ABSTRACT
INTRODUCTION: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results. PATIENTS AND METHODS: Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. RESULTS: A total of 240 transplants were performed in 236 patients (191â/45â) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. CONCLUSION: Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care.
Subject(s)
Enhanced Recovery After Surgery , Liver Transplantation , Aged , Bayes Theorem , Humans , Length of Stay , Middle Aged , Prospective StudiesABSTRACT
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Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/therapy , Pregnancy Complications/diagnosis , Liver Diseases/diagnosis , Liver Diseases/therapy , Risk Factors , Diagnosis, DifferentialABSTRACT
Endoscopic ligation (EBL) has shown to have greater effectiveness and minor number of adverse side effects than sclerotherapy in the treatment of esophageal varices. The introduction of multiband devices that allow 5-10 bands positioning in a single session, has obtained to simplify the technique execution, avoiding the use of overtube and inherent complications. EBL sessions are carried out every 2 weeks until eradicate the varices, which is obtained in around 90% of the patients after 2-4 sessions. In agreement with the present evidence, non-selective betablockers are the first therapeutic election in primary prophylaxis of hemorrhage by esophageal varices, whereas EBL would have to reserve for patients with betablockers intolerance or contraindications. Combined treatment with betablockers and isosorbide-5-mononitrate, with EBL is probably a good therapeutic option for the secondary prophylaxis of hemorrhage by varices. EBL effectiveness can be increased if it is combined with betablockers. Patients who have contraindications for betablockers treatment or present hemorrhage while receiving prophylaxis with them, must be treated with endoscopic ligation. EBL in combination with vasoactive pharmacological treatment is the election treatment of acute hemorrhage by esophageal varices; nevertheless varices sclerotherapy can be made if the execution of EBL is technically difficult.
