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Kling SM, Taylor GA, Peterson NR, Patel T, Fagenson AM, Poggio JL, Ross HM, Pitt HA, Lau KN, Philp MM. Colectomy in patients with liver disease: albumin-bilirubin score accurately predicts outcomes. J Gastrointest Surg 2024; 28:843-851. [PMID: 38522642 DOI: 10.1016/j.gassur.2024.03.012] [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: 12/21/2023] [Revised: 02/17/2024] [Accepted: 03/09/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction. METHODS All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score. RESULTS Of 86,273 patients identified, 48% (N = 41,624) were Albumin-Bilirubin Grade 1, 45% (N = 38,370) Grade 2 and 7% (N = 6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001). CONCLUSION Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.
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Affiliation(s)
- Sarah M Kling
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - George A Taylor
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Nicholas R Peterson
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Takshaka Patel
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Alexander M Fagenson
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Juan Lucas Poggio
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States; Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States
| | - Howard M Ross
- Department of Surgery, Hackensack University Medical Center, Hackensack, New Jersey, United States
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, United States
| | - Kwan N Lau
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States; Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States
| | - Matthew M Philp
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States; Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States.
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Delabays C, Demartines N, Joliat GR, Melloul E. Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis. Perioper Med (Lond) 2024; 13:24. [PMID: 38561792 PMCID: PMC10983761 DOI: 10.1186/s13741-024-00375-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Few studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care. METHODS A literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates. RESULTS After evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31-0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference - 2.04, 95% CI - 3.19 to - 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure. CONCLUSION In cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.
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Affiliation(s)
- Constant Delabays
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Emmanuel Melloul
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
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Nevarez NM, Chang G, Porembka MR, Mansour JC, Wang SC, Polanco PM, Zeh HJ, Yopp AC. Presence of underlying cirrhosis is associated with increased in-hospital mortality and length of stay following pancreatoduodenectomy. HPB (Oxford) 2024; 26:251-258. [PMID: 37867083 DOI: 10.1016/j.hpb.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/25/2023] [Accepted: 10/07/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Patient- and hospital-level factors associated with outcomes following pancreatoduodenectomy (PD) are well established. However, despite theoretical disruption in hepatopetal flow, the impact of cirrhosis on in-hospital mortality following PD is not well-studied. The objective of this study was to evaluate in-hospital mortality, length of stay (LOS), and post-discharge disposition in patients with cirrhosis undergoing PD. METHODS A retrospective analysis of the National Inpatient Sample (January 2002-August 2015) was conducted identifying patients undergoing PD. Using previously validated ICD-9-CM codes, patients were stratified into presence and absence of cirrhosis. Factors associated with in-hospital mortality following PD were analyzed adjusting for patient- and hospital-level factors. Following PD were analyzed after adjusting for patient- and hospital-level factors. RESULTS In 16,344 patients that underwent PD, 203 (1.2 %) patients had underlying cirrhosis prior to resection. Overall in-hospital mortality following PD was significantly worse in the cirrhosis cohort (11.3 % vs. 3.6 %, p < 0.001). Patients with underlying cirrhosis were less likely to be discharged home (73.9 % vs. 83.2 %, p < 0.001) and had a longer median LOS (12.0 vs. 10.0 days, p = 0.001). CONCLUSION The presence of underlying cirrhosis is associated with increased in-hospital mortality, longer LOS, and decreased likelihood of home discharge following PD. Given the prohibitive risks, PD should not be performed in patients with underlying cirrhosis.
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Affiliation(s)
- Nicole M Nevarez
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.
| | - Gloria Chang
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Matthew R Porembka
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - John C Mansour
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Sam C Wang
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Patricio M Polanco
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Herbert J Zeh
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Adam C Yopp
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
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Zamorano AAG, Valencia PS, Porrazzo GR, Almerey T, Stauffer JA. Comparison of complications for cirrhotic versus non-cirrhotic patients undergoing pancreaticoduodenectomy. Langenbecks Arch Surg 2023; 408:383. [PMID: 37770715 DOI: 10.1007/s00423-023-03120-y] [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: 04/04/2023] [Accepted: 09/21/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE To compare the outcomes between patients with cirrhosis and those without who have undergone pancreatoduodenectomy (PD) in our institution. METHODS A review of patients undergoing PD from the time period of January 2010 to December 2020 was performed. Patients that have undergone open or laparoscopic PD and had liver cirrhosis diagnosed prior to surgery were included and matched on a 1:2 basis with non-cirrhotic patients based on age, gender, Eastern Cooperative Oncology Group (ECOG), and date of surgery. Data was obtained from our medical records and ten major postoperative complications variables were compared to the matched group. RESULTS Overall, 16 patients with cirrhosis were compared to 32 matched controls. No significant differences were found in pancreatic fistula (18.8% vs. 21.8%; P= 1.000), hemorrhage (6.3% vs. 6.2%; P= 1.000), delayed gastric emptying (6.3% vs. 15.6%; P= 0.648), wound infection (0% vs. 9.3%; P= 0.541), and intraabdominal abscess (31.2% vs 6.2%; 0.4998) for cirrhotic vs. non-cirrhotic respectively. There were no postop ileus, gastric fistula, mesenteric portal thrombosis, biliary fistula, and abdominal ischemic event in either group. The average length of stay for both groups was similar (6.9 vs. 9.3 days; P= 0.4019). There were no mortalities and major morbidity was similar (37.5% vs 34.3%; P=0.3549). One patient required readmission for liver-related decompensation with full recovery. CONCLUSION PD in patients with cirrhosis can be safe and feasible in well-selected patients. In a high-volume institution, postoperative complications are similar to those patients without cirrhosis of the liver.
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Affiliation(s)
- Alicia Amairan G Zamorano
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
- Faculty of Health Sciences, Anahuac University, Lomas Anahuac 46, 52786, Anahuac, Mexico
| | - Paula Spang Valencia
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
- Faculty of Medicine, University of Navarra, 31008, Pamplona, Spain
| | - Gina R Porrazzo
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Tariq Almerey
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - John A Stauffer
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, 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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The Management of Postoperative Cognitive Dysfunction in Cirrhotic Patients: An Overview of the Literature. Medicina (B Aires) 2023; 59:medicina59030465. [PMID: 36984466 PMCID: PMC10053389 DOI: 10.3390/medicina59030465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Background and objectives: Postoperative cognitive dysfunction (POCD) represents a decreased cognitive performance in patients undergoing general anesthesia for major surgery. Since liver cirrhosis is associated with high mortality and morbidity rates, cirrhotic patients also assemble many risk factors for POCD. Therefore, preserving cognition after major surgery is a priority, especially in this group of patients. The purpose of this review is to summarize the current knowledge regarding the effectiveness of perioperative therapeutic strategies in terms of cognitive dysfunction reduction. Data Collection: Using medical search engines such as PubMed, Google Scholar, and Cochrane library, we analyzed articles on topics such as: POCD, perioperative management in patients with cirrhosis, hepatic encephalopathy, general anesthesia in patients with liver cirrhosis, depth of anesthesia, virtual reality in perioperative settings. We included 115 relevant original articles, reviews and meta-analyses, and other article types such as case reports, guidelines, editorials, and medical books. Results: According to the reviewed literature, the predictive capacity of the common clinical tools used to quantify cognitive dysfunction in cirrhotic settings is reduced in perioperative settings; however, novel neuropsychological tools could manage to better identify the subclinical forms of perioperative cognitive impairments in cirrhotic patients. Moreover, patients with preoperative hepatic encephalopathy could benefit from specific preventive strategies aimed to reduce the risk of further neurocognitive deterioration. Intraoperatively, the adequate monitoring of the anesthesia depth, appropriate anesthetics use, and an opioid-sparing technique have shown favorable results in terms of POCD. Early recovery after surgery (ERAS) protocols should be implemented in the postoperative setting. Other pharmacological strategies provided conflicting results in reducing POCD in cirrhotic patients. Conclusions: The perioperative management of the cognitive function of cirrhotic patients is challenging for anesthesia providers, with specific and targeted therapies for POCD still sparse. Therefore, the implementation of preventive strategies appears to remain the optimal attitude. Further research is needed for a better understanding of POCD, especially in cirrhotic patients.
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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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Chandan S, Deliwala S, Khan SR, Ramai D, Mohan BP, Bilal M, Facciorusso A, Kassab LL, Kamal F, Dhindsa B, Perisetti A, Adler DG. Advanced Endoscopic Resection Techniques in Cirrhosis-A Systematic Review and Meta-Analysis of Outcomes. Dig Dis Sci 2022; 67:4813-4826. [PMID: 34993682 DOI: 10.1007/s10620-021-07364-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/08/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS While safety and effectiveness of advanced endoscopic resection techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) has been well established in general population, data regarding their utility in patients with cirrhosis is limited. METHODS We searched multiple databases from inception through July 2021 to identify studies that reported on outcomes of EMR and/or ESD in patients with cirrhosis. Meta-analysis was performed to determine pooled rates of immediate and delayed bleeding, perforation, death as well as rates of successful en bloc and R0 resection. Pooled relative risk (RR) was calculated for each outcome between patients with and without cirrhosis. RESULTS Ten studies with a total of 3244 patients were included in the final analysis. Pooled rates of immediate & delayed bleeding, perforation, and death during EMR and/or ESD in patients with cirrhosis were 9.5% (CI 4.0-21.1), 6.6% (CI 4.2-10.3), 2.1% (CI 1.1-3.9) and 0.6% (CI 0.2-1.7), respectively. Pooled rates of successful en bloc and R0 resection were 93% (CI 85.9-96.7) and 90.8% (CI 86.5-93.8), respectively. While incidence of immediate bleeding was higher in patients with cirrhosis, there was no statistically significant difference in any of the other outcomes between the patient groups. CONCLUSIONS Our study shows that performing EMR and ESD for gastrointestinal lesions in patients with cirrhosis is both safe and effective. The risks of procedural complications parallel those reported in general population.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE, USA
| | - Smit Deliwala
- Internal Medicine, Hurley Medical Center, Flint, MI, USA
| | - Shahab R Khan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota & Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | | | - Faisal Kamal
- Division of Gastroenterology, University of California-San Francisco, San Francisco, CA, USA
| | - Banreet Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, CO, USA.
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Mittal T, Ahuja A, Dey A, Malik VK, Sheikh MTM, Bansal NK, Kanuri H. Safety and efficacy of laparoscopic sleeve gastrectomy in patients with portal hypertension with liver function of Childs A. Surg Endosc 2022; 36:2942-2948. [PMID: 34129090 DOI: 10.1007/s00464-021-08587-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/02/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Advanced liver disease and portal hypertension (PH) are seen as a relative contraindication for bariatric and metabolic surgery. Several studies have shown significant improvement in liver function and liver histology after bariatric surgery. There are very few studies describing bariatric surgery in patients with PH. The purpose of this retrospective study is to evaluate the feasibility and results of laparoscopic sleeve gastrectomy (SG) in patients with PH. MATERIAL AND METHODS We present our experience of performing laparoscopic SG in 15 patients with evidence of PH. All the patients were Childs Pugh Criteria A. PH was confirmed by the presence of dilated esophageal varices on endoscopy. RESULTS The mean operative time was 77.33 ± 15.22 min and mean blood loss was 80.67 ± 37.12 ml. The mean length of stay was 2.73 ± 0.59 days. There were no intraoperative or immediate postoperative complications. None of the patients required blood transfusion in the postoperative period. The weight, BMI, Excess body weight loss% (EBWL%), Total weight loss (TWL) and TWL% at 1 year were 86.05 ± 14.40 kg, 31.16 kg/m2 ± 3.82, 63.84% ± 15.24, 31.49 ± 9.54 kg and 26.50 ± 5.42%, respectively. Diabetes and hypertension resolution at 1 year was 80% and 72.72%, respectively. All the patients were followed up for mean 3 ± 1.5 years. There were no immediate or long-term morbidity and mortality noted. CONCLUSION SG is a feasible and safe option for the treatment of obesity in carefully selected patients with PH with good weight loss and comorbidity resolution.
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Affiliation(s)
- Tarun Mittal
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, Old Rajender Nagar, New Delhi, 110060, India.
| | - Anmol Ahuja
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, Old Rajender Nagar, New Delhi, 110060, India
| | - Ashish Dey
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, Old Rajender Nagar, New Delhi, 110060, India
| | - Vinod K Malik
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, Old Rajender Nagar, New Delhi, 110060, India
| | - Mohammad Taha Mustafa Sheikh
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, Old Rajender Nagar, New Delhi, 110060, India
| | - Naresh Kumar Bansal
- Institute of Liver Gastroenterology and Hepatobiliary Sciences, Sir Ganga Ram Hospital, Old Rajender Nagar, New Delhi, 110060, India
| | - Harish Kanuri
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, Old Rajender Nagar, New Delhi, 110060, India
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10
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Vedachalam S, Jalil S, Krishna SG, Porter K, Li N, Kelly SG, Conteh L, Mumtaz K. Call for action: Increased healthcare utilization with growing use of percutaneous cholecystectomy tube over initial cholecystectomy in cirrhotics. Hepatobiliary Pancreat Dis Int 2022; 21:56-62. [PMID: 34420884 DOI: 10.1016/j.hbpd.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/30/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute calculous cholecystitis (ACC) is frequently seen in cirrhotics, with some being poor candidates for initial cholecystectomy. Instead, these patients may undergo percutaneous cholecystostomy tube (PCT) placement. We studied the healthcare utilization and predictors of cholecystectomy and PCT in patients with ACC. METHODS The National Database was queried to study all cirrhotics and non-cirrhotics with ACC between 2010-2014 who underwent initial PCT (with or without follow-up cholecystectomy) or cholecystectomy. Cirrhotic patients were divided into compensated and decompensated cirrhosis. Independent predictors and outcomes of initial PCT and failure to undergo subsequent cholecystectomy were studied. RESULTS Out of 919 189 patients with ACC, 13 283 (1.4%) had cirrhosis. Among cirrhotics, cholecystectomy was performed in 12 790 (96.3%) and PCT in the remaining 493 (3.7%). PCT was more frequent in cirrhotics (3.7%) than in non-cirrhotics (1.4%). Multivariate analyses showed increased early readmissions [odds ratio (OR) = 2.12, 95% confidence interval (CI): 1.43-3.13, P < 0.001], length of stay (effect ratio = 1.39, 95% CI: 1.20-1.61, P < 0.001), calendar-year hospital cost (effect ratio = 1.34, 95% CI: 1.28-1.39, P < 0.001) and calendar-year mortality (hazard ratio = 1.89, 95% CI: 1.07-3.29, P = 0.030) in cirrhotics undergoing initial PCT compared to cholecystectomy. Decompensated cirrhosis (OR = 2.25, 95% CI: 1.67-3.03, P < 0.001) had the highest odds of getting initial PCT. Cirrhosis, regardless of compensated (OR = 0.56, 95% CI: 0.34-0.90, P = 0.020) or decompensated (OR = 0.28, 95% CI: 0.14-0.59, P < 0.001), reduced the chances of getting a subsequent cholecystectomy. CONCLUSIONS Cirrhotic patients undergo fewer cholecystectomy incurring initial PCT instead. Moreover, the rates of follow-up cholecystectomy are lower in cirrhotics. Increased healthcare utilization is seen with initial PCT amongst cirrhotic patients. This situation reflects suboptimal management of ACC in cirrhotics and a call for action.
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Affiliation(s)
- Srikanth Vedachalam
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sajid Jalil
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Somashaker G Krishna
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Na Li
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sean G Kelly
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Lanla Conteh
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Khalid Mumtaz
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
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11
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Honerkamp I, Sandmann L, Richter N, Manns MP, Voigtländer T, Vondran FW, von Hahn T. Surgical Procedures in Patients Awaiting Liver Transplantation: Complications and Impact on the Liver Function. J Clin Exp Hepatol 2022; 12:68-79. [PMID: 35068787 PMCID: PMC8766540 DOI: 10.1016/j.jceh.2021.03.011] [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] [Received: 08/18/2020] [Accepted: 03/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Potential indications for surgery frequently arise in patients awaiting liver transplantation. There is a risk of hepatic decompensation and death triggered by surgical trauma, but this has not been studied in detail in this unique population. We aimed to quantify the impact of surgical interventions in patients awaiting liver transplantation on hepatic function and identify risk factors for decompensation. METHODS All surgeries between 2000 and 2018 in patients awaiting liver transplantation in a highvolume German liver transplant center were analyzed retrospectively. Change in liver function measured as indicated by MELD score was assessed and complication rates recorded. The primary endpoint was a composite of an increase in MELD score by > 5 points or death. A logistic regression model was used for multivariate analysis to identify risk factors. RESULTS In total, 177 surgical procedures in 148 patients were analyzed. The primary endpoint was reached in 42 cases (23.7%). The overall in-hospital complication rate (including death) was 44.1%. Multivariate analysis identified elevated leukocyte count, perioperative blood transfusion, preoperative presence of ascites, and preoperative circulatory support as independent risk factors for a decline in liver function or death. CONCLUSION Surgery in patients awaiting liver transplantation carries a relevant risk of hepatic decompensation and death that needs to be considered when deciding whether to perform elective surgery prior to or defer until after liver transplantation.
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Key Words
- ACLF, Acute-on-Chronic Liver Failure
- ALT, Alanine transaminase
- ASA, American Society of Anesthesiologists physical status classification system
- AST, Aspartate transaminase
- CHE, Cholinesterase
- CRP, C-reactive Protein
- HCC, Hepatocellular carcinoma
- Hb, Hemoglobin
- INR, International Normalized Ratio
- MELD
- MELD, Model for End-stage Liver Disease
- OR, Odds Ratio
- SBP, Spontaneous Bacterial Peritonitis
- Tsd, Thousand
- aPTT, Activated partial thromboplastin time
- cirrhosis
- dl, Deciliter
- g, Gram
- i.e., id est
- l, Liter
- liver transplantation
- log, Logarithm
- mg, Milligram
- min, Minutes
- mmol, Millimole
- surgery
- vs, Versus
- waiting list
- μl, Microliter
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Affiliation(s)
- Imke Honerkamp
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany
| | - Lisa Sandmann
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany
| | - Torsten Voigtländer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany
| | - Florian W.R. Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany
| | - Thomas von Hahn
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany,Department of Gastroenterology, Hepatology and Interventional Endoscopy, Asklepios Hospital Barmbek, Semmelweis University Budapest, Campus Hamburg, Rübenkamp 220, Germany,Address for correspondence: Prof. Dr. Med. Thomas von Hahn, Department of Gastroenterology, Hepatology and Interventional Endoscopy, Rübenkamp 220, Hamburg, 22307, Germany. Tel.: +49 40 18 18 82 3810; Fax: +49 40 18 18 82 3809.
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12
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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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Kim J, Randhawa H, Sands D, Lambe S, Puglia M, Serrano PE, Pinthus JH. Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations. Bladder Cancer 2021. [DOI: 10.3233/blc-211536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.
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Affiliation(s)
- John Kim
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - David Sands
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Shahid Lambe
- Division of Urology, McMaster University, Hamilton, ON, Canada
- McMaster Institute of Urology, St. Joseph’s Hospital, Hamilton, ON, Canada
| | - Marco Puglia
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | | | - Jehonathan H. Pinthus
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
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Bariatric Surgery and Liver Disease: General Considerations and Role of the Gut-Liver Axis. Nutrients 2021; 13:nu13082649. [PMID: 34444807 PMCID: PMC8399840 DOI: 10.3390/nu13082649] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 02/07/2023] Open
Abstract
Weight loss is a therapeutic solution for many metabolic disorders, such as obesity and its complications. Bariatric surgery aims to achieve lasting weight loss in all patients who have failed after multiple dietary attempts. Among its many benefits, it has been associated with the regression of non-alcoholic fatty liver disease (NAFLD), which is often associated with obesity, with evidence of substantial improvement in tissue inflammation and fibrosis. These benefits are mediated not only by weight loss, but also by favorable changes in systemic inflammation and in the composition of the gut microbiota. Changes in microbial metabolites such as short-chain fatty acids (SCFAs), capable of acting as endocrine mediators, and bile acids (BAs) as well as modifications of the gut-brain axis, are among the involved mechanisms. However, not all bariatric surgeries show beneficial effects on the liver; those leading to malabsorption can cause liver failure or a marked worsening of fibrosis and the development of cirrhosis. Nevertheless, there are still many unclear aspects, including the extent of the benefits and the magnitude of the risks of bariatric surgery in cirrhotic patients. In addition, the usefulness and the safety of these procedures in patients who are candidates to or who have undergone liver transplant need solid supporting evidence. This paper aims to review literature data on the use of bariatric surgery in the setting of chronic liver disease.
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15
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Yane Y, Kawamura J, Ushijima H, Yoshioka Y, Kato H, Ueda K. 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. Int J Surg Case Rep 2021; 85:106207. [PMID: 34343796 PMCID: PMC8349998 DOI: 10.1016/j.ijscr.2021.106207] [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] [Received: 05/17/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 11/02/2022] Open
Abstract
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.
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Affiliation(s)
- Yoshinori Yane
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan.
| | - Junichiro Kawamura
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Hokuto Ushijima
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Yasumasa Yoshioka
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Hiroaki Kato
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Kazuki Ueda
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
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16
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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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17
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Oliver JB, Merchant AM, Koneru B. The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization. J INVEST SURG 2021; 34:617-626. [PMID: 31661332 DOI: 10.1080/08941939.2019.1676846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have shown high rates of postoperative morbidity and mortality in individuals with chronic liver disease (CLD). However, analyses from comparisons with individuals without CLD are not available. Such analyses might provide opportunities to improve outcomes. METHODS Data from The National Surgical Quality Improvement Program (NSQIP) from 2008 to 2011 were analyzed comparing CLD patients undergoing non-liver surgery propensity matched to those without CLD. Patients with CLD were stratified by Model of End Stage Liver Disease (MELD) scores <15 and ≥15. Primary outcome was all cause mortality, and secondary outcomes were composite and individual morbidity, hospital length of stay, readmission, reoperation, and discharge destination. Odds ratios (OR) were calculated, and length of hospital stay was estimated using Poisson regression. RESULTS There were 6,209 patients with CLD (4,013 with low MELD, 2,196 with high MELD) matched to 18,627 patients without. Patients with CLD had 1.8- and 3.3-times higher odds of mortality (95% CI 1.6-2.1 for Low MELD (10.6%), 2.9-3.8 for high MELD (35.2%), and 1.8- and 2.2-times higher odds of any morbidity (1.6-1.9 and 1.9-2.4). Complications specific to CLD were increased based on MELD specifically coma (OR 1.6, 0.9-2.9 for Low MELD, 2.2, 1.5-3.2 for High MELD), renal failure (OR 1.4, 1.1-1.8 and 2.4, 2.0-2.9), and bleeding (OR 1.7, 1.5-1.9 and 2.0, 1.8-2.3). They also had a 20% and 80% longer length of stay, 2.2- and 3.4-times higher odds of being discharged somewhere other than home, 1.7- and 1.6-times higher odds of readmission, and 1.5- and 1.6-times higher odds of reoperation. CONCLUSION Patients with CLD have significantly higher odds of mortality and morbidity, which is increased with a higher MELD. Interventions that decrease those morbidities are needed and have the potential to decrease mortality and resource utilization.
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Affiliation(s)
- Joseph B Oliver
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA.,Department of Surgery, East Orange Veterans Affairs Hospital, East Orange, NJ, USA
| | - Aziz M Merchant
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Baburao Koneru
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
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Tanaka H, Imai H, Higashi T, Murase K, Matsuhashi N, Yoshida K. Pancreaticoduodenectomy combined with splenectomy for a patient with pancreatic cancer and pancytopenia due to liver cirrhosis: Case report. Int J Surg Case Rep 2021; 81:105715. [PMID: 33689973 PMCID: PMC7941177 DOI: 10.1016/j.ijscr.2021.105715] [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] [Received: 02/02/2021] [Revised: 02/27/2021] [Accepted: 02/28/2021] [Indexed: 02/07/2023] Open
Abstract
Patients with LC are known to have a greater risk of postoperative morbidity and mortality than patients without LC. The outcomes of surgery in patients with LC have been reported to vary, based not only on the degree of damage to the liver but also the invasiveness of the surgery. For patients with PC with pancytopenia due to LC, PD combined with splenectomy is effective.
Introduction and importance The incidence of patients with liver cirrhosis (LC) is increasing. Patients with LC are known to have a greater risk of postoperative morbidity and mortality than patients without LC. A treatment option such as pancreaticoduodenectomy (PD) has not been validated to be safe for these patients, especially those with pancytopenia due to portal hypertension (PH). Providing an effective treatment option for these patients is essential. Case presentation Herein, we describe a patient with pancreatic cancer with pancytopenia due to LC that was successfully treated with PD combined with splenectomy. The patient was a 70-year-old woman who was referred to our hospital for evaluation of a mass in the pancreatic head after she developed obstructive jaundice. She was diagnosed with T2N0M0, Stage IB pancreatic cancer and pancytopenia due to PH associated with LC. She received 2 cycles of adjuvant gemcitabine/S-1 chemotherapy and underwent radical subtotal stomach-preserving pancreaticoduodenectomy with splenectomy to improve her pancytopenia. Histopathological examination of the resected specimen revealed an R0 resection showing an Evans grade IIa histological response. Her pancytopenia improved rapidly after surgery. Clinical discussion Strict indications for PD, haemostatic control of intraoperative bleeding, and optimal perioperative management were important for preventing hepatic decompensation in this patient. Splenectomy is effective for thrombocytopenia due to LC; however, attention to postoperative complications such as overwhelming post-splenectomy infection and portal vein thrombosis is required. Conclusion For patients with pancreatic cancer with pancytopenia due to LC, PD combined with splenectomy plus optimal perioperative management is effective.
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Affiliation(s)
- Hideharu Tanaka
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
| | - Hisashi Imai
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
| | - Toshiya Higashi
- Department of General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
| | - Katsutoshi Murase
- Department of General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
| | - Nobuhisa Matsuhashi
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
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Chou AH, Lin YS, Wu VCC, Chen FT, Yang CH, Chen DY, Chen SW. Effect of medications after cardiac surgery on long-term outcomes in patients with cirrhosis. Medicine (Baltimore) 2021; 100:e23075. [PMID: 33592816 PMCID: PMC7870262 DOI: 10.1097/md.0000000000023075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/13/2020] [Indexed: 01/05/2023] Open
Abstract
The aim of this study was to evaluate the effect of beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) after cardiac surgery in the liver cirrhosis (LC) patients. We conducted a population-based cohort study using data from the Taiwanese National Health Insurance Research Database (NHIRD) from 2001 to 2013. The outcomes of interest included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE) and liver and renal outcomes. Among 1470 LC patients, 35.6% (n = 524) received beta-blockers and 33.4% (n = 491) were prescribed ACEIs and/or ARBs after cardiac surgery. The risk of negative liver outcomes was significantly lower in the ARB group compared with the ACEI group (9.6% vs 22.7%, hazard ratio [HR] 0.50, 95% confidence interval [CI] 0.31-0.83). Furthermore, the risk of MACCE (44.2% vs 54.7%, HR 0.79, 95% CI 0.65-0.96), all-cause mortality (35.3% vs 46.4%, HR 0.74, 95% CI 0.60-0.92), composite liver outcomes (9.6% vs 16.5%, HR 0.56, 95% CI 0.38-0.85) and hepatic encephalopathy (2.7% vs 5.7%, HR 0.45, 95% CI 0.21-0.94) were lower in the ARB group than the control group. Our study demonstrated that ARBs provide a greater protective effect than ACEIs in regard to long-term outcomes following cardiac surgery in patients with LC.
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Affiliation(s)
- An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical, Center
- Collage of Medicine, Chang Gung University, Taoyuan City
| | - Yu-Sheng Lin
- Department of Cardiology, Chiayi Branch, Chiayi City
| | | | - Fang-Ting Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical, Center
| | | | | | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
- Graduate Institute of Clinical Medical Sciences, College of medicine, Chang Gung, University, Taoyuan City, Taiwan
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Cheng K, Liu W, You J, Shah S, Cai Y, Wang X, Peng B. Safety of laparoscopic pancreaticoduodenectomy in patients with liver cirrhosis using propensity score matching. PLoS One 2021; 16:e0246364. [PMID: 33513179 PMCID: PMC7845952 DOI: 10.1371/journal.pone.0246364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Currently, safety of laparoscopic pancreaticoduodenectomy (LPD) in patients with liver cirrhosis is unknown. The aim of this study was to explore postoperative morbidity and mortality and long-term outcomes of cirrhotic patients after LPD. The study was a one-center retrospective study comprising 353 patients who underwent LPD between October 2010 and December 2019. A total of 28 patients had liver cirrhosis and were paired with 56 non-cirrhotic counterparts through propensity score matching (PSM). Baseline data, intra-operative data, postoperative data, and survival data were collected. Postoperative morbidity was considered as primary outcome whereas postoperative mortality, surgical parameters (operative durations, intraoperative blood loss), and long-term overall survival were secondary outcomes. Cirrhotic patients showed postoperative complication rates of 82% compared with rates of patients in the control group (48%) (P = 0.003). Further, Clavien-Dindo ≥III complication rates of 14% and 11% (P = 0.634), Clavien-Dindo I-II complication rates of 68% and 38% (P = 0.009), hospital mortality of 4% and 2% (P = 0.613) were observed for cirrhotic patients and non-cirrhotic patients, respectively. In addition, an overall survival rate of 32 months and 34.5 months (P = 0.991), intraoperative blood loss of 300 (200-400) ml and 150 (100-250) ml (P<0.0001), drain amount of 2572.5 (1023.8-5275) ml and 1617.5 (907.5-2700) ml (P = 0.048) were observed in the cirrhotic group and control group, respectively. In conclusion, LPD is associated with increased risk of postoperative morbidity in patients with liver cirrhosis. However, the incidence of Clavien-Dindo ≥III complications and post-operative mortality showed no significant increase. In addition, liver cirrhosis showed no correlation with poor overall survival in patients who underwent LPD. These findings imply that liver cirrhosis patients can routinely be considered for LPD at high volume centers with rigorous selection and management.
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Affiliation(s)
- Ke Cheng
- Pancreatic Department, The West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei Liu
- Pancreatic Department, The West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiaying You
- Pancreatic Department, The West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shashi Shah
- Pancreatic Department, The West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yunqiang Cai
- Pancreatic Department, The West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Wang
- Pancreatic Department, The West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bing Peng
- Pancreatic Department, The West China Hospital, Sichuan University, Chengdu, Sichuan, China
- * E-mail:
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Predicting Operative Outcomes in Patients with Liver Disease: Albumin-Bilirubin Score vs Model for End-Stage Liver Disease-Sodium Score. J Am Coll Surg 2020; 232:470-480.e2. [PMID: 33346079 DOI: 10.1016/j.jamcollsurg.2020.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The albumin-bilirubin score (ALBI) has recently been shown to have increased accuracy in predicting post-hepatectomy liver failure and mortality compared with the Model for End-Stage Liver Disease (MELD). However, the use of ALBI as a predictor of postoperative mortality for other surgical procedures has not been analyzed. The aim of this study was to measure the predictive power of ALBI compared with MELD-sodium (MELD-Na) across a wide range of surgical procedures. STUDY DESIGN Patients undergoing cardiac, pulmonary, esophageal, gastric, gallbladder, pancreatic, splenic, appendix, colorectal, adrenal, renal, hernia, and aortic operations were identified in the 2015-2018 American College of Surgeons NSQIP database. Patients with missing laboratory data were excluded. Univariable analysis and receiver operator characteristic curves were performed for 30-day mortality and morbidity. Areas under the curves were calculated to validate and compare the predictive abilities of ALBI and MELD-Na. RESULTS Of 258,658 patients, the distribution of ALBI grades 1, 2, 3 were 51%, 42%, and 7%, respectively. Median MELD-Na was 7.50 (interquartile range 6.43 to 9.43). Overall 30-day mortality rate was 2.7% and overall morbidity was 28.6%. Increasing ALBI grade was significantly associated with mortality (ALBI grade 2: odds ratio [OR] 5.24; p < 0.001; ALBI grade 3: OR 25.6; p < 0.001) and morbidity (ALBI grade 2: OR 2.15; p < 0.001; ALBI grade 3: OR 6.12; p < 0.001). On receiver operator characteristic analysis, ALBI outperformed MELD-Na with increased accuracy in several operations. CONCLUSIONS ALBI score predicts mortality and morbidity across a wide spectrum of surgical procedures. When compared with MELD-Na, ALBI more accurately predicts outcomes in patients undergoing pulmonary, elective colorectal, and adrenal operations.
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Maeda H, Kageyama K, Yamamoto A, Jogo A, Sohgawa E, Matsushita K, Asano K, Yonezawa H, Nota T, Murai K, Ogawa S, Miki Y. Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report. CVIR Endovasc 2020; 3:90. [PMID: 33275189 PMCID: PMC7718362 DOI: 10.1186/s42155-020-00187-2] [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] [Received: 09/03/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background Colonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported. Case presentation A 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up. Conclusions CARTO-II can be one of the effective treatment techniques for ascending colonic varices.
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Affiliation(s)
- Hiroyuki Maeda
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan.
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Takehito Nota
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
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Spring A, Saran JS, McCarthy S, McCluskey SA. Anesthesia for the Patient with Severe Liver Failure. Adv Anesth 2020; 38:251-267. [PMID: 34106838 DOI: 10.1016/j.aan.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.
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Affiliation(s)
- Aidan Spring
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Jagroop S Saran
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Sinead McCarthy
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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Tessiatore KM, Mahmud N. Trends in surgical volume and in-hospital mortality among United States cirrhosis hospitalizations. Ann Gastroenterol 2020; 34:85-92. [PMID: 33414627 PMCID: PMC7774658 DOI: 10.20524/aog.2020.0554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022] Open
Abstract
Background In the aging population of patients with cirrhosis in the United States, there is a potentially increased need for surgical procedures. However, individuals with cirrhosis have increased perioperative risk relative to patients without cirrhosis. We sought to quantify temporal trends in cirrhosis surgical procedures and in-hospital mortality in relation to surgical procedure type, elective admission status and compensated vs. decompensated status. Methods We performed a retrospective cohort study of cirrhosis hospitalizations between 2005 and 2014 using the National Inpatient Sample. Surgical procedures of interest included cholecystectomy, hernia repair, and major abdominal, orthopedic and cardiovascular surgery. We plotted trends in volume and in-hospital mortality by procedure type, and used linear regression to test the significance of trends. Results While the number of cirrhosis hospitalizations increased over time, the number of surgeries per 1000 admissions decreased (b=-1.454, P<0.001). When stratified by elective admission status, elective major orthopedic surgeries significantly increased over time (b=177.9; P<0.001). In-hospital mortality rates for most surgeries were significantly higher in the non-elective vs. elective setting (each P<0.001). In patients with compensated cirrhosis, there was a significant increase in the number of orthopedic (b=272.4; P<0.001) and hernia repair surgeries over time (b=191.1; P<0.001). Overall, there was significantly greater in-hospital mortality among patients with decompensated cirrhosis (each P<0.05). Q. Please mention the exact P-value unless <0.001 Conclusions Despite an increasing number of cirrhosis hospitalizations, the decreasing relative number of cirrhosis surgeries may indicate progressive surgical risk aversion. Future cirrhosis surgical risk scores should consider surgical procedure type, elective/non-elective status, and decompensation status.
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Affiliation(s)
- Kristen M Tessiatore
- Department of Internal Medicine, Perelman School of Medicine (Kristen M. Tessiatore)
| | - Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine (Nadim Mahmud).,Leonard David Institute of Health Economics (Nadim Mahmud), University of Pennsylvania, Philadelphia, PA, USA
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Are VS, Knapp SM, Banerjee A, Shamseddeen H, Ghabril M, Orman E, Patidar KR, Chalasani N, Desai AP. Improving Outcomes of Bariatric Surgery in Patients With Cirrhosis in the United States: A Nationwide Assessment. Am J Gastroenterol 2020; 115:1849-1856. [PMID: 33156104 PMCID: PMC8021461 DOI: 10.14309/ajg.0000000000000911] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION With increasing burden of obesity and liver disease in the United States, a better understanding of bariatric surgery in context of cirrhosis is needed. We described trends of hospital-based outcomes of bariatric surgery among cirrhotics and determined effect of volume status and type of surgery on these outcomes. METHODS In this population-based study, admissions for bariatric surgery were extracted from the National Inpatient Sample using International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes from 2004 to 2016 and grouped by cirrhosis status, type of bariatric surgery, and center volume. In-hospital mortality, complications, and their trends were compared between these groups using weighted counts, odds ratios [ORs], and logistic regression. RESULTS Among 1,679,828 admissions for bariatric surgery, 9,802 (0.58%) had cirrhosis. Cirrhosis admissions were more likely to be in white men, had higher Elixhauser Index, and higher in-hospital complications rates including death (1.81% vs 0.17%), acute kidney injury (4.5% vs 1.2%), bleeding (2.9% vs 1.1%), and operative complications (2% vs 0.6%) (P < 0.001 for all) compared to those without cirrhosis. Overtime, restrictive surgeries have grown in number (12%-71%) and complications rates have trended down in both groups. Cirrhotics undergoing bariatric surgery at low-volume centers (<50 procedures per year) and nonrestrictive surgery had a higher inpatient mortality rate (adjusted OR 4.50, 95% confidence interval 3.14-6.45, adjusted OR 4.00, 95% confidence interval 2.68-5.97, respectively). DISCUSSION Contemporary data indicate that among admissions for bariatric surgery, there is a shift to restrictive-type surgeries with an improvement in-hospital complications and mortality. However, patients with cirrhosis especially those at low-volume centers have significantly higher risk of worse outcomes (see Visual abstract, Supplementary Digital Content, http://links.lww.com/AJG/B648).
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Affiliation(s)
- Vijay S. Are
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon M. Knapp
- University of Arizona Health Sciences and Bio5 Institute, Tucson, Arizona, USA
| | - Ambar Banerjee
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Quezada N, Maturana G, Irarrázaval MJ, Muñoz R, Morales S, Achurra P, Azócar C, Crovari F. Bariatric Surgery in Cirrhotic Patients: a Matched Case-Control Study. Obes Surg 2020; 30:4724-4731. [PMID: 32808168 DOI: 10.1007/s11695-020-04929-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Nicolás Quezada
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile.
| | - Gregorio Maturana
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - María Jesús Irarrázaval
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - Rodrigo Muñoz
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile
| | - Sebastián Morales
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - Pablo Achurra
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile
| | - Cristóbal Azócar
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - Fernando Crovari
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile
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Shin N, Han EC, Won S, Ryoo SB, Choe EK, Park BK, Park KJ. The prognoses and postoperative outcomes of patients with both colorectal cancer and liver cirrhosis based on a nationwide cohort in Korea. Ann Surg Treat Res 2020; 99:82-89. [PMID: 32802813 PMCID: PMC7406393 DOI: 10.4174/astr.2020.99.2.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/11/2020] [Accepted: 05/23/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose The management of patients with colorectal cancer (CRC) who have liver cirrhosis (LC) requires a thorough understanding of both diseases; however, the prognoses and postoperative outcomes of such patients remain understudied. We investigated the effect of LC on surgical and oncologic outcomes in patients with CRC, and identified prognostic factors. Methods We analyzed 453 patients with CRC and LC (CRC-LC group), 906 with CRC only (CRC group), 906 with LC only (LC group), and 1,812 healthy subjects using health insurance claim data (2008–2013). Results The CRC-LC group had a higher frequency of intensive care unit admission than the CRC group; there were no differences between the 2 groups in terms of early and late postoperative small bowel obstruction and incisional hernia. However, the 30-day, 60-day, and 90-day mortality rates were all significantly higher in the CRC-LC group. The higher Charlson comorbidity index (hazard ratio [HR], 1.127) and the lower socioeconomic status (HR, 0.985) were significant worse predictors of 5-year survival. Patients with underlying LC had a significantly higher HR in both the advanced CRC (HR, 1.858) and nonadvanced CRC (HR, 1.799) subgroups. However, the nonadvanced CRC subgroup showed a lower HR than the LC group (HR, 0.730). Conclusion Patients with CRC who had underlying LC had a lower survival rate than did those without LC, although the incidence rates of postoperative complications were not significantly different. The presence of LC was associated with a significantly lower survival rate regardless of CRC presence.
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Affiliation(s)
- Nari Shin
- Department of Public Health Sciences and Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Eon Chul Han
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Sungho Won
- Department of Public Health Sciences and Institute of Health and Environment, Seoul National University, Seoul, Korea.,Interdisciplinary Program in Bioinformatics, Seoul National University, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Choe
- Department of Surgery, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Byung Kwan Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Baimas-George M, Kirks RC, Cochran A, Baker EH, Lauren Paton B, Schiffern LM, Matthews BD, Martinie JB, Vrochides D, Iannitti DA. Patient Factors Lead to Extensive Variation in Outcomes and Cost From Cholecystectomy. Am Surg 2020; 86:643-651. [PMID: 32683960 DOI: 10.1177/0003134820923311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. RESULTS One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. CONCLUSION Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.
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Affiliation(s)
- Maria Baimas-George
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Russell C Kirks
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Lauren Paton
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lynnette M Schiffern
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Brent D Matthews
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Kazi A, Finco TB, Zakhary B, Firek M, Gerber A, Brenner M, Coimbra R. Acute Colonic Diverticulitis and Cirrhosis: Outcomes of Laparoscopic Colectomy Compared with an Open Approach. J Am Coll Surg 2020; 230:1045-1053. [PMID: 32229299 DOI: 10.1016/j.jamcollsurg.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The impact of cirrhosis on outcomes of acute colonic diverticulitis (ACD) has been studied infrequently. We investigated the effect of cirrhosis on outcomes of surgical patients with ACD treated by either an open or laparoscopic approach. METHODS A cross-sectional study was performed using the Nationwide Inpatient Sample 2012 to 2014. Patients with ACD were stratified into compensated and decompensated cirrhosis for comparisons of demographic characteristics, hospital length of stay, complications, mortality, and cost. Groups were stratified according to surgical treatment: open colectomy and laparoscopic colectomy. A comparative effectiveness analysis of outcomes was performed between the 2 surgical treatments. Univariate comparisons between groups and multivariate regression analysis were performed to identify risk factors for mortality and specific complications. RESULTS Of 1,172,875 patients hospitalized with the diagnosis of ACD during the study period, 1,145 were cirrhotic. The majority were male (59%). There were 660 compensated cirrhotic patients and 485 decompensated cirrhotic patients and all underwent either open (n = 875) or laparoscopic colectomy (n = 270). Consistently, marked increases in mortality, hospital length of stay, and cost were observed in decompensated cirrhotic patients regardless of the type of treatment. Laparoscopic colectomy was accompanied by shorter hospital length of stay, lower costs, and significantly decreased mortality rate compared with open colectomy in compensated and decompensated cirrhotic patients. CONCLUSIONS The presence of cirrhosis markedly impacts outcomes in patients with ACD, leading to prolonged hospitalization, higher cost, and increased complications and deaths. Laparoscopic colectomy is associated with better outcomes in patients requiring surgical management, including those with decompensated cirrhosis.
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Affiliation(s)
- Albert Kazi
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Tiago B Finco
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Matthew Firek
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Ari Gerber
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Megan Brenner
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA; Department of Surgery, University of California Riverside, Riverside, CA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA; Department of Surgery, Loma Linda University, Loma Linda, CA.
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30
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Vreeland TJ, Balla FM, Lin E, Davis SS, Yheulon CG. Post-operative outcomes for patients with liver-related ascites undergoing non-emergent laparoscopic cholecystectomy. Surg Endosc 2020; 35:884-890. [PMID: 32076860 DOI: 10.1007/s00464-020-07461-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 02/11/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Surgical procedures in patients with cirrhosis and associated ascites carry significant morbidity and mortality. However, these patients often undergo non-emergent but necessary procedures such as laparoscopic cholecystectomy. The purpose of this study is to determine the impact of cirrhosis with ascites on non-emergent laparoscopic cholecystectomy. METHODS The ACS-NSQIP database was queried from 2005 to 2017 for patients undergoing non-emergent laparoscopic cholecystectomy with or without intra-operative cholangiogram. Groups were propensity score matched for age, sex, BMI, smoking, inpatient status, ASA Class, presence of pre-operative SIRS/sepsis, and the individual components of the 5-item modified frailty index. RESULTS 346,105 patients were identified, 591 of which who had liver-related ascites. Patients without ascites were matched at a 5:1 ratio, producing 2955 controls. Patients with ascites had significantly higher rates of overall morbidity (15.6% vs. 11.3%, p = 0.0039), mortality (3.6% vs. 1.5%, p = 0.0020), and longer hospitalizations (7.4 vs. 4.4 days, p < 0.0001). Patients with ascites and a MELD score less than or equal to 9 had no difference in morbidity (p = 0.1124) or mortality (p = 0.6021) when compared to patients without ascites. Patients with ascites and a MELD score greater than 9 had significantly higher rates of both morbidity (25.8%, p = 0.0056) and mortality (7.1%, p = 0.0333). CONCLUSION Patients with cirrhosis and ascites have many comorbidities in addition to their liver disease. These patients are at significant risk for both morbidity and mortality related to non-emergent laparoscopic cholecystectomy. Surgeons should proceed with caution for patients with ascites and MELD scores greater than 9. These cases should only be performed by surgeons comfortable with difficult gallbladders at facilities equipped to take care of cirrhotic patients.
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Affiliation(s)
- Timothy J Vreeland
- Department of Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Fadi M Balla
- Department of Surgery, Kaiser Westside Medical Center, Hillsboro, OR, USA
| | - Edward Lin
- Division of General and GI Surgery, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - S Scott Davis
- Division of General and GI Surgery, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Christopher G Yheulon
- Division of General and GI Surgery, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA.
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Spring A, Saran JS, McCarthy S, McCluskey SA. Anesthesia for the Patient with Severe Liver Failure. Anesthesiol Clin 2020; 38:35-50. [PMID: 32008656 DOI: 10.1016/j.anclin.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.
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Affiliation(s)
- Aidan Spring
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Jagroop S Saran
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Sinead McCarthy
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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32
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Maassel NL, Fleming MM, Luo J, Zhang Y, Pei KY. Model for End-Stage Liver Disease Sodium as a Predictor of Surgical Risk in Cirrhotic Patients With Ascites. J Surg Res 2020; 250:45-52. [PMID: 32018142 DOI: 10.1016/j.jss.2019.12.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/11/2019] [Accepted: 12/30/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Model for End-Stage Liver Disease Sodium (MELD-Na) incorporates hyponatremia into the MELD score and has been shown to correlate with surgical outcomes. The pathophysiology of hyponatremia parallels that of ascites, which purports greater surgical risk. This study investigates whether MELD-Na accurately predicts morbidity and mortality in patients with ascites undergoing general surgery procedures. MATERIALS AND METHODS We used the National Surgical Quality Improvement Program database (2005-2014) to examine the adjusted risk of morbidity and mortality of cirrhotic patients with and without ascites undergoing inguinal or ventral hernia repair, cholecystectomy, and lysis of adhesions for bowel obstruction. Patients were stratified by the MELD-Na score and ascites. Outcomes were compared between patients with and without ascites for each stratum using low MELD-Na and no ascites group as a reference. RESULTS A total of 30,391 patients were analyzed. Within each MELD-Na stratum, patients with ascites had an increased risk of complications compared with the reference group (low MELD-Na and no ascites): low MELD-Na with ascites odds ratio (OR) 4.33 (95% confidence interval [CI] 1.96-9.59), moderate MELD-Na no ascites OR 1.70 (95% CI 1.52-1.9), moderate MELD-Na with ascites OR 3.69 (95% CI 2.49-5.46), high MELD-Na no ascites OR 3.51 (95% CI 3.07-4.01), and high MELD-Na ascites OR 7.18 (95% CI 5.33-9.67). Similarly, mortality risk was increased in patients with ascites compared with the reference: moderate MELD-Na no ascites OR 3.55 (95% CI 2.22-5.67), moderate MELD-Na ascites OR 13.80 (95% CI 5.65-33.71), high MELD-Na no ascites OR 8.34 (95% CI 5.15-13.51), and high MELD-Na ascites OR 43.97 (95% CI 23.76-81.39). CONCLUSIONS MELD-Na underestimates morbidity and mortality risk for general surgery patients with ascites.
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Affiliation(s)
- Nathan L Maassel
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Matthew M Fleming
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jiajun Luo
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, Texas
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Lu DY, Saybolt MD, Kiss DH, Matthai WH, Forde KA, Giri J, Wilensky RL. One-Year Outcomes of Percutaneous Coronary Intervention in Patients with End-Stage Liver Disease. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820901491. [PMID: 32030068 PMCID: PMC6977100 DOI: 10.1177/1179546820901491] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/01/2020] [Indexed: 12/18/2022]
Abstract
Background: Patients with cirrhosis and coronary artery disease (CAD) are at high risk
for morbidity during surgical revascularization so they are often referred
for complex percutaneous coronary intervention (PCI). Percutaneous coronary
intervention in the cirrhotic population also has inherent risks; however,
quantifiable data on long-term outcomes are lacking. Methods: Patients with angiographically significant CAD and cirrhosis were identified
from the catheterization lab databases of the University of Pennsylvania
Health System between 2007 and 2015. Outcomes were obtained from the medical
record and telephonic contact with patients/families. Results: Percutaneous coronary intervention was successfully performed in 42 patients
(51 PCIs). Twenty-nine patients with significant CAD were managed medically
(36 angiograms). The primary outcome (a composite of mortality, subsequent
revascularization, and myocardial infarction) was not significantly
different between the 2 groups during a follow-up period at 1 year (PCI:
50%, Control: 40%, P = .383). In the PCI group, a composite
adverse outcome rate that included acute kidney injury (AKI), severe bleed,
and peri-procedural stroke was elevated (40%), with severe bleeding
occurring after 23% of PCI events and post-procedural AKI occurring after
26% of events. The medical management group had significantly fewer total
matched adverse outcomes (17% vs 40% in the PCI group,
P = .03), with severe bleeding occurring after 11% of
events and AKI occurring after 6% of events. Increased risk of adverse
events following PCI was associated with severity of liver disease by
Child-Pugh class. Conclusions: Percutaneous coronary intervention in patients with cirrhosis is associated
with an elevated risk of adverse events, including severe bleeding and
AKI.
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Affiliation(s)
- Daniel Y Lu
- New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY, USA
| | - Matthew D Saybolt
- Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Daniel H Kiss
- Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, USA
| | - William H Matthai
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiovascular Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Kimberly A Forde
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay Giri
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert L Wilensky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Tabchouri N, Barbier L, Menahem B, Perarnau JM, Muscari F, Fares N, D'Alteroche L, Valette PJ, Dumortier J, Alves A, Lubrano J, Bureau C, Salamé E. Original Study: Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhotic Patients. J Gastrointest Surg 2019; 23:2383-2390. [PMID: 30820792 DOI: 10.1007/s11605-018-4053-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/08/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has been suggested to reduce portal hypertension-associated complications in cirrhotic patients undergoing abdominal surgery. The aim of this study was to compare postoperative outcome in cirrhotic patients with and without specific preoperative TIPS placement, following elective extrahepatic abdominal surgery. METHODS Patients were retrospectively included from 2005 to 2016 in four centers. Patients who underwent preoperative TIPS (n = 66) were compared to cirrhotic control patients without TIPS (n = 68). Postoperative outcome was analyzed using propensity score with inverse probability of treatment weighting analysis. RESULTS Overall, colorectal surgery accounted for 54% of all surgical procedure. TIPS patients had a higher initial Child-Pugh score (6[5-12] vs. 6[5-9], p = 0.043) and received more beta-blockers (65% vs. 22%, p < 0.001). In TIPS group, 56 (85%) patients managed to undergo planned surgery. Preoperative TIPS was associated with less postoperative ascites (hazard ratio = 0.330 [0.140-0.780]). Severe postoperative complications (Clavien-Dindo > 2) and 90-day mortality were similar between TIPS and no-TIPS groups (18% vs. 23%, p = 0.392, and 7.5% vs. 7.8%, p = 0.644, respectively). CONCLUSIONS Preoperative TIPS placement yielded an 85% operability rate with satisfying postoperative outcomes. No significant differences were found between TIPS and no-TIPS groups in terms of severe postoperative complications and mortality, although TIPS patients probably had worse initial portal hypertension.
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Affiliation(s)
- N Tabchouri
- Department of Digestive Surgery, Hepatobiliary Surgery and Liver Transplantation, University Hospital of Tours, CHU Tours, Avenue de la République, F37042, Tours, France.,FHU Support, F37000, Tours, France
| | - L Barbier
- Department of Digestive Surgery, Hepatobiliary Surgery and Liver Transplantation, University Hospital of Tours, CHU Tours, Avenue de la République, F37042, Tours, France.,FHU Support, F37000, Tours, France
| | - B Menahem
- Department of Digestive Surgery, University Hospital of Caen, Caen Cedex, France
| | - J-M Perarnau
- Department of Hepatology, University Hospital of Tours, CHU Tours, F37042, Tours, France
| | - F Muscari
- Department of Surgery, Hôpital Rangueil, Toulouse, France
| | - N Fares
- Department of Hepatology and Gastroenterology, Purpan Hospital, University Hospital of Toulouse, Place du Docteur Baylac TSA 40031, 31059, Toulouse Cedex 9, France
| | - L D'Alteroche
- Department of Hepatology, University Hospital of Tours, CHU Tours, F37042, Tours, France
| | - P-J Valette
- Department of Digestive Diseases, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, Lyon, France
| | - J Dumortier
- Department of Digestive Diseases, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, Lyon, France
| | - A Alves
- Department of Digestive Surgery, University Hospital of Caen, Caen Cedex, France
| | - J Lubrano
- Department of Digestive Surgery, University Hospital of Caen, Caen Cedex, France
| | - C Bureau
- Department of Hepatology and Gastroenterology, Purpan Hospital, University Hospital of Toulouse, Place du Docteur Baylac TSA 40031, 31059, Toulouse Cedex 9, France
| | - Ephrem Salamé
- Department of Digestive Surgery, Hepatobiliary Surgery and Liver Transplantation, University Hospital of Tours, CHU Tours, Avenue de la République, F37042, Tours, France. .,FHU Support, F37000, Tours, France.
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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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Reverter E, Cirera I, Albillos A, Debernardi-Venon W, Abraldes JG, Llop E, Flores A, Martínez-Palli G, Blasi A, Martínez J, Turon F, García-Valdecasas JC, Berzigotti A, de Lacy AM, Fuster J, Hernández-Gea V, Bosch J, García-Pagán JC. The prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery. J Hepatol 2019; 71:942-950. [PMID: 31330170 DOI: 10.1016/j.jhep.2019.07.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Surgery in cirrhosis is associated with a high morbidity and mortality. Retrospectively reported prognostic factors include emergency procedures, liver function (MELD/Child-Pugh scores) and portal hypertension (assessed by indirect markers). This study assessed the prognostic role of hepatic venous pressure gradient (HVPG) and other variables in elective extrahepatic surgery in patients with cirrhosis. METHODS A total of 140 patients with cirrhosis (Child-Pugh A/B/C: 59/37/4%), who were due to have elective extrahepatic surgery (121 abdominal; 9 cardiovascular/thoracic; 10 orthopedic and others), were prospectively included in 4 centers (2002-2011). Hepatic and systemic hemodynamics (HVPG, indocyanine green clearance, pulmonary artery catheterization) were assessed prior to surgery, and clinical and laboratory data were collected. Patients were followed-up for 1 year and mortality, transplantation, morbidity and post-surgical decompensation were studied. RESULTS Ninety-day and 1-year mortality rates were 8% and 17%, respectively. Variables independently associated with 1-year mortality were ASA class (American Society of Anesthesiologists), high-risk surgery (defined as open abdominal and cardiovascular/thoracic) and HVPG. These variables closely predicted 90-, 180- and 365-day mortality (C-statistic >0.8). HVPG values >16 mmHg were independently associated with mortality and values ≥20 mmHg identified a subgroup at very high risk of death (44%). Twenty-four patients presented persistent or de novo decompensation at 3 months. Low body mass index, Child-Pugh class and high-risk surgery were associated with death or decompensation. No patient with HVPG <10 mmHg or indocyanine green clearance >0.63 developed decompensation. CONCLUSIONS ASA class, HVPG and high-risk surgery were prognostic factors of 1-year mortality in cirrhotic patients undergoing elective extrahepatic surgery. HVPG values >16 mmHg, especially ≥20 mmHg, were associated with a high risk of post-surgical mortality. LAY SUMMARY The hepatic venous pressure gradient is associated with outcomes in patients with cirrhosis undergoing elective extrahepatic surgery. It enables a better stratification of risk in these patients and provides the foundations for potential interventions to improve post-surgical outcomes.
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Affiliation(s)
- Enric Reverter
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Isabel Cirera
- Gastroenterology and Hepatology, Hospital del Mar, Barcelona, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Juan G Abraldes
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Elba Llop
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Alexandra Flores
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, IDIBAPS, University of Barcelona, Spain
| | - Javier Martínez
- Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Annalisa Berzigotti
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Antoni M de Lacy
- Gastrointestinal Surgery Department, Hospital Clínic, IDIBAPS, University of Barcelona, Spain
| | - Josep Fuster
- Hepatobiliary and Pancreatic Surgery Department, Hospital Clínic. IDIBAPS, University of Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Jaume Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Joan Carles García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
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A step forward to accurately predict mortality in cirrhotic patients undergoing elective surgery: The role of the hepatic venous pressure gradient. J Hepatol 2019; 71:862-863. [PMID: 31558289 DOI: 10.1016/j.jhep.2019.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/02/2019] [Accepted: 09/04/2019] [Indexed: 12/23/2022]
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Outcomes of Patients With Cirrhosis Undergoing Orthopedic Procedures: An Analysis of the Nationwide Inpatient Sample. J Clin Gastroenterol 2019; 53:e356-e361. [PMID: 30001287 PMCID: PMC6443495 DOI: 10.1097/mcg.0000000000001091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The population of patients with cirrhosis is growing and shifting toward a more elderly demographic and thus are at risk of developing orthopedic complications. There is lack of data on safety of orthopedic procedures in this population. METHODS We performed an analysis of the Nationwide Inpatient Sample from 2005 to 2011 for patients undergoing hip arthroplasty, knee arthroplasty, and spinal laminectomy/fusion, stratified by presence of cirrhosis. The primary endpoint was in-hospital mortality and secondary endpoints included length of stay (LOS) and costs. RESULTS There were 693,610 inpatient stays for orthopedic procedures conducted during the study period, with 3014 (0.43%) patients coded as having cirrhosis. Patients with cirrhosis had a lower median age (62 vs. 66 y; P<0.001) and were more likely to be male (52.3% vs. 41.1%; P<0.001). The inpatient mortality rate was significantly higher in patients with cirrhosis (2.4% vs. 0.4%; P<0.001) as was median LOS (4 vs. 3 d; P<0.001) and mean costs ($19,321 vs. $18,833; P<0.001). Patients with decompensated cirrhosis (vs. compensated cirrhosis) had significantly higher inpatient mortality rates (5.8% vs. 1.1%; P<0.001) with higher LOS and costs (P<0.001). On multivariable analysis, cirrhosis was associated with an increased risk of mortality (odds ratio, 4.22; 95% confidence interval, 2.92-6.10). Hospital cirrhosis volume was inversely associated with mortality, while hospital orthopedic procedure volumes had an inconsistent impact on outcomes. CONCLUSIONS Inpatient orthopedic procedures in patients with cirrhosis result in high postoperative mortality, LOS, and costs. Careful patient selection is warranted to optimize cirrhosis patient postoperative outcomes.
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Kim SW, Kim MA, Chang Y, Lee HY, Yoon JS, Lee YB, Cho EJ, Lee JH, Yu SJ, Yoon JH, Park KJ, Kim YJ. Prognosis of surgical hernia repair in cirrhotic patients with refractory ascites. Hernia 2019; 24:481-488. [PMID: 31512088 DOI: 10.1007/s10029-019-02043-2] [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: 04/28/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Abdominal wall hernias are common in patients with ascites. Elective surgical repair is recommended for the treatment of abdominal wall hernias. However, surgical hernia repair in cirrhotic patients with refractory ascites is controversial. In this study, we aimed to evaluate the outcomes of elective surgical hernia repair in patients with liver cirrhosis with and without refractory ascites. METHOD From January 2005 to June 2018, we retrospectively reviewed the records of consecutive patients with liver cirrhosis who underwent a surgical hernia repair. RESULTS This study included 107 patients; 31 patients (29.0%) had refractory ascites. Preoperatively, cirrhotic patients with refractory ascites had a higher median model for end-stage liver disease (MELD) score (13.0 vs 11.0, P = 0.001) than those without refractory ascites. The 30-day mortality rate (3.2% vs 0%, P = 0.64) and the risk of recurrence (hazard ratio 0.410; 95% CI 0.050-3.220; P = 0.39) did not differ significantly between cirrhotic patients with refractory ascites and cirrhotic patients without refractory ascites. Among cirrhotic patients with refractory ascites, albumin (P = 0.23), bilirubin (P = 0.37), creatinine (P = 0.97), and sodium levels (P = 0.35) did not change significantly after surgery. CONCLUSION In advanced liver cirrhosis patients with refractory ascites, hernias can be safely treated with elective surgical repair. Mortality rate within 30 days did not differ by the presence or absence of refractory ascites. Elective hernia repair might be beneficial for treatment of abdominal wall hernia in cirrhotic patients with refractory ascites.
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Affiliation(s)
- S W Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - M A Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Y Chang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - H Y Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, South Korea
| | - J S Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Y B Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - E J Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - J-H Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - S J Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - J-H Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - K J Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Y J Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea. .,Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Elkrief L, Ferrusquia-Acosta J, Payancé A, Moga L, Tellez L, Praktiknjo M, Procopet B, Farcau O, De Lédinghen V, Yuldashev R, Tabchouri N, Barbier L, Dumortier J, Menahem B, Magaz M, Hernández-Gea V, Albillos A, Trebicka J, Spahr L, De Gottardi A, Plessier A, Valla D, Rubbia-Brandt L, Toso C, Bureau C, Garcia-Pagan JC, Rautou PE. Abdominal Surgery in Patients With Idiopathic Noncirrhotic Portal Hypertension: A Multicenter Retrospective Study. Hepatology 2019; 70:911-924. [PMID: 30924941 DOI: 10.1002/hep.30628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/13/2019] [Indexed: 12/13/2022]
Abstract
In patients with idiopathic noncirrhotic portal hypertension (INCPH), data on morbidity and mortality of abdominal surgery are scarce. We retrospectively analyzed the charts of patients with INCPH undergoing abdominal surgery within the Vascular Liver Disease Interest Group network. Forty-four patients with biopsy-proven INCPH were included. Twenty-five (57%) patients had one or more extrahepatic conditions related to INCPH, and 16 (36%) had a history of ascites. Forty-five procedures were performed, including 30 that were minor and 15 major. Nine (20%) patients had one or more Dindo-Clavien grade ≥ 3 complication within 1 month after surgery. Sixteen (33%) patients had one or more portal hypertension-related complication within 3 months after surgery. Extrahepatic conditions related to INCPH (P = 0.03) and history of ascites (P = 0.02) were associated with portal hypertension-related complications within 3 months after surgery. Splenectomy was associated with development of portal vein thrombosis after surgery (P = 0.01). Four (9%) patients died within 6 months after surgery. Six-month cumulative risk of death was higher in patients with serum creatinine ≥ 100 μmol/L at surgery (33% versus 0%, P < 0.001). An unfavorable outcome (i.e., either liver or surgical complication or death) occurred in 22 (50%) patients and was associated with the presence of extrahepatic conditions related to INCPH, history of ascites, and serum creatinine ≥ 100 μmol/L: 5% of the patients with none of these features had an unfavorable outcome versus 32% and 64% when one or two or more features were present, respectively. Portal decompression procedures prior to surgery (n = 10) were not associated with postoperative outcome. Conclusion: Patients with INCPH are at high risk of major surgical and portal hypertension-related complications when they harbor extrahepatic conditions related to INCPH, history of ascites, or increased serum creatinine.
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Affiliation(s)
- Laure Elkrief
- Service de Transplantation, Hôpitaux Universitaires de Genève, Geneva, Switzerland.,Service d'Hépato-Gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - José Ferrusquia-Acosta
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Audrey Payancé
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - Lucile Moga
- Service d'Hépato-Gastro-Entérologie, CHU Toulouse, Toulouse, France
| | - Luis Tellez
- Departamento de Gastroenterología y Hepatología, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Michael Praktiknjo
- Laboratory for Liver Fibrosis and Portal Hypertension, Universitatsklinikum, Bonn, Germany
| | - Bogdan Procopet
- Department of Gastroenterology, 3rd Medical Clinic, University of Medicine and Pharmacy "luliu Hatieganu," Regional Institute of Gastroenterology and Hepatology "O Fodor,", Cluj-Napoca, Romania
| | - Oana Farcau
- Department of Gastroenterology, 3rd Medical Clinic, University of Medicine and Pharmacy "luliu Hatieganu," Regional Institute of Gastroenterology and Hepatology "O Fodor,", Cluj-Napoca, Romania.,Department of Visceral Surgery and Medicine Intelspital, Bern, Switzerland
| | | | - Rustam Yuldashev
- Republican Specialized Scientific Practical Medical Center of Pediatrics, Tashkent, Uzbekistan
| | - Nicolas Tabchouri
- Service de Chirurgie Digestive, Oncologique, Endocrinienne et Transplantation Hépatique et FHU SUPORT, Hôpital Trousseau, Tours, France
| | - Louise Barbier
- Service de Chirurgie Digestive, Oncologique, Endocrinienne et Transplantation Hépatique et FHU SUPORT, Hôpital Trousseau, Tours, France
| | - Jérôme Dumortier
- Department of Digestive Diseases, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, Lyon, France
| | - Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Marta Magaz
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Virginia Hernández-Gea
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Agustin Albillos
- Departamento de Gastroenterología y Hepatología, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Jonel Trebicka
- Laboratory for Liver Fibrosis and Portal Hypertension, Universitatsklinikum, Bonn, Germany
| | - Laurent Spahr
- Service d'Hépato-Gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Andrea De Gottardi
- Department of Visceral Surgery and Medicine Intelspital, Bern, Switzerland
| | - Aurélie Plessier
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - Dominique Valla
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - Laura Rubbia-Brandt
- Service de pathologie Clinique, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Christian Toso
- Service de Transplantation, Hôpitaux Universitaires de Genève, Geneva, Switzerland.,Service de Chirurgie viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Juan-Carlos Garcia-Pagan
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France.,Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France.,Inserm, UMR 970, Paris Cardiovascular Research Center-PARCC, Paris, France
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Mahmud N, Fricker Z, Serper M, Kaplan DE, Rothstein KD, Goldberg DS. In-Hospital mortality varies by procedure type among cirrhosis surgery admissions. Liver Int 2019; 39:1394-1399. [PMID: 31141306 PMCID: PMC6675652 DOI: 10.1111/liv.14156] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/01/2019] [Accepted: 05/22/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with cirrhosis have increased peri-operative mortality risk relative to non-cirrhotic patients, however, the impact of surgical procedure category on this risk is poorly understood. METHODS We performed a retrospective cohort study of cirrhosis surgery admissions using the National Inpatient Sample between 2012 and 2014 to estimate the adjusted odds of in-hospital mortality by surgical procedure category. RESULTS In-hospital mortality differed by surgical procedure category. Relative to major orthopedic surgeries, major abdominal surgeries had the highest odds of in-hospital mortality (odds ratio [OR] 8.27, 95% confidence interval [CI] 5.96-11.49), followed by major cardiovascular surgeries (OR 3.45, 95% CI 2.33-5.09). There was also a significant interaction term, whereby elective/non-elective admission status impacted in-hospital mortality risk differently for each surgical procedure category (P < 0.001). CONCLUSION In-hospital mortality varies substantially by surgical procedure type. Accounting for procedure type in models may improve risk prediction for peri-operative mortality in patients with cirrhosis.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Zachary Fricker
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Kenneth D. Rothstein
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David S. Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tan HY, Gong JF, Tang WH, Li P, Yang K. Risk Assessment of Laparoscopic Cholecystectomy in Liver Cirrhotic Patients with Clinically Significant Portal Hypertension: A Retrospective Cohort Study. J Laparoendosc Adv Surg Tech A 2019; 29:1116-1121. [PMID: 31329021 DOI: 10.1089/lap.2019.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: This study was aimed to evaluate the correlation between clinically significant portal hypertension (CSPH) and postoperative complications and risk predictors of postoperative complications. Methods: The retrospective study was conducted to identify the effect. The cirrhotic patients were divided into two groups, those with or without CSPH. The intraoperative and postoperative conditions were evaluated. Multivariate logistic regression analysis was performed to identify potential risk predictors for postoperative complications in cirrhotic patients with CSPH. Results: The cirrhotic patients with CSPH who underwent laparoscopic cholecystectomy (LC) had postoperative hospitalization than the patients without CSPH. However, the incidence of postoperative complications between two groups showed no significant difference. The results of multivariate analysis showed that male, gallbladder wall >3 mm, size of stones ≥1 cm, scores of Model for end-stage liver disease (MELD) ≥10, and operation time >60 minutes were the potential risk predictors for postoperative complications. Conclusions: CSPH did not increase the incidence of postoperative complications in cirrhotic patients who underwent LC, but increased conversion rate and prolonged postoperative hospitalization. Furthermore, our study showed that gender, sizes of gallbladder wall and stones, scores of MELD, and operation time were the important postoperative risk predictors for cirrhotic patients with CSPH.
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Affiliation(s)
- Hao-Yang Tan
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun-Fei Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wen-Hao Tang
- Department of Hematology and Oncology, The Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Peizhi Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kang Yang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Futagawa Y, Yanaga K, Kosuge T, Suka M, Isaji S, Hirano S, Murakami Y, Yamamoto M, Yamaue H. Outcomes of pancreaticoduodenectomy in patients with chronic hepatic dysfunction including liver cirrhosis: results of a retrospective multicenter study by the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:310-324. [DOI: 10.1002/jhbp.630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Yasuro Futagawa
- Department of Surgery The Jikei University School o f Medicine 3‐25‐8 Nishishimbashi, Minato‐ku Tokyo105‐8461Japan
| | - Katsuhiko Yanaga
- Department of Surgery The Jikei University School o f Medicine 3‐25‐8 Nishishimbashi, Minato‐ku Tokyo105‐8461Japan
| | - Tomoo Kosuge
- Department of Surgery Sangenjaya Daiichi Hospital Tokyo Japan
| | - Machi Suka
- Department of Public Health and Environmental Medicine The Jikei University School of Medicine Tokyo Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic and Transplant Surgery Mie University Graduate School of Medicine Mie Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II Hokkaido University Faculty of Medicine Hokkaido Japan
| | - Yoshiaki Murakami
- Department of Surgery Institute of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Masakazu Yamamoto
- Department of Surgery Institute of Gastroenterology Tokyo Women's Medical University Tokyo Japan
| | - Hiroki Yamaue
- Second Department of Surgery Wakayama Medical University School of Medicine Wakayama Japan
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Outcomes of pancreatoduodenectomy in the cirrhotic patient: risk stratification and meta-analysis. HPB (Oxford) 2019; 21:301-309. [PMID: 30269948 DOI: 10.1016/j.hpb.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/26/2018] [Accepted: 08/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cirrhosis increases the risk of perioperative mortality in gastrointestinal surgery. Though cirrhosis is sometimes considered a contraindication to pancreatoduodenectomy (PD), few data are available in this patient population. The aim of the present study is to identify predictors of outcome in cirrhotic patients undergoing PD. METHODS Patients undergoing PD with biopsy-proved cirrhosis were evaluated. Primary endpoints were morbidity and mortality. Child score, MELD score, and radiographic evidence of portal hypertension (pHTN) were assessed for accuracy in preoperative risk stratification. A systematic review of the literature with meta-analysis was also performed to query morbidity and mortality of patients with cirrhosis reported to undergo PD. RESULTS Between 2005 and 2015, 36 cirrhotic patients underwent PD; three year follow-up was complete. Median Child score was 6 (range 5-10); median MELD score was 9 (range 7-18). Perioperative (90-day) mortality was 6/36. Median survival was 37 months (range 0.2-116). MELD ≥ 10 was associated with increased mortality (4/13 vs. 2/13, p = 0.004). Irrespective of Child or MELD score, those with pHTN had poor outcomes including significantly greater intraoperative blood loss, increased incidence of major complication, and length of stay. Postoperative mortality was significantly higher with pHTN (3/16 vs. 1/13, p = 0.012). CONCLUSION Pancreatoduodenectomy may be considered in carefully selected cirrhotic patients. MELD ≥ 10 predicts increased risk of postoperative mortality. Specific attention should be afforded to patients with preoperative radiographic evidence of portal hypertension as this group experiences poor outcomes irrespective of MELD or Child score.
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Goel NJ, Agarwal P, Mallela AN, Abdullah KG, Ali ZS, Ozturk AK, Malhotra NR, Schuster JM, Chen HI. Liver disease is an independent predictor of poor 30-day outcomes following surgery for degenerative disease of the cervical spine. Spine J 2019; 19:448-460. [PMID: 30053522 DOI: 10.1016/j.spinee.2018.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 07/14/2018] [Accepted: 07/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND CONTEXT The impact of underlying liver disease on surgical outcomes has been recognized in a wide variety of surgical disciplines. However, less empiric data are available about the importance of liver disease in spinal surgery. PURPOSE To measure the independent impact of underlying liver disease on 30-day outcomes following surgery for the degenerative cervical spine. STUDY DESIGN Retrospective comparative study. PATIENT SAMPLE A cohort of 21,207 patients undergoing elective surgery for degenerative disease of the cervical spine from the American College of Surgeons National Surgical Quality Improvement Program. OUTCOME MEASURES Outcome measures included mortality, hospital length of stay, and postoperative complications within 30 days of surgery. METHODS The NSQIP dataset was queried for patients undergoing surgery for degenerative disease of the cervical spine from 2006 to 2015. Assessment of underlying liver disease was based on aspartate aminotransferase-to-platelet ratio index and Model of End-Stage Liver Disease-Sodium scores, computed from preoperative laboratory data. The effect of liver disease on outcomes was assessed by bivariate and multivariate analyses, in comparison with 16 other preoperative and operative factors. RESULTS Liver disease could be assessed in 21,207 patients based on preoperative laboratory values. Mild liver disease was identified in 2.2% of patients, and advanced liver disease was identified in 1.6% of patients. The 30-day mortality rates were 1.7% and 5.1% in mild and advanced liver diseases, respectively, compared with 0.6% in patients with healthy livers. The 30-day complication rates were 11.8% and 31.5% in these patients, respectively, compared with 8.8% in patients with healthy livers. In multivariate analysis, the presence of any liver disease (mild or advanced) was independently associated with an increased risk of mortality (OR=2.00, 95% CI=1.12-3.55, p=.019), morbidity (OR=1.35, 95% CI=1.07-1.70, p=.012), and length of hospital stay longer than 7 days (OR=1.73, 95% CI=1.40-2.13, p<.001), when compared with 18 other preoperative and operative factors. Liver disease was also independently associated with perioperative respiratory failure (OR=1.80, 95% CI=1.21-2.68, p=.004), bleeding requiring transfusion (OR=1.43, 95% CI=1.01-2.02, p=.044), wound disruption (OR=2.82, 95% CI=1.04-7.66, p=.042), and unplanned reoperation (OR=1.49, 95% CI=1.05-2.11, p=.025). CONCLUSIONS Liver disease independently predicts poor perioperative outcome following surgery for degenerative disease of the cervical spine. Based on these findings, careful consideration of a patient's underlying liver function before surgery may prove valuable in surgical decision-making, preoperative patient counseling, and postoperative patient care.
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Affiliation(s)
- Nicholas J Goel
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Prateek Agarwal
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Arka N Mallela
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Kalil G Abdullah
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA
| | - Zarina S Ali
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA
| | - H Isaac Chen
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA
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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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Schwab R, Germer CT, Lang H. Relevante Nebenerkrankungen zu Notfallindikationen und Notfalloperationen in der Viszeral- und Allgemeinchirurgie. NOTFÄLLE IN DER ALLGEMEIN- UND VISZERALCHIRURGIE 2019. [PMCID: PMC7121273 DOI: 10.1007/978-3-662-53557-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Die Adipositas ist eine über das Normalmaß hinausgehende Vermehrung des Körperfetts und wird über den Body-Mass- Index (BMI = kg/m) bestimmt. Ab einem BMI von 30 kg/m liegt definitionsgemäß eine Adipositas vor. Der Krankheitswert ergibt sich aus der Assoziation von Folgeerkrankungen, deren Risiko mit der Prävalenzdauer und dem Schweregrad der Adipositas ansteigt (Tab. 28.1). Dabei korreliert das kardiovaskuläre Risiko besonders mit dem Vorliegen einer viszeralen Adipositas (>88/102 cm Taillenumfang bei Frauen/ Männern). Die Prävalenz der Adipositas steigt in Deutschland kontinuierlich an. Derzeit ist knapp ein Viertel der deutschen Bevölkerung als adipös einzustufen.
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Affiliation(s)
- Robert Schwab
- grid.493974.40000 0000 8974 8488BundeswehrZentralkrankenhaus Koblenz, Koblenz, Deutschland
| | | | - Hauke Lang
- grid.410607.4Universitätsmedizin Mainz, Mainz, Deutschland
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Yemini R, Keidar A, Nesher E, Mor E. Commentary: Peri-Transplant Bariatric Surgery. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Fleming MM, Liu F, Zhang Y, Pei KY. Model for End-Stage Liver Disease Underestimates Morbidity and Mortality in Patients with Ascites Undergoing Colectomy. World J Surg 2018. [PMID: 29541825 DOI: 10.1007/s00268-018-4591-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Model for End-Stage Liver Disease (MELD) score and ascites correlate with surgical morbidity and mortality. However, the MELD score does not account for ascites. We sought to evaluate whether the MELD score accurately risk stratifies patients with ascites. METHODS We analyzed the American College of Surgeons National Surgical Quality Improvement Program (2005-2014) to examine the risk-adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing colectomy for diverticulitis. Patients were stratified by MELD score, and the presence of ascites and outcomes were compared between patients with and without ascites to the reference group of low MELD and no ascites. Multivariable logistic regression was used to control for demographic factors and comorbidities. RESULTS A total of 16,877 colectomies were analyzed. For each MELD stratum, patients with ascites have increased risk of complications compared to those without ascites (P < 0.05 unless indicated): low MELD ascites OR 1.13, P = 0.69, moderate MELD no ascites OR 1.37, moderate MELD ascites OR 2.06, high MELD no ascites OR 1.93, and high MELD ascites OR 3.54. These trends hold true for mortality: low MELD ascites OR 2.91, P = 0.063, moderate MELD no ascites OR 1.47, moderate MELD ascites OR 5.62, high MELD no ascites OR 3.04, and high MELD ascites OR 9.91. CONCLUSION Ascites predicts an increased risk for postoperative morbidity and mortality for cirrhotic patients undergoing colectomy for all MELD classifications. These findings suggest that the MELD score significantly underestimates postoperative risk as it does not account for ascites.
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Affiliation(s)
- Matthew M Fleming
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB310, New Haven, CT, 06519, USA
| | - Fangfang Liu
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,, Beijing 302 Hospital, Beijing, China
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Kevin Y Pei
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB310, New Haven, CT, 06519, USA.
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