|
1
|
Hudson D, Valentin Cortez FJ, León IHDD, Malhi G, Rivas A, Afzaal T, Rad MR, Diaz LA, Khan MQ, Arab JP. Advancements in MELD Score and Its Impact on Hepatology. Semin Liver Dis 2024. [PMID: 39515784 DOI: 10.1055/a-2464-9543] [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: 11/16/2024]
Abstract
There continues to be an ongoing need for fair and equitable organ allocation. The Model for End-Stage Liver Disease (MELD) score has evolved as a calculated framework to evaluate and allocate patients for liver transplantation objectively. The original MELD score has undergone multiple modifications as it is continuously scrutinized for its accuracy in objectively representing the clinical context of patients with liver disease. Several refinements and iterations of the score have been developed, including the widely accepted MELD-Na score. In addition, the most recent updated iteration, MELD 3.0, has been created. The MELD 3.0 calculator incorporates new variables such as patient sex and serum albumin levels and assigns new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is anticipated that the use of MELD 3.0 scores will reduce overall waitlist mortality and enhance access for female liver transplant candidates. However, despite the emergence of the MELD score as one of the most objective measures for fair organ allocation, various countries and healthcare systems employ alternative methods for stratification and organ allocation. This review article will highlight the origins of the MELD score, its iterations, the current MELD 3.0, and future directions for managing liver transplantation organ allocation. LAY SUMMARY: Organ donation is crucial for the management of patients unwell with liver disease, but organs must be allocated fairly and equitably. One method used for this is the Model for End-Stage Liver Disease (MELD) score, which helps objectively decide which patient is a candidate for liver transplant. Over time, the MELD score has been refined to better reflect patients' needs. For example, the latest version, MELD 3.0, now considers factors like nutrition and gender. This should ensure that more patients, especially females, are candidates and receive appropriate access to liver transplantation. However, not every country uses the MELD score. Some countries have created their own scoring systems based on local research. This review will explain where the MELD score came from, how it has changed, the current characteristics of the MELD 3.0 score, and what the future might hold for organ allocation in liver transplants.
Collapse
Affiliation(s)
- David Hudson
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | | | - Ivonne Hurtado Díaz de León
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gurpreet Malhi
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Angelica Rivas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tamoor Afzaal
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Mahsa Rahmany Rad
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Luis Antonio Diaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology and Hepatology, MASLD Research Center, University of California San Diego, San Diego, California
| | - Mohammad Qasim Khan
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| |
Collapse
|
|
2
|
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; 39:1736-1740. [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] [MESH Headings] [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
|
|
3
|
Ostojic A, Mahmud N, Reddy KR. Surgical risk stratification in patients with cirrhosis. Hepatol Int 2024; 18:876-891. [PMID: 38472607 PMCID: PMC11864775 DOI: 10.1007/s12072-024-10644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.
Collapse
Affiliation(s)
- Ana Ostojic
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA.
| |
Collapse
|
|
4
|
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.
Collapse
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.
| |
Collapse
|
|
5
|
Elkbuli A, Breeding T, Martinez B, Patel H, Chin B, Wright DD, Patterson R, Roberts J, Rhodes H. Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis. Am Surg 2024; 90:1347-1356. [PMID: 38272456 DOI: 10.1177/00031348241230087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Patients with liver cirrhosis (LC) demonstrate significantly elevated mortality rates following a traumatic event. This study aims to examine and compare the clinical outcomes in adult trauma patients with pre-existing LC undergoing laparotomy or non-operative management (NOM). Additionally, the study aims to investigate various patient outcomes, including mortality rate based on transfusion needs and timing. METHODS This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017-21 to compare laparotomy vs NOM in adults (≥18 years) with pre-existing LC who presented to trauma facilities with isolated blunt solid organ abdominal injuries (Injury Severity Score ≥16, Abbreviated Injury Scale solid organ abdomen ≥3). RESULTS Among 929 patients, 38.2% underwent laparotomy, while 61.7% received NOM. The in-hospital mortality rate was lower for patients who received NOM (52.3% vs 20.0%, P < .01). The risk of in-hospital mortality was significantly associated with laparotomy (OR 5.22, 95% CI: 2.06-13.18, P < .01) and sepsis (OR 99.50, 95% CI: 6.99-1415.28, P < .01). On average an increase in blood units in 4 hours was observed among those who experienced an in-hospital mortality (OR 5.65, 95% CI: 3.05-8.24, P < .01) and those who underwent laparotomy (OR 3.85, 95% CI: 1.36-6.34, P < .01). CONCLUSION Trauma patients with moderate to severe isolated organ injury and Liver cirrhosis had significantly higher mortality rates, acute renal failure, whole blood units received, as well as longer ICU-LOS when undergoing laparotomy compared to non-operative management.
Collapse
Affiliation(s)
- Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Tessa Breeding
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Brian Martinez
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Heli Patel
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Brian Chin
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - D-Dre Wright
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Ryan Patterson
- Department of Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Jennifer Roberts
- Department of Trauma, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Heather Rhodes
- Center for Clinical Epidemiology and Public Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
| |
Collapse
|
|
6
|
Mangieri CW, Strode MA, Valenzuela CD, Erali RA, Shen P, Howerton R, Clark CJ. High-risk liver patients are not associated with adverse events following pancreaticoduodenectomy. Am J Surg 2023; 225:735-739. [PMID: 36428108 DOI: 10.1016/j.amjsurg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/26/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Pancreaticoduodenectomy performed with underlying hepatic disease has been reported to have increased adverse events postoperatively. This study aimed to further evaluate that association. METHODS Retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) main and targeted pancreatectomy registries for 2014-2016. High-risk liver patients were defined by MELD scores, received neoadjuvant chemotherapy, and had hepatosteatosis; two separate subgroups of MELD ≥9 and ≥ 11. High-risk liver patients were then compared to control cases via propensity score matching. RESULTS There were 156 and 132 cases that met the high-risk liver criteria for the MELD cutoffs of ≥9 and ≥ 11 respectively. Propensity score matching left 2527 cases for final adjusted analysis. On both univariate and multivariate analysis high-risk liver patients were not associated with increased adverse events following Whipple resection. Lack of association with increased adverse events held for both the ≥9 and ≥ 11 MELD score cohorts. CONCLUSION High-risk liver patients defined by MELD scores, neoadjuvant chemotherapy utilization, and hepatosteatosis were not associated with any increased incidence of adverse events following pancreaticoduodenectomy. Patients with underlying high-risk liver disease in this study did not appear to pose as a contraindication for oncologic resection of pancreatic adenocarcinoma.
Collapse
Affiliation(s)
- Christopher W Mangieri
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States.
| | - Matthew A Strode
- Womack Army Medical Center, Department of General Surgery, United States
| | - Cristian D Valenzuela
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Richard A Erali
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Perry Shen
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Russell Howerton
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| | - Clancy J Clark
- Wake Forest Baptist Health Medical Center, Division of Surgical Oncology, United States
| |
Collapse
|
|
7
|
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.
Collapse
|
|
8
|
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: 3] [Impact Index Per Article: 1.5] [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
|
|
9
|
The Conundrum of Patients With Compensated Cirrhosis Requiring Kidney Transplantation; Kidney Alone or Simultaneous Liver Kidney Transplantation. Transplantation 2023; 107:429-437. [PMID: 36194998 DOI: 10.1097/tp.0000000000004311] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with compensated cirrhosis and chronic kidney disease are increasing along with demand for simultaneous liver kidney transplant (SLKT) and shortages of organs for transplantation. Although these well-compensated patients may not need a liver organ, the alternative of kidney transplant alone (KTA) poses the risk of liver decompensation. Therefore, we aim to characterize outcomes among patients with compensated cirrhosis and chronic kidney disease listed for SLKT or receiving KTA to inform clinical decisions. METHODS The 2-part retrospective study included a national cohort of patients listed for SLKT in United Network for Organ Sharing from January 2003 to June 2019 with Child A cirrhosis, with model for end-stage liver disease <25, and receiving dialysis; and a cohort of patients who underwent KTA from 2004 to 2019 with Child A cirrhosis identified through a 4-center chart review. Waitlist outcomes (SLKT, death, and clinical improvement) and post-KTA liver decompensation and survival were evaluated in the cohorts, respectively. RESULTS In the national SLKT cohort (N = 705, median age 56 y, 68.8% male), 5-y cumulative incidence of SLKT was 43.1%, death 32.1%, and clinical improvement 9.1%. Among SLKT recipients, 36.3% remained Child A without ascites or encephalopathy at transplant. In the local KTA cohort (N = 34, median age 54 y, 79.4% male), none had ascites or hepatic encephalopathy before KTA, but 15 had clinical portal hypertension. Five-y post-KTA incidence of liver decompensation was 36.8%, and survival was 89.2%. CONCLUSIONS SLKT may not be necessary for some patients with compensated cirrhosis needing kidney transplant. KTA is safe for selected patients with intact liver biochemical function, even with portal hypertension but without hepatic encephalopathy or ascites.
Collapse
|
|
10
|
Francesca V, Francesco F, Eugenio C, Carmelo M. Management of Cholelithiasis in Cirrhotic Patients. J Pers Med 2022; 12:2060. [PMID: 36556280 PMCID: PMC9786294 DOI: 10.3390/jpm12122060] [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: 09/27/2022] [Revised: 11/06/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
Gallstone disease (GD) is a common disease worldwide and has a higher incidence in cirrhotic patients than in the general population. The main indications for cholecystectomy surgery in cirrhotic patients remain symptomatic cholelithiasis and its complications. Over the past two decades, numerous published reports have attested to the feasibility and safety of laparoscopic cholecystectomy in cirrhotic patients. Surgery in patients with liver cirrhosis represents an additional source of stress for an already impaired liver function and perioperative complications are remarkably high compared to non-cirrhotic patients, despite significant advances in surgical management. Therefore, preoperative risk stratification and adequate patient selection are mandatory to minimize postoperative complications. We have conducted a systematic review of the literature over the last 22 years for specific information on indications for surgery in cirrhotic patients and individual percentages of Child-Pugh grades undergoing treatment. There are very few reported cases of cholecystectomy and minimally invasive treatment, such as percutaneous transhepatic cholecystostomy (PTC), in patients with Child-Pugh grade C cirrhosis. With this work, we would like to pay attention to the treatment of cholelithiasis in cirrhotic patients who are still able to undergo cholecystectomy, thus also encouraging this type of intervention in cases of asymptomatic cholelithiasis in patients with Child-Pugh grades A and B.
Collapse
Affiliation(s)
| | | | | | - Mazzeo Carmelo
- Department of Human Pathology of the Adult and Evolutive Age “Gaetano Barresi”, Section of General Surgery, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
| |
Collapse
|
|
11
|
Jelicic J, Larsen TS, Fialla AD, Bukumiric Z, Andjelic B. Clinical Characteristics and Management of Patients With Concomitant Liver Cirrhosis and Lymphoma: A Systematic Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e981-e991. [PMID: 35948478 DOI: 10.1016/j.clml.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/07/2022] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
Over the years, a rising incidence of liver cirrhosis and lymphoma has been observed. Therefore, the risk of having cirrhosis as a comorbidity increases, thus challenging treatment approaches as data on the management of these patients is lacking. We performed a systematic review to summarize papers that analyzed patients with liver cirrhosis that occurred before and/or concomitantly to lymphoma. We identified 153 papers (230 patients) through Pubmed and/or Embase search. Publications comprised predominantly of case reports and/or case series. Most patients had HCV-related cirrhosis (62.6%), and aggressive lymphoma histology (59.6%). Data on liver status was available in 55.7% of all patients, with 46.1% having decompensated liver cirrhosis. These patients experienced more often treatment reductions and/or modifications, treatment side effects, and inferior survival than those with compensated cirrhosis (median 18 months vs. median not reached). Dose reductions and/or treatment modifications primarily due to concomitant liver disease were common. Moreover, liver toxicity was observed in 33.6% of patients with provided information on treatment side effects, ranging from mild toxicity to liver failure with fatal outcomes. Again, despite treatment modification/reduction, patients with decompensated liver cirrhosis developed hepatic toxicity more frequently than patients with compensated liver disease. Although patients suffering from cirrhosis and lymphoma can tolerate standard chemoimmunotherapy, a cautious multidisciplinary approach is needed to evaluate the risks and benefits.
Collapse
Affiliation(s)
- Jelena Jelicic
- Department of Hematology, Sygehus Lillebaelt, Vejle, Denmark; Department of Hematology, Odense University Hospital, Odense, Denmark.
| | - Thomas Stauffer Larsen
- Department of Hematology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Annette Dam Fialla
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Zoran Bukumiric
- Department of Statistics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bosko Andjelic
- Department of Hematology, Blackpool Victoria Hospital, Lancashire Haematology Centre, Blackpool
| |
Collapse
|
|
12
|
van Beekum CJ, Beckmann C, Semaan A, Manekeller S, Matthaei H, Braun L, Willis MA, Kalff JC, Vilz TO. Predictors of Morbidity and Mortality After Colorectal Surgery in Patients With Cirrhotic Liver Disease–A Retrospective Analysis of 54 Cases at a Tertiary Care Center. Front Med (Lausanne) 2022; 9:886566. [PMID: 35814748 PMCID: PMC9257019 DOI: 10.3389/fmed.2022.886566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDespite various existing scores that predict morbidity and mortality of patients with cirrhotic liver disease (CLD), data on specific risk stratification of patients with CLD undergoing colorectal surgery (CRS) are rare. The aim of this study was to assess in-hospital morbidity and mortality of patients with liver cirrhosis scheduled for CRS, with specific focus on possible pitfalls of surgery in this special cohort.MethodsBetween 1996 and 2018, 54 patients with CLD undergoing CRS were identified and included in this study cohort. Postoperative morbidity and mortality were assessed using the Clavien/Dindo (C/D) classification as well as by type of complication. Univariate and multivariate analyses were performed to analyze the predictive factors for increased postoperative morbidity.ResultsOf the patients, 37% patients died during the procedure or postoperatively. Major complications were seen in 23.1% of patients (>C/D IIIb). Patients with Child B or C cirrhosis as well as patients undergoing emergency surgery experienced significantly more major complications (p = 0.04 and p = 0.023, respectively). The most common complications were bleeding requiring blood transfusion (51.1%) and cardiocirculatory instability due to bleeding or sepsis (44.4%). In 53.7% of patients, an anastomosis was created without a protective ostomy. Anastomotic leakage occurred in 20.7% of these patients. Multivariate analysis showed that a primary anastomosis without a protective ostomy was the strongest risk factor for major complications (p = 0.042).DiscussionMorbidity and mortality after CRS in patients with CLD remains high and is not only influenced by liver function but also by surgical variables. Considering the high rate of anastomotic leakage, creating a protective or definitive ostomy must be considered with regard to the underlying pathology, the extent of CLD, and the patient's condition. Moreover, our data suggest that surgery in these most fragile patients should be performed only in experienced centers with immediate contact to hepatologists and experts in hemostasis.
Collapse
|
|
13
|
Renninger CH, Jaeblon T, Slobogean GP, O'Toole RV, O'Hara NN. Patients With Cirrhosis Who Have a Model for End-stage Liver Disease Sodium Score of 8 or Greater Are at Increased Risk of Poor Outcomes in Operatively Treated Tibia Fractures. Orthopedics 2022; 45:79-85. [PMID: 35021031 DOI: 10.3928/01477447-20220105-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare 30-day readmission rates for cirrhotic and non-cirrhotic patients after tibia fracture fixation by retrospectively identifying all surgically managed tibial plateau, tibial shaft, and pilon fractures from 2010 through 2018 in the National Surgical Quality Improvement Program database (N=14,028). The primary outcome measure was 30-day readmission rates. Secondary outcome measures included 30-day rates of reoperation, length of stay, pulmonary embolism, deep venous thrombosis, and wound complications, including deep or superficial infection. Cirrhotic patients (n=665) and non-cirrhotic patients (n=13,363) were identified using the aspartate aminotransferase to platelet ratio index test. Cirrhotic patients were more likely to have preoperative ascites, renal failure, bleeding disorders, and preoperative transfusions. No differences were reported between the two groups in readmission rate or any of the secondary outcome measures, except that cirrhotic patients' length of stay was longer by 0.5 day. Stratification of the cirrhotic cohort demonstrated that a Model for End-stage Liver Disease sodium (MELD-Na) score of 8 or greater was associated with a 4.1-fold increase in the rate of readmission (5.9% vs 1.5%; P<.01). No other differences were identified based on MELD-Na score stratification. Patients with advanced cirrhosis (MELD-Na score ≥8) have an increased risk of 30-day readmission after tibia fracture surgery. Cirrhosis associated with a lower MELD-Na score might not significantly increase the risk of 30-day complications in patients with tibia fractures. [Orthopedics. 2022;45(2):79-85.].
Collapse
|
|
14
|
Ducatti L, Haddad LBP, Meyer A, Nacif LS, Arantes RM, Martino RB, Rocha-Santos V, Waisberg DR, Pinheiro RS, D Albuquerque LAC, Andraus W. CIRRHOTIC PATIENTS WITH ACUTE KIDNEY INJURY (AKI) HAVE HIGHER MORTALITY AFTER ABDOMINAL HERNIA SURGERY. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2022; 34:e1622. [PMID: 35019134 PMCID: PMC8735160 DOI: 10.1590/0102-672020210002e1622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The incidence of abdominal hernia in cirrhotic patients is as higher as 20%; in cases of major ascites the incidence may increase up to 40%. One of the main and most serious complications in cirrhotic postoperative period (PO) is acute kidney injury (AKI). AIM To analyze the renal function of cirrhotic patients undergoing to hernia surgery and evaluate the factors related to AKI. METHODS Follow-up of 174 cirrhotic patients who underwent hernia surgery. Laboratory tests including the renal function were collected in the PO.AKI was defined based on the consensus of the ascite´s club. They were divided into two groups: with (AKI PO) and without AKI . RESULTS All 174 patients were enrolled and AKI occurred in 58 (34.9%). In the AKI PO group, 74.1% had emergency surgery, whereas in the group without AKI PO it was only 34.6%.In the group with AKI PO, 90.4% presented complications, whereas in the group without AKI PO they occurred only in 29.9%. Variables age, baseline MELD, baseline creatinine, creatinine in immediate postoperative (POI), AKI and the presence of ascites were statistically significant for survival. CONCLUSIONS There is association between AKI PO and emergency surgery and, also, between AKI PO and complications after surgery. The factors related to higher occurrence were initial MELD, basal Cr, Cr POI. The patients with postoperative AKI had a higher rate of complications and higher mortality.
Collapse
Affiliation(s)
- Liliana Ducatti
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Luciana B P Haddad
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Alberto Meyer
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Lucas S Nacif
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Rubens M Arantes
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Rodrigo B Martino
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Daniel R Waisberg
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Rafael S Pinheiro
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Luiz A C D Albuquerque
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| | - Wellington Andraus
- Department of Gastroenterology, University Hospital, School of Medicine, University of São Paulo - USP, São Paulo, SP, Brazil
| |
Collapse
|
|
15
|
Durleshter VM, Korochanskaya NV, Murashko DS, Basenko MA. [Risk factors of surgical treatment in patients with liver cirrhosis]. Khirurgiia (Mosk) 2022:64-69. [PMID: 35289551 DOI: 10.17116/hirurgia202203164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To optimize selection of patient for surgical treatment of comorbidities and complications of liver cirrhosis (LC) via analysis of perioperative risk factors. MATERIAL AND METHODS There were 610 patients with LC and comorbidities who underwent surgical treatment between 2015 and 2021 at the Regional Clinical Hospital No. 2. Thirty (4.9%) patients died. We analyzed Child-Pugh and MELD scores, Mayo Postoperative Surgical Risk Score and Charlson comorbidity index to predict postoperative mortality. RESULTS Perioperative risk in patients with LC depends on the type of surgery, degree of surgical invasiveness, liver function, and severity of LC-associated complications. CONCLUSION A thorough preoperative assessment of patients and adequate perioperative management are required to reduce the risk of mortality. UNLABELLED liver cirrhosis, surgical treatment, risk factors.
Collapse
Affiliation(s)
- V M Durleshter
- Kuban State Medical University, Krasnodar, Russia
- Regional Clinical Hospital No. 2, Krasnodar, Russia
| | - N V Korochanskaya
- Kuban State Medical University, Krasnodar, Russia
- Regional Clinical Hospital No. 2, Krasnodar, Russia
| | - D S Murashko
- Kuban State Medical University, Krasnodar, Russia
- Regional Clinical Hospital No. 2, Krasnodar, Russia
| | - M A Basenko
- Kuban State Medical University, Krasnodar, Russia
| |
Collapse
|
|
16
|
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: 1] [Impact Index Per Article: 0.3] [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
|
|
17
|
Jadaun SS, Saigal S. Surgical Risk Assessment in Patients with Chronic Liver Diseases. J Clin Exp Hepatol 2022; 12:1175-1183. [PMID: 35814505 PMCID: PMC9257927 DOI: 10.1016/j.jceh.2022.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/16/2022] [Indexed: 02/07/2023] Open
Abstract
Chronic liver diseases (CLD) is one of the leading causes of morbidity and mortality. The overall life span of patients with CLD has increased and so is the number of surgical procedures these patients undergo. Pathophysiological and hemodynamic changes in cirrhosis make these patients more susceptible to hypotension and hypoxia during surgery. They also have a high risk of drug induced liver injury, renal dysfunction and post-operative liver decompensation. Patients with CLD planned for elective or semi-elective surgery should undergo detailed preoperative risk assessment. Patients should be evaluated for the presence of clinically significant portal hypertension and cirrhosis. In the absence of both cirrhosis and clinically significant portal hypertension, patients with CLD can undergo surgery with minimal or low risk. Various risk assessment tools available for patients with advanced CLD are-CTP score, MELD Score, Mayo risk score, VOCAL-Penn score. A Child class C and/or Mayo risk score >15 in general is associated with high risk of post-operative mortality and elective surgery should be deferred in these patients. In patients with Child class, A and MELD 10-15 surgery is permissible with caution (except liver resection and cardiac surgery) while in Child A and MELD <10 surgery is well tolerated. VOCAL-Penn score is a new promising tool and can be the better alternative of CTP, MELD, and Mayo risk score models but more prospective studies with large patients' population are warranted. Certain surgeries like Hepatic resection, intraabdominal, and cardiothoracic have higher risk than abdominal wall hernia repair and orthopedic surgery. Laparoscopic approaches have better outcomes and less risk of liver failure than open surgery. Minimally invasive alternatives like colonic stent placement in case of obstruction can be considered in high-risk cases. Perioperative optimization and management of ascites, HE, bleeding, liver decompensation, and nutrition should be done with multidisciplinary approach. Patients with cirrhosis undergoing high risk elective surgery can develop liver failure in post-operative period and should be evaluated and counseled for liver transplantation if not contraindicated.
Collapse
Key Words
- ASA, American Society of Anaesthesiologists
- CLD, Chronic liver disease
- CTP, Child-Turcotte-Pugh
- Cirrhosis
- HCC, Hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- MELD, Model for end stage liver disease
- NASH, Non-alcoholic steatohepatitis
- ROTEM, rotational thromboelastometry
- Surgery in cirrhosis
- Surgical risk assessment
- TEG, Thromboelastography
- VOCAL-Penn score, Veterans Outcomes and Costs Associated with Liver Disease-Penn score
Collapse
Affiliation(s)
| | - Sanjiv Saigal
- Address for correspondence. Sanjiv Saigal MD DM MRCP CCST, Principal Director and Head, Hepatology and Liver Transplant Medicine Centre for Liver and Biliary Sciences CLBS Max Super Speciality Hospital, Saket New Delhi, 110017, India.
| |
Collapse
|
|
18
|
Torres MB, Schaefer EW, Jikaria N, Ortenzi G, Cooper AB. Does the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) accurately predict mortality for patients with elevated MELD scores? Am J Surg 2022; 224:475-482. [DOI: 10.1016/j.amjsurg.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/27/2021] [Accepted: 01/19/2022] [Indexed: 11/29/2022]
|
|
19
|
Xiang Z, Li Y, Zhu C, Hong T, He X, Zhu H, Jiang D. Gastrointestinal Cancers and Liver Cirrhosis: Implications on Treatments and Prognosis. Front Oncol 2021; 11:766069. [PMID: 34746008 PMCID: PMC8567751 DOI: 10.3389/fonc.2021.766069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Liver cirrhosis tends to increase the risk in the management of gastrointestinal tumors. Patients with gastrointestinal cancers and liver cirrhosis often have serious postoperative complications and poor prognosis after surgery. Multiple studies have shown that the stage of gastrointestinal cancers and the grade of cirrhosis can influence surgical options and postoperative complications. The higher the stage of cancer and the poorer the degree of cirrhosis, the less the surgical options and the higher the risk of postoperative complications. Therefore, in the treatment of patients with gastrointestinal cancer and liver cirrhosis, clinicians should comprehensively consider the cancer stage, cirrhosis grade, and possible postoperative complications. This review summarizes the treatment methods of patients with different gastrointestinal cancer complicated with liver cirrhosis.
Collapse
Affiliation(s)
- Ze Xiang
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Yiqi Li
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Chaojie Zhu
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tu Hong
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Xianglin He
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Hua Zhu
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
| | - Danbin Jiang
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
| |
Collapse
|
|
20
|
Pantea R, Meister P, Neuhaus JP, Nowak K, Paul A, Saner FH. [Surgery in patients with liver cirrhosis]. Chirurg 2021; 92:838-845. [PMID: 33459796 PMCID: PMC8384819 DOI: 10.1007/s00104-020-01319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with liver cirrhosis who are in need of surgery show a high in-hospital mortality. This study examined the risk of postoperative morbidity and in-hospital mortality after operations on patients with liver cirrhosis. MATERIAL AND METHODS In the time period from January 2010 to December 2017 a total of 321 patients with liver cirrhosis underwent general surgery in this department. Liver-specific scoring systems, such as the Child-Pugh score (CPS) and MELD score were retrospectively assessed and correlated with in-hospital mortality and perioperative morbidity using the Dindo-Clavien classification. RESULTS Of the 321 patients (68% male) 21.2% underwent emergency surgery. These patients showed a mortality of 60%, which is significantly higher than in elective surgery (12%, p < 0.0001). Complex interventions showed a 41% mortality, minor interventions still 20.5% (p = 0.0001). The postoperative complication rate and mortality were significantly different sorted by CPS with 11.8%/6.3% in the CPS A category and 84%/73% in the CPS C category, respectively (p = 0.001). Statistically in-hospital mortality was increased by 20% for every point increase in the MELD score (odds ratio, OR 1.23, p = 0.0001). The presence of hepatic decompensation had the worst prognosis. CONCLUSION Surgical interventions in patients with liver cirrhosis are associated with a high complication rate and in-hospital mortality. The CPS and MELD scores can be used for objective risk assessment, while clinical examination for signs of hepatic decompensation is also important. Laboratory values, such as sodium and creatinine can assist the assessment.
Collapse
Affiliation(s)
- Roxana Pantea
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr 55, 45147, Essen, Deutschland
| | - Phil Meister
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr 55, 45147, Essen, Deutschland
| | - Jan P Neuhaus
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr 55, 45147, Essen, Deutschland
| | - Knut Nowak
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr 55, 45147, Essen, Deutschland
| | - Andreas Paul
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr 55, 45147, Essen, Deutschland
| | - Fuat H Saner
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr 55, 45147, Essen, Deutschland.
| |
Collapse
|
|
21
|
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; 7:261-278. [PMID: 38993608 PMCID: PMC11181825 DOI: 10.3233/blc-211536] [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: 04/15/2021] [Accepted: 06/09/2021] [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.
Collapse
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
| |
Collapse
|
|
22
|
The imperative for an updated cirrhosis surgical risk score. Ann Hepatol 2021; 19:341-343. [PMID: 32474073 DOI: 10.1016/j.aohep.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023]
Abstract
The burden of cirrhosis is increasing, as is the need for surgeries in patients with cirrhosis. These patients have increased surgical risk relative to non-cirrhotic patients. Unfortunately, currently available cirrhosis surgical risk prediction tools are non-specific, poorly calibrated, limited in scope, and/or outdated. The Mayo score is the only dedicated tool to provide discrete post-operative mortality predictions for patients with cirrhosis, however it has several limitations. First, its single-center nature does not reflect institution-specific practices that may impact surgical risk. Second, it pre-dates major surgical changes that have changed the landscape of patient selection and surgical risk. Third, it has been shown to overestimate risk in external validation. Finally, and perhaps most importantly, the score does not account for differences in risk based on surgery type. The clinical consequences of inaccurate prediction and risk overestimation are significant, as patients with otherwise acceptable risk may be denied elective surgical procedures, thereby increasing their future need for higher-risk emergent procedures. Confident evaluation of the risks and benefits of surgery in this growing population requires an updated, generalizable, and accurate cirrhosis surgical risk calculator that incorporates the type of surgery under consideration.
Collapse
|
|
23
|
Jo HH, Min C, Kyoung DS, Park MA, Kim SG, Kim YS, Chang Y, Jeong SW, Jang JY, Lee SH, Kim HS, Jun BG, Kim YD, Cheon GJ, Yoo JJ. Adverse outcomes after surgeries in patients with liver cirrhosis among Korean population: A population-based study. PLoS One 2021; 16:e0253165. [PMID: 34125860 PMCID: PMC8202950 DOI: 10.1371/journal.pone.0253165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/30/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients with liver cirrhosis have an increased risk of in-hospital mortality or postoperative complication after surgery. However, large-scale studies on the prognosis of these patients after surgery are lacking. The aim of the study was to investigate the adverse outcomes of patients with liver cirrhosis after surgery over five years. Methods and findings We used the Health Insurance Review and Assessment Service-National Inpatient Samples (HIRA-NIS) between 2012 and 2016. In-hospital mortality and hospital stay were analyzed using the data. Mortality rates according to the surgical department were also analyzed. Of the 1,662,887 patients who underwent surgery, 16,174 (1.0%) patients had cirrhosis. The in-hospital mortality (8.0% vs. 1.0%) and postoperative complications such as respiratory (6.0% vs. 5.3%) or infections (2.8% vs. 2.4%) was significantly higher in patients with cirrhosis than in those without cirrhosis. In addition, the total hospitalization period and use of the intensive care unit were significantly higher in patients with liver cirrhosis. In propensity score matching analysis, liver cirrhosis increased the risk of adverse outcome significantly [adjusted OR (aOR) 1.67, 95% CI 1.56–1.79, P<0.001], especially in-hospital mortality. In liver cirrhosis group, presence of decompensation or varices showed significantly increased postoperative complication or mortality. Adverse outcomes in patients with cirrhosis was the highest in patients who underwent otorhinolaryngology surgery (aOR 1.86), followed by neurosurgery (aOR 1.72), thoracic and cardiovascular surgery (aOR 1.56), and plastic surgery (aOR 1.36). Conclusion The adverse outcomes of patients with cirrhosis is significantly high after surgery, despite advances in cirrhosis treatment.
Collapse
Affiliation(s)
- Hyun Ho Jo
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Changwook Min
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | | | - Min-Ae Park
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Korea
| | - Sang Gyune Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Young Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Soung Won Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jae Young Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Sae Hwan Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Hong Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Baek Gyu Jun
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Seoul, Korea
| | - Young Don Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Seoul, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Seoul, Korea
| | - Jeong-Ju Yoo
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
- * E-mail:
| |
Collapse
|
|
24
|
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: 1.3] [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.
Collapse
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
| |
Collapse
|
|
25
|
Cheng YX, Tao W, Zhang H, Peng D, Wei ZQ. Does liver cirrhosis affect the surgical outcome of primary colorectal cancer surgery? A meta-analysis. World J Surg Oncol 2021; 19:167. [PMID: 34107967 PMCID: PMC8191032 DOI: 10.1186/s12957-021-02267-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The purpose of this meta-analysis was to evaluate the effect of liver cirrhosis (LC) on the short-term and long-term surgical outcomes of colorectal cancer (CRC). METHODS The PubMed, Embase, and Cochrane Library databases were searched from inception to March 23, 2021. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of enrolled studies, and RevMan 5.3 was used for data analysis in this meta-analysis. The registration ID of this current meta-analysis on PROSPERO is CRD42021238042. RESULTS In total, five studies with 2485 patients were included in this meta-analysis. For the baseline information, no significant differences in age, sex, tumor location, or tumor T staging were noted. Regarding short-term outcomes, the cirrhotic group had more major complications (OR=5.15, 95% CI=1.62 to 16.37, p=0.005), a higher re-operation rate (OR=2.04, 95% CI=1.07 to 3.88, p=0.03), and a higher short-term mortality rate (OR=2.85, 95% CI=1.93 to 4.20, p<0.00001) than the non-cirrhotic group. However, no significant differences in minor complications (OR=1.54, 95% CI=0.78 to 3.02, p=0.21) or the rate of intensive care unit (ICU) admission (OR=0.76, 95% CI=0.10 to 5.99, p=0.80) were noted between the two groups. Moreover, the non-cirrhotic group exhibited a longer survival time than the cirrhotic group (HR=2.96, 95% CI=2.28 to 3.85, p<0.00001). CONCLUSION Preexisting LC was associated with an increased postoperative major complication rate, a higher rate of re-operation, a higher short-term mortality rate, and poor overall survival following CRC surgery.
Collapse
Affiliation(s)
- Yu-Xi Cheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wei Tao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Hua Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| |
Collapse
|
|
26
|
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.
Collapse
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:
| |
Collapse
|
|
27
|
Klein J, Spigel Z, Kalil J, Friedman L, Chan E. Postoperative Mortality in Patients With Cirrhosis: Reconsidering Expectations. Am Surg 2021; 88:181-186. [PMID: 33502232 DOI: 10.1177/0003134820988825] [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 A diagnosis of cirrhosis increases a patient's risk of postoperative mortality. Surgeons are reticent to operate when cirrhosis is known unless no option is available. This study aimed to identify the modern perioperative risk in cirrhotic patients undergoing intervention under general anesthesia for non-transplant operations. METHODS A retrospective chart review was conducted utilizing the Rush Medical Center electronic medical record. All patients over 18 years of age with a diagnosis of cirrhosis undergoing intervention between 2009 and 2019 were reviewed. 90-day mortality rates in patients grouped by Child's score, Model for End-Stage Liver Disease (MELD), and Model for End-Stage Liver Disease with sodium incorporated (MELDNa) were compared to previously accepted rates. RESULTS 93 patients (46% women) aged 22-72 years of all Child-Turcot-Pugh (CTP) (40% A, 36% B, and 25% C) classifications and MELD/MELDNa ranging 6-40 were analyzed. 90-day mortality of the entire population was 16%, significantly lower than expected based on CTP score (16% vs. 32%; P = .0005), MELD (16% vs. 41%; P < .0001), and MELDNa (16% vs. 46.8%; P < .0001). This was also true for CTP-B patients (12% vs. 30%; P = .025), CTP-C patients (35% vs. 70%; P = .0002), patients with MELD >14 (27% vs. 70%; P < .001), and patients with MELDNa >14 (23% vs. 70%; P < .0001). CONCLUSION Data indicate that perioperative mortality is lower than widely accepted. This suggests the need for a national database study using a representative population to determine the risk of mortality for patients with cirrhosis having surgery in recent times. Accurate estimation of this risk allows for meaningful discussion between physicians and patients when deciding to proceed with elective, necessary operations.
Collapse
Affiliation(s)
- John Klein
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Zachary Spigel
- Department of Surgery, Allegheny Health Network Medical Education Consortium, Pittsburgh, PA, USA
| | - Jennifer Kalil
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Lindsay Friedman
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Edie Chan
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
|
28
|
Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease-A Retrospective Analysis of 76 Cases in a Tertiary Center. BIOLOGY 2020; 9:biology9110349. [PMID: 33105795 PMCID: PMC7690599 DOI: 10.3390/biology9110349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/18/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
Simple Summary It is well known that the incidence of liver cirrhosis is increasing and it negatively affects outcome after surgery. While there are several studies investigating the influence of liver cirrhosis on colorectal, hepatobiliary, or hernia surgery, data about its impact on small bowel surgery are completely lacking. Therefore, a retrospective analysis over a period of 17 years was performed including 76 patients with liver cirrhosis and small bowel surgery. Postsurgical complications were analyzed, and 38 parameters as possible predictive factors for a worse outcome were investigated. We observed postsurgical complications in over 90% of the patients; in over 50%, the complications were classified as severe. When subdividing postoperative complications, bleeding, respiratory problems, wound healing disorders and anastomotic leakage, hydropic decompensation, and renal failure were most common. The most important predictive factors for those complications after uni- and multivariate analysis were portal hypertension, poor liver function, emergency or additional surgery, ascites, and high ASA score. We, therefore, recommend treatment of portal hypertension before small bowel surgery to avoid extension of the operation to other organs than the small bowel and in case of ascites to evaluate the creation of an anastomosis stoma instead of an unprotected anastomosis to prevent leakages. Abstract (1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were “additional surgery” (OR 5.3) and “bowel anastomosis” (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients’ outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.
Collapse
|
|
29
|
Schizas D, Peppas S, Giannopoulos S, Lagopoulou V, Mylonas KS, Giannopoulos S, Moris D, Felekouras E, Toutouzas K. The Impact of Cirrhosis on Pancreatic Cancer Surgery: A Systematic Review and Meta-Analysis. World J Surg 2020; 45:562-570. [PMID: 33073316 DOI: 10.1007/s00268-020-05821-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cirrhosis has been considered a contraindication to major abdominal surgeries, due to increased risk for postoperative morbidity and mortality. The aim of this study was to assess the safety of pancreatectomy in cirrhotic versus non-cirrhotic patients. METHODS The present systematic review and meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All meta-analyses were performed using the random effects model. RESULTS Eight studies were eventually included, enrolling 1229 patients (cirrhotics: 722; and Child-Pugh A: 593; Child-Pugh B/C: 129) who underwent surgery for pancreatic cancer. The overall postoperative morbidity rate was 66% (51%-80%). Infections (26%) and ascites formation/worsening (23%) were the most common postoperative complications, followed by anastomotic leak/fistula (17%). Non-cirrhotic patients were less likely to suffer from anastomotic leak/fistula (OR: 0.39; 95% CI: 0.23-0.65) and infections (OR: 0.41; 95% CI: 0.25-0.67). Postoperative mortality rate was statistically significantly lower in non-cirrhotic versus cirrhotic patients (OR: 0.18; 95% CI:0.18-0.39). The odds ratios of 1 year (OR: 0.62; 95% CI: 0.30-1.30), 2 year (OR: 0.67; 95% CI: 0.25-1.83) and 3 year all-cause mortality (OR: 0.32; 95% CI: 20.03-2.99) were not significantly different between cirrhotic versus non-cirrhotic patients. CONCLUSION This study demonstrated that non-cirrhotic patients were less likely to undergo any type of re-intervention and had statistically significant lower postoperative mortality rates compared to patients with cirrhosis.
Collapse
Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Spyridon Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens, Greece
| | | | - Vasiliki Lagopoulou
- Department of Surgery, 251 VA and Hellenic Air Force Hospital, Athens, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Giannopoulos
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Evangelos Felekouras
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Toutouzas
- First Propedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
|
30
|
Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions. Clin Gastroenterol Hepatol 2020; 18:2398-2414.e3. [PMID: 31376494 PMCID: PMC6994232 DOI: 10.1016/j.cgh.2019.07.051] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures. METHODS We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review. RESULTS Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate. CONCLUSIONS Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.
Collapse
Affiliation(s)
- Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, Washington.
| | - Kay M Johnson
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Paul B Cornia
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Kamal Itani
- Boston VA Health Care System and Boston University, Boston, Massachusetts
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| |
Collapse
|
|
31
|
The effect of cirrhosis on trauma outcomes: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 88:536-545. [PMID: 31389920 DOI: 10.1097/ta.0000000000002464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The negative effect of cirrhosis on mortality following traumatic injury has been quantified in multiple observational studies. However, to our knowledge, the information contained in these studies has never been synthesized. The aims of this study were: (1) to determine the magnitude of the effect of liver cirrhosis on mortality, morbidity, and hospital course among trauma patients and (2) to analyze sources of study heterogeneity that may lead to differing estimates in the observed mortality rate among patients with cirrhosis. METHODS A systematic search of EMBASE and PubMed was conducted. Data were extracted from eligible studies and analyzed using a random-effects model to compare trauma outcomes in cirrhotic and noncirrhotic patients (PROSPERO Registration CRD42018088464). Mortality was the primary outcome. Secondary outcomes included complication rate, length of hospital stay, length of intensive care unit stay, and mechanical ventilation days. RESULTS Title and abstract review of 15,958 articles led to the identification of 31 relevant articles. Ultimately, 18 observational studies were included in this meta-analysis. The pooled effect sizes for mortality (odds ratio [OR], 4.52; 95% confidence interval [CI], 3.13-6.54) and complication rate (OR, 1.92; 95% CI, 1.30-2.85) were higher in the cirrhotic group than the noncirrhotic group. Trauma patients with cirrhosis also incurred longer hospital stays (mean difference, 3.81 days; 95% CI, 1.22-6.41) and longer ICU stays (mean difference, 2.40 days; 95% CI, 0.65-4.15). There was no difference in days spent on mechanical ventilation. CONCLUSION Preexisting liver cirrhosis is associated with increased mortality rate, complication rate, and length of hospitalization among trauma patients, even after adjusting for confounding factors and potential sources of between-study heterogeneity. Trauma patients with cirrhosis would benefit from heightened surveillance and injury prevention interventions. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
Collapse
|
|
32
|
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: 2.8] [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.
Collapse
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
| |
Collapse
|
|
33
|
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: 0.8] [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.
Collapse
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
| |
Collapse
|
|
34
|
Sidhu A, Cabalag C, Lee E, Liew CH, Young A, Christophi C. Outcomes of inguinal hernia repair in cirrhotics: a single tertiary centre experience. ANZ J Surg 2020; 90:772-775. [DOI: 10.1111/ans.15666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 11/07/2019] [Accepted: 12/04/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Ankur Sidhu
- Department of SurgeryNorthern Hospital Melbourne Victoria Australia
| | - Carlos Cabalag
- Department of SurgeryPeter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Eunice Lee
- Department of Hepatopacreaticobiliary and Transplant SurgeryAustin Health Melbourne Victoria Australia
| | - Chon Hann Liew
- Hepatopancreatobiliary and Transplant UnitAustin Health Melbourne Victoria Australia
| | - Alastair Young
- Department of Hepatobiliary and Transplant SurgerySt James's University Hospital Leeds UK
| | - Christopher Christophi
- Department of SurgeryThe University of Melbourne, Austin Hospital Melbourne Victoria Australia
| |
Collapse
|
|
35
|
Fagenson AM, Gleeson EM, Pitt HA, Lau KN. Albumin-Bilirubin Score vs Model for End-Stage Liver Disease in Predicting Post-Hepatectomy Outcomes. J Am Coll Surg 2020; 230:637-645. [PMID: 31954813 DOI: 10.1016/j.jamcollsurg.2019.12.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND The Albumin-Bilirubin score (ALBI) has been established to predict outcomes after hepatectomy. However, the relative value of ALBI and Model for End-Stage Liver Disease (MELD) in predicting post-hepatectomy liver failure and mortality has not been adequately evaluated. Therefore, the aim of this study was to validate and compare ALBI and MELD with respect to post-hepatectomy liver failure and mortality. STUDY DESIGN Patients undergoing major hepatectomy (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014 to 2017 American College of Surgeons NSQIP Procedure Targeted Participant Use File. Univariable and multivariable analyses were performed for 30-day post-hepatectomy liver failure (PHLF) and mortality. Predictive accuracy was assessed using a receiver operator characteristic curve and calculating the area under the curve (AUC). RESULTS For 13,783 patients, median ALBI was -2.6, and median MELD score was 6.9. Severe PHLF (grade B to C) and mortality rates were 2.9% and 1.8%, respectively. Multivariable analyses revealed ALBI grade 2/3 to be a stronger predictor than MELD ≥10 with respect to severe PHLF (odds ratio [OR] 2.30; 95% CI, 1.95 to 2.73; p < 0.001 vs OR 1.00; 95% CI, 0.78 to 1.23; p = 0.99) and mortality (OR 3.35; 95% CI, 2.49 to 4.52; p < 0.001 vs OR 1.73; 95% CI, 1.36 to 2.20; p < 0.001). ALBI also had better discrimination compared with MELD for severe PHLF (AUC 0.67 vs AUC 0.60) and mortality (AUC 0.70 vs AUC 0.58) in patients with hepatocellular carcinoma. CONCLUSIONS ALBI is a powerful predictor of PHLF and mortality. Compared with MELD, ALBI is more accurate, especially in patients with hepatocellular carcinoma.
Collapse
Affiliation(s)
| | - Elizabeth M Gleeson
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Henry A Pitt
- Department of Surgery, Temple University Hospital, Philadelphia, PA; Temple University Health System, Philadelphia, PA.
| | - Kwan N Lau
- Department of Surgery, Temple University Hospital, Philadelphia, PA
| |
Collapse
|
|
36
|
de Oliveira ARCP, Castanhole-Nunes MMU, Biselli-Chicote PM, Pavarino ÉC, da Silva RDCMA, da Silva RF, Goloni-Bertollo EM. Differential expression of angiogenesis-related miRNAs and VEGFA in cirrhosis and hepatocellular carcinoma. Arch Med Sci 2020; 16:1150-1157. [PMID: 32864004 PMCID: PMC7444729 DOI: 10.5114/aoms.2020.97967] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Liver cirrhosis (LC) is a heterogeneous liver disease, the last stage of liver fibrosis, and the major risk factor for hepatocellular carcinoma (HCC). Our study aimed to evaluate the expression of microRNAs and the endothelial vascular growth factor (VEGFA) gene in LC and HCC. MATERIAL AND METHODS The sample group consisted of 46 tissue samples: 21 of LC, 15 of HCC, and 10 of non-tumoural and non-cirrhotic liver tissue (control group). MiRNAs were chosen based on a mirDIP prediction database as regulators of the VEGFA gene. Gene expression of VEGF and miRNAs was quantified by real-time quantitative polymerase chain reaction. VEGFA protein expression was evaluated by ELISA. RESULTS VEGFA gene expression was significantly overexpressed in LC compared to the control group (p < 0.0001). Hsa-miR-206 (p = 0.0313) and hsa-miR-637 (p = 0.0156) were down-expressed in LC. In HCC, hsa-miR-15b (p = 0.0010), hsa-miR-125b (p = 0.0010), hsa-miR-423-3p (p = 0.0010), hsa-miR-424 (p = 0.0313), hsa-miR-494 (p < 0.0001), hsa-miR-497 (p < 0.0001), hsa-miR-612 (p = 0.0078), hsa-miR-637 (p < 0.0001), and hsa-miR-1255b (p = 0.0156) presented down-expression. CONCLUSIONS Overexpression of VEGFA in LC suggests impairment of angiogenesis in this tissue. The differential expression of microRNAs in LC and HCC observed in our study can lead to the evaluation of possible biomarkers for these diseases.
Collapse
Affiliation(s)
- André R C P de Oliveira
- Departament of Molecular Biology, UPGEM - Genetics and Molecular Biology Research Unit, São José do Rio Preto Medical School - FAMERP, São José do Rio Preto, Brazil
- Study Group of Liver Tumors - GETF, Hospital de Base - São José do Rio Preto (SP) and Medical School Foundation - FUNFARME - São José do Rio Preto, Brazil
| | - Márcia M U Castanhole-Nunes
- Departament of Molecular Biology, UPGEM - Genetics and Molecular Biology Research Unit, São José do Rio Preto Medical School - FAMERP, São José do Rio Preto, Brazil
- Study Group of Liver Tumors - GETF, Hospital de Base - São José do Rio Preto (SP) and Medical School Foundation - FUNFARME - São José do Rio Preto, Brazil
| | - Patrícia M Biselli-Chicote
- Departament of Molecular Biology, UPGEM - Genetics and Molecular Biology Research Unit, São José do Rio Preto Medical School - FAMERP, São José do Rio Preto, Brazil
| | - Érika C Pavarino
- Departament of Molecular Biology, UPGEM - Genetics and Molecular Biology Research Unit, São José do Rio Preto Medical School - FAMERP, São José do Rio Preto, Brazil
| | - Rita de C M A da Silva
- Study Group of Liver Tumors - GETF, Hospital de Base - São José do Rio Preto (SP) and Medical School Foundation - FUNFARME - São José do Rio Preto, Brazil
| | - Renato F da Silva
- Study Group of Liver Tumors - GETF, Hospital de Base - São José do Rio Preto (SP) and Medical School Foundation - FUNFARME - São José do Rio Preto, Brazil
| | - Eny M Goloni-Bertollo
- Departament of Molecular Biology, UPGEM - Genetics and Molecular Biology Research Unit, São José do Rio Preto Medical School - FAMERP, São José do Rio Preto, Brazil
- Study Group of Liver Tumors - GETF, Hospital de Base - São José do Rio Preto (SP) and Medical School Foundation - FUNFARME - São José do Rio Preto, Brazil
| |
Collapse
|
|
37
|
Preoperative pulmonary function tests do not predict the development of pulmonary complications after elective major abdominal surgery: A prospective cohort study. Int J Surg 2019; 73:65-71. [PMID: 31809807 DOI: 10.1016/j.ijsu.2019.11.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/23/2019] [Accepted: 11/25/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Data describing the association of preoperative pulmonary function testing (PFT) with postoperative pulmonary complications (PPC) are inconsistent. We conducted this prospective study to determine the ability of PFT to predict PPC. MATERIALS AND METHODS Data were prospectively collected from 676 patients who underwent elective abdominal surgery (emergency and thoracic operations excluded). The primary outcome was the occurrence of PPC within 30 days. Patient and procedure-related factors were examined as risk factors. Multivariate logistic regression analysis was performed using risk factors identified with univariate analysis and area under the curve (AUC) analysis performed. RESULTS PPC occurred in 29 patients (4.9%). History of smoking or abnormal physical examination were not significantly associated. Multivariate analysis identified age (p = 0.03), operative time (p = 0.02), blood transfusions (p = 0.002), and %VC (p = 0.001) as significant risk factors. AUC with a model including age, operative time, and blood transfusion was 0.83. The addition of %VC to these three variables increased the AUC to 0.89 (p = 0.1). CONCLUSIONS Age, operative time, blood transfusion, and %VC are significantly associated with an increased risk of PPC. The addition of %VC to other risk factors did not significantly improve the ability to predict PPC, showing that preoperative PFT is not helpful to predict PPC.
Collapse
|
|
38
|
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.
Collapse
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.
| |
Collapse
|
|
39
|
Sarveazad A, Agah S, Babahajian A, Amini N, Bahardoust M. Predictors of 5 year survival rate in hepatocellular carcinoma patients. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:86. [PMID: 31741658 PMCID: PMC6856560 DOI: 10.4103/jrms.jrms_1017_18] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/25/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022]
Abstract
Background Hepatocellular carcinoma (HCC) is one of the most common primary hepatic malignancies and growing challenges of global health. In this study, for the first time in Iran, we investigated the 5-year survival rate and prognostic factors in patients with HCC. Materials and Methods In this historical cohort study, we examined the medical records of 227 HCC patients who were registered in the central tumor registry of our institution from September 2007 to September 2017. Demographic data, clinical parameters, received treatments, and survival curves from time of diagnosis were evaluated. Kaplan-Meier was used for univariate analysis, and multivariable analysis was performed by Cox regression. Results A total of 208 (91.63%) patients were dead. The 5-year survival rate was estimated 19 (8.37%). The average follow-up in this study was 14.3 months. Overall median survival rate was 12.1 months. Univariate analysis showed that tumor size, metastasis, number of involved lymph node, hepatitis type, and treatment were significantly related to the survival rate, and Cox regression analysis revealed that the tumor size >3 cm (hazard ratio [HR] = 3.06, 95% confidence interval [CI] = 1.68-4.97; P = 0.027), involved lymph nodes >2 (HR = 4.12, 95% CI = 2.66-6.38; P = 0.001), metastasis (HR = 3.87, 95% CI = 3.13-6.54; P = 0.011), combination therapy with surgery and chemotherapy (HR = 0.4, 95% CI = 0.15-0.79; P = 0.023), and coinfection with hepatitis B virus and hepatitis C virus (HR = 2.11, 95% CI = 1.81-4.6; P = 0.036) are the most relevant prognostic factors with 5-year survival rate in patients with HCC. Conclusion Results of this study will help estimate survival rates for patients with HCC according to their clinical status.
Collapse
Affiliation(s)
- Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shahram Agah
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Asrin Babahajian
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Naser Amini
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mansour Bahardoust
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
|
40
|
Hasanin AS, Mahmoud FM, Soliman HM. Factors affecting acid base status during hepatectomy in cirrhotic patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Ashraf S. Hasanin
- Department of Anesthesia & ICU, National Liver Institute, Menoufia University, Egypt
| | - Fatma M.A. Mahmoud
- Department of Anesthesia & ICU, National Liver Institute, Menoufia University, Egypt
| | - Hossam M. Soliman
- Department of Hepatobiliary Surgery & Liver Transplantation, National Liver Institute, Menoufia University, Egypt
| |
Collapse
|
|
41
|
Marullo AG, Biondi-Zoccai G, Giordano A, Frati G. No guts, no glory for aortic stenosis. J Cardiovasc Med (Hagerstown) 2019; 20:245-247. [PMID: 30829878 DOI: 10.2459/jcm.0000000000000776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
|
42
|
Northup PG, Friedman LS, Kamath PS. AGA Clinical Practice Update on Surgical Risk Assessment and Perioperative Management in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2019; 17:595-606. [PMID: 30273751 DOI: 10.1016/j.cgh.2018.09.043] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Lawrence S Friedman
- Departments of Medicine, Harvard Medical School, Tufts University School of Medicine, Newton-Wellesley Hospital, Rochester, Minnesota; Massachusetts General Hospital, Boston, Massachusetts, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| |
Collapse
|
|
43
|
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: 1.5] [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.
Collapse
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
| |
Collapse
|
|
44
|
Hernia Management in Cirrhosis: Risk Assessment, Operative Approach, and Perioperative Care. J Surg Res 2019; 235:1-7. [PMID: 30691782 DOI: 10.1016/j.jss.2018.09.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/31/2018] [Accepted: 09/13/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The rising incidence of liver disease has complicated the management of common surgical pathologies. Hernias, in particular, are problematic given the shortage of high-quality data and differing expert opinions. We aim to provide a narrative review of hernia management in cirrhosis as a first step toward developing evidence-based recommendations for the care of these patients. MATERIALS AND METHODS A literature review using separate search strings was conducted for PubMed and Cochrane Central Register of Controlled Trials databases. Review articles, conference abstracts, randomized clinical trials, and observational studies were included. Articles without a focus on patients with end-stage liver disease were excluded. Manuscripts were selected based on relevance to perioperative risk assessment, medical optimization, surgical decision-making, and considerations of hernia repair in patients with cirrhosis. RESULTS The existing literature is varied with regard to focus and quality of data. Of the 4516 articles identified, 51 full-text articles were selected for review. In general, there is evidence to suggest that individuals with compensated cirrhosis may successfully undergo and benefit from hernia repair. Patients at high risk for decompensated cirrhosis may be best served by nonoperative management. CONCLUSIONS Carefully selected patients with cirrhosis may proceed with herniorrhaphy. A multidisciplinary approach is essential to provide high-quality care and improve outcomes.
Collapse
|
|
45
|
De Stefano F, Garcia CR, Gupta M, Marti F, Turcios L, Dugan A, Gedaly R. Outcomes in patients with portal hypertension undergoing gastrointestinal surgery: A propensity score matched analysis from the NSQIP dataset. Am J Surg 2018; 217:664-669. [PMID: 30578032 DOI: 10.1016/j.amjsurg.2018.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM We aim to study the impact of PH in patients undergoing gastrointestinal surgery (GI). METHODS We queried the ACS-NSQIP database from 2005 through 2010 for patients undergoing GI surgery with PH. Esophageal varices (EV) diagnosis was used as a surrogate of PH. RESULTS A total of 192,296 patients underwent GI surgery, of which 379 had PH. Regression analyses revealed that patients with PH had a 6-fold (95% CI 4.6-7.9) increase in 30-day mortality, a 3-fold (95% CI 2.5-3.7) increase in morbidity, a 3.2-fold (95% CI 2.6-3.9) increase in critical care complications (CCC), and a 6.5-day (95% CI 5.1-7.8) increase in hospital LOS. After PSM, the impact of PH on the outcomes remained. These differences were significant regardless of the emergent or elective status of the procedure. AUC analysis demonstrated that MELD and MELDNa + score greater than 10.5 was the most predictive of peri-operative mortality in elective PH cases. CONCLUSIONS PH is associated with an increased risk of poor surgical outcomes in patients undergoing elective and emergent gastrointestinal surgery.
Collapse
Affiliation(s)
- Felice De Stefano
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Catherine R Garcia
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Meera Gupta
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Francesc Marti
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Lilia Turcios
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Adam Dugan
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Roberto Gedaly
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA.
| |
Collapse
|
|
46
|
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: 7] [Impact Index Per Article: 1.0] [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.
Collapse
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.
| |
Collapse
|
|
47
|
Surov A, Paul L, Meyer HJ, Schob S, Engelmann C, Wienke A. Apparent Diffusion Coefficient Is a Novel Imaging Biomarker of Myopathic Changes in Liver Cirrhosis. J Clin Med 2018; 7:jcm7100359. [PMID: 30326652 PMCID: PMC6210701 DOI: 10.3390/jcm7100359] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/03/2018] [Accepted: 10/13/2018] [Indexed: 02/06/2023] Open
Abstract
Diffusion weighted imaging can provide information regarding tissue composition and can quantitatively characterize different pathological changes by means of apparent diffusion coefficient (ADC). The study comprised of 114 patients with liver cirrhosis-22 women and 92 men with a mean age of 56.5 ± 9.0 years. In all patients, the Model for End Stage-Liver Disease (MELD) score was calculated. Furthermore, 12 healthy persons (5 women, 7 men), mean age, 42.1 ± 16.2 years, were investigated as a control group. In all cases, magnetic resonance imaging of the liver/trunk was performed using different 3T scanners and diffusion weighted images were obtained with a multi-shot SE-EPI sequence. In all cases, polygonal regions of interest were manually drawn on the ADC maps along the contours of the iliopsoas and paravertebral muscles. The comparison of ADC values in groups was performed by Mann-Whitney-U tests. The association between ADC and MELD score was calculated by Spearman's rank correlation coefficient. ADC values of the skeletal musculature were statistically much higher in comparison to those in the control group: 1.85 ± 0.46 × 10-3 mm² s-1 vs. 1.23 ± 0.12 × 10-3 mm² s-1, p = 0.001. ADC values showed statistically significant correlation with the MELD score (r = 0.473, p = 0.0001). Furthermore, ADC values differed between the subgroups with different values of the MELD score. ADC values correlated slightly with lactate dehydrogenase (LDH) (r = 0.381, p = 0.0001) and tended to correlate with C-reactive protein (CRP) (r = 0.171, p = 0.07) and alanine aminotransferase (ALAT) (r = -0.167, p = 0.076). ADC can reflect muscle changes in liver cirrhosis and shows statistically significant correlation with the MELD score. Therefore, ADC can be used as an imaging biomarker of myopathic changes in liver cirrhosis.
Collapse
Affiliation(s)
- Alexey Surov
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany.
| | - Lisa Paul
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany.
| | - Hans Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany.
| | - Stefan Schob
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany.
| | - Cornelius Engelmann
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany.
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK.
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther University, 06112 Halle-Wittenberg, Germany.
| |
Collapse
|
|
48
|
Salamone G, Licari L, Guercio G, Campanella S, Falco N, Scerrino G, Bonventre S, Geraci G, Cocorullo G, Gulotta G. The abdominal wall hernia in cirrhotic patients: a historical challenge. World J Emerg Surg 2018; 13:35. [PMID: 30065783 PMCID: PMC6064098 DOI: 10.1186/s13017-018-0196-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/18/2018] [Indexed: 12/20/2022] Open
Abstract
Background The incidence rate of abdominal wall hernia is 20–40% in cirrhotic patients. A surgical approach was originally performed only if complication signs and symptoms occurred. Several recent studies have demonstrated the usefulness of elective surgery. During recent decades, the indications for surgical timing have changed. Methods Cirrhotic patients with abdominal hernia who underwent surgical operation for abdominal wall hernia repair at the Policlinico “Paolo Giaccone” at Palermo University Hospital between January 2010 and September 2016 were identified in a prospective database, and the data collected were retrospectively reviewed; patients’ medical and surgical records were collected from charts and surgical and intensive care unit (ICU) registries. Postoperative morbidity was determined through the Clavien-Dindo classification. Cirrhosis severity was estimated by the Child-Pugh-Turcotte (CPT) score and MELD (model of end-stage liver disease) score. Postoperative mortality was considered up to 30 days after surgery. A follow-up period of at least 1 year was used to evaluate hernia recurrence. Results The univariate and multivariate analyses demonstrated the unique independent risk factors for the development of postsurgical morbidity (emergency surgery (OR 6.42; p 0.023), CPT class C (OR 3.72; p 0.041), American Society of Anesthesiologists (ASA) score ≥ 3 (OR 4.72; p 0.012) and MELD ≥ 20 (OR 5.64; p 0.009)) and postsurgical mortality (emergency surgery (OR 10.32; p 0.021), CPT class C (OR 5.52; p 0.014), ASA score ≥ 3 (OR 8.65; p 0.018), MELD ≥ 20 (OR 2.15; p 0.02)). Conclusions Concerning abdominal wall hernia repair in cirrhotic patients, the worst outcome is associated with emergency surgery and with uncontrolled disease. The correct timing of the surgical operation is elective surgery after ascites drainage and albumin/electrolyte serum level and coagulation alteration correction.
Collapse
Affiliation(s)
- Giuseppe Salamone
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Leo Licari
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Giovanni Guercio
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Sofia Campanella
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Nicolò Falco
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gregorio Scerrino
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Sebastiano Bonventre
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Girolamo Geraci
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gianfranco Cocorullo
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gaspare Gulotta
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| |
Collapse
|
|
49
|
The Effect of Underlying Liver Disease on Perioperative Outcomes Following Craniotomy for Tumor: An American College of Surgeons National Quality Improvement Program Analysis. World Neurosurg 2018; 115:e85-e96. [DOI: 10.1016/j.wneu.2018.03.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 01/10/2023]
|
|
50
|
Panuganti B, Chang ES, Helm CW, Schwartz T, Hsueh EC, Piao J, Lai J, Veerapong J. Cytoreductive Surgery and Normothermic Intraperitoneal Chemotherapy for Signet Ring Cell Appendiceal Adenocarcinoma With Peritoneal Metastases in the Setting of Cirrhosis. Gastroenterology Res 2018; 11:247-251. [PMID: 29915638 PMCID: PMC5997481 DOI: 10.14740/gr1029w] [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: 04/20/2018] [Accepted: 05/15/2018] [Indexed: 12/15/2022] Open
Abstract
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are combined to treat peritoneal surface malignancies (PSM). The objective of cytoreduction is to eradicate macroscopic disease, while HIPEC addresses residual microscopic disease. Currently, there are no protocols guiding treatment of cirrhotic patients with PSM. We report the case of a cirrhotic patient with signet ring cell (SRC) appendiceal adenocarcinoma who underwent normothermic, as opposed to hyperthermic intraperitoneal chemotherapy (IPC). A 50-year-old woman with compensated class A cirrhosis and chronic hepatitis B and C underwent a right hemicolectomy in 2007 and adjuvant chemotherapy in 2008 for appendiceal SRC adenocarcinoma. In 2011, she was found to have peritoneal disease after a laparotomy. She subsequently experienced intolerance to chemotherapy, with stable disease on serial restaging. In light of her cirrhosis, the decision was made to perform CRS and IPC without hyperthermia to treat her residual disease. In 2012, she underwent CRS (omentectomy, total abdominal hysterectomy, left salpingo-oophorectomy) and IPC with mitomycin C. Thirty-day postoperative morbidity included delayed abdominal closure (Clavien-Dindo Grade IIIb), prolonged ventilator support (IIIa), vasopressor requirements (II), and confusion (II). The patient’s liver function remained stable. Eight months later, she had evidence of recurrence on computed tomography. Twenty-two months later, she developed an extrinsic compression secondary to evolving disease, requiring a palliative endoscopic stent. The patient expired from her disease 29 months after her CRS and IPC. The criteria guiding selection of suitable candidates for CRS continues to evolve. Concomitant compensated cirrhosis in patients with PSM should not constitute a reason independently to exclude CRS with intraperitoneal chemotherapy, given the oncologic benefits of the procedure.
Collapse
Affiliation(s)
- Bharat Panuganti
- Department of Surgery, University of California-San Diego, La Jolla, CA, USA
| | - Ea-Sle Chang
- Department of General Surgery, Saint Louis University, Saint Louis, MO, USA
| | - Cyril W Helm
- Royal Cornwall Hospitals NHS Trust, Treliske, Truro, Cornwall, TR1 3LJ, United Kingdom
| | - Theresa Schwartz
- Division of Surgical Oncology, Department of General Surgery, Saint Louis University, Saint Louis, MO, USA
| | - Eddy C Hsueh
- Division of Surgical Oncology, Department of General Surgery, Saint Louis University, Saint Louis, MO, USA
| | - Jinhua Piao
- Department of Pathology, Saint Louis University, Saint Louis, MO, USA
| | - Jinping Lai
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of General Surgery, University of California-San Diego, La Jolla, CA, USA
| |
Collapse
|