Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk

Increased preoperative aspartate aminotransferase-to-platelet ratio index predicts complications following total shoulder arthroplasty

Background

This study investigates the association between aspartate aminotransferase-to-platelet ratio index (APRI), a noninvasive measure of liver function, and 30-day postoperative complications following total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2021. The study population was divided into 4 groups based on preoperative APRI: normal/reference (APRI ≤ 0.5), mild fibrosis (0.5 < APRI ≤ 0.7), significant fibrosis (0.7 < APRI ≤ 1), and cirrhosis (APRI > 1). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative APRI and postoperative complications.

Results

Compared to the reference group, significant fibrosis was independently associated with a greater likelihood of major complications (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.11-2.99; P = .017), minor complications (OR: 2.70, 95% CI: 1.67-4.37; P < .001), pneumonia (OR: 5.78, 95% CI: 2.58-12.95; P < .001), blood transfusions (OR: 2.89, 95% CI: 1.57-5.32; P < .001), readmission (OR: 1.88, 95% CI: 1.10-3.21; P = .022), and non-home discharge (OR: 1.83, 95% CI: 1.23-2.73; P = .003). Cirrhosis was independently associated with a greater likelihood of minor complications (OR: 3.96, 95% CI: 2.67-5.88; P < .001), blood transfusions (OR: 5.85, 95% CI: 3.79-9.03; P < .001), failure to wean off a ventilator (OR: 9.10, 95% CI: 1.98-41.82; P = .005), and non-home discharge (OR: 2.06, 95% CI: 1.43-2.96; P < .001).

Conclusion

Increasing preoperative APRI was associated with an increasing rate of postoperative complications following TSA.

Right heart failure and patient selection for isolated tricuspid valve surgery

OBJECTIVE

To characterize patients with right heart failure undergoing isolated tricuspid valve surgery, focusing on right heart morphology and function.

PATIENTS AND METHODS

From January 2007 to January 2014, 62 patients underwent isolated tricuspid valve surgery. Forty-five patients (73%) had undergone previous heart operations. Right heart morphology and function variables were measured de novo from stored echocardiographic images, and clinical and hemodynamic data were extracted from patient registries and records. Cluster analysis was performed and outcomes assessed.

RESULTS

On average, the right ventricle was dilated (diastolic area 32 cm2), but its function was preserved (free-wall strain -17% ± 5.8%) and right heart failure manifestations were moderate, with 40 (65%) having congested neck veins, 35 (56%) dependent edema, and 15 (24%) ascites. Average model for end-stage liver disease with sodium score was 11 ± 4.4, but individual values varied widely. Tricuspid valve variables split patients into 2 equal clusters: those with functional tricuspid regurgitation (TR) and those with structural TR. These groups had similar right ventricular function, but the functional TR group had worse right ventricular morphology and more severe manifestations of right heart failure, including greater model for end-stage liver disease with sodium scores (12 ± 44 vs 9.1 ± 3.9; P = .008). Both groups survived operation with low morbidity, but patients with functional TR had worse long-term survival, 48% versus 73% at 10 years after surgery.

CONCLUSIONS

The cluster analysis of patients with right heart failure undergoing isolated tricuspid valve surgery separated functional and structural tricuspid valve disease. Good early outcomes suggest expanding criteria for tricuspid valve surgery and earlier intervention for functional TR with right heart failure.

Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach

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.

Umbilical hernia repair in patients with cirrhosis: systematic review of mortality and complications

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.

Surgical Risk Assessment in Patients with Chronic Liver Diseases

Chronic liver diseases (CLD) is one of the leading causes of morbidity and mortality. The overall life span of patients with CLD has increased and so is the number of surgical procedures these patients undergo. Pathophysiological and hemodynamic changes in cirrhosis make these patients more susceptible to hypotension and hypoxia during surgery. They also have a high risk of drug induced liver injury, renal dysfunction and post-operative liver decompensation. Patients with CLD planned for elective or semi-elective surgery should undergo detailed preoperative risk assessment. Patients should be evaluated for the presence of clinically significant portal hypertension and cirrhosis. In the absence of both cirrhosis and clinically significant portal hypertension, patients with CLD can undergo surgery with minimal or low risk. Various risk assessment tools available for patients with advanced CLD are-CTP score, MELD Score, Mayo risk score, VOCAL-Penn score. A Child class C and/or Mayo risk score >15 in general is associated with high risk of post-operative mortality and elective surgery should be deferred in these patients. In patients with Child class, A and MELD 10-15 surgery is permissible with caution (except liver resection and cardiac surgery) while in Child A and MELD <10 surgery is well tolerated. VOCAL-Penn score is a new promising tool and can be the better alternative of CTP, MELD, and Mayo risk score models but more prospective studies with large patients' population are warranted. Certain surgeries like Hepatic resection, intraabdominal, and cardiothoracic have higher risk than abdominal wall hernia repair and orthopedic surgery. Laparoscopic approaches have better outcomes and less risk of liver failure than open surgery. Minimally invasive alternatives like colonic stent placement in case of obstruction can be considered in high-risk cases. Perioperative optimization and management of ascites, HE, bleeding, liver decompensation, and nutrition should be done with multidisciplinary approach. Patients with cirrhosis undergoing high risk elective surgery can develop liver failure in post-operative period and should be evaluated and counseled for liver transplantation if not contraindicated.

Incidence and Risk Factors of Postoperative Mortality and Morbidity After Elective Versus Emergent Abdominal Surgery in a National Sample of 8193 Patients With Cirrhosis

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.

Hybrid method using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia in a patient with liver cirrhosis and severe varicose veins: A case report

INTRODUCTION

Cirrhosis is a significant determinant of postoperative morbidity and mortality. Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment of inguinal hernia because of the substantial recurrence rate and high postoperative morbidity and mortality. However, hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with severe liver cirrhosis. No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis.

PRESENTATION OF CASE

A 62-year-old man with a history of chronic C-type liver cirrhosis (Child-Pugh classification C) and hepatocellular carcinoma was referred to us for surgical treatment of an irreducible right inguinal hernia. An abdominal computed tomography (CT) scan revealed that the small intestine had herniated into the scrotum and severe abdominal wall varicose veins due to liver cirrhosis. We performed a hybrid method that combines examination laparoscopy and Lichtenstein's technique to observe the abdominal cavity and to avoid the risks due to severe varicosis of the inferior epigastric vein.

DISCUSSION

There have been some reports of inguinal hernia with cirrhosis and ascites, but no reports of incarcerated inguinal hernia with abdominal wall varicose veins. In the present case, we chose a laparoscopic approach to observe the abdominal cavity to confirm intestinal necrosis. Hybrid surgery using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia could be performed safely.

CONCLUSION

Hybrid surgery using laparoscopy and Lichtenstein's technique may be an effective method for patients with incarcerated inguinal hernia with end-stage cirrhosis and severe abdominal varicosis.

Performance of non-invasive fibrosis scores in non-alcoholic fatty liver disease with and without morbid obesity

BACKGROUND

Non-invasive scores, such as the non-alcoholic fatty liver disease (NAFLD) Fibrosis Score (NFS), are increasingly used for liver fibrosis assessment in patients with NAFLD. The aim of this study was to assess the applicability and reliability of non-invasive fibrosis scores in NAFLD patients with and without morbid obesity.

METHODS

Three hundred sixty-eight patients with biopsy-proven NAFLD identified between January 2012 and December 2015 were studied; 225 with morbid obesity (biopsy obtained during bariatric surgery) and 143 patients without (termed as "conventional").

RESULTS

Median age was 47 years, 57% were female. Median body mass index (BMI) was 42.9 kg/m² with significant differences between our conventional and morbidly obese patients (BMI 29.0 vs. 50.8 kg/m², p < 0.001). Overall, 42% displayed mild/moderate and 16% advanced liver fibrosis (stage III/IV). All tested scores were significantly linked to fibrosis stage (p < 0.001 for all). FIB-4 (AUROC 0.904), APRI (AUROC 0.848), and NFS (AUROC 0.750) were identified as potent predictors of advanced fibrosis, although NFS overestimated fibrosis stage in morbid obesity. Limiting BMI to a maximum of 40 kg/m² improved NFS' overall performance (AUROC 0.838). FIB-4 > 1.0 indicated high probability of advanced fibrosis (OR = 29.1). FIB-4 predicted advanced fibrosis independently from age, sex, BMI, and presence of morbid obesity.

CONCLUSIONS

Our data suggest that FIB-4 score is an accurate predictor of advanced fibrosis in NAFLD throughout all BMI stages. Without adjustment, NFS tends to overestimate fibrosis in morbidly obese NAFLD patients. This problem may be solved by implementation of an upper BMI limit (for NFS) or adjustment of diagnostic thresholds.

Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions

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.

Bariatric Surgery in Cirrhotic Patients: a Matched Case-Control Study

INTRODUCTION

Laparoscopic bariatric surgery (LBS) in liver end-stage organ disease has been proven to improve organ function and patients' symptoms. A series of LBS in patients with cirrhosis have shown good results in weight loss, but increased risk of complications. Current literature is based on clinical series. This paper aims to compare LBS (69% gastric bypass) between patients with cirrhosis and without cirrhosis.

METHODS

We conducted a retrospective 1:3 matched case-control study including bariatric patients with cirrhosis and without cirrhosis. Demographics, operative variables, postoperative complications, long-term weight loss, and comorbidity resolution were compared between groups.

RESULTS

Sixteen Child A patients were included in the patients with cirrhosis (PC) group and 48 in patients without cirrhosis (control) group. Mean age was 50 years; preoperative BMI was 39 ± 6.8 kg/m². Laparoscopic gastric bypass and laparoscopic sleeve gastrectomy were performed in 69% and 31%, respectively. Follow-up was 81% at 2 years for both groups. PC group had a higher rate of overall (31% vs. 6%; p < 0.05) and severe (Clavien-Dindo ≥ III; 13% vs. 0%; p = 0.013) complications than that of the control group. Mean %EWL of PC at 2 years of follow-up was 84.9%, without differences compared with that of the control group (83.1%). Comorbidity remission in PC was 14%, 50%, and 85% for hypertension, type 2 diabetes, and dyslipidemia, respectively. Patients without cirrhosis had a higher resolution rate of hypertension (65% vs. 14%, p = 0.03).

CONCLUSION

LBS is effective for weight loss and comorbidity resolution in patients with obesity and Child A liver cirrhosis. However, these results are accompanied by significantly increased risk of complications.

Evaluation and Management of Cirrhotic Patients Undergoing Elective Surgery

PURPOSE OF REVIEW

Cirrhotic patients have an increased risk of surgical complications and higher perioperative morbidity and mortality based on the severity of their liver disease. Liver disease predisposes patients to perioperative coagulopathies, volume overload, and encephalopathy. The goal of this paper is to discuss the surgical risk of cirrhotic patients undergoing elective surgeries and to discuss perioperative optimization strategies.

RECENT FINDINGS

Literature thus far varies by surgery type and the magnitude of surgical risk. CTP and MELD classification scores allow for the assessment of surgical risk in cirrhotic patients. Once the decision has been made to undergo elective surgery, cirrhotic patients can be optimized pre-procedure with the help of a checklist and by the involvement of a multidisciplinary team. Elective surgeries should be performed at hospital centers staffed by healthcare providers experienced in caring for cirrhotic patients. Further research is needed to develop ways to prepare this complicated patient population before elective surgery.

Non-Hepatic Abdominal Surgery in Patients with Cirrhotic Liver Disease

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.

Dynamic changes of portal vein pressure gradient under different degrees of liver cirrhosis and resection volume in the first week post hepatectomy

AIM

We set out to acquire original pathophysiologic data of dynamic changes in portal vein pressure gradient (PVPG) following liver resection (LR) during post-operation days (POD) 1-7.

METHODS

Portal vein pressure gradient was measured in 31 patients daily until POD 7 at our liver surgery center. Patients were divided into non-, mild, moderate, and severe cirrhosis groups according to histopathology and were also divided into subgroups according to the volume of hepatectomy.

RESULTS

Portal vein pressure gradient reached its peak on POD 3 in mild cirrhosis (F = 7.525, P < 0.001), moderate cirrhosis (F = 11.200, P < 0.001), and severe cirrhosis groups (F = 26.634, P < 0.001). There were no significant changes in PVPG in the non-cirrhosis group (F = 1.050, P = 0.411). Moreover, PVPG on POD 3 was higher with increasing severity of cirrhosis under the same interval of LR volume (resection volume <200 cm³ : F = 13.040, P = 0.004; ≥200 cm³ but <400 cm³ : F = 13.243, P = 0.004; ≥400 cm³ : F = 43.685, P < 0.001). Finally, the LR volume had significant impact on PVPG for patients with moderate cirrhosis (F = 6.339, P = 0.033) and severe cirrhosis (t = -7.000, P = 0.020). A similar tendency was also observed when patients were divided according to the ratio of the resected liver volume to total liver volume.

CONCLUSIONS

The increase in PVPG following LR was positively associated with the degree of cirrhosis, significantly peaking on POD 3. The LR volume only had a significant impact on PVPG for patients with moderate and severe cirrhosis. This represents the first time, to our knowledge, that dynamic changes of PVPG after LR were measured and compared to cirrhosis and resection volume.

Changes of liver hemodynamic and elastography parameters in patients with colorectal liver metastases receiving preoperative chemotherapy: "a note of caution"

BACKGROUND

New systemic chemotherapy agents have improved prognosis in patients with colorectal liver metastases (CLM), but some of them damage the liver parenchyma and ultimately increase postoperative morbidity and mortality after liver resection. The aims of our study were to determine the degree of hemodynamic and pathological liver injury in CLM patients receiving preoperative chemotherapy and to identify an association between these injuries and postoperative complications after liver resection.

METHODS

This is a prospective descriptive study of patients with CLM receiving preoperative chemotherapy before curative liver resection from November 2013 to June 2014. All patients had preoperative elastography and hepatic hemodynamic evaluation. We analyzed clinical preoperative data and postoperative outcomes after grouping the patients by chemotherapy type, development of sinusoidal obstructive syndrome (SOS), and development of major complications.

RESULTS

Eleven from the 20 patients included in the study received preoperative oxaliplatin-based chemotherapy (OBC). Nine patients had SOS at pathological analysis and five patients developed major complications. Patients receiving preoperative OBC had higher values of hepatic venous pressure gradient (HVPG) and developed more SOS and major complications. Patients developing SOS had higher values of HVPG and developed more major complications. Patients with major complications had higher values of HVPG, and patients with a HVPG of 5 mmHg or greater had more major complications than those under 5 mmHg (20 vs 80%, p = 0.005).

CONCLUSIONS

OBC and SOS impair liver hemodynamics in CLM patients. An increase in major complications after liver resection in these patients develops at subclinical HVPG levels.