1
|
Lan R, Stiles ER, Ward SA, Lajam CM, Bosco JA. Patients With Moderate to Severe Liver Cirrhosis Have Significantly Higher Short-Term Complication Rates Following Total Knee Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2024:S0883-5403(24)00063-9. [PMID: 38280615 DOI: 10.1016/j.arth.2024.01.039] [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: 09/11/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Liver cirrhosis is associated with increased perioperative morbidity. Our study used the Model for End-Stage Liver Disease (MELD) score to assess the impact of cirrhosis severity on postoperative outcomes following total knee arthroplasty (TKA). METHODS A retrospective review identified 59 patients with liver cirrhosis who underwent primary TKA at a large, urban, academic center from January 2013 to August 2022. Cirrhosis was categorized as mild (MELD < 10; n = 47) or moderate-severe (MELD ≥ 10; n = 12). Modified Clavien-Dindo classification was used to grade complications, where grade 2+ denoted significant intervention. Hospital length of stay, nonhome discharge, and mortality were collected. A 1:1 propensity matching was used to control for demographics and selected comorbidities. RESULTS Moderate-severe cirrhosis was associated with significantly higher rates of intrahospital overall (58.33 versus 16.67%, P = .036) complications, 30-day overall complications (75 versus 33.33%, P = .042), and 90-day overall complications (75 versus 33.33%, P = .042) when compared to matched mild cirrhosis patients. Compared to matched noncirrhotic controls, mild cirrhosis patients had no significant increase in complication rate or other outcomes (P > .05). CONCLUSIONS Patients with moderate-severe liver cirrhosis are at risk of short-term complications following primary TKA. Patients with mild cirrhosis have comparable outcomes to matched noncirrhotic patients. Surgeons can use MELD score prior to scheduling TKA to determine which patients require optimization or higher levels of perioperative care.
Collapse
Affiliation(s)
- Rae Lan
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Elizabeth R Stiles
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Spencer A Ward
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| |
Collapse
|
2
|
Liu SH, Cerri-Droz P, Ling K, Loyst RA, Bowen S, Lung B, Komatsu DE, Wang ED. Increased preoperative aspartate aminotransferase-to-platelet ratio index predicts complications following total shoulder arthroplasty. JSES Int 2023; 7:855-860. [PMID: 37719816 PMCID: PMC10499853 DOI: 10.1016/j.jseint.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background This study investigates the association between aspartate aminotransferase-to-platelet ratio index (APRI), a noninvasive measure of liver function, and 30-day postoperative complications following total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2021. The study population was divided into 4 groups based on preoperative APRI: normal/reference (APRI ≤ 0.5), mild fibrosis (0.5 < APRI ≤ 0.7), significant fibrosis (0.7 < APRI ≤ 1), and cirrhosis (APRI > 1). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative APRI and postoperative complications. Results Compared to the reference group, significant fibrosis was independently associated with a greater likelihood of major complications (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.11-2.99; P = .017), minor complications (OR: 2.70, 95% CI: 1.67-4.37; P < .001), pneumonia (OR: 5.78, 95% CI: 2.58-12.95; P < .001), blood transfusions (OR: 2.89, 95% CI: 1.57-5.32; P < .001), readmission (OR: 1.88, 95% CI: 1.10-3.21; P = .022), and non-home discharge (OR: 1.83, 95% CI: 1.23-2.73; P = .003). Cirrhosis was independently associated with a greater likelihood of minor complications (OR: 3.96, 95% CI: 2.67-5.88; P < .001), blood transfusions (OR: 5.85, 95% CI: 3.79-9.03; P < .001), failure to wean off a ventilator (OR: 9.10, 95% CI: 1.98-41.82; P = .005), and non-home discharge (OR: 2.06, 95% CI: 1.43-2.96; P < .001). Conclusion Increasing preoperative APRI was associated with an increasing rate of postoperative complications following TSA.
Collapse
Affiliation(s)
- Steven H. Liu
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Patricia Cerri-Droz
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Kenny Ling
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Rachel A. Loyst
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Stephen Bowen
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Brandon Lung
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
3
|
Liu SH, Patel V, Loyst RA, Lung B, Cohen D, Kashanchi K, Komatsu DE, Wang ED. Preoperative Risk Stratification in Arthroscopic Rotator Cuff Repair: Aspartate Aminotransferase-to-Platelet Ratio Index as an Estimate of Liver Dysfunction. Cureus 2023; 15:e41980. [PMID: 37593301 PMCID: PMC10427769 DOI: 10.7759/cureus.41980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Aspartate Aminotransferase-to-Platelet Ratio Index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy which is resource-intensive and invasive. This study investigates the association between various degrees of liver dysfunction based on APRI and 30-day postoperative complications following arthroscopic rotator cuff repair (aRCR). METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aRCR between 2015 and 2021. The study population was divided into four groups based on preoperative APRI: normal/reference (APRI ≤ 0.5), mild fibrosis (0.5 < APRI ≤ 0.7), significant fibrosis (0.7 < APRI ≤ 1), and cirrhosis (APRI > 1). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative APRI and postoperative complications. RESULTS Compared to normal liver function, mild fibrosis was significantly associated with male gender, lower BMI, American Society of Anesthesiologists (ASA) classification ≥ 3, and comorbid diabetes, hypertension, chronic obstructive pulmonary disease, and bleeding disorders. Significant fibrosis was significantly associated with male gender, greater BMI, ASA classification ≥ 3, and comorbid diabetes, hypertension, and bleeding disorders. Cirrhosis was significantly associated with younger age, ASA classification ≥ 3, smokers, and comorbid diabetes and bleeding disorders. Compared to normal liver function, fibrosis was not associated with complications, significant fibrosis was associated with myocardial infarction, and cirrhosis was associated with major complications, sepsis, non-home discharge, and mortality. However, mild fibrosis, significant fibrosis, and cirrhosis were independently associated with any adverse 30-day postoperative complications following aRCR. CONCLUSION Among those with predicted liver damage based on preoperative APRI, 30-day postoperative complications following aRCR were not found to be independently associated with preoperative mild fibrosis, significant fibrosis, or cirrhosis. Our results suggest that APRI predictive of liver dysfunction may be a weaker deterrent to undergoing aRCR compared to other orthopedic surgeries.
Collapse
Affiliation(s)
- Steven H Liu
- Department of Orthopaedic Surgery, Stony Brook University, Stony Brook, USA
| | - Vaidehi Patel
- Department of Orthopaedic Surgery, Stony Brook University, Stony Brook, USA
| | - Rachel A Loyst
- Department of Orthopaedic Surgery, Stony Brook University, Stony Brook, USA
| | - Brandon Lung
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, USA
| | - Dorian Cohen
- Department of Orthopaedic Surgery, Stony Brook University, Stony Brook, USA
| | - Kevin Kashanchi
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, USA
| | - David E Komatsu
- Department of Orthopaedic Surgery, Stony Brook University, Stony Brook, USA
| | - Edward D Wang
- Department of Orthopaedic Surgery, Stony Brook University, Stony Brook, USA
| |
Collapse
|
4
|
Chen YC, Lee MH, Hsueh SN, Liu CL, Hui CK, Soong RS. The influence of the Pringle maneuver in laparoscopic hepatectomy: continuous monitor of hemodynamic change can predict the perioperatively physiological reservation. Front Big Data 2023; 6:1042516. [PMID: 37388503 PMCID: PMC10303928 DOI: 10.3389/fdata.2023.1042516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 05/23/2023] [Indexed: 07/01/2023] Open
Abstract
Importance This is the first study to investigate the correlation between intra-operative hemodynamic changes and postoperative physiological status. Objective Design settings and participants Patients receiving laparoscopic hepatectomy were routinely monitored using FloTract for goal-directed fluid management. The Pringle maneuver was routinely performed during parenchymal dissection and the hemodynamic changes were prospectively recorded. We retrospectively analyzed the continuous hemodynamic data from FloTrac to compare with postoperative physiological outcomes. Exposure The Pringle maneuver during laparoscopic hepatectomy. Main outcomes and measures Results Stroke volume variation that did not recover from the relief of the Pringle maneuver during the last application of Pringle maneuver predicted elevated postoperative MELD-Na scores. Conclusions and relevance The complexity of the hemodynamic data recorded by the FloTrac system during the Pringle Maneuver in laparoscopic hepatectomy can be effectively analyzed using the growth mixture modeling (GMM) method. The results can potentially predict the risk of short-term liver function deterioration.
Collapse
Affiliation(s)
- Yi-Chan Chen
- Department of General Surgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Min-Hsuan Lee
- Department of Industrial Engineering and Management, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Shan-Ni Hsueh
- Department of Industrial Engineering and Management, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Chien-Liang Liu
- Department of Industrial Engineering and Management, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Chung-Kun Hui
- Department of Anestheiology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ruey-Shyang Soong
- Division of Transplantation, Department of Surgery, Taipei Municipal Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
- College of Medicine, Taipei, Medical University, Taipei, Taiwan
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease. Eur J Gastroenterol Hepatol 2022; 34:1060-1066. [PMID: 36062496 DOI: 10.1097/meg.0000000000002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. METHODS A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan-Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. RESULTS One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). CONCLUSIONS Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.
Collapse
|
7
|
Endale Simegn A, Yaregal Melesse D, Belay Bizuneh Y, Mekonnen Alemu W. Perioperative management of patients with liver disease for non-hepatic surgery: A systematic review. Ann Med Surg (Lond) 2022; 75:103397. [PMID: 35242334 PMCID: PMC8886011 DOI: 10.1016/j.amsu.2022.103397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 02/07/2023] Open
Abstract
Background Liver disease is a multisystem condition that is classified as acute or chronic depending on the length of time. Cirrhosis patients are expected to undergo surgery in the last two years of their lives, according to estimates. In patients with elevated liver enzyme levels, anesthesia and surgery may deteriorate liver function. Preoperative identification, optimization and anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. Methods The literatures are searched using medical search engines like Google scholar, PubMed, Cochrane library and HINARI to get access for current and update evidence on perioperative optimization of patients with liver disease. The key words for literature search were (liver disease OR liver failure) AND (liver disease OR perioperative management) AND (non-hepatic surgery OR anesthesia). After searching using these search engines then collected by filtering based on the level of significance to this guideline with proper appraisal and evaluation of study quality with different level of evidences. Conclusions and recommendations: Patients with liver disease presenting with non-hepatic surgery might have postoperative complications that can lead to death. Efforts should be expended to favorably alter a patient's preoperative Child's class before undertaking an elective operation. Liver disease is a multisystem condition that is classified as acute or chronic. Preoperative assessment and risk stratification are paramount for optimization. Nephrotoxic drugs should be avoided.
Collapse
Affiliation(s)
- Atsedu Endale Simegn
- Department of Anesthesia, College of Medicine and Health Science, Wachemo University, Hosaena, Ethiopia
| | - Debas Yaregal Melesse
- Department of Anaesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia, P. O. Box 196, Ethiopia
- Corresponding author. Department of anaesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Northwest Ethiopia, P. O. Box 196, Ethiopia
| | - Yosef Belay Bizuneh
- Department of Anaesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia, P. O. Box 196, Ethiopia
| | - Wudie Mekonnen Alemu
- Department of Anaesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia, P. O. Box 196, Ethiopia
| |
Collapse
|
8
|
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.
Collapse
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
Collapse
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.
| |
Collapse
|
9
|
Sequeira SB, Labaran LA, Bell JE, Amin RM, Rao SS, Werner BC. Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database. J Arthroplasty 2021; 36:1361-1366.e1. [PMID: 33121848 DOI: 10.1016/j.arth.2020.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA. METHODS In total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications. RESULTS Cirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls-other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls. CONCLUSION Cirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.
Collapse
Affiliation(s)
- Sean B Sequeira
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Lawal A Labaran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Joshua E Bell
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Raj M Amin
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Sandesh S Rao
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| |
Collapse
|
10
|
Bell JE, Amin R, Labaran LA, Sequeira SB, Rao SS, Werner BC. Impact of Compensated Cirrhosis Etiology on Postoperative Outcomes Following Total Knee Arthroplasty. J Arthroplasty 2021; 36:148-153.e1. [PMID: 32739079 DOI: 10.1016/j.arth.2020.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Cirrhotics often demonstrate worse outcomes than their non-cirrhotic counterparts following orthopedic surgery; however, there are limited arthroplasty-focused data on this occurrence. Additionally, variances in postoperative outcomes among the different etiologies of cirrhosis have not been well described. The aim of this study is to evaluate the effect compensated cirrhosis had on postoperative outcomes following elective total knee arthroplasty (TKA). METHODS In total, 1,734,568 patients who underwent primary TKA from 2006 to 2013 were identified using the Medicare Claims Database. Patients were divided into those with a history of compensated cirrhosis and those with no history of liver disease. Subgroup analysis was performed based on the etiology of cirrhosis. Multivariate logistic regression was used to evaluate postsurgical outcomes of interest. RESULTS Cirrhotic patients had higher risk of developing disseminated intravascular coagulation (odds ratio [OR] 2.76, P = .003), encephalopathy (OR 3.00, P < .001), and periprosthetic infection (OR 1.79, P < .001) compared to controls. Following subgroup analysis, alcoholic cirrhotics had high risk of periprosthetic infection (OR 2.12, P < .001), fracture (OR 3.28, P < .001), transfusion (OR 2.45, P < .001), and encephalopathy (OR 7.34, P < .001) compared to controls. Viral cirrhosis was associated with an increase in 90-day charges ($14,941, P < .001) compared to controls, while cirrhosis secondary to other causes was associated with few adverse outcomes compared to controls. CONCLUSION Liver cirrhosis is an independent risk factor for increased perioperative morbidity and financial burden following TKA. Cirrhosis due to etiologies other than viral infections and alcoholism are associated with few adverse outcomes. Surgeons should be aware of these complications to properly optimize postoperative management.
Collapse
Affiliation(s)
- Joshua E Bell
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Raj Amin
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Lawal A Labaran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Sean B Sequeira
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Sandesh S Rao
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| |
Collapse
|
11
|
Nickel C, Segarra D, Padhya T, Mifsud M. The evidence-based preoperative assessment for the otolaryngologist. Laryngoscope 2019; 130:38-44. [PMID: 30702154 DOI: 10.1002/lary.27845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2019] [Indexed: 11/05/2022]
Abstract
There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient-centric, personalized, and often multidisciplinary approach. We present an up-to-date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope, 130:38-44, 2020.
Collapse
Affiliation(s)
- Christopher Nickel
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
| | - Daniel Segarra
- Morsani College of Medicine, University of South Florida, Tampa, Florida, U.S.A
| | - Tapan Padhya
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
| | - Matthew Mifsud
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
| |
Collapse
|
12
|
Kundu R, Subramaniam R, Sardar A. Anesthetic Management for Prolonged Incidental Surgery in Advanced Liver Disease. Anesth Essays Res 2017; 11:1101-1104. [PMID: 29284885 PMCID: PMC5735460 DOI: 10.4103/aer.aer_94_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In spite of advances in perioperative management, operative procedures in patients with chronic liver disease pose a significant challenge for the anesthesiologist due to multisystem involvement, high risk of postoperative hepatic decompensation, and mortality. We describe the anesthetic management of an elderly patient with advanced liver disease (model for end-stage liver disease 16) for prolonged abdominal surgery. The use of invasive hemodynamic monitoring, point-of-care biochemical, and hematological surveillance coupled with prompt correction of all abnormalities was responsible for good outcome. The patient's inguinal swellings turned out to be extensions of a large peritoneal mesothelioma, necessitating a large abdominal incision and blood loss. Analgesia was provided by bilateral transversus abdominis plane blocks, which helped to reduce opioid use and rapid extubation.
Collapse
Affiliation(s)
- Riddhi Kundu
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Arijit Sardar
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
13
|
|
14
|
Abstract
Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.
Collapse
Affiliation(s)
- O Boehm
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - M K A Pfeiffer
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - G Baumgarten
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - A Hoeft
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland.
| |
Collapse
|
15
|
Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: A prospective, observational study. Eur J Anaesthesiol 2016; 32:458-70. [PMID: 26020123 DOI: 10.1097/eja.0000000000000223] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative respiratory failure (PRF) is the most frequent respiratory complication following surgery. OBJECTIVE The objective of this study was to build a clinically useful predictive model for the development of PRF. DESIGN A prospective observational study of a multicentre cohort. SETTING Sixty-three hospitals across Europe. PATIENTS Patients undergoing any surgical procedure under general or regional anaesthesia during 7-day recruitment periods. MAIN OUTCOME MEASURES Development of PRF within 5 days of surgery. PRF was defined by a partial pressure of oxygen in arterial blood (PaO2) less than 8 kPa or new onset oxyhaemoglobin saturation measured by pulse oximetry (SpO2) less than 90% whilst breathing room air that required conventional oxygen therapy, noninvasive or invasive mechanical ventilation. RESULTS PRF developed in 224 patients (4.2% of the 5384 patients studied). In-hospital mortality [95% confidence interval (95% CI)] was higher in patients who developed PRF [10.3% (6.3 to 14.3) vs. 0.4% (0.2 to 0.6)]. Regression modelling identified a predictive PRF score that includes seven independent risk factors: low preoperative SpO2; at least one preoperative respiratory symptom; preoperative chronic liver disease; history of congestive heart failure; open intrathoracic or upper abdominal surgery; surgical procedure lasting at least 2 h; and emergency surgery. The area under the receiver operating characteristic curve (c-statistic) was 0.82 (95% CI 0.79 to 0.85) and the Hosmer-Lemeshow goodness-of-fit statistic was 7.08 (P = 0.253). CONCLUSION A risk score based on seven objective, easily assessed factors was able to predict which patients would develop PRF. The score could potentially facilitate preoperative risk assessment and management and provide a basis for testing interventions to improve outcomes.The study was registered at ClinicalTrials.gov (identifier NCT01346709).
Collapse
|
16
|
Nyberg EM, Batech M, Cheetham TC, Pio JR, Caparosa SL, Chocas MA, Singh A. Postoperative Risk of Hepatic Decompensation after Orthopedic Surgery in Patients with Cirrhosis. J Clin Transl Hepatol 2016; 4:83-9. [PMID: 27350938 PMCID: PMC4913079 DOI: 10.14218/jcth.2015.00049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/20/2016] [Accepted: 02/24/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND AIMS Previous studies have shown increased hepatic decompensation in patients with cirrhosis undergoing surgery. However, there are little data available in cirrhotics undergoing orthopedic surgery compared to cirrhotics who did not undergo surgery. The aim of this study was to examine the demographics, comorbid conditions, and clinical factors associated with hepatic decompensation within 90 days in cirrhotics who underwent orthopedic surgery. METHODS This is a retrospective matched cohort study. Inclusion criteria were cirrhosis diagnosis, age > 18 years, ≥ 6 months continuous health plan membership, and a procedure code for orthopedic surgery. Up to five cirrhotic controls without orthopedic surgery were matched on age, gender, and cirrhosis diagnosis date. Data abstraction was performed for demographics, socioeconomics, clinical, and decompensation data. Chart review was performed for validation. Multivariable analysis estimated relative risk of decompensation. RESULTS Eight hundred fifty-three orthopedic surgery cases in cirrhotics were matched with 4,263 cirrhotic controls. Among the cases and matched controls, the mean age was 60.5 years, and 52.2% were female. Within 90 days after surgery, cases had more decompensation compared to matched controls (12.8% vs 4.9%). Using multivariable analysis, orthopedic surgery, a 0.5 g/dL decrease in serum albumin, and a 1-unit increase in Charlson Comorbidity Index were associated with a significant increase in decompensation within 90 days of surgery. Diabetes, chronic obstructive pulmonary disease, and chronic kidney disease were seen with increased frequency in cases vs. matched controls. CONCLUSIONS Cirrhotics who underwent orthopedic surgery had a significant increase in hepatic decompensation within 90 days of surgery compared to matched controls. An incremental decrease in serum albumin and an incremental increase in the Charlson Comorbidity Index were significantly associated with hepatic decompensation after surgery.
Collapse
Affiliation(s)
- Eric M. Nyberg
- Department of Orthopaedics, Kaiser Permanente, San Diego, USA
| | - Michael Batech
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, USA
| | - T. Craig Cheetham
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, USA
| | - Jose R. Pio
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, USA
| | - Susan L. Caparosa
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, USA
| | | | - Anshuman Singh
- Department of Orthopaedics, Kaiser Permanente, San Diego, USA
- Department of Orthopaedics, University of California at San Diego, San Diego, USA
- *Correspondence to: Anshuman Singh, Department of Orthopedics, The Garfield Specialty Center, 5893 Copley Drive, San Diego, CA 92111, USA. Tel: +1-213-359-2269, E-mail:
| |
Collapse
|
17
|
Boehm O, Baumgarten G, Hoeft A. Preoperative patient assessment: Identifying patients at high risk. Best Pract Res Clin Anaesthesiol 2016; 30:131-43. [DOI: 10.1016/j.bpa.2016.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/19/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
|
18
|
|
19
|
Rahimzadeh P, Safari S, Faiz SHR, Alavian SM. Anesthesia for patients with liver disease. HEPATITIS MONTHLY 2014; 14:e19881. [PMID: 25031586 PMCID: PMC4080095 DOI: 10.5812/hepatmon.19881] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/01/2014] [Indexed: 12/11/2022]
Abstract
CONTEXT Liver plays an important role in metabolism and physiological homeostasis in the body. This organ is unique in its structure and physiology. So it is necessary for an anesthesiologist to be familiar with various hepatic pathophysiologic conditions and consequences of liver dysfunction. EVIDENCE ACQUISITION WE SEARCHED MEDLINE (PUB MED, OVID, MD CONSULT), SCOPUS AND THE COCHRANE DATABASE FOR THE FOLLOWING KEYWORDS: liver disease, anesthesia and liver disease, regional anesthesia in liver disease, epidural anesthesia in liver disease and spinal anesthesia in liver disease, for the period of 1966 to 2013. RESULTS Although different anesthetic regimens are available in modern anesthesia world, but anesthetizing the patients with liver disease is still really tough. Spinal or epidural anesthetic effects on hepatic blood flow and function is not clearly investigated, considering both the anesthetic drug-induced changes and outcomes. Regional anesthesia might be used in patients with advanced liver disease. In these cases lower drug dosages are used, considering the fact that locally administered drugs have less systemic effects. In case of general anesthesia it seems that using inhalation agents (Isoflurane, Desflurane or Sevoflurane), alone or in combination with small doses of fentanyl can be considered as a reasonable regimen. When administering drugs, anesthetist must realize and consider the substantially changed pharmacokinetics of some other anesthetic drugs. CONCLUSIONS Despite the fact that anesthesia in chronic liver disease is a scary and pretty challenging condition for every anesthesiologist, this hazard could be diminished by meticulous attention on optimizing the patient's condition preoperatively and choosing appropriate anesthetic regimen and drugs in this setting. Although there are paucity of statistics and investigations in this specific group of patients but these little data show that with careful monitoring and considering the above mentioned rules a safe anesthesia could be achievable in these patients.
Collapse
Affiliation(s)
- Poupak Rahimzadeh
- Department of Anesthesiology and Pain Medicine, Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Saeid Safari
- Department of Anesthesiology and Pain Medicine, Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, IR Iran
- Middle East Liver Disease Center (MELD), Tehran, IR Iran
| | - Seyed Hamid Reza Faiz
- Department of Anesthesiology and Pain Medicine, Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Seyed Moayed Alavian
- Middle East Liver Disease Center (MELD), Tehran, IR Iran
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Seyed Moayed Alavian, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. Tel: +98-2188945186, Fax: +98-2188945188, E-mail:
| |
Collapse
|
20
|
Shrikhande SV, Gaikwad V, Purohit D, Goel M. Major abdominal cancer resections in cirrhotic patients: how frequent is postoperative hepatocellular decompensation? Indian J Gastroenterol 2014; 33:258-64. [PMID: 24214581 DOI: 10.1007/s12664-013-0426-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/14/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND The reported incidence of postoperative liver failure in cirrhotic patients is highly varied with diverse risk factors identified to predict risk, mainly drawn from organ or disease-specific studies. We aimed to assess risk factors for the development of postoperative liver failure in a specific cohort of patients with cirrhosis undergoing abdominal cancer resection. METHODS From November 2007 to October 2012, 30 cirrhotic patients who underwent curative resection for abdominal cancer were analyzed. The postoperative trends in liver function were followed and the incidence of postoperative liver failure was demonstrated. RESULTS Among the 30 patients, the tumors were located in the stomach (n = 5), pancreas (n = 5), colon/rectum (6), liver (n = 11), gallbladder (n = 1), and retroperitoneum (n = 2). Eighteen (60 %) patients experienced postoperative liver failure of which 7 (23 %) patients required deviation from the clinical course or management. There was one mortality due to grade C liver failure and hepatorenal syndrome. On multivariate analysis, only age (>55 years) was found to be statistically significant to predict postoperative liver failure (p = 0.024). CONCLUSION Liver dysfunction remains a major problem during the postoperative phase of major gastrointestinal cancer resections. However, less than one fourth of well-selected patients will develop significant postoperative liver failure. This incidence may be further reduced if the selection is restricted to younger patients.
Collapse
Affiliation(s)
- Shailesh Vinayak Shrikhande
- Division of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, 400 012, India,
| | | | | | | |
Collapse
|