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Boussier J, Lemasle A, Hantala N, Scatton O, Vaillant JC, Paye F, Langeron O, Lescot T, Quesnel C, Verdonk F, Eyraud D, Sitbon A, Delorme L, Monsel A. Lung Ultrasound Score on Postoperative Day 1 Is Predictive of the Occurrence of Pulmonary Complications after Major Abdominal Surgery: A Multicenter Prospective Observational Study. Anesthesiology 2024; 140:417-429. [PMID: 38064713 DOI: 10.1097/aln.0000000000004855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Postoperative pulmonary complications after major abdominal surgery are frequent and carry high morbidity and mortality. Early identification of patients at risk of pulmonary complications by lung ultrasound may allow the implementation of preemptive strategies. The authors hypothesized that lung ultrasound score would be associated with pulmonary postoperative complications. The main objective of the study was to evaluate the performance of lung ultrasound score on postoperative day 1 in predicting pulmonary complications after major abdominal surgery. Secondary objectives included the evaluation of other related measures for their potential prediction accuracy. METHODS A total of 149 patients scheduled for major abdominal surgery were enrolled in a bicenter observational study. Lung ultrasound score was performed before the surgery and on days 1, 4, and 7 after surgery. Pulmonary complications occurring before postoperative day 10 were recorded. RESULTS Lung ultrasound score on postoperative day 1 was higher in patients developing pulmonary complications before day 10 (median, 13; interquartile range, 8.25 to 18; vs. median, 10; interquartile range, 6.5 to 12; Mann-Whitney P = 0.002). The area under the curve for predicting postoperative pulmonary complications before day 10 was 0.65 (95% CI, 0.55 to 0.75; P = 0.003). Lung ultrasound score greater than 12 had a sensitivity of 0.54 (95% CI, 0.40 to 0.67), specificity of 0.77 (95% CI, 0.67 to 0.85), and negative predictive value of 0.74 (95% CI, 0.65 to 0.83). Lung ultrasound score greater than 17 had sensitivity of 0.33 (95% CI, 0.21 to 0.47), specificity of 0.95 (95% CI, 0.88 to 0.98), and positive predictive value of 0.78 (95% CI, 0.56 to 0.93). Anterolateral lung ultrasound score and composite scores using lung ultrasound score and other patient characteristics showed similar predictive accuracies. CONCLUSIONS An elevated lung ultrasound score on postoperative day 1 is associated with the occurrence of pulmonary complications within the first 10 days after major abdominal surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Jeremy Boussier
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - Aymeric Lemasle
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - Nicolas Hantala
- Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Sorbonne University, GRC 29, DMU DREAM, Greater Paris University Hospitals, Paris, France
| | - Olivier Scatton
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - Jean-Christophe Vaillant
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - François Paye
- Department of Surgery, Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Henri-Mondor University Hospital, Greater Paris University Hospitals, University Paris-Est-Créteil, Paris, France
| | - Thomas Lescot
- Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Sorbonne University, GRC 29, DMU DREAM, Greater Paris University Hospitals, Paris, France
| | - Christophe Quesnel
- Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Sorbonne University, GRC 29, DMU DREAM, Greater Paris University Hospitals, Paris, France
| | - Franck Verdonk
- Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Sorbonne University, GRC 29, DMU DREAM, Greater Paris University Hospitals, Paris, France
| | - Daniel Eyraud
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - Alexandre Sitbon
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - Louis Delorme
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Sorbonne University, Paris, France; Sorbonne Université-INSERM UMRS_959, Immunology-Immunopathology-Immunotherapy, Paris, France; Biotherapy (CIC-BTi), La Pitié-Salpêtrière Hospital, Greater Paris University Hospitals, Paris, France
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Eyraud D, Creux M, Lastennet D, Lemoine L, Vaillant JC, Savier E, Vézinet C, Scatton O, Granger B, Puybasset L, Loncar Y. Restrictive intraoperative fluid intake in liver surgery and postoperative renal function: A propensity score matched study. Clin Res Hepatol Gastroenterol 2022; 46:101899. [PMID: 35257960 DOI: 10.1016/j.clinre.2022.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) is a common complication in hepatic surgery. In hepatic surgery, relative hypovolemia may help to limit blood loss, but the consequences of restrictive fluid intake are unknown. The goal of this study was to determine the influence of intraoperative fluid intake on the incidence of AKI and its consequences. METHODS Data from 397 consecutive patients who underwent liver resection were prospectively recorded and retrospectively analyszed. We compared the incidence of postoperative acute kidney failure in patients given restrictive (≤ 5 mL/kg/h) versus liberal (> 5 mL/kg/h) fluid therapy. We calculated a 1:1 match propensity score using logistic regression to estimate the likelihood of patients receiving restrictive or liberal intraoperative fluid intakes. The association between the intraoperative fluid intake strategy and occurrence of postoperative AKI were tested using a Cox frailty model on the database of matched patients. RESULTS Postoperative AKI was diagnosed in 133 of the 397 patients. Fluid intake strategy was restrictive for 121 patients and liberal for 276 patients. After propensity score matching to balance confounding factors, the liberal strategy was associated with a significantly lower risk for postoperative AKI compared to the restrictive strategy (Hazard Ratio 0.40 [0.29; 0.56], P<0.001). Patients with postoperative AKI had longer hospital stays and higher mortality. There were no cases of further blood loss in the liberal fluid intake group. CONCLUSIONS A restrictive fluid intake strategy is a risk factor for developing postoperative AKI, with serious consequences, without reducing blood loss in liver surgery.
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Affiliation(s)
- Daniel Eyraud
- Department of Anesthesiology and Critical Care, GRC 29, DREAM DMU, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France; Department of Digestive, HPB Surgery, and Liver Transplantation, University Hospitals Pitié-Salpêtrière Charles-Foix, Sorbonne University, Paris, France.
| | - Marine Creux
- Department of Anesthesiology and Critical Care, GRC 29, DREAM DMU, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Diane Lastennet
- Department of Biostatistics Public Health and Medical Informatics, University Hospitals Pitié-Salpêtrière Charles-Foix, Sorbonne University, Paris, France
| | - Louis Lemoine
- Department of Anesthesiology and Critical Care, GRC 29, DREAM DMU, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Jean Christophe Vaillant
- Department of Digestive, HPB Surgery, and Liver Transplantation, University Hospitals Pitié-Salpêtrière Charles-Foix, Sorbonne University, Paris, France
| | - Eric Savier
- Department of Digestive, HPB Surgery, and Liver Transplantation, University Hospitals Pitié-Salpêtrière Charles-Foix, Sorbonne University, Paris, France
| | - Corinne Vézinet
- Department of Anesthesiology and Critical Care, GRC 29, DREAM DMU, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Olivier Scatton
- Department of Digestive, HPB Surgery, and Liver Transplantation, University Hospitals Pitié-Salpêtrière Charles-Foix, Sorbonne University, Paris, France
| | - Benjamin Granger
- Department of Biostatistics Public Health and Medical Informatics, University Hospitals Pitié-Salpêtrière Charles-Foix, Sorbonne University, Paris, France
| | - Louis Puybasset
- Department of Anesthesiology and Critical Care, GRC 29, DREAM DMU, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Yann Loncar
- Department of Anesthesiology and Critical Care, GRC 29, DREAM DMU, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
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Saliba F, Dharancy S, Salamé E, Conti F, Eyraud D, Radenne S, Antonini T, Guillaud O, Guguenheim J, Neau-Cransac M, Demartin E, Lasailly G, Duvoux C, Sobesky R, Coilly A, Tresson S, Cailliez V, Boillot O, Pageaux GP, Samuel D, Calmus Y, Dumortier J. Time to Conversion to an Everolimus-Based Regimen: Renal Outcomes in Liver Transplant Recipients From the EVEROLIVER Registry. Liver Transpl 2020; 26:1465-1476. [PMID: 32869469 DOI: 10.1002/lt.25879] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/12/2020] [Accepted: 06/28/2020] [Indexed: 12/14/2022]
Abstract
Longterm use of a calcineurin inhibitor (CNI)-based regimen is one of the major reasons for chronic renal failure in liver transplantation recipients (LTRs). The Everolimus Liver registry (EVEROLIVER) evaluated renal function in LTRs who were converted to everolimus (EVR). This observational registry included all LTRs receiving EVR across 9 centers from France. Data are being collected in an electronic database over 10 years (12 visits/patient) to evaluate efficacy, renal function (estimated glomerular filtration rate [eGFR]), and safety of EVR use in clinical practice, and the current analysis is reporting up to 60 months of findings. Until September 2017, 1045 patients received EVR after a mean time of 3.6 ± 5.1 years. CNI withdrawal was feasible in 57.7% of patients as of month 60. Mean eGFR improved in patients with baseline eGFR <60 mL/minute/1.73 m2 and was maintained in those with baseline eGFR ≥60 mL/minute/1.73 m2 . Among patients with chronic kidney disease (CKD; baseline eGFR <60 mL/minute/1.73 m2 ), 55% converted to EVR within 3 months (early conversion) and 39.4% converted between 4 and 12 months after transplantation (mid-conversion) experienced improvement in eGFR (≥60 mL/minute/1.73 m2 ) at month 36. Only 20.9% and 17.4% among those converted beyond 12 months (late conversion) experienced improvement respectively at month 36 and 60. A logistic regression analysis in patients with CKD stage ≥3 demonstrated that late conversion, age, and female sex were associated with nonimprovement of eGFR (≥60 mL/minute/1.73 m2 ). Data from this real-life use of EVR indicate that renal function was maintained from the preconversion period until month 36 even in patients with advanced CKD. However, early rather than late conversion appears to be a safe approach to preserve longterm renal function in LTRs.
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Affiliation(s)
- Faouzi Saliba
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Sébastien Dharancy
- Service d'Hépato-Gastroentérologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Ephrem Salamé
- Service de Chirurgie Hépato-Biliaire et Digestive, Hôpital Trousseau, Centre Hospitalier Universitaire Tours, Tours, France
| | - Filoména Conti
- Service de Chirurgie Digestive et Hépato-Biliaire, AP-HP Hôpital Pitié Salpêtrière, Transplantation Hépatique, Paris, France
| | - Daniel Eyraud
- Département d'Anesthésie-Réanimation, Service de Chirurgie Digestive et Hépato-Biliaire et de Transplantation Hépatique, Groupe Hospitalier Pitié Salpêtrière, Paris, France
| | - Sylvie Radenne
- Service de Chirurgie Digestive et Transplantation Hépatique, Hôpital la Croix Rousse, Lyon, France
| | - Térésa Antonini
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Olivier Guillaud
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, Lyon, France
| | - Jean Guguenheim
- Département de Chirurgie Digestive et Transplantation Hépatique, Hôpital Archet, University of Nice Sophia Antipolis, Nice, France
| | - Martine Neau-Cransac
- Unité de Chirurgie Hépato-Biliaire et de Transplantation Hépatique, Hôpital Magellan, Centre Hospitalier Universitaire Bordeaux, Pessac, France
| | - Eléonora Demartin
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Guillaume Lasailly
- Service d'Hépato-Gastroentérologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Christophe Duvoux
- Service d'Hépato-Gastro-Entérologie, AP-HP Hôpital Henri Mondor, Créteil, France
| | - Rodolphe Sobesky
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Audrey Coilly
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Sylvie Tresson
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Valérie Cailliez
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Olivier Boillot
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, Lyon, France
| | - Georges Philippe Pageaux
- Service d'Hépato-Gastro-Entérologie, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Didier Samuel
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Université Paris Saclay, Villejuif, France
| | - Yvon Calmus
- Service de Chirurgie Digestive et Hépato-Biliaire, AP-HP Hôpital Pitié Salpêtrière, Transplantation Hépatique, Paris, France
| | - Jérôme Dumortier
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, Lyon, France
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Loncar Y, Lefevre T, Nafteux L, Genser L, Manceau G, Lemoine L, Vaillant JC, Eyraud D. Preoperative nutrition forseverely malnourished patients in digestive surgery: A retrospective study. J Visc Surg 2019; 157:107-116. [PMID: 31366442 DOI: 10.1016/j.jviscsurg.2019.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Malnutrition increases postoperative morbidity and mortality. The objective of this study was to evaluate preoperative refeeding in malnourished patients at risk of refeeding syndrome (RS). METHODOLOGY A retrospective study, conducted between June 2016 and January 2017, reported to the CNIL, compared two groups of malnourished patients: a group of refeeding patients (RP) and a group of non-refeeding patients (NRP). The inclusion criteria were weight loss of more than 10% or albuminemia less than 35g/L and RS risk factor. The primary endpoint was postoperative morbidity. The secondary endpoints were weight change and serum albumin over 6 months. RESULTS Seventy-three patients (30 RP and 43 NRP) were included. At the time of initial management, median weight loss was 18% [1-71], while albuminemia was 26g/L [13-40] in the RP group and 32.5g/L [32-48] in the NRP group (P=0.01). The overall postoperative morbidity rate was 88% (83% RP versus 90% NRP, P=0.47), and there was no significant difference between the 2 groups. The rate of anastomotic complications was 4% for RP versus 26% for NRP (P=0.03) after exclusion of liver surgery. Medium-term weight loss tended to be greater in RP (P=0.7). Nutritional support was continued until the third postoperative month in 13% of RPs vs. no NRPs (P=0.0002). CONCLUSION After preoperative renutrition, we did not observe a decrease in morbidity but rather a decrease in the rate of anastomotic complications in favor of the RP group. This study underscores the middle-term importance of nutritional management in view of preserving the benefits of preoperative renutrition.
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Affiliation(s)
- Y Loncar
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France; Dietetics unit, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France.
| | - T Lefevre
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - L Nafteux
- Dietetics unit, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France.
| | - L Genser
- Visceral and hepato-biliary surgery and transplantation unit, hospital group Pitié-Salpêtrière Charles Foix, université de la Sorbonne, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - G Manceau
- Visceral and hepato-biliary surgery and transplantation unit, hospital group Pitié-Salpêtrière Charles Foix, université de la Sorbonne, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - L Lemoine
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France.
| | - J C Vaillant
- Visceral and hepato-biliary surgery and transplantation unit, hospital group Pitié-Salpêtrière Charles Foix, université de la Sorbonne, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
| | - D Eyraud
- Department of anesthesia and resuscitation, hospital group Pitié-Salpêtrière Charles Foix, AP-HP, 75013 Paris, France; Sorbonne university, 75000 Paris, France.
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Brustia R, Monsel A, Conti F, Savier E, Rousseau G, Perdigao F, Bernard D, Eyraud D, Loncar Y, Langeron O, Scatton O. Enhanced Recovery in Liver Transplantation: A Feasibility Study. World J Surg 2019; 43:230-241. [PMID: 30094639 DOI: 10.1007/s00268-018-4747-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT. METHODS We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery. RESULTS Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0-10.5) days versus 18.0 (14.3-24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm. CONCLUSION Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.
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Affiliation(s)
- Raffaele Brustia
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Filomena Conti
- Liver Transplantation and Hepatology Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.,Sorbonne Universités, Paris, France
| | - Eric Savier
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Geraldine Rousseau
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Fabiano Perdigao
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Denis Bernard
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Daniel Eyraud
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yann Loncar
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Langeron
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Olivier Scatton
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France. .,Sorbonne Universités, Paris, France.
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6
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Poynard T, Peta V, Deckmyn O, Munteanu M, Moussalli J, Ngo Y, Rudler M, Lebray P, Pais R, Bonyhay L, Charlotte F, Thibault V, Fartoux L, Lucidarme O, Eyraud D, Scatton O, Savier E, Valantin MA, Ngo A, Drane F, Rosmorduc O, Imbert‐Bismut F, Housset C, Thabut D, Ratziu V. LCR1 and LCR2, two multi-analyte blood tests to assess liver cancer risk in patients without or with cirrhosis. Aliment Pharmacol Ther 2019; 49:308-320. [PMID: 30569507 PMCID: PMC6590635 DOI: 10.1111/apt.15082] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/20/2018] [Accepted: 11/12/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND No blood test has been shown to be effective in the prediction of primary liver cancer in patients without cirrhosis. AIM To construct and internally validate two sequential tests for early prediction of liver cancer. These tests enable an algorithm which could improve the performance of the standard surveillance protocol recommended (imaging with or without AFP), limited to patients with cirrhosis. METHODS We performed a retrospective analysis in prospectively collected specimens from an ongoing cohort. We designed an early sensitive high-risk test (LCR1) that combined (using Cox model) hepatoprotective proteins (apolipoproteinA1, haptoglobin) with known risk factors (gender, age, gammaglutamyltranspeptidase), and a marker of fibrosis (alpha2-macroglobulin). To increase the specificity, we then combined (LCR2) these components with alpha-fetoprotein. RESULTS A total of 9892 patients, 85.9% without cirrhosis, were followed up for 5.9 years [IQR: 4.3-9.4]. LCR1 and LCR2 time-dependent AUROCs were not different in construction and validation randomised subsets. Among 2027 patients with high-LCR1 then high-LCR2, 167 cancers (113 with cirrhosis, 54 without cirrhosis) were detected, that is 12 patients needed to screen one cancer. The negative predictive value was 99.5% (95% CI 99.0-99.7) in the 2026 not screened patients (11 cancers without cirrhosis) higher than the standard surveillance, which detected 113 cancers in 755 patients screened, that is seven patients needed to screen one cancer, but with a lower negative predictive value 98.0% (97.5-98.5; Z = 4.3; P < 0.001) in 3298 not screened patients (42 cancers without cirrhosis). CONCLUSIONS In patients with chronic liver disease the LCR1 and LCR2 tests identify those with a high risk of liver cancer, including in those without cirrhosis. NCT01927133.
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Affiliation(s)
- Thierry Poynard
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance,Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance
| | - Valentina Peta
- Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance,BioPredictiveParisFrance
| | | | - Mona Munteanu
- Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance,BioPredictiveParisFrance
| | - Joseph Moussalli
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | | | - Marika Rudler
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Pascal Lebray
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Raluca Pais
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance,Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance
| | - Luminita Bonyhay
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Frederic Charlotte
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Vincent Thibault
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Laetitia Fartoux
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Olivier Lucidarme
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Daniel Eyraud
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Olivier Scatton
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance,Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance
| | - Eric Savier
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance,Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance
| | - Marc Antoine Valantin
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | | | | | - Olivier Rosmorduc
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Françoise Imbert‐Bismut
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
| | - Chantal Housset
- Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance
| | - Dominique Thabut
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance,Sorbonne Université, INSERM, Saint‐Antoine Research Center & Institute of Cardiometabolism and Nutrition (ICAN)ParisFrance
| | - Vlad Ratziu
- Hepatology DepartmentAssistance Publique‐Hôpitaux de Paris, Pitié‐Salpêtrière HospitalParisFrance
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7
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Eyraud D, Granger B, Bardier A, Loncar Y, Gottrand G, Le Naour G, Siksik JM, Vaillant JC, Klatzmann D, Puybasset L, Charlotte F, Augustin J. Immunological environment in colorectal cancer: a computer-aided morphometric study of whole slide digital images derived from tissue microarray. Pathology 2018; 50:607-612. [PMID: 30166125 DOI: 10.1016/j.pathol.2018.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/10/2018] [Accepted: 04/20/2018] [Indexed: 12/13/2022]
Abstract
Cancer research has moved from investigating tumour cells to including analysis of the tumour microenvironment as well. The aim of this study was to assess the cellular infiltrate of colorectal cancer (CRC) using computer-aided analysis of whole slide digital image derived from tissue microarray (TMA). TMA slides from 31 CRC patients were immunostained for forkhead box protein 3 (FOXP3) and immunomodulatory enzyme indoleamine 2,3-dioxygenase (IDO) at four sites: centre (C) and invasive front (F) of the tumour, proximal non-metastatic draining lymph node (N-), tumour-draining lymph node with metastasis (N+) and healthy mucosa at 10 cm from the cancer (M). We analysed the proportion of IDO+ tissue areas in the lamina propria or in the non-epithelial area of the lymph node and in epithelial cells in each site. The normal mucosa of patients operated on for benign disease was also analysed. The proportion (%) of FOXP3+ tissue area in C, F, N-, N+ and M were 2.3 ± 1.8, 2.6 ± 2.9, 6.0 ± 2.9, 14.2 ± 5.8 and 1.2 ± 0.8 (p < 0.001). The proportion (%) of IDO+ tissue area in the lamina propria of C, F, N-, N+ and M were 1.6 ± 3.1, 1.1 ± 1.3, 3.4 ± 2.5, 9.1 ± 8.5 and 6.7 ± 5.4 (p < 0.001). IDO+ tissue area in the lamina propria was not significantly different between healthy mucosa of patients with cancer than without (1.8 ± 3 vs 1.1 ± 0.95). The proportion of IDO positive tissue area in the epithelium was significantly higher in healthy mucosa of patients with cancer than without (5.4 ± 13.8 vs 2.1 ± 2.4). The FOXP3+ tissue area was increased in healthy mucosa of CRC patients in comparison with healthy mucosa of patients with colorectal resection for disease other than cancer: 1.20 ± 1.81 versus 0.81 ± 0.51 (p < 0.05). The proportion of IDO+ tissue area in lymph node (N-) was correlated with the proportion of FOXP3+ tissue area in tumour area (r = 0.44, p < 0.01). TMA technique permits simultaneous analysis of FOXP3+ and IDO+ cells at different sites including tumour, draining non-metastatic lymph node, metastatic lymph node and normal mucosa.
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Affiliation(s)
- Daniel Eyraud
- Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Paris, France; Service d'Anatomie Pathologique, UIMAP, Hôpital Pitié-Salpêtrière, Paris, France; Service de Biothérapies, UPMC, CNRS 7211, INSERM 959, Hôpital Pitié-Salpêtrière, Paris, France.
| | - Benjamin Granger
- Département de Biostatistiques, de Santé Publique et d'Information Médicale, Hôpital Pitié-Salpêtrière, Paris, France
| | - Armelle Bardier
- Service d'Anatomie Pathologique, UIMAP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yann Loncar
- Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Paris, France
| | - GaËlle Gottrand
- Service de Biothérapies, UPMC, CNRS 7211, INSERM 959, Hôpital Pitié-Salpêtrière, Paris, France
| | - Gilles Le Naour
- Service d'Anatomie Pathologique, UIMAP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Jean-Michel Siksik
- Service de Chirurgie Digestive et de Transplantation Hépatique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Jean-Christophe Vaillant
- Service de Chirurgie Digestive et de Transplantation Hépatique, Hôpital Pitié-Salpêtrière, Paris, France
| | - David Klatzmann
- Service de Biothérapies, UPMC, CNRS 7211, INSERM 959, Hôpital Pitié-Salpêtrière, Paris, France
| | - Louis Puybasset
- Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Paris, France
| | - Frederic Charlotte
- Service d'Anatomie Pathologique, UIMAP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Jeremy Augustin
- Service d'Anatomie Pathologique, UIMAP, Hôpital Pitié-Salpêtrière, Paris, France
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8
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Eyraud D, Suner L, Dupont A, Bachelot-Loza C, Smadja DM, Helley D, Bertil S, Gostian O, Szymezak J, Loncar Y, Puybasset L, Lebray P, Vezinet C, Vaillant JC, Granger B, Gaussem P. Evolution of platelet functions in cirrhotic patients undergoing liver transplantation: A prospective exploration over a month. PLoS One 2018; 13:e0200364. [PMID: 30071043 PMCID: PMC6072007 DOI: 10.1371/journal.pone.0200364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/25/2018] [Indexed: 12/23/2022] Open
Abstract
This prospective observational study was designed to analyze platelet functions across time in 50 patients scheduled for liver transplantation (LT) secondary to decompensated cirrhosis or hepatocellular carcinoma. Platelet functions were assessed before LT (pre-LT), one week (D7) and 1 month (D28) after LT. Platelet count significantly increased from pre-LT time to day 28 as well as circulating CD34+hematopoietic stem cells. To avoid any influence of platelet count on assays, platelet function was evaluated on platelet-rich-plasma adjusted to pre-LT platelet count. Although platelet secretion potential did not differ between time-points, as evaluated by the expression of CD62P upon strong activation, platelet aggregation in response to various agonists significantly increased along time, however with no concomitant increase of circulating markers of platelet activation: platelet microvesicles, platelet-leukocyte complexes, soluble CD40L and soluble CD62P. In the multivariate analysis, hepatic function was associated with platelet count and function. A lower platelet aggregation recovery was correlated with Child C score. History of thrombosis or bleeding was associated with respective higher or lower values of platelet aggregation. This longitudinal analysis of platelet functions in LT patients showed an improvement of platelet functions along time together with platelet count increase, with no evidence of platelet hyperactivation at any time-point.
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Affiliation(s)
- Daniel Eyraud
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Digestive, HPB Surgery, and Liver Transplantation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Ludovic Suner
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
| | - Axelle Dupont
- Université Pierre et Marie Curie, Paris, France
- AP-HP, Pitié-Salpêtrière University Hospital, Department of statistics, Clinical Research Unit, Paris, France
| | - Christilla Bachelot-Loza
- Inserm UMR-S1140, Faculté de Pharmacie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - David M. Smadja
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
- Inserm UMR-S1140, Faculté de Pharmacie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Dominique Helley
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Inserm UMR-S970, Paris, France
| | - Sébastien Bertil
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
| | - Ovidiu Gostian
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Jean Szymezak
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
| | - Yann Loncar
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Louis Puybasset
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Pascal Lebray
- AP-HP, Pitié-Salpêtrière University Hospital, Hepatology Department, Paris, France
| | - Corinne Vezinet
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Anesthesiology and Reanimation, Paris, France
| | - Jean-Christophe Vaillant
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Digestive, HPB Surgery, and Liver Transplantation, Paris, France
- Université Pierre et Marie Curie, Paris, France
| | - Benjamin Granger
- Université Pierre et Marie Curie, Paris, France
- AP-HP, Pitié-Salpêtrière University Hospital, Department of statistics, Clinical Research Unit, Paris, France
| | - Pascale Gaussem
- AP-HP, European University Hospital Georges Pompidou, Hematology Department, Paris, France
- Inserm UMR-S1140, Faculté de Pharmacie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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9
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Saliba F, Duvoux C, Gugenheim J, Kamar N, Dharancy S, Salamé E, Neau-Cransac M, Durand F, Houssel-Debry P, Vanlemmens C, Pageaux G, Hardwigsen J, Eyraud D, Calmus Y, Di Giambattista F, Dumortier J, Conti F. Efficacy and Safety of Everolimus and Mycophenolic Acid With Early Tacrolimus Withdrawal After Liver Transplantation: A Multicenter Randomized Trial. Am J Transplant 2017; 17:1843-1852. [PMID: 28133906 DOI: 10.1111/ajt.14212] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 01/25/2023]
Abstract
SIMCER was a 6-mo, multicenter, open-label trial. Selected de novo liver transplant recipients were randomized (week 4) to everolimus with low-exposure tacrolimus discontinued by month 4 (n = 93) or to tacrolimus-based therapy (n = 95), both with basiliximab induction and enteric-coated mycophenolate sodium with or without steroids. The primary end point, change in estimated GFR (eGFR; MDRD formula) from randomization to week 24 after transplant, was superior with everolimus (mean eGFR change +1.1 vs. -13.3 mL/min per 1.73 m2 for everolimus vs. tacrolimus, respectively; difference 14.3 [95% confidence interval 7.3-21.3]; p < 0.001). Mean eGFR at week 24 was 95.8 versus 76.0 mL/min per 1.73 m2 for everolimus versus tacrolimus (p < 0.001). Treatment failure (treated biopsy-proven acute rejection [BPAR; rejection activity index score >3], graft loss, or death) from randomization to week 24 was similar (everolimus 10.0%, tacrolimus 4.3%; p = 0.134). BPAR was more frequent between randomization and month 6 with everolimus (10.0% vs. 2.2%; p = 0.026); the rate of treated BPAR was 8.9% versus 2.2% (p = 0.055). Sixteen everolimus-treated patients (17.8%) and three tacrolimus-treated patients (3.2%) discontinued the study drug because of adverse events. In conclusion, early introduction of everolimus at an adequate exposure level with gradual calcineurin inhibitor (CNI) withdrawal after liver transplantation, supported by induction therapy and mycophenolic acid, is associated with a significant renal benefit versus CNI-based immunosuppression but more frequent BPAR.
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Affiliation(s)
- F Saliba
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Villejuif, France
| | - C Duvoux
- Service d'Hépato-Gastro-Entérologie, AP-HP Hôpital Henri Mondor, Créteil, France
| | - J Gugenheim
- Département de Chirurgie Digestive et Transplantation Hépatique, Hôpital Archet, University of Nice Sophia Antipolis, Nice, France
| | - N Kamar
- Département de Néphrologie et Transplantation d'Organes, CHU Rangueil, Toulouse, France
| | - S Dharancy
- Service d'Hépato-Gastroentérologie, CHRU de Lille, Lille, France
| | - E Salamé
- Service de Chirurgie Hépato-Biliaire et Digestive, Hôpital Trousseau, CHU Tours, Tours, France
| | - M Neau-Cransac
- Unité de Chirurgie Biliaire et de Transplantation Hépatique, Hôpital Magellan, CHU Bordeaux, Pessac, France
| | - F Durand
- Service d'Hépatologie et Transplantation Hépatique, University Paris Diderot, INSERM U1149, Clichy, France
| | - P Houssel-Debry
- Service de Chirurgie Hépatobiliaire et Digestive, CIC 1414, Hôpital Pontchaillou, Rennes, France
| | - C Vanlemmens
- Service d'Hépatologie et Soins Intensifs Digestifs, Hôpital Jean Minjoz, Besançon, France
| | - G Pageaux
- Service Hépato-Gastroentérologie, Hôpital Saint Eloi, Montpellier, France
| | - J Hardwigsen
- Service de Chirurgie et Transplantation Hépatique, Hôpital la Timone, Marseille, France
| | - D Eyraud
- Département d'Anesthésie-Réanimation, Service de Chirurgie Digestive et Hépato-Biliaire et de Transplantation Hépatique, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Y Calmus
- Service de Chirurgie Digestive et Hépato-Biliaire, Transplantation Hépatique, AP-HP Hôpital Pitié Salpêtrière, Paris, France
| | | | - J Dumortier
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, Lyon, France
| | - F Conti
- Service de Chirurgie Digestive et Hépato-Biliaire, Transplantation Hépatique, AP-HP Hôpital Pitié Salpêtrière, Paris, France
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10
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Lepere V, Vanier A, Loncar Y, Lemoine L, Vaillant JC, Monsel A, Savier E, Coriat P, Eyraud D. Risk factors for pulmonary complications after hepatic resection: role of intraoperative hemodynamic instability and hepatic ischemia. BMC Anesthesiol 2017. [PMID: 28633644 PMCID: PMC5477742 DOI: 10.1186/s12871-017-0372-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background Postoperative operative pulmonary complications (PPCs) after hepatic surgery are associated with increased length of hospital stays. Intraoperative blood transfusion, extensive resection and different comorbidities have been identified. Other parameters, like time of hepatic ischemia, have neither been clinically studied, though experimental studies show that hepatic ischemia can provide lung injury. The objective of this study was to determinate the risk factors of postoperative pulmonary complications (PPCs) after hepatic resection within 7 postoperative days. Method Ninety-four patients consecutively who underwent elective hepatectomy between January and December 2013. Demographic data, pathological variables, and preoperative, intraoperative, and postoperative variables had been prospectively collected in a data base. The dependant variables studied were the occurrence of PPCs, defined before analysis of the data. Results PPCs occurred in 32 (34%) patients. A multivariate analysis allowed identifying the risk factors for PPCs. On multivariate analysis, preoperative gamma-glutamyltransferase (GGT) elevation OR =5,12 [1,85-15,69] p = 0,002, liver ischemia duration OR = 1,03 [1,01-1,06] p = 0,01 and the intraoperative use of vasopressor OR = 4,40 [1,58-13,36] p = 0,006 were independently associated with PPCs. For every 10 min added in ischemia duration, the OR of the risk of PPCs was estimated to be 1.37 (CI95% = [1.08-1.81], p = 0.01). Conclusion Three risk factors for PPCs have been identified in a population undergoing liver resection: preoperative GGT elevation, ischemia duration and the intraoperative use of vasopressor. PPCs after liver surgery could be related to lung injury induced by liver ischemia reperfusion and not solely by direct infectious process. That could explain why factors influencing directly or indirectly liver ischemia were independently associated with PPCs. Electronic supplementary material The online version of this article (doi:10.1186/s12871-017-0372-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Victoria Lepere
- Department of Anesthesiology and Reanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospitals Pitié-Salpêtrière Charles-Foix, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Antoine Vanier
- Department of Biostatistics, Sorbonne University, UPMC University, Paris 06, Paris, France.,Department of Biostatistics Public Health and Medical Informatics University Hospitals Pitié-Salpêtrière Charles-Foix, AP-HP, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Yann Loncar
- Department of Anesthesiology and Reanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospitals Pitié-Salpêtrière Charles-Foix, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Louis Lemoine
- Department of Anesthesiology and Reanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospitals Pitié-Salpêtrière Charles-Foix, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Jean Christophe Vaillant
- Department of Digestive, HPB Surgery, and Liver Transplantation University Hospitals Pitié-Salpêtrière Charles-Foix, AP-HP, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Antoine Monsel
- Department of Anesthesiology and Reanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospitals Pitié-Salpêtrière Charles-Foix, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Eric Savier
- Department of Digestive, HPB Surgery, and Liver Transplantation University Hospitals Pitié-Salpêtrière Charles-Foix, AP-HP, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Pierre Coriat
- Department of Anesthesiology and Reanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospitals Pitié-Salpêtrière Charles-Foix, 43-87 Boulevard de l'Hôpital, 75013, Paris, France
| | - Daniel Eyraud
- Department of Anesthesiology and Reanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospitals Pitié-Salpêtrière Charles-Foix, 43-87 Boulevard de l'Hôpital, 75013, Paris, France. .,Department of Digestive, HPB Surgery, and Liver Transplantation University Hospitals Pitié-Salpêtrière Charles-Foix, AP-HP, 43-87 Boulevard de l'Hôpital, 75013, Paris, France.
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11
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Pais R, Lebray P, Rousseau G, Charlotte F, Esselma G, Savier E, Thabut D, Rudler M, Eyraud D, Vezinet C, Siksik JM, Vaillant JC, Hannoun L, Poynard T, Ratziu V. Nonalcoholic fatty liver disease increases the risk of hepatocellular carcinoma in patients with alcohol-associated cirrhosis awaiting liver transplants. Clin Gastroenterol Hepatol 2015; 13:992-9.e2. [PMID: 25459558 DOI: 10.1016/j.cgh.2014.10.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 09/29/2014] [Accepted: 10/10/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS Many patients with alcohol-associated cirrhosis also have diabetes, obesity, or insulin resistance-mediated steatosis, but little is known about how these disorders affect the severity of liver disease. We analyzed the prevalence and prognostic implications of metabolic risk factors (MRFs) such as overweight, diabetes, dyslipidemia, and hypertension in patients with alcohol-associated cirrhosis awaiting liver transplants. METHODS We performed a retrospective study of 110 patients with alcohol-associated cirrhosis (77% male; mean age, 55 y; 71% with >6 mo of abstinence) who received liver transplants at a single center in Paris, France, from 2000 through 2013. We collected data on previous exposure to MRFs, steatosis (>10% in the explant), and histologically confirmed hepatocellular carcinoma (HCC). RESULTS HCC was detected in explants from 29 patients (26%). Steatosis was detected in explants from 47 patients (70% were abstinent for ≥6 mo); 50% had a history of overweight or type 2 diabetes. Fifty-two patients (47%) had a history of MRFs and therefore were at risk for nonalcoholic fatty liver disease. A higher proportion of patients with MRF had HCC than those without MRF (46% vs 9%; P < .001). A previous history of overweight or type 2 diabetes significantly increased the risk for HCC (odds ratio, 6.23; 95% confidence interval [CI], 2.47-15.76, and odds ratio, 4.63; 95% CI, 1.87-11.47, respectively; P < .001). MRF, but not steatosis, was associated with the development of HCC (odds ratio, 11.76; 95% CI, 2.60-53; P = .001) independent of age, sex, amount of alcohol intake, or severity of liver disease. CONCLUSIONS Patients with alcohol-associated cirrhosis who received transplants frequently also had nonalcoholic fatty liver disease. MRFs, particularly overweight, obesity, and type 2 diabetes, significantly increase the risk of HCC.
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Affiliation(s)
- Raluca Pais
- Service d'Hépatogastroentérologie, Hôpital Pitié Salpêtrière, Paris, France
| | - Pascal Lebray
- Service d'Hépatogastroentérologie, Hôpital Pitié Salpêtrière, Paris, France
| | - Geraldine Rousseau
- Service de Chirurgie Hépatobiliaire et de Transplantation, Hôpital Pitié Salpêtrière, Paris, France
| | - Frédéric Charlotte
- Service d'Anatomie Pathologique, Hôpital Pitié Salpêtrière, Paris, France
| | - Ghizlaine Esselma
- Service d'Hépatogastroentérologie, Hôpital Pitié Salpêtrière, Paris, France
| | - Eric Savier
- Service de Chirurgie Hépatobiliaire et de Transplantation, Hôpital Pitié Salpêtrière, Paris, France
| | - Dominique Thabut
- Service d'Hépatogastroentérologie, Hôpital Pitié Salpêtrière, Paris, France
| | - Marika Rudler
- Service d'Hépatogastroentérologie, Hôpital Pitié Salpêtrière, Paris, France
| | - Daniel Eyraud
- Service d'Anesthésie et Réanimation, Hôpital Pitié Salpêtrière, Paris, France
| | - Corinne Vezinet
- Service d'Anesthésie et Réanimation, Hôpital Pitié Salpêtrière, Paris, France
| | - Jean-Michel Siksik
- Service de Chirurgie Hépatobiliaire et de Transplantation, Hôpital Pitié Salpêtrière, Paris, France
| | - Jean-Christophe Vaillant
- Service de Chirurgie Hépatobiliaire et de Transplantation, Hôpital Pitié Salpêtrière, Paris, France
| | - Laurent Hannoun
- Service de Chirurgie Hépatobiliaire et de Transplantation, Hôpital Pitié Salpêtrière, Paris, France
| | - Thierry Poynard
- Service d'Hépatogastroentérologie, Hôpital Pitié Salpêtrière, Paris, France
| | - Vlad Ratziu
- Service d'Hépatogastroentérologie, Hôpital Pitié Salpêtrière, Paris, France.
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12
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Savier E, Dondero F, Vibert E, Eyraud D, Brisson H, Riou B, Fieux F, Naili-Kortaia S, Castaing D, Rouby JJ, Langeron O, Dokmak S, Hannoun L, Vaillant JC. First experience of liver transplantation with type 2 donation after cardiac death in France. Liver Transpl 2015; 21:631-43. [PMID: 25865077 DOI: 10.1002/lt.24107] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 12/26/2014] [Accepted: 02/08/2015] [Indexed: 02/07/2023]
Abstract
Organ donation after unexpected cardiac death [type 2 donation after cardiac death (DCD)] is currently authorized in France and has been since 2006. Following the Spanish experience, a national protocol was established to perform liver transplantation (LT) with type 2 DCD donors. After the declaration of death, abdominal normothermic oxygenated recirculation was used to perfuse and oxygenate the abdominal organs until harvesting and cold storage. Such grafts were proposed to consenting patients < 65 years old with liver cancer and without any hepatic insufficiency. Between 2010 and 2013, 13 LTs were performed in 3 French centers. Six patients had a rapid and uneventful postoperative recovery. However, primary nonfunction occurred in 3 patients, with each requiring urgent retransplantation, and 4 early allograft dysfunctions were observed. One patient developed a nonanastomotic biliary stricture after 3 months, whereas 8 patients showed no sign of ischemic cholangiopathy at their 1-year follow-up. In comparison with a control group of patients receiving grafts from brain-dead donors (n = 41), donor age and cold ischemia time were significantly lower in the type 2 DCD group. Time spent on the national organ wait list tended to be shorter in the type 2 DCD group: 7.5 months [interquartile range (IQR), 4.0-11.0 months] versus 12.0 months (IQR, 6.8-16.7 months; P = 0.08. The 1-year patient survival rates were similar (85% in the type 2 DCD group versus 93% in the control group), but the 1-year graft survival rate was significantly lower in the type 2 DCD group (69% versus 93%; P = 0.03). In conclusion, to treat borderline hepatocellular carcinoma, LT with type 2 DCD donors is possible as long as strict donor selection is observed.
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Affiliation(s)
- Eric Savier
- Service de Chirurgie Digestive, Hépato-Bilio-Pancréatique, Transplantation Hépatique, Centre Hospitalier Universitaire Pitié Salpetriere, AP-HP, Université Pierre et Marie Curie, Université Paris 06, Paris, France; Ischémie Reperfusion en Transplantation d'Organes Mécanismes et Innovations Thérapeutiques (IRTOMIT), INSERM U1082, Poitiers, France
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Affiliation(s)
- Daniel Eyraud
- Department of hepatic surgery and liver transplantation, Department of anesthesiology and intensive care, GH Pitié Salpétrière, 43-87, boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
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Poynard T, Lenaour G, Vaillant JC, Capron F, Munteanu M, Eyraud D, Ngo Y, M'Kada H, Ratziu V, Hannoun L, Charlotte F. Liver biopsy analysis has a low level of performance for diagnosis of intermediate stages of fibrosis. Clin Gastroenterol Hepatol 2012; 10:657-63.e7. [PMID: 22343514 DOI: 10.1016/j.cgh.2012.01.023] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 01/18/2012] [Accepted: 01/24/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy about the performance of noninvasive tests such as FibroTest in diagnosing intermediate stages of fibrosis. We investigated whether this controversy results from limitations of biopsy analysis for intermediate-stage fibrosis and inappropriate determination of the standard area under the receiver-operator characteristic curve (AUROC). METHODS To determine whether biopsy has a lower diagnostic performance for fibrosis stage F2 (few septa) vs F1 (fibrosis without septa), compared with its performance for F1 vs F0 or F4 vs F3, we determined the fibrotic areas of large surgical samples collected from 20 consecutive patients with chronic liver disease or normal liver tissue that surrounded tumors. We analyzed digitized images of 27,869 virtual biopsies of increasing length and also analyzed data from 6500 patients with interpretable FibroTest results who also underwent biopsy analysis. RESULTS The overall performance of biopsy analysis (by Obuchowski measure) increased with biopsy length from 0.885 for 5-mm to 0.912 for 30-mm samples (P < .0001). The performance of biopsy was lower for the diagnosis of F2 vs F1 samples (weighted AUROC [wAUROC] = 0.505) than for F1 vs F0 (wAUROC = 0.773; 53% difference; P < .0001) or F4 vs F3 (wAUROC = 0.700; 39% difference; P < .0001), even when 30-mm biopsy samples were used. The performance of FibroTest was also lower for the diagnosis of F2 vs F1 samples (wAUROC = 0.512) than for F1 vs F0 samples (wAUROC = 0.626; 22% difference; P < .0001) or F4 vs F3 (wAUROC = 0.628; 23% difference; P < .0001). However, the FibroTest had smaller percentage differences among wAUROC values than biopsy. CONCLUSIONS Biopsy has a low level of diagnostic performance for fibrosis stages F2 and F1. The recommendation for biopsy analysis, instead of a validated biomarker panel such as FibroTest, for the diagnosis of intermediate stages of fibrosis is therefore misleading.
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Affiliation(s)
- Thierry Poynard
- Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie Liver Center, Paris, France.
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Eyraud D, Granger B, Ionescu C, Fratéa S, Darnat S, Vaillant JC, Siksik JM, Hannoun L, Coriat P. Thrombocytopenia, splenomegaly, and portal blood flow in patients who have undergone liver transplantation for cirrhosis. Liver Transpl 2012; 18:340-6. [PMID: 22006447 DOI: 10.1002/lt.22456] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The platelet count (PC), the spleen size (SS), and the portal blood flow (PBF) have been independently studied in the perioperative period after orthotopic liver transplantation (OLT) for cirrhosis, but these parameters have not been described and analyzed in combination. We analyzed PC data and Doppler sonography measurements of SS and PBF from 125 adult patients before OLT and 1, 3, 6, 9, and 12 months after transplantation. A linear mixed model with fixed subject random intercepts was used. PCs increased significantly from 101.5 ± 68.5 × 10(9) /L before OLT to 162.4 ± 86 × 10(9) /L 1 month after OLT and remained stable for 1 year after the operation. PBF increased significantly from 619 ± 239 mL/minute before OLT to 1379 ± 491 mL/minute after OLT and remained stable during the first year. SS slowly decreased after OLT, but the decrease became significant only 9 months after the operation (13.8 ± 4.2 cm before OLT versus 11.7 ± 3.7 cm at 9 months, P < 0.05). The cirrhosis etiology did not influence the evolution of the parameters. With or without replication or interferon treatment before OLT, the hepatitis C group viruses did not influence PCs postoperatively. The evolution of SS was correlated to the evolution of PCs in the year after transplantation. In conclusion, PCs and PBF increase rapidly after OLT, whereas SS slowly decreases. The cirrhosis etiology does not influence the evolution of PCs. Thrombocytopenia and splenomegaly are 2 results of portal hypertension, but the rapid normalization of PBF does not completely or rapidly reverse these 2 phenomena.
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Affiliation(s)
- Daniel Eyraud
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Public Hospital System of Paris, Pierre and Marie Curie University, Paris, France.
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16
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Monsel A, Mal H, Brisson H, Luo R, Eyraud D, Vézinet C, Do CH, Lu Q, Vaillant JC, Hannoun L, Houssel P, Durand F, Rouby JJ. Extracorporeal membrane oxygenation as a bridge to liver transplantation for acute respiratory distress syndrome-induced life-threatening hypoxaemia aggravated by hepatopulmonary syndrome. Crit Care 2011; 15:R234. [PMID: 21958549 PMCID: PMC3334782 DOI: 10.1186/cc10476] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 05/04/2011] [Accepted: 09/29/2011] [Indexed: 02/07/2023]
Abstract
Introduction Combined with massive lung aeration loss resulting from acute respiratory distress syndrome, hepatopulmonary syndrome, a liver-induced vascular lung disorder characterized by diffuse or localized dilated pulmonary capillaries, may induce hypoxaemia and death in patients with end-stage liver disease. Methods The case of such a patient presenting with both disorders and in whom an extracorporeal membrane oxygenation was used is described. Results A 51-year-old man with a five-year history of alcoholic cirrhosis was admitted for acute respiratory failure, platypnoea and severe hypoxaemia requiring emergency tracheal intubation. Following mechanical ventilation, hypoxaemia remained refractory to positive end-expiratory pressure, 100% of inspired oxygen and inhaled nitric oxide. Two-dimensional contrast-enhanced (agitated saline) transthoracic echocardiography disclosed a massive right-to-left extracardiac shunt, without patent foramen ovale. Contrast computed tomography (CT) of the thorax using quantitative analysis and colour encoding system established the diagnosis of acute respiratory distress syndrome aggravated by hepatopulmonary syndrome. According to the severity of the respiratory condition, a veno-venous extracorporeal membrane oxygenation was implemented and the patient was listed for emergency liver transplantation. Orthotopic liver transplantation was performed at Day 13. At the end of the surgical procedure, the improvement in oxygenation allowed removal of extracorporeal membrane oxygenation (Day 5). The patient was discharged from hospital at Day 48. Three months after hospital discharge, the patient recovered a correct physical autonomy status without supplemental O2. Conclusions In a cirrhotic patient, acute respiratory distress syndrome was aggravated by hepatopulmonary syndrome causing life-threatening hypoxaemia not controlled by standard supportive measures. The use of extracorporeal membrane oxygenation, by controlling gas exchange, allowed the performing of a successful liver transplantation and final recovery.
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Affiliation(s)
- Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, UPMC Univ Paris 06, 83 Bd de l'Hôpital, 75013, Paris, France
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Eyraud D, Vaillant J, Ionescu C, Siksik J, Pavie A, Chastre J, Hannoun L, Coriat P. Early primary cardiac graft failure and combined heart–liver transplantation: need for an uncommon double bypass. Br J Anaesth 2011; 107:280-1. [DOI: 10.1093/bja/aer217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Dewachter P, Vézinet C, Nicaise-Roland P, Chollet-Martin S, Eyraud D, Creusvaux H, Vaillant JC, Mouton-Faivre C. Passive transient transfer of peanut allergy by liver transplantation. Am J Transplant 2011; 11:1531-4. [PMID: 21668638 DOI: 10.1111/j.1600-6143.2011.03576.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report a case of transient symptomatic transferred IgE-mediated peanut allergy after elective blood-group compatible liver transplantation. We show that the allergy was transient and therefore passive, authorizing further uneventful peanut consumption. Skin tests with commercial peanut extract and native peanut were performed in the recipient. Circulating specific IgE against peanut and recombinant peanut allergens (rArah1, rArah2, rArah3) was measured in stored serum samples collected from the recipient between 6 months before and 8 months after liver transplantation. Specific IgE levels in the donor were measured at the time of multiorgan donation. In the recipient, diagnosis of IgE-mediated peanut anaphylaxis was based on the clinical history and detection of specific IgE against peanut and recombinant major peanut allergens (rArah1, rArah2 and rArah3). Skin tests were negative and specific IgE undetectable 6 months after the clinical reaction. Oral peanut challenge was negative excluding persistent peanut allergy. This case confirms that IgE-mediated peanut allergy can be transferred by liver transplantation and shows that it may be transient and therefore passively acquired.
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Affiliation(s)
- P Dewachter
- Service d'Anesthésie-Réanimation & SAMU de Paris, Université Paris-Descartes, INSERM UMRS-970 & Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, France.
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Eyraud D, Ben Menna M, Vaillant JC, Kitajima K, Lebray P, Pavie A, Poynard T, Coriat P, Hannoun L. Perioperative management of combined heart-liver transplantation in patients with cirrhosis, renal insufficiency, or pulmonary hypertension. Clin Transplant 2011; 25:228-34. [DOI: 10.1111/j.1399-0012.2010.01240.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bourrat E, Cabotin PP, Baccard M, Fitoussi C, Eyraud D, Eudes AM, Sepaser M, Kornfeld S, Chaine B, Poli F, Raynaud E, Dadzie O, Petit A. Palmoplantar keratodermas in black patients (Fitzpatrick skin phototype V-VI) of African descent: a multicentre comparative and descriptive series. Br J Dermatol 2011; 165:219-21. [PMID: 21428971 DOI: 10.1111/j.1365-2133.2011.10325.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kitajima K, Vaillant JC, Charlotte F, Eyraud D, Hannoun L. Intractable ascites without mechanical vascular obstruction after orthotopic liver transplantation: etiology and clinical outcome of sinusoidal obstruction syndrome. Clin Transplant 2009; 24:139-48. [PMID: 19222508 DOI: 10.1111/j.1399-0012.2009.00971.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Intractable ascites after orthotopic liver transplantation (OLT) is a relatively rare complication. However, it often takes a life threatening course, which requires re-transplantation. In previous studies, several reports gave hepatic sinusoidal obstruction syndrome (SOS) as one of the causes of refractory ascites. However, the detailed etiology of SOS after OLT and its association with clinical consequences remain unclear because there have been few studies to date. We report two recent cases with rapidly progressive refractory ascites associated with SOS, following completely different clinical courses. In case 1, the first episode of acute allograft rejection triggered SOS and subsequent intractable ascites, while the second acute rejection worsened his clinical status. A transjugular intrahepatic portosystemic stent-shunt (TIPS) was placed and this procedure resulted in complete disappearance of ascites and of renal dysfunction. In contrast, refractory ascites in case 2, who had neither rejection nor mechanical outlet obstruction, worsened despite TIPS stent placement, and re-transplantation was necessary. We speculate that the pre-existing diseased liver of the cadaver donor caused this serious complication, necessitating a second graft.
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Affiliation(s)
- Kumiko Kitajima
- Department of Digestive, and Hepato-Biliary-Pancreatic Surgery, Liver Transplantation Unit, Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Université Pierre et Marie Curie - Paris VI, Paris, France
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Eyraud D, Ben Ayed S, Tanguy ML, Vézinet C, Siksik JM, Bernard M, Fratéa S, Movschin M, Vaillant JC, Coriat P, Hannoun L. Procalcitonin in liver transplantation: are high levels due to donors or recipients? Crit Care 2008; 12:R85. [PMID: 18601732 PMCID: PMC2575559 DOI: 10.1186/cc6942] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 06/24/2008] [Accepted: 07/04/2008] [Indexed: 11/10/2022]
Abstract
Introduction To date, a specific marker to evaluate and predict the clinical course or complication of the liver-transplanted patient is not available in clinical practice. Increased procalcitonin (PCT) levels have been found in infectious inflammation; poor organ perfusion and high PCT levels in the cardiac donor appeared to predict early graft failure. We evaluated PCT as a predictor of early graft dysfunction and postoperative complications. Methods PCT serum concentrations were measured in samples collected before organ retrieval from 67 consecutive brain-dead donors and in corresponding recipients from day 0, before liver transplantation, up to day 7 after liver transplantation. The following parameters were recorded in donors: amount of vasopressive drug doses, cardiac arrest history 24 hours before retrieval, number of days in the intensive care unit, age of donor, and infection in donor, and the following parameters were recorded in recipients: cold and warm ischemia time, veno-venous bypass, transfusion amount during orthotopic liver transplantation (OLT), and occurrence of postoperative complication or hepatic dysfunction. Results In the donor, the preoperative level of PCT was associated with cardiac arrest and high doses of catecholamines before organ retrieval. In the recipient, elevated PCT levels were observed early after OLT, with a peak at day 1 or 2 after OLT, then a decrease until day 7. A postoperative peak of PCT levels was associated neither with preoperative PCT levels in the donor or the recipients nor with hepatic post-OLT dysfunction or other postoperative complications, but with two donor parameters: infection and cardiac arrest. Conclusion PCT level in the donor and early PCT peak in the recipient are not predictive of post-OLT hepatic dysfunction or other complications. Cardiac arrest and infection in the donor, but not PCT level in the donor, are associated with high post-OLT PCT levels in the recipient.
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Affiliation(s)
- Daniel Eyraud
- Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière 43-47 Boulevard de l'Hôpital, 75013 Paris, France.
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Kalfon P, de Vaumas C, Samba D, Boulet E, Lefrant JY, Eyraud D, Lherm T, Santoli F, Naija W, Riou B. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients*. Crit Care Med 2007; 35:1032-9. [PMID: 17334256 DOI: 10.1097/01.ccm.0000259378.53166.1b] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate a new silver-impregnated multi-lumen central venous catheter for reducing catheter-related colonization in intensive care patients. DESIGN Multicenter, prospective, randomized, controlled clinical study. SETTING Ten adult intensive care units (multidisciplinary, medical and surgical, university and nonuniversity hospitals) in eight institutions. PATIENTS A total of 577 patients who required 617 multi-lumen central venous catheters between November 2002 and April 2004 were studied. INTERVENTIONS Intensive care adult patients requiring multi-lumen central venous catheters expected to remain in place for >or=3 days were randomly assigned to undergo insertion of silver-impregnated catheters (silver group) or standard catheters (standard group). Catheter colonization was defined as the growth of >or=1,000 colony-forming units in culture of the intravascular tip of the catheter by the vortexing method. Diagnosis of catheter-related infection was performed by an independent and blinded expert committee. RESULTS A total of 320 catheters were studied in the silver group and 297 in the standard group. Characteristics of the patients, insertion site, duration of catheterization (median, 11 vs. 10 days), and other risk factors for infection were similar in the two groups. Colonization of the catheter occurred in 47 (14.7%) vs. 36 (12.1%) catheters in the silver and the standard groups (p = .35), for an incidence of 11.2 and 9.4 per 1,000 catheter days, respectively. Catheter-related bloodstream infection was recorded in eight (2.5%) vs. eight (2.7%) catheters in the silver and the standard groups (p = .88), for an incidence of 1.9 and 2.1 per 1,000 catheter days, respectively. CONCLUSION The use of silver-impregnated multi-lumen catheters in adult intensive care patients is not associated with a lower rate of colonization than the use of standard multi-lumen catheters.
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Affiliation(s)
- Pierre Kalfon
- Service de Réanimation Polyvalente, Hôpitaux de Chartres, Chartres, France.
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Lodge JPA, Jonas S, Oussoultzoglou E, Malagó M, Jayr C, Cherqui D, Anthuber M, Mirza DF, Kuhlman L, Bechstein WO, Díaz JCM, Tartiere J, Eyraud D, Fridberg M, Erhardtsen E, Mimoz O. Recombinant Coagulation Factor VIIa in Major Liver Resection. Anesthesiology 2005; 102:269-75. [PMID: 15681939 DOI: 10.1097/00000542-200502000-00006] [Citation(s) in RCA: 170] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
Prevention of bleeding episodes in noncirrhotic patients undergoing partial hepatectomy remains unsatisfactory in spite of improved surgical techniques. The authors conducted a randomized, placebo-controlled, double-blind trial to evaluate the hemostatic effect and safety of recombinant factor VIIa (rFVIIa) in major partial hepatectomy.
Methods
Two hundred four noncirrhotic patients were equally randomized to receive either 20 or 80 microg/kg rFVIIa or placebo. Partial hepatectomy was performed according to local practice at the participating centers. Patients were monitored for 7 days after surgery. Key efficacy parameters were perioperative erythrocyte requirements (using hematocrit as the transfusion trigger) and blood loss. Safety assessments included monitoring of coagulation-related parameters and Doppler examination of hepatic vessels and lower extremities.
Results
The proportion of patients who required perioperative red blood cell transfusion (the primary endpoint) was 37% (23 of 63) in the placebo group, 41% (26 of 63) in the 20-microg/kg group, and 25% (15 of 59) in the 80-microg/kg dose group (logistic regression model; P = 0.09). Mean erythrocyte requirements for patients receiving erythrocytes were 1,024 ml with placebo, 1,354 ml with 20 microg/kg rFVIIa, and 1,036 ml with 80 microg/kg rFVIIa (P = 0.78). Mean intraoperative blood loss was 1,422 ml with placebo, 1,372 ml with 20 microg/kg rFVIIa, and 1,073 ml with 80 microg/kg rFVIIa (P = 0.07). The reduction in hematocrit during surgery was smallest in the 80-microg/kg group, with a significant overall effect of treatment (P = 0.04).
Conclusions
Recombinant factor VIIa dosing did not result in a statistically significant reduction in either the number of patients transfused or the volume of blood products administered. No safety issues were identified.
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Affiliation(s)
- J Peter A Lodge
- St. James's University Hospital, Hospital Haute-Pierre, Strasbourg, France.
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Fléron MH, Weiskopf RB, Bertrand M, Mouren S, Eyraud D, Godet G, Riou B, Kieffer E, Coriat P. A comparison of intrathecal opioid and intravenous analgesia for the incidence of cardiovascular, respiratory, and renal complications after abdominal aortic surgery. Anesth Analg 2003; 97:2-12, table of contents. [PMID: 12818934 DOI: 10.1213/01.ane.0000066355.07482.0c] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Major surgery evokes a stress response that can produce deleterious consequences, especially in a population at high risk for those complications. We tested the hypothesis that decreasing or eliminating one of the sources of stress by providing intense analgesia in the immediate postoperative period via application of neuraxial opioids would decrease major nonsurgical complications. Two-hundred-seventeen patients scheduled to undergo abdominal aortic surgery were randomly allocated to receive either general anesthesia alone (control) or general anesthesia combined with intrathecal opioid (1 micro g/kg sufentanil with 8 micro g/kg preservative-free morphine injected at the L4-5 interspace). Postoperative care was identical in the two groups, including patient-controlled analgesia. Each patient provided an assessment of postoperative pain using a visual analog scale. Postopera-tive complications were recorded according to criteria established a priori. The administration of intrathecal opioid provided more intense analgesia than patient-controlled analgesia during the first 24 h postoperatively (P < 0.05). There was no difference between groups for the incidence of combined major cardiovascular, respiratory, and renal complications (P > 0.05) or mortality (P > 0.05). The incidence of myocardial damage or infarction, as defined by abnormal plasma concentration of troponin I, did not differ between the two groups (P > 0.05). In patients undergoing major abdominal vascular surgery, decrease of one contributor to postoperative stress, by provision of intense analgesia for the intraoperative and initial postoperative period, via application of neuraxial opioid, does not alter the combined major cardiovascular, respiratory, and renal complication rate. IMPLICATIONS Provision of intense analgesia for the initial postoperative period after major abdominal vascular surgery, via the administration of neuraxial opioid, does not alter the combined incidence of major cardiovascular, respiratory, and renal complications.
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Affiliation(s)
- Marie-Hélène Fléron
- Department of Anesthesiology and Critical Care, CHU Pitié-Salpêtrière, Institut Mutualiste Montsouris, Paris, France
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Eyraud D, Richard O, Borie DC, Schaup B, Carayon A, Vézinet C, Movschin M, Vaillant JC, Coriat P, Hannoun L. Hemodynamic and hormonal responses to the sudden interruption of caval flow: insights from a prospective study of hepatic vascular exclusion during major liver resections. Anesth Analg 2002; 95:1173-8, table of contents. [PMID: 12401586 DOI: 10.1097/00000539-200211000-00008] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Hepatic vascular exclusion (HVE) combines portal triad clamping and occlusion of the inferior vena cava. Although HVE has been performed for major liver resections during the last 2 decades, little is known about the mechanisms that explain its satisfactory hemodynamic tolerance. Consequently, we performed a comprehensive study of both hemodynamic and hormone responses to HVE. Twenty-two patients who underwent liver resection for secondary tumors developed in noncirrhotic livers were prospectively studied. Heart rate, arterial blood pressure, pulmonary artery pressure, mixed venous saturation, cardiac output, and left ventricular dimensions determined by transesophageal echocardiography were monitored in HVE patients. Blood concentrations of arginine vasopressin (AVP), epinephrine, norepinephrine, dopamine, and atrial natriuretic peptide and plasma renin activity (PRA) were measured before clamping; 5, 15, and 30 min after clamping; and 15 min after unclamping. Hemodynamic response to HVE was characterized by a significant (P < 0.05) decrease in left ventricular dimensions, fractional area change, and pulmonary artery pressure. We also observed a marked decrease in cardiac output (50%) and an increase in heart rate and systemic vascular resistance. After unclamping, there was peripheral vasodilation, assessed by a significant decrease in systemic vascular resistance from the preclamping value to unclamping. An acute and sustained increase in AVP and norepinephrine that returned to baseline after unclamping and the absence of modification in PRA concentrations were noted. The marked decrease in venous return that characterizes HVE is compensated for by an increase in vascular resistance secondary to an important activation of the AVP and sympathetic systems. The PRA system does not play an important role in maintaining arterial blood pressure during HVE. IMPLICATIONS Hemodynamic and hormonal responses to the acute interruption of caval venous return to the heart were investigated in patients undergoing liver resection with hepatic vascular exclusion. A compensatory role for arginine vasopressin and sympathetic systems that provoked increased vascular resistance was demonstrated.
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Affiliation(s)
- Daniel Eyraud
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie, 47 Boulevard de l'Hôpital, 75013 Paris, France.
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Borie DC, Eyraud D, Boleslawski E, Lemoine A, Sebagh M, Cramer DV, Roussi J, Imbert-Bismut F, Germain G, Hannoun L. Functional metabolic characteristics of intact pig livers during prolonged extracorporeal perfusion: potential for a unique biological liver-assist device. Transplantation 2001; 72:393-405. [PMID: 11502966 DOI: 10.1097/00007890-200108150-00007] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The clinical development of liver-support devices based on perfusion of either pig hepatocytes cartridges or whole pig livers has been hampered by the ability to use sufficient liver cell mass to provide adequate metabolic support, limited perfusion times, and the potential for patient exposure to pig zoonotic diseases. METHODS We designed an original system in which an isolated intact pig liver was perfused extracorporeally under physiological conditions in a closed loop circuit with allogeneic pig blood and constant monitoring of major physiological and functional parameters. The perfusion circuit further included an interface membrane to provide for separation of patient and liver perfusion circulation. RESULTS Prolonged (6-21 hr) liver perfusion did not produce significant liver damage as reflected by modest rises in the levels of the serum transaminases, stability of main biochemical parameters (including potassium), and the maintenance of normal cellular morphology. Optimal liver function was documented as measured by lactate consumption, control of glycemia, and the results of clotting studies and functional assays. The perfused liver cleared 82% and 79% of peak bilirubin and ammonia concentrations with clearing kinetics identical throughout perfusion. Indocyanine green clearance was identical to that observed in the living donor before explant surgery. CONCLUSIONS In conclusion, the extracorporeal pig liver perfusion apparatus described here allows optimal pig liver function for prolonged periods of time. The microporous membrane to provide separation of donor organ and recipient and the high level of functional activity suggest that this form of liver metabolic support may have important clinical applications.
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Affiliation(s)
- D C Borie
- Department of Hepato-Biliary Surgery, Laboratory of Biology and Biochemistry, Pitie-Salpetriere Hospital, Paris, France.
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Daunizeau A, Borgard JP, Corso AD, Devilliers C, Duchassaing D, Eyraud D, Feuillu A, Guillosson JJ, Kulpa M. [Recommendations for setting up and using point of care blood gas systems]. Ann Biol Clin (Paris) 2001; 59:507-10. [PMID: 11470652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Affiliation(s)
- A Daunizeau
- Service de biochimie, Centre hospitalier Docteur-Schaffner, SP 8, 62307 Lens cedex
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Huraux C, Ankri A A, Eyraud D, Sevin O, Ménégaux F, Coriat P, Samama CM. Hemostatic Changes in Patients Receiving Hydroxyethyl Starch: The Influence of ABO Blood Group. Anesth Analg 2001; 92:1396-401. [PMID: 11375811 DOI: 10.1097/00000539-200106000-00007] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hydroxyethyl starches (HES) interfere with coagulation because of their molecular structure and the amount infused during surgery. Coagulation defects include platelet dysfunction and a decrease of the VIII/von Willebrand factor complex (VIII/vWF). We examined the effects of 6% HES 200/0.6 on hemostasis by using an in vitro platelet function analyzer, the usual coagulation tests, the VIII/vWF complex assessment, and TEG analysis in patients undergoing abdominal surgery. The influence of the blood group was investigated. HES infusion induced primary hemostasis alterations, assessed by a prolonged platelet function analyzer closure time in the presence of epinephrine and adenosine diphosphate, which was not correlated with the platelet count. The decrease in VIII/vWF complex was proportional to the volume of infused HES (20 and 30 mL/kg) and was more pronounced in patients of the O blood group. The preoperative hypercoagulability status assessed by TEG analysis was reversed 24 h after HES infusion. In conclusion, 6% HES 200/0.6 induced immediate hemostasis alterations. Patients of the O blood group were likely to develop a von Willebrand-like syndrome after HES infusion. We conclude that intraoperative use of 6% HES 200/0.6 should be restricted in patients of the O blood group undergoing surgical procedures with high risk for bleeding.
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Affiliation(s)
- C Huraux
- Department of Anesthesiology, Hôpital Pitié-Salpêtrière, Paris, France.
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30
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Kieffer E, Koskas F, Godet G, Bertrand M, Bahnini A, Benhamou AC, Cluzel P, Eyraud D. Treatment of aortic arch dissection using the elephant trunk technique. Ann Vasc Surg 2000; 14:612-9. [PMID: 11128456 DOI: 10.1007/s100169910111] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The elephant trunk technique was developed to facilitate multiple-stage treatment of extensive aneurysm of the thoracic aorta. However, little information is available concerning its usefulness for aortic dissection. From April 1992 to July 1998, we used the elephant trunk technique for treatment of aortic arch dissection in 22 patients (including 19 men) with a mean age of 58.5 years (range 21 to 85 years). Twelve patients presented with type A dissection (acute in 3 and chronic in 9), 3 with type B acute dissection, and 7 with "non A/non B" dissections with retrograde extension to the aortic arch or entry site located in the aortic arch without involvement of the ascending aorta. All patients had aneurysms of the descending (n = 7) or thoracoabdominal (n = 15) aorta. Procedures were performed under hypothermic circulatory arrest at between 15 degrees and 20 degrees C. Antegrade cerebral perfusion was used in three cases. The procedure was associated with aortic valve replacement and/or coronary bypass in 6 cases and bypass of one or more supraaortic vessels in 13. In two patients the distal end of the elephant trunk was attached with an endovascular prosthesis during the same procedure. The ensuing results in these patients indicate that the elephant trunk technique can be highly effective for treatment of complex aortic arch dissection.
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Affiliation(s)
- E Kieffer
- Departement d'Anesthésie-Réanimation, Pitié-Salpêtrière University Hospital, Paris, France
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Abstract
OBJECTIVE To analyse pre and peroperative variables for predicting mortality after abdominal aortic surgery. STUDY DESIGN Prospective study. PATIENTS We prospectively included 658 consecutive patients undergoing abdominal aortic surgery from January 1993 to July 1997. METHODS Age, gender, hypertension, history of myocardial infarction or coronary revascularization, angina pectoris, diabetes, arrhythmia, cardiac insufficiency, serum creatinine > 150 mumol.L-1, beta-blockers therapy, calcium channel inhibitors, angiotensin converting enzyme inhibitors were preoperative analysed variable. Type of aortic disease (anuerysms versus aortic occlusion), duration of surgery, blood loss, type of laparotomy (medium versus lombotomy) were peroperative analysed variables. Haemoglobinemia was monitored during surgery and patients were transfused if haemoglobinaemia < 80 g.L-1. RESULTS Thirty-three patients died after aortic surgery (5%). In multivariate analysis, angina pectoris (OR = 5.47, P < 0.001), chronic obstructive bronchopulmonary disease (OR = 2.27, P = 0.05) and duration of surgery (OR = 1.60, P < 0.001) were the independent predictive factors of mortality. Age, blood loss were predictive factors only in univariate analysis. CONCLUSION Angina pectoris and COBP were the two independent preoperative factors of mortality. The duration of surgery was the only peroperative factor. Well monitored blood loss was not a predictive factor.
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Affiliation(s)
- D Eyraud
- Département d'anesthésie-réanimation, hôpital Pitié-Salpêtrière, Paris, France
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32
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Brabant SM, Bertrand M, Eyraud D, Darmon PL, Coriat P. The hemodynamic effects of anesthetic induction in vascular surgical patients chronically treated with angiotensin II receptor antagonists. Anesth Analg 1999; 89:1388-92. [PMID: 10589613 DOI: 10.1097/00000539-199912000-00011] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED The use of angiotensin II receptor subtype-1 antagonists (ARA), recently introduced as antihypertensive drugs, is becoming more prevalent. We studied the prevalence and severity of hypotension after the induction of general anesthesia in 12 patients treated with ARA until the morning of surgery. The hemodynamic response to induction was compared with that of patients treated with beta-adrenergic blockers (BB) and/or calcium channel blockers (CB) (BB/CB group, n = 45) and angiotensin-converting enzyme inhibitors (ACEI) (ACEI group, n = 27). A standardized anesthesia induction protocol was followed for all patients. Hypotension occurred significantly (p < or = 0.05) more often in ARA-treated patients (12 of 12) compared with BB/CB-treated patients (27 of 45) or with ACEI-treated patients (18 of 27). There was a significantly (P < or = 0.001) increased ephedrine requirement in the ARA group (21+/-3 mg) compared with the BB/CB group (10+/-6 mg) or the ACEI group (7+/-4 mg). Hypotension refractory to repeated ephedrine or phenylephrine administration occurred significantly (P < or = 0.05) more in the ARA group (4 of 12) compared with the BB/CB group (0 of 45) or the ACEI group (1 of 27), but it was treated successfully by using a vasopressin system agonist. Treatment with angiotensin II antagonism until the day of surgery is associated with severe hypotension after the induction of anesthesia, which, in some cases, can only be treated with an agonist of the vasopressin system. IMPLICATIONS Hypotensive episodes occur more frequently after anesthetic induction in patients receiving Angiotensin II receptor subtype-1 antagonists under anesthesia than with other hypotensive drugs. They are less responsive to the vasopressors ephedrine and phenylephrine. The use of a vasopressin system agonist was effective in restoring blood pressure when hypotension was refractory to conventional therapy.
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Affiliation(s)
- S M Brabant
- Department of Anesthesiology, University Hospital Pitié-Salpêtrière, Paris, France
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33
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Brabant SM, Eyraud D, Bertrand M, Coriat P. Refractory hypotension after induction of anesthesia in a patient chronically treated with angiotensin receptor antagonists. Anesth Analg 1999; 89:887-8. [PMID: 10512259 DOI: 10.1097/00000539-199910000-00012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- S M Brabant
- Department of Anesthesiology, University Hospital Pitié-Salpêtrière, Paris, France
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34
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Brabant SM, Eyraud D, Bertrand M, Coriat P. Refractory Hypotension After Induction of Anesthesia in a Patient Chronically Treated with Angiotensin Receptor Antagonists. Anesth Analg 1999. [DOI: 10.1213/00000539-199910000-00012] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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Eyraud D, Benmalek F, Teugels K, Bertrand M, Mouren S, Coriat P. Does desflurane alter left ventricular function when used to control surgical stimulation during aortic surgery? Acta Anaesthesiol Scand 1999; 43:737-43. [PMID: 10456814 DOI: 10.1034/j.1399-6576.1999.430709.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although desflurane is commonly used to control surgically induced hypertension, its effects on left ventricular (LV) function have not been investigated in this clinical situation. The purpose of the present study was to evaluate the LV function response to desflurane, when used to control intraoperative hypertension. METHODS In 50 patients, scheduled for vascular surgery, anesthesia was induced with sufentanil 0.5 microg/kg, midazolam 0.3 mg/kg and atracurium 0.5 mg/kg. After tracheal intubation, anesthesia was maintained with increments of drugs with controlled ventilation (N2O/O2=60/40%) until the start of surgery. A 5 Mhz transesophageal echocardiography (TEE) probe was inserted after intubation. Pulmonary artery catheter and TEE measurements were obtained after induction (to)(control value), at surgical incision (t1) if it was associated with an increase in systolic arterial pressure (SAP) greater than 140 mmHg (hypertension) and after control of hemodynamic parameters by administration of desflurane (return of systolic arterial pressure to within 20% of the control value) (t2) in a fresh gas flow of 31/ min. RESULTS Sixteen patients developed hypertension at surgical incision. SAP was controlled by desflurane in all 16 patients. Afterload assessed by systemic vascular resistance index (SVRI), end-systolic wall-stress (ESWS) and left-ventricular stroke work index (LVSWI) increased with incision until the hypertension returned to post-induction values with mean end-tidal concentration of 5.1+/-0.7% desflurane. No change in heart rate, cardiac index, mean pulmonary arterial pressure, stroke volume, end-diastolic and end-systolic cross-sectional areas, fractional area change and left ventricular circumferential fiber shortening was noted when desflurane was added to restore blood pressure. CONCLUSION This study demonstrates that in patients at risk for cardiac morbidity undergoing vascular surgery, desflurane is effective to control intraoperative hypertension without fear of major cardiac depressant effect.
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Affiliation(s)
- D Eyraud
- Department of Anesthesiology and Intensive Care, Hôpital de la Pitié-Salpêtrière, Paris VI University, France
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36
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Eyraud D, Brabant S, Nathalie D, Fleron MH, Gilles G, Bertrand M, Coriat P. Treatment of Intraoperative Refractory Hypotension with Terlipressin in Patients Chronically Treated with an Antagonist of the Renin-Angiotensin System. Anesth Analg 1999. [DOI: 10.1213/00000539-199905000-00003] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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37
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Eyraud D, Brabant S, Nathalie D, Fléron MH, Gilles G, Bertrand M, Coriat P. Treatment of intraoperative refractory hypotension with terlipressin in patients chronically treated with an antagonist of the renin-angiotensin system. Anesth Analg 1999; 88:980-4. [PMID: 10320155 DOI: 10.1097/00000539-199905000-00003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED The goal of the present study was to determine whether terlipressin, an agonist of the vasopressin system, could counteract perioperative hypotension refractory to common vasopressor therapy and to analyze its circulatory effects. We enrolled 51 consecutive vascular surgical patients chronically treated with angiotensin-converting enzyme inhibitors or antagonists of the receptor of angiotensin II, who received a standardized opioid-propofol anesthetic. Of these 51 patients, 32 had at least one episode of hypotension, which responded to epinephrine or phenylephrine. In 10 other patients, systolic arterial pressure (SAP) did not remain above 100 mm Hg for 1 min, despite three bolus doses of ephedrine or phenylephrine. In these patients, we injected a bolus of 1 mg of terlipressin, repeated twice if necessary. Hemodynamic and echocardiographic variables were recorded every 30 s over 6 min. In eight patients, arterial pressure was restored with one injection of terlipressin; in two other patients, three injections were necessary. One minute after the last injection of terlipressin, the SAP increased from 88+/-3 to 100+/-4 mm Hg and reached 117+/-5 mm Hg (P = 0.001) 3 min after the injection and remained stable around this value. This increase in SAP was associated with significant changes in left ventricular end-diastolic area (17.9+/-2 vs 20.2+/-2.2 cm2; P = 0.003), end-systolic area (8.1+/-1.3 vs 9.6+/-1.5 cm2; P = 0.004), end-systolic wall stress (45+/-8 vs 66+/-12; P = 0.001), and heart rate (60+/-4 vs 55+/-3 bpm; P = 0.001). Fractional area change and velocity of fiber shortening did not change significantly. No additional injection of vasopressor was required during the perioperative period. No change in ST segment was observed after the injection. IMPLICATIONS Terlipressin is effective to rapidly correct refractory hypotension in patients chronically treated with antagonists of the renin-angiotensin system without impairing left ventricular function.
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Affiliation(s)
- D Eyraud
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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38
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Coriat P, Eyraud D. [Incidence and prevention of coronary complications after general surgery]. Arch Mal Coeur Vaiss 1998; 91 Spec No 4:17-22; discussion 29-30. [PMID: 9834834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The frequency, the nature and physiopathological mechanisms of cardiac complications of general surgical patients are well known. Acute myocardial infarction, the main complication, occurs in 3 to 5% of high risk cases. Though usually subendocardial and asymptomatic, it jeopardizes short and medium term survival of patients. It occurs in the first 48 hours after surgery in the majority of cases, the diagnosis being confirmed by increased serum troponine I levels. The circulatory, mechanical and inflammatory changes and hypercoagulability, which are present during the perioperative period, interact, disturbing the energetic equilibrium of the myocardium and causing episodes of myocardial ischaemia which, if prolonged, result in necrosis of the subendocardial myocardium. These effects must be taken into consideration if the operative risk of coronary patients is to be reduced. It is essential to monitor the haemodynamic parameters which affect myocardial energy consumption both during and after surgery. Particular attention must be paid in the postoperative period which is characterised by metabolic stress and sympathetic hyperreactivity which predispose to prolonged episodes of silent myocardial ischaemia. Betablockers, which effectively prevent per and postoperative ischaemia without causing jeopardy to the haemodynamic status and which reduce the cardiac risk of general surgery have a role to play in the prevention of acute myocardial infarction in the postoperative period when prescribed before surgery and continued by oral administration during the first 6 postoperative days. The alpha-2-agonists affect sympathetic reactivity during and after surgery and are very well tolerated haemodynamically. If the current on-going multicenter trials show that they prevent postoperative cardiovascular complications, they could be prescribed prophylactically in patients at risk.
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Affiliation(s)
- P Coriat
- Service d'anesthésie-réanimation, hôpital Pitié-Saipêtrière, Paris
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39
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Eyraud D, Mouren S, Teugels K, Bertrand M, Coriat P. Treating anesthesia-induced hypotension by angiotensin II in patients chronically treated with angiotensin-converting enzyme inhibitors. Anesth Analg 1998; 86:259-63. [PMID: 9459229 DOI: 10.1097/00000539-199802000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Although angiotensin II bolus administration may be used to increase blood pressure in patients chronically treated with angiotensin-converting enzyme inhibitors (ACEI) who have severe hypotension on anesthetic induction, no data are available describing its time course and its effects on the left ventricular function. Fourteen patients chronically treated with ACEI for hypertension and scheduled for vascular surgery were prospectively studied. Patients with cardiac insufficiency were excluded. A transesophageal echocardiography probe was inserted to assess systolic left ventricular function. When hypotension was observed (systolic arterial pressure [SAP] <85 mm Hg), an I.V. bolus of 2.5 microg of angiotensin II (AII) was given, and hemodynamic variables were recorded each 30 s over 5.5 min. Results are expressed as mean +/- SEM. Sixty seconds after the AII bolus injection, the SAP increased from 78 +/- 3 to 152 +/- 6 mm Hg. SAP remained higher than control until the 5th min. This was associated with significant increases in end-diastolic area (from 15.1 +/- 0.6 to 19.3 +/- 1.0 cm2, P < or = 0.001), end-systolic area (from 6.6 +/- 0.4 to 10.7 +/- 0.7 cm2, P < or = 0.001), end-systolic wall stress (from 32 +/- 0.05 to 82 +/- 7 kdynes/cm2, P < or = 0.001). In addition, a decrease in fiber-shortening velocity (from 1.1 +/- 0.05 to 0.76 +/- 0.04 circ/s, P < or = 0.05) and in fractional area change (from 0.57 +/- 0.02 to 0.44 +/- 0.02, P < or = 0.05) was observed. Heart rate did not significantly change during the study. Increases in preload and afterload were observed. However, the administration of AII causes a transient impairment in left ventricular function. We conclude that AII, given as an I.V. bolus of 2.5 microg, is effective in restoring arterial blood pressure within 60 s in patients chronically treated with ACEI. IMPLICATIONS Severe hypotension on anesthetic induction in patients chronically treated with angiotensin-converting enzyme inhibitors for hypertension could be treated with an I.V. bolus of 2.5 microg of angiotensin II.
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Affiliation(s)
- D Eyraud
- Department of Anesthesiology and Intensive Care, Hôpital de la Pitié-Salpétrière, Paris, France
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40
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Eyraud D, Mouren S, Teugels K, Bertrand M, Coriat P. Treating Anesthesia-Induced Hypotension by Angiotensin II in Patients Chronically Treated with Angiotensin-Converting Enzyme Inhibitors. Anesth Analg 1998. [DOI: 10.1213/00000539-199802000-00007] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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41
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Ozier YM, Le Cam B, Chatellier G, Eyraud D, Soubrane O, Houssin D, Conseiller C. Intraoperative blood loss in pediatric liver transplantation: analysis of preoperative risk factors. Anesth Analg 1995; 81:1142-7. [PMID: 7486095 DOI: 10.1097/00000539-199512000-00005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The relative contribution of 14 preoperative risk factors to a high intraoperative blood loss was studied in 95 consecutive first pediatric orthotopic liver transplantations (OLT). Patients were distributed in two groups according to red blood cell (RBC) requirements. Wide interindividual RBC requirements were observed (median, 79 mL/kg; range, 4-586). The upper quartile of the population was defined as the high blood loss group and required 123 mL/kg or more (median, 161). On univariate analysis, the high blood loss group had a significantly higher proportion of patients with portal vein hypoplasia, intraabdominal malformations, signs of severe liver failure (encephalopathy, ascites, prolonged prothrombin time), and requiring inpatient support. Age, previous abdominal surgery, and platelet count had no prognostic value. All variables used in the univariate analysis were included in a stepwise logistic regression analysis. Only presence of portal vein hypoplasia, inpatient support, and use of a reduced-size liver graft were independently associated with a high blood loss. Adjusted odds ratios were 40.4 (95% confidence interval; 5.9-278), 5.4 (1.6-17.9), and 3.8 (0.9-15.2), respectively, highlighting the importance of portal vein hypoplasia as a risk factor for high blood loss.
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Affiliation(s)
- Y M Ozier
- Département d'Anesthésie-Réanimation, Groupe Hospitalier Cochin, Paris, France
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42
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Ozier YM, Le Cam B, Chatellier G, Eyraud D, Soubrane O, Houssin D, Conseiller C. Intraoperative Blood Loss in Pediatric Liver Transplantation. Anesth Analg 1995. [DOI: 10.1213/00000539-199512000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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43
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Samama CM, Diaby M, Fellahi JL, Mdhafar A, Eyraud D, Arock M, Guillosson JJ, Coriat P, Rouby JJ. Inhibition of platelet aggregation by inhaled nitric oxide in patients with acute respiratory distress syndrome. Anesthesiology 1995; 83:56-65. [PMID: 7605019 DOI: 10.1097/00000542-199507000-00007] [Citation(s) in RCA: 126] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Nitric oxide inhibits platelet adhesion and aggregation in vitro. The aim of this prospective study was to assess the platelet antiaggregating activity of nitric oxide administered to patients with acute respiratory distress syndrome (ARDS) at increasing concentrations. METHODS In six critically ill patients (mean age 37 +/- 16 yr) with ARDS (lung injury severity score > or = 2.2), the lungs were mechanically ventilated with inhaled nitric oxide (1, 3, 10, 30, and 100 ppm) randomly administered. Patients with cardiac dysrhythmias, septic shock, an underlying hemostasis disorder (constitutive or acquired), a platelet count less than 100 Giga/l, or a decreased platelet aggregation and those treated with antiplatelet or anticoagulant agents were excluded. Platelet aggregation was measured without nitric oxide and at each nitric oxide concentration in platelet-rich plasma issued from radial artery. Ivy bleeding time using a horizontal incision was simultaneously performed. RESULTS After nitric oxide, a non-dose-dependent but statistically significant decrease in ex vivo platelet aggregation induced by three aggregating agents was observed: adenosine diphosphate = -56 +/- 18%, collagen = -37 +/- 18%, and ristocetin = -45 +/- 18% (P < 0.05). In each individual, Ivy bleeding time remained within normal values measured in healthy volunteers, and variations after nitric oxide did not correlate with changes in platelet aggregation. Simultaneously, arterial oxygenation improved significantly and pulmonary artery pressure decreased significantly. CONCLUSIONS In patients with ARDS and without preexisting coagulation disorders, the beneficial effects of inhaled nitric oxide on arterial oxygenation and pulmonary circulation are associated with a significant inhibition of platelet aggregation. This antithrombotic effect is not associated with a significant prolongation of the bleeding time.
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Affiliation(s)
- C M Samama
- Département d'Anesthésiologie, Hôpital de la Pitié-Salpêtrière, Université Paris VI, France
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Azoulay D, Castaing D, Dennison A, Martino W, Eyraud D, Bismuth H. Transjugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: preliminary report of a prospective study. Hepatology 1994. [PMID: 8276348 DOI: 10.1002/hep.1840190121] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The aim of this prospective nonrandomized study was to assess the immediate and short-term sequelae of transjugular intrahepatic portosystemic shunting on the circulatory hyperdynamic state of the cirrhotic patient. Twelve transjugular portosystemic shunting procedures were performed in 12 cirrhotic patients for sclerotherapy failure (10 cases) and/or intractable ascites (4 cases). Self-expandable stents 10 mm in diameter were used in all cases. Portal pressure measurement and right-heart catheterization were performed before and 30 min and 1 mo after the procedure. The portoatrial pressure gradient decreased from 15 +/- 3 to 7 +/- 3 mm Hg 30 min after surgery (p < 0.0001) to 8 +/- 3 mm Hg 1 mo after surgery (p < 0.001, in comparison with basal values). The cardiac index increased from 4.5 +/- 1.3 to 5.7 +/- 1.5 L/min.m2 30 min after surgery (p < 0.001) to 7.4 +/- 1.4 L/min.m2 1 mo after surgery (p < 0.001). Systemic vascular resistance decreased from 808 +/- 323 to 646 +/- 209 dyne.sec.cm-5 30 min after surgery (p < 0.01) to 467 +/- 101 dyne.sec.cm-5 1 mo after surgery (p < 0.05). This study demonstrates that transjugular portosystemic shunting rapidly and significantly worsens the hyperdynamic circulatory state of the cirrhotic patient. Although apparently noninvasive, this procedure should be considered with caution in cirrhotic patients with limited cardiac reserve.
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Affiliation(s)
- D Azoulay
- Hepato-Biliary Surgery and Liver Transplant Research Center, Paul Brousse Hospital, Villejuif, France
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Saliba F, Eyraud D, Samuel D, David MF, Arulnaden JL, Dussaix E, Mathieu D, Bismuth H. Randomized controlled trial of acyclovir for the prevention of cytomegalovirus infection and disease in liver transplant recipients. Transplant Proc 1993; 25:1444-5. [PMID: 8382876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- F Saliba
- Hepato-Biliary and Liver Transplant Unit, Hôpital Paul Brousse, Villejuif, France
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Delamare J, Eyraud D, Monnerot-Dumaine M, Sournia JC, Vanhoof M. [FRANGLAISE IN MEDICINE]. Sem Hop Inf 1964:8-10. [PMID: 14153137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
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