Faculty Bibliography

OBJECTIVE:We sought to determine the ability of the Model for End-Stage Liver Disease (MELD) score to predict 30-day postoperative mortality for patients with cirrhosis undergoing nontransplant surgical procedures. SUMMARY BACKGROUND DATA/BACKGROUND:The Child-Pugh class historically has been used by clinicians to assist in management decisions involving patients with cirrhosis. However, this classification scheme has a number of limitations. Recently, MELD was introduced. It has been shown to be highly predictive of mortality in a variety of clinical scenarios. METHODS:Adult patients with a diagnosis of cirrhosis undergoing nontransplant surgical procedures between January 1, 1996, and January 1, 2002, at a single center were analyzed. The preoperative MELD score was calculated for all patients, and the MELD's performance in predicting 30-day mortality was determined using multivariate regression techniques. RESULTS:A total of 140 surgical procedures were identified and analyzed. The 30-day mortality rate was 16.4%. The mean admission MELD score for the patients who died (23.3, 95% confidence interval 19.6-27.0) was significantly different from those patients surviving beyond 30 days (16.9, 15.6-18.2), P = 0.0003. The c-statistic for MELD score predicting 30-day mortality was 0.72. Further subgroup analysis of 67 intra-abdominal surgeries showed an in-hospital mortality of 23.9%. The mean MELD score for patients dying (24.8, 20.4-29.3) was significantly different from survivors (16.2, 14.2-18.2), P = 0.0001. The c-statistic for this subgroup was 0.80. CONCLUSIONS:The MELD score, as an objective scale of disease severity in patients with cirrhosis, shows promise as being a useful preoperative predictor of surgical mortality risk.

Adult-to-adult living donor liver transplantation (LDLT) is in a state of flux. Technical innovations and demand have outpaced internal and external regulatory efforts. This has led to a wide array of centers performing LDLT for a variety of indications without clear evidence on the risks to the donor or recipient or the system as a whole. The birth from necessity of LDLT in Asia has led to the extrapolation of the technique in America and Europe that has not been sufficiently studied in the appropriate populations. While there is a clear benefit in some patients, the appropriate donors and recipients have not been defined. Regulatory and ethical consideration should be focused on minimizing acceptable risk in donors and recipients and expanding the investigation into the costs and outcomes of this challenging procedure. The recently funded adult-to-adult living donor liver transplantation cohort sponsored by the National Institutes of Health aims to answer some of these questions over the next five years.

BACKGROUND:Traditional endoscopy center scheduling often results in nonurgent inpatient endoscopic procedures being delayed until late in the day and can prolong length of hospital stay and costs. We report the first controlled study designed to evaluate the effect of an early morning fast-track triage endoscopy unit on the cost and length of stay of a general GI inpatient population. METHODS:A case-control methodology matched a cohort of patients undergoing morning triage procedures with historical controls that underwent standard add-on scheduling endoscopy. Outcome indices and patient quality of care measures were compared between cases and controls. RESULTS:Analysis of patients most likely to benefit from rapid endoscopy showed significant advantage comparing fast-track endoscopy patients to controls in time to endoscopy (0.63 vs. 1.00 days, P = 0.01), length of stay (1.22 vs. 1.78 days, P = 0.05), and hospital costs (2,793 dollars vs. 3,586 dollars, P = 0.02). CONCLUSIONS:When routine endoscopy is the rate-limiting step for hospital discharge in the general GI patient, early morning scheduling with a reserved time and space for inpatient endoscopy is a cost-minimizing factor in a busy endoscopy center that may save significant hospital costs while preserving optimal patient outcomes.

Changes in model for end-stage liver disease (MELD) score of > or = 5 points over 30 days (delta-MELD) is an independent predictor for death in patients awaiting liver transplantation. The aim of the current study was to determine if a positive change in MELD score occurring over the 30 days immediately prior to liver transplantation was predictive of posttransplant mortality. MELD scores from the day of transplantation and 30 days prior to transplantation were calculated for 1510 UNOS patients and used to compute a delta-MELD score. Multivariate modeling determined predictors of posttransplant mortality. Patients with a preoperative delta-MELD > or = 5 had higher absolute MELD scores at transplant, shorter mean posttransplant survival and higher mortality. However, multivariate analysis showed that none of the excess mortality was attributable to the high delta-MELD score (p = 0.43 for delta-MELD > or = 5) and the majority of the excess risk was attributable to absolute MELD score (p < 0.001) at the time of transplantation. Mortality of patients with rapidly worsening chronic liver disease who undergo transplantation depends substantially on absolute MELD score at the time of transplantation but not the rate of change immediately preceding transplant. Allocation policymakers should consider that a high delta-MELD in the immediate pretransplant period does not indicate greater posttransplant mortality.

Acute acalculous cholecystitis (AAC) is marked by a very high mortality rate but its relative rarity makes its features obscure to many physicians. This often contributes to a delayed diagnosis. In this study, we review one center's experience, examine the clinical features of the disorder, and describe the progression of pathological events that culminate in AAC. We performed a 10-year retrospective review of cases of AAC reported at our institution between 1988 and 1998. Fifteen cases of AAC were identified from this period, during which 5804 cardiovascular operations were performed. The mortality rate was 46.6%. Multiple organ failure was present in 12 of the 15 cases, and 9 of the patients were over 60 years of age. Prolonged hypotension occurred in 13 patients, and fever in all 15. Nine cases of gangrenous gallbladder occurred. Gram-negative septicemia was present in 12. Visceral arterial hypoperfusion was frequently evident at operation or necropsy. Thirteen patients showed clinical jaundice, a disproportionate elevation of the alkaline phosphatase, or both. Heart failure was found in 9 patients. Open cholecystectomy was most often the definitive intervention. Arterial hypoperfusion of the gut and or sepsis appear central to the pathogenesis of AAC in our series. Gallbladder inflammation and cholestasis result and bacterial invasion of the organ ensues, culminating in AAC, frequently with gangrene. A model of the pathogenesis of AAC is discussed.