Risk Factor Analysis for Developing Major Complications Following Esophageal Surgery-A Two-Center Study.

BACKGROUND: Esophagectomy carries a high risk of morbidity and mortality compared to other major surgeries. With the aim of creating an easy-to-use clinical preoperative risk assessment tool and to validate previously described risk factors for major complications following surgery, esophagectomies at two tertiary medical centers were analyzed. METHODS: A total of 450 patients who underwent esophagectomy for esophageal carcinoma at the University Medical Centre, Hamburg, or at the Medical Center University Duisburg-Essen, Germany (January 2008 to January 2020) were retrospectively analyzed. Epidemiological and perioperative data were analyzed to identify the risk factors that impact major complication rates. The primary endpoint of this study was to determine the incidence of major complications. RESULTS: The mean age of the patients was 63 years with a bimodal distribution. There was a male predominance across the cohort (81% vs. 19%, respectively). Alcohol abuse (p = 0.0341), chronic obstructive pulmonary disease (p = 0.0264), and cardiac comorbidity (p = 0.0367) were associated with a significantly higher risk of major complications in the multivariate analysis. Neoadjuvant chemotherapy significantly reduced the risk of major postoperative complications (p < 0.0001). CONCLUSIONS: Various patient-related risk factors increased the rate of major complications following esophagectomy. Patient-tailored prehabilitation programs before esophagectomy that focus on minimizing these risk factors may lead to better surgical outcomes and should be analyzed in further studies.

Use or Misuse of Albumin in Critical Ill Patients.

Since 1940 albumin has been used worldwide and is widely available commercially since this time. However, a meta-analysis in 1998 challenged the use of albumin and identified a trend toward higher mortality in critically ill patients who had received albumin. Since then, many studies including multicenter randomized controlled trials have been carried out investigating the safety and efficacy of albumin treatment in different patient cohorts. In this context, patient cohorts that benefit from albumin were identified. However, particularly in non-liver patients, the use of albumin remains controversial. In our comprehensive review, we would like to highlight the most important studies in the recent 20 years and therefore offer an evidence-based outlook for the use of albumin for patients treated in the ICU.

Risk Factors for High Mortality on the Liver Transplant Waiting List in Times of Organ Shortage: A Single-Center Analysis.

BACKGROUND Germany has the highest rate of patients dying or becoming unfit for transplant while waitlisted within the Eurotransplant region. Therefore, the aim of the current study was to analyze mortality as well as risk factors for mortality of candidates listed for liver transplantation at our center. MATERIAL AND METHODS Between 01/2011 and 12/2013, 481 adult patients were listed for primary liver transplantation (LT) at a single German center. Clinical and laboratory parameters were prospectively collected and retrospectively analyzed by univariable and multivariable logistic regression and Cox proportional hazards. RESULTS The mean model for end-stage liver disease (MELD) score of all liver transplant waitlist registrants (52.4 years, 60.1% male) was 16.9 (±10.2) at time of listing, with 10% of the listed patients having a MELD score of >32. After waitlisting, 133 (27.7%) candidates died within the follow-up period. Three-month-survival after listing for transplantation was 89% for patients ultimately receiving LT vs. 71.2% that did not receive LT (p<0.001). Multivariable analysis identified clinical parameters such as ICU treatment, preceding abdominal surgery, variceal bleeding, and ascites, as well as hydropic decompensation, as independent risk factors for waitlist mortality. CONCLUSIONS Consideration of independent risk factors of mortality within the MELD-based allocation system potentially improves assessment of individual urgency and might improve utilization of available organs.

A non-interventional study of the genetic polymorphisms of NOD2 associated with increased mortality in non-alcoholic liver transplant patients.

BACKGROUND: Infections after liver transplantation are the main cause of death in the first year. Recent reports indicate that NOD2 gene mutations increase the risk for inflammatory bowl disease and the severity of graft-versus-host disease in bone marrow transplant patients. Data on polymorphisms in liver transplant patients are sparse. We analyzed 13 single-nucleotide polymorphisms (SNPs) of 13 different gene variants including the SNPs of NOD2 genes from liver recipients. The aim of the study was to evaluate the impact of the SNPs on dialysis-dependent kidney failure, the incidence of infections and patient survival. METHODS: During a period of 20-months, 231 patients were recruited in this non-interventional, prospective study. Thirteen different SNPs and their impact on the patients' survival, infection rate, and use of dialysis were assessed. RESULTS: NOD 2 wildtype genes were protective with respect to the survival of non-alcoholic, cirrhotic transplant patients (3 year survival: 66.8% wildtype vs. 42.6% gene mutation, p = 0.026). This effect was not observed in alcoholic transplant recipients.The incidence of dialysis-dependent kidney failure and infection in the liver transplant patients was not influenced by NOD 2 gene polymorphisms. No effect was noted in the remaining 12 SNPs.Patients with early allograft dysfunction experienced significantly more infections, required dialysis and had significantly worse survival.In contrast, the donor-risk-index had no impact on the infection rate, use of dialysis or survival. CONCLUSION: NOD2 gene variants seem to play a key role in non-alcoholic, liver transplant recipients. However these data should be validated in a larger cohort.

Delicate balance of bleeding and thrombosis in end-stage liver disease and liver transplantation.

Liver transplantation in cirrhotic patients is accompanied by severe bleeding. Indeed, the first 100 recipients of liver allografts transplanted by Thomas E. Starzl died mainly by uncontrolled bleeding. Since then, much progress has been made as to the understanding of the pathophysiology and the treatment of hemostatic disorders in cirrhotic patients. The aim of this review is to provide a state-of-the-art overview on recent developments and treatment options for hemostatic disorder in cirrhotic patients. Patients with end-stage-liver disease (ESLD) do not suffer only from procoagulant deficiency; there is also a lack of natural anticoagulants (i.e. proteins C and S) and profibrinolytics. Conventional laboratory methods such as the determination of the international normalized ratio or the activated partial thromboplastin time cannot predict bleeding complications in these patients. Progressive diagnostic techniques reveal that cirrhotic patients have the same capacity to produce thrombin like healthy volunteers. Moreover, cirrhotic patients--and particularly those with primary biliary cirrhosis or primary sclerosing cholangitis-- are at a higher risk for developing thrombosis as compared with healthy controls. Hemostatic alterations are common in cirrhotic patients; they involve both the pro- and the anticoagulant pathways. However, this is a very delicate balance, which may be shifted to either of these pathways by different treatments thereby causing bleeding or thrombosis, respectively.

Klatskin-mimicking lesions: still a diagnostical and therapeutical dilemma?

BACKGROUND/AIMS: The preoperative as well as the intraoperative differentiation between Klatskin-mimicking lesions and malignant bile duct tumors at hilar bifurcation is still challenging. Our intention was to review the preoperative diagnostics including preoperative CA19-9 and bilirubin serum levels to compare benign and malignant tumors. METHODOLOGY: We analyzed our prospectively established bile duct tumor database. From 1999 to 2008, 238 patients suspicious for hilar cholangiocarcinoma underwent surgery. In 24 patients the postoperative histological diagnosis showed a Klatskin-mimicking lesion. The histological report from 20 out of the 24 patients showed a chronic inflammatory transformation of the bile ducts. The histology of two patients showed a primary sclerosing cholangitis and the histological examination of the two remaining patients diagnosed a sarcoidosis of the extrahepatic bile duct. RESULTS: Reassessment of preoperative diagnostics did not deliver any change of interpretation of the tumors' dignity compared to how it had been assessed preoperatively. Also, preoperative CA19-9 serum levels do not show a statistically reliable differentiation between benign or malignant dignity. CONCLUSION: Current diagnostics cannot differentiate malignant from benign tumor masses in the hepatic hilum with the necessitated reliability. Therefore surgical resection of suspect hilar tumors is still the only appropriate therapy.

Does long-term ventilation with PEEP > or = 10mbar influence graft-function in patients following liver transplantation?

BACKGROUND/AIMS: Long-term positive end-expiratory pressure (PEEP) ventilation, particular with PEEP up to 15 mbar may impair graft-function in liver transplant (LT) patients. The aim of our study was to evaluate the impact of long-term high PEEP (at least 48 hours) on liver graft function. We retrospectively reviewed the records of 50 patients, who required artificial ventilation for at least 1 week with a PEEP level > or = 10mbar due to pulmonary complication caused mainly by sepsis (n = 19), pneumonia (n = 7) and lung edema associated with reperfusion syndrome or primary non-function of the graft (n = 13). Patients who required a PEEP > or = 10mbar within the first two days after transplantation (group A, n = 23) showed significant decrease of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin on day 3 and day 7 after initiation of high PEEP, whereas prothrombin time (PT) significantly increased on day 7. Group B (patients ventilated with PEEP > or = 10mbar after more than 2 days after transplantation, n = 27) showed a significant decrease of bilirubine and a significantly increase of PT on day 7. CONCLUSION: Long-term ventilation with PEEP levels of at least 10mbar does not harm graft function in patients following LT.

Neurologic complications in adult living donor liver transplant patients: an underestimated factor?

Liver transplantation is the only curative treatment in patients with end-stage liver disease. Neurological complications (NC) are increasingly reported to occur in patients after cadaveric liver transplantation. This retrospective cohort study aims to evaluate the incidence and causes of NC in living donor liver transplant (LDLT) patients in our transplant center. Between August 1998 and December 2005, 121 adult LDLT patients were recruited into our study. 17% of patients experienced NC, and it occurred significantly more frequently in patients with alcoholic cirrhosis (42%) and autoimmune hepatitis (43%) as compared with patients with hepatitis B or C (9/10%, P = 0.013). The most common NC was encephalopathy (47.6%) followed by seizures (9.5%). The choice of immunosuppression by calcineurin inhibitor (Tacrolimus or Cyclosporin A) showed no significant difference in the incidence of NC (19 vs. 17%). The occurrence of NC did not influence the clinical outcome, since mortality rate, median ICU stay and length of hospital stay were similar between the two groups. Most patients who survived showed a nearly complete recovery of their NC. NCs occur in approximately 1 in 6 patients after LDLT and seem to be predominantly transient in nature, without major impact on clinical outcome.

Severe neurological events following liver transplantation.

BACKGROUND: Problems related to the central nervous system may have major impact on morbidity and mortality. The aim of this retrospective study was to evaluate the nature and incidence of serious neurologic events in patients following liver transplantation. METHODS: Between January 2001 and May 2004, 168 patients (105 female, 63 male) requiring transplantation for alcoholic cirrhosis, hepatitis B and C, and acute liver failure were admitted to the Intensive Care Unit (ICU) of University Hospital Essen after liver transplantation. We identified the reason for the neurologic events, the underlying disease, type of immunosuppression, and the survival rate. RESULTS: Severe neurologic events occurred in 46 (27.3%) of the patients. The length of stay of these patients in the ICU (18.4 +/- 19.7 days) was longer in comparison to the total patients (8.3 +/- 9.5 days, p < 0.05). The most common neurological complications were encephalopathy (18.5%) and seizures (5.4%). The survival rate after liver transplantation with neurological events was lower compared to patients without, but not significantly different (73.9 vs. 79.5%). The calcineurin inhibitor used had no impact on neurological events [cyclosporine (25.5%); tacrolimus (32.5%)]. CONCLUSIONS: There was a high incidence of serious neurologic events after liver transplantation. The major neurologic manifestation in our patients was encephalopathy followed by seizures.