Prediction of intraoperative transfusion requirements during orthotopic liver transplantation and the influence on postoperative patient survival.

BACKGROUND: Predicting blood product transfusion requirements during orthotopic liver transplantation (OLT) remains difficult. Our primary aim in this study was to determine which patient variables best predict recipient risk for large blood transfusion requirements during OLT. The secondary aim was to determine whether the amount of blood products transfused during OLT impacted patient survival. METHODS: Eight hundred four primary adult OLTs performed during a 9-year period were retrospectively analyzed, and predictive models were developed for blood product usage, usage >20 and usage >30 units of red blood cells (RBCs) plus cell salvage (CS). For survival analysis, potential predictors included all blood products administered during OLT. RESULTS: For analyses of RBC + CS usage, we used several statistical techniques: regression analysis, logistic regression, and classification and regression tree analysis. Several preoperative factors were highly statistically significant predictors of intraoperative blood product usage in each of the analyses, namely lower platelet count and higher Model for End-Stage Liver Disease Score or one or more of its components (creatinine, total bilirubin, international normalized ratio). Despite these highly significant associations, the models were unable to predict reliably that patients might require the largest amount of blood products during OLT. For example, the classification and regression tree analyses were able to predict only 32% and 11% of patients requiring >20 and >30 units of RBC + CS, respectively. Survival analysis demonstrated poorer survival among patients receiving larger amounts of RBC + CS during OLT. CONCLUSION: Prediction of intraoperative blood product requirements based on preoperatively available variables is unreliable; however, there is a strong measurable association between transfusion and postoperative mortality.

Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies.

BACKGROUND: Major bile duct injuries remain a potentially devastating complication after laparoscopic cholecystectomy. A retrospective review was conducted of patients who underwent a biliary-enteric reconstruction of a biliary injury to assess their long-term outcome. METHODS: Retrospective review of bile duct injury database from January 1990 to December 2005. RESULTS: A total of 144 patients were treated for bile duct injury, and 84 (58%) required a biliary-enteric reconstruction. Stratification by Bismuth-Strasberg injury level revealed E1 or E2 in 23, E3 in 33, E4 in 17, E5 in 1, and B+C in 10. Forty-four (52%) were operated within 7 days of laparoscopic cholecystectomy, the remainder operated at a median of 79 days after referral. Early or late mortality occurred in 3 (4%). At a mean follow-up of 67 months, 9 patients (11%) developed a biliary stricture presented at a median of 13 months after bile duct repair. Level of injury was very important in predicting a postoperative biliary stricture: E4 (35%) versus E3 (9%; P = .023), and E4 versus E1, E2 B+C (0%; P = .001). More strictures occurred in patients operated within 7 days of laparoscopic cholecystectomy (19%) versus delayed repair (8%; P = .053). Overall, 90% of patients are alive and nonstented; 5 patients have chronic liver disease (1 on the waiting list for liver transplant). Nonbiliary complications occurred in 15 patients; the total morbidity was 40%. CONCLUSIONS: Bile duct injuries that require a biliary-enteric repair are commonly associated with long-term complications. Level of injury and likely timing of repair predict risk of postoperative stricture.

Perioperative and oncologic outcomes of minimally invasive liver resection for colorectal metastases: A case-control study of 130 patients.

BACKGROUND: Our aim was to compare the perioperative and oncologic outcomes of open liver resection and minimally invasive liver resection in the management of colorectal liver metastases. METHODS: Patients who underwent minimally invasive liver resection for colorectal liver metastases between January 2006 and June 2015 at a single center were identified and matched by extent of resection to consecutive open liver resection patients from the same period. Clinicopathologic characteristics, perioperative data, recurrence, and survival outcomes were collected and analyzed based on intention-to-treat. RESULTS: Sixty-five patients underwent minimally invasive liver resection during this period and were matched to 65 consecutive open liver resection patients, with similar baseline demographic, tumor, and chemotherapy parameters. Conversion to open occurred in 5 (7.7%) minimally invasive liver resection patients. R0 resection rates and operative times were comparable, but the estimated blood loss was less in the minimally invasive liver resection group (median 200 mL vs 400 mL, P < .001), as were perioperative transfusion rates (4.6% vs 15.4%, P = .04). The duration of stay was shorter after minimally invasive liver resection (median 4 days vs 6 days, P < .001), while major and minor complication rates were similar and no perioperative mortality was recorded. At a median follow-up of 28 months, there was no difference regarding disease-free (P = .90) or overall survival (P = .37). CONCLUSION: In selected patients with colorectal liver metastases, minimally invasive liver resection resulted in similar oncologic outcomes, with decreased blood loss and shorter duration of stay compared to patients who underwent open liver resection.

Natural history of indeterminate pancreatic cysts.

BACKGROUND: The optimal treatment for incidental asymptomatic pancreatic cysts is not known. The purpose of this study was to determine whether nonmucinous cysts by cyst-aspiration analysis can be observed safely. METHODS: A prospective protocol was initiated in September of 1999 for all suspected cystic neoplasms. Asymptomatic patients with negative cyst aspirates (no extracellular mucin, and concentration of carcinoembryonic antigen in the cyst fluid <200 ng/mL) were followed-up clinically and radiographically. RESULTS: Through December 2004, 221 patients have been evaluated, and 80 (36%) initially were operated. There were 141 (64%) patients with indeterminate cysts, 98 have been followed-up for more than 12 months. Compared with resected patients, observed patients were older (62 vs 56 y, P < .006), and had smaller cysts (2.4 vs 4.0, P = .001). At a mean follow-up period of 24 months, 4 patients (4%) were resected. The indication, time to resection, and pathology were as follows: 2 patients for symptoms (abdominal pain and obstructive jaundice) at 24 and 72 months, respectively: mucinous and serous cystadenomas; 1 patient for an increase in size (6.6 to 7.8 cm) at 18 months: lymphoepithelial cyst; and 1 patient for abdominal pain and increase in size (2.0 to 3.7 cm) at 41 months: pseudocyst. The only patient resected for a mucinous neoplasm had a cyst fluid carcinoembryonic antigen level of 896 ng/mL. In the remaining observed patients, 20 (23%) showed a decrease in cyst size, and 16 (19%) showed an increase in size (mean diameter change, 21%). CONCLUSIONS: Initial follow-up evaluation indicates that asymptomatic patients without evidence of a mucinous neoplasm by cyst aspiration can be followed clinically and with interval imaging.

Cystadenoma and cystadenocarcinoma of the liver: a single center experience.

BACKGROUND: Biliary cystadenomas and cystadenocarcinomas comprise 5% of cystic lesions in the liver. Cystadenomas are often incorrectly diagnosed as simple cysts, which results in inadequate therapy. Recurrence and possible malignant transformation are consequences of incomplete excision. Cystadenocarcinomas are very rare tumors that are felt to be biologically indolent. STUDY DESIGN: A retrospective review of 18 cystadenomas and 4 cystadenocarcinomas treated at the Cleveland Clinic from July 1985 to November 2002. RESULTS: All 18 patients with cystadenomas were women; mean age was 48 years. The majority (16 of 18) were symptomatic. Preoperative CT scans demonstrated cyst(s) with septations in all patients. Fifty-five percent had undergone prior intervention(s) to treat the cyst. Thirteen patients had complete excision of the cystadenoma, either by enucleation or liver resection. None of the patients developed recurrent cystadenomas (mean followup 37 months). Of 4 patients with cystadenocarcinoma, 3 were women; mean age was 60 years. All were symptomatic. Preoperative CT scans demonstrated masses with both cystic and solid components. No patient had undergone prior intervention. All had a liver resection. Two patients died of metastatic disease at 6 and 12 months, respectively. One patient is alive and disease-free at 16 years; 1 is alive with metastatic disease 10 years after the liver resection. CONCLUSIONS: Cystadenomas are uncommon tumors that are often incorrectly diagnosed as simple cysts. Preoperative imaging that demonstrates the presence of internal septations highly suggests the diagnosis of cystadenoma. Intraoperative biopsy and frozen section(s) are essential, although they are not 100% accurate. Cystadenomas require complete excision to prevent recurrence and the possibility of malignant transformation. Cystadenocarcinomas are very rare. Despite complete resection, cystadenocarcinomas can recur in a short period of time. The biologic behavior of these tumors can vary widely.

Hepatic abscess after liver transplantation: 1990-2000.

BACKGROUND: Infections following solid-organ transplants are a major cause of morbidity and mortality. Few studies have reported the complications of hepatic abscesses. METHODS: This investigation consisted of a retrospective chart review of all solid-organ transplant recipients from 1990 to 2000. Criteria for diagnosis included parenchymal hepatic lesions, positive cultures from liver aspirates or blood cultures, or both, and a compatible clinical presentation. RESULTS: Of 2,175 recipients of all organ transplants (heart, lung, kidney, liver, pancreas), we identified 12 patients who had experienced 14 episodes of hepatic abscess, all in liver transplant recipients. Median time from transplant to hepatic abscess was 386 days (range 25-4,198). The most common predisposing factor was hepatic artery thrombosis (HAT), which occurred in eight patients, and was diagnosed at an average of 249 days (range 33-3,215) after transplantation. Clinical presentation of hepatic abscess was similar to that described in non-immunosuppressed patients. All but one patient showed hypoalbuminemia (<3.5 g/dL); those with HAT also had significantly elevated lactate dehydrogenase. Liver aspirates grew gram-positive aerobic bacteria (50% of isolates), gram-negative aerobic bacteria (30%), and anaerobes and yeasts (10% each). Patients received an average of 6 weeks of intravenous antibiotic therapy. Catheter drainage was successful in 70% of cases; and five patients required retransplantation. Altogether, five of the patients died, yielding a mortality rate of 42%. CONCLUSIONS: Hepatic abscess, a rare complication after liver transplantation, was frequently associated with hepatic artery thrombosis. Mortality was higher than in patients who had not undergone transplantation. Prolonged antibiotic therapy, drainage, and even retransplantation may be required to improve the outcome in these patients.

The long-term survival and causes of death in patients who survive at least 1 year after liver transplantation.

BACKGROUND: The purpose of this study was to examine the long-term survival and causes of death in patients who survive the first year after liver transplantation. METHODS: The focus of the analysis was 433 patients who survived for at least 1 year after liver transplantation between November 1, 1984, and December 31, 2001. A total of 586 liver transplants were performed in 542 patients during this time period. The overall 1-, 5-, and 10-year survivals and the 5- and 10-year survivals for those patients who lived for a year were analyzed on the basis of Kaplan-Meier survival estimates. Factors examined included diagnosis, sex, age, and retransplantation. The causes of death were also analyzed. RESULTS: The overall 1-, 5-, and 10-year survivals were 85%, 73%, and 55%, respectively. The 5- and 10-year survivals for those patients who lived for a year were 86% and 65%, respectively. Fifty-one percent of the causes of late death were graft-related, 71% from recurrent primary disease. Cardiovascular events and de novo malignancies were responsible for 65% of the nongraft-related deaths. CONCLUSIONS: The long-term survival in patients who survive for the first year after liver transplantation is excellent. Recurrent primary disease is responsible for the majority of graft-related deaths. Cardiovascular events and de novo malignancy cause most of the nongraft-related deaths.

Prospective preoperative determination of mucinous pancreatic cystic neoplasms.

BACKGROUND: Optimal management of pancreatic cystic neoplasms includes identification and resection of mucinous neoplasms. This study was performed to assess the accuracy of preoperative variables in determining a mucinous lesion. METHODS: Patients referred for a cystic neoplasm were prospectively assessed by presenting symptoms, blinded radiologic review, and endoscopic ultrasound-guided cyst aspirate analysis. Patients who were symptomatic, or had aspirate findings of a mucinous neoplasm were resected. RESULTS: Eighty-seven patients were enrolled over a 22-month period ending in December 2001. There were 56 (64%) women and 31 (36%) men, with a mean age of 63 (27-86) years. Thirty-five (40%) patients were resected including 24 (69%) women and 11 (31%) men with a mean age of 58 years. Twenty-eight (80%) patients who had resection were symptomatic. Specimen histology included 18 (51%) mucinous neoplasms, 8 (23%) serous neoplasms, 4 (11%) ductal or neuroendocrine carcinomas, and 3 (9%) pseudocysts. The positive predictive value (PPV) for cyst-aspirate extracellular mucin (83%) was significant in predicting a mucinous neoplasm (P =.009). No other aspirate variables (amylase, carcinoembryonic antigen, CA15-3, viscosity), or patient characteristics were predictive of final histology. Diagnostic agreement between all 3 radiologists was 8% (P =.98). At a median follow-up of 12 months, no patients who were observed required resection. CONCLUSIONS: Patients with suspected pancreatic cystic neoplasms can be selectively treated on the basis of symptoms and cyst-aspirate mucin analysis. Symptomatic and mucin containing lesions should be resected.

Management of failed biliary repairs for major bile duct injuries after laparoscopic cholecystectomy.

BACKGROUND: Many bile injuries are managed without referral to tertiary centers. Management of patients referred for a primary repair, or after a failed repair, was reviewed to compare outcomes. STUDY DESIGN: Retrospective review of data collected in prospective database. RESULTS: A total of 133 patients had been treated over 12 years ending in December 2002. Forty-six (35%) were treated for failed earlier repairs and 40 (30%) had their primary surgical repair at our institution. Patients with a failed repair were referred at a longer interval (165 versus 9 days, p < 0.001), were more often diagnosed intraoperatively (28 [61%] versus 13 [33%], p = 0.009), and presented with biliary obstruction (41 [89%] versus 13 [33%], p < 0.001). Of the failed repairs, 26 patients (56%) had an earlier biliary-enteric anastomosis and 20 had primary end-to-end repair. One-third of failed repairs was successfully treated with stenting and was significantly more successful after a biliary-enteric anastomosis. Surgical revision of failed repairs was required in 27 patients (59%) and was more likely in earlier primary repairs. At a mean followup of 64 months, recurrent biliary strictures occurred in 5 patients (6%). CONCLUSIONS: Management of a failed major bile duct repair requires multiple modalities, but eventually the majority of repairs require surgical revision. Good results can be expected for all surgical biliary repairs at tertiary centers.

Gallbladder disease: an update on diagnosis and treatment.

This paper reviews the clinical presentation of gallstone disease, acalculous cholecystitis, biliary dyskinesia, and gallbladder cancer, as well as how to make best use of current diagnostic and treatment methods, particularly ultrasonography, cholescintigraphy, laparoscopic cholecystectomy, and endoscopic retrograde cholangiopancreatography.

Leukocyte reduction during orthotopic liver transplantation and postoperative outcome: a pilot study.

STUDY OBJECTIVE: To investigate the effect of intraoperative leukocyte reduction of administered blood products on the incidence of acute cellular rejection and postoperative patient outcome. DESIGN: Prospective, nonrandomized, historical control study. SETTING: Academic tertiary medical center. PATIENTS: The study group (Group 1) consisted of 30 consecutive adult patients with end-stage liver disease scheduled to undergo orthotopic liver transplantation (OLT) between 1998 and 2000. The historical control group (Group 2) consisted of 30 adult patients with end-stage liver disease matched to study group patients as closely as possible for age, gender, and etiology of liver disease who underwent OLT between 1995 and 1999. INTERVENTIONS: Group 1 patients had all intraoperative allogeneic and cell salvaged blood products leukocyte reduced before administration. Group 2 patients underwent OLT without leukocyte filtration of any administered blood products. MEASUREMENTS: Demographic data were collected for both patient groups and included age, gender, etiology of liver disease, and both intraoperative and postoperative immunosuppression. Demographic allograft donor data for both patient groups were collected and included age, gender, use of vasopressors during procurement, and cold and warm donor organ ischemic times. Outcome variables measured included incidence of acute cellular rejection, length of intensive care unit (ICU) and length of hospital stay, incidence of both graft loss and retransplantation, and mortality. MAIN RESULTS: The incidence of acute cellular rejection was 40% in Group 1 and 66.7% in Group 2 (p = 0.037). Length of ICU stay was 3.0 (2.0, 5.0) days in Group 1 and 4.0 (3.0, 6.0) days in Group 2 (p = 0.16). Length of hospital stay was 14.0 (11.0, 18.0) days in Group 1 and 18.0 (14.0, 27.0) days in Group 2 (p = 0.035). One allograft was lost in Group 2 because of primary nonfunction requiring retransplantation (p = 0.31), and three postoperative deaths occurred in Group 1 as a result of multisystem organ failure (p = 0.08). CONCLUSIONS: Coincident with leukocyte reduction of all administered blood products during OLT, an improved outcome was observed in Group 1 patients as demonstrated by both a decreased incidence of acute cellular rejection and length of hospital stay.

Jejunal cavernous lymphangioma.

Cavernous lymphangiomas are usually identified in infants and children with the majority of lesions found around the head and neck, trunk or extremities. Tumours affecting the intra-abdominal organs are rare. The authors report a case of small bowel cavernous lymphangioma arising within the jejunum of a 34-year-old woman presenting with dyspnoea and anaemia, and review the existing literature relating to this uncommon tumour.

Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients?

BACKGROUND: Blood flow to the liver is partly maintained by the hepatic arterial buffer response (HABR), which is an intrinsic autoregulatory mechanism. Temporary clamping of the portal vein (PV) results in augmentation in hepatic artery flow (augHAF). Portal hyperperfusion impairs HAF due to the HABR in liver transplantation (LT). The aim of this study is to examine the effect of the HABR on biliary anastomotic stricture (BAS). METHODS: In 234 cadaveric whole LTs, PV flow (PVF), basal HAF, and augHAF were measured intra-operatively after allograft implantation. All recipients with a vascular complication were excluded. Buffer capacity (BC) was calculated as (augHAF - basal HAF)/PVF to quantify the HABR. Recipients were divided into 2 groups based on their BC: low BC (<0.074; n = 117) or high BC (> or =0.074; n = 117). RESULTS: Of the 234 recipients, 23 (9.8%) had early BAS (< or =60 days after LT) and 18 (7.7%) had late BAS (>60 days after LT). The incidence of late BAS and bile leakage was similar between the groups; however, the incidence of early BAS in the low BC group was greater than that in the high BC group (15% vs 5.1%; P = .0168). In the multivariate analysis, low BC (P = .0325) and bile leakage (P = .0002) were found to be independent risk factors affecting early BAS. CONCLUSION: Recipients with low BC who may have impaired HABR are at greater risk of early BAS after LT. Intraoperative measurements of blood flow help predict the risk of BAS.

Management of suspected pancreatic cystic neoplasms based on cyst size.

BACKGROUND: Evaluation and management of cystic pancreatic neoplasms remain problematic. International consensus guidelines have advised resection for lesions greater than 3 cm. METHODS: We reviewed our prospective pancreatic cystic neoplasm database for outcomes based on a cyst size of 3 cm. RESULTS: Five hundred patients have been managed from 1999 to 2006. There were 349 patients (70%) with cysts less than or equal to 3 cm: 293 (84%) were not operated, including 243 nonmucinous cysts: 2 failed observation (0.8%, mean follow-up of 24 months). Fifty-six patients with cysts less than or equal to 3 cm were initially operated (16%), including 23 asymptomatic patients. Histopathology showed intraductal papillary mucinous neoplasm (IPMN) in 20, mucinous cystic neoplasm (MCN) in 18, and serous cystadenoma in 5. Twelve had carcinoma (21%). A total of 151 patients (30%) had cysts greater than cm: 87 (50%) were not operated, including 68 that were nonmucinous: 2 failed observation (2.9%, mean follow-up of 47 months). Sixty-four patients with cysts greater than 3 cm (42%) were initially operated, and final pathology showed MCN in 27, serous cystadenoma in 11, IPMN in 7, and pseudocyst in 7. Twelve had carcinoma (19%). Patients with cysts less than or equal to 3 cm were less likely to be operated (16 vs 42%; P < .001), less often symptomatic (39 vs 50%; P = .017), while older (mean age, 65 vs 61 years; P = .03). Had patients been managed by size alone, up to 20% would have received inappropriate treatment. Management based on aspiration was significantly better in predicting mucinous neoplasms compared with size (75% vs 57%; P < .001), including asymptomatic patients less than or equal to 3 cm (78% vs 65%; P = .003). CONCLUSION: Size of pancreatic cystic lesions alone is not a reasonable basis for determining management.

Intestinal malrotation: a rare but important cause of bowel obstruction in adults.

PURPOSE: Complications of intestinal malrotation are familiar to pediatric surgeons but are rarely encountered by those caring strictly for adults. The aim of this study was to review our experience with disorders of intestinal rotation in adult patients and to emphasize the clinical presentation, radiographic features, and results of surgical treatment. METHODS: Ten adult patients (mean age, 42 (range, 22-73) years) with complications of intestinal malrotation were identified by review of department records. Clinical presentation, operative treatment, and outcome were recorded. RESULTS: Nine patients presented with obstructive symptoms (five chronic and four acute). A diagnosis of malrotation was made preoperatively in all cases by a small-bowel contrast study or CT scan. Patients were treated by laparotomy with adhesiolysis (4 cases including one paraduodenal hernia and two midgut volvuli), Ladd's procedure (4 cases), or duodenopexy and cecopexy (1 case). One patient presented with an acute abdomen and was found to have appendicitis. There was no mortality. Two patients developed complications (wound infection and ileus). Two patients had recurrent episodes of small-bowel obstruction with a mean follow-up of 30 (range, 2-69) months and one required reoperation. CONCLUSIONS: Complications of intestinal rotation can occur in adult patients and may present with chronic or acute symptoms. Prompt recognition and surgical treatment usually lead to a successful outcome. The diagnosis of intestinal malrotation should be considered in any adult patient with signs and symptoms of small-bowel obstruction.