Impact of Surgeon's Experience on Vascular and Haemorrhagic Complications After Kidney Transplantation.

OBJECTIVE: The aim of this study was to investigate the independent risk factors of vascular and haemorrhagic complications after kidney transplantation (KTx) and to evaluate how the surgeon's experience affects the rate of vascular and haemorrhagic complications. METHODS: After exclusion of paediatric and multi-organ transplantations, 1462 KTx operations between 2000 and 2016 were analysed. Independent risk factors were evaluated by multivariable logistic regression analysis. The generalised estimating equation logit model was used to display learning curve progression and determine the best cut off number of KTx operations to reduce vascular and haemorrhagic complications. RESULTS: Vascular and haemorrhagic complications occurred in 38 KTx cases (2.6%). Renal vein thrombosis was the most common complication (0.6%). Graft loss occurred in 11 of 38 (28.9%) cases. Donor age of >60 years (OR 3.687, 95% CI 1.663-8.175, p = 0.001), recipient cardiovascular disease (CVD) (OR 2.270, 95% CI 1.071-4.810, p = 0.032), and surgeon's experience (OR 0.875, 95% CI 0.783-0.977, p = 0.018) were independent predictors of vascular and haemorrhagic complications. Twenty-six previous KTx operations are needed to decrease predicted probability of post-KTx vascular and haemorrhagic complications below 2.6%. CONCLUSIONS: The surgeon's experience is an independent risk factor for vascular and haemorrhagic complications after KTx. Acceptable post-operative vascular and haemorrhagic complications are achieved after a minimum of 26 KTx. As a donor age of >60 years and recipient CVD are also independent risk factors for vascular and haemorrhagic complications, it is suggested that these patients should preferably be operated on by surgeons who have performed more than 26 KTx operations.

Does acid-base equilibrium correlate with remnant liver volume during stepwise liver resection?

Small for size and flow syndrome (SFSF) is one of the most challenging complications following extended hepatectomy (EH). After EH, hepatic artery flow decreases and portal vein flow increases per 100 g of remnant liver volume (RLV). This causes hypoxia followed by metabolic acidosis. A correlation between acidosis and posthepatectomy liver failure has been postulated but not studied systematically in a large animal model or clinical setting. In our study, we performed stepwise liver resections on nine pigs to defined SFSF limits as follows: step 1: segment II/III resection, step 2: segment IV resection, step 3: segment V/VIII resection (RLV: 75, 50, and 25%, respectively). Blood gas values were measured before and after each step using four catheters inserted into the carotid artery, internal jugular vein, hepatic artery, and portal vein. The pH, [Formula: see text], and base excess (BE) decreased, but [Formula: see text] values increased after 75% resection in the portal and jugular veins. EH correlated with reduced BE in the hepatic artery. Pco2 values increased after 75% resection in the jugular vein. In contrast, arterial Po2 increased after every resection, whereas the venous Po2 decreased slightly. There were differences in venous [Formula: see text], BE in the hepatic artery, and Pco2 in the jugular vein after 75% liver resection. Because 75% resection is the limit for SFSF, these noninvasive blood evaluations may be used to predict SFSF. Further studies with long-term follow-up are required to validate this correlation.NEW & NOTEWORTHY This is the first study to evaluate acid-base parameters in major central and hepatic vessels during stepwise liver resection. The pH, [Formula: see text], and base excess (BE) decreased, but [Formula: see text] values increased after 75% resection in the portal and jugular veins. Extended hepatectomy correlated with reduced BE in the hepatic artery. Because 75% resection is the limit for small for size and flow syndrome (SFSF), postresection blood gas evaluations may be used to predict SFSF.