Reversal of fibrosis in patients with nonalcoholic steatohepatosis after gastric bypass surgery.

Background: Roux-en-Y gastric bypass (RYGB) improves the pathophysiology that contributes to obesity-related nonalcoholic steatohepatitis (NASH). Whether obesity-related fibrosis improves is unclear. We hypothesized that RYGB reverses NASH and fibrosis, and indocyanine green (ICG) clearance provides a sensitive measure for detecting asymptomatic fatty liver disease.

Postoperative vision loss after spine surgery: a single-institution case-control comparison.

Background: Postoperative vision loss (POVL) after spine surgery is a rare but devastating outcome. We present the first case-control study from a single institution for POVL with the diagnoses of ischemic optic neuropathy or central vision loss after complex spine surgery.

Methods: POVL cases following spine surgeries between December 1995 and December 2010 at the Cleveland Clinic were identified retrospectively using administrative codes.

Deceased donor hyperglycemia and liver graft dysfunction.

Context: Hyperglycemia is common in deceased donors, and provokes numerous adverse events in hepatocytic mitochondria.

Objective: To determine whether hyperglycemia in deceased donors is associated with graft dysfunction after orthotopic liver transplant.

Methods: Charts on 572 liver transplants performed at the Cleveland Clinic between January 2005 and October 2010 were reviewed.

Prediction of intraoperative transfusion requirements during orthotopic liver transplantation and the influence on postoperative patient survival.

Background: Predicting blood product transfusion requirements during orthotopic liver transplantation (OLT) remains difficult. Our primary aim in this study was to determine which patient variables best predict recipient risk for large blood transfusion requirements during OLT. The secondary aim was to determine whether the amount of blood products transfused during OLT impacted patient survival.

Transfusion of older red blood cells is associated with decreased graft survival after orthotopic liver transplantation.

Investigations have demonstrated conflicting results regarding the influence of the red blood cell (RBC) storage duration on outcomes. We evaluated whether graft failure or mortality after orthotopic liver transplantation (OLT) increased when recipients were transfused with older RBCs. This study included 637 patients who underwent OLT between January 2001 and June 2011.

An evolution in blood management: past, present, and future.

Blood management is a concept that adopts a principle of improving patient outcome by integrating all available techniques to ensure safety, availability, and appropriate allocation of blood products. This constitutes a model of multidisciplinary care where the changes in culture are system directed on the basis of evidence-based medicine. There are about 14% US hospitals where any kind of blood management program exists, although the idea remains the same but the programs vary in their execution, implementation, and ultimately providing the value to patients.

Pre-transplant MELD and sodium MELD scores are poor predictors of graft failure and mortality after liver transplantation.

Background: Incorporating serum sodium concentrations into the model for end-stage liver disease (MELD) score may increase its sensitivity for identifying priority patients for orthotopic liver transplantation (OLT). We, therefore, evaluated and compared the ability of the sodium MELD and MELD scores to predict graft and patient survival after OLT.

Methods: The United Network for Organ Sharing (UNOS) registry includes all US adult OLTs performed between January 2000 and August 2008.

Association between donor-recipient serum sodium differences and orthotopic liver transplant graft function.

Previous studies have shown that donor hypernatremia and possibly recipient hyponatremia negatively impact graft function after orthotopic liver transplant (OLT). The purpose of this retrospective investigation was to determine whether measured differences in serum sodium values between cadaveric donors and OLT recipients (DeltaNa(+)) influence immediate postoperative allograft function and short-term patient outcomes. Two hundred and fifty patients that underwent OLT from January 2001 to December 2005 were included in this study.

Predicting immunosuppressant dosing in the early postoperative period with noninvasive indocyanine green elimination following orthotopic liver transplantation.

Twenty adult patients undergoing orthotopic liver transplantation (OLT) were enrolled in this study, with the noninvasive indocyanine green plasma disappearance rate (ICG-PDR) measured both during and after OLT to assess the relationship between ICG-PDR and the ability of patients to achieve therapeutic postoperative tacrolimus immunosuppressant blood levels. Liver function was determined at both 2 and 18 hours post reperfusion with the ICG-PDR k value (1/min). Postoperative standard serum measures of liver function as well as liver biopsies were also collected and analyzed.

Six sigma methodology can be used to improve adherence for antibiotic prophylaxis in patients undergoing noncardiac surgery.

Background: Six Sigma methodology is a data management process that can be used to achieve a goal of near perfection in process performance. An audit of 615 surgeries over 2 mo revealed only 38% of noncardiac patients admitted on the day of surgery at our institution received perioperative antimicrobial prophylaxis within the target interval of < or =60 min before incision.

Methods: Six Sigma methodology was used to improve our process of timing of antimicrobial prophylaxis administration.

Anesthetics and anesthesia techniques: impacts on perioperative management and postoperative outcomes.

Inhaled and intravenous anesthetic agents have diverse effects on the nervous, cardiovascular, and respiratory systems. Spinal and epidural anesthetics also produce significant physiologic changes. Some evidence points to improved immediate postoperative outcomes (in terms of cardiovascular outcomes, blood loss, and venous thromboembolism) for certain types of surgical procedures with epidural and spinal techniques relative to general anesthesia.

Dynamic left ventricular outflow tract obstruction in an orthotopic liver transplant recipient.

A 53 year-old man with Laennec's and hepatitis C-related cirrhosis was found to have dynamic left ventricular outflow tract obstruction during routine evaluation for orthotopic liver transplantation. The outflow tract obstruction gradient was quantified as being 155 to 189 mmHg maximally during dobutamine stress echocardiography. The patient subsequently underwent successful orthotopic liver transplantation at our institution.

A comparison of postoperative pain control in patients after right lobe donor hepatectomy and major hepatic resection for tumor.

After initiating a living donor liver transplant program at our institution, we observed that donor patients experienced significant postoperative pain despite the use of thoracic patient-controlled epidural analgesia (PCEA) infusion catheters. We retrospectively compared patients who underwent right lobe donor hepatectomy (RLDH, n = 15) with patients who had undergone major hepatic resection for tumor (MHRT, n = 15) to elucidate the cause for this observation. All patients had preoperative thoracic epidural catheters placed, and both groups had similar surgical exposure.

Spontaneous spinal epidural hematoma in a pregnant patient.

Spontaneous spinal epidural hematoma is a rare occurrence during pregnancy with only five cases described in the literature since 1900. Even in the general population, the frequency of spontaneous spinal epidural hematoma is extremely low and the etiology unclear. Several theories exist for the cause of spontaneous spinal epidural hematoma, however, none has gained uniform acceptance.

Quality and resource utilization in managing preoperative evaluation.

The evaluation of patients before surgery is a component of anesthesia practice that must be performed to ensure the safe delivery of anesthesia for every patient. How an anesthesia group performs this evaluation differs from institution to institution as the structure of preoperative clinics in hospitals across the country can be quite variable. However, the major question that anesthesiologists must ask when approaching this area of practice is: "Can a system for preoperative evaluation that uses the expertise of anesthesiologists,surgeons, and internists to deliver high quality, cost conscious, and efficient patient preparation for surgery be developed.

Leukocyte reduction during orthotopic liver transplantation and postoperative outcome: a pilot study.

Study Objective: To investigate the effect of intraoperative leukocyte reduction of administered blood products on the incidence of acute cellular rejection and postoperative patient outcome.

Design: Prospective, nonrandomized, historical control study.

Setting: Academic tertiary medical center.