Faculty Bibliography

OBJECTIVES/OBJECTIVE:Obesity has been associated with worse postoperative outcomes. No data are available regarding short-term results after liver resection (LR). The aim of this study was to analyse outcomes in obese patients (body mass index [BMI] > 30 kg/m(2) ) undergoing LR. METHODS:85 consecutive obese patients undergoing LR between 1998 and 2008 were matched on a ratio of 1:2 with 170 non-obese patients. Matching criteria were diagnosis, ASA score, METAVIR fibrosis score, extent of LR, and Child-Pugh score in patients with cirrhosis. RESULTS:Operative time, blood loss and blood transfusions were similar in the two groups. Mortality was 2.4% in both groups. Morbidity was significantly higher in the obese group (32.9% vs. 21.2%; P= 0.041). However, only grade II morbidity was increased in obese patients (14.1% vs. 1.8%; P < 0.001) and this was mainly related to abdominal wall complications (8.2% vs. 2.4%; P= 0.046). No differences were encountered in terms of grade III or IV morbidity. The same results were observed in major LR and cirrhotic patients. When patients were stratified by BMI (<20, 20-25, 25-30 and >30 kg/m(2) ), progressive increases in overall and infectious morbidity were observed (5.6%, 22.4%, 23.7%, 32.9%, and 5.6%, 11.8%, 14.5%, 18.8%, respectively). Rates of grade III and IV morbidity did not change. DISCUSSION/CONCLUSIONS:Obese patients have increased postoperative morbidity after LR in comparison with non-obese patients, but this is mainly related to minor abdominal wall complications. Severe morbidity rates and mortality are similar to those in non-obese patients, even in cirrhosis or after major LR.

Sickle cell disease (SCD) frequently affects the liver; if acute liver failure (ALF) develops, the only potentially effective therapeutic option is liver transplantation (LT). Only 12 patients for whom LT was performed for SCD-related ALF have been described so far. We report a retrospective series of 6 adult patients with SCD (3 men and 3 women, median age = 40.1 years) who underwent emergency LT. The indication for LT was ALF complicating cirrhosis in 5 patients (hepatitis C/iron overload-induced cirrhosis in 3 and iron overload-induced cirrhosis in 2); one patient had autoimmune hepatitis. The median follow-up was 52.7 months (0.5-123 months). The 1-, 3-, 5-, and 10-year survival rates were 83.3%, 66.7%, 44.4%, and 44.4%, respectively. One patient died of hepatocellular failure precipitated by hyperacute allograft rejection on post-LT day 10. Soon after LT, 2 patients developed seizures; in 1 case, the seizures were a complication of early calcineurin inhibitor-induced leukoencephalopathy. Four long-term survivors benefited from specific management of SCD; specifically, the hemoglobin S fraction was maintained below 30% and the total hemoglobin level was maintained between 8 and 10 g/dL. Two patients had mild vaso-occlusive crises. Three patients experienced a recurrence of hepatitis C virus (HCV) infection; 2 of these patients experienced reversible neurological complications while they were receiving antiviral treatment. Carefully selected patients with SCD may benefit from emergency LT. However, such patients seem to be particularly susceptible to neurological complications after LT. In contrast, severe SCD-related crises do not seem to recur if specific management is provided. Outcomes may be improved if the neurological complications can be minimized; for example, the administration of a calcineurin inhibitor can be delayed, and the management of HCV infection recurrence can be improved.

BACKGROUND:There has been little focus lately on operative techniques for full graft liver transplantation, and the standard technique is unclear. METHODS:An internet survey addressing the key technical issues was e-mailed to programme directors. RESULTS:Responses were obtained from 93 out of 128 (73%) directors contacted. Programmes performed a median of 60 (8-240) transplants per year. Maximum mean cold time of 13 ± 3 h and maximum median steatosis of 40% (15-90%) were tolerated. The inferior vena cava was preserved by 48% of centres all the time and 43% selectively. European centres used temporary portacaval shunting (42%) four times more often than USA programmes. Venous bypass was always used when not preserving the inferior vena cava by less than 25%, and used selectively by approximately 40% of centres. Portal vein anastomosis with room for expansion (88%), graft hepatic artery to native gastroduodenal/common hepatic artery bifurcation (57%) and bile duct-to-duct (47%) were the favoured techniques. DISCUSSION/CONCLUSIONS:A standard international operative technique for deceased donor liver transplantation does not exist, although there is a trend towards inferior vena cava preservation. Donor selection criteria were more homogenous across programmes. As suggested by the high response rate, there likely exists interest to investigate technical variations on an international scale.

AIMS/OBJECTIVE:The standard of care for diffuse malignant peritoneal mesothelioma involves operative cytoreduction and intraperitoneal chemotherapy. Most centers favor aggressive operative cytoreduction, accepting high morbidity and mortality. In our trials, patients underwent less extensive cytoreduction followed by prolonged intraperitoneal chemotherapy. Patients underwent a second cytoreduction with heated intraperitoneal chemotherapy. We hypothesized this would result in lower operative morbidity and mortality with similar survival. METHODS:Hospital records, discharge summaries, microbiology, radiography, and office records were retrospectively reviewed to supplement a prospective database. 30-day morbidity and mortality were categorized, and classified according to the Clavien methodology. RESULTS:47 first and 39 second operations were performed with 13% and 26% morbidity, respectively. Mortality was 2%. Infections comprised 59% of the morbidity. Inclusive of both operations, formal peritonectomy was performed in 16% of patients, resection of isolated lesions in less than half, and only 19% had a visceral organs other than the spleen resected. At the completion of the protocol, only 3% of patients had visible intraperitoneal disease. The mean total length of stay for both operations combined was 16 ± 23 days. Overall median survival was 54.9 months, and median survival for the epithelioid subtype was 70.2 months. CONCLUSIONS:A two-stage cytoreduction with intraperitoneal chemotherapy offers median survival comparable to one-stage protocols, with relatively low morbidity, mortality, visceral resections and length of stay despite two operations. This series supports that our protocol is a feasible and safe approach.

OBJECTIVES/OBJECTIVE:This study investigated retrospective validation of a prospective surveillance system for unexplained illness and death due to possibly infectious causes. METHODS:A computerized search of hospital discharge data identified patients with potential unexplained illness and death due to possibly infectious causes. Medical records for such patients were reviewed for satisfaction of study criteria. Cases identified retrospectively were combined with prospectively identified cases to form a reference population against which sensitivity could be measured. RESULTS:Retrospective validation was 41% sensitive, whereas prospective surveillance was 73% sensitive. The annual incidence of unexplained illness and death due to possibly infectious causes during 1995 and 1996 in the study county was conservatively estimated to range from 2.7 to 6.2 per 100,000 residents aged 1 to 49 years. CONCLUSIONS:Active prospective surveillance for unexplained illness and death due to possibly infectious causes is more sensitive than retrospective surveillance conducted through a published list of indicator codes. However, retrospective surveillance can be a feasible and much less labor-intensive alternative to active prospective surveillance when the latter is not possible or desired.