Predictors of micro-costing components in liver transplantation

OBJECTIVES: Although liver transplantation procedures are common and highly expensive, their cost structure is still poorly understood. This study aimed to develop models of micro-costs among patients undergoing liver transplantation procedures while comparing the role of individual clinical predictors using tree regression models. METHODS: We prospectively collected micro-cost data from patients undergoing liver transplantation in a tertiary academic center. Data collection was conducted using an Intranet registry integrated into the institution’s database for the storing of financial and clinical data for transplantation cases. RESULTS: A total of 278 patients were included and accounted for 300 procedures. When evaluating specific costs for the operating room, intensive care unit and ward, we found that in all of the sectors but the ward, human resources were responsible for the highest costs. High cost supplies were important drivers for the operating room, whereas drugs were among the top four drivers for all sectors. When evaluating the predictors of total cost, a MELD score greater than 30 was the most important predictor of high cost, followed by a Donor Risk Index greater than 1.8. CONCLUSION: By focusing on the highest cost drivers and predictors, hospitals can initiate programs to reduce cost while maintaining high quality care standards

Abdominal and inguinal hernia in cirrhotic patients: what's the best approach?

INTRODUÇÃO: Tradicionalmente os procedimentos abdominais eletivos em pacientes cirróticos têm sido amplamente desencorajados graças à elevada morbi-mortalidade consequente às complicações da cirrose, descritas por diversos autores. Outros serviços, em contrapartida, obtiveram resultados distintos, advogando a favor de cirurgia eletiva. MÉTODOS: Uma revisão de artigos utilizando-se a palavras "abdominal wall hernia" e "cirrhotic patients" foi realizada na base de dados PubMed. Dos resultados obtidos, 28 artigos foram considerados para elaboração desta revisão. RESULTADOS: Pôde-se observar que a incidência de hérnias em parede abdominal é relativamente elevada em pacientes cirróticos, sendo que muitas delas têm evolução desfavorável e requerem tratamento cirúrgico específico. Com o advento do sistema de alocação de órgãos baseados no escore de MELD, muitos centros estão repensando suas condutas em situações como esta, dado que muitos dos pacientes em questão encontram-se em lista de espera para transplante hepático. Dessa forma a cirurgia eletiva tem conquistado maior papel no manejo desta condição com intuito de diminuir morbi-mortalidade nesses pacientes. Além disso, a qualidade de vida mostrou-se um importante fator a ser considerado, estando muito prejudicada nesta condição. CONCLUSÃO: Poucos estudos com grandes amostragens foram conduzidos até o momento e não há consenso sobre qual conduta é a mais indicada levando em consideração taxas de morbi-mortalidade

The role of living donor liver transplantation in treating intrahepatic cholangiocarcinoma

IntroductionIntrahepatic cholangiocarcinoma (iCC) is the liver’s second most common neoplasm. Until now, surgery is the only curative option, but only 35% of the cases are considered resectable at the diagnosis, with a post-resection survival of around 30%. Advancements in surgical techniques and perioperative care related to liver transplantation (LT) have facilitated the expansion of indications for hepatic neoplasms.MethodThis study is a comprehensive review of the global experience in living donor LT (LDLT) for treating iCC and describes our first case of LDLT for an unresectable iCC.ResultsWhile exploring LT for intrahepatic cholangiocarcinoma dates to the 1990s, the initial outcomes were discouraging, marked by poor survival and high recurrence rates. Nevertheless, contemporary perspectives underscore a reinvigorated emphasis on extending the frontiers of LT indications within the context of the “oncologic era.” The insights gleaned from examining explants, wherein incidental iCC was categorized as hepatocellular carcinoma in the preoperative period, have demonstrated comparable survival rates to small hepatocellular carcinoma. These findings substantiate the potential viability of LT as a curative alternative for iCC. Another investigated scenario pertains to “unresectable tumors with favorable biological behavior,” LT presents a theoretical advantage by providing free margins without the concern of a small future liver remnant. The constraint of organ shortage persists, particularly in nations with low donation rates. LDLT emerges as a viable and secure alternative for treating iCC.ConclusionLDLT is an excellent option for augmenting the graft pool, particularly in carefully selected patients

Risk factors for acute kidney injury in the postoperative phase after herniorraphy in patients with cirrhosis

Introdução: A incidência de hérnia abdominal em pacientes cirróticos é elevada, em torno de 20%. Em casos de ascite volumosa, a incidência atinge valores até 40%.Uma das principais e mais graves complicações no pósoperatório (PO) de correção de hérnias de pacientes cirróticos é a insuficiência renal aguda, conhecida como acute kidney injury - insuficiência renal aguda (AKI). Objetivos: O objetivo deste estudo é analisar a função renal de pacientes cirróticos submetidos à cirurgia de correção de hérnias abdominais em nosso serviço. Além disso, comparar os pacientes que apresentam AKI PO com os demais, para determinar os fatores relacionados à sua ocorrência. Métodos: Seguimento de pacientes cirróticos submentidos à cirurgia de hérnia entre 2001 e 2014 no Serviço de Transplante de Fígado. Foram coletados exames laboratoriais para avaliar a função renal no pós-operatório rotineiramente. A AKI foi definida com base no consenso do clube da ascite em 2015. Resultados: Dos 174 pacientes incluídos, ocorreu AKI em 58 pacientes (34,9%). Houve diferença entre grupos para as seguintes variáveis: model for end-stage liver disease - modelo para doença hepática terminal (MELD) inicial, creatinina basal e creatinina, o grupo com AKI apresentou médias superiores ao grupo que não apresentou AKI. No grupo do AKI PO, 74,1% das cirurgias, foram realizadas em caráter de emergência, enquanto que no grupo sem AKI PO, 34,6%. No grupo AKI,90,4% dos indivíduos apresentaram complicações no PO, enquanto no grupo sem AKI, 29,9%. As variáveis Idade, MELD inicial, creatinina basal e creatinina no pós-operatório inicial (POI) foram estatisticamente significantes na análise de sobrevida. Conclusão: Existe uma associação entre AKI PO e cirurgia de emergência e AKI PO e complicações PO. Os fatores relacionados à maior ocorrência de AKI em pacientes cirróticos submetidos à cirurgia de hérnia são o MELD inicial, creatinina basal, creatinina POI. O preparo de pacientes cirróticos com hérnia abdominal antes de procedimentos cirúrgicos deve ocorrer sistematicamente pois apresentam alta incidência de AKI POBackground: The incidence of abdominal hernia in cirrhotic patients is as higher 20% and in cases of major ascites the incidence may increase up to 40%. One of the main and most serious complications in the postoperative period of cirrhotic patients is acute renal failure, known as acute kidney injury (AKI). Objectives: The objective of this study is to analyze the renal function of cirrhotic patients undergoing hernia surgery in our service, and compare the patients who presented AKI postoperative (PO) with the others, to determine the factors related to their occurrence. Methods: Follow-up of cirrhotic patients who underwent hernia surgery between 2001 and 2014. Laboratory tests were routinely collected on the PO period. AKI was defined based on the consensus of the ascite´s club in 2015. Results: Of 174 patients included, the primary outcome of AKI occurred in 58 (34.9%) patients. We observed that there was a significant difference between the groups in the variables: initial MELD, basal creatinine, and creatinine POI, the group with AKI PO had averages higher than the group that did not have AKI PO. In the AKI PO group, we observed that 74.1% of the patients had emergency surgery, whereas in the group without AKI PO, we had 34.6%. In the group with AKI PO, we observed that 90.4% of the individuals had complications in the PO, whereas in the group without AKI PO, we had 29.9%. We observed that the variables Age, Initial MELD, Baseline Creatinine, and Creatinine POI were statistically significant for survival analysis. Conclusions: There is an association between AKI PO and emergency surgery and also between AKI PO and complications after surgery. The factors related to higher occurrence of AKI PO in cirrhotic patients underwent hernia surgery are initial MELD, basal Cr, Cr Poi. We believe that cirrhotic patients with abdominal hernia must be well prepared before surgery because they present high incidence of AKI P

Risk factors for acute kidney injury in the postoperative phase after herniorraphy in patients with cirrhosis

Introdução: A incidência de hérnia abdominal em pacientes cirróticos é elevada, em torno de 20%. Em casos de ascite volumosa, a incidência atinge valores até 40%.Uma das principais e mais graves complicações no pósoperatório (PO) de correção de hérnias de pacientes cirróticos é a insuficiência renal aguda, conhecida como acute kidney injury - insuficiência renal aguda (AKI). Objetivos: O objetivo deste estudo é analisar a função renal de pacientes cirróticos submetidos à cirurgia de correção de hérnias abdominais em nosso serviço. Além disso, comparar os pacientes que apresentam AKI PO com os demais, para determinar os fatores relacionados à sua ocorrência. Métodos: Seguimento de pacientes cirróticos submentidos à cirurgia de hérnia entre 2001 e 2014 no Serviço de Transplante de Fígado. Foram coletados exames laboratoriais para avaliar a função renal no pós-operatório rotineiramente. A AKI foi definida com base no consenso do clube da ascite em 2015. Resultados: Dos 174 pacientes incluídos, ocorreu AKI em 58 pacientes (34,9%). Houve diferença entre grupos para as seguintes variáveis: model for end-stage liver disease - modelo para doença hepática terminal (MELD) inicial, creatinina basal e creatinina, o grupo com AKI apresentou médias superiores ao grupo que não apresentou AKI. No grupo do AKI PO, 74,1% das cirurgias, foram realizadas em caráter de emergência, enquanto que no grupo sem AKI PO, 34,6%. No grupo AKI,90,4% dos indivíduos apresentaram complicações no PO, enquanto no grupo sem AKI, 29,9%. As variáveis Idade, MELD inicial, creatinina basal e creatinina no pós-operatório inicial (POI) foram estatisticamente significantes na análise de sobrevida. Conclusão: Existe uma associação entre AKI PO e cirurgia de emergência e AKI PO e complicações PO. Os fatores relacionados à maior ocorrência de AKI em pacientes cirróticos submetidos à cirurgia de hérnia são o MELD inicial, creatinina basal, creatinina POI. O preparo de pacientes cirróticos com hérnia abdominal antes de procedimentos cirúrgicos deve ocorrer sistematicamente pois apresentam alta incidência de AKI POBackground: The incidence of abdominal hernia in cirrhotic patients is as higher 20% and in cases of major ascites the incidence may increase up to 40%. One of the main and most serious complications in the postoperative period of cirrhotic patients is acute renal failure, known as acute kidney injury (AKI). Objectives: The objective of this study is to analyze the renal function of cirrhotic patients undergoing hernia surgery in our service, and compare the patients who presented AKI postoperative (PO) with the others, to determine the factors related to their occurrence. Methods: Follow-up of cirrhotic patients who underwent hernia surgery between 2001 and 2014. Laboratory tests were routinely collected on the PO period. AKI was defined based on the consensus of the ascite´s club in 2015. Results: Of 174 patients included, the primary outcome of AKI occurred in 58 (34.9%) patients. We observed that there was a significant difference between the groups in the variables: initial MELD, basal creatinine, and creatinine POI, the group with AKI PO had averages higher than the group that did not have AKI PO. In the AKI PO group, we observed that 74.1% of the patients had emergency surgery, whereas in the group without AKI PO, we had 34.6%. In the group with AKI PO, we observed that 90.4% of the individuals had complications in the PO, whereas in the group without AKI PO, we had 29.9%. We observed that the variables Age, Initial MELD, Baseline Creatinine, and Creatinine POI were statistically significant for survival analysis. Conclusions: There is an association between AKI PO and emergency surgery and also between AKI PO and complications after surgery. The factors related to higher occurrence of AKI PO in cirrhotic patients underwent hernia surgery are initial MELD, basal Cr, Cr Poi. We believe that cirrhotic patients with abdominal hernia must be well prepared before surgery because they present high incidence of AKI P

MELD Score Is Not Related to Spontaneous Bacterial Peritonitis

This study investigates the correlation between SBP and repeated paracentesis, and its relation to MELD score, in cirrhotic patients with refractory ascites in an outpatient setting. Through the data base, 148 cirrhotic patients were prospectively included in the study with refractory ascites undergoing relief paracentesis from March 2012 to March 2013. Demographics data, etiology of liver disease, MELD score, and inscription on the waiting list for liver transplantation were analyzed. The ascites removed was analyzed through cellular count and culture for the diagnosis of spontaneous bacterial peritonitis. The cirrhotic patients underwent a total of 854 paracentesis procedures in the ambulatory setting during the study period. Eighty-one patients (54%) were on the waiting list for liver transplantation. Patients on the liver transplant list had higher associated costs due to a higher total number of outpatient paracentesis procedures (394.7 ± 512.3 versus 291.7 ± 384.7) and a higher volume drained per procedure (6.5 ± 8.5 versus 4.8 ± 6.4). There were 28 episodes of SBP (3.3%) diagnosed in 24 patients. In conclusion, the prevalence of asymptomatic SBP in cirrhotic patients with refractory ascites undergoing repeated paracentesis is low. MELD score is not related to spontaneous bacterial peritonitis

Reconstrução arterial no transplante hepático: a melhor reconstrução para variação da artéria hepática direita Artery reconstruction in liver transplantation: the best reconstruction of right hepatic artery variation

INTRODUÇÃO: Variações na anatomia da artéria hepática são comuns, com incidência de 20-50%. No transplante hepático, reconstruções durante a operção de bandeja são frequentemente necessárias para proporcionar anastomoses arteriais adequadas. O uso de "patch" é frequente, visando reduzir a incidência de complicações. Entretanto, quando está presente a variação da artéria hepática direita, ramo da artéria mesentérica superior, a reconstrução ocasionalmente produz torções e problemas de fluxo. MÉTODOS: Descreve-se uma técnica cirúrgica alternativa para reconstrução da variação da artéria hepática direita usando um "patch de Carrel" da artéria mesentérica superior. O "patch" é anastomosado no coto da artéria esplênica permitindo orientação vertical e bom fluxo sanguíneo. RESULTADOS: Entre 120 transplantes hepáticos, quatro casos consecutivos de variação da artéria hepática direita foram reconstruídas utilizando essa técnica. Todos eles apresentaram patência e bom fluxo no pós-operatório. CONCLUSÃO: A técnica proposta mostra-se interessante método alternativo para reconstrução da variação da artéria hepática direita no transplante hepático.<br>INTRODUCTION: Variations on the anatomy of the hepatic artery are common, with incidence of 20-50%. In liver transplantation, back-table reconstruction is often necessary for an easier and prompt arterial anastomosis and so, the use of arterial patches has been related to lower the incidence of complications. However, when a right hepatic artery variation from the superior mesenteric artery is present, the reconstruction occasionally produces twisting and flow problems. METHODS: Is described a surgical alternative for right hepatic artery variation reconstruction using a Carrel-patch from the superior mesenteric artery. The patch is anastomosed with the splenic artery stump to allow vertical orientation and improve blood flow. RESULTS: Among 120 liver transplants, four consecutive cases of right hepatic artery variation were reconstructed using this technique. All of them showed good flow and patency in postoperative period. CONCLUSION: The proposed technique proved to be an interesting alternative for the reconstruction of right hepatic artery variation in liver transplantation