who underwent left renal vein ligation for spontaneous splenorenal shunts and their outcomes. MATERIALS AND METHODS: This retrospective analysis included all orthotopic liver transplant recipients who underwent left renal vein ligation for spontaneous splenorenal shunts between 2016 and 2017. Portal venous flow, patency, and renal function were assessed postoperatively. Liver Doppler ultrasonography scans were obtained 1, 3, and 5 days postligation, and serum creatinine was evaluated at 1 and 2 weeks and 1, 3, 6, and 12 months postligation. RESULTS: Over the 1-year study period, 92 orthotopic liver transplants were performed. In 6 patients who underwent left renal vein ligation, spontaneous splenorenal shunts were identified preoperatively. One patient received a retransplant complicated by portal vein thrombus and underwent thrombectomy with left renal vein ligation. Concurrent left renal vein ligation and liver transplant were performed in 5 patients, 2 with known portal vein thrombus at the time of transplant requiring thrombectomy. All patients had subjective intraoperative improvements in portal venous flow after ligation. Zero patients developed postoperative portal vein thrombus. No patients developed clinically significant renal dysfunction at 1-year follow-up. CONCLUSIONS: Left renal vein ligation is technically feasible, has minimal and transient effects on renal function, and can improve portal venous flow, thus mitigating the risk for portal vein thrombus, graft hypoperfusion, and possible dysfunction.

Kidney Transplantation Confers Survival Benefit for Candidates With Pulmonary Hypertension.

Kidney transplantation (KT) is controversial in patients with pretransplant pulmonary hypertension (PtPH). We aimed to quantify post-KT graft and patient survival as well as survival benefit in recipients with PtPH. Methods: Using UR Renal Data System (2000-2018), we studied 90 819 adult KT recipients. Delayed graft function, death-censored graft failure, and mortality were compared between recipients with and without PtPH using inverse probability weighted logistic and Cox regression. Survival benefit of KT was determined using stochastic matching and stabilized inverse probability treatment Cox regression. Results: Among 90 819 KT recipients, 2641 (2.9%) had PtPH. PtPH was associated with higher risk of delayed graft function (odds ratio, 1.23; 95% CI, 1.10-1.36; P < 0.01), death-censored graft failure (hazard ratio [HR], 1.23; 95% CI, 1.11-1.38; P < 0.01), and mortality (HR, 1.56; 95% CI, 1.44-1.69; P < 0.01). However, patients with PtPH who received a KT had a 46% reduction in mortality (HR, 0.54; 95% CI, 0.48-0.61; P < 0.01) compared with those who remained on the waitlist. Conclusions: Although PtPH is associated with inferior post-KT outcomes, KT is associated with better survival compared with remaining on the waitlist. Therefore, KT is a viable treatment modality for appropriately selected patients with PtPH.

Transplant of SARS-CoV-2-infected Living Donor Liver: Case Report.

Given the high community prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), transplant programs will encounter SARS-CoV-2 infections in living donors or recipients in the perioperative period. There is limited data on SARS-CoV-2 viremia and organotropism beyond the respiratory tract to inform the risk of transplant transmission of SARS-CoV-2. We report a case of a living donor liver transplant recipient who received a right lobe graft from a living donor with symptomatic PCR-confirmed SARS-CoV-2 infection 3 d following donation. The donor was successfully treated with remdesivir, dexamethasone, and coronavirus disease 2019 (COVID-19) convalescent plasma. No viral transmission was identified, and both donor and recipient had excellent postoperative outcomes.

En bloc liver-kidney transplantation with renal artery variation using donor splenic artery and left gastric artery as inflow to the kidney: Case report.

INTRODUCTION: En bloc liver-kidney transplantation can be difficult with renal artery variations for which the risk of multiple anastomoses can outweigh the benefits. PRESENTATION OF CASE: This report is the first to describe an en bloc liver-kidney transplantation using a donor kidney with double renal arteries. The indication for a combined liver-kidney transplant was non-alcoholic steatohepatitis (NASH) cirrhosis with chronic kidney disease secondary to hypertension and diabetes compounded by hepato-renal syndrome. The explant pathology was consistent with steatohepatitis, but did have PAS/D-positive intracytoplastic globules which suggest an additional component of alpha-1-antitrypsin deficiency. DISCUSSION: Diminished arterial inflow to the inferior renal pole was noted intraoperatively, requiring re-anastomosis of the inferior renal polar artery to the donor left gastric artery. The post-operative course was uncomplicated with patient discharge on post-operative day six. CONCLUSION: With increasing numbers of simultaneous liver-kidney transplants being performed, kidneys with multiple renal arteries can successfully be transplanted en-bloc without compromising ischemia time.

Daily review of AHRQ patient safety indicators has important impact on value-based purchasing, reimbursement, and performance scores.

BACKGROUND: The Patient Safety Indicators (PSIs) Composite (PSI 90) of the Agency for Healthcare Research and Quality has been found to have low positive predictive values. Because scores can affect hospital reimbursement and ranking, our institution designed a review process to ensure accurate data and incur minimal penalties under the Hospital Value-Based Purchasing Program. METHODS: A multidisciplinary team was assembled to review PSI 90 within a performance period. The positive predictive value of each PSI was calculated. Weight-adjusted PSI rates were used to recalculate the PSI 90 Performance Period Index Value (PPIV). The adjusted PPIV was used to estimate what the achievement points and financial impact would have been if PSI review had not been implemented. Differences in PPIV, achievement points, and financial impact before and after PSI review were calculated. RESULTS: A total of 1,470 cases were flagged for PSI over a 2-year period. The positive predictive value was 63.3%. Refuting 36.7% of PSIs resulted in a decrease in the PPIV from 0.696 to 0.508, an increase in achievement points from 5 to 10, resulting in a decreased net loss of $111,773. CONCLUSION: Multidisciplinary review processes are practical and effective in identifying false-positive patient safety events. The real-time process affects hospital performance and resultant Medicare reimbursement substantially.

The Link Between Clinically Validated Patient Safety Indicators and Clinical Outcomes.

There is a paucity of evidence on the association between clinically validated Patient Safety Indicators (PSIs) and inpatient length of stay, mortality, and 30-day unplanned readmission. The authors perform a retrospective analysis of patient discharges from an academic medical center comprising 6 hospitals from July 2012 to June 2014. Multivariable regression models are used to assess the relationship between length of stay, mortality, and 30-day unplanned readmission and the presence of a clinically validated PSI. Cases flagged with a clinically validated PSI are associated with a statistically greater length of stay, 30-day unplanned readmission, and mortality as compared to cases without a PSI. This study demonstrates a strong association between clinically validated PSIs and patient outcomes. The findings have important implications in policy and practice as health care reform dictates improvement in the experience of care, health of populations, and per capita costs.

Mortality and readmission of outcomes after discharge from the surgical intensive care unit to long-term, acute-care hospitals.

BACKGROUND: Patients with prolonged hospitalizations in the surgical intensive care unit often have ongoing medical needs that require further care at long-term, acute-care hospitals upon discharge. Setting expectations for patients and families after protracted operative intensive care unit hospitalization is challenging, and there are limited data to guide these conversations. The purpose of this study was to determine patient survival and readmission rates after discharge from the surgical intensive care unit directly to a long-term, acute-care hospital. METHODS: All patients who were admitted to the surgical intensive care unit at an academic, tertiary care medical center from 2009-2014 and discharged directly to long-term, acute-care hospitals were retrospectively reviewed. Patients represented all surgical subspecialties excluding cardiac and vascular surgery patients. Primary outcomes included 30-day readmission, and 1- and 3-year mortality rates following discharge. RESULTS: In total, 296 patients were discharged directly from the surgical intensive care unit to a long-term, acute-care hospital during the study period. There were 190 men (64%) and mean age was 61 ± 16 years. Mean duration of stay in the surgical intensive care unit was 27 ± 17 days. The most frequent complication was prolonged mechanical ventilation (277, 94%) followed by pneumonia (139, 47%), sepsis (78, 26%), and acute renal failure (32, 11%); 93% of patients required tracheostomy and enteral feeding access prior to discharge, and 19 patients (6%) were newly dependent on hemodialysis. The readmission rate was 20%. There were 86 deaths within 1 year from discharge (29%) with an overall 3-year mortality of 32%. In a multiple logistic regression analysis, a history of end-stage renal disease had a greater odds of readmission (odds ratio 6.07, P = .028). Patients with history of cancer had greater odds of 1- and 3-year mortality (odds ratio = 2.99, P = .028 and odds ratio 2.56, P = .053, respectively), and patients with a neurologic diagnosis had greater odds of 3-year mortality (odds ratio 4.69, P = .031). Readmission significantly increased the odds of 1- and 3-year mortality (odds ratio 3.12, P = .020 and odds ratio 2.90, P = .027, respectively). Patients who had both private insurance and Medicare had greater odds of 1- and 3-year mortality (odds ratio 10.39, P = .005 and odds ratio 10.65, P = .004, respectively). CONCLUSION: Patients who are discharged to long-term, acute-care hospitals have prolonged hospitalizations with high complication rates. These patients have high readmission and 1-year mortality rates. Patients and families should be counseled regarding these outcomes related to post-intensive care unit recovery after discharge to a long-term, acute-care hospital to allow for realistic expectations of survival after prolonged intensive care unit hospitalization.