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Staubli SM, Jobeir B, Spiro M, Raptis DA. Invitation to join the Healthcare AI Language Group: HeALgroup.AI Initiative. BMJ Health Care Inform 2024; 31:e100884. [PMID: 38471783 DOI: 10.1136/bmjhci-2023-100884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/24/2024] [Indexed: 03/14/2024] Open
Affiliation(s)
- Sebastian Manuel Staubli
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Basel Jobeir
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Michael Spiro
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dimitri Aristotle Raptis
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Walker HL, Ghani S, Kuemmerli C, Nebiker CA, Müller BP, Raptis DA, Staubli SM. Reliability of Medical Information Provided by ChatGPT: Assessment Against Clinical Guidelines and Patient Information Quality Instrument. J Med Internet Res 2023; 25:e47479. [PMID: 37389908 PMCID: PMC10365578 DOI: 10.2196/47479] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [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] [Received: 04/07/2023] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND ChatGPT-4 is the latest release of a novel artificial intelligence (AI) chatbot able to answer freely formulated and complex questions. In the near future, ChatGPT could become the new standard for health care professionals and patients to access medical information. However, little is known about the quality of medical information provided by the AI. OBJECTIVE We aimed to assess the reliability of medical information provided by ChatGPT. METHODS Medical information provided by ChatGPT-4 on the 5 hepato-pancreatico-biliary (HPB) conditions with the highest global disease burden was measured with the Ensuring Quality Information for Patients (EQIP) tool. The EQIP tool is used to measure the quality of internet-available information and consists of 36 items that are divided into 3 subsections. In addition, 5 guideline recommendations per analyzed condition were rephrased as questions and input to ChatGPT, and agreement between the guidelines and the AI answer was measured by 2 authors independently. All queries were repeated 3 times to measure the internal consistency of ChatGPT. RESULTS Five conditions were identified (gallstone disease, pancreatitis, liver cirrhosis, pancreatic cancer, and hepatocellular carcinoma). The median EQIP score across all conditions was 16 (IQR 14.5-18) for the total of 36 items. Divided by subsection, median scores for content, identification, and structure data were 10 (IQR 9.5-12.5), 1 (IQR 1-1), and 4 (IQR 4-5), respectively. Agreement between guideline recommendations and answers provided by ChatGPT was 60% (15/25). Interrater agreement as measured by the Fleiss κ was 0.78 (P<.001), indicating substantial agreement. Internal consistency of the answers provided by ChatGPT was 100%. CONCLUSIONS ChatGPT provides medical information of comparable quality to available static internet information. Although currently of limited quality, large language models could become the future standard for patients and health care professionals to gather medical information.
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Affiliation(s)
| | - Shahi Ghani
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Christoph Kuemmerli
- Clarunis - University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | | | - Beat Peter Müller
- Clarunis - University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Dimitri Aristotle Raptis
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Sebastian Manuel Staubli
- Royal Free London NHS Foundation Trust, London, United Kingdom
- Clarunis - University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
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O, Mateo-Sierra O, Azzis O, Ojewuyi O, Habeeb O, Idowu O, Elebute O, Agboola O, Ladipo-Ajayi O, Oyinloye O, Adebola O, Ekor O, Ogundoyin O, Salamanca O, Vergara-Fernandez O, Wafi O, Aladawi O, Bahassan OM, Tammo Ö, Ozkan OF, Williams OM, Salami O, Akinajo O, Sakhov O, Gallo O, Sole OM, Milella O, Alser O, Bettar OA, Alomar O, Osman OS, Aisuodionoe-Shadrach O, Basnayake O, Bozbiyik O, Hodges O, Ojo O, Yanık Ö, Mutlu ÖPZ, Kazan O, Calavia P, García PR, Urriza PV, Lopez PR, Christidis P, Dorovinis P, Kokoropoulos P, Mourmouris P, Papatheodorou P, Garg PK, Patel P, Vassiliu P, Campennì P, De Nardi P, Bernante P, Ubiali P, Baroffio P, Pizzini P, Sapienza P, Myrelid P, Chatzikomnitsa P, Tsiantoula P, Gada P, Avella P, Cianci P, Romero P, Méndez PS, Pazmiño PAF, Coughlin P, Kirchweger P, Pessaux P, Maguire PJ, Petrone P, Cullis P, Köglberger P, Marriott P, Nankivell P, Santos-Costa P, Martins PN, Panahi P, Botelho P, Teixeira P, Escobar P, Vázquez PJG, Gribnev P, Nolte P, Agbonrofo P, Bobak P, Choong P, Elbe P, Hutchinson P, Labib P, Paal P, Pockney P, Reemst P, Szatmary P, Vaughan-Shaw PG, Alexander P, Pucher P, Stather P, Foessleitner P, Winnand P, Zehnder P, Kruse P, Matos PAW, Lapolla P, Cicerchia PM, Solli P, Di Lascio P, Zarif P, Champagne PO, Anoldo P, Bertoglio P, Fransvea P, Familiari P, Lombardi PM, Stogowski PT, Bruzzaniti P, Tripathi P, D'sa P, Salunke P, Shah PA, Punjabi PPP, Christodoulou P, Hamdan Q, Tawalbeh R, Gadelkareem R, Awad R, Callcut R, Clegg R, Choron R, Payne R, Gefen R, Costea R, Drasovean R, Mirica RM, Ravindra R, Fajardo RT, Nunes RL, Aspide R, Lombardi R, Vidya R, Elboraei R, Saaid R, Ghodke R, Gupta R, Sharma RD, Lunevicius R, Kalayarasan R, Mohan R, Singh R, Sivaprakasam R, Seenivasagam RK, Rajendram R, Radulescu RB, Goicea R, Seshadri RA, Sarı R, Nataraja R, Aslam R, Abdelemam R, Shrestha R, Bharathan R, Pellini R, Guevara R, Agarwal R, Vissapragada R, Alharmi RA, Sayyed R, Browning R, Critchley R, Mallick R, Alarabi R, Beron RI, Függer R, Othman R, Saad R, Amores RR, Colombari RC, Radivojević RC, Patrone R, Novysedlák R, Palacios Huatuco RM, Baertschiger R, Liang R, Luckwell R, Escrevente R, Rezende RF, Cruz RP, Lenzi R, Rosati R, Donovan R, Egan R, Morris R, Page R, Seglenieks R, Unsworth R, Wilkin R, Skipworth RJ, Davies RJ, Bezirci R, Talwar R, Azami R, Bohmer R, Crichton R, Fruscio R, Hooker R, Jach R, Parker R, Pillerstorff R, Sinnerton R, Stabler R, O'connell RM, Ragozzino R, Tutino R, Angelico R, Cammarata R, Colasanti R, Macchiavello R, Peltrini R, Pirrello R, Vaschetti R, Pires RE, Papalia R, Arrangoiz R, Hompes R, Mittal R, Salah R, Pinto R, Flumignan R, Callan R, Cuthbert R, Dennis R, Scaramuzzo R, Macías RM, Sánchez R, Ogu R, Ramely R, Sgarzani R, Ramli R, Hillier R, Thumbadoo R, Ooi R, Abdus-Salam R, Masri R, Hodgson R, Mathew R, Wade R, D'archi S, Khan S, Ngaserin S, Kale S, Hassan S, Merghani S, Benamar S, Muhammad S, Badran S, Elsahli S, Heta S, Hammouche S, Baeesa S, Paiella S, Eldeen STEHT, Arkani S, Mittal S, Hirji S, Tebha S, Emile S, Dbouk S, Bandyopadhyay SK, Muhammad S, Olori S, Asirifi SA, Hailu S, Ling S, Newman S, Ross S, Wanjara S, Kumar S, Seneviratne S, Tamburello S, Suarez SB, Ingallinella S, Irshaidat S, Konswa S, Mambrilla S, Nasser S, Parini S, Pitoni S, Ornaghi S, Rodrigues SC, Abdelmohsen S, Aitken S, Tian S, Badiani S, Ahmad S, Swed S, Muthu S, Lakpriya S, Alzahrani S, Mikalauskas S, Lasrado S, Satoskar S, Bawa S, Altiner S, Garcia S, Stevens S, Demir S, Ken-Amoah S, Tranca S, Ziemann S, Awad S, Atici SD, Subramaniam S, Erel S, Jiang S, Efetov S, Efremov S, Katorkin S, Valladares SC, Contreras SM, Meriç S, Zenger S, Safi S, Leventoğlu S, Elsalhawy S, Shaikh S, Sheik S, Islam S, Shamim S, Waqar SH, Ahmad S, Farid S, Seraj SS, Sundarraju S, Karandikar S, Sambhwani S, Chopra S, Chowdhury S, Laura S, Ahmed S, Wason S, Tan SJH, Fraser S, Williams S, Ghozy S, Abdelmawgoud S, Shehata S, Sharma S, Ahmed S, Al-Touny SA, Ramzanali S, Nah SA, Jansen S, Rajan S, Dindyal S, Amin S, Ahmad S, Shoukrie SIM, Karar S, Patkar S, Abdulsalam S, Lin S, Hegde S, Fiorelli S, Quaresima S, Redondo SV, Palmisano S, Ruggiero S, Balogun S, Cais S, Cole S, Federer S, Le Roux S, Ippoliti S, Meneghini S, Viola S, Manfredelli S, Novello S, Gananadha S, Mesli SN, Kale S, Tani SI, Malik S, Anastasiadou S, Boligo S, Esposito S, Valanci S, Xenaki S, Pejkova S, Bandyopadhyay S, Trungu S, Basu S, Alkhatib S, Pérez-Bertólez S, Flores SL, Donoghue S, Lunca S, Orsoo S, Potamianos S, Devarakonda S, Suresh S, Croghan SM, Turi S, Capella S, Lucchini S, Magnone S, Salizzoni S, Scabini S, Scaringi S, Cioffi SPB, Seyfried S, Degener S, Potten S, Taha-Mehlitz S, Ali S, Angamuthu S, Mcaleer S, Knight SR, White S, Mantziari S, Kykalos S, Goh SK, Chowdhury SP, Ibrahim S, Elzwai S, Bansal S, Tripathy S, Amrayev S, Anwar SL, Banerjee S, Thakar S, Saeed S, Venkatappa SK, Das S, Techapongsatorn S, Dube SK, Lee S, González-Suárez S, Henriques S, Konjevoda S, Gisbertz S, Bravo SL, Mannan S, Bukhari SI, Zafar SN, Batista S, Chin SL, Arif T, Lawal TA, Aktokmakyan TV, Osborn T, Szakmany T, Sztipits T, Triantafyllou T, Valadez TAC, Singh T, Khaliq T, Patel T, Fadalla T, Jichi T, Sammour T, Al-Shaiji T, Naggs T, Barišić T, Nikolouzakis T, Bisgin T, Perra T, Uprak TK, Dagklis T, Liakakos T, Sidiropoulos T, Adjeso TJK, Dölker T, Oung T, Aherne T, Diehl T, Pinkney T, Raymond T, Rhomberg T, Schmitz-Rixen T, Madhuri TK, Lohmann TK, Yeoh T, Zaimis T, Bright T, Vilz TO, Glowka TR, Board T, Hardcastle T, Cohnert T, Mahečić TT, William TG, Klatte T, Abbott T, Watcyn-Jones T, Mendes T, Kulis T, Sečan T, Campagnaro T, Frisoni T, Simoncini T, Violante T, Safranovs TJ, Risteski T, Pang T, Akinyemi T, Yotsov T, Laeke T, Kochiyama T, Sholadoye TT, Alekberli T, Ezomike U, Giustizieri U, Grossi U, Köksoy ÜC, Bork U, Kisser U, Ronellenfitsch U, Saeed U, Bracale U, Jayarajah U, Rauf UHA, Bumbasirevic U, Ferrer UMJ, Ahmed U, Bello UM, Jogiat U, Sadia U, Galandarov V, Narayanan V, Calu V, Bianchi V, Ciniero V, Tonini V, Silvestri V, Vijay V, Dewan V, Lohsiriwat V, Thuduvage V, Mousafeiris V, Dragisic V, Sasireka V, Santric V, Kusuma VRM, Kolli VS, Alonso V, De Simone V, Picotti V, Martínez VM, Panduro-Correa V, Kakotkin V, Angulo VP, Turrado-Rodriguez V, Krishnamoorthy V, Ban VS, Shah V, Maiola V, Giordano V, La Vaccara V, Lizzi V, Papagni V, Schiavone V, Satchithanantham V, Garcia-Virto V, Jimenez V, Kumar V, Shelat V, Bhat V, Sodhai V, Graziadei V, Kutuzov V, Stoyanov V, Oktseloglou V, Flis V, Elhassan WAF, Yang W, Soon WC, Tashkandi W, Al-Khyatt W, Mabood W, Bijou W, Wijenayake W, D W, Krawczyk W, Atkins W, Bolton W, White W, Ceelen W, Vagena X, Gozal Y, Baba YI, Subramani Y, Jansen Y, Mittal Y, Kara Y, Zwain Y, Noureldin Y, Alawneh Y, Aydin Y, Lam YH, Tang Y, Lim Y, Dean Y, Tanas Y, Su YX, Fujimoto Y, Altinel Y, Frolova Y, Oshodi Y, Fadel ZT, Zahid Z, Elahi Z, Djama Z, Zaheen Z, Jawad Z, Demetrashvili Z, Gebremeskel Z, Gudisa Z, Alyami Z, Garoufalia Z, Li Z, Zimak Z, Radin Z, Balogh ZJ. Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries. Br J Surg 2023; 110:804-817. [PMID: 37079880 PMCID: PMC10364528 DOI: 10.1093/bjs/znad092] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. METHODS This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries. RESULTS In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. CONCLUSION This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.
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Kostakis ID, Raptis DA, Davidson BR, Iype S, Nasralla D, Imber C, Sharma D, Pissanou T, Pollok JM. Donor-Recipient Body Surface Area Mismatch and the Outcome of Liver Transplantation in the UK. Prog Transplant 2023; 33:61-68. [PMID: 36537056 DOI: 10.1177/15269248221145035] [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] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Too small or too big liver grafts for recipient's size has detrimental effects on transplant outcomes. Research Questions: The purpose was to correlate donor-recipient body surface area ratio or body surface area index with recipient survival, graft survival, hepatic artery or portal vein, or vena cava thrombosis. High and low body surface area index cut-off points were determined. Design: There were 11,245 adult recipients of first deceased donor whole liver-only grafts performed in the UK from January 2000 until June 2020. The transplants were grouped according to the body surface area index and compared to complications, graft and recipient survival. Results: The body surface area index ranged from 0.491 to 1.691 with a median of 0.988. The body surface area index > 1.3 was associated with a higher rate of portal vein thrombosis within the first 3 months (5.5%). This risk was higher than size-matched transplants (OR: 2.878, 95% CI: 1.292-6.409, P = 0.01). Overall graft survival was worse in transplants with body surface area index ≤ 0.85 (HR: 1.254, 95% CI: 1.051-1.497, P = 0.012) or body surface area index > 1.4 (HR: 3.704, 95% CI: 2.029-6.762, P < 0.001) than those with intermediate values. The graft survival rates were reduced by 2% for cases with body surface area index ≤ 0.85 but were decreased by 20% for cases with body surface area index > 1.4. These findings were confirmed by bootstrap internal validation. No statistically significant differences were detected for hepatic artery thrombosis, occlusion of hepatic veins/inferior vena cava or recipient survival. Conclusions: Donor-recipient size mismatch affects the rates of portal vein thrombosis within the first 3 months and overall graft survival in deceased-donor liver transplants.
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Affiliation(s)
- Ioannis D Kostakis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Dimitri Aristotle Raptis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Brian R Davidson
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Satheesh Iype
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - David Nasralla
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Charles Imber
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Dinesh Sharma
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Theodora Pissanou
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Joerg Matthias Pollok
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
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Korenblik R, van Zon JFJA, Olij B, Heil J, Dewulf MJL, Neumann UP, Olde Damink SWM, Binkert CA, Schadde E, van der Leij C, van Dam RM, van Baardewijk LJ, Barbier L, Binkert CA, Billingsley K, Björnsson B, Andorrà EC, Arslan B, Baclija I, Bemelmans MHA, Bent C, de Boer MT, Bokkers RPH, de Boo DW, Breen D, Breitenstein S, Bruners P, Cappelli A, Carling U, Robert MCI, Chan B, De Cobelli F, Choi J, Crawford M, Croagh D, van Dam RM, Deprez F, Detry O, Dewulf MJL, Díaz-Nieto R, Dili A, Erdmann JI, Font JC, Davis R, Delle M, Fernando R, Fisher O, Fouraschen SMG, Fretland ÅA, Fundora Y, Gelabert A, Gerard L, Gobardhan P, Gómez F, Guiliante F, Grünberger T, Grochola LF, Grünhagen DJ, Guitart J, Hagendoorn J, Heil J, Heise D, Herrero E, Hess G, Hilal MA, Hoffmann M, Iezzi R, Imani F, Inmutto N, James S, Borobia FJG, Jovine E, Kalil J, Kingham P, Kollmar O, Kleeff J, van der Leij C, Lopez-Ben S, Macdonald A, Meijerink M, Korenblik R, Lapisatepun W, Leclercq WKG, Lindsay R, Lucidi V, Madoff DC, Martel G, Mehrzad H, Menon K, Metrakos P, Modi S, Moelker A, Montanari N, Moragues JS, Navinés-López J, Neumann UP, Nguyen J, Peddu P, Primrose JN, Olde Damink SWM, Qu X, Raptis DA, Ratti F, Ryan S, Ridouani F, Rinkes IHMB, Rogan C, Ronellenfitsch U, Serenari M, Salik A, Sallemi C, Sandström P, Martin ES, Sarría L, Schadde E, Serrablo A, Settmacher U, Smits J, Smits MLJ, Snitzbauer A, Soonawalla Z, Sparrelid E, Spuentrup E, Stavrou GA, Sutcliffe R, Tancredi I, Tasse JC, Teichgräber U, Udupa V, Valenti DA, Vass D, Vogl TJ, Wang X, White S, De Wispelaere JF, Wohlgemuth WA, Yu D, Zijlstra IJAJ. Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis. BJS Open 2022; 6:6844022. [PMID: 36437731 PMCID: PMC9702575 DOI: 10.1093/bjsopen/zrac141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone. METHODS A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase. RESULTS Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients). CONCLUSION Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.
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Affiliation(s)
- Remon Korenblik
- Correspondence to: R. K., Universiteigssingel 50 (room 5.452) 6229 ER Maastricht, The Netherlands (e-mail: ); R. M. v. D., Maastricht UMC+, Dept. of Surgery, Level 4, PO Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail: )
| | - Jasper F J A van Zon
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,GROW—Department of Surgery, School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Heil
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Maxime J L Dewulf
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany,NUTRIM—Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Christoph A Binkert
- Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Erik Schadde
- Department of General, Visceral and Transplant Surgery, Klinik Hirslanden, Zurich, Switzerland,Department of General, Visceral and Transplant Surgery, Hirslanden Klink St. Anna Luzern, Luzern, Switzerland
| | | | - Ronald M van Dam
- Correspondence to: R. K., Universiteigssingel 50 (room 5.452) 6229 ER Maastricht, The Netherlands (e-mail: ); R. M. v. D., Maastricht UMC+, Dept. of Surgery, Level 4, PO Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail: )
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Cheah YL, Heimbach J, Kwon CHD, Pomposelli J, Rudow DL, Broering D, Spiro M, Raptis DA, Roberts JP. Influence of surgical technique in donor hepatectomy on immediate and short-term living donor outcomes - A systematic review of the literature, meta-analysis, and expert panel recommendations. Clin Transplant 2022; 36:e14703. [PMID: 35538019 DOI: 10.1111/ctr.14703] [Citation(s) in RCA: 1] [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: 01/12/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are currently no guidelines pertaining to ERAS pathways in living donor hepatectomy. OBJECTIVES The aim of this study was to identify whether surgical technique influences immediate and short-term outcomes after living liver donation surgery. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review and meta-analysis following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021260707). Endpoints were mortality, overall complications, serious complications, bile eaks, pulmonary complications, estimated blood loss and length of stay. RESULTS Of the 2410 screened articles, 21 articles were included for final analysis; three observational, 13 retrospective cohort, four prospective cohort studies, and one randomized trial. Overall complications were higher with right versus left hepatectomy (26.8% vs. 20.8%; OR 1.4, P = .010). Donors after left hepatectomy had shorter length of stay (MD 1.4 days) compared to right hepatectomy. There was no difference in outcomes after right donor hepatectomy with versus without middle hepatic vein. We had limited data on the influence of incision type and minimally invasive approaches on living donor outcomes, and no data on the effect of operative time on donor outcomes. CONCLUSIONS Left donor hepatectomy should be preferred over right hepatectomy, as it is related to improved donor short-term outcomes (QOE; Moderate | Grade of Recommendation; Strong). Right donor hepatectomy with or without MHV has equivalent outcomes (QOE; Moderate | Grade of Recommendation; Strong); no preference is recommended, decision should be based on program's experience and expertise. No difference in outcomes was observed related to incision type, minimally invasive vs. open (QOE; Low | Grade of Recommendation; Weak); no preference can be recommended.
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Affiliation(s)
- Yee L Cheah
- Roger L Jenkins Transplant Institute, Lahey Hospital & Medical Center, Burlington, USA
| | - Julie Heimbach
- Division of Transplantation Surgery, Mayo Clinic, Rochester, USA
| | | | - James Pomposelli
- Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | | | - Dieter Broering
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - John P Roberts
- Department of Surgery, University of California San Francisco, San Francisco, USA
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Sun LY, Gitman M, Malik A, Te Terry PL, Spiro M, Raptis DA, Ramsay M. Optimal management of perioperative analgesia regarding immediate and short-term outcomes after liver transplantation - A systematic review, meta-analysis and expert panel recommendations. Clin Transplant 2022; 36:e14640. [PMID: 35285074 DOI: 10.1111/ctr.14640] [Citation(s) in RCA: 1] [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: 12/30/2021] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Adequate pain control is essential for patients undergoing liver transplantation (LT). Multiple analgesic strategies have been implemented during the perioperative period. There is no consensus on the optimal perioperative analgesia management. OBJECTIVES To provide recommendations, on the optimal perioperative analgesia management for LT. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review and meta-analysis following PRISMA guidelines and recommendations using GRADE. Studies describing outcomes, morbidity, mortality, pain scores, intensive care unit and hospital length of stay in patients that received different pain management techniques during and after LT were included (CRD42021243282). RESULTS One thousand nine hundred ten articles were screened, but only two randomized controlled trials, one prospective and six retrospective studies were included. The opioid-avoidance protocols included, thoracic epidural analgesia (TEA), Transversus Abdominis Plane (TAP) block, as well as other non-opioid analgesics, resulted in improved short-term outcomes. Mortality was reduced in this group versus control cohorts (OR = 0.51; CI 0.14, 1.83; P = 0.350), Time to extubation, and intensive care unit LOS were shorter; pain scores after surgery were lower in opioid-avoidance group (percentage decrease, 35%, 12%, and 55%, respectively). However, hospital LOS was longer (percentage increase 8%). CONCLUSIONS Opioid-avoidance analgesia management for LT results in improved short-term outcomes. (Quality of Evidence; Moderate to low | Grade of Recommendation; Weak). Medications such as acetaminophen(paracetamol), gabapentin, ketamine, tramadol and local anesthesia may be used instead of, or as adjuncts to opioids for postoperative analgesia. Overall evidence remains weak and more robust studies are required.
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Affiliation(s)
- Li-Ying Sun
- Liver Transplantation Center & Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Marina Gitman
- Department of Anesthesia Cleveland Clinic, Cleveland, Ohio, USA
| | - Ashish Malik
- Department of Anaesthesia and Critical Care, Indraprastha Apollo Hospital, New Delhi, India
| | | | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Michael Ramsay
- Department of Anesthesia Baylor University Medical Center, Dallas, Texas, USA
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Mazzola A, Pittau G, Hong SK, Chinnakotla S, Tautenhahn HM, Maluf DG, Settmacher U, Spiro M, Raptis DA, Jafarian A, Cherqui D. When is it safe for the liver donor to be discharged home and prevent unnecessary re-hospitalizations? - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14677. [PMID: 35429941 DOI: 10.1111/ctr.14677] [Citation(s) in RCA: 1] [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: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few data are available on discharge criteria after living liver donation (LLD). OBJECTIVES To identify the features for fit for discharge checklist after LLD to prevent unnecessary re-hospitalizations and to provide international expert recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The critical outcomes included were complications rates and liver function (defined by elevated bilirubin and INR) (CRD42021260725). RESULTS Total 57/1710 studies were included in qualitative analysis and 28/57 on the final analysis. No randomized controlled trials were identified. The complications rate was reported in 20/28 studies and ranged from 7.8% to 71.2%. Post hepatectomy liver function was reported in 13 studies. The Quality of Evidence (QoE) was Low and Very-Low for complications rate and liver function test, respectively. CONCLUSIONS Monitoring and prevention of donor complications should be crucial in decision making of discharge. Pain and diet control, removal of all drains and catheters, deep venous thrombosis prophylaxis, and use routine imaging (CT scan or liver ultrasound) before discharge should be included as fit for discharge checklist (QoE; Low | GRADE of recommendation; Strong). Transient Impaired liver function (defined by elevated bilirubin and INR), a prognostic marker of outcome after liver resection, usually occurs after donor right hepatectomy and should be monitored. Improving trends for bilirubin and INR value should be observed by day 5 post hepatectomy and be included in the fit for discharge checklist. (QoE; Very-Low | GRADE; Strong).
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Affiliation(s)
- Alessandra Mazzola
- Department of Hepatology and Gastroenterology, Liver transplant unit, Pité-Salpêtrière Hospital, Paris, France
| | - Gabriella Pittau
- Liver transplant unit, Centre hépato biliaire Hopital Paul Brousse, Villejuif, France
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, USA
| | | | - Daniel G Maluf
- Program in Transplantation, University of Maryland Medical School, Baltimore, Maryland, USA
| | - Utz Settmacher
- Department of General-, Visceral-, and Vascular Surgery, University Hospital, Jena, Germany
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Ali Jafarian
- Division HPB Surgery and Liver Transplantation, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Daniel Cherqui
- Liver transplant unit, Centre hépato biliaire Hopital Paul Brousse, Villejuif, France
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Ramírez-Del Val A, Guarrera J, Porte RJ, Selzner M, Spiro M, Raptis DA, Friend PJ, Nasralla D. Does machine perfusion improve immediate and short-term outcomes by enhancing graft function and recipient recovery after liver transplantation? A systematic review of the literature, meta-analysis and expert panel recommendations. Clin Transplant 2022; 36:e14638. [PMID: 35279883 DOI: 10.1111/ctr.14638] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 01/17/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent evidence supports the use of machine perfusion technologies (MP) for marginal liver grafts. Their effect on enhanced recovery, however, remains uncertain. OBJECTIVES To identify areas in which MP might contribute to an ERAS program and to provide expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review and meta-analysis following PRISMA guidelines and recommendations using the GRADE approach. CRD42021237713 RESULTS: Both hypothermic (HMP) and normothermic (NMP) machine perfusion demonstrated significant benefits in preventing postreperfusion syndrome (PRS) (HMP OR .33, .15-.75 CI; NMP OR .51, .29-.90 CI) and early allograft dysfunction (EAD) (HMP OR .51, .35-.75 CI; NMP OR .66, .45-.97 CI), while shortening LOS (HMP MD -3.9; NMP MD -12.41). Only NMP showed a significant decrease in the length of ICU stay (L-ICU) (MD -7.07, -8.76; -5.38 CI), while only HMP diminishes the likelihood of major complications. Normothermic regional perfusion (NRP) reduces EAD (OR .52, .38-.70 CI) and primary nonfunction (PNF) (OR .51, .27-.98 CI) without effect on L-ICU and LOS. CONCLUSIONS The use of HMP decreases PRS and EAD, specifically for marginal grafts. This is supported by a shorter LOS and a lower rate of major postoperative complications (QOE; moderate | Recommendation; Strong). NMP reduces the incidence of PRS and EAD with associated shortening in L-ICU for both DBD and DCD grafts (QOE; moderate | Recommendation; High) This technology also shortens the length of hospital stay (QOE; low | Recommendation; Strong). NRP decreases the likelihood of EAD (QOE; moderate) and the risk of PNF (QOE; low) when compared to both DBD and SRR-DCD grafts preserved in SCS. (Recommendation; Strong).
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Affiliation(s)
| | - James Guarrera
- Division of Liver Transplantation and Hepatobiliary Surgery at Rutgers, New Jersey Medical School, Newark, New Jersey, USA
| | - Robert J Porte
- Department of Surgery, University of Groningen, Groningen, The Netherlands
| | - Markus Selzner
- Department of Abdominal Transplant, Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery and Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Peter J Friend
- Transplant Unit, Churchill Hospital, Oxford University Hospitals, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David Nasralla
- Division of Surgery and Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
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De Martin E, Londoño MC, Emamaullee J, Lerut J, Potts J, Aluvihare V, Spiro M, Raptis DA, McCaughan G. The optimal immunosuppression management to prevent early rejection after liver transplantation: A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14614. [PMID: 35143096 DOI: 10.1111/ctr.14614] [Citation(s) in RCA: 1] [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: 01/16/2022] [Accepted: 02/06/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal immunosuppression protocol to prevent early acute cellular rejection (ACR) after liver transplantation (LT) avoiding prolonged hospitalization and early hospital readmission is undefined. OBJECTIVES To identify the most suitable immunosuppression regimen for inclusion in ERAS programs in order to minimize early ACR after LT and to provide expert panel recommendations DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies from January 2000 onward focusing on early ACR were included. Rates of early renal dysfunction and infection were evaluated. CRD42021245586 RESULTS: Thirty-seven studies met inclusion criteria; 23 randomized controlled trials, 14 retrospective or prospective observational comparative or noncomparative studies. Several sources of biases which potentially confound conclusions were identified: heterogeneity in immunosuppression protocols, higher serum tacrolimus levels than currently used in clinical practice, differences in the definition of ACR. CONCLUSIONS Tacrolimus is the standard immunosuppression after LT and can be used in combination with other drugs such as corticosteroids and MMF, and in association with anti-IL2 receptor antibody (IL2Ra) induction. (Quality of Evidence; Low | Grade of Recommendation; Strong). Low dose or delayed introduction of tacrolimus in association with corticosteroids and MMF and/or anti-IL2Ra induction can be used to reduce acute kidney injury. (Quality of Evidence; Low | Grade of Recommendation; Strong). Use of tacrolimus in association with corticosteroids and MMF and/or anti-IL2Ra induction does not lead to increased infection rates. (Quality of Evidence; Low | Grade of Recommendation; Weak).
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Affiliation(s)
- Eleonora De Martin
- APHP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
| | - Maria-Carlota Londoño
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I Sunyer and Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Catalonia, Spain
| | - Juliet Emamaullee
- Department of Surgery, University of Southern California, Los Angeles, USA
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Université catholique Louvain (UCL), Brussels, Belgium
| | - Jonathan Potts
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Varuna Aluvihare
- Transplant Hepatology Lead Institute of Liver Studies, King's College Hospital, London, UK
| | - Michael Spiro
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Geoffrey McCaughan
- A.W. Morrow Gastroenterolgy and Liver Center, Sydney Medical School, Centenary Institute, Australian National Liver Transplant Unit, University of Sydney, Sydney, Australia
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- APHP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
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11
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Testa G, Nadalin S, Klair T, Florman S, Balci D, Frola C, Spiro M, Raptis DA, Selzner M. Optimal surgical workup to ensure safe recovery of the donor after living liver donation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14641. [PMID: 35258132 DOI: 10.1111/ctr.14641] [Citation(s) in RCA: 1] [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: 01/21/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The essential premise of living donor liver transplantation is the assurance that the donors will have a complication-free perioperative course and a prompt recovery. Selection of appropriate donors is the first step to support this premise and is based on tests that constitute the donor workup. The exclusion of liver pathologies and assessment of liver anatomy and volume in the donor candidate are the most important elements in the selection of the appropriate candidate. OBJECTIVE To determine whether there is evidence to define an optimal donor surgical workup that would improve short-term outcomes of the donor after living liver donation. DATA SOURCES Ovid Medline, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. RESULTS Although a liver biopsy remains the only method to exactly determine the percentage and type of steatosis and to detect other liver pathologies, its routine use is not supported. Both magnetic resonance imaging (MRI) and computed tomography (CT) appear to be adequate for quantifying liver volume; the preference for one or the other is often based on center expertise. MRI is clearly a better technique to assess biliary anatomy, although aberrant biliary anatomy may not be clearly detected. MRI is also more accurate than CT in determining low grades of steatosis. CT angiography is the imaging test of choice to assess the vascular anatomy. There is no evidence of the need for catheter angiography in the modern evaluation of a living liver donor. CONCLUSIONS A donor liver biopsy is indicated if abnormalities are present in serological or imaging tests. Both MRI and CT imaging appear to be adequate methodologies. The routine use of catheter angiography is not supported in view of the adequacy of CT angiography in delineating liver vascular anatomy. No imaging modality available to quantify liver volume is superior to another. Biliary anatomy is better defined with MRI, although poor definition can be expected, particularly for abnormal ducts.
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Affiliation(s)
- Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital, Tuebingen, Germany
| | - Tarunjeet Klair
- Transplant Center, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Health System, New York, New York, USA
| | - Deniz Balci
- Ankara University School of Medicine, Ankara, Turkey
| | - Carlo Frola
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery and Interventional Science, University College, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK.,Division of Surgery and Interventional Science, University College, London, UK
| | - Markus Selzner
- Department of Surgery, Ajmera Transplant Program, University of Toronto, Toronto, Canada
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12
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Weiss E, Kabacam G, Gorvin L, Spiro M, Raptis DA, Keskin O, Orloff S, Belghiti J. The role of preoperative psychosocial counseling on the improvement of the recipient compliance and speed of recovery after liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14632. [PMID: 35253275 DOI: 10.1111/ctr.14632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 01/12/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Psychosocial disorders ranging from anxiety to severe psychiatric diseases and active alcohol/substance abuse are frequent in liver transplant candidates and potentially associated with worse post- transplant outcomes. Therefore, psychosocial evaluation is mandatory to optimize success after liver transplantation. However, how to carry out this evaluation, the type of intervention needed and its potential impact on patient outcome remain unclear. OBJECTIVES To investigate whether psychosocial assessment may help in predicting risks of poor outcome; and to investigate whether psychosocial interventions may mitigate these risks and improve posttransplant outcomes, in particular compliance and speed of recovery. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The protocol was registered on PROSPERO CRD42021238361. Main outcomes assessed were mortality, alcohol relapse, rejection, and medication compliance. RESULTS Fifteen studies were analyzed including five observational comparative and ten observational noncomparative studies. Preoperative psychosocial evaluation of LT candidates was associated with higher concordance with the treatment plan (i.e., higher adherence to treatment and lower alcohol relapse) and lower rates of rejection. Psychosocial assessment tools were used in some studies to guide the evaluation, but their predictive ability remains debated, and they should not be used in isolation. Most of the interventions were studied in patients with alcohol related issues. In this context, support by specialized teams was associated with better posttransplant outcome, especially through a decrease in post-transplant alcohol relapse. CONCLUSIONS Preoperative psychosocial assessment should be provided in order to detect patients at increased risk of poorer post-transplant outcome, in particular in terms of concordance to the treatment plan (Quality of Evidence; Low | Grade of Recommendation; Strong/For). The experts suggest that, when possible, provision of preoperative psychological assessment and concomitant interventions aimed at improving the concordance to treatment plans will positively impact the success of liver transplantation. (Quality of Evidence; Very Low | Grade of Recommendation; Strong/For].
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Affiliation(s)
- Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord and Paris University, Clichy, France
| | - Gokhan Kabacam
- Division of Internal Medicine, Yuksek Ihtisas University School of Medicine, Ankara, Turkey.,Department of Gastroenterology, Guven Hospital, Ankara, Turkey
| | - Lucy Gorvin
- Liver Transplant Psychology, Royal Free Hospital, London, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Onur Keskin
- Division of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Susan Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Portland, Oregon, USA
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13
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Liu J, Martins PN, Bhat M, Pang L, Yeung OWH, Ng KTP, Spiro M, Raptis DA, Man K, Mas VR. Biomarkers and predictive models of early allograft dysfunction in liver transplantation - A systematic review of the literature, meta-analysis, and expert panel recommendations. Clin Transplant 2022; 36:e14635. [PMID: 35291044 DOI: 10.1111/ctr.14635] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/02/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prompt identification of early allograft dysfunction (EAD) is critical to reduce morbidity and mortality in liver transplant (LT) recipients. OBJECTIVES Evaluate the evidence supporting biomarkers that can provide diagnostic and predictive value for EAD. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach was derived from an international expert panel. Studies that investigated biomarkers or models for predicting EAD in adult LT recipients were included for in-depth evaluation and meta-analysis. Olthoff's criteria were used as the standard reference for the diagnostic accuracy evaluation. PROSPERO ID CRD42021293838 RESULTS: Ten studies were included for the systematic review. Lactate, lactate clearance, uric acid, Factor V, HMGB-1, CRP to ALB ratio, phosphocholine, total cholesterol, and metabolomic predictive model were identified as potential early EAD predictive biomarkers. The sensitivity ranged between .39 and .92, while the specificity ranged from .63 to .90. Elevated lactate level was most indicative of EAD after adult LT (pooled diagnostic odds ratio of 7.15 (95%CI: 2.38-21.46)). The quality of evidence (QOE) for lactate as indicator was moderate according to the GRADE approach, whereas the QOE for other biomarkers was very low to low likely as consequence of study design characteristics such as single study, small sample size, and large ranges of sensitivity or specificity. CONCLUSIONS Lactate is an early indicator to predict EAD after LT (Quality of Evidence: Moderate | Grade of Recommendation: Strong). Further multicenter studies and the use of machine perfusion setting should be implemented for validation.
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Affiliation(s)
- Jiang Liu
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China.,Department of Surgery & HKU-Shenzhen Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | | | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network and Division of Gastroenterology & Hepatology, University of Toronto, Toronto, Canada
| | - Li Pang
- Department of Surgery & HKU-Shenzhen Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Oscar W H Yeung
- Department of Surgery & HKU-Shenzhen Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kevin T P Ng
- Department of Surgery & HKU-Shenzhen Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Kwan Man
- Department of Surgery & HKU-Shenzhen Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Valeria R Mas
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, USA
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14
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Patel MS, Egawa H, Kwon YK, Chok KSH, Spiro M, Raptis DA, Vij V, Chaudhary A, Genyk Y. The role of graft to recipient weight ratio on enhanced recovery of the recipient after living donor liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14630. [PMID: 35258108 DOI: 10.1111/ctr.14630] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 01/04/2022] [Revised: 01/01/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND There continues to be debate about the lower limit of graft-to-recipient weight ratio (GRWR) for living donor liver transplant (LDLT). OBJECTIVES To identify the lower limit of GRWR compatible with enhanced recovery after living donor liver transplant and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies assessing how GRWR affects recipient outcomes such as small for size syndrome, other complications, patient and graft survival, and length of stay were included. PROTOCOL REGISTRATION CRD42021260794. RESULTS Twenty articles were included in the qualitative synthesis, and all were retrospective observational studies. There was heterogeneity in the definition of study cohorts and key outcome measures such as small-for-size syndrome. Most studies lacked risk adjustment given limited single-center sample size. GRWR of ≥ .8% is associated with enhanced recovery. Recipients of grafts with GRWR < .8%, however, were found to have similar outcomes as those with ≥ .8% when appropriate consideration is made for portal flow modulation and recipient illness severity. CONCLUSIONS GRWR ≥ .8% is often compatible with enhanced recovery, but grafts < .8% can be used in selected LDLT recipients with optimal donor-recipient selection, surgical technique, and perioperative management (Quality of Evidence; Low | Grade of Recommendation; Strong).
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Affiliation(s)
- Madhukar S Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yong Kyong Kwon
- Department of Surgery, Keck Medical Center of University of Southern California, Los Angles, California, USA
| | - Kenneth Siu Ho Chok
- Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Vivek Vij
- Liver Transplant and Hepatobiliary Surgery, Fortis Hospital, Noida, UP, India
| | - Abhideep Chaudhary
- Department of HPB Surgery & Liver Transplant, BL Kapur Superspeciality Hospital, Delhi, India
| | - Yuri Genyk
- Department of Surgery, Keck Medical Center of University of Southern California, Los Angles, California, USA
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15
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Rammohan A, Rela M, Kim DS, Soejima Y, Kasahara M, Ikegami T, Spiro M, Aristotle Raptis D, Humar A. Does modification of portal pressure and flow enhance recovery of the recipient after living donor liver transplantation? A systematic review of literature and expert panel recommendations. Clin Transplant 2022; 36:e14657. [PMID: 35344628 DOI: 10.1111/ctr.14657] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 01/13/2022] [Revised: 02/11/2022] [Accepted: 03/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Portal inflow modulation (PIM) aimed at reducing portal hyperperfusion is commonly used in living donor liver transplantation (LDLT) to reduce the risk of small-for-size syndrome (SFSS). Many different techniques, both pharmacological and surgical have been used for this purpose. There is, however, little consensus on the best method of PIM, its exact role in preventing SFSS and on early post-LDLT recovery. OBJECTIVES To identify whether modifications of portal pressures and flows enhance recovery after LDLT and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO ID CRD42021260997. RESULTS Five hundred and ninety four articles were identified through databases' search. Of the 24 included for a final review by the working group (WG), there were five randomized control trials, four prospective studies and 15 retrospective series. Six outcome measures which were likely to influence early recovery after LDLT, especially in small-for-size grafts (SFSG) were shortlisted. These included acute kidney injury, SFSS, morbidity including sepsis, length of ICU and hospital stay, morbidity of the PIM technique and overall mortality. The WG noted that PIM in this subset of LDLT recipients had a beneficial effect on all the outcomes measures. CONCLUSIONS Considering all decision domains, the panel recommends pre- and intraoperative actual graft weight validation, portal pressure/flow measurements, and a comprehensive donor evaluation for the determination of potentially small-for-size/ small-for-flow grafts as mandatory. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) Pharmacological PIM helps improve early renal function in LDLT recipients. (Quality of Evidence: High | Grade of Recommendation: Strong) In selected patients with SFSG, PIM helps reduce SFSS/EAD and sepsis. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) PIM in the form of splenectomy has increased morbidity compared to splenic artery ligation (SAL). (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, PIM may help reduce morbidity/mortality. (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, modification of portal pressures and flows enhances recovery after LDLT. (Quality of Evidence: Moderate | Grade of Recommendation: Strong).
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Affiliation(s)
- Ashwin Rammohan
- Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Mohamed Rela
- Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Yuji Soejima
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, USA
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16
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Yoon U, Bartoszko J, Bezinover D, Biancofiore G, Forkin KT, Rahman S, Spiro M, Raptis DA, Kang Y. Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short-term outcomes after liver transplantation-A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14637. [PMID: 35249250 DOI: 10.1111/ctr.14637] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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: 01/11/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplantation (LT) is frequently complicated by coagulopathy associated with end-stage liver disease (ESLD), that is, often multifactorial. OBJECTIVES The objective of this systematic review was to identify evidence based intraoperative transfusion and coagulation management strategies that improve immediate and short-term outcomes after LT. METHODS PRISMA-guidelines and GRADE-approach were followed. Three subquestions were formulated. (Q); Q1: transfusion management; Q2: antifibrinolytic therapy; and Q3: coagulation monitoring. RESULTS Sixteen studies were included for Q1, six for Q2, and 10 for Q3. Q1: PRBC and platelet transfusions were associated with higher mortality. The use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) were not associated with reductions in intraoperative transfusion or increased thrombotic events. The use of cell salvage was not associated with hepatocellular carcinoma (HCC) recurrence or mortality. Cell salvage and transfusion education significantly decreased blood product transfusions. Q2: Epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA) were not associated with decreased blood product transfusion, improvements in patient or graft survival, or increases in thrombotic events. Q3: Viscoelastic testing (VET) was associated with decreased allogeneic blood product transfusion compared to conventional coagulation tests (CCT) and is likely to be cost-effective. Coagulation management guided by VET may be associated with increases in FC and PCC use. CONCLUSION Q1: A specific blood product transfusion practice is not recommended (QOE; low | Recommendation; weak). Cell salvage and educational interventions are recommended (QOE: low | Grade of Recommendation: moderate). Q2: The routine use of antifibrinolytics is not recommended (QOE; low | Recommendation; weak). Q3: The use of VET is recommended (QOE; low-moderate | Recommendation; strong).
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania, USA
| | | | - Katherine T Forkin
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Suehana Rahman
- Department of Anaesthesiology, Royal Free London NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Yoogoo Kang
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Goldaracena N, Bhangui P, Yoon YI, Vargas PA, Spiro M, Raptis DA, Tokat Y. Early removal of drains and lines after liver transplantation to reduce the length of hospital stay and enhance recovery - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14687. [PMID: 35468235 DOI: 10.1111/ctr.14687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 01/21/2022] [Accepted: 04/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The timing of removing abdominal drains, central venous catheters (CVC), and urinary catheters (UC) on post liver transplantation (LT) outcomes is not well elucidated. OBJECTIVES To provide international expert panel recommendations and guidelines on time of drain and catheter removal as a part of an ERAS protocol to reduce the length of hospital stay and enhance recovery. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Papers considered were those reporting one or more outcomes of interest related to drainage and line removal in the setting of LT. POSPERO Protocol ID: CRD42021238349 RESULTS: On analyzing five relevant studies pertaining to drains in patients undergoing LT (four retrospectives and one prospective), the length of hospital and/or ICU stay was similar or shorter, and postoperative morbidity and mortality were lower in those without drains. No studies pertaining specifically to the time of removal of drains, CVC's, or UC's in LT were found. Studies in patients undergoing major abdominal surgery or hepatectomies recommend early removal of CVC and UC to reduce catheter-associated infections. CONCLUSIONS Based more on expert recommendation, we propose that abdominal drains, if placed during LT, should be removed by postoperative day 5 after LT, based on quantity and fluid characteristics (Quality of Evidence; Low to Moderate | Grade of Recommendation; Strong). Larger studies are needed to more reliably determine indications for early drain and line removal in an ERAS protocol setting.
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Affiliation(s)
- Nicolas Goldaracena
- Department of Surgery, Division of Transplantation, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta - The Medicitiy, Gurugram, Delhi NCR, India
| | | | - Paola A Vargas
- Department of Surgery, Division of Transplantation, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Yaman Tokat
- International Liver Center and Acibadem Healthcare System Hospitals, New Delhi, India
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18
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Chadha R, Patel D, Bhangui P, Blasi A, Xia V, Parotto M, Wray C, Findlay J, Spiro M, Raptis DA. Optimal anesthetic conduct regarding immediate and short-term outcomes after liver transplantation - Systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14613. [PMID: 35147248 DOI: 10.1111/ctr.14613] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 01/15/2022] [Accepted: 02/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND In the era of enhanced recovery after surgery, there is significant discussion regarding the impact of intraoperative anesthetic management on short-term outcomes following liver transplantation (LT), with no clear consensus in the literature. OBJECTIVES To identify whether or not intraoperative anesthetic management affects short-term outcomes after liver transplantation. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review following PRISMA guidelines was undertaken. The systematic review was registered on PROSPERO (CRD42021239758). An international expert panel made recommendations for clinical practice using the GRADE approach. RESULTS After screening, 14 studies were eligible for inclusion in this systematic review. Six were prospective randomized clinical trials, three were prospective nonrandomized clinical trials, and five were retrospective studies. These manuscripts were reviewed to look at five questions regarding anesthetic care and its impact on short term outcomes following liver transplant. After review of the literature, the quality of evidence according to the following outcomes was as follows: intraoperative and postoperative morbidity and mortality (low), early allograft dysfunction (low), and hospital and ICU length of stay (moderate). CONCLUSIONS For optimal short term outcomes after liver transplantation, the panel recommends the use of volatile anesthetics in preference to total intravenous anesthesia (TIVA) (Level of Evidence: Very low; Strength of Recommendation: Weak) and minimum alveolar concentration (MAC) versus bispectral index (BIS) for depth of anesthesia monitoring (Level of Evidence: Very low; Strength of Recommendation: Weak). Regarding ventilation and oxygenation, the panel recommends a restrictive oxygenation strategy targeting a PaO2 of 70-120 mmHg (10-14 kPa), a tidal volume of 6-8 ml/kg ideal body weight (IBW), administration of positive end expiratory pressure (PEEP) tailored to patient intraoperative physiology, and recruitment maneuvers. (Level of evidence: Very low; Strength of Recommendation: Strong). Finally, the panel recommends the routine use of antiemetic prophylaxis. (Level of evidence: low; Strength of Recommendation: Strong).
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Affiliation(s)
- Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, USA
| | - Dhupal Patel
- Department of Anesthesia and Intensive Care Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Pooja Bhangui
- Department of Anesthesiology, Medanta Liver Institute, Gurgaon, India
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clinic Barcelona, Institut d'Insvestigacio Biomèdica Pi I Suner (IDIBAPS), Spain
| | - Victor Xia
- Department of Anesthesiology, University of California, Los Angeles, USA
| | - Matteo Parotto
- Department of Anesthesiology and Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Canada
| | - Christopher Wray
- Department of Anesthesiology, University of California, Los Angeles, USA
| | - James Findlay
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
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19
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Fernandez TMA, Schofield N, Krenn CG, Rizkalla N, Spiro M, Raptis DA, De Wolf AM, Merritt WT. What is the optimal anesthetic monitoring regarding immediate and short-term outcomes after liver transplantation?-A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14643. [PMID: 35262975 PMCID: PMC10077907 DOI: 10.1111/ctr.14643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/14/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplant centers vary in approach to intraoperative vascular accesses, monitoring of cardiac function and temperature management. Evidence is limited regarding impact of selected modalities on postoperative outcomes. OBJECTIVES To review the literature and provide expert panel recommendations on optimal intraoperative arterial blood pressure (BP), central venous pressure (CVP), and vascular accesses, monitoring of cardiac function and intraoperative temperature management regarding immediate and short-term outcomes after orthotopic liver transplant (OLT). METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Recommendations made for: (1) Vascular accesses, arterial BP and CVP monitoring, (2) cardiac function monitoring, and (3) Intraoperative temperature management (CRD42021239908). RESULTS Of 2619 articles screened 16 were included. Studies were small, retrospective, and observational. Vascular access studies demonstrated low rates of insertion complications. TEE studies demonstrated low rates of esophageal hemorrhage. One study found lower hospital-LOS and 30-day mortality in patients monitored with both PAC and TEE. Other monitoring studies were heterogenous in design and outcomes. Temperature studies showed increased blood transfusion and ventilation times in hypothermic groups. CONCLUSIONS Recommendations were made for; routine arterial and CVP monitoring as a minimum standard of practice, consideration of discrepancy between peripheral and central arterial BP in patients with hemodynamic instability and high vasopressor requirements, and routine use of high flow cannulae while monitoring for extravasation and hematoma formation. Availability and expertise in PAC and/or TEE monitoring is strongly recommended particularly in hemodynamic instability, portopulmonary HT and/or cardiac dysfunction. TEE use is recommended as an acceptable risk in patients with treated esophageal varices and is an effective diagnostic tool for emergency cardiovascular collapse. Maintenance of intraoperative normothermia is strongly recommended.
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Affiliation(s)
- Thomas M A Fernandez
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand.,Department of Anesthesia, University of Auckland, Auckland, New Zealand
| | - Nick Schofield
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Claus G Krenn
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Nicole Rizkalla
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Andre M De Wolf
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - William T Merritt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
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20
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Adams MA, Andacoglu O, Crouch CE, de Santibañes M, Jackson WE, Jalal A, Montasser IF, Rubman S, Spiro M, Raptis DA, Miller C, Pomfret E. Does pre-operative counselling of the donor improve immediate and short-term outcomes after living liver donation? - A review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14636. [PMID: 35343601 DOI: 10.1111/ctr.14636] [Citation(s) in RCA: 1] [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: 12/28/2021] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is some evidence in the literature to suggest that pre-operative counselling improves pain scores postoperatively. However, it is unclear whether pre-operative counselling of the donor improves immediate and short-term outcomes after living liver donation. OBJECTIVES This systematic review aimed to investigate the available quality of evidence (QOE) of pre-operative counselling for living donors on short term outcomes, provide expert opinion, grade recommendations and identify relevant components for Enhanced Recovery after Surgery (ERAS) protocols. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Endpoints were defined by the WHOQOL-BREF scale: physical health, psychological, social relationships, and environment. PROSPERO ID CRD42021260677. RESULTS Screening of 452 records and full texts led to 12 articles matching inclusion criteria, of which one was a randomized controlled trial (RCT), and 11 were observational retrospective cohort studies. A total of 933 individuals undergoing donor hepatectomy were included, of whom only 90 received dedicated perioperative ERAS protocols. Donors that received pre-operative counselling had fewer physical symptoms post donation, lower rates of fatigue, lower rates of pain, shorter recovery times and fewer unexpected medical problems, and less anxiety post donation. Female donors had higher affective and adverse effects scores, and 50% of donors reported adverse effects to analgesia that interfered with functional activity. Receiving information about analgesic options increased perception of care among donors. CONCLUSIONS Providing comprehensive pre-operative counselling to living liver donors is associated with improved short-term outcomes after donation (QOE; moderate to low I Grade of Recommendation; Strong).
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Affiliation(s)
- Megan A Adams
- Division of Transplantation, Department of Surgery, and Colorado Center for Transplantation Care, University of Colorado School of Medicine, Research and Education (CCTCARE), Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Oya Andacoglu
- Division of Transplantation, Department of Surgery, The University of Oklahoma College of Medicine, Istanbul, Turkey
| | - Cara E Crouch
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Martin de Santibañes
- Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Whitney E Jackson
- Division of Gastroenterology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Arif Jalal
- University College London Medical Schools, London, UK
| | - Iman F Montasser
- Division of Hepatology, Department of Tropical Medicine, Ain Shams Center for Organ Transplantation (ASCOT), Ain Shams University, Cairo, Egypt
| | - Susan Rubman
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Charles Miller
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve, Cleveland, USA
| | - Elizabeth Pomfret
- Division of Transplantation, Department of Surgery, and Colorado Center for Transplantation Care, University of Colorado School of Medicine, Research and Education (CCTCARE), Aurora, Colorado, USA
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21
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Tinguely P, Badenoch A, Krzanicki D, Kronish K, Lindsay M, Khanal P, Wells G, Spiro M, Raptis DA, McCluskey SA. The role of early extubation on short-term outcomes after liver transplantation - A systematic review, meta-analysis and expert recommendations. Clin Transplant 2022; 36:e14642. [PMID: 35266235 DOI: 10.1111/ctr.14642] [Citation(s) in RCA: 1] [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: 12/27/2021] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early extubation in liver transplantation (LT) and its potential benefits such as reduction in pulmonary complications and enhanced postoperative recovery have been described. The extent of the effect of early extubation on short-term outcomes after LT across the published literature is to the best of our knowledge unknown. OBJECTIVES The objective of this systematic review and meta-analysis was to determine whether early extubation improves immediate and short-term outcomes after LT and to provide expert recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review and meta-analysis on short-term outcomes after early extubation in LT was performed (CRD42021241402), following PRISMA guidelines and quality of evidence (QOE) and recommendations grading using the GRADE approach, derived from an international experts panel. Endpoints were reintubation rates, pulmonary and other complications/organ dysfunction, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS Of 831 screened articles, 20 observational studies with a total of 3573 patients addressing early extubation protocols were included, of which 12 studies compared results after early versus deferred extubation. Reintubation and pulmonary complication rates were lower in the early versus deferred extubation groups (OR 0.29, CI 0.22-0.39; OR 0.17, CI 0.09-0.33, respectively). ICU and hospital LOS were shorter in eight out of eight and seven out of eight comparative studies, respectively. CONCLUSIONS Early extubation after LT is associated with improved short-term outcomes after LT and should be performed in the majority of patients (QOE; Moderate to low | Grade of Recommendation; Strong). Randomized controlled trials using standardized definitions of early extubation and short-term outcomes are needed to demonstrate causality, validate and allow comparability of the results.
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Affiliation(s)
- Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK
| | - Adam Badenoch
- Flinders University, Adelaide, South Australia, Australia.,Department of Anaesthesia and Pain Management, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Dominik Krzanicki
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Martine Lindsay
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gemma Wells
- Department of Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK
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22
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Hannon VN, Tinguely P, McKenna GJ, Brustia R, Kaldas FM, Scatton O, Spiro M, Raptis DA, Busuttil RW, Klintmalm GB. New ERAS in liver transplantation - Past, present, and next steps. Clin Transplant 2022; 36:e14625. [PMID: 35238415 DOI: 10.1111/ctr.14625] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 02/06/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023]
Abstract
There are parallels between the history of Enhanced Recovery after Surgery (ERAS) and liver transplantation. Both have been established and advanced by innovative individuals, often going against perceived wisdom and convention. Liver transplantation has traditionally been considered too complex for ERAS pathways, despite a small number of trials showing them to be both safe and of benefit. To date, there are very few randomized controlled trials and cohort studies publishing outcomes on liver transplant patients enrolled in comprehensive ERAS pathways. To progress our field, the 2022 International Liver Transplantation Society's Consensus Conference has created expert panels to analyze the evidence in 32 domains of the liver transplantation pathway using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to generate expert recommendations. These recommendations will be voted on by the international community to gain consensus using the Danish model, and create the ERAS4OLT.org Enhanced Recovery after Liver Transplantation Pathway.
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Affiliation(s)
- Vivienne N Hannon
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | | | - Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Fady M Kaldas
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France.,Pierre et Marie Curie University, Paris, France
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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23
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Balci D, Kirimker EO, Raptis DA, Gao Y, Kow AWC. Uses of a dedicated 3D reconstruction software with augmented and mixed reality in planning and performing advanced liver surgery and living donor liver transplantation (with videos). Hepatobiliary Pancreat Dis Int 2022; 21:455-461. [PMID: 36123242 DOI: 10.1016/j.hbpd.2022.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 07/28/2022] [Accepted: 09/02/2022] [Indexed: 02/05/2023]
Abstract
The development of digital intelligent diagnostic and treatment technology has opened countless new opportunities for liver surgery from the era of digital anatomy to a new era of digital diagnostics, virtual surgery simulation and using the created scenarios in real-time surgery using mixed reality. In this article, we described our experience on developing a dedicated 3 dimensional visualization and reconstruction software for surgeons to be used in advanced liver surgery and living donor liver transplantation. Furthermore, we shared the recent developments in the field by explaining the outreach of the software from virtual reality to augmented reality and mixed reality.
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Affiliation(s)
- Deniz Balci
- Department of Surgery, Medical Park Göztepe Hastanesi Organ Nakli Merkezi Nisan Sok, Bahçeşehir University, No. 23 Merdivenköy Kadıköy, İstanbul, Türkiye.
| | | | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK; Division of Surgery & Interventional Science, University College London, London, UK
| | - Yujia Gao
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore; Liver Transplant Program, National University Center for Organ Transplantation (NUCOT), National University Health System, Singapore
| | - Alfred Wei Chieh Kow
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore; Liver Transplant Program, National University Center for Organ Transplantation (NUCOT), National University Health System, Singapore
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24
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Alconchel F, Tinguely P, Frola C, Spiro M, Ciria R, Rodríguez G, Petrowsky H, Raptis DA, Brombosz EW, Ghobrial M. Are short-term complications associated with poor allograft and patient survival after liver transplantation? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14704. [PMID: 36490223 DOI: 10.1111/ctr.14704] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 12/28/2021] [Accepted: 02/28/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Maximizing patient and allograft survival after liver transplant (LT) is important from both a patient care and organ utilization perspective. Although individual studies have addressed the effects of short-term post-LT complications on a limited scale, there has not been a systematic review of the literature formally assessing the potential effects of early complications on long-term outcomes. OBJECTIVES To identify whether short-term complications after LT affect allograft and overall survival, to identify short-term complications of particular clinical interest and significance, and to provide recommendations to improve post-LT graft and patient survival. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. RESULTS The literature review and analysis provided show that short-term complications have a large impact on allograft and patient survival after LT. The complications with the strongest effect on survival are acute kidney injury (AKI), biliary complications, and early allograft dysfunction (EAD). CONCLUSION This panel recommends taking measures to reduce the risk and incidence of short-term complications post-LT. Clinicians should pay particular attention to preventing or ameliorating AKI, biliary complications, and EAD (Quality of evidence; Moderate | Grade of Recommendation; Strong).
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Affiliation(s)
- Felipe Alconchel
- Department of Surgery and Organ Transplantation, Virgen de la Arrixaca University Hospital, Murcia, Spain.,Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, UK
| | - Carlo Frola
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Ruben Ciria
- HPB Surgery and Liver Transplantation, Reina Sofía University Hospital, Córdoba, Spain
| | - Gonzalo Rodríguez
- Department of General & Digestive Surgery, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General Universitario de Alicante, Alicante, Spain
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | | | - Mark Ghobrial
- J.C. Walter Jr. Transplant Center, Department of Surgery, Weill Cornell Medical College, Houston Methodist Institute for Academic Medicine, Houston, USA
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25
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Kalisvaart M, de Jonge J, Abt P, Orloff S, Muiesan P, Florman S, Spiro M, Raptis DA, Eghtesad B. The role of T-tubes and abdominal drains on short-term outcomes in liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14719. [PMID: 35596705 PMCID: PMC10078006 DOI: 10.1111/ctr.14719] [Citation(s) in RCA: 1] [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: 01/13/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This systematic review and expert panel recommendation aims to answer the question regarding the routine use of T-tubes or abdominal drains to better manage complications and thereby improve outcomes after liver transplantation. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel to assess the potential risks and benefits of T-tubes and intra-abdominal drainage in liver transplantation (CRD42021243036). RESULTS Of the 2996 screened records, 33 studies were included in the systematic review, of which 29 (six RCTs) assessed the use of T-tubes and four regarding surgical drains. Although some studies reported less strictures when using a T-tube, there was a trend toward more biliary complications with T-tubes, mainly related to biliary leakage. Due to the small number of studies, there was a paucity of evidence on the effect of abdominal drains with no clear benefit for or against the use of drainage. However, one study investigating the open vs. closed circuit drains found a significantly higher incidence of intra-abdominal infections when open-circuit drains were used. CONCLUSIONS Due to the potential risk of biliary leakage and infections, the routine intraoperative insertion of T-tubes is not recommended (Level of Evidence moderate - very low; grade of recommendation strong). However, a T-tube can be considered in cases at risk for biliary stenosis. Due to the scant evidence on abdominal drainage, no change in clinical practice in individual centers is recommended. (Level of Evidence very low; weak recommendation).
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Affiliation(s)
- Marit Kalisvaart
- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jeroen de Jonge
- Erasmus MC Transplant Institute, Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter Abt
- Department of Surgery, Division of Transplantation, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/ Hepatobiliary Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Paolo Muiesan
- Policlinico di Milano Ospedale Maggiore
- Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Sander Florman
- The Recanati Miller Transplantation Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
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26
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Roll GR, Spiro M, Raptis DA, Jalal A, Yan CT, Olthoff KM, Caicedo JC, Lee KW, Yagi S, Cattral MS, Soin AS. Which recipient pretransplant factors, such as MELD, renal function, sarcopenia, and recent sepsis influence suitability for and outcome after living donor liver transplantation? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14656. [PMID: 35340054 DOI: 10.1111/ctr.14656] [Citation(s) in RCA: 1] [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: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Varied access to deceased donors across the globe has resulted in differential living donor liver transplant (LDLT) practices and lack of consensus over the influence of models for end stage liver disease (MELD), renal function, sarcopenia, or recent infection on short-term outcomes. OBJECTIVES Consider these risk factors in relation to patient selection and provide recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, Cochrane Central. METHODS PRIMSA systematic review and GRADE. PROSPERO ID RD42021260809 RESULTS: MELD >25-30 alone is not a contraindication to LDLT, and multiple studies found no increase in short term mortality in high MELD patients. Contributing factors such as muscle mass, acute physiologic assessment and chronic health evaluation score, donor age, graft weight/recipient weight ratio, and inclusion of the middle hepatic vein in a right lobe graft influence morbidity and mortality in high MELD patients. Higher mortality is observed with pretransplant renal dysfunction, but short-term mortality is rare. Sarcopenia and recent infection are not contraindications to LDLT. Morbidity and prolonged LOS are common, and more frequent in patients with renal dysfunction, nutritional deficiency or recent infection. CONCLUSIONS When individual risk factors are studied mortality is low and graft loss is infrequent, but morbidity is common. MELD, especially with concomitant risk factors, had the greatest influence on short term outcome, and recent infection had the least. A multidisciplinary team of experts should carefully assess patients with multiple risk factors, and an optimal graft is recommended.
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Affiliation(s)
- Garrett R Roll
- Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Michael Spiro
- Department of Anesthesia and, Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Arif Jalal
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Cheung Tsz Yan
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kim M Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, USA
| | - Juan C Caicedo
- Department of Surgery, Northwestern Medicine, Chicago, USA
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Shintaro Yagi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Kanazawa University, Kanawaza, Japan
| | - Mark S Cattral
- Department of Surgery, University of Toronto, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Arvinder S Soin
- Institute of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity Hospital, Gurugram, India
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Hogan BJ, Pai SL, Planinsic R, Suh KS, Hillingso JG, Ghani SA, Fan KS, Spiro M, Raptis DA, Vohra V, Auzinger G. Does multimodal perioperative pain management enhance immediate and short-term outcomes after living donor partial hepatectomy? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14649. [PMID: 35297508 DOI: 10.1111/ctr.14649] [Citation(s) in RCA: 1] [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: 01/28/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal analgesic strategy for patients undergoing donor hepatectomy is not known and the potential short- and long-term physical and psychological consequences of complications are significant. OBJECTIVES To identify whether a multimodal approach to pain of the donor intraoperatively enhances immediate and short-term outcomes after living liver donation, and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO 2021 CRD42021260699. RESULTS Nine studies assessing multi-modal analgesia strategies were included in a qualitative assessment. Interventions included local, regional, and neuro-axial anesthetic techniques, pharmacological intervention (NSAIDs, COX-2 inhibitors, ketamine, dexmedetomidine, and lidocaine), and acupuncture. Overall, there was a significant (40%) reduction in opioid requirement on day 1 and a significant reduction in pain scores in the intervention vs control groups. Significant reductions in either length of stay or post-operative complications were demonstrated in four of nine studies. CONCLUSIONS Opioid use for patients undergoing donor hepatectomy is likely to impact both their short- and long-term outcomes. To reduce post-operative pain scores, shorten length of hospital stay, and promote earlier post-operative return of bowel function, we recommend that multi-modal analgesia be offered to patients undergoing living donor hepatectomy. Further research is required to confirm which multi-modal techniques are most associated with enhanced recovery in living liver donors.
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Affiliation(s)
- Brian J Hogan
- Institute of Liver Studies, King's College Hospital, London, UK.,Cleveland Clinic London, London, UK
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Florida, USA
| | - Raymond Planinsic
- Anaesthesiology & Perioperative Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jens G Hillingso
- Department of Surgery and Transplantation, Rigshospitalet University of Copenhagen, Copenhagen, Denmark
| | | | - Ka Siu Fan
- Royal County Surrey Hospital, Surrey, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Vijay Vohra
- Liver Transplant, GI Anaesthesia and Intensive Care, Medanta - The Medicity Hospital, South Delhi, Delhi, India
| | - Georg Auzinger
- Institute of Liver Studies, King's College Hospital, London, UK.,Cleveland Clinic London, London, UK
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28
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Victor DW, Zanetto A, Montano-Loza AJ, Heimbach JK, Towey J, Spiro M, Raptis DA, Burra P. The role of preoperative optimization of the nutritional status on the improvement of short-term outcomes after liver transplantation? A review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14647. [PMID: 35303370 PMCID: PMC10078549 DOI: 10.1111/ctr.14647] [Citation(s) in RCA: 1] [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: 01/20/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malnutrition is a known risk factor for postoperative morbidity and mortality in patients awaiting liver transplantation (LT). Malnutrition is a potentially reversible risk factor, though there are no clear guidelines on the best mechanism for an improvement. It also remains unclear if preoperative nutritional interventions have benefits to post-transplant outcomes for transplant recipients. OBJECTIVES Primary objective: To identify if preoperative optimization of nutritional status is associated with improved short-term outcomes after LT. SECONDARY OBJECTIVES To determine if preoperative improvement of malnutrition improves short-term outcomes after LT, as well as if weight loss in obese patients affects short-term outcomes after LT. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. POSPERO Protocol ID: CRD42021237450 RESULTS: 3851 records were identified in searching the databases, 3843 records were excluded by not fulfilling eligibility criteria. Seven full-text articles were included for the final analysis of which three were randomized controlled trials, one was prospective observational studies, and three were retrospective observational studies. No appreciable difference in mortality, post-transplant complication rate was noted across the studies. Length of stay (LOS) was noted to be shorter in two observational studies of Vitamin D deficiency in liver transplant patients. CONCLUSIONS We have made a weak recommendation supporting pre-transplant nutritional supplementation due to possible benefit in reducing LOS as well as the lack of harm (Quality of Evidence low | Grade of Recommendation; Weak). No effective conclusions were reached for the secondary objectives due to the conflicting evidence.
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Affiliation(s)
- David W Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas, USA
| | - Alberto Zanetto
- Multivisceral Transplant Unit/Gastroenterology, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Julie K Heimbach
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer Towey
- Department of Dietetics, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Patrizia Burra
- Multivisceral Transplant Unit/Gastroenterology, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
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Crespo G, Hessheimer AJ, Armstrong MJ, Berzigotti A, Monbaliu D, Spiro M, Raptis DA, Lai JC. Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14644. [PMID: 35293025 DOI: 10.1111/ctr.14644] [Citation(s) in RCA: 1] [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: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post-LT outcomes. OBJECTIVE We aimed to identify pre-LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post-LT outcomes. METHODS We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre-LT modalities that identify LT recipients at higher risk of worse early post-LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS. RESULTS Twenty-two studies were included in the review, encompassing three different types of pre-LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single-center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post-LT mortality, length of stay or postoperative complications. CONCLUSIONS We identified four pre-LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: (1) KPS (quality of evidence moderate, grade of recommendation strong); (2) LFI (quality of evidence moderate, grade of recommendation strong); (3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong); and (4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine preoperative assessment when considering implementation of ERAS protocols for LT.
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Affiliation(s)
- Gonzalo Crespo
- Hepatology and Liver Transplant Units, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Amelia J Hessheimer
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Matthew J Armstrong
- Liver Transplant Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Annalisa Berzigotti
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Diethard Monbaliu
- Department of Microbiology, Immunology, and Transplantation, and Laboratory of Abdominal Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Jennifer C Lai
- Department of Medicine, San Francisco (UCSF), University of California, San Francisco, California, USA
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Tanaka T, Reichman TW, Olmos A, Akamatsu N, Mrzljak A, Spiro M, Raptis DA, Berlakovich G. When is the optimal time to discharge patients after liver transplantation with respect to short-term outcomes? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14685. [PMID: 35470472 PMCID: PMC10078433 DOI: 10.1111/ctr.14685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 01/03/2022] [Accepted: 04/19/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Several factors associated with prolonged hospital stay have been described. A recent study demonstrated that hospital length of stay (LOS) is directly associated with an increased cost for liver transplantation (LT) and may be associated with greater mortality; however, the factors associated with post-LT mortality are also related to a prolonged hospital stay, that is, those factors are confounders. Thus, the actual impact of the length of post-LT hospital stay on both short-term and long-term patient and graft survival remains uncertain. OBJECTIVES To identify the optimal time to discharge patients after LT with respect to short-term outcomes; readmission rate, 30-90-mortality and morbidity. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Initial search keywords for screening were as follows; ((discharge AND (time OR "time point" OR "time-point")) OR "length of hospital stay" OR "length of stay") AND ((liver OR hepatic) AND (transplant OR transplantation)). PROSPERO ID CRD42021245598 RESULTS: The strength of recommendation was rated as Weak, and we did not identify the direction of recommendations regarding the optimal timing after LT concerning short-term outcomes, including "Readmission rate," six studies on 30- and/or 90-day mortality, and five studies on "30- and/or 90-day morbidity rate." CONCLUSIONS Evidence is scarce to judge the optimal timing to discharge patients after LT with respect to short-term outcomes. In centers with robust outpatient follow-up, discharge can occur safely as early as post-transplant 6-8 days (Quality of Evidence [QOE]; Low | Grade of Recommendation; Weak).
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Affiliation(s)
- Tomohiro Tanaka
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, Iowa, USA
| | - Trevor W Reichman
- Ajmera Transplant Centre, Toronto General Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Olmos
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Japan
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Gabriela Berlakovich
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
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31
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Izzy M, Brown RS, Eguchi S, Hwang S, Matamoros MA, Quintini C, Rajakumar A, Raptis DA, Spiro M, Ascher NL. Optimizing pre-donation physiologic evaluation for enhanced recovery after living liver donation - Systematic review and multidisciplinary expert panel recommendations. Clin Transplant 2022; 36:e14680. [PMID: 35502664 DOI: 10.1111/ctr.14680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 01/16/2022] [Revised: 04/04/2022] [Accepted: 04/09/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND While preoperative physiologic evaluation of live liver donors is routinely performed to ensure donor safety and minimize complications, the optimal approach to this evaluation is unknown. OBJECTIVES We aim to identify predonation physiologic evaluation strategies to improve postoperative short-term outcomes, enhance donor's recovery, and reduce length of stay. We also aim to provide multidisciplinary expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS The systematic review followed PRISMA guidelines, and the recommendations were formulated using GRADE approach and experts' opinion. The search included retrospective or prospective studies, describing outcomes of physiologic evaluation predonation. The outcomes of interest were length of stay, postoperative complications (POC), recovery after donation, and mortality. PROSERO protocol ID CRD42021260662. RESULTS Of 1386 articles screened, only three retrospective cohort studies met eligibility criteria. Two studies demonstrated no impact of age (< 70 years) on POC. Increased body mass index's (BMI) association with POC was present in one study (23.8 vs 21.7 kg/m2 , OR 1.67 (1.14-2.48), P = .01) and absent in another (< 30 vs 30-35 kg/m2 , P = .61). One study demonstrated decreased risk for postdonation subclinical hepatic dysfunction in donors with higher normal platelet count (PLT). None of the studies noted donor death. Given the scarce data on predonation physiologic testing, the expert panel recommended a battery of tests to guide clinical practice and future investigations. CONCLUSION Advancing age (60-69 years) is not a contraindication for liver donation. There is insufficient evidence for a specific predonation BMI cut-off. Abbreviated predonation physiologic testing is recommended in all candidates. Comprehensive testing is recommended in high-risk candidates while considering the pretest probability in various populations (Quality of evidence; Low to Very Low | Grade of Recommendation; Strong).
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Affiliation(s)
- Manhal Izzy
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, USA
| | - Robert S Brown
- Department of Medicine, Weill Cornell Medical College, New York, USA
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shin Hwang
- Department of Liver Transplantation and Hepatobiliary Surgery, University of Ulsan, Seoul, South Korea
| | - Maria A Matamoros
- Department of Surgery, Center CCSS-Hospital México, San Jose, Costa Rica
| | | | - Akila Rajakumar
- Department of Liver Anesthesia and Intensive Care, Rela Institute, Chennai, India
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
- Department of Surgery & Interventional Science, University College London, London, UK
| | - Michael Spiro
- Department of Surgery & Interventional Science, University College London, London, UK
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Nancy L Ascher
- Department of Surgery, University of California San Francisco, San Francisco, USA
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Shaker TM, Eason JD, Davidson BR, Barth RN, Pirenne J, Imventarza O, Spiro M, Raptis DA, Fung J. Which cava anastomotic techniques are optimal regarding immediate and short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14681. [PMID: 35567584 PMCID: PMC10078200 DOI: 10.1111/ctr.14681] [Citation(s) in RCA: 1] [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: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has long been debated whether cava anastomosis should be performed with the piggyback technique or cava replacement, with or without veno-venous bypass (VVB), with or without temporary portocaval shunt (PCS) in the setting of liver transplantation. OBJECTIVES To identify whether different cava anastomotic techniques and other maneuvers benefit the recipient regarding short-term outcomes and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021240979). RESULTS Of 3205 records screened, 307 publications underwent full-text assessment for eligibility and 47 were included in qualitative synthesis. Four studies were randomized control trials. Eighteen studies were comparative. The remaining 25 were single-center retrospective noncomparative studies. CONCLUSION Based on existing data and expert opinion, the panel cannot recommend one cava reconstruction technique over another, rather the surgical approach should be based on surgeon preference and center dependent, with special consideration toward patient circumstances (Quality of evidence: Low | Grade of Recommendation: Strong). The panel recommends against routine use of vevo-venous bypass (Quality of evidence: Very Low | Grade of Recommendation: Strong) and against the routine use of temporary porto-caval shunt (Quality of evidence: Very Low | Grade of Recommendation: Strong).
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Affiliation(s)
- Tamer M Shaker
- Division of Transplant, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - James D Eason
- James D. Eason Transplant Institute, University of Tennessee, Memphis, Tennessee, USA
| | - Brian R Davidson
- UCL Division of Surgery & Interventional Science, University College London, Royal Free Campus, Rowland Hill Street, London, United Kingdom of Great Britain and Northern Ireland
| | - Rolf N Barth
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Jacques Pirenne
- Department of Microbiology, Immunology, and Transplantation, Lab of Abdominal Transplantation, Transplantation Research Group, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplantation Surgery and Coordination, University Hospitals of Leuven, Leuven, Belgium
| | - Oscar Imventarza
- Liver Transplant Unit, Hospital Argerich, Hospital Garrahan, Stalyc Representative, Buenos Aires, Argentina
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - John Fung
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
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Campos-Varela I, Blumberg EA, Giorgio P, Kotton CN, Saliba F, Wey EQ, Spiro M, Raptis DA, Villamil F. What is the optimal antimicrobial prophylaxis to prevent postoperative infectious complications after liver transplantation? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14631. [PMID: 35257411 DOI: 10.1111/ctr.14631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antimicrobial prophylaxis is well-accepted in the liver transplant (LT) setting. Nevertheless, optimal regimens to prevent bacterial, viral, and fungal infections are not defined. OBJECTIVES To identify the optimal antimicrobial prophylaxis to prevent post-LT bacterial, fungal, and cytomegalovirus (CMV) infections, to improve short-term outcomes, and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO ID CRD42021244976. RESULTS Of 1853 studies screened, 34 were included for this review. Bacterial, CMV, and fungal antimicrobial prophylaxis were evaluated separately. Pneumocystis jiroveccii pneumonia (PJP) antimicrobial prophylaxis was analyzed separately from other fungal infections. Overall, eight randomized controlled trials, 21 comparative studies, and five observational noncomparative studies were included. CONCLUSIONS Antimicrobial prophylaxis is recommended to prevent bacterial, CMV, and fungal infection to improve outcomes after LT. Universal antibiotic prophylaxis is recommended to prevent postoperative bacterial infections. The choice of antibiotics should be individualized and length of therapy should not exceed 24 hours (Quality of Evidence; Low | Grade of Recommendation; Strong). Both universal prophylaxis and preemptive therapy are strongly recommended for CMV prevention following LT. The choice of one or the other strategy will depend on individual program resources and experiences, as well as donor and recipient serostatus. (Quality of Evidence; Low | Grade of Recommendation; Strong). Antifungal prophylaxis is strongly recommended for LT recipients at high risk of developing invasive fungal infections. The drug of choice remains controversial. (Quality of Evidence; High | Grade of Recommendation; Strong). PJP prophylaxis is strongly recommended. Length of prophylaxis remains controversial. (Quality of Evidence; Very Low | Grade of Recommendation; Strong).
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Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Emily A Blumberg
- Perelman School of Medicine at the University of Pennsylvania, Philadephia, Pennsylvania, USA
| | - Patricia Giorgio
- Department of Infectious Disease, Hospital Británico, Buenos Aires City, Argentina
| | - Camille N Kotton
- Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Fauzi Saliba
- APHP, Hopital Paul Brousse, Université Paris Saclay, INSERM unit No. 1193, Villejuif, France
| | - Emmanuel Q Wey
- ILDH, Division of Medicine, University College London Medical School, London, UK.,Centre for Clinical Microbiology, Division of Infection & Immunity, UCL, London, UK.,Department of Infection, Royal Free London NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Federico Villamil
- Liver Transplantation Unit, British Hospital, Buenos Aires City, Argentina.,Hepatology and Liver Transplantation Unit, Hospital El Cruce, Florencio Varela, Buenos Aires Province, Argentina
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Vinaixa C, Martínez Palli G, Milliken D, Sellers D, Dharancy S, Spiro M, Aristotle Raptis D, Samuel D. The role of prehabilitation on short-term outcomes after liver transplantation: A review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14686. [PMID: 35462421 DOI: 10.1111/ctr.14686] [Citation(s) in RCA: 1] [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: 01/12/2022] [Accepted: 04/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prehabilitation programs as part of ERAS protocols are being increasingly used in multiple surgeries, improving postoperative outcomes. Data regarding prehabilitation programs in patients awaiting liver transplantation and their outcomes is scarce. OBJECTIVES To identify whether prehabilitation programs based on exercise training conducted prior to liver transplantation improve short-term postoperative outcomes, and to provide expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating postoperative outcomes, as well as those evaluating functional outcomes. PROSPERO ID CRD42021236305. RESULTS Of the 170 studies screened, only one assessed the primary objective. Most studies focus on the preoperative impact of exercise training on aerobic capacity, muscle mass and/or strength, showing positive effects and no significant adverse events, but are underpowered and with heterogenous designs and interventions. The non-randomized observational study which assessed relevant postoperative outcomes, showed a non-significant trend towards reduced 90-day readmission rate and shorter length of stay in the prehabilitation group. CONCLUSIONS Prehabilitation prior to liver transplantation is unlikely to be harmful, and likely to have short term benefits on functional status. We cautiously recommend prehabilitation on the basis of absence of harm and possibility of benefit (Quality of Evidence; Very Low | Grade of Recommendation; Low).
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Affiliation(s)
- Carmen Vinaixa
- Department of Digestive Diseases, Section of Hepatology, La Fe University Hospital, Valencia, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Graciela Martínez Palli
- Department of Anesthesia, Hospital Clínic, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Donald Milliken
- Department of Anesthesia and Perioperative Medicine, The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Didier Samuel
- Centre Hépato-Biliaire, APHP, Hôpital Paul-Brousse, Université Paris-Saclay, UMR-S 1193 INSERM, FHU Hepatinov, Villejuif, 94800, France
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35
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Mina DS, Tandon P, Kow AWC, Chan A, Edbrooke L, Raptis DA, Spiro M, Selzner N, Denehy L. The role of acute in-patient rehabilitation on short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14706. [PMID: 35546523 DOI: 10.1111/ctr.14706] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Received: 01/05/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The indication and surgical complexity of orthotopic liver transplantation underscore the need for strategies to optimize the recovery for transplant recipients. We conducted a systematic review aimed at identifying, evaluating, and synthesizing the evidence examining the effect of in-patient rehabilitation for liver transplant recipients and provide related practice recommendations. METHODS Health research databases were systematically reviewed for studies that included adults who received liver transplantation and participated in acute, post-transplant rehabilitation. Postoperative morbidity, mortality, length of hospital stay, length of intensive care unit stay, and other markers of surgical recovery were extracted. Practice recommendations are provided by an international panel using GRADE. RESULTS Twelve studies were included in the review (including 3901 participants). Rehabilitation interventions varied widely in design and composition; however, details regarding intervention delivery were poorly described in general. The quality of evidence was rated as very low largely owing to "very serious" imprecision, poor reporting, and limited data from comparative studies. Overall, the studies suggest that in-patient rehabilitation for recipients of liver transplantation is safe, tolerable, and feasible, and may benefit functional outcomes. CONCLUSION Two practice recommendations related to in-patient rehabilitation following LT were yielded from this review: (1) it is safe, tolerable, and feasible; and (2) it improves postoperative functional outcomes. Each of the recommendations are weak and supported by low quality of evidence. No recommendation could be made related to benefits or harms for clinical, physiological, and other outcomes. Adequately powered and high quality randomized controlled trials are urgently needed in this area.
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Affiliation(s)
- Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Alfred Wei Chieh Kow
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Liver Transplantation Program, National University Center for Organ Transplantation, National University Health System Singapore, Singapore, Singapore
| | - Albert Chan
- Division of Liver Transplantation, Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Lara Edbrooke
- Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Michael Spiro
- Division of Surgery & Interventional Science, University College London, London, UK
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Nazia Selzner
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Linda Denehy
- Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
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Raptis DA, Raptis A, Tinguely P. A Platform (Authorships.org) for the Objective Qualification and Order of Academic Authorship in Medical and Science Journals: Development and Evaluation Study Using the Design Science Research Methodology. JMIR Form Res 2022; 6:e34258. [PMID: 35298392 PMCID: PMC8972106 DOI: 10.2196/34258] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/01/2021] [Accepted: 01/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background The qualification and order of authorship in scientific manuscripts are the main disputes in collaborative research work. Objective The aim of this project was to develop an open-access web-based platform for objective decision-making of authorship qualification and order in medical and science journals. Methods The design science process methodology was used to develop suitable software for authorship qualification and order. The first part of the software was designed to differentiate between qualification for authorship versus acknowledgment, using items of the recommendations of the International Committee of Medical Journal Editors. The second part addressed the order of authorship, using the analytical hierarchy process for objective multiple criteria decision-making and ranking. The platform was evaluated qualitatively (n=30) and quantitatively (n=18) using a dedicated questionnaire, by an international panel of medical and biomedical professionals and research collaborators worldwide. Results Authorships.org represents an open-access software compatible with all major platforms and web browsers. Software usability and output were evaluated and presented for 3 existing clinical and biomedical research studies. All 18 international evaluators felt that the Authorships.org platform was easy to use or remained neutral. Moreover, 59% (n=10) were satisfied with the software output results while the rest were unsure, 59% (n=10) would definitely use it for future projects while 41% (n=7) would consider it, 94% (n=16) felt it may prove useful to eliminate disputes regarding authorship, 82% (n=14) felt that it should become mandatory for manuscript submission to journals, and 53% (n=9) raised concerns regarding the potential unethical use of the software as a tool. Conclusions Authorships.org allows transparent evaluation of authorship qualification and order in academic medical and science journals. Objectified proof of authorship contributions may become mandatory during manuscript submission in high-quality academic journals.
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Affiliation(s)
- Dimitri Aristotle Raptis
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Royal Free Hospital, London, United Kingdom.,Division of Surgical and Interventional Science, University College London, London, United Kingdom.,Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Aristotle Raptis
- Division of Information and Communications Technology, University of Athens, Athens, Greece
| | - Pascale Tinguely
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Royal Free Hospital, London, United Kingdom
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Gloor S, Misirlic M, Frei-Lanter C, Herzog P, Müller P, Schäfli-Thurnherr J, Lamdark T, Schregel D, Wyss R, Unger I, Gisi D, Greco N, Mungo G, Wirz M, Raptis DA, Tschuor C, Breitenstein S. Prehabilitation in patients undergoing colorectal surgery fails to confer reduction in overall morbidity: results of a single-center, blinded, randomized controlled trial. Langenbecks Arch Surg 2022; 407:897-907. [PMID: 35084526 DOI: 10.1007/s00423-022-02449-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 10/25/2021] [Accepted: 01/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Currently, there are solely weak recommendations in the enhanced recovery after surgery (ERAS) protocol regarding the role of preoperative physical activity and prehabilitation in patients undergoing colorectal surgery. Studies in heterogenous groups showed contradictory results regarding the impact of prehabilitation on the reduction of postoperative complications. The aim of this study was to assess the impact of prehabilitation on postoperative complications in patients undergoing colorectal surgery within an ERAS protocol. METHODS Between July 2016 and June 2019, a single-center, blinded, randomized controlled trial designed to test whether physiotherapeutic prehabilitation vs. normal physical activities prior to colorectal surgery may decrease morbidity within a stringent ERAS protocol was carried out. The primary endpoint was postoperative complications assessed by Comprehensive Complications Index (CCI®). Primary and secondary endpoints for both groups were analyzed and compared. RESULTS A total of 107 patients (54 in the prehabilitation enhanced recovery after colorectal surgery [pERACS] group and 53 in the control group) were included in the study and randomized. Dropout rate was 4.5% (n = 5). Baseline characteristics were comparable between the pERACS and control groups. The percentage of colorectal adenocarcinoma was low in both groups (pERACS 32% vs. control 23%, p = 0.384). Almost all patients underwent minimally invasive surgery in both groups (96% vs. 98%, p = 1.000). There was no between-group difference in the primary outcome, as the mean CCI at 30-day postoperative in the pERACS group was 18 (SD 0-43) compared to 15 (SD 0-49) in the control group (p = 0.059). Secondary outcome as complications assessed according to Clavien-Dindo, length of hospital stay, reoperation rate, and mortality showed no difference between both groups. CONCLUSIONS Routine physiotherapeutic prehabilitation has no additional benefit for patients undergoing colorectal surgery within an ERAS protocol. TRIAL REGISTRATION ClinicalTrial.gov: ID: NCT02746731; Institution Ethical Board Approval: KEK-ZH Nr. 2016-00,229.
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Affiliation(s)
- Severin Gloor
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Department of Visceral Surgery and Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Merima Misirlic
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Cornelia Frei-Lanter
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Departement of Surgery, Hospital Zollikerberg, Zollikerberg Zurich, Switzerland
| | - Pascal Herzog
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Phaedra Müller
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Tenzin Lamdark
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Dorothee Schregel
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Roland Wyss
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Ines Unger
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - David Gisi
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Nicola Greco
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Giuseppe Mungo
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Markus Wirz
- Institute of Physiotherapy, ZHAW School of Engineering, Zurich, Switzerland
| | - Dimitri Aristotle Raptis
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital London, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Christoph Tschuor
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stefan Breitenstein
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.
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Raptis DA, Hanna T, Machairas N, Owen T, Davies D, Fusai GK. The Economic Burden of Postoperative Complications Predicted by the Comprehensive Complication Index ® in Patients Undergoing Elective Major Hepatopancreaticobiliary Surgery for Malignancy - A Prospective Cost Analysis. In Vivo 2021; 35:1065-1071. [PMID: 33622903 DOI: 10.21873/invivo.12351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/08/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIM Postoperative complications have a tremendous impact on in-hospital costs. The novel Comprehensive Complication Index® (CCI®) summarizes all complications together and is more sensitive than existing morbidity endpoints. The purpose of this study was to assess the correlation of CCI® with in-hospital costs and externally validate a novel cost prediction calculator. PATIENTS AND METHODS This was a prospective study including consecutive patients undergoing elective major hepatopancreaticobiliary (HPB) surgery for malignancy at a London tertiary referral hospital. A priori sample size and post-hoc power calculations were performed. RESULTS Thirty patients were included in the analysis, 14 were female, and the median age was 67 [interquartile range (IQR)=54-74] years. The median Charlson Comorbidity Index was 6 (IQR=5-8). Eighteen patients underwent liver, 9 pancreatic surgery and three a palliative bypass; 11 patients had a major complication (≥grade 3a) according to the Clavien-Dindo classification. The median CCI® was 30.2 (IQR=12.18-39.5). The mean cost per case was 13,908 (SD=4,600) GBP. There was no correlation between the Charlson Comorbidity Index or age with actual cost. However, there was very good correlation of actual cost with the CCI® (r=0.77, 95% confidence interval=0.57-0.89, p<0.001) as well as with the predicted cost (Clavien Cost Prediction Calculator) (r=0.70, 95% confidence interval=0.44-0.85, p<0.001). CONCLUSION These findings support the hypothesis that complications are the most important predictor of overall cost in the setting of elective major HPB surgery for malignancy. Furthermore, CCI® and the novel Cost Prediction Calculator can be used in this setting to accurately predict costs using no additional resources.
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Affiliation(s)
| | - Thomas Hanna
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Timothy Owen
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Daniel Davies
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Giuseppe Kito Fusai
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K.
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Gloor S, Misirlic M, Frei-Lanter C, Herzog P, Müller P, Schäfli-Thurnherr J, Schregel D, Lamdark T, Wyss R, Unger I, Gisi D, Greco N, Mungo G, Wirz M, Raptis DA, Tschuor C, Breitenstein S. Prehabilitation in patients undergoing colorectal surgery fails to confer reduction in overall morbidity: Results of a single-center, single-blinded, randomized controlled trial. Br J Surg 2021. [DOI: 10.1093/bjs/znab202.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
Patients undergoing major surgery are prone to a functional decline due to the impairment of muscle, cardiorespiratory and neurological function as a response to surgical stress. Currently, there are solely weak recommendations in the ERAS protocol regarding the role of preoperative physical activity and prehabilitation in patients undergoing colorectal surgery. Studies in heterogenous cohorts showed contradictory results regarding the impact of prehabilitation on the reduction of postoperative complications. This randomized controlled trial assesses the impact of prehabilitation on postoperative complications in patients undergoing colorectal surgery within an ERAS protocol.
Methods
Between July 2016 and June 2019, a single-center, single-blinded , randomized controlled trial designed to test whether physiotherapeutic prehabilitation vs. normal physical activities prior to colorectal surgery may decrease morbidity within a stringent ERAS protocol was carried out. The primary endpoint was postoperative complications assessed by Comprehensive Complications Index (CCI®). Primary and secondary endpoints for both groups were analyzed and compared.
Results
A total of 107 patients (54 in the pERACS and 53 in the control cohort) were included in the study and randomized. Dropout rate was 4.5% (n = 5). Mean age (SD) in the control cohort was 65 (29–86) and 66 (24–90) years in pERACS cohort. The pERACS cohort contained more female patients (40% vs. 55%, p = 0.123) and a higher percentage of colorectal adenocarcinoma (32% vs. 23%, p = 0.384) although not significant. Almost all patients underwent minimally invasive surgery in both cohorts (96% vs 98%, p = 1.000). There was no between-cohort difference in the primary outcome measure 30-day Comprehensive Complications Index (15 [0 – 49] vs. 18 [0 – 43], p = 0.059). Secondary outcome as complications assessed according to Clavien-Dindo, length of hospital stay, reoperation rate and mortality showed no difference between both cohorts.
Conclusion
Routine physiotherapeutic prehabilitation cannot be recommended for patients undergoing colorectal surgery within an ERAS protocol (Grade A recommendation). To eliminate other confounders like geographical difference or difference in surgical technique, further multicenter RCTs are needed.
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Affiliation(s)
- S Gloor
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - M Misirlic
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - C Frei-Lanter
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Department of Surgery, Hospital Zollikerberg, Zollikerberg, Switzerland
| | - P Herzog
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - P Müller
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - J Schäfli-Thurnherr
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - D Schregel
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - T Lamdark
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - R Wyss
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - I Unger
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - D Gisi
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - N Greco
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - G Mungo
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - M Wirz
- Institute of Physiotherapy, Zurich University of Applied Sciences (ZHAW), Winterthur, Switzerland
| | - D A Raptis
- Department of HPB Surgery and Liver Transplantat, Royal Free Hospital London, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - C Tschuor
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Division of Visceral Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - S Breitenstein
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
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40
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Gero D, Vannijvel M, Okkema S, Deleus E, Lloyd A, Lo Menzo E, Tadros G, Raguz I, San Martin A, Kraljević M, Mantziari S, Frey S, Gensthaler L, Sammalkorpi H, Garcia-Galocha JL, Zapata A, Tatarian T, Wiggins T, Bardisi E, Goreux JP, Vonlanthen R, Widmer J, Thalheimer A, Himpens J, Hollymann M, Welbourn R, Aggarwal R, Beekley A, Sepulveda M, Torres A, Juuti A, Salminen P, Prager G, Iannelli A, Suter M, Peterli R, Boza C, Rosenthal R, Higa K, Lannoo M, Hazebroek EJ, Dillemans B, Clavien PA, Puhan M, Raptis DA, Bueter M. Defining global benchmarks in elective secondary bariatric surgery comprising conversional, revisional and reversal procedures. Br J Surg 2021. [DOI: 10.1093/bjs/znab202.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Objective
Management of poor response and of long-term complications after bariatric surgery (BS) is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Benchmarking uses best performance in a given field as reference point for improvement. Our aim was to define ‘‘best possible’’ outcomes for elective secondary BS.
Methods
The establishment of benchmarks in secondary BS followed a standardized methodology, based on recommendations of a Delphi consensus panel of experts. This multicenter study analyzed patients undergoing elective secondary BS in 18 high-volume centers on 4 continents from 06/2013 to 05/2019. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers. Benchmark cases had no: previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI>50kg/m2 or age>65 years. Descriptive statistics, multivariate logistic regression and data visualization were performed using the R software.
Results
Out of 44’884 elective bariatric procedures performed in the participating centers, 5’328 secondary BS cases were identified. The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8±10 years, 8.4±5.3 years after primary BS, with a body mass index 35.2±7kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.57% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.36) and after conversional or revisional procedures with gastrointestinal suture/stapling (OR 1.7). Benchmark cutoffs at 90-days postoperatively were ≤5.8% re-intervention and ≤8.8% re-operation rate. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.
Conclusion
Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.
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Affiliation(s)
- D Gero
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - M Vannijvel
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - S Okkema
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | - E Deleus
- Department of Surgery, University Hospital Leuven, Leuven, Belgium
| | - A Lloyd
- Department of Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, USA
| | - E Lo Menzo
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, USA
| | - G Tadros
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, USA
| | - I Raguz
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - A San Martin
- Department of Surgery, Clinica Las Condes, Santiago de Chile, Chile
| | - M Kraljević
- Department of Visceral Surgery, Clarunis - University Abdominal Center, Basel, Switzerland
| | - S Mantziari
- Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - S Frey
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d’Azur, Nice, France
| | - L Gensthaler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - H Sammalkorpi
- Department of Surgery, University Hospital of Helsinki, Helsinki, Finland
| | - J L Garcia-Galocha
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - A Zapata
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Santiago de Chile, Chile
| | - T Tatarian
- Bariatric and Metabolic Surgery Department, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - T Wiggins
- Bariatric and Metabolic Surgery Center, Musgrove Park Hospital, Taunton, United Kingdom
| | - E Bardisi
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
| | - J -P Goreux
- Department of Surgery, Delta CHIREC Hospital, Brussels, Belgium
| | - R Vonlanthen
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - J Widmer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - A Thalheimer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - J Himpens
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
| | - M Hollymann
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, United Kingdom
| | - R Welbourn
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, United Kingdom
| | - R Aggarwal
- Bariatric and Metabolic Surgery Department, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - A Beekley
- Bariatric and Metabolic Surgery Center, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - M Sepulveda
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Santiago de Chile, Chile
| | - A Torres
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - A Juuti
- Department of Surgery, University Hospital of Helsinki, Helsinki, Finland
| | - P Salminen
- Department of Surgery, University of Turku, Turku, Finland
| | - G Prager
- Department of Surgery, Medical University Vienna, Vienna, Austria
| | - A Iannelli
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d’Azur, Nice, France
| | - M Suter
- Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - R Peterli
- Department of Visceral Surgery, Clarunis - University Abdominal Center, Basel, Switzerland
| | - C Boza
- Department of Surgery, Clinica Las Condes, Santiago de Chile, Chile
| | - R Rosenthal
- Bariatric and Metabolic Surgery Department, Cleveland Clinic Florida, Weston, USA
| | - K Higa
- Bariatric and Metabolic Surgery Center, Fresno Heart and Surgical Hospital, Fresno, USA
| | - M Lannoo
- Department of Surgery, University Hospital Leuven, Leuven, Belgium
| | - E J Hazebroek
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | - B Dillemans
- Department of Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - P -A Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - M Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - D A Raptis
- Department of Hepatobiliary and Pancreas Surgery and Liver Transplantation, Royal Free Hospital, London, United Kingkom
| | - M Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Schnyder F, Cabalzar-Wondberg D, Raptis DA, Eisner L, Zuber M, Weixler B. Outcome of open inguinal hernia repair using sutureless self-gripping mesh - a retrospective single cohort study. Swiss Med Wkly 2021; 151:w20455. [PMID: 33638354 DOI: 10.4414/smw.2021.20455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neurological disturbances after open inguinal hernia repair affect approximately one in ten patients. Sutureless, self-gripping meshes were developed with the aim of reducing postoperative neurological disturbances or neuralgia. This study assessed short- and long-term outcomes after open inguinal hernia repair using a self-gripping light-weight mesh in a peripheral teaching hospital. METHODS Patients with uni- or bilateral inguinal hernia were included in this study. Open inguinal hernia repair was performed according to the Lichtenstein technique with a self-gripping, lightweight macroporous mesh. Postoperative follow-up was at 6 weeks after surgery and any long-term complications or recurrences were recorded up to 5 years postoperatively. RESULTS The median follow up time for all patients was 5–6 years and the median operation time was 40.0 minutes (inter quartile range 25.0–55.8). Of the 162 included patients, the mean numeric rating scale for pain (0 = no pain, 10 = excruciating pain) before hospital discharge was 2.7 (standard deviation [SD] 2.6) and 1.1 (SD 1.1) at 6 weeks postoperatively. The overall incidence of neurological disturbances at 6 weeks postoperatively was 11% when surgery was performed by the chief of surgery and 40% when it was performed by a senior consultant, 49% by chief-residents and 47% by supervised residents (p = 0.005). Patients with neurological disturbances were younger than asymptomatic patients (age 50, SD 15 vs 62, SD 17, p <0.001). The 1-, 3- and 5-year recurrence rates were 1%, 2% and 3%, respectively. CONCLUSIONS This study shows that open inguinal hernia repair using a self-gripping mesh is feasible, with a short operation time and low hernia recurrence rates in a peripheral teaching hospital. However, significant differences in neurological disturbances dependent on the surgeons experience were identified. Especially younger patients should be operated on by an experienced surgeon to reduce neurological disturbances and neuralgia.
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Affiliation(s)
- Flurin Schnyder
- Department of Surgery, Cantonal Hospital Olten, Switzerland / Department of Surgery, Hospital Limmattal, Schlieren, Switzerland
| | | | | | - Lukas Eisner
- Department of Surgery, Cantonal Hospital Olten, Switzerland
| | - Markus Zuber
- Department of Surgery, Cantonal Hospital Olten, Switzerland / Clarunis Visceral Surgery Centre, St Clara Hospital and University Hospital Basel, Switzerland
| | - Benjamin Weixler
- Department of Surgery, Cantonal Hospital Olten, Switzerland / Department of General, Visceral and Vascular Surgery, Campus Benjamin Franklin, Charité Universitätsmedizin, Berlin, Germany
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Fan KS, Ghani SA, Machairas N, Lenti L, Fan KH, Richardson D, Scott A, Raptis DA. COVID-19 prevention and treatment information on the internet: a systematic analysis and quality assessment. BMJ Open 2020; 10:e040487. [PMID: 32912996 PMCID: PMC7485261 DOI: 10.1136/bmjopen-2020-040487] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the quality of information regarding the prevention and treatment of COVID-19 available to the general public from all countries. DESIGN Systematic analysis using the 'Ensuring Quality Information for Patients' (EQIP) Tool (score 0-36), Journal of American Medical Association (JAMA) benchmark (score 0-4) and the DISCERN Tool (score 16-80) to analyse websites containing information targeted at the general public. DATA SOURCES Twelve popular search terms, including 'Coronavirus', 'COVID-19 19', 'Wuhan virus', 'How to treat coronavirus' and 'COVID-19 19 Prevention' were identified by 'Google AdWords' and 'Google Trends'. Unique links from the first 10 pages for each search term were identified and evaluated on its quality of information. ELIGIBILITY CRITERIA FOR SELECTING STUDIES All websites written in the English language, and provides information on prevention or treatment of COVID-19 intended for the general public were considered eligible. Any websites intended for professionals, or specific isolated populations, such as students from one particular school, were excluded, as well as websites with only video content, marketing content, daily caseload update or news dashboard pages with no health information. RESULTS Of the 1275 identified websites, 321 (25%) were eligible for analysis. The overall EQIP, JAMA and DISCERN scores were 17.8, 2.7 and 38.0, respectively. Websites originated from 34 countries, with the majority from the USA (55%). News Services (50%) and Government/Health Departments (27%) were the most common sources of information and their information quality varied significantly. Majority of websites discuss prevention alone despite popular search trends of COVID-19 treatment. Websites discussing both prevention and treatment (n=73, 23%) score significantly higher across all tools (p<0.001). CONCLUSION This comprehensive assessment of online COVID-19 information using EQIP, JAMA and DISCERN Tools indicate that most websites were inadequate. This necessitates improvements in online resources to facilitate public health measures during the pandemic.
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Affiliation(s)
- Ka Siu Fan
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital, London, UK
| | - Lorenzo Lenti
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | - Aneya Scott
- St George's University Hospitals NHS Foundation Trust, London, UK
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Hayoz C, Hermann T, Raptis DA, Brönnimann A, Peterli R, Zuber M. Comparison of metabolic outcomes in patients undergoing laparoscopic roux-en-Y gastric bypass versus sleeve gastrectomy - a systematic review and meta-analysis of randomised controlled trials. Swiss Med Wkly 2018; 148:w14633. [PMID: 30035801 DOI: 10.4414/smw.2018.14633] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Bariatric surgery is the most effective treatment for morbid obesity and is known to have beneficial effects on glycaemic control in patients with type 2 diabetes mellitus (T2DM) and in diabetes prevention. The preferred type of surgery and mechanism of action is, however, unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effects of laparoscopic roux-en-Y gastric bypass (RYGB) with those of sleeve gastrectomy (SG) on metabolic outcome, with a special focus on glycaemic control. METHODS A literature search of the Medline, Pubmed, Cochrane, Embase and SCOPUS databases was performed in November 2014 for RCTs comparing RYGB with SG in overweight and obese patients with or without T2DM. The primary outcome was improvement in postoperative glycaemic control. Secondary outcomes included weight-related and lipid metabolism parameters. Synthesis of these data followed established statistical procedures for meta-analysis. RESULTS Sixteen RCTs with a total of 1132 patients with overweight or obesity were included in the analysis. When compared with patients who underwent SG, those who underwent RYGB showed no difference after 12 months in mean fasting blood glucose (mean difference [MD] -6.22 mg/dl, 95% confidence interval [CI] -17.27 to 4.83; p <0.001). However, there was a better outcome with RYGB, with lower mean fasting glucose levels at 24 months (MD -16.92 mg/dl, 95% CI -21.67 to -12.18), 36 months (MD -5.97mg/dl, 95% CI -9.32 to -2.62) and at 52 months (MD -15.20 mg/dl, 95% CI -27.35 to -3.05) mg/dl; p = 0.010) and lower mean glycated haemoglobin (HbA1 at 12 months (MD -0.47%, 95% CI -0.73 to -0.20%; p <0.001) and at 36 months postoperatively compared to SG. Fasting insulin levels and HOMA indices showed no difference at any stage of follow-up. In the subgroup including only diabetic patients HbA1c showed lower levels at 12 months (MD -0.46%, 95% CI-0.73 to -0.20%). No difference was found for the fasting insulin at baseline and after 12 months. Similarly, when compared to SG, patients that underwent RYGB had lower low-density lipoproteins at 12 months. This effect was lost at 36 months. Patients undergoing RYGB also had lower triglycerides at 12 months and at 52 months, lower cholesterol at 60 months and an improvement of BMI at 52 months postoperatively. BMI values at 12 months and low-density lipoprotein levels at 12 and 36 months were lower for diabetic patients only, as in the overall analysis. CONCLUSION Based on this meta-analysis, RYGB is more effective than SG in improving weight loss and short- and mid-term glycaemic and lipid metabolism control in patients with and without T2DM. Therefore, unless contraindicated, RYGB should be the first choice to treat patients with obesity and T2DM and/or dyslipidaemia.
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Affiliation(s)
| | | | - Dimitri Aristotle Raptis
- Department of Surgery, Cantonal Hospital Olten, Switzerland / Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Alain Brönnimann
- Department of Anaesthesia and Intensive Care, Cantonal Hospital Olten, Switzerland
| | - Ralph Peterli
- Department of Surgery, St. Claraspital, Basel, Switzerland
| | - Markus Zuber
- Department of Surgery, Cantonal Hospital Olten, Switzerland
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Hayoz C, Hermann T, Raptis DA, Brönnimann A, Peterli R, Zuber M. Comparison of metabolic outcomes in patients undergoing laparoscopic roux-en-Y gastric bypass versus sleeve gastrectomy - a systematic review and meta-analysis of randomised controlled trials. Swiss Med Wkly 2018; 148:w14633. [PMID: 30035801 DOI: 10.57187/smw.2018.14633] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Bariatric surgery is the most effective treatment for morbid obesity and is known to have beneficial effects on glycaemic control in patients with type 2 diabetes mellitus (T2DM) and in diabetes prevention. The preferred type of surgery and mechanism of action is, however, unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effects of laparoscopic roux-en-Y gastric bypass (RYGB) with those of sleeve gastrectomy (SG) on metabolic outcome, with a special focus on glycaemic control. METHODS A literature search of the Medline, Pubmed, Cochrane, Embase and SCOPUS databases was performed in November 2014 for RCTs comparing RYGB with SG in overweight and obese patients with or without T2DM. The primary outcome was improvement in postoperative glycaemic control. Secondary outcomes included weight-related and lipid metabolism parameters. Synthesis of these data followed established statistical procedures for meta-analysis. RESULTS Sixteen RCTs with a total of 1132 patients with overweight or obesity were included in the analysis. When compared with patients who underwent SG, those who underwent RYGB showed no difference after 12 months in mean fasting blood glucose (mean difference [MD] -6.22 mg/dl, 95% confidence interval [CI] -17.27 to 4.83; p <0.001). However, there was a better outcome with RYGB, with lower mean fasting glucose levels at 24 months (MD -16.92 mg/dl, 95% CI -21.67 to -12.18), 36 months (MD -5.97mg/dl, 95% CI -9.32 to -2.62) and at 52 months (MD -15.20 mg/dl, 95% CI -27.35 to -3.05) mg/dl; p = 0.010) and lower mean glycated haemoglobin (HbA1 at 12 months (MD -0.47%, 95% CI -0.73 to -0.20%; p <0.001) and at 36 months postoperatively compared to SG. Fasting insulin levels and HOMA indices showed no difference at any stage of follow-up. In the subgroup including only diabetic patients HbA1c showed lower levels at 12 months (MD -0.46%, 95% CI-0.73 to -0.20%). No difference was found for the fasting insulin at baseline and after 12 months. Similarly, when compared to SG, patients that underwent RYGB had lower low-density lipoproteins at 12 months. This effect was lost at 36 months. Patients undergoing RYGB also had lower triglycerides at 12 months and at 52 months, lower cholesterol at 60 months and an improvement of BMI at 52 months postoperatively. BMI values at 12 months and low-density lipoprotein levels at 12 and 36 months were lower for diabetic patients only, as in the overall analysis. CONCLUSION Based on this meta-analysis, RYGB is more effective than SG in improving weight loss and short- and mid-term glycaemic and lipid metabolism control in patients with and without T2DM. Therefore, unless contraindicated, RYGB should be the first choice to treat patients with obesity and T2DM and/or dyslipidaemia.
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Affiliation(s)
| | | | - Dimitri Aristotle Raptis
- Department of Surgery, Cantonal Hospital Olten, Switzerland / Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Alain Brönnimann
- Department of Anaesthesia and Intensive Care, Cantonal Hospital Olten, Switzerland
| | - Ralph Peterli
- Department of Surgery, St. Claraspital, Basel, Switzerland
| | - Markus Zuber
- Department of Surgery, Cantonal Hospital Olten, Switzerland
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A, Al Barrawi FE, Alkhatib A, Al-Faqawi M, Fares M, Elmashala A, Adawi M, Adawi I, Khreishi R, Khreishi R, Ashour A, Ghaben A, Machain Vega GM, Cardozo JT, Roche MO, Pertersen Servin GR, Segovia Lohse HA, Páez Lopez LI, Cardozo RAM, Espinoza F, Pérez Rojas AD, Sanchez D, Samaniego CS, Guevara Torres S, Calua AC, Razuri C, Ortiz N, Rodriguez X, Carrasco N, Saravia F, Shibao Miyasato H, Valcarcel-Saldaña M, Bermúdez YEA, Carpio J, Ruiz Panez W, Toribio Orbegozo PA, Guzmán Dueñas C, Turpo Espinoza K, Sandoval Barrantes AM, Chungui Bravo JA, Fuentes-Rivera L, Fernández C, Málaga B, Ye J, Velasquez R, Salcedo J, Contreras-Vergara AL, Vergara Mejia AG, Gonzales Montejo MS, Escalante Salas MDC, Alcca Ticona W, Vargas M, Manrique Sila GC, Mas R, del Pilar Paucar A, Román Velásquez AJ, Robledo-Rabanal A, Solis LAZ, Turpo Espinoza K, Hamasaki Hamaguchi JL, Florez Farfan ES, Madrid Barrientos LA, Herrera Matta JJ, Mora JJV, Redota MAP, Roxas MF, Maño MJB, Parreno-Sacdalan MD, Almanon CL, Walędziak M, Roszkowski R, Janik M, Lasek A, Radkowiak D, Rubinkiewicz M, Fernandes C, Costa-Maia J, Melo R, Muntean L, Mironescu AS, Vida LC, Popa M, Mircea H, Vartic M, Diaconescu B, Bratu MR, Negoi I, Beuran M, Ciubotaru C, Uzabumwana N, Duhoranenayo D, Jovine E, Zanini N, Landolfo G, Aljiffry M, Idris F, Alghamdi MSA, Maghrabi A, Altaf A, Alkaaki A, Khoja A, Nawawi A, Turkustani S, Khalifah E, Albiety A, Sahel S, Alshareef R, Najjar M, Alzahrani A, Alghamdi A, Alhazmi W, Al Saied G, Alamoudi M, Riaz MM, Hassanain M, Alhassan B, Altamimi A, Alyahya R, Al Subaie N, Al Bastawis F, Altamimi A, Nouh T, Khan R, Radojkovic M, Jeremic L, Nestorovic M, Law JH, Tan KSK, Tan RCK, Tan JK, Joel LWL, Chan XW, Leong FQH, Chong CS, Koh S, Lee KY, Lee KC, Pluke K, Dedekind B, Nashidengo P, Hampton MI, Joosten J, Sobnach S, Roodt L, Sander A, Pape J, Maistry N, Ndwambi P, Kinandu K, Tun M, Du Toit F, Ellison Q, Burger S, Grobler DC, Khulu LB, Moore R, Jennings V, Leusink A, Kariem N, Gouws J, Chu K, Bougard H, Noor F, Dell A, Van Straten S, Khamajeet A, Tshisola SK, Kabongo K, Kong V, Moodley Y, Anderson F, Madiba T, du Plooy F, Hartford L, Chilton G, Karjiker P, Mabitsela ME, Ndlovu SR, Badicel M, Jaich R, Ruiz-Tovar J, Garcia-Florez L, Otero-Díez JL, Ramos Pérez V, Aguado Suárez N, Minguez García J, Corral Moreno S, Collado MV, Jiménez Carneros V, García Septiem J, Gonzalez M, Picardo A, Esteban E, Ferrero E, Espin-Basany E, Blanco-Colino R, Andriola V, Solar García L, Contreras E, García Bernardo C, Pagnozzi J, Sanz S, Miyar de León A, Dorismé A, Rodicio J, Suarez A, Stuva J, Diaz Vico T, Fernandez-Vega L, Soldevila-Verdeguer C, Sena-Ruiz F, Pujol-Cano N, Diaz-Jover P, Garcia-Perez JM, Segura-Sampedro JJ, Pineño-Flores C, Ambrona-Zafra D, Craus-Miguel A, Jimenez-Morillas P, Mazzella A, Jayathilake AB, Thalgaspitiya SPB, Wijayarathna LS, Wimalge PMSN, Sanni HA, Okenabirhie O, Homeida A, Younis A, Omer OA, Abdulaziz M, Mussad A, Adam A, Björklund I, Ahlqvist S, Thorell A, Wogensen F, Sokratous A, Breistrand M, Thorarinsdottir H, Sigurdadottir J, Nikberg M, Chabok A, Hjertberg M, Elbe P, Saraste D, Rutkowski W, Forlin L, Niska K, Sund M, Oswald D, Peros G, Bluelle R, Reinisch K, Frey D, Palma A, Raptis DA, Zumbühl L, Zuber M, Schmid R, Werder G, Nocito A, Gerosa A, Mahanty S, Widmer LW, Müller J, Gübeli A, Zuk G, Gulcicek OB, Vartanoglu T, Kose E, Karahan SR, Aydin MC, Sahbaz NA, Halicioglu I, Alis H, Sapci I, Adiyaman C, Pektaş AM, Cengiz TB, Tansoker I, Işler V, Cevik M, Mutlu D, Ozben V, Ozmen BB, Bayram S, Yolcu S, Kobal BB, Toto ÖF, Çakaloğlu HC, Karabulut K, Mutlu V, Ozkan BB, Celik S, Semiz A, Bodur S, Gül E, Murutoglu B, Yildirim R, Baki BE, Arslan E, Ulusahin M, Guner A, Tomas K, Walker N, Shrimanker N, Cole S, Breslin R, Srinivasan R, Elshaer M, Hunter K, Al-Bahrani A, Liew I, Mairs NG, Rocke A, Dick L, Qureshi M, Chowdhury D, Wright N, Skerritt C, Kufeji D, Ho A, Dissanayake T, Tennakoon A, Ali W, Lim SJ, Tan C, O'Neill S, Jones C, Knight S, Nassif D, Sharma A, Warren O, White R, Mehdi A, Post N, Kalakouti E, Dashnyam E, Stourton F, Mykoniatis I, Currow C, Wong F, Gupta A, Shatkar V, Luck J, Kadiwar S, Smedley A, Wakefield R, Herrod P, Blackwell J, Lund J, Cohen F, Bandi A, Giuliani S, Bond-Smith G, Pezas T, Farhangmehr N, Urbonas T, Perenyei M, Ireland P, Blencowe N, Bowling K, Bunting D, Longstaff L, Keogh K, Jeon H, Iqbal MR, Khosla S, Jeffery A, Perera J, Ibrahem AA, Alhammali T, Salama Y, Oram S, Kidd T, Cullen F, Owen C, Wilson M, Chiu S, Sarafilovic H, Ploski J, Evans E, Abbas A, Kamya S, Ishak N, Bisset C, Andress C, Chin YR, Patel P, Evans D, Haslegrave A, Boggon A, Laurie K, Connor K, Mann T, Mansuri A, Davies R, Griffiths E, Shahbaz AR, Eng C, Din F, L'Heveder A, Park EHG, Ravishankar R, McIntosh K, Yau JD, Chan L, McGarvie S, Tang L, Lim H, Yap S, Park J, Ng ZH, Mirza S, Ang YL, Walls L, Roy C, Paterson-Brown S, Camilleri-Brennan J, Mclean K, D'Souza MS, Pronin S, Henshall DE, Ter EZ, Fouad D, Minocha A, English W, Morgan C, Townsend D, Maciejec L, Mahdi S, Akpenyi O, Hall E, Caydiid H, Rob Z, Abbott T, Torrance HD, Johnston R, Gani MA, Gravante G, Rajmohan S, Majid K, Dindyal S, Smith C, Palliyil M, Patel S, Nicholson L, Harvey N, Baillie K, Shillito S, Kershaw S, Bamford R, Orton P, Reunis E, Tyler R, Soon WC, Jama GM, Dhillon D, Patel K, Nanthakumaran S, Heard R, Chen KY, Barmayehvar B, Datta U, Kamarajah SK, Karandikar S, Iftekhar Tani S, Monaghan E, Donnelly P, Walker M, Parakh J, Blacker S, Kaul A, Paramasivan A, Farag S, Nessa A, Awadallah S, Lim J, Chean Khun Ng J, Kiran RP, Murray A, Etchill E, Dasari M, Puyana J, Haddad N, Zielinski M, Choudhry A, Caliman C, Beamon M, Duane T, Swaroop M, Myers J, Deal R, Schadde E, Hemmila M, Napolitano L, To K, Makupe A, Musowoya J, van der Naald N, Kumwenda D, Reece-Smith A, Otten K, Verbeek A, Prins M, Baquero Suarez AA, Balmaceda R, Deane C, Dijan E, Elfiky M, Koskenvuo L, Thollot A, Limoges B, Capito C, Alexandre C, Kotobi H, Leroux J, Pinnagoda K, Henric N, Azzis O, Rosello O, Francois P, Etienne S, Buisson P, Hmila S, Clegg-Lamptey JN, Imoro O, Abem OE, Papageorgiou D, Soulou V, Asturias S, Peña L, O'Connor DB, Luc AR, Russo AA, Ruzzenente A, Taddei A, Cona C, Bottini C, Pascale G, Rotunno G, Solaini L, Pascale MM, Notarnicola M, Corbellino M, Sacco M, Ubiali P, Cautiero R, Bocchetti T, Muzio E, Guglielmo V, Morandi E, Mao P, de Luca E, Ali FM, Žilinskas J, Strupas K, Kondrotas P, Baltrunas R, Kutkevicius J, Ignatavicius P, Tan CL, Siaw JY, Yam SY, Wilson L, Aziz MRA, Bondin J, Zorrilla CD, Majbar A, Sale D, Abdullahi L, Osagie O, Faboya O, Fatuga A, Taiwo A, Nwabuoku E, Bliksøen M, Khan ZA, Coronel J, Miranda C, Vasquez I, Helguero-Santin LM, Rickard J, Adedeji A, Alqahtani S, Rath M, Van Niekerk M, Koto MZ, Matos-Puig R, Israelsson L, Schuetz T, Yuksek MA, Mericliler M, Ulusahin M, Wolf B, Fairfield C, Yong GL, Whitehurst K, Redgrave N, Musyoka CK, Olivier J, Lee K, Cox M, Farhan-Alanie MMH, Callan R, Chibuye C, Ali THA, Rekhis S, Rommaneh M, Sam ZH, Pugliesi TB, Pardo G, Blanco R. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis 2018; 18:516-525. [PMID: 29452941 PMCID: PMC5910057 DOI: 10.1016/s1473-3099(18)30101-4] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/06/2017] [Accepted: 12/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. METHODS This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. FINDINGS Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). INTERPRETATION Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. FUNDING DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.
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Weixler B, Rickenbacher A, Raptis DA, Viehl CT, Guller U, Rueff J, Zettl A, Zuber M. Sentinel Lymph Node Mapping with Isosulfan Blue or Indocyanine Green in Colon Cancer Shows Comparable Results and Identifies Patients with Decreased Survival: A Prospective Single-Center Trial. World J Surg 2018; 41:2378-2386. [PMID: 28508233 DOI: 10.1007/s00268-017-4051-2] [Citation(s) in RCA: 18] [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] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) mapping was reported to improve lymph node staging in colon cancer. This study compares isosulfan blue (IB) with indocyanine green (ICG)-based SLN-mapping and assesses the prognostic value of isolated tumor cells (ITC) and micro-metastases in upstaged patients. METHODS A total of 220 stage I-III colon cancer patients were included in this prospective single-center study. In 170 patients, SLN-mapping was performed in vivo with IB and in 50 patients ex vivo with ICG. Three levels of each SLN were stained with H&E. If negative for tumor infiltration, immunostaining for cytokeratin (AE1/3; cytokeratin-19) was performed. RESULTS SLN detection rate for IB and ICG was 100 and 98%, respectively. Accuracy and sensitivity was 88 and 75% for IB, 82 and 64% for ICG, respectively (p = 0.244). Overall, 149 (68%) patients were node negative. In these patients, ITC and micro-metastases were detected in 26% (31/129) with IB and 17% (5/29) with ICG (p = 0.469). Patients with ITC and micro-metastases did show decreased overall survival (hazard ratio = 1.96, p = 0.09) compared to node negative disease. CONCLUSIONS This study demonstrates a high diagnostic accuracy for both the IB and the ICG SLN-mapping. SLN-mapping upstaged a quarter of patients with node negative colon cancer, and the detected ITC and micro-metastases were an independent negative prognostic marker in multivariate analysis.
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Affiliation(s)
- Benjamin Weixler
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland
| | - Andreas Rickenbacher
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland.,Department of Visceral Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Dimitri Aristotle Raptis
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland.,Department of Visceral Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Carsten T Viehl
- Department of Surgery, Hospital Center Biel, Biel/Bienne, Switzerland
| | - Ulrich Guller
- Division of Oncology/Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,University Clinic for Visceral Surgery and Medicine, Inselspital Berne, University of Berne, Berne, Switzerland
| | - Jessica Rueff
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland
| | - Andreas Zettl
- Viollier AG, Histopathology/Cytology, Basel, Switzerland
| | - Markus Zuber
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland.
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Merki-Künzli C, Kerstan-Huber M, Switalla D, Gisi D, Raptis DA, Greco N, Mungo G, Wirz M, Gloor S, Misirlic M, Breitenstein S, Tschuor C. Assessing the Value of Prehabilitation in Patients Undergoing Colorectal Surgery According to the Enhanced Recovery After Surgery (ERAS) Pathway for the Improvement of Postoperative Outcomes: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2017; 6:e199. [PMID: 29079551 PMCID: PMC5681719 DOI: 10.2196/resprot.7972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 05/03/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 02/04/2023] Open
Abstract
Background A key element in the postoperative phase of the standardized Enhanced Recovery After Surgery (ERAS) treatment pathways is mobilization. Currently, there are no recommendations in the ERAS guidelines for preoperative physical activity. Patients undergoing major surgery are prone to functional decline due to the impairment of muscle, cardiorespiratory, and neurological function as a response to surgical stress. It has been shown that preoperative physical training reduces postoperative complications. To date, there are limited studies that investigate preoperative physical training combined with ERAS. Objective The aim of this study is to assess the impact of tailored physical training prior to colorectal surgery conducted according to an ERAS protocol on overall morbidity. This study proposes the initial hypothesis that 3-6 weeks of prehabilitation before elective colorectal surgery may improve postoperative outcome and reduce complication rates, assessed using the Comprehensive Complication Index. The primary objective is to evaluate overall morbidity due to postoperative complications. Additionally, complications are assessed according to the Clavien-Dindo classification, length of stay, readmission rate, mortality rate, and treatment-related costs. Methods The prehabilitation Enhanced Recovery After colorectal Surgery (pERACS) study is a single-center, single-blinded prospective randomized controlled trial. Patients scheduled for colorectal resections are randomly assigned either to the prehabilitation group or the control group. All patients are treated with the ERAS pathway for colorectal resections according to a standardized study schedule. Sample size calculation performed by estimating a clinically relevant 25% reduction of postoperative complications (alpha=.05, power 80%, dropout rate of 10%) resulted in 56 randomized patients per group. Results Following ethical approval of the study protocol, the first patient was included in June 2016. At this time, a total of 40 patients have been included; 27 patients terminated the study by the end of March 2017. Results are expected to be published in 2018. Conclusions The pERACS trial is a single-center, single-blinded prospective randomized controlled trial to assess the impact of tailored physical training prior to colorectal surgery, conducted according to an ERAS protocol, in order to evaluate overall morbidity. Trial Registration Clinicaltrials.gov NCT02746731; https://clinicaltrials.gov/ct2/show/NCT02746731 (Archived by WebCite at http://www.webcitation.org/6tzblGwge)
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Affiliation(s)
| | - Marta Kerstan-Huber
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Denise Switalla
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - David Gisi
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Dimitri Aristotle Raptis
- Division of Visceral Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Nicola Greco
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Giuseppe Mungo
- Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Markus Wirz
- Institute of Physiotherapy, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Severin Gloor
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Merima Misirlic
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Stefan Breitenstein
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Division of Visceral Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Skipworth JRA, Fanshawe AE, Hewitt M, Raptis DA, Efthimiou E, Smellie WJB. Laparoscopic Adjustable Gastric Band Slippage Rates Following Laparoscopic Gastric Band Insertion: a Single Centre Experience. Obes Surg 2017; 26:1511-6. [PMID: 26660915 DOI: 10.1007/s11695-015-1962-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Laparoscopic adjustable gastric bands (LAGB) are placed around the superior aspect of the stomach to aid weight loss and co-morbidity resolution in morbidly obese patients. Slippage of the LAGB from its original position to lower in the fundus of the stomach leads to gastric obstruction, and sometimes ischaemia or perforation, necessitating LAGB repositioning or removal. This study aimed to identify the incidence of LAGB slippage, as well as predisposing factors that may influence its development. METHODS All LAGBs inserted at one centre, via a pars flaccida technique, by four Bariatric specialist consultants, were reviewed utilising a prospectively maintained Bariatric database, computer records and case notes review. RESULTS Seven hundred nineteen LAGBs were inserted and 33 slips treated; however, only 22 slips had their LAGB inserted at our centre (local slip rate 3.1 %). Multivariate analysis demonstrated a significant association between LAGB slip and younger median age at LAGB insertion (41 years slip vs. 45 years non-slip; p = 0.027), higher median total excess weight loss (64 % slip vs. 36 % non-slip; p < 0.001) and higher mean excess weight loss per month (2.41 % slip vs. 1.00 % non-slip; p < 0.001). There was no significant effect by sex, BMI at insertion or band type. CONCLUSIONS Band slips are associated with greater excess weight loss and younger age. Larger studies may be necessary to further elucidate the risk factors contributing to, and mechanisms of, band slippage.
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Affiliation(s)
- J R A Skipworth
- Department of Bariatric Surgery, Chelsea and Westminster Hospital NHS Trust, 369 Fulham Road, London, SW10 9NH, UK.
| | - A E Fanshawe
- Department of Bariatric Surgery, Chelsea and Westminster Hospital NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - M Hewitt
- Department of Bariatric Surgery, Chelsea and Westminster Hospital NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - D A Raptis
- University of Zurich, Zurich, Switzerland.,Canto Hospital Olten, Zurich, Switzerland
| | - E Efthimiou
- Department of Bariatric Surgery, Chelsea and Westminster Hospital NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - W J B Smellie
- Department of Bariatric Surgery, Chelsea and Westminster Hospital NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
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Haueter R, Schütz T, Raptis DA, Clavien PA, Zuber M. Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis. Br J Surg 2017; 104:1141-1159. [PMID: 28569406 DOI: 10.1002/bjs.10574] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 12/29/2016] [Accepted: 03/29/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate improvements in cosmetic results and postoperative morbidity for single-incision laparoscopic cholecystectomy (SILC) in comparison with multiport laparoscopic cholecystectomy (MLC). METHODS A literature search was undertaken for RCTs comparing SILC with MLC in adult patients with benign gallbladder disease. Primary outcomes were body image and cosmesis scores at different time points. Secondary outcomes included intraoperative and postoperative complications, postoperative pain and frequency of port-site hernia. RESULTS Thirty-seven RCTs were included, with a total of 3051 patients. The body image score favoured SILC at all time points (short term: mean difference (MD) -2·09, P < 0·001; mid term: MD -1·33, P < 0·001), as did the cosmesis score (short term: MD 3·20, P < 0·001; mid term: MD 4·03, P < 0·001; long-term: MD 4·87, P = 0·05) and the wound satisfaction score (short term: MD 1·19, P = 0·03; mid term: MD 1·38, P < 0·001; long-term: MD 1·19, P = 0·02). Duration of operation was longer for SILC (MD 13·56 min; P < 0·001) and SILC required more additional ports (odds ratio (OR) 6·78; P < 0·001). Postoperative pain assessed by a visual analogue scale (VAS) was lower for SILC at 12 h after operation (MD in VAS score -0·80; P = 0·007). The incisional hernia rate was higher after SILC (OR 2·50, P = 0·03). All other outcomes were similar for both groups. CONCLUSION SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is four times higher after SILC than after MLC.
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Affiliation(s)
- R Haueter
- Department of Surgery, Cantonal Hospital Olten, Olten, Switzerland
| | - T Schütz
- Department of Surgery, Cantonal Hospital Olten, Olten, Switzerland
| | - D A Raptis
- Department of Surgery, Cantonal Hospital Olten, Olten, Switzerland.,Department of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - P-A Clavien
- Department of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - M Zuber
- Department of Surgery, Cantonal Hospital Olten, Olten, Switzerland
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50
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Eshmuminov D, Tschuor C, Raptis DA, Boss A, Wurnig MC, Sergeant G, Schadde E, Clavien PA. Rapid liver volume increase induced by associating liver partition with portal vein ligation for staged hepatectomy (ALPPS): Is it edema, steatosis, or true proliferation? Surgery 2017; 161:1549-1552. [DOI: 10.1016/j.surg.2017.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/04/2017] [Accepted: 01/11/2017] [Indexed: 01/14/2023]
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