Association between intraoperative fluid balance, vasopressors and graft complications in liver transplantation: A cohort study

Introduction Biliary complications following liver transplantation are common. The effect of intraoperative fluid balance and vasopressors on these complications is unknown. Materials and methods We conducted a cohort study between July 2008 and December 2017. Our exposure variables were the total intraoperative fluid balance and the use of vasopressors on ICU admission. Our primary outcome was any biliary complication (anastomotic and non-anastomotic strictures) up to one year after transplantation. Our secondary outcomes were vascular complications, primary graft non-function and survival. Results We included 562 consecutive liver transplantations. 192 (34%) transplants had a biliary complication, 167 (30%) had an anastomotic stricture and 56 had a non-anastomotic stricture (10%). We did not observe any effect of intraoperative fluid balance or vasopressor on biliary complications (HR = 0.97; 95% CI, 0.93 to 1.02). A higher intraoperative fluid balance was associated with an increased risk of primary graft non-function (non-linear) and a lower survival (HR = 1.40, 95% CI, 1.14 to 1.71) in multivariable analyses. Conclusion Intraoperative fluid balance and vasopressors upon ICU admission were not associated with biliary complications after liver transplantation but may be associated with other adverse events. Intraoperative hemodynamic management must be prospectively studied to further assess their impact on liver recipients’ outcomes.

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O6: EARLY ANASTOMOTIC BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION

British Journal of Surgery ◽

10.1093/bjs/znab117.006 ◽

2021 ◽

Vol 108 (Supplement_1) ◽

Author(s):

SJ Tingle ◽

ER Thompson ◽

SS Ali ◽

IK Ibrahim ◽

E Irwin ◽

...

Keyword(s):

Risk Factors ◽

Liver Transplantation ◽

Hospital Stay ◽

Graft Survival ◽

Cox Regression ◽

Risk Groups ◽

Biliary Complications ◽

Anastomotic Strictures ◽

Selection Of Variables ◽

Independent Risk Factors

Abstract Introduction Biliary leaks and anastomotic strictures are common early biliary complications (EBC) following liver transplantation. However, their impact on outcomes remains controversial and poorly described. Method The NHS registry on adult liver transplantation between 2006 and 2017 was retrospectively reviewed (n=8304). Multiple imputations were performed to account for missing data. Adjusted regression models were used to assess predictors of EBC, and their impact on outcomes. 35 potential variables were included, and backwards stepwise selection enabled unbiased selection of variables for inclusion in final models. Result EBC occurred in 9.6% of patients. Adjusted cox regression revealed that EBCs have a significant and independent impact on graft survival (Leak HR=1.325; P=0.021, Stricture HR=1.514; P=0.002, Leak plus stricture HR=1.533; P=0.034) and patient survival (Leak HR=1.218; P=0.131, Stricture HR=1.578; P<0.001, Leak plus stricture HR=1.507; P=0.044). Patients with EBC had longer median hospital stay (23 versus 15 days; P<0.001) and increased chance for readmission within the first year (56% versus 32%; P<0.001). On adjusted logistic regression the following were identified as independent risk factors for development of EBC: donation following circulatory death (OR=1.280; P=0.009), accessory hepatic artery (OR=1.324; P=0.005), vascular anastomosis time in minutes (OR=1.005; P=0.032) and ethnicity ‘other’ (OR=1.838; P=0.011). Conclusion EBCs prolong hospital stay, increase readmission rates and are independent risk factors for diminished graft survival and increased mortality in liver transplantation. We have identified factors that increase the likelihood of EBC occurrence; further research into interventions to prevent EBCs in these at-risk groups is vital to improve liver transplantation outcomes. Take-home message Using a large registry database we have shown that early anastomotic biliary complications are independent risk factors for decreased graft survival and increased mortality after liver transplantation. Research into interventions to prevent biliary complications in high risk groups are essential to improve liver transplant outcomes.

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Intraoperative Cryoprecipitate Transfusion and Its Association with the Incidence of Biliary Complications after Liver Transplantation-A Retrospective Cohort Study

PLoS ONE ◽

10.1371/journal.pone.0060727 ◽

2013 ◽

Vol 8 (5) ◽

pp. e60727 ◽

Cited By ~ 12

Author(s):

Shuang Liu ◽

Junwei Fan ◽

Xiaoliang Wang ◽

Zijun Gong ◽

Shuyun Wang ◽

...

Keyword(s):

Liver Transplantation ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Biliary Complications

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Ischemic Complications after Liver Transplantation

Digestive Disease Interventions ◽

10.1055/s-0038-1667343 ◽

2018 ◽

Vol 02 (03) ◽

pp. 244-248

Author(s):

Martin Montenovo ◽

Christopher Ingraham

Keyword(s):

Liver Transplantation ◽

Patient Survival ◽

Vascular Complications ◽

Biliary Tree ◽

Biliary Complications ◽

Surgical Anastomosis ◽

Biliary Leak ◽

The Past ◽

Ischemic Complications ◽

Transplantation Complications

AbstractDespite major advances in the field of liver transplantation over the past few decades with both increased graft and patient survival, biliary complications still occur in many patients after liver transplantation. Complications can range from a biliary leak or biloma to strictures most commonly involving the surgical anastomosis, or elsewhere in the biliary tree. Etiologies of these complications include surgical technique, rejection, complications secondary to infection, and vascular complications causing ischemia of the bile ducts. Biliary complications, particularly biliary ischemia, can cause significant morbidity to the patient, and may require multiple endoscopic, endovascular, or percutaneous therapies for successful treatment, or even retransplantation in severe cases. This review will provide an overview of common biliary complications with a focus on biliary ischemia.

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The first consecutive 5000 patients with Coronavirus Disease 2019 from Qatar; a nation-wide cohort study

BMC Infectious Diseases ◽

10.1186/s12879-020-05511-8 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Ali S. Omrani ◽

Muna A. Almaslamani ◽

Joanne Daghfal ◽

Rand A. Alattar ◽

Mohamed Elgara ◽

...

Keyword(s):

Risk Factors ◽

Chronic Kidney Disease ◽

Cohort Study ◽

Kidney Disease ◽

Older Age ◽

Icu Admission ◽

Increased Risk ◽

All Cause Mortality ◽

Male Sex

Abstract Background There are limited data on Coronavirus Disease 2019 (COVID-19) outcomes at a national level, and none after 60 days of follow up. The aim of this study was to describe national, 60-day all-cause mortality associated with COVID-19, and to identify risk factors associated with admission to an intensive care unit (ICU). Methods This was a retrospective cohort study including the first consecutive 5000 patients with COVID-19 in Qatar who completed 60 days of follow up by June 17, 2020. The primary outcome was all-cause mortality at 60 days after COVID-19 diagnosis. In addition, we explored risk factors for admission to ICU. Results Included patients were diagnosed with COVID-19 between February 28 and April 17, 2020. The majority (4436, 88.7%) were males and the median age was 35 years [interquartile range (IQR) 28–43]. By 60 days after COVID-19 diagnosis, 14 patients (0.28%) had died, 10 (0.2%) were still in hospital, and two (0.04%) were still in ICU. Fatal COVID-19 cases had a median age of 59.5 years (IQR 55.8–68), and were mostly males (13, 92.9%). All included pregnant women (26, 0.5%), children (131, 2.6%), and healthcare workers (135, 2.7%) were alive and not hospitalized at the end of follow up. A total of 1424 patients (28.5%) required hospitalization, out of which 108 (7.6%) were admitted to ICU. Most frequent co-morbidities in hospitalized adults were diabetes (23.2%), and hypertension (20.7%). Multivariable logistic regression showed that older age [adjusted odds ratio (aOR) 1.041, 95% confidence interval (CI) 1.022–1.061 per year increase; P < 0.001], male sex (aOR 4.375, 95% CI 1.964–9.744; P < 0.001), diabetes (aOR 1.698, 95% CI 1.050–2.746; P 0.031), chronic kidney disease (aOR 3.590, 95% CI 1.596–8.079, P 0.002), and higher BMI (aOR 1.067, 95% CI 1.027–1.108 per unit increase; P 0.001), were all independently associated with increased risk of ICU admission. Conclusions In a relatively younger national cohort with a low co-morbidity burden, COVID-19 was associated with low all-cause mortality. Independent risk factors for ICU admission included older age, male sex, higher BMI, and co-existing diabetes or chronic kidney disease.

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Salvage therapy using self-expandable metal stents for recalcitrant anastomotic strictures after living-donor liver transplantation

Therapeutic Advances in Gastroenterology ◽

10.1177/1756283x16685059 ◽

2017 ◽

Vol 10 (3) ◽

pp. 297-309 ◽

Cited By ~ 11

Author(s):

Sung Ill Jang ◽

Se Yong Sung ◽

Hyunsung Park ◽

Kwang-Hun Lee ◽

Seung-Moon Joo ◽

...

Keyword(s):

Liver Transplantation ◽

Clinical Success ◽

Anastomotic Stricture ◽

Clinical Success Rate ◽

Metal Stents ◽

Success Rates ◽

Donor Liver Transplantation ◽

Percutaneous Procedure ◽

Anastomotic Strictures ◽

The Mean

Background: Recently, there has been an increase in clinical success rates using nonsurgical methods to resolve anastomotic biliary strictures (ABSs) that develop after liver transplantation (LT). However, some strictures are particularly refractory and cannot be completely resolved by an endoscopic or percutaneous procedure. Consequently, the aim of this study was to examine the feasibility and efficacy of using a newly designed fully covered self-expandable metal stent (FCSEMS) to resolve refractory ABS. Methods: A total of 35 patients with an ABS that developed after LT, but could not be resolved by an endoscopic or percutaneous procedure, were included in this study. FCSEMSs were positioned endoscopically and removed after 2–3 months. After stent removal, the patients were followed to assess complications, including re-stenosis. Results: The mean period from LT to stricture was 13.7 months, and the mean duration of the stricture was 31.8 months. The type and mean number of procedures previously attempted were endoscopic retrograde cholangiopancreatography (ERCP) (9.1 ± 5.1) in 19 patients and percutaneous transhepatic biliary drainage (9.2 ± 4.8) in 16 patients. All patients had successful FCSEMS insertions and removals; the mean stent indwelling time was 3.2 months. The mean follow-up period was 18.7 months (range: 6.4–37.8 months). Stricture recurrence was observed in 6 of 29 patients (recurrence rate: 20.7%). The anastomotic stricture resolved with the FCSEMS insertion in 29 of 35 patients (clinical success rate: 82.9%). Conclusions: The newly designed FCSEMS is a potentially feasible and effective treatment for anastomotic strictures that develop after LT but are not amenable to treatment by conventional procedures.

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The Role of Endoscopy in the Treatment of Biliary Complications after Orthotopic Liver Transplantation

Russian Journal of Gastroenterology Hepatology Coloproctology ◽

10.22416/1382-4376-2019-29-1-62-67 ◽

2019 ◽

Vol 29 (1) ◽

pp. 62-67

Author(s):

Alexey V. Kurenkov ◽

Yury S. Teterin ◽

Oleg D. Olisov ◽

Petr A. Yartsev ◽

Murad S. Novruzbekov ◽

...

Keyword(s):

Liver Transplantation ◽

Orthotopic Liver Transplantation ◽

Endoscopic Treatment ◽

Biliary Complications ◽

Long Term Results ◽

Biliary Strictures ◽

Anastomotic Strictures ◽

Invasive Method ◽

Nasobiliary Drainage

Aim:to improve the results of treating patients with anastomotic biliary strictures of the bile ducts after orthotopic liver transplantation.Materials and methods.This study is based on the results of the endoscopic treatment of 36 patients with biliary complications after orthotopic liver transplantation, who were admitted to the N.V. Sklifosovsky Research Institute for Emergency Medicine from December 2001 to December 2017. The endoscopic treatment program included diagnostic ERCP, endoscopic papillosphincterotomy (EPST), bilioduodenal stenting, nasobiliary drainage, balloon dilatation.Results.Against the background of the staged endoscopic treatment, the stable remission of anastomotic biliary strictures (ABS) was achieved in 17 (53.1 %) patients, with 4 of them (12.5 %) showing a successfully resolved insufficiency of biliobiliary anastomosis (BBA). The average duration of endoscopic treatment was 12 ± 1.9 months. The number of ERCPs performed for each patient varied from 1 to 12 and averaged 3. In the majority of patients (75 %) who received one or more courses of endoscopic treatment, a successful correction of anastomotic strictures with no recurrence within 2–5 years was achieved.Conclusion.Staged endoscopic treatment is established to be highly effective in patients with anastomotic biliary strictures and the insufficiency of bilobiliary anastomoses occurred after orthotopic liver transplantation. Such a treatment allows good long-term results to be achieved by a minimally invasive method.

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IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT?

Arquivos de Gastroenterologia ◽

10.1590/s0004-2803.202000000-67 ◽

2020 ◽

Vol 57 (4) ◽

pp. 347-353

Author(s):

Fernanda Prata MARTINS ◽

Silvia Mansur Reimão SELETI ◽

Mônica Lucia CONTINI ◽

Gustavo Andrade DE PAULO ◽

Angelo Paulo FERRARI

Keyword(s):

Liver Transplant ◽

Endoscopic Treatment ◽

Endoscopic Therapy ◽

Anastomotic Stricture ◽

Graft Loss ◽

Biliary Complications ◽

Biliary Leakage ◽

Anastomotic Strictures ◽

Stricture Recurrence ◽

Inflammatory Changes

ABSTRACT BACKGROUND Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. OBJECTIVE On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). METHODS: Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. RESULTS: At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. CONCLUSION: Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.

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The dose - response association between fluid overload and hospital mortality in critically ill patients: a multicenter, prospective, observational cohort study

10.21203/rs.2.20792/v1 ◽

2020 ◽

Author(s):

Meiping Wang ◽

Bo Zhu ◽

Li Jiang ◽

Ying Wen ◽

Bin Du ◽

...

Keyword(s):

Hospital Mortality ◽

Critically Ill ◽

Dose Response ◽

Fluid Balance ◽

Critically Ill Patients ◽

Fluid Overload ◽

Fluid Management ◽

Management Strategies ◽

Icu Admission ◽

Increased Risk

Abstract Background Fluid management is important for ensuring hemodynamic stability in critically ill patients but easily leads to fluid overload. However, the optimal fluid balance plot or range for critically ill patients is unknown. This study aimed to explore the dose-response relationship between fluid overload (FO) and hospital mortality in critically ill patients.Methods Data were derived from the China Critical Care Sepsis Trial (CCCST). Patients with sequential fluid data for the first 3 days of admission to the ICU were included. FO was expressed as the ratio of the cumulative fluid balance (L) and initial body weight (kg) at ICU admission as a percentage. Maximum fluid overload (MFO) was defined as the peak FO value during the first 3 days of ICU admission. We used logistic regression models with restricted cubic splines to assess the relationship between MFO and the risk of hospital mortality.ResultsIn total, 3850 patients were included, 929 (24.1%) of whom died in hospital. For each 1% L/kg increase in the FO, the risk of hospital mortality increased by 4% (HR 1.04, 95% CI 1.03 - 1.05, P < 0.001). FO greater than 10% was associated with a 44% increased HR of hospital mortality compared with FO less than 5% (HR 1.44, 95% CI 1.27 - 1.67). Notably, we also found a non-linear dose-response association between MFO and hospital mortality.Conclusions Both higher and lower fluid balance were associated with an increased risk of hospital mortality. Further studies should explore this relationship and seek for the optimal fluid management strategies for critically ill patients.

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Dose–response association between fluid overload and in-hospital mortality in critically ill patients: a multicentre, prospective, observational cohort study

BMJ Open ◽

10.1136/bmjopen-2020-039875 ◽

2020 ◽

Vol 10 (12) ◽

pp. e039875

Author(s):

Meiping Wang ◽

Bo Zhu ◽

Li Jiang ◽

Ying Wen ◽

Bin Du ◽

...

Keyword(s):

Hospital Mortality ◽

Critically Ill ◽

Dose Response ◽

Fluid Balance ◽

Critically Ill Patients ◽

Fluid Overload ◽

Multivariable Analysis ◽

Main Diagnosis ◽

Icu Admission ◽

Increased Risk

ObjectivesFluid management is important in ensuring haemodynamic stability in critically ill patients, but can easily lead to fluid overload (FO). However, the optimal fluid balance plot or range for critically ill patients is unknown. This study aimed to explore the dose–response relationship between FO and in-hospital mortality in critically ill patients.DesignMulticentre, prospective, observational study.SettingEighteen intensive care units (ICUs) of 16 tertiary hospitals in China.ParticipantsCritically ill patients in the ICU for more than 3 days.Primary outcome measures and analysesFO was defined as the ratio of the cumulative fluid balance (L) and initial body weight (kg) on ICU admission, expressed as a percentage. Maximum FO was defined as the peak value of FO during the first 3 days of ICU admission. Logistic regression models with restricted cubic splines were used to explore the pattern and magnitude of the association between maximum FO and risk of in-hospital mortality. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score on admission, main diagnosis on admission to ICU, comorbidities, time of maximum FO, mechanical ventilation, renal replacement therapy, use of vasopressors and centres were adjusted in multivariable analysis.ResultsA total of 3850 patients were included in the study, 929 (24.1%) of whom died in the hospital. For each 1% L/kg increase in maximum FO, the risk of in-hospital mortality increased by 4% (adjusted HR (aHR) 1.04, 95% CI 1.03 to 1.05, p<0.001). A maximum FO greater than 10% was associated with a 44% increased HR of in-hospital mortality compared with an FO less than 5% (aHR 1.44, 95% CI 1.27 to 1.67). Notably, we found a non-linear dose–response association between maximum FO and in-hospital mortality.ConclusionsBoth higher and negative fluid balance levels were associated with an increased risk of in-hospital mortality in critically ill patients.Trial registration numberChiCTR-ECH-13003934.

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