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Biomedical subjects

Jonathan R Hiatt

Publications and source records attributed to Jonathan R Hiatt.

At least 19 recordsLinked to original sources
PubMed2007

Postresection hepatic failure: successful treatment with liver transplantation.

Postoperative liver failure (PLF) is a rare but often fatal complication of major hepatic resection. Use of orthotopic liver transplantation (OLT) for PLF remains undefined. We conducted a retrospective review of 435 patients who underwent hepatic resection between 1990 and 2004; 9 of them (2.0%) developed PLF. Indications for resection included primary hepatic malignancies (8), colonic metastases (2), and echinococcic cyst (1); all resections were multisegmental, 6 were extended, and 2 were lobectomies. A total of 7 patients underwent OLT at a mean of 25 days after resection. Patients developing PLF had significantly lower preoperative platelet counts and significant elevations of total bilirubin, direct bilirubin, prothrombin time, and international normalized ratio (INR) by postoperative day 2. Pathological cirrhosis and extended right lobectomy were associated with significantly increased risk of PLF. Following OLT, there were no in-hospital deaths, but 1 patient required retransplantation for primary nonfunction. Mean survival with and without OLT was 42.2 and 1.4 months, respectively (P = 0.03). Following OLT, 1- and 5-yr patient survivals were 88% and 40%, respectively; 1- and 5-yr graft survivals were 75% and 34%, respectively. In conclusion, patients with low platelets, biopsy-proven cirrhosis, or those undergoing extended resection are at increased risk for PLF. OLT for PLF has significant morbidity but allows salvage of an otherwise fatal condition.

Adult↗
PubMed2006

Incisional hernia after liver transplantation.

BACKGROUND: Incisional hernia is a potential complication of orthotopic liver transplantation (OLT), with various options for repair. STUDY DESIGN: We conducted a retrospective review of a series of adult patients with incisional hernias after OLT to identify risk factors and to compare methods of repair. RESULTS: Incisional hernia repair was performed in 44 of 959 patients (4.6%) who underwent OLT from 1999 to 2005. Mean age at time of OLT was 53 years, and 73% were men. One or more complications of OLT occurred in 33 patients (75%) and included reoperation for bile leak or hemoperitoneum (34%), pulmonary problems (27%), early acute rejection (7%), and severe ascites and retransplantation (5% each). Incisional hernia was diagnosed at 419 days (range 62 to 1,524 days) and repaired at 471 days (range 109 to 1,581 days) after OLT. Presentation included pain or discomfort (78%) and incarceration or strangulation (5%); 17% were asymptomatic. Herniorrhaphy techniques included fascial repair with onlay polypropylene mesh reinforcement (n=25, 57%); fascial repair only (n=15, 34%); or inlay mesh sewn to fascial edges (n=4, 9%). Complications of repair included recurrence in seven patients (16%) and wound infection and seroma in one patient each. Recurrence occurred in five patients with primary repair and two with mesh techniques (33% versus 6%, p=0.04). CONCLUSIONS: Incisional hernia is a late complication of OLT for which male gender and early post-OLT complications are risk factors. Repair is safe when undertaken after acute problems have resolved and is best accomplished using mesh reinforcement of autologous tissue.

Adult↗
PubMed2006

Long-term analysis of combined liver and kidney transplantation at a single center.

OBJECTIVE: To analyze use of combined liver and kidney transplantation (CLKT) for patients with chronic primary diseases of both organs and for patients with hepatorenal syndrome. DESIGN: Retrospective case series. SETTING: Multiorgan transplantation service in a large university medical center. PATIENTS: A total of 98 patients underwent 99 CLKTs during a 16-year period; 76 had primary renal diseases, and 22 had hepatorenal syndrome. Patients receiving isolated liver and kidney transplants were analyzed for comparison. MAIN OUTCOME MEASURES: Patient and graft survival, rejection rates, and need for hemodialysis before and after transplantation. RESULTS: Overall patient survival was 76%, 72%, and 70% at 1, 3, and 5 years, respectively; liver graft survival was 70%, 65%, and 65%; and kidney graft survival was 76%, 72%, and 70%. No risk factors analyzed for recipients or donors were associated significantly with early posttransplantation mortality or graft loss. In 28 patients who received monoclonal antibody induction therapy with interleukin 2 blockers, there were significantly fewer episodes of acute liver rejection. For patients with hepatorenal syndrome, CLKT did not confer a survival advantage over liver-only transplantation (1-year patient survival was 72% vs 66%; P = .88). The 1-year acute kidney rejection rate in the adult CLKT group was 14% vs 23% in a 5-year cadaveric renal transplantation cohort (P<.01). CONCLUSIONS: First, CLKT is indicated in patients with dual organ disease and achieves excellent results. Second, CLKT for hepatorenal syndrome is indicated in patients receiving hemodialysis for longer than 8 weeks and confers advantages in patient survival and use of hospital resources. Third, the liver is immunoprotective for the kidney.

Adolescent↗
PubMed2006

Preoperative characteristics and intraoperative transfusion and vasopressor requirements in patients with low vs. high MELD scores.

Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation.

Adult↗
PubMed2006

Portocaval hemitransposition in pediatric liver transplant recipients: a single-center experience.

Few studies have reported a series of patients who have undergone portocaval hemitransposition at the time of orthotopic liver transplantation (OLT). Furthermore, no series report the outcome of pediatric patients who required the procedure. This work analyzes the experience with portocaval hemitransposition in the pediatric liver transplant population at a single center since the initial description of the procedure. We carried out a retrospective analysis of all pediatric liver transplants performed in our institution during the 8-year period from January 1, 1997, to December 31, 2004. Of 320 pediatric patients who received OLT during the study period, 7 underwent portocaval hemitransposition (2.2%). Five of the patients had biliary atresia. Four grafts were whole cadaveric livers, while the remaining 4 were left lateral segments from either in situ cadaveric split (n = 3) or living donation (n = 1). One patient received a whole cadaveric allograft and was retransplanted with a segment 2/3 graft; in both cases portocaval hemitransposition was utilized. Average warm ischemia time was 54 +/- 16 minutes. Three patients had primary nonfunction of the allograft; 2 were retransplanted with successful outcome, and the remaining patient died before retransplantation. Another patient died from recurrent disease. Four of 7 are long-term survivors and demonstrate good liver function as long as 8 years posttransplant. In conclusions, long-term survival is possible following OLT with portocaval hemitransposition in pediatric patients. However, rates of primary graft nonfunction can be high. Appropriate selection of recipient and type of donor graft are essential for good outcomes. Portocaval hemitransposition should be used cautiously and as a last resort to establish portovenous inflow.

Adult↗
PubMed2006

Collagenase and surgical disease.

Collagen types I, II, and III are the most abundant extracellular matrix (ECM) proteins. Collagenase is a member of the matrix metalloproteinase (MMP) family of enzymes, and is the principal enzyme involved with collagen degradation. Cellular-ECM interactions are vitally important to tissue structure and function. In this review, we summarize recent work that highlights the role of collagenase in ECM remodeling and repair, and further report that alterations of collagenase expression, function, and/or regulation are found in many diverse disease states, including aortic aneurysms, tumor invasiveness and their metastases, and hernias. Collagenase is intimately involved in many surgical diseases, and represents a potential target for therapy.

Animals↗
PubMed2006

Optimal utilization of donor grafts with extended criteria: a single-center experience in over 1000 liver transplants.

OBJECTIVE: Severely limited organ resources mandate maximum utilization of donor allografts for orthotopic liver transplantation (OLT). This work aimed to identify factors that impact survival outcomes for extended criteria donors (ECD) and developed an ECD scoring system to facilitate graft-recipient matching and optimize utilization of ECDs. METHODS: Retrospective analysis of over 1000 primary adult OLTs at UCLA. Extended criteria (EC) considered included donor age (>55 years), donor hospital stay (>5 days), cold ischemia time (>10 hours), and warm ischemia time (>40 minutes). One point was assigned for each extended criterion. Cox proportional hazard regression model was used for multivariate analysis. RESULTS: Of 1153 allografts considered in the study, 568 organs exhibited no extended criteria (0 score), while 429, 135 and 21 donor allografts exhibited an EC score of 1, 2 and 3, respectively. Overall 1-year patient survival rates were 88%, 82%, 77% and 48% for recipients with EC scores of 0, 1, 2 and 3 respectively (P < 0.001). Adjusting for recipient age and urgency at the time of transplantation, multivariate analysis identified an ascending mortality risk ratio of 1.4 and 1.8 compared to a score of 0 for an EC score of 1, and 2 (P < 0.01) respectively. In contrast, an EC score of 3 was associated with a mortality risk ratio of 4.5 (P < 0.001). Further, advanced recipient age linearly increased the death hazard ratio, while an urgent recipient status increased the risk ratio of death by 50%. CONCLUSIONS: Extended criteria donors can be scored using readily available parameters. Optimizing perioperative variables and matching ECD allografts to appropriately selected recipients are crucial to maintain acceptable outcomes and represent a preferable alternative to both high waiting list mortality and to a potentially futile transplant that utilizes an ECD for a critically ill recipient.

Adult↗
PubMed2006

Effect of nonviral factors on hepatitis C recurrence after liver transplantation.

OBJECTIVE: Hepatitis C (HCV) is now the most common indication for orthotopic liver transplantation (OLT). While graft reinfection remains universal, progression to graft cirrhosis is highly variable. This study examined donor, recipient, and operative variables to identify factors that affect recurrence of HCV post-OLT to facilitate graft-recipient matching. METHODS: Retrospective review of 307 patients who underwent OLT for HCV over a 10-year period at our center. Recurrence of HCV was identified by the presence of biochemical graft dysfunction and concurrent liver biopsy showing diagnostic pathologic features. Time to recurrence was the endpoint for statistical analysis. Five donor, 6 recipient, and 2 operative variables that may affect recurrence were analyzed by univariate comparison and Cox proportional hazard regression models. RESULTS: Recurrence-free survival in the 307 study patients was 69% and 34% at 1 and 5 years, respectively. Four predictive variables related to either donor or recipient characteristics were identified. Advanced donor age, prolonged donor hospitalization, increasing recipient age, and elevated recipient MELD scores were found to increase the relative risk of HCV recurrence. Examination of HLA disparity between donors and recipients demonstrated no correlation between class I or class II mismatches and recurrence-free survival. CONCLUSIONS: We have identified donor and recipient characteristics that significantly predict hepatitis C recurrence following liver transplantation. These factors are identifiable before transplant and, if considered when matching donors to HCV recipients, may decrease the incidence of HCV recurrence after OLT. A change in the current national liver allocation system would be needed to realize the full value of this benefit.

Adult↗
PubMed2006

Intraoperative hypokalemia in pediatric liver transplantation: incidence and risk factors.

In this retrospective study of 268 children undergoing liver transplantation, we investigated the incidence of intraoperative potassium (K+) disturbances and the risk factors for hypokalemia in the preperfusion and postreperfusion periods. Overall, hypokalemia was the predominant disturbance, occurring in 72.0% of pediatric patients during liver transplantation. Hypokalemia was more common during the postreperfusion period than the prereperfusion period. Hyperkalemia, though a commonly cited complication, was infrequent during pediatric liver transplantation. Using multivariate logistic regression analysis, baseline serum K+ < or =3.5 mmol/L, base excess >5 mmol/L, and creatinine < or =0.5 mg/dL were found to be predictors for hypokalemia in the prereperfusion period; and body weight < or =15 kg, K+ < or =3.5 mmol/L, fresh-frozen plasma transfusion >90 mL/kg, and absence of ascites at surgery were independent predictors for hypokalemia in the postreperfusion period. These findings support the use of K+ replacement to maintain normokalemia and avoid the potential complications related to hypokalemia in pediatric liver transplantation, especially in children with the risk factors for hypokalemia.

Adolescent↗
PubMed2006

Pelvic fractures in children.

Although rare, pelvic fractures in children have significant morbidity and mortality. No specific guidelines have been developed for the management of these injuries. We reviewed all trauma patients of age 16 years or younger with pelvic fractures treated at our Level I trauma center over the past 12 years. Of 1008 patients with pelvic fractures, 74 were children. Early hemodynamic instability was seen in 14 per cent of cases. Blood transfusions were required in 26 per cent of cases, angiography in 3 per cent of cases, operations for associated injuries in 46 per cent of cases, operative pelvic fracture fixation in 18 per cent of cases, and intensive care unit care in 58 per cent of cases. Mortality was 5 per cent, mostly from hemorrhage and multiple complex injuries. We conclude that pelvic fractures in children are associated with a high frequency of pelvic bleeding and associated injuries that often require operative interventions and intensive care unit care.

Adolescent↗
PubMed2005

Fulminant hepatic failure from primary hepatic lymphoma: successful treatment with orthotopic liver transplantation and chemotherapy.

Systemic lymphomas may involve the liver but rarely cause fulminant hepatic failure (FHF). Acute liver failure from primary hepatic lymphoma (PHL) is even less common with most patients succumbing to the sequelae of FHF before the correct diagnosis is made. We report a patient who underwent successful orthotopic liver transplant (OLT) and chemotherapy for FHF secondary to PHL. This previously-well male developed profound coagulopathy and encephalopathy 6 weeks after the onset of jaundice and fatigue. Workup failed to reveal the underlying cause of his liver failure and the patient soon required urgent OLT. Pathologic evaluation of his explanted liver revealed a malignant T-cell rich, large B-cell non-Hodgkin's lymphoma with widespread hepatocellular necrosis. The patient made an excellent clinical recovery and is undergoing CHOP-Rituxan chemotherapy. This scenario demonstrates that lymphoma should be considered in the differential diagnosis of FHF without clear etiology because of the potential for intervention with transplant and chemotherapy.

Combined Modality Therapy↗
PubMed2005

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation.

Orthotopic liver transplantation (OLT) can be a definitive treatment for patients with hepatocellular carcinoma (HCC). Prolonged waiting times for cadaveric livers, however, may lead to dropout from the waiting list or worsened post-OLT prognosis as a result of interval tumor progression. Percutaneous radiofrequency ablation (RFA) is widely used for local control of small unresectable HCC, but its pretransplant role remains unclear. We studied the outcome of 52 consecutive patients accepted for OLT bearing 87 HCC nodules and treated with percutaneous RFA. On initial staging, the tumor burden exceeded the Milan criteria in 10 patients. Complete tumor coagulation was observed in 74 of 87 (85.1%) nodules based on postablation imaging. After a mean of 12.7 months (range: 0.3-43.5) on the waiting list, 3 of 52 patients (5.8%) had dropped out due to tumor progression. Forty-one patients had undergone transplantation, with 1- and 3-year post-OLT survival rates of 85% and 76%, respectively. No patient developed HCC recurrence. There were three major complications in 76 RFA procedures (hepatic arterial hemorrhage, small bowel perforation, and liver decompensation salvaged by OLT), without resultant death or dropout. In conclusion, percutaneous RFA is an effective bridge to OLT for patients with compensated liver function and safely accessible tumors. Tumor-related dropout rate and post-OLT outcome compared favorably with published controls of patients with early-stage disease. This can be attributed to the efficacy of RFA in producing local cure or curbing tumor progression during the waiting period.

Adult↗
PubMed2005

Analysis of long-term outcomes of 3200 liver transplantations over two decades: a single-center experience.

OBJECTIVE: Few studies have evaluated long-term outcomes after orthotopic liver transplantation (OLT). This work analyzes the experience of nearly 2 decades by the same team in a single center. Outcomes of OLT and factors affecting survival were analyzed. METHODS: Retrospective analysis of 3200 consecutive OLTs that were performed at our institution, between February 1984 and December 31, 2001. RESULTS: Of 2662 recipients, 578 (21.7%) and 659 (24.7%) were pediatric and urgent patients, respectively. Overall 1-, 5-, 10-, and 15-year patient and graft survival estimates were 81%, 72%, 68%, 64% and 73%, 64%, 59%, 55%, respectively. Patient survival significantly improved in the second (1992-2001) versus the era I (1984-1991) of transplantation (P < 0.001). Similarly, graft survival was better in the era II of transplantation (P < 0.02). However, biliary and infectious complications increased in era II. When OLT indications were considered, best recipient survival was obtained in children with biliary atresia (82%, 79%, and 78% at 1, 5, and 10 years, respectively), while malignant disease in adult patients resulted in the worst outcomes of 68% and 43% at 1 and 5 years, post-OLT. Further, patients <18 years and nonurgent recipients exhibited superior survival when compared with recipients >18 years (P < 0.001) or urgent patients (P < 0.001). Of 13 donor and recipient variables, era of OLT, recipient age, urgent status, donor age, donor length of hospital stay, etiology of liver disease, retransplantation, warm and cold ischemia, but not graft type (whole, split, living-donor), significantly impacted patient survival. CONCLUSIONS: Long-term benefits of OLT are greatest in pediatric and nonurgent patients. Multiple factors involving the recipient, etiology of liver disease, donor characteristics, operative variables, and surgical experience influence long-term survival outcomes. By balancing and matching these factors with a given recipient, optimum results can be achieved.

Adolescent↗
PubMed2004

Quantification of pain and satisfaction following laparoscopic and open hernia repair.

HYPOTHESIS: Subjective experiences can be quantified by visual analog scale (VAS) scoring to improve comparison of surgical techniques. DESIGN: Prospective collection of outcome data by interview of patients at 1 day and 1 week following nonrandomized elective hernia repair by a single surgical group between May 1998 and April 2003. SETTING: Cedars-Sinai Medical Center, Los Angeles, Calif. PATIENTS: A total of 253 patients (239 men; mean age, 59 years) underwent repair by laparoscopic (n = 110, 105 bilateral, 92 total extraperitoneal, and 18 transabdominal preperitoneal) or tension-free open (n = 143, 133 unilateral) approach. Laparoscopic patients were significantly younger (52.0 vs 63.8 years, P<.001). MAIN OUTCOME MEASURES: Subjective measures included VAS scores (1-10, 1 indicates best) for pain at 1 day and 1 week postoperatively and overall satisfaction at 1 week. Objective measures included quantity and days of analgesic use and days before return to regular activities, including work and driving. Results were also compared by patient age (Spearman analysis). RESULTS: Satisfaction was high for both procedures; the laparoscopic procedure was superior only for return to work and driving. Spearman analysis showed a significant inverse relation between age and first-day pain (r= -0.15, P=.01), independent of operative approach. Because laparoscopic patients were younger, patients younger than 65 years were analyzed separately; laparoscopic patients had significantly less first-day pain (5.44 vs 6.30, P=.02). CONCLUSIONS: Pain following hernia repair was age dependent. Following laparoscopic repair, patients had lower first-day pain scores in younger patients and earlier return to normal activities in all patients. Satisfaction was similar for both approaches. Subjective experiences can be quantified, compared to detect subtle differences in outcome for competing surgical techniques, and used to counsel patients before operation, with the goal of improving satisfaction.

Adult↗
PubMed2004

Giant cavernous liver hemangiomas: effect of operative approach on outcome.

HYPOTHESIS: The choice of operative technique for resection of giant cavernous hepatic hemangiomas has an effect on outcome. DESIGN: Case series. SETTING: Tertiary hepatobiliary surgery-liver transplantation service. PATIENTS AND INTERVENTIONS: Fifty-two adult patients who underwent resection of symptomatic hepatic hemangiomas (38 [73%] in the right lobe; average diameter, 10.9 cm) by means of lobectomy or enucleation, with or without Pringle inflow occlusion. MAIN OUTCOME MEASURES: Blood transfusion, morbidity, mortality, and length of hospitalization. RESULTS: Patient age and sex and the size of hemangiomas were similar for patients who underwent lobectomy and enucleation. Right-lobe lesions were more often treated by enucleation, and inflow occlusion was used more frequently; transfusion requirements and length of hospitalization were similar for both techniques. Complications were more frequent after lobectomy. There were no deaths. In the latter years of the series, enucleation was used in 22 (63%) and inflow occlusion in 24 (69%) of 35 patients. CONCLUSIONS: Outcome is related to the operative approach used for resection of giant cavernous liver hemangiomas. Although lobectomy and enucleation are curative, enucleation offers greater preservation of normal hepatic parenchyma and fewer complications and is the preferred technique for suitable lesions.

Adult↗
PubMed2004

Symptoms before and after laparoscopic cholecystectomy for gallstones.

Between 1989 and 1995, 1380 patients underwent laparoscopic cholecystectomy for symptomatic cholelithiasis by a single surgical group at a large private teaching hospital. Thirteen hundred surveys were mailed, and 573 (44.3%) were completed at least 6 months postoperatively. Pain and nonpain symptoms were present preoperatively in 432 (75%) and 457 (80%) patients, respectively. Postoperatively, pain and nonpain symptoms were present in 141 (25%) and 247 (43%) patients, respectively (P < 0.05). All nonpain symptoms were significantly reduced postoperatively except for diarrhea (P < 0.05). Longer duration of pain, age < 40, frequent episodes of pain, postprandial pain, and increased sites of pain preoperatively were all predictive of a higher incidence of persistent postoperative pain (P < 0.05). Persistent nonpain symptoms were more likely if diarrhea, fatty food intolerance, age < 40, or both pain and nonpain symptoms were present preoperatively (P = 0.05) and less likely if only pain symptoms were present preoperatively (P = 0.0001). This series quantifies symptom-specific outcomes for the surgeon. While most symptoms improve, a significant number of pain and nonpain symptoms persist after laparoscopic cholecystectomy. With these data, surgeons can modulate postoperative expectations and advise on the possible persistence of symptoms.

Adolescent↗
PubMed2004

The Santa Monica crash: an urban multicasualty event.

Mass casualty events provide dramatic challenges for trauma centers and trauma systems. We analyzed the management of victims and assessed the response of the UCLA Healthcare System to the Santa Monica multicasualty event of July 16, 2003, when an elderly man drove his car through a crowded outdoor market and injured 73 people, 10 of whom died (eight at the scene). Of the victims, 26 were treated at UCLA (n = 15) and Santa Monica (n = 11) Medical Centers. Fourteen patients (54%) were female; average age was 41.9 years (range 7 months to 88 years). Fifteen patients were treated in the ER only, and 11 patients required admission. Of the latter, 10 (91%) had multisystem injuries, most commonly musculoskeletal, which occurred in nine patients (82%). Seven patients required immediate operations (orthopedic in six and a pericardial window in one). Three patients required delayed operations (orthopedic and plastic surgery). Most surgical and medical specialties were needed in consultation. Average LOH was 11.8 (range 2-23) days. Mean ISS was 21.2 (range 1-75). There were six complications (three early and three late) and one death from head injury. Seven patients (64%) required rehabilitation. We conclude that mass casualty victims have multisystem injuries of variable severity, which underscores the importance of trauma centers and trauma systems. The large trauma scene and particular need for orthopedic services were notable features of this event.

Accidents, Traffic↗