Surgery News - May 2008 - (Page 10)

10 TRANSPLANT SURGERY NEWS • M AY 2 0 0 8 Less Invasive Surgery Lung • from page 1 surgeon and head of cardiopulmonary transplantation. Dr. Toyoda reviewed his experience performing singleor double-lung transplantation at the university since the start of 2006. The conventional surgical approach, used in 48 patients, usually consisted of a posterolateral thoracotomy for single-lung transplantation, or a clamshell approach for double-lung transplantation. Since the new approach was first used last year, it has been performed on 68 patients, including 60 of 63 consecutive patients treated through April 2008. This series included 23 patients (34%) aged 65 or older, of whom 10 patients were aged 70 or older. The oldest patient he has treated with the anteroaxillary approach was 81. When the anteroaxillary approach is used, the patient is in a supine position with arms fixed in front of his or her face. An 8- to 12-cm incision is made far from the sternum, parallel to the intercostal spaces. Although the opening this produces is small, it provides excellent exposure of the hilum, he said. In addition, the hilum is exposed without the need to push the heart, which makes this approach less invasive and less prone to produce hemodynamic instability than is an anterolateral or median sternotomy approach. The anteroaxillary incision shows bronchial and pulmonary arterial anastomoses for transplantation. The anteroaxillary incision on the patient’s right side was used as part of a double-lung transplantation. Use of cardiopulmonary bypass, as well as cardiopulmonary bypass time, was similar in the two surgical groups, and the outcomes were also very similar. The survival rate to 180 days following surgery was 91% in the patients treated by the anteroaxillary route and 92% in patients having conventional surgery. The anteroaxillary approach led to a significant increase in the rate of patients becoming extubated within 48 hours of surgery (68% vs. 48% of those having conventional surgery), and a significant drop in the rate of mechanical ventilation more than 5 days (15% vs. 35%). The average hospital length of stay was shorter with the anteroaxillary approach, 31 days, compared with 37 days with standard surgery, but this difference was not significant. The only contraindications to use of the anteroaxillary approach are in patients who require multivessel coronary artery bypass surgery, and patients who need aortic repair in the region from the aortic root to the arch, Dr. Toyoda said. MELD Scores Gauge Wide Range of Preoperative Risks BY MITCHEL L. ZOLER Else vier Global Medical Ne ws B O S T O N — A well-established risk-scoring system is turning out to have helpful new uses for gauging the preoperative risk associated with a variety of procedures. The Model for End-Stage Liver Disease (MELD) score was first devised to assess progression in patients with cirrhotic liver disease. But the MELD score can also be used to integrate noninvasively collected data on a patient’s hepatic, renal, and coagulopathy states, making it well suited to quickly assess a patient’s risk for multisystem organ dysfunction and other adverse surgical outcomes. When applied retrospectively in 211 pa- tients receiving a left ventricular assist device (LVAD) at one center, a modified MELD score predicted the risk for death, renal failure, and right ventricular failure following surgery, as well as patients’ perioperative and postoperative need for blood products and their hospital length of stay, Dr. Jennifer C. Matthews reported at the annual meeting of the International Society for Heart and Lung Transplantation. In other recent studies, the MELD score has been used successfully to predict the risk for adverse outcomes in patients undergoing abdominal surgery and certain cardiac procedures such as coronary bypass and valve repair or replacement, said Dr. Matthews, a cardiologist at the University of Michigan, Ann Arbor. “I stole the score and applied it to a dif- ferent population and different organ systems,” she said. MELD scores are determined by plugging patients’ serum creatinine and biliru- EACH 1-POINT RISE IN MELD SCORES BOOSTED THE RISK OF OPERATIVE DEATH BY 20% AND WAS LINKED WITH ABOUT A HALFDAY LONGER HOSPITAL STAY. bin levels and their international normalized ratios (INRs) into a formula that’s available on the Internet. In her study, Dr. Matthews used values obtained within 24 STUDENT MANUAL, 7TH EDITION The ATLS® Program was developed to teach doctors one safe, reliable method for assessing and initially managing the trauma patient. The course teaches an organized approach for evaluation and management of seriously injured patients and offers a foundation of common knowledge for all members of the trauma team. The emphasis is on the critical “ﬁrst hour” of care, focusing on initial assessment, lifesaving intervention, reevaluation, stabilization, and, when needed, transfer to a trauma center. This publication, in its 7th edition, was written for use in ATLS Student Courses and is updated approximately every four years. Price: $80 each ATLS FOR DOCTORS NOW AVAILABLE : To obtain an ATLS for Doctors Student Manual, visit the American College of Surgeons online publication catalog at: https://web2.facs.org/timssnet464/acspub/frontpage.cfm?product_class=trauma hours before LVAD placement surgery. She used a version of the MELD score formula that has been modified by the United Network for Organ Sharing. Her study used data collected on all 211 patients who received a LVAD at the University of Michigan during October 1996–February 2007. Their average age was 50, their average serum values were a creatinine of 1.5 mg/dL and a bilirubin of 1.8 mg/dL, and their average INR was 1.2. Their average MELD score was 13.7. Perioperative deaths occurred in 29 patients. A multivariate analysis showed that each 1-point rise in patients’ MELD scores boosted their risk of operative death by 20%. A MELD score of 17 or greater was seen in the sickest quartile of patients. Patients in this subgroup had a threefold increased risk of death, and about a fivefold increased risk for both renal failure and right ventricular failure, compared with patients whose MELD scores were less than 17. Each 1-point rise in MELD score was linked with about a half-day longer ICU stay. Higher MELD scores were also linked with a greater need for blood products (including use of red cells, platelets, plasma, or cryoprecipitate) during or within 24 hours following surgery. In addition to emerging as an effective prognostic tool, the MELD score can guide physicians to taking preoperative measures that might improve a patient’s score, such as optimizing right ventricular filling pressure, correcting coagulopathy by improved nutrition or vitamin K supplementation, and using mechanical circulatory support early on. Dr. Matthews cautioned that it’s premature to use MELD scoring to assess patients scheduled to receive a LVAD, because she has not yet shown that improving patients’ scores preoperatively will yield better outcomes. She has a project underway to further validate the score’s prognostic ability in another set of LVAD recipients, she said in an interview. PHOTOS COURTESY DR. YOSHIYA TOYODA https://web2.facs.org/timssnet464/acspub/frontpage.cfm?product_class=trauma

Table of Contents Feed for the Digital Edition of Surgery News - May 2008

Surgery News - May 2008 Contents New Lung Approach Speeds Extubation Innovative GI Procedures May Improve Diabetes Quality Programs Differ on Risk Data Crystal Ball Medical Modeling Ventricular Valve Taking Stock

Surgery News - May 2008

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