Intensive Care Unit Enhanced Recovery Pathway for Patients Undergoing Orthotopic Liver Transplants Recipients: A Prospective, Observational Study.

BACKGROUND: Liver transplant recipients continue to have high perioperative resource utilization and prolonged length of stay despite improvements in perioperative care. Enhanced recovery pathways have been shown in other surgical populations to produce reductions in hospital resource utilization. METHODS: A prospective, observational study was performed to examine the effect of an enhanced recovery pathway for postoperative care after liver transplantation. Outcomes from patients undergoing liver transplantation from November 1, 2013, to October 31, 2014, managed by the pathway were compared to transplant recipients from the year before pathway implementation. Multivariable regression analysis was used to assess the association of the clinical pathway on clinical outcomes. RESULTS: The intervention and control groups included 141 and 106 patients, respectively. There were no demographic differences between the control and intervention group including no differences between the length of surgery and cold ischemic time. Median intensive care unit length of stay was reduced from 4.4 to 2.6 days (P < .001). The intervention group had a higher likelihood of earlier discharge (hazard ratio [95% CI], 2.01 [1.55-2.62]; P < .001), and a 69% and 65% lower odds of receiving a plasma (P < .001) or packed red blood cell (P < .001) transfusion. There was no significant effect on hospital mortality (P = .40), intensive care unit readmission rates (P = .75), or postoperative infections (urinary traction infections: P = .09; pneumonia: P = .27). CONCLUSIONS: An enhanced recovery pathway focused on milestone-based elements of intensive care unit management and predetermined management triggers including hemodynamic goals, fluid therapy, perioperative antibiotics, glycemic control, and standardized transfusion triggers led to reductions in intensive care unit length of stay without an increase in perioperative complications.

Intraoperative blood loss predicts hemorrhage-related reoperation after orthotopic liver transplantation.

Postoperative hemorrhage after orthotopic liver transplantation (OLT) may require early reoperative intervention. Previous studies have shown intraoperative transfusion requirement as a main determinant of reoperative intervention after OLT. The goal of this study was to develop an intraoperative hemorrhage model predicting need for reoperation after OLT. A single institution, retrospective review of adult primary OLT patients from January 2002 to 2008 was conducted. Multivariate logistical regression analysis was performed to identify predictors of reoperation due to postoperative hemorrhage. Secondary analysis was conducted on patients in the reoperation group managed with temporary open abdomen techniques. Four hundred and ten primary transplantations were performed with 59 patients (14.4%) requiring reoperation. The adjusted odds of reoperation when intraoperative blood loss (IBL) increases from 1.5 L to 10.0 L is 2.48 [95% confidence interval: (1.18, 5.31)]. IBL of 10.0 L predicts a 19.4 per cent probability of reoperation. Patients managed with open abdomen (n = 8) exhibited a significant IBL difference (16.0 L vs. 6.0 L, P < 0.001) when compared with the closed abdomen cohort. Our results indicate that intraoperative blood loss is the primary predictor of reoperation after OLT and provide a hemorrhage threshold to guide postoperative management of complicated OLT patients.

Health insurance status affects staging and influences treatment strategies in patients with hepatocellular carcinoma.

BACKGROUND: Lack of health insurance is associated with poorer outcomes for patients with cancers amenable to early detection. The effect of insurance status on hepatocellular carcinoma (HCC) presentation stage and treatment outcomes has not been examined. We examined the effect of health insurance status on stage of presentation, treatment strategies, and survival in patients with HCC. METHODS: The Tennessee Cancer Registry was queried for patients treated for HCC between January 2004 and December 2006. Patients were stratified by insurance status: (1) private insurance; (2) government insurance (non-Medicaid); (3) Medicaid; (4) uninsured. Logistic, Kaplan-Meier, and Cox models tested the effects of demographic and clinical covariates on the likelihood of having surgical or chemotherapeutic treatments and survival. RESULTS: We identified 680 patients (208 private, 356 government, 75 Medicaid, 41 uninsured). Uninsured patients were more likely to be men, African American, and reside in an urban area (all P < 0.05). The uninsured were more likely to present with stage IV disease (P = 0.005). After adjusting for demographics and tumor stage, Medicaid and uninsured patients were less likely to receive surgical treatment (both P < 0.01) but were just as likely to be treated with chemotherapy (P ≥ 0.243). Survival was significantly better in privately insured patients and in those treated with surgery or chemotherapy (all P < 0.01). Demographic adjusted risk of death was doubled in the uninsured (P = 0.005). CONCLUSIONS: Uninsured patients with HCC are more likely to present with late-stage disease. Although insurance status did not affect chemotherapy utilization, Medicaid and uninsured patients were less likely to receive surgical treatment.

The negative effect of pretransplant overweight and obesity on the rate of improvement in physical quality of life after liver transplantation.

BACKGROUND: Recent studies suggest that obesity does not affect survival after liver transplantation. Overweight and obesity, however, impair health-related quality of life (HRQOL) in patients with chronic illnesses. We tested the effect of pretransplant body weight on HRQOL in liver transplant recipients. METHODS: Prospective, longitudinal HRQOL data were collected using the SF-36 health survey. Pretransplant body weight was stratified based on body mass index (BMI), as follows: normal (18.5-24.9), overweight (25.0-29.9), and obese (> or =30.0). Linear mixed-effects models were used to test the effects pretransplant BMI category on the trajectory of HRQOL after liver transplantation. RESULTS: The sample included 154 adults who underwent liver transplantation. Thirty-one percent had normal BMI, 41% were overweight, and 28% were obese pretransplant. The mean pretransplant physical HRQOL did not differ by BMI group (P > or = .697). Physical and mental HRQOL improved (P < .001) in all groups after transplantation, but the rate of improvement in physical HRQOL was significantly greater during the first year posttransplant in the normal BMI compared with the overweight and obese patients (P < or = .032). There was no effect of BMI on the rate of improvement in mental HRQOL. CONCLUSION: Excess pretransplant body weight hinders the rate of improvement in physical quality of life during the first year after liver transplantation.

Liver transplantation for iatrogenic porta hepatis transection.

Iatrogenic porta hepatis transection is a rare but devastating surgical complication. There are no systematic studies examining the best treatment strategy in patients with this injury. We report two cases of transection of all three portal structures, one during an open right adrenalectomy and another during a laparoscopic cholecystectomy, both of which were transferred to our tertiary care center hours postinjury. Diagnostic imaging and exploration revealed nonsalvageable livers, and both patients underwent total hepatectomies and portocaval shunting. Donor livers were available 12 to 20 hours after United Network for Organ Sharing Status 1 listing and both patients survived their postoperative course with 2- and 6-year follow up to date. Two-stage total hepatectomy with portocaval shunting followed by liver transplantation should be considered for patients presenting with porta hepatis transection.

The impact of tumor extent (T stage) and lymph node involvement (N stage) on survival after surgical resection for gallbladder adenocarcinoma.

INTRODUCTION: Tumor extent (T stage) and lymph node involvement (N stage) have a known combined negative effect on survival in patients with gallbladder adenocarcinoma, but the independent effects of these factors have been less well described. We investigated whether T stage and N stage independently predict survival after surgery for gallbladder adenocarcinoma. METHODS: We queried the Surveillance, Epidemiology and End Results database for patients treated with surgical resection for gallbladder adenocarcinoma between 1988 and 2004. Cases were stratified by disease severity based on tumor extent and nodal involvement. Kaplan-Meier and Cox regression methods were used to test the effect of disease severity and to develop multivariate models of the effects of demographic and clinical covariates on survival. Univariate and multivariate models were tested in the entire cohort and in a subsample with pathologically confirmed lymph node status. RESULTS: Four thousand and forty-eight patients who survived the immediate perioperative period comprised the full cohort. The subsample with pathologically confirmed lymph node status included 1298 patients. Age, gender, radiation treatment, tumor grade, tumor extent and lymph node status had statistically significant independent effects on survival in both models (all p<0.03). After accounting for T by N stage interactions, both tumor extent (1.21 < or = HR < or = 3.81, all p < or = 0.005) and lymph node involvement (1.80 < or = HR < or = 2.84, p<0.001) had independent effects on survival. CONCLUSIONS: Tumor extent and lymph node metastases are independent predictors of survival after surgical resection for gallbladder adenocarcinoma. Tumor penetration of the gallbladder wall and pathologically confirmed lymph node involvement each carry poor prognosis.

A prognostic system applicable to patients with resectable liver metastasis from colorectal carcinoma staged by positron emission tomography with [18F]fluoro-2-deoxy-D-glucose: role of primary tumor variables.

BACKGROUND: The purpose of this study was to develop a prognostic system applicable to patients with hepatic metastasis from colorectal cancer in whom extrahepatic disease was excluded by preoperative PET with [(18)F]fluoro-2-deoxy-D-glucose (FDG-PET). Data from two institutions were analyzed separately and together to improve general applicability of results. STUDY DESIGN: Data were analyzed for 285 consecutive patients undergoing liver resection for colorectal metastases from 1995 to 2005 at 2 institutions routinely using preoperative FDG-PET with. Fifteen clinicopathologic variables of the primary and secondary tumors were examined to identify factors predictive of survival. RESULTS: Outcomes were correlated with poorly differentiated tumor grade in both data sets. Because patients with poorly differentiated tumors comprised a small proportion (16%) of the population, patients with well-differentiated or moderately differentiated tumors were analyzed independently. In this subgroup, positive lymph node status in the primary colorectal tumor resection specimen was the only characteristic that predicted survival of patients in both institutions. Consequently, patients were sorted into three prognostic categories: poor tumor differentiation; well-differentiated or moderately differentiated tumors and node positive; and well-differentiated or moderately differentiated tumors and node negative. These groups had significantly different overall survival on Kaplan-Meier analysis (p=0.0014). CONCLUSIONS: In patients with colorectal liver metastases staged with FDG-PET with overall survival can be predicted directly from data in the pathology report of the colorectal primary tumor. This study also indicates the need for new molecular tumor markers of prognosis to complement clinicopathologic markers if the goal of prediction of outcomes in individual patients is to be reached.

Primary hepatic myxoid leiomyosarcoma: a case report and review of the literature.

Sarcomas of the adult liver are unusual neoplasms, and can sometimes pose a difficult differential diagnosis. The authors report a myxoid spindle cell tumor arising in the liver of a 26-year-old woman. Histopathologic, immunohistochemical, and ultrastructural analysis demonstrated features of smooth muscle differentiation. Neoplastic nuclei were positive for estrogen receptor-beta and androgen receptor, but not estrogen receptor-alpha or progesterone receptor. Based on the large size of the tumor and the presence of conspicuous mitotic activity, the diagnosis of myxoid leiomyosarcoma was made. This case represents the third documented example of this tumor in the liver. The differential diagnosis in relation to this particular site of origin is discussed.

Physician predictions of graft survival following liver transplantation.

INTRODUCTION: Due to the scarcity of cadaveric livers, clinical judgment must be used to avoid futile transplants. However, the accuracy of human judgment for predicting outcomes following liver transplantation is unknown. The study aim was to assess expert clinicians' ability to predict graft survival and to compare their performance to published survival models. MATERIALS AND METHODS: Pre-transplant case summaries were prepared based on 16 actual, randomly selected liver transplants. Clinicians specializing in the care of liver transplant patients were invited to assess the likelihood of 90-day graft survival for each case using (1) a 4-point Likert scale ranging from poor to excellent, and (2) a visual analog scale denoting the probability of survival. Four published models were also used to predict survival for the 16 cases. RESULTS. Completed instruments were received from 50 clinicians. Prognostic estimates on the two scales were highly correlated (median r=0.88). Individual clinicians' predictive ability was 0.61+/-0.13, by area under the receiver operating characteristic curve. The performance of published models was MELD 0.59, Desai 0.66, Ghobrial 0.61, and Thuluvath 0.45. For three cases, clinicians consistently overestimated the probability of survival (87+/-10%, 89+/-9%, 86+/-9%); these patients had early graft failures caused by postoperative complications. DISCUSSION. Clinicians varied in their ability to predict survival for a set of pre-transplant scenarios, but performed similarly to published models. When clinicians overestimated the chance of transplant success, either sepsis or hepatic artery thrombosis was involved; such events may be hard to predict before surgery.

National analysis of adverse patient safety for events in bariatric surgery.

Identifying risk factors for adverse events after bariatric surgery (BaS) can help define high-risk groups to improve patient safety. We calculated cumulative incidence of adverse events and identified risk factors for these events using validated surgical patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality. BaS patients > or =18 years old were identified using the 2002 Nationwide Inpatient Sample. Cumulative incidence at discharge was calculated for accidental puncture or laceration (APL), pulmonary embolus or deep venous thrombosis (PE/DVT), and postoperative respiratory failure (RF). Factors predictive of these PSIs were identified. From 7,853,982 discharges, a national cohort of 69,490 BaS patients was identified. During BaS hospitalization, the cumulative incidences per 1000 discharges of APL, PE/DVT, and RF were 12.6, 3.4, and 7.3, respectively. Risk factors for APL included male gender (odds ratio [OR] 1.6, 95% confidence interval 1.1-2.3, P < 0.05) and age of 40-49 years (OR 1.6 [1.1-2.3], P < 0.05) compared to ages 18-39 years. Patients aged 50-59 years (OR 3.5 [1.6-7.7], P < 0.05) had a higher chance of PE/DVT compared to those 18-39 years. Male gender (OR 1.8 [1.1-2.9], P < 0.05), ages 40-49 (OR 2.1 [1.1-4.2], P < 0.05) and 50-59 (OR 3.8 [2.1-6.9], P < 0.05), a history of chronic lung disease (OR 1.7 [1.1-2.7], P < 0.05), and Medicare coverage compared to private insurance (OR 2.2 [1.2-3.8], P < 0.05) were predictive of RF. This study established national measures for BaS adverse events. Further, risk factors associated with adverse events varied by gender, age, insurance status, and comorbidity. Evaluation of these higher risk BaS groups is needed to improve patient safety.

National variations in morbid obesity and bariatric surgery use.

BACKGROUND: Exploring bariatric surgery use provides data on effective treatment allocation. This study analyzed national rates of bariatric surgery use and the burden of morbid obesity by gender, census region, and age. STUDY DESIGN: Patients 18 years of age or older undergoing bariatric surgery were identified from the US 2002 Nationwide Inpatient Sample, and the national morbidly obese population 18 years of age or older was determined using the Centers for Disease Control and Prevention 2002 Behavioral Risk Factor Surveillance System databases. General population data were obtained from 2000 census data. Annual rates of bariatric surgery procedures were determined by gender, age group, and census region (Northeast, Midwest, South, and West). Rate ratios were calculated and significance tested through 95% confidence intervals (95% CI), accounting for the Nationwide Inpatient Sample and Behavioral Risk Factor Surveillance System sampling design. RESULTS: In 2002, a national cohort of 69,490 bariatric surgery patients was identified. Of these patients 85% were women and 76% were ages 18 to 49 years. The prevalence of morbid obesity (body mass index > or = 40 kg/m(2)) in the US in 2002 was 1.8%; 60% of morbidly obese people were women, and 63% were ages 18 to 49 years. The rates of bariatric surgery procedures per 100,000 morbidly obese individuals ranged from a low of 139 in men aged 60 years and older in the Midwest to a high of 5,156 in women ages 40 to 49 years in the Northeast. For both men and women, bariatric surgery rates in the West and Northeast were 1.35 (95% CI 1.31 to 1.40, p < 0.05) to 4.51 (95% CI 4.15 to 4.89, p < 0.05) times higher than in the South, respectively; rates in the Midwest were similar to those in the South. CONCLUSIONS: National estimates suggest that bariatric surgery rates do not parallel the burden of morbid obesity by region or age. Additional evaluation of these differences is necessary for optimal bariatric surgery use.

Risk factors for post-operative mortality in bariatric surgery.

BACKGROUND: Appropriate patient selection is crucial to the success of bariatric surgery (BaS). The objective of this study was to identify risk factors for increased post-operative mortality in patients undergoing BaS using a nationally representative sample. MATERIALS AND METHODS: BaS patients > or = 18 years old in the United States were identified from the 2001 Nationwide Inpatient Sample (NIS). The effect of gender, age, insurance status, and need for re-operation on post-operative mortality was examined using a multivariate logistic regression model. RESULTS: A national cohort of 54,878 patients was identified with age 41 +/- 0.2 years (mean +/- SE), 84% women, length of stay (LOS) 3.9 +/- 0.2 days, and overall mortality of 4 per 1,000 BaS patients. Mean LOS of those who died was 17.6 +/- 3.7 days. Adjusting for comorbidities and demographics, men had increased likelihood of death [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.1-4.3, P < 0.05]. Compared to younger patients, those aged above 39 years had over two-fold risk of death [ages 40-49: OR 2.6, 95% CI 1.1-6.5, P < 0.05; ages 50-59: OR 4.3, 95% CI 1.7-11, P < 0.05]. Medicaid patients [OR 4.7, 95% CI 1.2-13, P < 0.05 compared to privately insured] and those requiring re-operation [OR 22, 95% CI 5.4-88, P < 0.05] had higher odds of dying. CONCLUSION: Based on national data, risk factors for increased post-operative mortality in BaS patients include male gender, age > 39 years, Medicaid insured, and need for re-operation. These data can assist in optimizing BaS patient outcomes.

Survival after pediatric liver transplantation: why does living donation offer an advantage?

HYPOTHESIS: Living donor liver transplantation (LDLT) results in improved survival compared with deceased whole and split organ transplantation in children. OBJECTIVE: To evaluate the effect of LDLT on graft and patient survival in pediatric liver transplantation. DESIGN: Retrospective cohort. METHODS: Data included all pediatric recipients (aged <18 years) registered in the UNOS (United Network for Organ Sharing) database from October 1, 1987, to May 24, 2004. Covariates predictive of survival by univariate analyses were included in the Cox proportional hazards regression models in a blockwise fashion to determine predictors of survival. RESULTS: Kaplan-Meier graft and patient survival rates were improved in LDLT recipients compared with recipients of deceased whole and split organ transplantations (P<.01). In the initial model (model P<.001), prognostic factors for graft and patient survival included recipient age, race, origin of liver disease, certain pretransplantation laboratory data, medical condition, multiorgan transplantation, retransplantation, recipient-donor ABO blood compatibility, and cold and warm ischemia times. The addition of graft type to the initial covariate set did not significantly change the model (P = .21, covariate P = .09). However, most of the positive prognostic factors identified in the model were inherent characteristics of LDLT recipients and the LDLT procedure. CONCLUSIONS: Graft and patient survival in the pediatric population is better with LDLT than deceased organ transplantation. Factors that contribute to this difference include recipients who are less ill, who have shorter cold and warm ischemia times, and those with a decreased need for retransplantation but not the type of graft per se.

Effective treatment of biliary cystadenoma.

OBJECTIVE: Evaluate experience over 15 years with treatment of this lesion. SUMMARY BACKGROUND DATA: Biliary cystadenoma, a benign hepatic tumor arising from Von Meyenberg complexes, usually present as septated intrahepatic cystic lesions. METHODS: Data were collected concurrently and retrospectively on patients identified from hospital medical records reviewed for pertinent International Classification of Diseases, Ninth Revision, Clinical Modification and CPT codes, pathology logs, and from operative case logs. Pathology specimens were rereviewed to confirm the diagnosis of biliary cystadenoma or biliary cystadenocarcinoma by 2 GI pathologists. RESULTS: From October 1989 to April 2004 at our institution, 19 (18F:1M) patients had pathologically confirmed biliary cystadenomas, including one with a biliary cystadenocarcinoma. The mean age was 48 +/- 15 years at initial evaluation. Complaints included abdominal pain in 74%, abdominal distension in 26%, and nausea/vomiting in 11%. Only 1 patient presented with an incidental finding. Symptoms had been present for 3 +/- 5 years, with 1 to 4 different surgeons and many other physicians involved in the diagnosis or treatment prior to definitive ablation. Eight patients had undergone 20 previous treatments, including multiple percutaneous aspirations in 4 and 11 operative procedures. CT or US was diagnostic in 95%, with internal septations present in the hepatic cysts. Definitive operative intervention consisted of hepatic resection in 12 patients, enucleation in 6 patients, and fenestration and complete fulguration in 1 patient. There were no perioperative deaths. No recurrences were observed after definitive therapy, with follow-up of 4 +/- 4 years. CONCLUSIONS: Biliary cystadenoma must be recognized and treated differently than most hepatic cysts. There remains a need for education about the imaging findings for biliary cystadenoma to reduce the demonstrated delay in appropriate treatment. Traditional treatment of simple cysts such as aspiration, drainage, and marsupialization results in near universal recurrence and occasional malignant degeneration. This experience demonstrates effective options include total ablation by standard hepatic resection and cyst enucleation.

Impact of donor, technical, and recipient risk factors on survival and quality of life after liver transplantation.

HYPOTHESIS: Donor, technical, and recipient risk factors cumulatively impact survival and health-related quality of life after liver transplantation. DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: A total of 483 adults undergoing primary orthotopic liver transplantation between January 1, 1991, and July 31, 2003. MAIN OUTCOME MEASURES: Graft and patient survival, Karnofsky functional performance scores, Medical Outcomes Study Short Form 36 Health Survey scores, and Psychosocial Adjustment to Illness Scale scores as influenced by potential risk factors including donor age, weight, warm ischemia time, cold ischemia time (CIT), sex, United Network for Organ Sharing (UNOS) status (1 or 2A vs 2B or 3), recipient age and disease, bilirubin level, and creatinine level. RESULTS: Five-year graft survival was 72% for recipients of donors younger than 60 years and 35% for recipients of donors 60 years and older (P<.001). A CIT of 12 hours or more was associated with shorter 5-year graft survival (71% vs 58%; P = .004). Five-year graft survival for UNOS status 2B or 3 was 71% vs 60% for status 1 or 2A (P = .02). A comparable pattern was seen for patient survival in relation to donor age (P = .003), CIT (P = .005), and urgency status (P = .03). Urgent UNOS status, advanced donor age, and prolonged CIT were independently associated with shorter graft and patient survival (P<.05). Functional performance and health-related quality of life were not affected by donor, recipient, or technical characteristics. CONCLUSIONS: Combining advanced donor age, urgent status, and prolonged CIT adversely affects graft and patient survival, and the cumulative effects of these risk factors can be modeled to predict posttransplant survival.

Is there racial disparity in outcomes after solid organ transplantation?

BACKGROUND: We sought to determine if disparities in survival and health-related quality of life (HRQOL) occurred after solid organ transplantation at our institution. METHODS: Data were extracted from a database including information regarding transplants that took place from 1990 to 2002. The HRQOL was assessed in patients by using the Karnofsky functional performance (FP) index and the Medical Outcomes Study Short Form 36 (SF-36) questionnaire. RESULTS: Data were collected on recipients of liver (n = 413), heart (n = 299), kidney (n = 892), and lung (n = 156). Blacks represented a minority of recipients: liver 7%, heart 8%, kidney 23%, and lung 6%. There were no statistically significant differences in patient survival between blacks and whites. Graft survival differed in kidney only with a 5-year survival: 72% for blacks versus 79% for whites (P <0.001). The FP and HRQOL improved (P <0.05) after transplantation in both groups. There were no differences on measures of the FP or HRQOL. CONCLUSIONS: Blacks had comparable survival and improvement in FP and HRQOL in comparison with whites.

Contralateral portal vein embolization for hepatectomy in the setting of hepatic steatosis.

Portal vein embolization is evolving as an important adjunctive tool in hepatic surgery. In select patients, preoperative hypertrophy of the future remnant liver via contralateral portal vein embolization decreases postoperative liver dysfunction. Hepatic steatosis is the most common liver parenchymal disorder in Western populations. Moderate and severe degrees of hepatic steatosis convey an increased risk of postoperative liver dysfunction following major hepatic resections, but no studies exist examining the role of preoperative portal vein embolization in patients with hepatic steatosis. In this manuscript, we review the indications for portal vein embolization currently supported by the literature and present a patient with moderate to severe steatosis who successfully underwent portal vein embolization and a subsequent major liver resection.

Use of percutaneous drainage to treat hepatic abscess after radiofrequency ablation of metastatic pancreatic adenocarcinoma.

Radiofrequency ablation (RFA) is well described in the treatment of primary hepatic malignancies and colorectal carcinoma hepatic metastases. A known complication of RFA is the development of hepatic abscess. The management of hepatic abscesses subsequent to RFA for metastatic disease is not well described. A 49-year-old female with pancreatic adenocarcinoma underwent pancreaticoduodenectomy followed by adjuvant chemoradiation. Following 6 months' treatment, a new liver metastasis was identified. It remained stable for 6 months during additional chemotherapy and thereafter was treated with RFA. Three weeks after RFA, the patient presented with malaise and leukocytosis, and a CT scan demonstrated a large hepatic abscess at the site of the RFA. She remained febrile despite needle aspiration and intravenous antibiotics. A percutaneous drain was placed and the symptoms resolved. Contrast injection of the drain 4 weeks later demonstrated resolution of the abscess cavity but communication with the biliary tree. The drain was removed and the tract embolized with Gel-foam to prevent complications of biliary-cutaneous fistula. She remains well without evidence of abscess or disease recurrence. Thus, RFA can be used in treatment of limited isolated hepatic metastases from previously treated pancreatic adenocarcinoma. However, the incidence of hepatic abscess is increased due to bilioenteric anastomosis; extended antibiotic prophylaxis should be considered.

Long-term detrimental effect of bile duct injury on health-related quality of life.

HYPOTHESIS: Long-term quality of life (QOL) in patients undergoing laparoscopic cholecystectomy (LC) incurring bile duct injury (BDI) and repair is comparable to that of patients undergoing uncomplicated LC. DESIGN: Case comparison study. SETTING: Secondary and tertiary care centers. PATIENTS: Eighty-six patients incurring BDI during LC between January 1, 1991, and July 31, 2003, were surveyed. Comparison subjects underwent uncomplicated LC during the same period. MAIN OUTCOME MEASURES: Health-related QOL as assessed by the Karnofsky Performance Scale, Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), and Psychosocial Adjustment to Illness Scale. RESULTS: Fifty patients with BDI (39 [78%] female; mean +/- SEM age, 55 +/- 2 years) and 74 patients with uncomplicated LC (51 [69%] female, mean +/- SEM age, 52 +/- 2 years) responded. Of the 50 BDI patients, 48 (96%) had no stricture and normal liver function at QOL assessment. The mean +/- SEM follow-up period to QOL assessment for the BDI and uncomplicated LC groups was 62 +/- 6 and 47 +/- 3 months, respectively. The mean +/- SD Karnofsky Performance Scale scores were 77 +/- 9 vs 93 +/- 8 for the 2 groups, respectively (P <.001). The mean +/- SD SF-36 physical component scale scores after BDI vs uncomplicated LC were 36 +/- 11 vs 47 +/- 12, respectively (P <.001), compared with 50 +/- 10 for the normal population (P <.001). The mean +/- SD SF-36 mental component scale scores were 43 +/- 14 vs 49 +/- 11 for the 2 groups, respectively (P =.02), compared with 50 +/- 10 for the normal population (P =.01). Patients with BDI scored poorer on the Psychosocial Adjustment to Illness Scale health care orientation and domestic environment scales (P=.01). CONCLUSION: After BDI and repair, there are long-term detrimental effects of BDI on health-related QOL.