1. Curr Probl Surg. 2003 May;40(5):266-310. Organ donation and treatment of the multi-organ donor... more 1. Curr Probl Surg. 2003 May;40(5):266-310. Organ donation and treatment of the multi-organ donor. Tuttle-Newhall JE, Collins BH, Kuo PC, Schoeder R. Section of Transplant Surgery, Duke University Medical Center, Durham, North Carolina, USA. ...
In response to the critical organ shortage, transplant professionals have utilized living donors ... more In response to the critical organ shortage, transplant professionals have utilized living donors in an attempt to decrease the mortality rate associated with waiting on the liver transplant list. Although the surgical techniques were first utilized clinically 15 years ago, application of LDLT has been somewhat limited by the steep learning curve associated with developing a program. Clinical success with LDLT in children was realized early in the experience and application of the techniques to the adult population has occurred more recently. Although transplant centers embark on LDLT with enthusiasm, the safety of the donor must always be at the forefront of the process. Potential donors must come to the decision to donate without pressure from members of the family or transplant team. He/she should also be assigned advocates who constantly promote the donor's best interest. Failure to adhere to strict donor evaluation protocols and standardized operative techniques could result...
Guillain-Barre Syndrome (GBS) is believed to be caused by autoimmune mechanisms that are predomin... more Guillain-Barre Syndrome (GBS) is believed to be caused by autoimmune mechanisms that are predominantly T-cell mediated. We report GBS in organ transplant patients and bone marrow transplant patients, both of whom have iatrogenically suppressed T-cell function. We reviewed the Duke University Medical Center database from 1989-1999 for all patients who met the criteria for GBS. There were a total of 212 patients. Of these patients, two had undergone organ transplantation and two had undergone autologous bone marrow transplantation. Our report supports the notion that the humoral immune system is involved in the pathogenesis of GBS. Contrary to previous reports, however, functional recovery can occur without return of T-cell function. This suggests that in organ transplant patients, GBS may be humorally mediated and, even more importantly, responds well to treatment.
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2001
Biliary complications after orthotopic liver transplantation (OLT) lead to considerable morbidity... more Biliary complications after orthotopic liver transplantation (OLT) lead to considerable morbidity and occasional mortality after surgery. Bile duct strictures secondary to localized lymphoproliferative disorder of the porta hepatis is rare, with only 12 cases reported in the English literature. Posttransplant lymphoproliferative disorder develops in up to 9% of liver allograft recipients. We describe 2 adult patients who developed Epstein-Barr virus-associated localized B-cell lymphoma of donor-tissue origin confined to the porta hepatis 3 and 5 months after OLT. Both patients were administered cyclosporine (CyA) and prednisone as primary immunosuppression. One patient was administered basiliximab as induction therapy. Neither patient had CyA trough levels greater than 250 ng/mL. Both patients were treated with a hepatojejunostomy, 75% reduction in immunosuppression therapy, and acyclovir. One patient had complete involution of the tumor, and the second patient had an 80% reduction ...
The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mor... more The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to analyze the frequency and outcome of PE in an entire state's trauma population using a large, population-based, hospital discharge data base. With the inclusion of an entire population, the reported incidence, high risk groups of patients, and specific risk factors regarding PE were assessed. A multivariate, logistic regression model was created from the data to determine predictive power of selected risk factors in patients at risk. The data source was a statewide, hospital discharge data base that includes data on all hospitalized patients for all of the hospitals in North Carolina. Data were available from 1988 to 1993. Using primary discharge diagnosis and nine additional ICD-9 coded diagnoses from the discharge abstract, patients were selecte...
Acute humoral rejection (AHR) has been associated with enhanced graft loss. Our study compared th... more Acute humoral rejection (AHR) has been associated with enhanced graft loss. Our study compared the renal allograft survival of patients with AHR treated with plasmapheresis (PP) and intravenous immunoglobulin (IVIG) with allograft survival in patients with acute cellular rejection (ACR). We retrospectively analyzed all kidney transplants performed at our institution between January 1999 and August 2001 (n=286). Recipients were classified into three groups according to biopsy reports: AHR, ACR, or no rejection. The ACR group was further divided into early and late rejection (<90 and >90 days posttransplant, respectively). After a mean follow-up of 569+/-19 days, the incidence of AHR was 5.6% (n=16). Recipient presensitization, delayed graft function, early rejection, and higher creatinine at diagnosis were characteristic of AHR. Most AHR patients (14/16) were treated with PP and IVIG. One patient received only IVIG, whereas another received only PP. All AHR patients were given ...
Although graft and patient survival data are available for pancreas and kidney transplants, they ... more Although graft and patient survival data are available for pancreas and kidney transplants, they are rarely reported in terms of half-life. Our aim was to determine whether a more relevant measure of outcome is patient and allograft half-life. Using the data from the Organ Procurement and Transplantation Network Registry on kidney and pancreas transplants from January 1988 to December 1996, patient and graft half-life and 95% confidence intervals were calculated and demographic variables compared. No significant differences were found between demographic variables. Kidneys transplanted in diabetics as a simultaneous kidney-pancreas (SPK) fared better than diabetics receiving a kidney alone (9.6 vs. 6.3 years). Pancreatic graft survival in an SPK pair was better than pancreas after kidney transplant or pancreas transplant alone (11.2 vs. 2.5 years). Because kidney and pancreatic grafts have a longer half-life when transplanted with their mate grafts, we should consider the relative benefits of SPKs over pancreas after kidney transplant or pancreas transplant alone to limit the loss of precious resources.
To analyze the practice of surgical intensive care unit (SICU) admission of postoperative urologi... more To analyze the practice of surgical intensive care unit (SICU) admission of postoperative urologic patients and to define objective criteria to predict active treatment requirements and length of stay in the SICU. The records of 90 consecutive patients admitted to the SICU postoperatively in the 12-month period from January 1996 to December 1996 were retrospectively reviewed. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated from patient parameters acquired within the first 12 hours. The correlation of outcome variables to the length of stay and the requirements for active treatment in the SICU were analyzed and used to develop a risk stratification model. This algorithm was subsequently validated on a population of 46 patients who underwent radical cystectomy the following year. Only the preoperative American Society of Anesthesia class, the event of an intraoperative complication, and the APACHE II score were statistically significant (P &lt;0.05) predictors of length of stay and active treatment. The patients were subsequently categorized into high and low-risk groups, which were found to have mean SICU stays of 39.9 +/- 3.92 hours and 20.2 +/- 0.45 hours, respectively (P = 0. 001), and an active SICU-specific treatment rate of 58.0% and 14.3%, respectively (P = 0.001). These results were confirmed in the validation population. Postoperative risk stratification may be helpful in predicting SICU requirements in the immediate postoperative period and in identifying patients at lower or higher risk of an adverse outcome.
We sought to evaluate the role of recipient body mass index (BMI) on postoperative complications ... more We sought to evaluate the role of recipient body mass index (BMI) on postoperative complications in patients receiving pancreas transplants. A single-institution retrospective study of 145 consecutive patients undergoing either simultaneous kidney pancreas (SPK) or pancreas after kidney (PAK) transplantation from January 1997 through December 2003. Variables analyzed included: age, sex, BMI, number of prior transplants, cytomegalovirus status of donor and recipient, postoperative insulin resistance, complications, and overall patient and graft survival. Differences in continuous variables and dichotomous variables were evaluated using two-tailed t test and Fisher exact test, respectively. Univariate and multivariate logistic regression analyses were employed to identify predictors of overall complications following surgery. Obesity was defined by a BMI &gt; or = 30. Of the 145 patients, 33 (23%) had a BMI &gt; or = 30 and 112 (77%) had a BMI &lt; 30. There was no significant difference in age or sex between obese and nonobese patients (P = .98 and P = .56, respectively). The type of transplantation, SPK or PAK, did not affect the complication rate (P = .36). Overall complications (infection, dehiscence, evisceration, ventral hernia, allograft failure, gangrene, necrotizing fasciitis, postoperative bleeding, or death) were significantly higher in the obese group (81% vs 40%, P &lt; .001). Obesity was specifically associated with increased frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, necrotizing fasciitis, and repeat laparotomy. Obese patients also had a threefold higher rate of graft pancreatitis/enteric leak. Multivariate logistic regression analysis identified age &gt; or = 50 and BMI &gt; or = 30 as independent predictors of overall complications following surgery (odds ratio 4.0, P = .014 and OR 6.8, P &lt; .001, respectively). There was no difference identified between groups with regards to allograft failure, posttransplant insulin resistance, and death. Obese patients are at increased risk of overall complications following pancreas transplantation. Specifically, obese patients experience higher frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, and necrotizing fasciitis. This study demonstrates the need for careful postoperative monitoring in the obese patient.
BackgroundThe complement-dependent microcytotoxicity crossmatch (CDCXM) is a standard method for ... more BackgroundThe complement-dependent microcytotoxicity crossmatch (CDCXM) is a standard method for evaluating the presence of preformed antibodies before transplantation. The flow cytometry crossmatch (FCXM) is more sensitive, but there is controversy regarding translation of its increased sensitivity to clinically relevant graft outcomes.
The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient ev... more The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;accountable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; providers of transplant services. Novel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;accountable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 years old diagnosed between 2000 and 2008. In total, 113 TRRs were defined, 51% of which included &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001) and transplantation (0.90; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Residence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve.
In the beginning of the past decade, a series of highly publicized events led the general public ... more In the beginning of the past decade, a series of highly publicized events led the general public to question the ability of the transplant community to effectively police itself. Common to the events was the perception that insufficient regulation of the transplant community allowed both unintentional errors and, rarely, purposeful violations of policy, to affect the safety and justice of organ allocation and transplant practice. The goal of this article is to discuss the resulting regulatory responses to these events and to highlight one transplant center&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s experience with the current external review process. The potential benefits of using process control charts to prospectively monitoring a center&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s outcomes, as well as the benefits of implementing procedures that ensure the quality of publically reported data, are described. Specifically, the critical need for each center to understand the components, limitations, and implications of public outcome reporting and to define processes that promote real time self-evaluation and quality improvement are demonstrated.
We analyzed the practice of mandatory surgical intensive care unit admission after radical cystec... more We analyzed the practice of mandatory surgical intensive care unit admission after radical cystectomy, and defined objective criteria to predict active treatment requirements and surgical intensive care unit stay. We retrospectively reviewed the records of 115 consecutive patients admitted to the surgical intensive care unit after radical cystectomy and urinary diversion during the 36-month study period of January 1996 to December 1998. An Acute Physiology and Chronic Health Evaluation II score was calculated from postoperative patient parameters at admission to the unit. Active treatment mandating admission was defined as postoperative invasive cardiopulmonary monitoring, administration of vasopressors or inotropic medications, monitoring or treatment for life threatening complications, or mechanical ventilation for longer than 12 hours. We analyzed the correlation of outcome variables with the requirements for active treatment and surgical intensive care unit stay, and developed a stratification model of low versus high risk. Low risk was defined as a calculated likelihood of less than 10% for requiring active treatment postoperatively. Mean stay in the surgical intensive care unit plus or minus standard error was 34.4 +/- 3.1 hours. No active treatment was required in 63.5% of patients during the stay. The evaluation score, intraoperative complications and number of intraoperative transfusions were the strongest predictors of required postoperative active treatment. By combining these variables we developed a clinically applicable algorithm to stratify patients into a low and a high risk category. In patients at low and high risk the active treatment rate was 5.9% and 42.8% (p = 0.001), and the mean stay was 24.6 +/- 2.2 and 38.7 +/- 4.5 hours (p = 0.039), respectively. Mandatory surgical intensive care unit admission of all patients after radical cystectomy and urinary diversion does not appear indicated. A subset of patients at low risk for requiring active treatment may be identified who may be safely treated in an intermediate care setting after initial postoperative observation in the recovery room. The results of our retrospective analysis and risk stratification model should be validated in a prospective trial.
1. J Hepatol. 2006 Apr;44(4):659-62. Epub 2006 Feb 9. What impact does a specialized center for t... more 1. J Hepatol. 2006 Apr;44(4):659-62. Epub 2006 Feb 9. What impact does a specialized center for transplantation and heptobiliary disease have on post-graduate resident training of gastroenterologists and surgeons? Tuttle-Newhall JE, Diehl AM. ...
Recent data suggests that the previously demonstrable relationship between hospital volume and ou... more Recent data suggests that the previously demonstrable relationship between hospital volume and outcomes for liver transplant procedures may no longer exist. Furthermore, to our knowledge, no study has been published examining whether individual surgeon volume is associated with outcomes in liver transplantation. The Nationwide Inpatient Sample database was used to obtain early clinical outcome and resource utilization data for liver transplant procedures performed in the USA from 1988 through 2003. The relationship between surgeon and hospital volume and early clinical outcomes was analyzed with and without adjustment for certain confounding variables such as patient age and presence of co-morbid disease. The in-hospital mortality rate, major postoperative complication rate, and length of hospital stay after liver transplantation did not differ significantly based on hospital procedural volume. These outcome variables did, however, exhibit a statistically significant inverse relationship with individual surgeon volume of liver transplant procedures. A significant relationship between procedure volume and outcomes for liver transplantation cannot be demonstrated at the level of transplant center, but does appear to exist at the level of the individual transplant center. Minimal volume requirements for individual liver transplant surgeons may be justified, pending validation of this volume-outcomes relationship using a clinical data source.
1. Curr Probl Surg. 2003 May;40(5):266-310. Organ donation and treatment of the multi-organ donor... more 1. Curr Probl Surg. 2003 May;40(5):266-310. Organ donation and treatment of the multi-organ donor. Tuttle-Newhall JE, Collins BH, Kuo PC, Schoeder R. Section of Transplant Surgery, Duke University Medical Center, Durham, North Carolina, USA. ...
In response to the critical organ shortage, transplant professionals have utilized living donors ... more In response to the critical organ shortage, transplant professionals have utilized living donors in an attempt to decrease the mortality rate associated with waiting on the liver transplant list. Although the surgical techniques were first utilized clinically 15 years ago, application of LDLT has been somewhat limited by the steep learning curve associated with developing a program. Clinical success with LDLT in children was realized early in the experience and application of the techniques to the adult population has occurred more recently. Although transplant centers embark on LDLT with enthusiasm, the safety of the donor must always be at the forefront of the process. Potential donors must come to the decision to donate without pressure from members of the family or transplant team. He/she should also be assigned advocates who constantly promote the donor's best interest. Failure to adhere to strict donor evaluation protocols and standardized operative techniques could result...
Guillain-Barre Syndrome (GBS) is believed to be caused by autoimmune mechanisms that are predomin... more Guillain-Barre Syndrome (GBS) is believed to be caused by autoimmune mechanisms that are predominantly T-cell mediated. We report GBS in organ transplant patients and bone marrow transplant patients, both of whom have iatrogenically suppressed T-cell function. We reviewed the Duke University Medical Center database from 1989-1999 for all patients who met the criteria for GBS. There were a total of 212 patients. Of these patients, two had undergone organ transplantation and two had undergone autologous bone marrow transplantation. Our report supports the notion that the humoral immune system is involved in the pathogenesis of GBS. Contrary to previous reports, however, functional recovery can occur without return of T-cell function. This suggests that in organ transplant patients, GBS may be humorally mediated and, even more importantly, responds well to treatment.
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2001
Biliary complications after orthotopic liver transplantation (OLT) lead to considerable morbidity... more Biliary complications after orthotopic liver transplantation (OLT) lead to considerable morbidity and occasional mortality after surgery. Bile duct strictures secondary to localized lymphoproliferative disorder of the porta hepatis is rare, with only 12 cases reported in the English literature. Posttransplant lymphoproliferative disorder develops in up to 9% of liver allograft recipients. We describe 2 adult patients who developed Epstein-Barr virus-associated localized B-cell lymphoma of donor-tissue origin confined to the porta hepatis 3 and 5 months after OLT. Both patients were administered cyclosporine (CyA) and prednisone as primary immunosuppression. One patient was administered basiliximab as induction therapy. Neither patient had CyA trough levels greater than 250 ng/mL. Both patients were treated with a hepatojejunostomy, 75% reduction in immunosuppression therapy, and acyclovir. One patient had complete involution of the tumor, and the second patient had an 80% reduction ...
The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mor... more The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to analyze the frequency and outcome of PE in an entire state's trauma population using a large, population-based, hospital discharge data base. With the inclusion of an entire population, the reported incidence, high risk groups of patients, and specific risk factors regarding PE were assessed. A multivariate, logistic regression model was created from the data to determine predictive power of selected risk factors in patients at risk. The data source was a statewide, hospital discharge data base that includes data on all hospitalized patients for all of the hospitals in North Carolina. Data were available from 1988 to 1993. Using primary discharge diagnosis and nine additional ICD-9 coded diagnoses from the discharge abstract, patients were selecte...
Acute humoral rejection (AHR) has been associated with enhanced graft loss. Our study compared th... more Acute humoral rejection (AHR) has been associated with enhanced graft loss. Our study compared the renal allograft survival of patients with AHR treated with plasmapheresis (PP) and intravenous immunoglobulin (IVIG) with allograft survival in patients with acute cellular rejection (ACR). We retrospectively analyzed all kidney transplants performed at our institution between January 1999 and August 2001 (n=286). Recipients were classified into three groups according to biopsy reports: AHR, ACR, or no rejection. The ACR group was further divided into early and late rejection (<90 and >90 days posttransplant, respectively). After a mean follow-up of 569+/-19 days, the incidence of AHR was 5.6% (n=16). Recipient presensitization, delayed graft function, early rejection, and higher creatinine at diagnosis were characteristic of AHR. Most AHR patients (14/16) were treated with PP and IVIG. One patient received only IVIG, whereas another received only PP. All AHR patients were given ...
Although graft and patient survival data are available for pancreas and kidney transplants, they ... more Although graft and patient survival data are available for pancreas and kidney transplants, they are rarely reported in terms of half-life. Our aim was to determine whether a more relevant measure of outcome is patient and allograft half-life. Using the data from the Organ Procurement and Transplantation Network Registry on kidney and pancreas transplants from January 1988 to December 1996, patient and graft half-life and 95% confidence intervals were calculated and demographic variables compared. No significant differences were found between demographic variables. Kidneys transplanted in diabetics as a simultaneous kidney-pancreas (SPK) fared better than diabetics receiving a kidney alone (9.6 vs. 6.3 years). Pancreatic graft survival in an SPK pair was better than pancreas after kidney transplant or pancreas transplant alone (11.2 vs. 2.5 years). Because kidney and pancreatic grafts have a longer half-life when transplanted with their mate grafts, we should consider the relative benefits of SPKs over pancreas after kidney transplant or pancreas transplant alone to limit the loss of precious resources.
To analyze the practice of surgical intensive care unit (SICU) admission of postoperative urologi... more To analyze the practice of surgical intensive care unit (SICU) admission of postoperative urologic patients and to define objective criteria to predict active treatment requirements and length of stay in the SICU. The records of 90 consecutive patients admitted to the SICU postoperatively in the 12-month period from January 1996 to December 1996 were retrospectively reviewed. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated from patient parameters acquired within the first 12 hours. The correlation of outcome variables to the length of stay and the requirements for active treatment in the SICU were analyzed and used to develop a risk stratification model. This algorithm was subsequently validated on a population of 46 patients who underwent radical cystectomy the following year. Only the preoperative American Society of Anesthesia class, the event of an intraoperative complication, and the APACHE II score were statistically significant (P &lt;0.05) predictors of length of stay and active treatment. The patients were subsequently categorized into high and low-risk groups, which were found to have mean SICU stays of 39.9 +/- 3.92 hours and 20.2 +/- 0.45 hours, respectively (P = 0. 001), and an active SICU-specific treatment rate of 58.0% and 14.3%, respectively (P = 0.001). These results were confirmed in the validation population. Postoperative risk stratification may be helpful in predicting SICU requirements in the immediate postoperative period and in identifying patients at lower or higher risk of an adverse outcome.
We sought to evaluate the role of recipient body mass index (BMI) on postoperative complications ... more We sought to evaluate the role of recipient body mass index (BMI) on postoperative complications in patients receiving pancreas transplants. A single-institution retrospective study of 145 consecutive patients undergoing either simultaneous kidney pancreas (SPK) or pancreas after kidney (PAK) transplantation from January 1997 through December 2003. Variables analyzed included: age, sex, BMI, number of prior transplants, cytomegalovirus status of donor and recipient, postoperative insulin resistance, complications, and overall patient and graft survival. Differences in continuous variables and dichotomous variables were evaluated using two-tailed t test and Fisher exact test, respectively. Univariate and multivariate logistic regression analyses were employed to identify predictors of overall complications following surgery. Obesity was defined by a BMI &gt; or = 30. Of the 145 patients, 33 (23%) had a BMI &gt; or = 30 and 112 (77%) had a BMI &lt; 30. There was no significant difference in age or sex between obese and nonobese patients (P = .98 and P = .56, respectively). The type of transplantation, SPK or PAK, did not affect the complication rate (P = .36). Overall complications (infection, dehiscence, evisceration, ventral hernia, allograft failure, gangrene, necrotizing fasciitis, postoperative bleeding, or death) were significantly higher in the obese group (81% vs 40%, P &lt; .001). Obesity was specifically associated with increased frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, necrotizing fasciitis, and repeat laparotomy. Obese patients also had a threefold higher rate of graft pancreatitis/enteric leak. Multivariate logistic regression analysis identified age &gt; or = 50 and BMI &gt; or = 30 as independent predictors of overall complications following surgery (odds ratio 4.0, P = .014 and OR 6.8, P &lt; .001, respectively). There was no difference identified between groups with regards to allograft failure, posttransplant insulin resistance, and death. Obese patients are at increased risk of overall complications following pancreas transplantation. Specifically, obese patients experience higher frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, and necrotizing fasciitis. This study demonstrates the need for careful postoperative monitoring in the obese patient.
BackgroundThe complement-dependent microcytotoxicity crossmatch (CDCXM) is a standard method for ... more BackgroundThe complement-dependent microcytotoxicity crossmatch (CDCXM) is a standard method for evaluating the presence of preformed antibodies before transplantation. The flow cytometry crossmatch (FCXM) is more sensitive, but there is controversy regarding translation of its increased sensitivity to clinically relevant graft outcomes.
The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient ev... more The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;accountable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; providers of transplant services. Novel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;accountable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 years old diagnosed between 2000 and 2008. In total, 113 TRRs were defined, 51% of which included &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001) and transplantation (0.90; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Residence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve.
In the beginning of the past decade, a series of highly publicized events led the general public ... more In the beginning of the past decade, a series of highly publicized events led the general public to question the ability of the transplant community to effectively police itself. Common to the events was the perception that insufficient regulation of the transplant community allowed both unintentional errors and, rarely, purposeful violations of policy, to affect the safety and justice of organ allocation and transplant practice. The goal of this article is to discuss the resulting regulatory responses to these events and to highlight one transplant center&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s experience with the current external review process. The potential benefits of using process control charts to prospectively monitoring a center&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s outcomes, as well as the benefits of implementing procedures that ensure the quality of publically reported data, are described. Specifically, the critical need for each center to understand the components, limitations, and implications of public outcome reporting and to define processes that promote real time self-evaluation and quality improvement are demonstrated.
We analyzed the practice of mandatory surgical intensive care unit admission after radical cystec... more We analyzed the practice of mandatory surgical intensive care unit admission after radical cystectomy, and defined objective criteria to predict active treatment requirements and surgical intensive care unit stay. We retrospectively reviewed the records of 115 consecutive patients admitted to the surgical intensive care unit after radical cystectomy and urinary diversion during the 36-month study period of January 1996 to December 1998. An Acute Physiology and Chronic Health Evaluation II score was calculated from postoperative patient parameters at admission to the unit. Active treatment mandating admission was defined as postoperative invasive cardiopulmonary monitoring, administration of vasopressors or inotropic medications, monitoring or treatment for life threatening complications, or mechanical ventilation for longer than 12 hours. We analyzed the correlation of outcome variables with the requirements for active treatment and surgical intensive care unit stay, and developed a stratification model of low versus high risk. Low risk was defined as a calculated likelihood of less than 10% for requiring active treatment postoperatively. Mean stay in the surgical intensive care unit plus or minus standard error was 34.4 +/- 3.1 hours. No active treatment was required in 63.5% of patients during the stay. The evaluation score, intraoperative complications and number of intraoperative transfusions were the strongest predictors of required postoperative active treatment. By combining these variables we developed a clinically applicable algorithm to stratify patients into a low and a high risk category. In patients at low and high risk the active treatment rate was 5.9% and 42.8% (p = 0.001), and the mean stay was 24.6 +/- 2.2 and 38.7 +/- 4.5 hours (p = 0.039), respectively. Mandatory surgical intensive care unit admission of all patients after radical cystectomy and urinary diversion does not appear indicated. A subset of patients at low risk for requiring active treatment may be identified who may be safely treated in an intermediate care setting after initial postoperative observation in the recovery room. The results of our retrospective analysis and risk stratification model should be validated in a prospective trial.
1. J Hepatol. 2006 Apr;44(4):659-62. Epub 2006 Feb 9. What impact does a specialized center for t... more 1. J Hepatol. 2006 Apr;44(4):659-62. Epub 2006 Feb 9. What impact does a specialized center for transplantation and heptobiliary disease have on post-graduate resident training of gastroenterologists and surgeons? Tuttle-Newhall JE, Diehl AM. ...
Recent data suggests that the previously demonstrable relationship between hospital volume and ou... more Recent data suggests that the previously demonstrable relationship between hospital volume and outcomes for liver transplant procedures may no longer exist. Furthermore, to our knowledge, no study has been published examining whether individual surgeon volume is associated with outcomes in liver transplantation. The Nationwide Inpatient Sample database was used to obtain early clinical outcome and resource utilization data for liver transplant procedures performed in the USA from 1988 through 2003. The relationship between surgeon and hospital volume and early clinical outcomes was analyzed with and without adjustment for certain confounding variables such as patient age and presence of co-morbid disease. The in-hospital mortality rate, major postoperative complication rate, and length of hospital stay after liver transplantation did not differ significantly based on hospital procedural volume. These outcome variables did, however, exhibit a statistically significant inverse relationship with individual surgeon volume of liver transplant procedures. A significant relationship between procedure volume and outcomes for liver transplantation cannot be demonstrated at the level of transplant center, but does appear to exist at the level of the individual transplant center. Minimal volume requirements for individual liver transplant surgeons may be justified, pending validation of this volume-outcomes relationship using a clinical data source.
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Papers by Janet Tuttle-newhall