Protocolo ERAS (Enhanced Recovery After Surgery) en el trasplante hepático de bajo y medio riesgo

ANTECEDENTES Y OBJETIVOS: Pocos estudios han aplicado por completo un protocolo de recuperación mejorada (Enhanced Recovery After Surgery, ERAS) en el trasplante hepático. Nuestro objetivo fue evaluar los efectos de un protocolo ERAS integral en nuestra cohorte de pacientes con trasplante hepático de bajo y medio riesgo. MÉTODO: El protocolo ERAS incluyó pasos pre, intra y postoperatorios. Durante los cinco años del estudio se realizaron 181 trasplantes hepáticos en nuestra institución. Se identificaron dos cohortes: los pacientes de bajo riesgo (n= 101) tenían una puntuación según Model for End-stage Liver Disease (MELD) de 20 puntos o menos en el momento del trasplante hepático, recibieron un hígado de un donante en muerte cerebral y tenían un Balance Risk Score (BAR) de 9 puntos o menos; los pacientes de medio riesgo (n=15) tenían características idénticas excepto por una puntuación MELD más alta (21-30 puntos). Además, analizamos por separado los pacientes restantes (n=65) que fueron trasplantados durante el mismo periodo de estudio utilizando el protocolo ERAS. RESULTADOS: La cohorte de bajo riesgo casi no necesitó transfusión de concentrados de hematíes (mediana: 0 unidades) ni de terapia de reemplazo renal (1%), y tuvo una corta estancia tanto en la unidad de cuidados críticos (mediana: 13 horas) como en el hospital (mediana: 4 días); la morbilidad durante el seguimiento a año y la probabilidad de sobrevivir uno (89,30%) y cinco años (76,99%) coincidieron con los datos de referencia bien establecidos. Se obtuvieron resultados similares en la cohorte de riesgo medio. CONCLUSIONES: Este estudio de cohorte observacional, prospectivo unicéntrico muestra que el protocolo ERAS es factible y seguro en el trasplante hepático de bajo y medio riesgo.BACKGROUND & AIMS: Few studies have fully applied an enhanced recovery after surgery (ERAS) protocol to liver transplantation (LT). Our aim was to assess the effects of a comprehensive ERAS protocol in our cohort of low- and medium-risk LT patients. METHODS: The ERAS protocol included pre-, intra-, and post-operative steps. During the five-year study period, 181 LT were performed in our institution. Two cohorts were identified: low risk patients (n = 101) had a laboratory model for end- stage liver disease (MELD) score of 20 points or less at the time of LT, received a liver from a donor after brain death, and had a balance of risk score of 9 points or less; medium-risk patients (n= 15) had identical characteristics except for a higher MELD score (21 to 30 points). In addition, we analyzed the remaining patients (n = 65) who were transplanted over the same study period separately using the ERAS protocol. RESULTS: The low-risk cohort showed a low need for packed red blood cells transfusion (median: 0 units) and renal replacement therapy (1%), as well as a short length of stay both in the intensive care unit (13 hours) and in the hospital (4 days); morbidity during one-year follow-up, and probability of surviving to one year (89.30%) and five years (76.99%) were in line with well-established reference data. Similar findings were observed in the medium-risk cohort. CONCLUSIONS: This single-center prospective observational cohort study provides evidence that ERAS is feasible and safe for low- and medium-risk LT

A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort.Methods An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.Results A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score >= 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%.Conclusion Patients with a Shin score <= 1 should undergo surveillance, while patients with a score = 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines