Operative Start Times and Complications After Liver Transplantation

Abstract

The recent national focus on patient safety has led to a re-examination of the risks and benefits of nighttime surgery. In liver transplantation, the hypothetical risks of nighttime operation must be weighed against either the well-established risks of prolonging cold ischemia or the potential risks of strategies to manipulate operative start times. A retrospective review was conducted of 578 liver transplants performed at a single institution between 1995 and 2008 to determine whether the incidence of postoperative complications correlated with operative start times. We hypothesized that no correlation would be observed between complication rates and operative start times. No consistent trends in relative risk of postoperative wound, vascular, biliary, or other complications were observed when eight 3-h time strata were compared. When two 12-h time strata (night, 3 p.m.-3 a.m., and day, 3 a.m.-3 p.m.) were compared, complications were not significantly different, but nighttime operations were longer in duration, and were associated a twofold greater risk of early death compared to daytime operations (adjusted OR 2.9, 95% CI 1.16-7.00, p = 0.023), though long-term survival did not differ significantly between the subgroups. This observation warrants further evaluation and underscores the need to explore and identify institution-specific practices that ensure safe operations regardless of time of day.

Reply

“…There were no differences due to the nighttime or weekend timing of liver transplantation (Table 1). Our observations were different from those of Lonze et al, 2 possibly because of the sample size (94,768 patients versus 578 patients) and the data source (the United Network for Organ Sharing versus a single center). We did perform sensitivity analyses and adjusted for the definition of nighttime in our original article to make valid comparisons with other articles in the published literature; again, no differences were found.…”

Tissue-intrinsic dysfunction of circadian clock confers transplant arteriosclerosis

“…Moreover, recent human studies suggest that the time of day conditions the success in liver transplant patients, with nighttime operative start times being prone to worse outcome (41). Our data directly implicate the circadian clock mechanism to condition transplant arteriosclerosis, buttressed by the congruence of phenotype in mice mutated in both activators (Bmal1) and repressors of the circadian clock (Per) and underscoring the significance of the oscillatory function per se of this unique signaling mechanism (34).…”

Prognostic impact of off-hour liver transplants on graft and survival outcomes

“…3 Logistically, early death can be linked to off-hour transplant times because of the absence of a multidisciplinary transplant team. As reported previously, 4 the risk of death within 7 days of transplantation can be doubled if liver transplantation is performed during off-hours. Although the 30-day, 90-day, and 1-year all-cause mortality rates were not statistically different between the 2 groups, it would be interesting to know the incidence of death early (within a week) after transplantation.…”