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Ostojic A, Mahmud N, Reddy KR. Surgical risk stratification in patients with cirrhosis. Hepatol Int 2024; 18:876-891. [PMID: 38472607 DOI: 10.1007/s12072-024-10644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.
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Affiliation(s)
- Ana Ostojic
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA.
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2
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Adiamah A, Rashid A, Crooks CJ, Hammond J, Jepsen P, West J, Humes DJ. The impact of urgency of umbilical hernia repair on adverse outcomes in patients with cirrhosis: a population-based cohort study from England. Hernia 2024; 28:109-117. [PMID: 38017324 PMCID: PMC10891219 DOI: 10.1007/s10029-023-02898-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/18/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Umbilical hernia is common in patients with cirrhosis; however, there is a paucity of dedicated studies on postoperative outcomes in this group of patients. This population-based cohort study aimed to determine the outcomes after emergency and elective umbilical hernia repair in patients with cirrhosis. METHODS Two linked electronic healthcare databases from England were used to identify all patients undergoing umbilical hernia repair between January 2000 and December 2017. Patients were grouped into those with and without cirrhosis and stratified by severity into compensated and decompensated cirrhosis. Length of stay, readmission, 90-day case fatality rate and the odds ratio of 90-day postoperative mortality were defined using logistic regression. RESULTS In total, 22,163 patients who underwent an umbilical hernia repair were included and 297 (1.34%) had cirrhosis. More patients without cirrhosis had an elective procedure, 86% compared with 51% of those with cirrhosis (P < 0.001). In both the elective and emergency settings, patients with cirrhosis had longer hospital length of stay (elective: 0 vs 1 day, emergency: 2 vs 4 days, P < 0.0001) and higher readmission rates (elective: 4.87% vs 11.33%, emergency:11.39% vs 29.25%, P < 0.0001) than those without cirrhosis. The 90-day case fatality rates were 2% and 0.16% in the elective setting, and 19% and 2.96% in the emergency setting in patients with and without cirrhosis respectively. CONCLUSION Emergency umbilical hernia repair in patients with cirrhosis is associated with poorer outcomes in terms of length of stay, readmissions and mortality at 90 days.
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Affiliation(s)
- A Adiamah
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - A Rashid
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C J Crooks
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - J Hammond
- Division of Hepatobiliary and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle Upon Tyne, NE7 7DN, UK
| | - P Jepsen
- Department of Hepatology and Gastroenterology and Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
| | - D J Humes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
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Kerekes DM, Sznol JA, Khan SA, Becher RD. Impact of nonmalignant ascites on outcomes of open inguinal hernia repair in the USA. Hernia 2023; 27:1497-1506. [PMID: 37029887 DOI: 10.1007/s10029-023-02790-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/02/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE Studies on inguinal hernia repair in patients with ascites are limited, small, and inconsistent, exacerbating a challenging clinical dilemma for surgeons. To fill this gap in the literature, this retrospective cohort study used a national US database to examine the impact of ascites on the outcomes of open inguinal herniorrhaphy. METHODS Patients who underwent open inguinal herniorrhaphy between 2005 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Two groups were defined by the presence or absence of nonmalignant preoperative ascites. Ascites patients were propensity matched 1:10 with non-ascites patients. Surgical outcomes at 30 days for the matched groups, stratified by electiveness of procedure, were compared, with the primary end points of mortality and the NSQIP composite outcome "serious complication". RESULTS The study included 682 patients with ascites. Compared to matched controls, those with ascites had significantly increased odds of mortality (OR 3.3, 95% CI 1.5-7.0) after elective repair, but not after nonelective repair. Ascites was associated with increased odds of serious complication after both elective (OR 1.7, 1.2-2.3) and nonelective (OR 2.0, 1.3-3.0) surgery. Among ascites patients, age ≥ 65 years was associated with increased mortality (risk-adjusted OR 3.8, 1.2-14.4) and serious complication (OR 2.2, 1.2-3.9). CONCLUSION In this largest study to date on patients with ascites undergoing open inguinal herniorrhaphy, ascites increased the odds of mortality after elective repair and of serious complication after elective and nonelective repair. Age ≥ 65 was a risk factor for poor outcome. Inguinal herniorrhaphy is fraught with complications in this population.
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Affiliation(s)
- D M Kerekes
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA.
| | - J A Sznol
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA
| | - S A Khan
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA
| | - R D Becher
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA
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Torabi J, Florman S, Divino C. Leaking Umbilical Hernias in Cirrhotic Patients, Repair or Observe? Am Surg 2023; 89:5365-5371. [PMID: 36571828 DOI: 10.1177/00031348221148362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Umbilical hernias (UHs) in cirrhotic patients are common, can be quite complicated and are associated with significant morbidity and mortality. Leakage of ascites is a challenging entity and poses significant risks. METHODS This is a retrospective study of patients with cirrhosis and UHs with ascitic leakage. Patients were divided into two groups: patients managed operatively during index admission (Group 1) and those managed non-surgically during index admission (Group 2). Group 2 was further divided into those that subsequently underwent repair of UH and those managed medically. RESULTS Of 47 cirrhotic patients with leaking UHs, 19 patients were managed surgically during index admission (Group 1). In Group 2, 15 patients were managed non-surgically and 13 subsequently underwent surgery. The groups had comparable demographics, MELD-Na and Child-Pugh class. Group 2 had a higher rate of emergency surgery (92% vs 58%, P = .04) and higher rate of recurrence (31 vs. 0%, P = .02). The non-surgical patients in Group 2 had higher 1-year mortality (67%) compared to Group 1 (21%) and surgical patients in Group 2 (31%, P = .007). Multi-variable logistic regression for 1-year mortality demonstrated MELD-Na as the most significant risk factor (OR = 1.2, P = .05) and undergoing UH repair as the most significant protective factor (OR = .16, P = .02). CONCLUSIONS Cirrhotic patients with leaking UHs should undergo urgent repair. Non-operative management confers high risk of continued or increased ascitic leakage necessitating more emergent surgery. Despite high rate of post-operative complications related to cirrhosis, there is a clear mortality benefit to the repair of leaking UHs in cirrhotic patients.
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Affiliation(s)
- Julia Torabi
- Division of General Surgery, Mount Sinai Hospital, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sander Florman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Hospital, Recanati/Miller Transplantation Institute, New York, NY, USA
| | - Celia Divino
- Division of General Surgery, Mount Sinai Hospital, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Snitkjær C, Christoffersen MW, Gluud LL, Kimer N, Helgstrand F, Jensen KK, Henriksen NA. Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities-A Nationwide Cohort Study. World J Surg 2023; 47:2733-2740. [PMID: 37202491 DOI: 10.1007/s00268-023-07047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Umbilical hernia is a frequent condition in patients with cirrhosis. The aim of the study was to evaluate the risks associated with umbilical hernia repair in patients with cirrhosis in the elective and emergency setting. Secondly, to compare patients with cirrhosis with a population of patients with equally severe comorbidities but without cirrhosis. METHODS Patients with cirrhosis who underwent umbilical hernia repair from January 1, 2007, to December 31, 2018, were included from the Danish Hernia Database. A control group of patients with a similar Charlson score (≥ 3) without cirrhosis was generated using propensity score matching. The primary outcome was postoperative re-intervention within 30 days following hernia repair. Secondary outcomes were mortality within 90 days and readmission within 30 days following hernia repair. RESULTS A total of 252 patients with cirrhosis and 504 controls were included. Emergency repair in patients with cirrhosis was associated with a significantly increased rate of re-intervention (54/108 (50%) vs. 24/144 (16.7%), P < 0.001), 30-day readmission rate (50/108 (46.3%) compared with elective repair vs. 36/144 (25%) (P < 0.0001)), and 90-day mortality (18/108 (16.7%) vs. 5/144 (3.5%), P < 0.001). Patients with cirrhosis were more likely to undergo a postoperative re-intervention compared with comorbid patients without cirrhosis (OR = 2.10; 95% CI [1.45-3.03]). CONCLUSION Patients with cirrhosis and other severe comorbidity undergo emergency umbilical hernia repair frequently. Emergency repair is associated with increased risk of poor outcome. Patients with cirrhosis undergo a postoperative reintervention more frequently than patients with other severe comorbidity undergoing umbilical hernia repair.
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Affiliation(s)
- Christian Snitkjær
- Abdominalcenter, University of Copenhagen, Herlev Hospital, 2730, Herlev, Denmark.
| | - Mette W Christoffersen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lise Lotte Gluud
- Gastro Unit, Medical Division, University Hospital Hvidovre, Copenhagen, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, University Hospital Hvidovre, Copenhagen, Denmark
| | | | - Kristian Kiim Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nadia A Henriksen
- Abdominalcenter, University of Copenhagen, Herlev Hospital, 2730, Herlev, Denmark
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Shahait A, Mesquita-Neto JWB, Weaver D, Mostafa G. Outcomes of umbilical hernia repair in cirrhotic veterans: a VASQIP study. Langenbecks Arch Surg 2023; 408:246. [PMID: 37358646 DOI: 10.1007/s00423-023-02984-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE Umbilical hernia repair (UHR) in cirrhotics with ascites is a challenging problem associated with increased morbidity and mortality. This study examines the outcomes of UHR in veterans, comparing those undergoing elective versus emergent repair. METHODS VASQIP was queried for all UHRs during the period 2008-2015. Data collection included demographics, operative details, Model for End-stage Liver Disease (MELD) score, and postoperative outcomes. Univariate and multivariate regression analyses were performed, and a p value of ≤ 0.05 was considered significant. RESULTS A total of 383 patients were included in the analysis. Overall, mean age was 58.9, 99.0% were males, mean body mass index (BMI) was 26.7 kg/m2, 98.2% had American Society of Anesthesiologists (ASA) classification ≥ III, and 87.7% had independent functional status. More than 1/3 the patients underwent emergent UHR (37.6%). Compared with the elective UHR group, who underwent emergent repair were older, more likely to be functionally dependent, higher MELD score. Hypoalbuminemia, emergency repair and MELD score were found to be independent predictors of poor outcomes. CONCLUSION UHR in cirrhotic veterans has worse outcomes when performed emergently. Diagnosis should be followed by medical optimization and elective repair, rather than waiting for an emergent indication in > 1/3 of patients.
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Affiliation(s)
- Awni Shahait
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA.
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA.
| | - Jose Wilson B Mesquita-Neto
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Donald Weaver
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Gamal Mostafa
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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Morris SM, Abbas N, Osei-Bordom DC, Bach SP, Tripathi D, Rajoriya N. Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach. Expert Rev Gastroenterol Hepatol 2023; 17:155-173. [PMID: 36594658 DOI: 10.1080/17474124.2023.2163627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Patients with liver disease and portal hypertension frequently require surgery carrying high morbidity and mortality. Accurately estimating surgical risk remains challenging despite improved medical and surgical management. AREAS COVERED This review aims to outline a comprehensive approach to preoperative assessment, appraise methods used to predict surgical risk, and provide an up-to-date overview of outcomes for patients with cirrhosis undergoing non-hepatic surgery. EXPERT OPINION Robust preoperative, individually tailored, and precise risk assessment can reduce peri- and postoperative complications in patients with cirrhosis. Established prognostic scores aid stratification, providing an estimation of postoperative mortality, albeit with limitations. VOCAL-Penn Risk Score may provide greater precision than established liver severity scores. Amelioration of portal hypertension in advance of surgery may be considered, with prospective data demonstrating hepatic venous pressure gradient as a promising surrogate marker of postoperative outcomes. Morbidity and mortality vary between types of surgery with further studies required in patients with more advanced liver disease. Patient-specific considerations and practicing precision medicine may allow for improved postoperative outcomes.
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Affiliation(s)
- Sean M Morris
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
| | - Nadir Abbas
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Daniel-Clement Osei-Bordom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Simon P Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Dhiraj Tripathi
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Neil Rajoriya
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease. Eur J Gastroenterol Hepatol 2022; 34:1060-1066. [PMID: 36062496 DOI: 10.1097/meg.0000000000002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. METHODS A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan-Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. RESULTS One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). CONCLUSIONS Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.
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10
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Johnson KM, Newman KL, Berry K, Itani K, Wu P, Kamath PS, Harris AHS, Cornia PB, Green PK, Beste LA, Ioannou GN. Risk factors for adverse outcomes in emergency versus nonemergency open umbilical hernia repair and opportunities for elective repair in a national cohort of patients with cirrhosis. Surgery 2022; 172:184-192. [PMID: 35058058 DOI: 10.1016/j.surg.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Whether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair. METHODS Veterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair. RESULTS Among 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years. CONCLUSIONS Nonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Kira L Newman
- Gastroenterology Fellowship Program, University of Michigan Medical School, Ann Arbor, MI
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, MA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, and Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Lauren A Beste
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle WA and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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11
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Bronswijk M, Jaekers J, Vanella G, Struyve M, Miserez M, van der Merwe S. Umbilical hernia repair in patients with cirrhosis: who, when and how to treat. Hernia 2022; 26:1447-1457. [PMID: 35507128 DOI: 10.1007/s10029-022-02617-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/09/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past. METHODS The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia. RESULTS Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances. CONCLUSION Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.
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Affiliation(s)
- M Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium.,Imelda GI Clinical Research Center, Bonheiden, Belgium
| | - J Jaekers
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - G Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Struyve
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - S van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Laboratory of Hepatology, CHROMETA Department, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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12
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Snitkjær C, Jensen KK, Henriksen NA, Werge MP, Kimer N, Gluud LL, Christoffersen MW. Umbilical hernia repair in patients with cirrhosis: systematic review of mortality and complications. Hernia 2022; 26:1435-1445. [PMID: 35412192 DOI: 10.1007/s10029-022-02598-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Umbilical hernia is a common and potential serious condition in patients with cirrhosis. This systematic review evaluated the risks associated with emergency and elective hernia repair in patients with cirrhosis. METHODS Systematic review of clinical trials identified through manual and electronic searches in several databases (last update November 2021). The primary random-effects meta-analyses evaluated mortality in patients with or without cirrhosis or following emergency versus elective repair. The quality of the evidence was assessed using GRADE and Newcastle Ottawa Scale. RESULTS Thirteen prospective and 10 retrospective studies including a total of 3229 patients were included. The evidence was graded as very low quality for all outcomes (mortality and postoperative complications within 90 days). In total 191 patients (6%) died after undergoing umbilical hernia repair. Patients with cirrhosis were more than eight times as likely to die after surgery compared with patients without cirrhosis [OR = 8.50, 95% CI (1.91-37.86)] corresponding to 69 more deaths/1000 patients. Among patients with cirrhosis, mortality was higher after emergency versus elective repair [OR = 2.67, 95% CI (1.87-3.97)] corresponding to 52 more deaths/1000 patients. Postoperative complications were more common in patients with cirrhosis compared with patients without cirrhosis. CONCLUSION Patients with cirrhosis undergoing emergency umbilical hernia repair have a considerably increased risk of death and severe complications. Accordingly, additional evidence is needed to evaluate methods that would allow elective umbilical hernia repair in patients with cirrhosis.
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Affiliation(s)
- C Snitkjær
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.
| | - K K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - N A Henriksen
- Abdominal Center, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M P Werge
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - N Kimer
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - L L Gluud
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - M W Christoffersen
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
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13
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McDaniel C, Bell R, Farha N, Vozzo C, Bullen J, Rosen M, Romero-Marrero C, Partovi S, Kapoor B. Risk of hernia-related complications after transjugular intrahepatic portosystemic shunt creation in patients with pre-existing ventral abdominal hernias: 15-year experience at a quaternary medical center. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000876. [PMID: 35318192 PMCID: PMC8943763 DOI: 10.1136/bmjgast-2022-000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/16/2022] [Indexed: 11/12/2022] Open
Abstract
Objective Transjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat the sequelae of portal hypertension, including refractory variceal bleeding, ascites and hepatic hydrothorax. However, hernia-related complications such as incarceration and small bowel obstruction can occur after TIPS placement in patients with pre-existing hernias. The aim of this study was to determine the incidence of hernia complications in the first year after TIPS placement and to identify patient characteristics leading to an increased risk of these complications. Design This retrospective analysis included patients with pre-existing abdominal hernias who underwent primary TIPS placement with covered stents at our institution between 2004 and 2018. The 1-year hernia complication rate and the average time to complications were documented. Using a Wilcoxon rank-sum test, the characteristics of patients who developed hernia-related complications versus the characteristics of those without complications were compared. Results A total of 167 patients with pre-existing asymptomatic abdominal hernias were included in the analysis. The most common reason for TIPS placement was refractory ascites (80.6%). A total of 36 patients (21.6%) developed hernia-related complications after TIPS placement, including 20 patients with acute complications and 16 with non-acute complications. The mean time to presentation of hernia-related complications was 66 days. Patients who developed hernia-related complications were more likely than those without complications to have liver cirrhosis secondary to alcohol consumption (p=0.049), although this association was no longer significant after multivariate analysis. Conclusion Within 1 year after TIPS placement, approximately 20% of patients with pre-existing hernias develop hernia-related complications, typically within the first 2 months after the procedure. Patients with pre-existing hernia undergoing TIPS placement should be educated regarding the signs and symptoms of hernia-related complications, including incarceration and small bowel obstruction.
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Affiliation(s)
- Charles McDaniel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ruth Bell
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Natalie Farha
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Catherine Vozzo
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer Bullen
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Rosen
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Sasan Partovi
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Srivastava KS. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac011. [PMID: 35145625 PMCID: PMC8826029 DOI: 10.1093/jscr/rjac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 11/14/2022] Open
Abstract
Flood syndrome is a very rare complication that can be found in patients with end-stage liver cirrhosis with concurrent ventral hernias. If the hernia ruptures, ascites can begin to leak uncontrollably from the opening which can become a nidus for infection if left untreated. This scenario is known as Flood syndrome, which was first described by Frank Flood in 1961. Flood syndrome is very difficult to manage for physicians as these patients are poor candidates for surgery but the ascitic leak will continue without surgical intervention. Currently, there is no standard of care for Flood syndrome. As such, physicians must rely on case reports to help guide their treatment plan. Our case report highlights the case of a 66-year-old cirrhotic patient with an ascitic leak from a ruptured umbilical hernia with discussion of both medical and surgical approaches to managing this very rare syndrome.
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Affiliation(s)
- Kumaraman S Srivastava
- TCU School of Medicine, Fort Worth 76105, TX, USA
- Correspondence address. TCU and UNTHSC School of Medicine, Fort Worth 76105, TX, USA. Tel: 781-927-4817; E-mail:
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15
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Johnson KM, Newman KL, Green PK, Berry K, Cornia PB, Wu P, Beste LA, Itani K, Harris AHS, Kamath PS, Ioannou GN. Incidence and Risk Factors of Postoperative Mortality and Morbidity After Elective Versus Emergent Abdominal Surgery in a National Sample of 8193 Patients With Cirrhosis. Ann Surg 2021; 274:e345-e354. [PMID: 31714310 DOI: 10.1097/sla.0000000000003674] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the incidence and risk factors for mortality and morbidity in patients with cirrhosis undergoing elective or emergent abdominal surgeries. BACKGROUND Postoperative morbidity and mortality are higher in patients with cirrhosis; variation by surgical procedure type and cirrhosis severity remain unclear. METHODS We analyzed prospectively-collected data from the Veterans Affairs (VA) Surgical Quality Improvement Program for 8193 patients with cirrhosis, 864 noncirrhotic controls with chronic hepatitis B infection, and 5468 noncirrhotic controls without chronic liver disease, who underwent abdominal surgery from 2001 to 2017. Data were analyzed using random-effects models controlling for potential confounders. RESULTS Patients with cirrhosis had significantly higher 30-day mortality than noncirrhotic patients with chronic hepatitis B [4.4% vs 1.3%, adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.57-4.98] or with no chronic liver disease (0.8%, aOR 4.68, 95% CI 3.27-6.69); mortality difference was highest in patients with Model for End-stage Liver Disease (MELD) score ≥10. Among patients with cirrhosis, postoperative mortality was almost 6 times higher after emergent rather than elective surgery (17.2% vs. 2.1%, aOR 5.82, 95% CI 4.66-7.27). For elective surgeries, 30-day mortality was highest after colorectal resection (7.0%) and lowest after inguinal hernia repair (0.6%). Predictors of postoperative mortality included cirrhosis-related characteristics (high MELD score, low serum albumin, ascites, encephalopathy), surgery-related characteristics (emergent vs elective, type of surgery, intraoperative blood transfusion), comorbidities (chronic obstructive pulmonary disease, cancer, sepsis, ventilator dependence, functional status), and age. CONCLUSIONS Accurate preoperative risk assessments in patients with cirrhosis should account for cirrhosis severity, comorbidities, type of procedure, and whether the procedure is emergent versus elective.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Lauren A Beste
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, Boston, MA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Patrick S Kamath
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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Strainiene S, Peciulyte M, Strainys T, Stundiene I, Savlan I, Liakina V, Valantinas J. Management of Flood syndrome: What can we do better? World J Gastroenterol 2021; 27:5297-5305. [PMID: 34539133 PMCID: PMC8409160 DOI: 10.3748/wjg.v27.i32.5297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/03/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Approximately 20% of cirrhotic patients with ascites develop umbilical herniation. These patients usually suffer from multisystemic complications of cirrhosis, have a significantly higher risk of infection, and require accurate surveillance– especially in the context of the coronavirus disease 2019 pandemic. The rupture of an umbilical hernia, is an uncommon, life-threatening complication of large-volume ascites and end-stage liver disease resulting in spontaneous paracentesis, also known as Flood syndrome. Flood syndrome remains a challenging condition for clinicians, as recommendations for its management are lacking, and the available evidence for the best treatment approach remains controversial. In this paper, four key questions are addressed regarding the management and prevention of Flood syndrome: (1) Which is the best treatment approach–conservative treatment or urgent surgery? (2) How can we establish the individual risk for herniation and possible hernia rupture in cirrhotic patients? (3) How can we prevent umbilical hernia ruptures? And (4) How can we manage these patients in the conditions created by the coronavirus disease 2019 pandemic?
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Affiliation(s)
- Sandra Strainiene
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Milda Peciulyte
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Tomas Strainys
- Clinic of Anesthesiology and Reanimatology, Centre of Anesthesiology, Intensive Care and Pain Management, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Ieva Stundiene
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Ilona Savlan
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Valentina Liakina
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
- Department of Chemistry and Bioengineering, Faculty of Fundamental Science, Vilnius Gediminas Technical University, Vilnius 10223, Lithuania
| | - Jonas Valantinas
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
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17
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The imperative for an updated cirrhosis surgical risk score. Ann Hepatol 2021; 19:341-343. [PMID: 32474073 DOI: 10.1016/j.aohep.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023]
Abstract
The burden of cirrhosis is increasing, as is the need for surgeries in patients with cirrhosis. These patients have increased surgical risk relative to non-cirrhotic patients. Unfortunately, currently available cirrhosis surgical risk prediction tools are non-specific, poorly calibrated, limited in scope, and/or outdated. The Mayo score is the only dedicated tool to provide discrete post-operative mortality predictions for patients with cirrhosis, however it has several limitations. First, its single-center nature does not reflect institution-specific practices that may impact surgical risk. Second, it pre-dates major surgical changes that have changed the landscape of patient selection and surgical risk. Third, it has been shown to overestimate risk in external validation. Finally, and perhaps most importantly, the score does not account for differences in risk based on surgery type. The clinical consequences of inaccurate prediction and risk overestimation are significant, as patients with otherwise acceptable risk may be denied elective surgical procedures, thereby increasing their future need for higher-risk emergent procedures. Confident evaluation of the risks and benefits of surgery in this growing population requires an updated, generalizable, and accurate cirrhosis surgical risk calculator that incorporates the type of surgery under consideration.
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18
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Adiamah A, Ban L, Hammond J, Jepsen P, West J, Humes DJ. Mortality After Extrahepatic Gastrointestinal and Abdominal Wall Surgery in Patients With Alcoholic Liver Disease: A Systematic Review and Meta-Analysis. Alcohol Alcohol 2021; 55:497-511. [PMID: 32558895 DOI: 10.1093/alcalc/agaa043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/26/2020] [Accepted: 04/28/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS This meta-analysis aimed to define the perioperative risk of mortality in patients with alcoholic liver disease (ALD) undergoing extrahepatic gastrointestinal surgery. METHODS Systematic searches of Embase, Medline and CENTRAL were undertaken to identify studies reporting about patients with ALD undergoing extrahepatic gastrointestinal surgery published since database inception to January 2019. Studies were only considered if they reported on mortality as an outcome. Pooled analysis of mortality was stratified as benign and malignant surgery and specific operative procedures where feasible. RESULTS Of the 2899 studies identified, only five studies met inclusion criteria, representing cholecystectomy (one study), umbilical hernia repair surgery (one study) and oesophagectomy (three studies). The total number of patients with ALD in these studies was 172. Therefore, any study on liver disease patients undergoing extrahepatic surgery that crucially included a subset with alcohol aetiology was included as a secondary analysis even though they failed to stratify mortality by underlying aetiology. The total number of studies that met this expanded inclusion criteria was 62, reporting on 37,703 patients with liver disease of which 1735 (4.5%) had a definite diagnosis of ALD. Meta-analysis of proportions of in-hospital mortality in patients with ALD undergoing upper gastrointestinal cancer surgery (oesophagectomy) was 23% [95% confidence interval (CI) 14-35%, I2 = 0%]. In-hospital mortality following oesophagectomy in liver disease patients of all aetiologies was lower, 14% (95% CI 9-21%, I2 = 41.1%). CONCLUSION Postoperative in-hospital mortality is high in patients with liver disease and ALD in particular. However, the currently available evidence on ALD is limited and precludes definitive conclusions on postoperative mortality risk.
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Affiliation(s)
- Alfred Adiamah
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK
| | - Lu Ban
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK
| | - John Hammond
- Division of Hepatobiliary and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology and Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark ,8200
| | - Joe West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
| | - David J Humes
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
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19
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Mahmud N, Fricker Z, Hubbard RA, Ioannou GN, Lewis JD, Taddei TH, Rothstein KD, Serper M, Goldberg DS, Kaplan DE. Risk Prediction Models for Post-Operative Mortality in Patients With Cirrhosis. Hepatology 2021; 73:204-218. [PMID: 32939786 PMCID: PMC7902392 DOI: 10.1002/hep.31558] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of postoperative mortality. Currently available tools to predict postoperative risk are suboptimally calibrated and do not account for surgery type. Our objective was to use population-level data to derive and internally validate cirrhosis surgical risk models. APPROACH AND RESULTS We conducted a retrospective cohort study using data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) cohort, which contains granular data on patients with cirrhosis from 128 U.S. medical centers, merged with the Veterans Affairs Surgical Quality Improvement Program (VASQIP) to identify surgical procedures. We categorized surgeries as abdominal wall, vascular, abdominal, cardiac, chest, or orthopedic and used multivariable logistic regression to model 30-, 90-, and 180-day postoperative mortality (VOCAL-Penn models). We compared model discrimination and calibration of VOCAL-Penn to the Mayo Risk Score (MRS), Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease-Sodium MELD-Na, and Child-Turcotte-Pugh (CTP) scores. We identified 4,712 surgical procedures in 3,785 patients with cirrhosis. The VOCAL-Penn models were derived and internally validated with excellent discrimination (30-day postoperative mortality C-statistic = 0.859; 95% confidence interval [CI], 0.809-0.909). Predictors included age, preoperative albumin, platelet count, bilirubin, surgery category, emergency indication, fatty liver disease, American Society of Anesthesiologists classification, and obesity. Model performance was superior to MELD, MELD-Na, CTP, and MRS at all time points (e.g., 30-day postoperative mortality C-statistic for MRS = 0.766; 95% CI, 0.676-0.855) in terms of discrimination and calibration. CONCLUSIONS The VOCAL-Penn models substantially improve postoperative mortality predictions in patients with cirrhosis. These models may be applied in practice to improve preoperative risk stratification and optimize patient selection for surgical procedures (www.vocalpennscore.com).
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rebecca A. Hubbard
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George N. Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - James D. Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Kenneth D. Rothstein
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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20
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Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial). Langenbecks Arch Surg 2020; 406:219-225. [PMID: 33237442 PMCID: PMC7870599 DOI: 10.1007/s00423-020-02033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/15/2020] [Indexed: 11/08/2022]
Abstract
Purpose To establish optimal management of patients with an umbilical hernia complicated by liver cirrhosis and ascites. Methods Patients with an umbilical hernia and liver cirrhosis and ascites were randomly assigned to receive either elective repair or conservative treatment. The primary endpoint was overall morbidity related to the umbilical hernia or its treatment after 24 months of follow-up. Secondary endpoints included the severity of these hernia-related complications, quality of life, and cumulative hernia recurrence rate. Results Thirty-four patients were included in the study. Sixteen patients were randomly assigned to elective repair and 18 to conservative treatment. After 24 months, 8 patients (50%) assigned to elective repair compared to 14 patients (77.8%) assigned to conservative treatment had a complication related to the umbilical hernia or its repair. A recurrent hernia was reported in 16.7% of patients who underwent repair. For the secondary endpoint, quality of life through the physical (PCS) and mental component score (MCS) showed no significant differences between groups at 12 months of follow-up (mean difference PCS 11.95, 95% CI − 0.87 to 24.77; MCS 10.04, 95% CI − 2.78 to 22.86). Conclusion This trial could not show a relevant difference in overall morbidity after 24 months of follow-up in favor of elective umbilical hernia repair, because of the limited number of patients included. However, elective repair of umbilical hernia in patients with liver cirrhosis and ascites appears feasible, nudging its implementation into daily practice further, particularly for patients experiencing complaints. Trial registration Clinicaltrials.gov, NCT01421550, on 23 August 2011.
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Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions. Clin Gastroenterol Hepatol 2020; 18:2398-2414.e3. [PMID: 31376494 PMCID: PMC6994232 DOI: 10.1016/j.cgh.2019.07.051] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures. METHODS We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review. RESULTS Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate. CONCLUSIONS Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.
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Affiliation(s)
- Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, Washington.
| | - Kay M Johnson
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Paul B Cornia
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Kamal Itani
- Boston VA Health Care System and Boston University, Boston, Massachusetts
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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22
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Hill CE, Olson KA, Roward S, Yan D, Cardenas T, Teixeira P, Coopwood BT, Trust M, Aydelotte J, Ali S, Brown C. Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients. Am J Surg 2020; 220:1402-1404. [PMID: 32988606 DOI: 10.1016/j.amjsurg.2020.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/08/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND We hypothesize that patients with compensated cirrhosis undergoing elective UHR have an improved mortality compared to those undergoing emergent UHR. METHOD The NIS was queried for patients undergoing UHR by CPT code, and ICD-10 codes were used to define separate patient categories of non-cirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC). RESULTS A total of 32,526 patients underwent UHR, 97% no cirrhosis, 1.1% compensated cirrhosis, 1.7% decompensated cirrhosis. On logistic regression, cirrhosis was found to be independently associated with mortality (OR 2.841, CI 2.14-3.77). On subset analysis of only cirrhosis patients, elective repair was found to be protective from mortality (OR 0.361, CI 0.15-0.87, p = 0.02). CONCLUSIONS In this retrospective review, cirrhosis as well as emergent UHR in cirrhotic patients were independently associated with mortality. More specifically, electively (rather than emergently) repairing an umbilical hernia in cirrhotic patients was independently associated with a 64% reduction in mortality.
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Affiliation(s)
- Charles E Hill
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA.
| | - Kristofor A Olson
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Simin Roward
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Derek Yan
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Tatiana Cardenas
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Pedro Teixeira
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Ben T Coopwood
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Marc Trust
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Jayson Aydelotte
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Sadia Ali
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Carlos Brown
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
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23
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Sheikh MM, Siraj B, Fatima F, Ehsan H, Shahid MH. Flood Syndrome: A Rare and Fatal Complication of Umbilical Hernia in Liver Cirrhosis. Cureus 2020; 12:e9915. [PMID: 32968577 PMCID: PMC7505645 DOI: 10.7759/cureus.9915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Flood syndrome, first reported in 1961 by Frank B Flood, refers to spontaneous umbilical hernia rupture followed by a sudden rush of ascitic fluid. It is a rare sequela in the setting of refractory ascites and liver cirrhosis. Clues to impending rupture include color changes, ulceration, or necrosis over the umbilical hernia that warrants urgent surgical intervention. In this report, we present a unique case of Flood syndrome in a patient with decompensated cirrhosis and umbilical hernia. The patient underwent urgent umbilical herniorrhaphy without mesh; even though adequate postoperative management of ascites was performed, the patient still developed other comorbidities.
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Affiliation(s)
| | - Bakhtawer Siraj
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Faraeha Fatima
- Internal Medicine, King Edward Medical University, Lahore, PAK
| | - Hamid Ehsan
- Internal Medicine, MedStar Union Memorial Hospital, Baltimore, USA.,Biomedical Sciences, Georgetown University, Washington, D.C., USA
| | - Muhammad Hassaan Shahid
- Pulmonary and Critical Care Medicine, The University of Tennessee Health Science Center, Memphis, USA
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24
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Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients. J Visc Surg 2020; 158:27-37. [PMID: 32553558 DOI: 10.1016/j.jviscsurg.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites. METHODS Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival. RESULTS Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group. CONCLUSION Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.
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25
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Kumar S, Edmunds RW, Nisiewicz MJ, Warriner ZD, Chang YWW, Plymale MA, Davenport DL, Wade A, Roth JS. Totally extraperitoneal approach for open complex abdominal wall reconstruction. Surg Endosc 2020; 35:159-164. [PMID: 32030549 DOI: 10.1007/s00464-020-07374-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 01/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. METHODS This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. RESULTS One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively. CONCLUSIONS TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.
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Affiliation(s)
- Shyanie Kumar
- General Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | - R Wesley Edmunds
- Plastic Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | | | - Zachary D Warriner
- General Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | - Yu-Wei Wayne Chang
- General Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | - Margaret A Plymale
- Division of General Surgery, Department of Surgery, C 222, Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA
| | | | - Alexander Wade
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - John Scott Roth
- Division of General Surgery, Department of Surgery, C 222, Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA.
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26
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Henriksen NA, Kaufmann R, Simons MP, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Montgomery A. EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances. BJS Open 2020; 4:342-353. [PMID: 32207571 PMCID: PMC7093793 DOI: 10.1002/bjs5.50252] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/26/2019] [Indexed: 01/11/2023] Open
Abstract
Background Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management. Methods The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed. Results Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence. Conclusion This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.
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Affiliation(s)
- N A Henriksen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - R Kaufmann
- Erasmus University Medical Centre, Rotterdam, the Netherlands.,Tergooi, Hilversum, the Netherlands
| | - M P Simons
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - F Berrevoet
- Department of General and Hepato-Pancreato-Biliary Surgery, Gent University Hospital, Gent, Belgium
| | - B East
- Third Department of Surgery, Motol University Hospital, Prague, Czech Republic.,First and Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - J Fischer
- University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - W Hope
- New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - D Klassen
- Department of Surgery, Dalhousie University, Halifax, Canada
| | - R Lorenz
- Praxis 3+CHIRURGEN, Berlin, Germany
| | - Y Renard
- Department of Digestive Surgery, Robert Debré University Hospital, Reims, France
| | - M A Garcia Urena
- Henares University Hospital, Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain
| | - A Montgomery
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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27
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Abstract
Patients with portal hypertension will increasingly present for nontransplant surgery because of the increasing incidence of, and improving long-term survival for, chronic liver disease. Such patients have increased perioperative morbidity and mortality caused by the systemic pathophysiology of liver disease. Preoperative assessment should identify modifiable causes of liver injury and distinguish between compensated and decompensated cirrhosis. Risk stratification, which is crucial to preparing patients and their families for surgery, relies on scores such as Child-Turcotte-Pugh and Model for End-stage Liver Disease to translate disease severity into quantified outcomes predictions. Risk factors for postoperative complications should also be recognized.
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Affiliation(s)
- Melissa Wong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Transplant Center, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, The Dumont-UCLA Transplant Center, 757 Westwood Blvd, Suite 8236, Los Angeles, CA 90095, USA.
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28
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Hickman L, Tanner L, Christein J, Vickers S. Non-Hepatic Abdominal Surgery in Patients with Cirrhotic Liver Disease. J Gastrointest Surg 2019; 23:634-642. [PMID: 30465191 PMCID: PMC7102012 DOI: 10.1007/s11605-018-3991-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Abstract
Cirrhotic liver disease is an important cause of peri-operative morbidity and mortality in general surgical patients. Early recognition and optimization of liver dysfunction is imperative before any elective surgery. Patients with MELD <12 or classified as Child A have a higher morbidity and mortality than matched controls without liver dysfunction, but are generally safe for elective procedures with appropriate patient education. Patients with MELD >20 or classified as Child C should undergo transplantation before any elective procedure given mortality exceeds 40%. Laparoscopic procedures are feasible and safe in cirrhotic patients.
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Affiliation(s)
- Laura Hickman
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - John Christein
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Selwyn Vickers
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
- Dean's Office, UAB School of Medicine, FOT 1203, 510 20th Street South, Birmingham, AL, 35233, USA.
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29
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Salamone G, Licari L, Guercio G, Campanella S, Falco N, Scerrino G, Bonventre S, Geraci G, Cocorullo G, Gulotta G. The abdominal wall hernia in cirrhotic patients: a historical challenge. World J Emerg Surg 2018; 13:35. [PMID: 30065783 PMCID: PMC6064098 DOI: 10.1186/s13017-018-0196-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/18/2018] [Indexed: 12/20/2022] Open
Abstract
Background The incidence rate of abdominal wall hernia is 20–40% in cirrhotic patients. A surgical approach was originally performed only if complication signs and symptoms occurred. Several recent studies have demonstrated the usefulness of elective surgery. During recent decades, the indications for surgical timing have changed. Methods Cirrhotic patients with abdominal hernia who underwent surgical operation for abdominal wall hernia repair at the Policlinico “Paolo Giaccone” at Palermo University Hospital between January 2010 and September 2016 were identified in a prospective database, and the data collected were retrospectively reviewed; patients’ medical and surgical records were collected from charts and surgical and intensive care unit (ICU) registries. Postoperative morbidity was determined through the Clavien-Dindo classification. Cirrhosis severity was estimated by the Child-Pugh-Turcotte (CPT) score and MELD (model of end-stage liver disease) score. Postoperative mortality was considered up to 30 days after surgery. A follow-up period of at least 1 year was used to evaluate hernia recurrence. Results The univariate and multivariate analyses demonstrated the unique independent risk factors for the development of postsurgical morbidity (emergency surgery (OR 6.42; p 0.023), CPT class C (OR 3.72; p 0.041), American Society of Anesthesiologists (ASA) score ≥ 3 (OR 4.72; p 0.012) and MELD ≥ 20 (OR 5.64; p 0.009)) and postsurgical mortality (emergency surgery (OR 10.32; p 0.021), CPT class C (OR 5.52; p 0.014), ASA score ≥ 3 (OR 8.65; p 0.018), MELD ≥ 20 (OR 2.15; p 0.02)). Conclusions Concerning abdominal wall hernia repair in cirrhotic patients, the worst outcome is associated with emergency surgery and with uncontrolled disease. The correct timing of the surgical operation is elective surgery after ascites drainage and albumin/electrolyte serum level and coagulation alteration correction.
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Affiliation(s)
- Giuseppe Salamone
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Leo Licari
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Giovanni Guercio
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Sofia Campanella
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Nicolò Falco
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gregorio Scerrino
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Sebastiano Bonventre
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Girolamo Geraci
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gianfranco Cocorullo
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gaspare Gulotta
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
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30
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Nguyen ET, Tudtud-Hans LA. Flood Syndrome: Spontaneous Umbilical Hernia Rupture Leaking Ascitic Fluid-A Case Report. Perm J 2018; 21:16-152. [PMID: 28678688 DOI: 10.7812/tpp/16-152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION We report a rare case of Flood syndrome, which is a spontaneous rupture of an umbilical hernia. CASE PRESENTATION A 42-year-old man with decompensated hepatitis C and alcoholic cirrhosis complicated by ascites and esophageal varices presented with 1 day of ascitic fluid drainage after rupture of a preexisting umbilical hernia associated with diffuse abdominal pain and tenderness. A pigtail drain was placed in the right upper abdominal quadrant to decrease fluid drainage from the abdominal wall defect, allowing it to heal naturally. DISCUSSION The spontaneous rupture of an umbilical hernia in our patient highlights a rare complication with high mortality rates and stresses the challenge of treatment that falls in the area between medical and surgical management.
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Affiliation(s)
- Emilie T Nguyen
- Radiology resident in the Department of Diagnostic Imaging at the Los Angeles Medical Center in CA.
| | - Leah A Tudtud-Hans
- Associate Chair for Continuing Medical Education and an Associate Professor of Medicine at the Loma Linda University School of Medicine in CA.
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31
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Coelho JCU, Claus CMP, Campos ACL, Costa MAR, Blum C. Umbilical hernia in patients with liver cirrhosis: A surgical challenge. World J Gastrointest Surg 2016; 8:476-482. [PMID: 27462389 PMCID: PMC4942747 DOI: 10.4240/wjgs.v8.i7.476] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/02/2016] [Accepted: 05/11/2016] [Indexed: 02/06/2023] Open
Abstract
Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.
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32
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Juo YY, Skancke M, Holzmacher J, Amdur RL, Lin PP, Vaziri K. Laparoscopic versus open ventral hernia repair in patients with chronic liver disease. Surg Endosc 2016; 31:769-777. [PMID: 27334967 DOI: 10.1007/s00464-016-5031-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients. METHODS Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors. RESULTS A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p < 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p < 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR. CONCLUSIONS In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.
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Affiliation(s)
- Yen-Yi Juo
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA.
| | - Matthew Skancke
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Jeremy Holzmacher
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Paul P Lin
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
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Lopez-Delgado JC, Ballus J, Esteve F, Betancur-Zambrano NL, Corral-Velez V, Mañez R, Betbese AJ, Roncal JA, Javierre C. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol 2016; 22:2657-2667. [PMID: 26973406 PMCID: PMC4777990 DOI: 10.3748/wjg.v22.i9.2657] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/30/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.
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Chen CC, Huang YC, Yeh CN. Neurosurgical procedures in patients with liver cirrhosis: A review. World J Hepatol 2015; 7:2352-7. [PMID: 26413225 PMCID: PMC4577643 DOI: 10.4254/wjh.v7.i21.2352] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/22/2015] [Accepted: 08/30/2015] [Indexed: 02/06/2023] Open
Abstract
Liver cirrhosis, a devastating liver fibrosis caused by hepatitis/inflammation or tumors, is a major comorbid factor in known surgery fields, such as cardiovascular and abdominal surgeries. It is important to review possible comorbid results in neurosurgical procedures in cirrhotic patients. In the reviewed literature, Child-Pugh and model for end-stage liver disease scores are commonly used in the assessment of surgical risks for cirrhotic patients undergoing abdominal, cardiovascular or neurosurgical procedures. The major categories of neurosurgery are traumatic brain injury (TBI), spontaneous intracranial hemorrhage (SICH), brain tumors, and spinal instrumentation procedures. TBI was reported with surgical mortality as high as 34.5% and a complication rate of 87.2%. For SICH, mortality ranged from 22.7% to 47.0%, while complications were reported to be 43.2%. Less is discussed in brain tumor patients; still the postoperative hemorrhage rate approached 26.7%. In spinal fusion instrumentation procedures, the complication rate was as high as 41.0%. Preoperative assessment and correction could possibly decrease complications such as hemorrhage, wound infection and other cirrhosis-related complications (renal, pulmonary, ascites and encephalopathy). In this study, we reviewed the neurosurgical-related literature with regard to liver cirrhosis as a prognostic factor influencing neurosurgical outcomes.
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Affiliation(s)
- Ching-Chang Chen
- Ching-Chang Chen, Yin-Cheng Huang, Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Yin-Cheng Huang
- Ching-Chang Chen, Yin-Cheng Huang, Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chun-Nan Yeh
- Ching-Chang Chen, Yin-Cheng Huang, Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
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Umbilical paracentesis for incarcerated umbilical hernia in patients with end-stage liver disease. Hernia 2015; 20:531-3. [DOI: 10.1007/s10029-015-1421-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/14/2015] [Indexed: 01/27/2023]
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Andraus W, Pinheiro RS, Lai Q, Haddad LBP, Nacif LS, D'Albuquerque LAC, Lerut J. Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality. BMC Surg 2015; 15:65. [PMID: 25990110 PMCID: PMC4443633 DOI: 10.1186/s12893-015-0052-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 05/11/2015] [Indexed: 02/07/2023] Open
Abstract
Background Patients with cirrhosis have a high incidence of abdominal wall hernias and carry an elevated perioperative morbidity and mortality. The optimal surgical management strategy as well as timing of abdominal hernia repair remains controversial. Methods A cohort study of 67 cirrhotic patients who underwent hernia repair during the period of January 1998-December 2009 at the University Hospital of Sao Paulo were included. After meeting study criteria, a total of 56 patients who underwent 61 surgeries were included in the final analysis. Patient characteristics, morbidity (Clavien score), mortality, Child-Turcotte-Pugh score, MELD score, use of prosthetic material, and elective or emergency surgery have been analysed with regards to morbidity and 30-day mortality. Results The median MELD score of the patient population was 14 (range: 6 to 24). Emergency surgery was performed in 34 patients because of ruptured hernia (n = 13), incarceration (n = 10), strangulation (n = 4), and skin necrosis or ulceration (n = 7). Elective surgery was performed in 27 cases. After a multivariable analysis, emergency surgery (OR 7.31; p 0.017) and Child-Pugh C (OR 4.54; p 0.037) were risk factors for major complications. Moreover, emergency surgery was a unique independent risk factor for 30-day mortality (OR 10.83; p 0.028). Conclusions Higher morbidity and mortality are associated with emergency surgery in advanced cirrhotic patients. Therefore, using cirrhosis as a contraindication for hernia repair in all patients may be reconsidered in the future, especially after controlling ascites and in those patients with hernias that are becoming symptomatic or show signs of possible skin necrosis and rupture. Future prospective randomized studies are needed to confirm this surgical strategy.
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Affiliation(s)
- Wellington Andraus
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
| | - Rafael Soares Pinheiro
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Quirino Lai
- Department of Hepatic Surgery and Liver Transplantation, Azienda Universitario-ospedaliera Pisana, Pisa, Italy
| | - Luciana B P Haddad
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Lucas S Nacif
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Luiz Augusto C D'Albuquerque
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Jan Lerut
- Starzl Unit of Abdominal Transplantation, University Hospital of Saint Luc, Université Catholique of Louvain, Brussels, Belgium
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Management of umbilical hernias in patients with ascites: development of a nomogram to predict mortality. Am J Surg 2014; 209:302-7. [PMID: 25066022 DOI: 10.1016/j.amjsurg.2014.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/11/2014] [Accepted: 04/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The objective of this study was to develop an easy-to-use nomogram to assist clinicians in predicting patient-specific mortality in this patient population. METHODS American College of Surgeons National Surgical Quality Improvement Program participant use files were used from 2005 to 2011. Multivariable logistic regression was used to model 30-day postoperative mortality in patients with ascites who underwent umbilical hernia repair. RESULTS A total of 688 patients with ascites undergoing umbilical hernia repair were included. There were 643 (94%) survivors and 45 (7%) mortalities. A total of 300 (44%) patients were classified as emergent cases. Using logistic regression to predict 30-day mortality, preoperative Model for End-Stage Liver Disease score, albumin, white blood cell count, and platelet count were found to be significant predictors (P < .05) of mortality and were included in our model. CONCLUSION We propose a nomogram to enable clinicians to better estimate mortality in patients with ascites undergoing umbilical hernia repair.
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Abstract
Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.
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Affiliation(s)
- D Dante Yeh
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA 02114, USA.
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Hassan AMA, Salama AF, Hamdy H, Elsebae MM, Abdelaziz AM, Elzayat WA. Outcome of sublay mesh repair in non-complicated umbilical hernia with liver cirrhosis and ascites. Int J Surg 2013; 12:181-5. [PMID: 24378913 DOI: 10.1016/j.ijsu.2013.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/19/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Umbilical hernia repair is often accompanied by complications in patients with liver cirrhosis and ascites. It appears that the early elective repair of umbilical hernias in these patients is safer and can be considered for selected patients. The objective of this study is to evaluate the feasibility, safety, complications and technical aspects of sublay mesh repair of umbilical hernia in cirrhotic patients with ascites. METHODS Between October 2010 and April 2013, 70 patients with non-complicated umbilical hernia, liver cirrhosis and ascites were enrolled in this study. All patients underwent sublay mesh repair. Demographic data, preoperative variables, peri-operative course, and postoperative complications were recorded and analyzed. RESULTS A total of 38 women and 32 men underwent operation at an average age 51.24 years. The patients mean MELD score was 18 (range 12-25). The mean operative time was 67.45 min and the average hospital stay was 3.8 days. 2 patients had wound infection, 3 patients developed seroma and 1 patient had an ascitic fistula. Recurrence occurred in 1 (1.4%) patient and no mortality related to the procedure. CONCLUSION elective sublay umbilical hernia mesh repair is a safe approach and feasible technique in selected non-complicated cirrhotic patients with ascites.
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Affiliation(s)
| | - Asaad Fayrouz Salama
- General Surgery Department, Theodor Bilharz Research Institute, Giza 12411, Egypt.
| | - Hussam Hamdy
- General Surgery Department, Theodor Bilharz Research Institute, Giza 12411, Egypt.
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Abstract
BACKGROUND The optimal treatment for abdominal wall hernias in the setting of ascites is not clear. We describe our experience with emergent surgery for hernias in patients with cirrhosis and ascites and assess variables associated with poor short- and long-term outcomes to inform decisions about aggressive early repair. METHODS We performed a retrospective review of all emergency abdominal wall hernia repairs admitted from the emergency department from January 2000 to December 2011 in all patients with ascites caused by liver cirrhosis. Demographic data, comorbidities, complications, operative details, hospital length of stay, and admission model of end-stage liver disease (MELD) score was determined. Follow-up was detailed via comprehensive liver service electronic records. RESULTS There were 69 emergent hernia surgeries in 68 patients during the study period. There were two early deaths (both MELD score> 20). Multivariate analysis revealed MELD score (18% increase in risk with each point of MELD), preoperative anemia (sevenfold increase in risk), and preoperative small bowel obstruction (ninefold increase in risk) as predictive factors of major complication. In patients with MELD score greater than 10, morbidity was more than 50%, and major morbidity is greater than 12% when MELD score is greater than 20. CONCLUSION Emergent hernia surgery in patients with ascites has low mortality but high morbidity and requires intense use of resources. To decrease the incidence of emergent hernia surgery, we recommend the aggressive use of elective repair. Emergent hernia repair, when necessary, should be performed at experienced centers and must include adequate ascites control with diuretic therapy and percutaneous paracentesis. Preoperative anemia and electrolyte abnormalities should be aggressively treated. Finally, while wound complications are common and frequently require reintervention, they are not associated with increased mortality. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level V.
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Abstract
Umbilical and epigastric hernias are primary midline defects that are present in up to 50% of the population. In the United States, only about 1% of the population carries this specific diagnosis, and only about 11% of these are repaired. Repair is aimed at symptoms relief or prevention, and the patient's goals and expectations should be explicitly identified and aligned with the health care team. This article details some relevant and interesting anatomic issues, reviews existing data, and highlights some common and important surgical techniques. Emphasis is placed on a patient-centered approach to the repair of umbilical and epigastric hernias.
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Russell KW, Mone MC, Scaife CL. Umbilical paracentesis for acute hernia reduction in cirrhotic patients. BMJ Case Rep 2013; 2013:bcr-2013-201304. [PMID: 24132449 DOI: 10.1136/bcr-2013-201304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Emergent repair of umbilical hernias in cirrhotic patients is associated with a high risk for morbidity and mortality. We propose a new technique, umbilical paracentesis, for reduction of incarcerated hernias in the patient with ascites. Under ultrasound guidance, removal of ascitic fluid from the umbilical hernia sac can reduce the local pressure and thereby allow for easy hernia reduction, thus avoiding the need for an emergent operation.
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Affiliation(s)
- Katie W Russell
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
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Umbilical hernia management during liver transplantation. Hernia 2013; 17:515-9. [PMID: 23793929 DOI: 10.1007/s10029-013-1131-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 06/14/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE Patients with liver cirrhosis scheduled for liver transplantation often present with a concurrent umbilical hernia. Optimal management of these patients is not clear. The objective of this study was to compare the outcomes of patients who underwent umbilical hernia correction during liver transplantation through a separate infra-umbilical incision with those who underwent correction through the same incision used to perform the liver transplantation. METHODS In the period between 1990 and 2011, all 27 patients with umbilical hernia and liver cirrhosis who underwent hernia correction during liver transplantation were identified in our hospital database. In 17 cases, umbilical hernia repair was performed through a separate infra-umbilical incision (separate incision group) and 10 were corrected from within the abdominal cavity without a separate incision (same incision group). Six patients died during follow-up; no deaths were attributable to intraoperative umbilical hernia repair. All 21 patients who were alive visited the outpatient clinic to detect recurrent umbilical hernia. RESULTS One recurrent umbilical hernia was diagnosed in the separate incision group (6 %) and four (40 %) in the same incision group (p = 0.047). Two patients in the same incision group required repair of the recurrent umbilical hernia; one of whom underwent emergency surgery for bowel incarceration. The one recurrent hernia in the separate incision group was corrected electively. CONCLUSION In the event of liver transplantation, umbilical hernia repair through a separate infra-umbilical incision is preferred over correction through the same incision used to perform the transplantation.
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Abstract
Umbilical hernia (UH) is the most frequent abdominal wall complication of ascites in cirrhotic patients. Treatment to control ascites, which mainly consists of repeated paracentesis or transjugular intrahepatic portosystemic shunt (TIPS), is mandatory; otherwise the risk of hernia recurrence is very high. Nowadays, surgical portosystemic shunts are rarely performed. Classically, hernia repair was offered only to patients with symptomatic UH, but presently, even if the hernia is minimally symptomatic, there is tendency to perform elective repair to avoid emergency surgery for complications associated with very high mortality and morbidity rates (rupture and strangulation). If liver transplantation is indicated, treatment of UH can be performed simultaneously, unless the hernia is highly symptomatic or complicated or if the waiting time on the transplantation list is long. During repair, necrotic skin tissue should be excised; the use of prosthetic material (if the defect is large) is possible with a low risk of infection as long as ascites is sterile. The advantage of laparoscopic repair of large UH is to avoid any skin incision (precluding ascitic fluid leak) and avoid exposing prosthetic mesh to necrotic infected tissue. If the defect is small, UH repair can be performed under local anesthesia.
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Silva FD, Andraus W, Pinheiro RSN, Arantes-Junior RM, Lemes MPL, Ducatti LDSES, D'albuquerque LAC. Hérnias abdominais e inguinais em pacientes cirróticos: qual é a melhor conduta? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012; 25:52-5. [DOI: 10.1590/s0102-67202012000100012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUÇÃO: Tradicionalmente os procedimentos abdominais eletivos em pacientes cirróticos têm sido amplamente desencorajados graças à elevada morbi-mortalidade consequente às complicações da cirrose, descritas por diversos autores. Outros serviços, em contrapartida, obtiveram resultados distintos, advogando a favor de cirurgia eletiva. MÉTODOS: Uma revisão de artigos utilizando-se a palavras "abdominal wall hernia" e "cirrhotic patients" foi realizada na base de dados PubMed. Dos resultados obtidos, 28 artigos foram considerados para elaboração desta revisão. RESULTADOS: Pôde-se observar que a incidência de hérnias em parede abdominal é relativamente elevada em pacientes cirróticos, sendo que muitas delas têm evolução desfavorável e requerem tratamento cirúrgico específico. Com o advento do sistema de alocação de órgãos baseados no escore de MELD, muitos centros estão repensando suas condutas em situações como esta, dado que muitos dos pacientes em questão encontram-se em lista de espera para transplante hepático. Dessa forma a cirurgia eletiva tem conquistado maior papel no manejo desta condição com intuito de diminuir morbi-mortalidade nesses pacientes. Além disso, a qualidade de vida mostrou-se um importante fator a ser considerado, estando muito prejudicada nesta condição. CONCLUSÃO: Poucos estudos com grandes amostragens foram conduzidos até o momento e não há consenso sobre qual conduta é a mais indicada levando em consideração taxas de morbi-mortalidade.
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Altom LK, Graham LA, Gray SH, Snyder CW, Vick CC, Hawn MT. Outcomes for Incisional Hernia Repair in Patients Undergoing Concomitant Surgical Procedures. Am Surg 2012. [DOI: 10.1177/000313481207800246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The safety and efficacy of performing concomitant surgical procedures with an incisional hernia repair (IHR) is not well understood. There are conflicting reports on the outcomes for permanent mesh implantation in the setting of clean-contaminated procedures. The purpose of this study was to review the effect of concomitant surgical procedures on IHR outcomes. This is a retrospective multisite cohort of patients undergoing elective IHR at 16 Veterans Affairs hospitals from 1998 to 2002. Concomitant procedure status, hernia characteristics, and operative details were determined using physician-abstracted operative notes. Hernia outcomes of recurrence and mesh explantation were determined from the medical chart. χ2 tests, Kaplan-Meier curves, and Cox regression were used to evaluate the effects of concomitant status on hernia outcomes. Of the 1495 elective IHRs, 75 (4.8%) were same site and 56 (3.8%) different site concomitant procedures. At median follow-up of 69.3 months (range 19.1–98.3), 33.6 per cent of patients had a recurrence, mesh explantation, or both. Permanent mesh placement was less likely among concomitant procedures as compared with nonconcomitant procedures ( P < 0.0001). Adjusted Cox proportional hazards models of hernia outcomes resulted in an increased hazard for recurrence among same site clean procedures (Hazard Ratio (HR) = 1.8, P = 0.03) and an increased hazard for mesh explantation among same site clean-contaminated procedures (HR = 8.4, P = 0.002). Concomitant same site procedures are significantly associated with adverse hernia outcomes as compared with isolated IHR or IHR with other site concomitant procedures. The high failure rate of hernia repairs among same site concomitant procedures should be taken into account during the surgical decision-making process.
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Affiliation(s)
- Laura K. Altom
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama; the, Birmingham, Alabama
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and the, Birmingham, Alabama
- Health Services/Comparative Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura A. Graham
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama; the, Birmingham, Alabama
| | - Stephen H. Gray
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and the, Birmingham, Alabama
| | - Christopher W. Snyder
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and the, Birmingham, Alabama
| | - Catherine C. Vick
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama; the, Birmingham, Alabama
| | - Mary T. Hawn
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama; the, Birmingham, Alabama
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and the, Birmingham, Alabama
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de Goede B, Klitsie PJ, Lange JF, Metselaar HJ, Kazemier G. Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review. Best Pract Res Clin Gastroenterol 2012; 26:47-59. [PMID: 22482525 DOI: 10.1016/j.bpg.2012.01.010] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/17/2012] [Accepted: 01/17/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study is to review systematically morbidity and mortality after non-hepatic surgery in patients with liver cirrhosis. METHODS Comprehensive searches were conducted in PubMed, Embase and the Cochrane Library for articles using the words: liver failure, hepatic insufficiency, liver cirrhosis, cirrhosis, cirrhotic, surgical procedures, operative complications, operative mortality, postoperative complications, surgical complication, surgical risk, hernia. RESULTS Forty-six articles were selected from 5247 included after the initial search. Level of evidence provided in the articles varied greatly. Non-hepatic surgery of patients with cirrhosis resulted in increased postoperative morbidity and mortality compared to similar surgery for non-cirrhotic patients. Cholecystectomy and umbilical and inguinal hernia correction were associated with the lowest increased morbidity and mortality while pancreatic surgery, cardiovascular, and trauma surgery correlated with the highest. The preoperative model for end stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores appeared to be predictive of postoperative risks. Portal hypertension and surgery in the emergency setting were associated with extra increased mortality and morbidity rates. CONCLUSION This systematic review of the literature showed that in patients with liver cirrhosis who undergo non-hepatic surgery, postoperative morbidity and mortality rates varied greatly depending on severity of the cirrhosis and the surgical procedure. However, the majority of procedures can be safely performed in patients with low MELD scores or CTP A cirrhosis without portal hypertension.
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Affiliation(s)
- B de Goede
- Erasmus University Medical Center, Department of Surgery, Medical Center, Rotterdam, The Netherlands
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Choi SB, Hong KD, Lee JS, Han HJ, Kim WB, Song TJ, Suh SO, Kim YC, Choi SY. Management of umbilical hernia complicated with liver cirrhosis: an advocate of early and elective herniorrhaphy. Dig Liver Dis 2011; 43:991-5. [PMID: 21872542 DOI: 10.1016/j.dld.2011.07.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 06/08/2011] [Accepted: 07/23/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with umbilical hernias complicated by liver cirrhosis have an increased likelihood of complications following herniorrhaphy. The aim of this study was to investigate the clinical outcomes in patients with umbilical hernias complicated by liver cirrhosis. METHODS Between 2001 and 2010, 44 patients were enrolled in this study. The comparison between non-operative and operative group was performed. Patients who underwent emergency versus elective surgery were also compared. RESULTS Of the 44 patients, there were 33 men and 11 women. Thirty-one patients (70.5%) underwent surgery and 13 patients (29.5%) were treated conservatively. Overall morbidity and mortality rates following herniorrhaphy were 42% and 6.5%. The mean albumin level was significantly lower and total bilirubin, creatinine and mean model of end-stage liver disease score were significantly higher in non-operative group than in operative group. Combined resection was performed more frequently in the emergency group than in elective group. A significantly higher proportion of patients in emergency operation group had postoperative complications (P=0.01), especially ascites (P=0.02). The operative time and postoperative hospital stay were significantly shorter in the elective operation group than in emergency operation group. CONCLUSIONS Early, elective repair of umbilical hernias in cirrhotic patients should be advocated considering the hepatic reserve and patient's condition. Ascites control is the mainstay of post-operative management.
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Affiliation(s)
- Sae Byeol Choi
- Department of Surgery, Korea University College of Medicine, Korea University Guro Hospital, 80 Guro-dong, Guro-gu, Seoul, Republic of Korea
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Eker HH, van Ramshorst GH, de Goede B, Tilanus HW, Metselaar HJ, de Man RA, Lange JF, Kazemier G. A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery 2011; 150:542-6. [PMID: 21621237 DOI: 10.1016/j.surg.2011.02.026] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 02/17/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with both cirrhosis and ascites have a 20% risk of developing umbilical hernia. A retrospective study from our center comparing conservative management of umbilical hernia with elective repair in these patients showed a significant risk of mortality as a result of hernia incarceration in conservatively treated patients. The goal of this study was to assess the safety and efficacy of elective umbilical hernia repair in these patients prospectively. METHODS Patients with liver cirrhosis and ascites presenting with an umbilical hernia were included in this study. For all patients, the expected time to liver transplantation was more than 3 months, and they did not have a patent umbilical vein in the hernia sac. The following data were collected prospectively for all patients: Child-Pugh-Turcotte (CPT) classification, model for end-stage liver disease (MELD) score, kidney failure, cardiovascular comorbidity, operation-related complications, and duration of hospital stay. Mortality rates were registered in hospital records and verified in government records during follow-up. Mortality rates were registered in hospital records and verified in government records during follow-up. On completion of the study, a retrospective survey was performed to search for any patients who met the study inclusion criteria but were left out of the study cohort. RESULTS In total, 30 patients (25 males) underwent operation at a mean age of 58 years (standard deviation [SD] ± 9 years). Of these 30 patients, 6 were classified as CPT grade A (20%), 19 (63%) as grade B, and 5 (17%) as grade C. The patients' median MELD score was 12 (interquartile range [IQR], 8-16). In 10 (33%) of the 30 patients hernia repair was performed with mesh. The median duration of hospital stay was 3 days (IQR, 2-4). None of the patients were admitted to the intensive care unit. Postoperative complications included pneumonia and decompensation of cirrhosis (1 case each,) resulting in prolonged hospital stay for those 2 patients. After a median follow-up period of 25 months (IQR, 14-34), 2 (7%) of the 30 patients died; neither of the deaths were attributable to the umbilical hernia repair. A total of 2 patients suffered recurrence. CONCLUSION Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites.
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Affiliation(s)
- Hasan H Eker
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Abstract
The most common complications of umbilical hernias in patients with cirrhosis and ascites include leakage, ulceration, rupture and incarceration. If such a complication is present, there is a high mortality rate after surgical repair. Elective repair is the most effective choice, as it prevents complications with a lower mortality. However, the control of ascites before and/or after repair is mandatory but may not always be possible with diuretics and paracentesis. Portal decompression by transjugular intrahepatic portosystemic shunt (TIPS) with better control of ascites may allow these patients to undergo surgery. Patients with cirrhosis and umbilical hernias should be referred for consideration of an elective surgical repair with mesh, preferably after optimal management of ascites. There should be a low threshold for placement of a TIPS to facilitate surgery and reduce the chance of severe recurrence of ascites. If surgery is contraindicated, a TIPS must be considered for control of ascites.
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