As the gap between a shortage of organs and the im-mense demand for liver grafts persists, every available donor liver needs to be optimized for utility, urgency and equity. To overcome this challenge, decision modell...As the gap between a shortage of organs and the im-mense demand for liver grafts persists, every available donor liver needs to be optimized for utility, urgency and equity. To overcome this challenge, decision modelling might allow us to gather evidence from previous studies as well as compare the costs and consequences of alternative options. For public health policy and clinical intervention assessment, it is a potentially powerful tool. The most commonly used types of decision analytical models include decision trees, the Markov model, microsimulation, discrete event simulation and the system dynamic model. Analytic models could support decision makers in the field of liver transplantation when facing specifc problems by synthesizing evidence, comprising all relevant options, generalizing results to other contexts, extending the time horizon and exploring the uncertainty. For modeling studies of economic evaluation for transplantation, understanding the current nature of the disease is crucial, as well as the selection of appropriate modelling techniques. The quality and availability of data is another key element for the selection and development of decision analytical models. In addition, good practice guidelines should be complied, which is important for standardization and comparability between economic outputs.展开更多
AIM To identify independent risk factors for biliary complications in a center with three decades of experience in liver transplantation.METHODS A total of 1607 consecutive liver transplantations were analyzed in a re...AIM To identify independent risk factors for biliary complications in a center with three decades of experience in liver transplantation.METHODS A total of 1607 consecutive liver transplantations were analyzed in a retrospective study. Detailed subset analysis was performed in 417 patients, which have been transplanted since the introduction of Model of End-Stage Liver Disease(MELD)-based liver allocation. Risk factors for the onset of anastomotic biliary complications were identified with multivariable binary logisticregression analyses. The identified risk factors in regression analyses were compiled into a prognostic model. The applicability was evaluated with receiver operating characteristic curve analyses. Furthermore, Kaplan-Meier analyses with the log rank test were applied where appropriate. RESULTS Biliary complications were observed in 227 cases(14.1%). Four hundred and seventeen(26%) transplantations were performed after the introduction of MELD-based donor organ allocation. Since then, 21%(n = 89) of the patients suffered from biliary complications, which are further categorized into anastomotic bile leaks [46%(n = 41)], anastomotic strictures [25%(n = 22)], cholangitis [8%(n = 7)] and non-anastomotic strictures [3%(n = 3)]. The remaining 18%(n = 16) were not further classified. After adjustment for all univariably significant variables, the recipient MELD-score at transplantation(P = 0.006; OR = 1.035; 95%CI: 1.010-1.060), the development of hepatic artery thrombosis post-operatively(P = 0.019; OR = 3.543; 95%CI: 1.233-10.178), as well as the donor creatinine prior to explantation(P = 0.010; OR = 1.003; 95%CI: 1.001-1.006) were revealed as independent risk factors for biliary complications. The compilation of these identified risk factors into a prognostic model was shown to have good prognostic abilities in the investigated cohort with an area under the receiver operating curve of 0.702.CONCLUSION The parallel occurrence of high recipient MELD and impaired donor kidney function should be avoided. Risk is especially increased when post-transplant hepatic artery thrombosis occurs.展开更多
Background:Limb loss has a drastic impact on a patient’s life.Severe trauma to the extremities is common in current military conflicts.Among other aspects,"life before limb"damage control surgery hinders im...Background:Limb loss has a drastic impact on a patient’s life.Severe trauma to the extremities is common in current military conflicts.Among other aspects,"life before limb"damage control surgery hinders immediate replantation within the short post-traumatic timeframe,which is limited in part by the ischemic time for successful replantation.Ex vivo limb perfusion is currently being researched in animal models and shows promising results for its application in human limb replantation and allotransplantation.Presentation of the hypothesis:The current lack of replantation possibilities in military operations with high rates of amputation can be addressed with the development of a portable ex vivo limb perfusion device,as there are several opportunities present with the introduction of this technique on the horizon.We hypothesize that ex vivo limb perfusion will enable overcoming the critical ischemic time,provide surgical opportunities such as preparation of the stump and limb,allow for spare-part surgery,enable rigorous antibiotic treatment of the limb,reduce ischemiareperfusion injuries,enable a tissue function assessment before replantation,and enable the development of large limb transplant programs.Testing the hypothesis:Data from in vivo studies in porcine models are limited by the relatively short perfusion time of 24 h.In the military setting,notably longer perfusion times need to be realized.Therefore,future animal studies must focus especially on long-term perfusion,since this represents the military setting,considering the time for stabilization of the patient until evacuation to a tertiary treatment center.Implications of the hypothesis:The development and clinical introduction of ex vivo limb perfusion in the military setting could lead to a drastic reduction in the number of limb amputations among service members.Ex vivo limb perfusion enables replantation surgery in Role 4 facilities and changes the clinical setting from a highly urgent,lifethreatening situation to a highly methodical,well-prepared starting point for optimal treatment of the wounded service member.With its introduction,the principle of"life before limb"will change to"life before limb before elective replantation/allotransplantation after ex vivo limb perfusion".展开更多
Background:Pre-operative risk factors for post-operative ventilation and their influence on survival after pancreaticoduodenectomy for malignancy are unknown.Methods:Totally 391 patients operated in Hannover,Germany w...Background:Pre-operative risk factors for post-operative ventilation and their influence on survival after pancreaticoduodenectomy for malignancy are unknown.Methods:Totally 391 patients operated in Hannover,Germany were investigated with multivariable logistic regression and Cox regression modeling to identify independent risk factors for post-operative ventilation≥6 h,patient survival and 90-day mortality.And 84 patients operated in Birmingham,United Kingdom were analyzed to assess the external relevance of findings.Results:Longer operations,history of thrombosis,intra-operative blood transfusion,lower estimated glomerular filtration rates(eGFR)and higher values of the age at operation divided by the Horovitz Quotient independently increased the risk of post-operative ventilation≥6 h in German patients(n=108;27.6%)(P<0.050).Blood transfusion and lower pre-operative eGFR levels increased the risk of early death in German patients significantly and independently of established prognostic factors.A history of thrombosis and lower eGFR levels were also independent significant risk factors for 90-day mortality in German patients but not in English patients.None of the English patients received post-operative ventilation.Significantly more German patients were>75 years,had a history of thrombosis,received blood transfusions,and had significantly worse lung function parameters.pT4 tumors were detected in 18 German patients(4.6%),but not in the English patients.Conclusions:Identified risk factors for post-operative ventilation are clinically relevant in Germany but not in England and may be used to lower mortality risk.The German and the English cohorts displayed significant differences in the approach to patient selection and early post-operative extubation.展开更多
Background:Due to the clinically unapparent course the entity of left-sided pancreatic adenocarcinoma is often diagnosed at advanced stages,resulting in small numbers of patients qualifying for pancreatectomy.This stu...Background:Due to the clinically unapparent course the entity of left-sided pancreatic adenocarcinoma is often diagnosed at advanced stages,resulting in small numbers of patients qualifying for pancreatectomy.This study strives to develop a prognostic model for survival after left-sided pancreatic resection.Methods:A total of 54 patients were analyzed.Pre-and intra-operative predictive factors for 18-month mortality were identified with multivariable binary logistic regression analysis and compiled into a prognostic model.The applicability was evaluated by assessment of the area under the receiver operating characteristic curve(AUROC).The model was internally validated applying a randomized backwards bootstrapping analysis.Results:The 18-month mortality rate was 74.1%(n=40).Mean survival was 19.1 months.A prognostic model for 18-month mortality after left sided-pancreatectomy showed an AUROC>0.800:18-month mortality risk in%=Exp(Y)/(1+Exp(Y))with y=-0.927+(1.724,if CA 19-9 elevated,otherwise 0)+(1.212×number of intra-operative transfused packed red blood cells)+(2.771,if prior abdominal surgery,otherwise 0)-(3.612,if gastric resection,otherwise 0)This model was internally validated in 40 randomized backwards bootstrapping steps with AUROCs ranging from 0.757 to 0.971.Conclusions:The 18-month mortality risk for patients after left-sided pancreatectomy for adenocarcinoma of the pancreatic body can be assessed with the number of intra-operatively transfused packed red blood cells,elevated CA 19-9 levels,additional gastric resection and prior abdominal surgeries in the patient’s history.展开更多
基金Supported by a grant from the German Federal Ministry of Education and Research,No.01EO1302
文摘As the gap between a shortage of organs and the im-mense demand for liver grafts persists, every available donor liver needs to be optimized for utility, urgency and equity. To overcome this challenge, decision modelling might allow us to gather evidence from previous studies as well as compare the costs and consequences of alternative options. For public health policy and clinical intervention assessment, it is a potentially powerful tool. The most commonly used types of decision analytical models include decision trees, the Markov model, microsimulation, discrete event simulation and the system dynamic model. Analytic models could support decision makers in the field of liver transplantation when facing specifc problems by synthesizing evidence, comprising all relevant options, generalizing results to other contexts, extending the time horizon and exploring the uncertainty. For modeling studies of economic evaluation for transplantation, understanding the current nature of the disease is crucial, as well as the selection of appropriate modelling techniques. The quality and availability of data is another key element for the selection and development of decision analytical models. In addition, good practice guidelines should be complied, which is important for standardization and comparability between economic outputs.
文摘AIM To identify independent risk factors for biliary complications in a center with three decades of experience in liver transplantation.METHODS A total of 1607 consecutive liver transplantations were analyzed in a retrospective study. Detailed subset analysis was performed in 417 patients, which have been transplanted since the introduction of Model of End-Stage Liver Disease(MELD)-based liver allocation. Risk factors for the onset of anastomotic biliary complications were identified with multivariable binary logisticregression analyses. The identified risk factors in regression analyses were compiled into a prognostic model. The applicability was evaluated with receiver operating characteristic curve analyses. Furthermore, Kaplan-Meier analyses with the log rank test were applied where appropriate. RESULTS Biliary complications were observed in 227 cases(14.1%). Four hundred and seventeen(26%) transplantations were performed after the introduction of MELD-based donor organ allocation. Since then, 21%(n = 89) of the patients suffered from biliary complications, which are further categorized into anastomotic bile leaks [46%(n = 41)], anastomotic strictures [25%(n = 22)], cholangitis [8%(n = 7)] and non-anastomotic strictures [3%(n = 3)]. The remaining 18%(n = 16) were not further classified. After adjustment for all univariably significant variables, the recipient MELD-score at transplantation(P = 0.006; OR = 1.035; 95%CI: 1.010-1.060), the development of hepatic artery thrombosis post-operatively(P = 0.019; OR = 3.543; 95%CI: 1.233-10.178), as well as the donor creatinine prior to explantation(P = 0.010; OR = 1.003; 95%CI: 1.001-1.006) were revealed as independent risk factors for biliary complications. The compilation of these identified risk factors into a prognostic model was shown to have good prognostic abilities in the investigated cohort with an area under the receiver operating curve of 0.702.CONCLUSION The parallel occurrence of high recipient MELD and impaired donor kidney function should be avoided. Risk is especially increased when post-transplant hepatic artery thrombosis occurs.
文摘Background:Limb loss has a drastic impact on a patient’s life.Severe trauma to the extremities is common in current military conflicts.Among other aspects,"life before limb"damage control surgery hinders immediate replantation within the short post-traumatic timeframe,which is limited in part by the ischemic time for successful replantation.Ex vivo limb perfusion is currently being researched in animal models and shows promising results for its application in human limb replantation and allotransplantation.Presentation of the hypothesis:The current lack of replantation possibilities in military operations with high rates of amputation can be addressed with the development of a portable ex vivo limb perfusion device,as there are several opportunities present with the introduction of this technique on the horizon.We hypothesize that ex vivo limb perfusion will enable overcoming the critical ischemic time,provide surgical opportunities such as preparation of the stump and limb,allow for spare-part surgery,enable rigorous antibiotic treatment of the limb,reduce ischemiareperfusion injuries,enable a tissue function assessment before replantation,and enable the development of large limb transplant programs.Testing the hypothesis:Data from in vivo studies in porcine models are limited by the relatively short perfusion time of 24 h.In the military setting,notably longer perfusion times need to be realized.Therefore,future animal studies must focus especially on long-term perfusion,since this represents the military setting,considering the time for stabilization of the patient until evacuation to a tertiary treatment center.Implications of the hypothesis:The development and clinical introduction of ex vivo limb perfusion in the military setting could lead to a drastic reduction in the number of limb amputations among service members.Ex vivo limb perfusion enables replantation surgery in Role 4 facilities and changes the clinical setting from a highly urgent,lifethreatening situation to a highly methodical,well-prepared starting point for optimal treatment of the wounded service member.With its introduction,the principle of"life before limb"will change to"life before limb before elective replantation/allotransplantation after ex vivo limb perfusion".
文摘Background:Pre-operative risk factors for post-operative ventilation and their influence on survival after pancreaticoduodenectomy for malignancy are unknown.Methods:Totally 391 patients operated in Hannover,Germany were investigated with multivariable logistic regression and Cox regression modeling to identify independent risk factors for post-operative ventilation≥6 h,patient survival and 90-day mortality.And 84 patients operated in Birmingham,United Kingdom were analyzed to assess the external relevance of findings.Results:Longer operations,history of thrombosis,intra-operative blood transfusion,lower estimated glomerular filtration rates(eGFR)and higher values of the age at operation divided by the Horovitz Quotient independently increased the risk of post-operative ventilation≥6 h in German patients(n=108;27.6%)(P<0.050).Blood transfusion and lower pre-operative eGFR levels increased the risk of early death in German patients significantly and independently of established prognostic factors.A history of thrombosis and lower eGFR levels were also independent significant risk factors for 90-day mortality in German patients but not in English patients.None of the English patients received post-operative ventilation.Significantly more German patients were>75 years,had a history of thrombosis,received blood transfusions,and had significantly worse lung function parameters.pT4 tumors were detected in 18 German patients(4.6%),but not in the English patients.Conclusions:Identified risk factors for post-operative ventilation are clinically relevant in Germany but not in England and may be used to lower mortality risk.The German and the English cohorts displayed significant differences in the approach to patient selection and early post-operative extubation.
文摘Background:Due to the clinically unapparent course the entity of left-sided pancreatic adenocarcinoma is often diagnosed at advanced stages,resulting in small numbers of patients qualifying for pancreatectomy.This study strives to develop a prognostic model for survival after left-sided pancreatic resection.Methods:A total of 54 patients were analyzed.Pre-and intra-operative predictive factors for 18-month mortality were identified with multivariable binary logistic regression analysis and compiled into a prognostic model.The applicability was evaluated by assessment of the area under the receiver operating characteristic curve(AUROC).The model was internally validated applying a randomized backwards bootstrapping analysis.Results:The 18-month mortality rate was 74.1%(n=40).Mean survival was 19.1 months.A prognostic model for 18-month mortality after left sided-pancreatectomy showed an AUROC>0.800:18-month mortality risk in%=Exp(Y)/(1+Exp(Y))with y=-0.927+(1.724,if CA 19-9 elevated,otherwise 0)+(1.212×number of intra-operative transfused packed red blood cells)+(2.771,if prior abdominal surgery,otherwise 0)-(3.612,if gastric resection,otherwise 0)This model was internally validated in 40 randomized backwards bootstrapping steps with AUROCs ranging from 0.757 to 0.971.Conclusions:The 18-month mortality risk for patients after left-sided pancreatectomy for adenocarcinoma of the pancreatic body can be assessed with the number of intra-operatively transfused packed red blood cells,elevated CA 19-9 levels,additional gastric resection and prior abdominal surgeries in the patient’s history.
