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Giri S, Dash KA, Varghese J, Afzalpurkar S. The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates. Euroasian J Hepatogastroenterol 2023; 13:18-25. [PMID: 37554975 PMCID: PMC10405807 DOI: 10.5005/jp-journals-10018-1390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/26/2023] [Indexed: 08/10/2023] Open
Abstract
Renal transplant is the most common organ transplant worldwide, accounting for 65% of the total number of transplants. End-stage renal disease (ESRD) often has multiple significant comorbidities. Among the gastrointestinal (GI) disorders, peptic ulcer disease (PUD), cholelithiasis, and colon and liver diseases increase the risk of posttransplant morbidity. Potential renal transplantation (RT) candidates need a multidisciplinary assessment of coexisting illnesses, which may affect the perioperative risk and survival after transplantation. Successful outcome of RT depends on careful selection of the recipients by a thorough medical evaluation and screening. This review summarizes the role of gastroenterologists and hepatologists in preoperative assessment and management of renal transplant recipients. How to cite this article Giri S, Dash KA, Varghese J, et al. The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates. Euroasian J Hepato-Gastroenterol 2023;13(1):18-25.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Kumar Avijeet Dash
- Department of Nephrology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Jijo Varghese
- Department of Gastroenterology, KM Cherian Institute of Medical Sciences, Kallissery, India
| | - Shivaraj Afzalpurkar
- Department of Gastroenterology, Nanjappa Multi-Speciality Hospitals, Davanagere, Karnataka, India
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Bierle DM, Wight EC, Ganesh R, Himes CP, Sundsted KK, Jacob AK, Mohabbat AB. Preoperative Evaluation and Management of Patients With Select Chronic Gastrointestinal, Liver, and Renal Diseases. Mayo Clin Proc 2022; 97:1380-1395. [PMID: 35787866 DOI: 10.1016/j.mayocp.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/22/2021] [Accepted: 03/29/2022] [Indexed: 11/28/2022]
Abstract
Patients with chronic gastrointestinal, hepatic, and renal disease are frequently encountered in clinical practice. This is due in part to the rising prevalence of risk factors associated with these conditions. These patients are increasingly being considered for surgical intervention and are at higher risk for multiple perioperative complications. Many are able to safely undergo surgery but require unique considerations to ensure optimal perioperative care. In this review, we highlight relevant perioperative physiology and outline our approach to the evaluation and management of patients with select chronic gastrointestinal, hepatic, and renal diseases. A comprehensive preoperative evaluation with a multidisciplinary approach is often beneficial, and specialist involvement should be considered. Intraoperative and postoperative plans should be individualized based on the unique medical and surgical characteristics of each patient.
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Affiliation(s)
- Dennis M Bierle
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Elizabeth C Wight
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Karna K Sundsted
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arya B Mohabbat
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Spring A, Saran JS, McCarthy S, McCluskey SA. Anesthesia for the Patient with Severe Liver Failure. Adv Anesth 2020; 38:251-267. [PMID: 34106838 DOI: 10.1016/j.aan.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.
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Affiliation(s)
- Aidan Spring
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Jagroop S Saran
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Sinead McCarthy
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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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.
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Affiliation(s)
- Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, Washington.
| | - Kay M Johnson
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Paul B Cornia
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Kamal Itani
- Boston VA Health Care System and Boston University, Boston, Massachusetts
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Spring A, Saran JS, McCarthy S, McCluskey SA. Anesthesia for the Patient with Severe Liver Failure. Anesthesiol Clin 2020; 38:35-50. [PMID: 32008656 DOI: 10.1016/j.anclin.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.
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Affiliation(s)
- Aidan Spring
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Jagroop S Saran
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Sinead McCarthy
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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Diaz KE, Schiano TD. Evaluation and Management of Cirrhotic Patients Undergoing Elective Surgery. Curr Gastroenterol Rep 2019; 21:32. [PMID: 31203525 DOI: 10.1007/s11894-019-0700-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Cirrhotic patients have an increased risk of surgical complications and higher perioperative morbidity and mortality based on the severity of their liver disease. Liver disease predisposes patients to perioperative coagulopathies, volume overload, and encephalopathy. The goal of this paper is to discuss the surgical risk of cirrhotic patients undergoing elective surgeries and to discuss perioperative optimization strategies. RECENT FINDINGS Literature thus far varies by surgery type and the magnitude of surgical risk. CTP and MELD classification scores allow for the assessment of surgical risk in cirrhotic patients. Once the decision has been made to undergo elective surgery, cirrhotic patients can be optimized pre-procedure with the help of a checklist and by the involvement of a multidisciplinary team. Elective surgeries should be performed at hospital centers staffed by healthcare providers experienced in caring for cirrhotic patients. Further research is needed to develop ways to prepare this complicated patient population before elective surgery.
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Affiliation(s)
- Kelly E Diaz
- Department of Medicine, Mount Sinai Medical Center, New York, NY, USA
| | - Thomas D Schiano
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY, USA.
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Kennedy ND, Winter DC. Impact of alcohol & smoking on the surgical management of gastrointestinal patients. Best Pract Res Clin Gastroenterol 2017; 31:589-595. [PMID: 29195679 DOI: 10.1016/j.bpg.2017.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/24/2017] [Accepted: 10/20/2017] [Indexed: 01/31/2023]
Abstract
Alcohol and smoking are repeatedly described as modifiable risk factors in clinical studies across all surgical specialities. These lifestyle choices impart a sub-optimal physiology via multiple processes and play an important role in the surgical management of the gastrointestinal patient. Cessation is imperative to optimise the patient's fitness for surgery with surgery itself being a prime opportunity for sustained cessation. A consistent, planned and integrated management involving surgical, anaesthetic, medical, and primary care facets will aid in successful cessation and perioperative care. This review highlights the pathological processes which contribute to perioperative complications and details the current practices to detect, predict and appropriately manage the perioperative gastrointestinal patient who smokes and consumes alcohol.
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Affiliation(s)
- Niall D Kennedy
- St Vincents University Hospital, Elm Park, Dublin 4, Ireland.
| | - Des C Winter
- St Vincents University Hospital, Elm Park, Dublin 4, Ireland
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Abstract
The anesthesiologist may encounter patients with pre-exist ing liver disease who are scheduled to undergo surgery and anesthesia or may care for patients with postoperative liver dysfunction caused by various intraoperative events. A re view of pre-existing or intraoperative factors that can con tribute to liver dysfunction will enhance the clinician's abil ity to establish a differential diagnosis and course of clinical care. The clinician should become familiar with the prognos tic indicators of perioperative morbidity and mortality in the patient with pre-existing liver disease to carefully weigh the risks and benefits of proceeding with surgery and anesthe sia; the patient and the surgeon should be counseled accord ingly. The first section of this article, on liver dysfunction after vascular surgery, addresses various intraoperative fac tors that may contribute to postoperative hepatic dysfunc tion and reviews the impact of pre-existing liver disease on perioperative morbidity and mortality. Today, more patients undergo transjugular intrahepatic portosystemic shunt (TIPS) procedures than surgical portosystemic shunts. The introduction of liver transplantation into clinical medicine has also reduced surgical portosystemic shunts. The second section of this article, on current status of portosystemic shunts, reviews both surgically and radiographically placed shunts and their current role in caring for patients with portal hypertension.
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Affiliation(s)
- Suanne M. Daves
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
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Leong WQ, Ganpathi IS, Kow AWC, Madhavan K, Chang SKY. Comparative study and systematic review of laparoscopic liver resection for hepatocellular carcinoma. World J Hepatol 2015; 7:2765-2773. [PMID: 26644820 PMCID: PMC4663396 DOI: 10.4254/wjh.v7.i27.2765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/25/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the surgical outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) as a curative treatment in patients with hepatocellular carcinoma (HCC).
METHODS: A PubMed database search was performed systematically to identify comparative studies of LLR vs OLR for HCC from 2000 to 2014. An extensive text word search was conducted, using combinations of search headings such as “laparoscopy”, “hepatectomy”, and “hepatocellular carcinoma”. A comparative study was also performed in our institution where we analysed surgical outcomes of 152 patients who underwent liver resection between January 2005 to December 2012, of which 42 underwent laparoscopic or hand-assisted laparoscopic resection and 110 underwent open resection.
RESULTS: Analysis of our own series and a review of 17 high-quality studies showed that LLR was superior to OLR in terms of short-term outcomes, as patients in the laparoscopic arm were found to have less intraoperative blood loss, less blood transfusions, and a shorter length of hospital stay. In our own series, both LLR and OLR groups were found to have similar overall survival (OS) rates, but disease-free survival (DFS) rates were higher in the laparoscopic arm.
CONCLUSION: LLR is associated with better short-term outcomes compared to OLR as a curative treatment for HCC. Long-term oncologic outcomes with regards to OS and DFS rates were found to be comparable in both groups. LLR is hence a safe and viable option for curative resection of HCC.
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Tapper EB, Patwardhan V, Mazer LM, Vaughn B, Piatkowski G, Evenson AR, Malik R. Predictors of negative intraoperative findings at emergent laparotomy in patients with cirrhosis. J Gastrointest Surg 2014; 18:1777-83. [PMID: 25091839 PMCID: PMC5557345 DOI: 10.1007/s11605-014-2599-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/16/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Emergent surgery in the setting of decompensated cirrhosis is highly morbid. We sought to determine the clinical factors associated with negative intraoperative findings at emergent laparotomy. METHODS We performed a retrospective cohort study of consecutive inpatients with a diagnosis of cirrhosis (ICD-9 571) admitted to the Beth Israel Deaconess Medical Center (Boston, MA) who underwent emergent, nonhepatic, abdominal surgery between May 6, 2005 and September 3, 2012. RESULTS Eighty-six patients with cirrhosis were included with a mean model for end-stage liver disease score of 21.3 ± 7.95 and a 90-day mortality rate of 39.5%. Twelve (16.2%) patients had negative laparotomies. Negative intraoperative findings were independently associated with (1) paracentesis prior to a preoperative diagnosis of perforated viscus (P = 0.006), (2) development of an indication for emergent surgery after 24 h into hospital admission for another reason (P = 0.020), and (3) a preoperative diagnosis of bowel ischemia (P = 0.005), with odds ratios of 10.1 (CI 1.92-66.83), 5.80 (CI 1.32-33.39), and 11.1 (CI 2.08-77.4), respectively. Free air on computed tomography (CT) imaging was found in 64.3% (9/14) of patients who had a paracentesis within the preceding 48 h compared to 10.1% (7/72) among patients who did not undergo a paracentesis (P < 0.001). Only 45% of patients with free air following a paracentesis had positive findings at laparotomy compared to 100% in those without a preceding paracentesis (P = 0.038). Negative laparotomy was independently predictive of in-hospital mortality (OR 4.7; P = 0.034). CONCLUSION The possibility of a negative laparotomy is suggested by preoperative clinical factors. In particular, free air following a paracentesis does not necessarily indicate that operative intervention is required. Consideration of close observation before laparotomy in these patients is reasonable.
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Affiliation(s)
- Elliot B. Tapper
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA. Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Vilas Patwardhan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Laura M. Mazer
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Byron Vaughn
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Gail Piatkowski
- Decision Support, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Amy R. Evenson
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Raza Malik
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
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Im GY, Lubezky N, Facciuto ME, Schiano TD. Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk. Clin Liver Dis 2014; 18:477-505. [PMID: 24679507 DOI: 10.1016/j.cld.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.
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Affiliation(s)
- Gene Y Im
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Nir Lubezky
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Marcelo E Facciuto
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Thomas D Schiano
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA.
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Yin Z, Fan X, Ye H, Yin D, Wang J. Short- and long-term outcomes after laparoscopic and open hepatectomy for hepatocellular carcinoma: a global systematic review and meta-analysis. Ann Surg Oncol 2013; 20:1203-15. [PMID: 23099728 DOI: 10.1245/s10434-012-2705-8] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 08/15/2023]
Abstract
BACKGROUND Laparoscopic hepatectomy (LH) has been proposed as a safe and feasible treatment option for liver diseases. However, the short- and long-term outcomes of LH versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) have not been adequately assessed. Thus, as another means of surgical therapy for hepatocellular carcinoma (HCC), we assessed the feasibility of performing LH as the standard procedure for disease in the left lateral lobe and peripheral right segments for HCC in selected patients. METHODS Literature search included PubMed, Embase, Science Citation Index, SpringerLink, and secondary sources, from inception to March 2012, with no restrictions on languages or regions. The fixed-effects and random-effects models were used to measure the pooled estimates. The test of heterogeneity was performed by the Q statistic. Subgroup and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of study quality. RESULTS A total of 1238 patients (LH 485, OH 753) from 15 studies were included. The pooled odds ratios for postoperative morbidity and incidence of negative surgical margin in LH were found to be 0.37 (95 % confidence interval [CI] 0.27-0.52; P < 0.01) and 1.63 (95 % CI 0.82-3.22; P = 0.16), respectively, compared with OH. Blood loss was significantly decreased in the LH (weighted mean difference -224.63; 95 % CI -384.87 to -64.39; P = 0.006). No significant difference was observed between the both groups for long-term outcomes of overall survival and recurrence-free survival. CONCLUSIONS In patients with solitary left lateral lobe/right peripheral subcapsular tumors treated with minor resection, this meta-analysis demonstrated that compared to OH, LH may have short-term advantages in terms of blood loss and postoperative morbidity for HCC. Both procedures have similar long-term outcomes. It may be time to consider changing the standard procedures for treatment of HCC in the left lateral lobe and peripheral subcapsular right segments in selected patients.
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Affiliation(s)
- Zi Yin
- General Surgery Department, Cancer Research Center, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
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Pandey CK, Karna ST, Pandey VK, Tandon M, Singhal A, Mangla V. Perioperative risk factors in patients with liver disease undergoing non-hepatic surgery. World J Gastrointest Surg 2012; 4:267-74. [PMID: 23494910 PMCID: PMC3596521 DOI: 10.4240/wjgs.v4.i12.267] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 08/25/2012] [Accepted: 12/20/2012] [Indexed: 02/06/2023] Open
Abstract
The patients with liver disease present for various surgical interventions. Surgery may lead to complications in a significant proportion of these patients. These complications may result in considerable morbidity and mortality. Preoperative assessment can predict survival to some extent in patients with liver disease undergoing surgical procedures. A review of literature suggests nature and the type of surgery in these patients determines the peri-operative morbidity and mortality. Optimization of premorbid factors may help to reduce perioperative mortality and morbidity. The purpose of this review is to discuss the effect of liver disease on perioperative outcome; to understand various risk scoring systems and their prognostic significance; to delineate different preoperative variables implicated in postoperative complications and morbidity; to establish the effect of nature and type of surgery on postoperative outcome in patients with liver disease and to discuss optimal anaesthesia strategy in patients with liver disease.
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Affiliation(s)
- Chandra Kant Pandey
- Chandra Kant Pandey, Sunaina Tejpal Karna, Vijay Kant Pandey, Manish Tandon, Amit Singhal, Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi 110070, India
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Kim SH, Lee JG, Kwon SY, Lim JH, Kim WO, Kim KS. Is close monitoring in the intensive care unit necessary after elective liver resection? JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:155-61. [PMID: 22977762 PMCID: PMC3433552 DOI: 10.4174/jkss.2012.83.3.155] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 06/14/2012] [Accepted: 07/14/2012] [Indexed: 02/06/2023]
Abstract
Purpose Many surgical patients are admitted to the intensive care unit (ICU), resulting in an increased demand, and possible waste, of resources. Patients who undergo liver resection are also transferred postoperatively to the ICU. However, this may not be necessary in all cases. This study was designed to assess the necessity of ICU admission. Methods The medical records of 313 patients who underwent liver resections, as performed by a single surgeon from March 2000 to December 2010 were retrospectively reviewed. Results Among 313 patients, 168 patients (53.7%) were treated in the ICU. 148 patients (88.1%) received only observation during the ICU care. The ICU re-admission and intensive medical treatment significantly correlated with major liver resection (odds ratio [OR], 6.481; P = 0.011), and intraoperative transfusions (OR, 7.108; P = 0.016). Patients who underwent major liver resection and intraoperative transfusion were significantly associated with need for mechanical ventilator care, longer postoperative stays in the ICU and the hospital, and hospital mortality. Conclusion Most patients admitted to the ICU after major liver resection just received close monitoring. Even though patients underwent major liver resection, patients without receipt of intraoperative transfusion could be sent to the general ward. Duration of ICU/hospital stay, ventilator care and mortality significantly correlated with major liver resection and intraoperative transfusion. Major liver resection and receipt of intraoperative transfusions should be considered indicators for ICU admission.
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Affiliation(s)
- Sung Hoon Kim
- Department of Surgery, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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16
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Abstract
Patients with chronic liver disease face greater risk of perioperative morbidity and mortality, with the greatest risk among patients with cirrhosis. Both the Child-Pugh score and the Model for End-Stage Liver Disease have been evaluated as predictors of postoperative mortality. Other comorbidities, age, and American Society of Anesthesiologists physical status classification are also important predictors of these outcomes. In patients with liver disease, elective surgeries should be delayed to allow complete evaluation of the severity of liver disease, including the role of transplantation in the event of hepatic decompensation postoperatively.
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Affiliation(s)
- Andrew J Muir
- Division of Gastroenterology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC 27715, USA.
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Kim SH, Han YD, Lee JG, Kim DY, Choi SB, Choi GH, Choi JS, Kim KS. MELD-based indices as predictors of mortality in chronic liver disease patients who undergo emergency surgery with general anesthesia. J Gastrointest Surg 2011; 15:2029-35. [PMID: 21913042 DOI: 10.1007/s11605-011-1669-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 08/10/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Underlying chronic liver disease is associated with high morbidity and mortality after emergency surgery, which complicates clinical decisions over performing such surgery. In addition, the Child-Turcotte-Pugh (CTP) score is limited in its ability to predict postoperative residual liver function. This study was designed to determine whether the scores of the Model for End-stage Liver Disease (MELD)-based indices are effective predictors of mortality following emergency surgery in patients with chronic liver disease. METHOD Medical records of 53 chronic liver disease patients who underwent emergency surgery under general anesthesia from 2001 to 2008 were analyzed retrospectively. RESULTS Median preoperative CTP score was 6 (5-12); MELD, 11 (6-33); MELD-Na, 15 (7-34); integrated MELD (iMELD), 33 (14-64); and MELD to sodium ratio, 8 (4-24). During a median 11-month follow-up period, 19 (35.8%) patients died. Five of them (26.3%) had operative mortality (i.e., mortality within 30 days after surgery). On multivariate analysis, CTP class C was correlated with operative mortality, and estimated blood loss above 300 ml and the iMELD score above 35 were significantly correlated with overall mortality. CONCLUSIONS iMELD reflects underlying liver function and predicts overall mortality more accurately than CTP and other MELD-based indices scores do in chronic liver disease patients after emergency surgery with general anesthesia.
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Affiliation(s)
- Sung Hoon Kim
- Department of Surgery, Yonsei University College of Medicine, 134, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, South Korea
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18
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Laparoscopic resection vs. open liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: a case-matched study. Surg Endosc 2011; 25:3668-77. [PMID: 21688080 DOI: 10.1007/s00464-011-1775-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 05/16/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studies that compare laparoscopic to open liver resection for hepatocellular carcinoma (HCC) in cirrhotic patients are rare and may have suffered from low patient numbers. This work was designed to determine the impact of laparoscopic resection on postoperative and long-term outcomes in a large series of cirrhotic patients with hepatocellular carcinoma (HCC) compared with open resection. METHODS From 2002 to 2009, 36 patients with chronic liver disease with complicating HCC were selected for laparoscopic resection (laparoscopic group, LG). The outcomes were compared with those of 53 patients who underwent open hepatectomy (open group, OG) during the same period in a matched-pair analysis. The two groups were similar in terms of tumor number and size and number of resected segments. RESULTS Morbidity and mortality rates were similar in the two groups (respectively 25 and 0% in LG vs. 35.8 and 7.5% in OG; p = 0.3). Severe complications were more frequent in OG (13.2%) than in LG (2.8%; p = 0.09). Despite similar portal hypertension levels, complications related to ascites (namely evisceration or variceal bleeding) were fatal in 4 of 12 affected patients in OG but 0 of 5 cases in LG (p = 0.2). The mean hospitalization durations were 6.5 ± 2.7 days and 9.5 ± 4.8 days in LG and OG, respectively (p = 0.003). The surgical margins were similar in the two groups. Although there was a trend toward better 5-year overall survival in LG (70 vs. 46% in OG; p = 0.073), 5-year disease-free survival was similar (35.5 vs. 33.6%). CONCLUSIONS Laparoscopic resection of HCC in patients with chronic liver disease has similar results to open resection in terms of postoperative outcomes, surgical margins, and long-term survival.
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Abstract
Patients with underlying liver disease often present for non-liver-related surgery and are at risk for postoperative decompensation. Several predictive models exist to determine the risk of morbidity and mortality after surgery in such patients, but the risk depends on the severity of liver disease and also the type and urgency of the surgery. Clinicians should be cognizant of the various risk assessment tools and incorporate them into their practice when encountering patients with liver disease undergoing surgery.
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Affiliation(s)
- Shahid M Malik
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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20
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Abstract
Systemic abnormalities often occur in patients with liver disease. In particular, cardiopulmonary or renal diseases accompanied by advanced liver disease can be serious and may determine the quality of life and prognosis of patients. Therefore, both hepatologists and non-hepatologists should pay attention to such abnormalities in the management of patients with liver diseases.
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Frye JW, Perri RE. Perioperative risk assessment for patients with cirrhosis and liver disease. Expert Rev Gastroenterol Hepatol 2009; 3:65-75. [PMID: 19210114 DOI: 10.1586/17474124.3.1.65] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis are at an increased risk of complications of operative procedures. There is a growing understanding of the nature of the risks that cirrhotic patients experience, as well as more precise and objective tools to gauge the patients at risk for surgical complications. Surgical procedures that are common and high risk for patients with cirrhosis are cardiac surgery, cholecystectomy and hepatic resections, as well as other abdominal surgeries and orthopedic surgeries. The physicians who care for patients with cirrhosis who require a surgical procedure can apply an understanding of the type of surgery anticipated with knowledge of the severity of the patient's liver disease to predict those patients at risk for operative morbidity and mortality. A sound knowledge of the specific operative risks faced by patients with cirrhosis should prompt the clinician to take steps to prevent these complications.
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Affiliation(s)
- Jeanetta W Frye
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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22
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Morrison CA, Wyatt MM, Carrick MM. The Effects of Cirrhosis on Trauma Outcomes: An Analysis of the National Trauma Data Bank. J Surg Res 2008. [DOI: 10.1016/j.jss.2008.04.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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23
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Gueret G, Bourgain JL, Luboinski B. Sudden death after major head and neck surgery. Curr Opin Otolaryngol Head Neck Surg 2007; 14:89-94. [PMID: 16552265 DOI: 10.1097/01.moo.0000193171.31580.a3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review will discuss the mortality after major ear, nose and throat surgery, particularly sudden death. It will also discuss the postoperative follow-up of patients. RECENT FINDINGS Sudden death is a rare event after major ear, nose and throat surgery, and occurs mainly during the first three postoperative days. SUMMARY In more recent studies, the mortality rate after neck dissection was below 4%, which is at a lower value than reported in previous studies. Sudden deaths have been described, however, mainly during the first three postoperative days. Alcoholism and perioperative hypotension are two predictive factors for cardiac complications. Careful follow-up of these patients during the early postoperative period should be performed to reduce the mortality by shortening the delay of care.
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Millwala F, Nguyen GC, Thuluvath PJ. Outcomes of patients with cirrhosis undergoing non-hepatic surgery: Risk assessment and management. World J Gastroenterol 2007; 13:4056-63. [PMID: 17696222 PMCID: PMC4205305 DOI: 10.3748/wjg.v13.i30.4056] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The reported mortality rates in patients with cirrhosis undergoing various non-transplant surgical procedures range from 8.3% to 25%. This wide range of mortality rates is related to severity of liver disease, type of surgery, demographics of patient population, expertise of the surgical, anesthesia and intensive care unit team and finally, reporting bias. In this article, we will review the pathophysiology, morbidity and mortality associated with non-hepatic surgery in patients with cirrhosis, and then recommend an algorithm for risk assessment and evidence based management strategy to optimize post-surgical outcomes.
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Affiliation(s)
- Farida Millwala
- Hepatology Section, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Hanje AJ, Patel T. Preoperative evaluation of patients with liver disease. ACTA ACUST UNITED AC 2007; 4:266-76. [PMID: 17476209 DOI: 10.1038/ncpgasthep0794] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 03/13/2007] [Indexed: 12/13/2022]
Abstract
Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child-Turcotte-Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.
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Affiliation(s)
- A James Hanje
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH 43210, USA
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Abstract
Patients with liver disease are at appreciable risk when undergoing anesthesia and surgery. Attempts to quantify this risk have been thwarted by the diversity of disease states and illness severity that such patients bring to the operating theater and the myriad of procedures they may undergo. This review discusses the indications and contraindications for surgery in patients with liver disease and attempts to give specific recommendations for optimizing the clinical status of a patient with hepatic dysfunction prior to operative intervention.
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Affiliation(s)
- Mark T Keegan
- Department of Anesthesiology, Division of Critical Care, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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27
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Sinha A, Olah KSJ. Acute fatty liver of pregnancy: an unusual presentation. J OBSTET GYNAECOL 2005. [DOI: 10.1080/jog.25.01.60.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Murakami S, Okubo K, Tsuji Y, Sakata H, Takahashi T, Kikuchi M, Hirayama R. Changes in liver enzymes after surgery in anti-hepatitis C virus-positive patients. World J Surg 2004; 28:671-4. [PMID: 15175902 DOI: 10.1007/s00268-004-7377-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to assess the influence of surgical intervention on changes in liver enzymes in patients with antibodies to hepatitis C virus (HCV). Of 623 patients who underwent laparotomy in our department during the 2 years between January 2000 and December 2001, a group of 39 (6.3%) who were positive for the HCV antibody were enrolled in this study. Serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), and cholinesterase (ChE) were the standard liver tests performed. The antibody to HCV was measured in serum using an ELISA kit that can detect antibodies against the combined epitopes. The postoperative elevated values of AST and ALP in the anti-HCV-positive group were significantly higher than those in the anti-HCV-negative group ( p < 0.05). The postoperative decreased values of ChE in the anti-HCV-positive group were significantly greater than those in the anti-HCV-negative group ( p < 0.02). The postoperatively decreased ratios of ChE in the anti-HCV positive group were significantly greater than those in the anti-HCV negative group ( p < 0.0001). Using multivariate logistic regression modeling, testing positive for the antibody to HCV was independently and significantly associated with abnormal levels of ALT and ALP ( p = 0.035 and 0.018, respectively). Monitoring liver enzymes such as ChE, ALT, and ALP might be effective for evaluating liver function after surgery in anti-HCV-positive patients.
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Affiliation(s)
- Saburo Murakami
- Department of Surgery, Saitama Medical School, Morohongo 38, Moroyama-machi, Iruma-gunn, Saitama 350-0495, Japan.
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Abstract
BACKGROUND Viral hepatitis is a major world-wide public health issue. An increasing number of virus hepatitis carriers with acute or chronic hepatitis at all stages of the disease will be referred to anaesthetists. An update of what anaesthetists should know about viral hepatitis was believed to be warranted. METHODS The present review focuses on (a) diagnosis criteria and main biological and clinical patterns of acute and chronic hepatitis, and (b) extrahepatic manifestations, and adverse effects resulting from specific drug therapy likely to influence anaesthetic care. RESULTS Elective surgery should be postponed and any medications that could be harmful to the liver should be disregarded in patients suspected of having acute viral hepatitis. A prothrombin time decrease to less than 50% (INR > 1.75) is the first sign of acute severe liver failure. Extrahepatic manifestations resulting mainly from small- and medium-sized vessel alteration, and adverse effects caused by specific drug therapy are associated with chronic viral hepatitis and are likely to alter anaesthetic care. A titrated anaesthesia should be provided and agents not eliminated by the liver should be favoured. Vasopressor therapy should be administered early to control a systemic intraoperative blood pressure decrease associated with a high cardiac output. Prophylactic antibiotics should take into consideration the risk of translocation of gut bacteria to the systemic circulation. Prophylactic guidelines of hepatitis nosocomial transmission should be respected. CONCLUSIONS Anaesthetists are likely to play a key role in immediate acute hepatitis and chronic hepatitis perioperative assessment and care.
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Affiliation(s)
- C Lentschener
- Department of Anaesthesia and Intensive Care, University Paris V - René Descartes, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
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Lesurtel M, Cherqui D, Laurent A, Tayar C, Fagniez PL. Laparoscopic versus open left lateral hepatic lobectomy: a case-control study. J Am Coll Surg 2003; 196:236-42. [PMID: 12595052 DOI: 10.1016/s1072-7515(02)01622-8] [Citation(s) in RCA: 263] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND After technical advances in hepatic surgery and laparoscopic surgery, some teams evaluated the possibilities of laparoscopic liver resections. The aim of our study was to assess the results of laparoscopic left lateral lobectomy (bisegmentectomy 2-3) and to perform a case-control comparison with the same operation performed by open surgery. STUDY DESIGN From 1996 to 2002, 60 laparoscopic resections were performed in selected patients, including 18 left lateral lobectomies. The resected lesions were benign tumors, hepatocellular carcinomas with compensated cirrhosis, and metastases. Surgical procedures were performed with a harmonic scalpel, an ultrasonic dissector, linear staplers, and portal pedicule clamping when necessary. Results were compared with those of patients who underwent open left lateral lobectomies selected from our liver resection database in a case-control analysis. Both groups were similar for age, type and size of the tumor, and presence of underlying liver disease. RESULTS Compared with laparotomy, laparoscopic left lateral lobectomies were associated with a longer surgical time (202 versus 145 minutes, p < 0.01), a longer portal triad clamping (39 versus 23 minutes, p < 0.05), and a decreased blood loss (236 versus 429 mL, p < 0.05). There were no deaths in either group, and the morbidity rates were 11% in the laparoscopic group and 15% in the open group. There were no specific complications of hepatic resection after laparoscopy (no hemorrhage, subphrenic collection, or biliary leak), but some were observed in the open group. CONCLUSIONS This study demonstrates the safety of laparoscopic left lateral lobectomy. Despite longer operation and clamping time, without any clinical consequences, the laparoscopic approach was associated with decreased blood loss and absence of specific complications of the hepatic resection.
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Affiliation(s)
- Mickael Lesurtel
- Department of Digestive Surgery, Hôpital Henri Mondor-University Paris 12, Creteil, France
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31
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Abstract
Management of the surgical patient with liver disease begins with a careful preoperative assessment (Fig. 1). Any clues to liver disease on history and physical examination should be investigated to ascertain the cause of the clinical finding. More data on surgical patients with unexpected liver disease are now available. Patients undergoing emergent surgery are at significant risk of developing liver dysfunction. Child's class still correlates strongly to postoperative complications. Cornerstones of perioperative management in these patients are medical treatment of complications of chronic liver disease, such as ascites; coagulopathy; prevention of encephalopathy; and rapid treatment of dangerous postoperative complications, such as acute acalculous cholecystitis. Evolving knowledge of the effects of anesthesia, improving surgical techniques, and use of better diagnostic tests will help in the reduction of perioperative complications in these patients.
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Affiliation(s)
- Mohammed K Rizvon
- Medical Consultation Service, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA.
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32
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Prince MI, Gunn MC, Hudson M. Alcoholic hepatitis with ascites may mimic advanced ovarian malignancy. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2002; 63:368-9. [PMID: 12096668 DOI: 10.12968/hosp.2002.63.6.2009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Cancer antigen-125 (CA125) is a glycoprotein tumour marker that may be helpful in screening, diagnosis and monitoring of ovarian carcinoma (Kehoe and Selman, 2001). However, elevated CA125 levels are not specific for this condition. In the case described here elevated CA125 levels lead to a missed diagnosis of alcoholic liver disease complicated by ascites.
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Gueret G, Cosset MF, McGee K, Luboinski FB, Bourgain JL. Sudden death after neck dissection for cancer. Ann Otol Rhinol Laryngol 2002; 111:115-9. [PMID: 11860062 DOI: 10.1177/000348940211100202] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The goal of this study was to analyze the mortality data following neck dissection and determine the risk factors of early death. The hospital mortality records were analyzed from 3,015 consecutive patients who underwent neck dissection. A case control study analyzed risk factors of death during the first 3 postoperative days. The mortality incidences were 0.50% and 1.33%, respectively, during the first 3 and the first 30 postoperative days. Eleven of the 12 unexplained deaths occurred during the first 3 postoperative days, and most of these patients died suddenly. They were more likely to be alcoholic and to have undergone nerve section. In most of the patients who died after the third postoperative day, death was related to a postoperative complication. Although the mechanisms of sudden death remain unclear, careful follow-up of these patients during the early postoperative days should be performed to reduce the mortality risk by shortening the delay of care.
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Affiliation(s)
- Gildas Gueret
- Department of Anesthesiology, Gustave Roussy Institute, Villejuif, France
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34
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Abdel-Atty MY, Farges O, Jagot P, Belghiti J. Laparoscopy extends the indications for liver resection in patients with cirrhosis. Br J Surg 1999; 86:1397-400. [PMID: 10583285 DOI: 10.1046/j.1365-2168.1999.01283.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clinical or biological evidence of liver failure is usually considered a contraindication to open liver surgery as it is associated with a prohibitive risk of postoperative death. METHODS This report describes three patients who had resection of a superficial hepatocellular carcinoma suspected either to be ruptured, or at high risk of rupture, using the laparoscopic approach. All three patients had intractable ascites, in two superimposed on active hepatitis. Surgery was per- formed under continuous carbon dioxide pneumoperitoneum with intermittent clamping of the hepatic pedicle. RESULTS Intraoperative blood loss was between 100 and 400 ml; no blood transfusion was required. The postoperative course was uneventful except for a transient leak of ascites through the trocar wounds. Duration of in-hospital stay was 6-10 days. Liver function tests had returned to preoperative values within 1 month of surgery in all patients. CONCLUSION The laparoscopic approach may enable liver resection in patients with cirrhosis and evidence of liver failure that would contraindicate open surgery.
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Affiliation(s)
- M Y Abdel-Atty
- Department of Hepato-biliary and Digestive Surgery, Beaujon Hospital, University Paris VII, Clichy, France
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35
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Affiliation(s)
- L S Friedman
- Gastrointestinal Unit (Medical Services), Massachusetts General Hospital and the Department of Medicine, Harvard Medical School, Boston, MA, USA.
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36
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Abstract
Patients with liver disease often undergo surgery. With the increasing prevalence of liver disease and improved survival due to newer medications and treatments, a growing number of patients with liver disease will require preoperative assessment. Because of the multiple physiological roles of the liver, hepatic dysfunction places these patients at an increased risk of perioperative morbidity and mortality. The precise risks associated with specific liver diseases are poorly understood but are greater with increased impairment of hepatic function. Identifying preexisting problems that could be optimally and appropriately managed before surgery (e.g., coagulation status, intravascular volume, renal function, electrolytes, cardiovascular status, and nutrition) may reduce these risks and decrease mortality in patients with liver disease undergoing surgery.
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Affiliation(s)
- T Patel
- Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic Rochester, Minn., USA
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Abstract
Routine preoperative testing of all patients before elective surgery is unjustified. The frequency of unanticipated abnormalities or abnormalities shown to change patient management is too low to justify a practice pattern of testing all patients. Furthermore, little evidence exists that test result abnormalities are associated with perioperative morbidity. Table 12 lists a compilation of the findings from this article and recommendations regarding routine testing.
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Affiliation(s)
- D S Macpherson
- Department of Medicine, University of Pittsburgh, Pennsylvania
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39
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Affiliation(s)
- P A Reeve
- Department of Medicine, Vila Central Hospital, Vanuatu
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40
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Antognini JF, Andrews S. Anaesthesia for caesarean section in a patient with acute fatty liver of pregnancy. Can J Anaesth 1991; 38:904-7. [PMID: 1742827 DOI: 10.1007/bf03036971] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A 23-yr-old woman presented in labour and hepatic failure. The clinical diagnosis was acute fatty liver of pregnancy. A Caesarean section was performed under epidural anaesthesia, after correction of a coagulopathy. Epidural anaesthesia was chosen because of the potential deleterious effects of general anaesthesia on liver blood flow and function.
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Affiliation(s)
- J F Antognini
- Department of Anesthesiology, American River Hospital, Carmichael, CA
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41
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Affiliation(s)
- D Rosenak
- Department of Surgery A, Assaf Harofeh Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Zerifin, Israel
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42
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Abstract
This article deals with the effects of anesthesia and surgery on the healthy and diseased liver and the preoperative assessment of patients with liver disease. Emphasis is placed on estimating surgical risk. Guidelines for optimal preoperative preparation are discussed.
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Powell-Jackson PR, Karani J, Ede RJ, Meire H, Williams R. Ultrasound scanning and 99mTc sulphur colloid scintigraphy in diagnosis of Budd-Chiari syndrome. Gut 1986; 27:1502-6. [PMID: 3542741 PMCID: PMC1433960 DOI: 10.1136/gut.27.12.1502] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Ultrasound scanning and 99mTc sulphur colloid scintigraphy are widely used in the diagnosis of the Budd-Chiari syndrome and have been compared at the time of presentation in 18 patients in whom the diagnosis was subsequently confirmed by histology and hepatic venography. Ultrasound was diagnostic in 16 (87%). The findings seen most often included hepatic vein abnormalities, caudate lobe hypertrophy with decreased reflectivity and compression of the inferior vena cava. Additional information not shown by scintigraphy included intracaval tumour, or thrombosis, and concomitant portal vein thrombosis. Although scintigraphic abnormalities were present in all patients, only in three (17%) was the 'classical' appearance of increased uptake and/or enlargement of the caudate lobe present. In one patient with nonspecific abnormalities on ultrasound, scintigraphy gave a positive diagnosis and it is in such cases that scintigraphy should continue to be used.
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45
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Abstract
Two cases of the Budd-Chiari syndrome are described in whom the diagnosis was finally confirmed at necropsy. The presentation was with encephalopathy, occurring within eight weeks of first symptoms and coming therefore within the definition of fulminant hepatic failure. In one, thought to have non-A, non-B hepatitis, encephalopathy progressed to grade 4 coma with death 12 days after presentation. In the other, mistakenly thought to have intra-abdominal malignancy, an exploratory laparotomy exacerbated the encephalopathy with death three weeks later. In neither case were non-invasive investigations, such as ultrasound and isotope scanning, carried out which might have facilitated an earlier diagnosis and consideration for orthotopic liver transplantation, probably the most appropriate form of therapy for these very severe cases.
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46
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Menzies RI, Fitzgerald JM, Mulpeter K. Laparoscopic diagnosis of ascites in Lesotho. BMJ : BRITISH MEDICAL JOURNAL 1985; 291:473-5. [PMID: 3160432 PMCID: PMC1416300 DOI: 10.1136/bmj.291.6493.473] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In a prospective study of 98 consecutive patients with undiagnosed ascites examined by laparoscopy a correct immediate diagnosis was made in 76 (78%) and a final diagnosis in 92 (94%) of those who underwent laparoscopy. Visual diagnosis was highly accurate in patients with tuberculous peritonitis but only moderately accurate in those with carcinomatosis and liver disease. When the laparoscopic findings were compared with histological and microbiological results visual diagnosis was found to be the most accurate diagnostic method. Laparoscopy may readily be used in rural hospitals for diagnosing ascites.
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47
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Watson A, Williams R. Anoxic hepatic and intestinal injury from carbon monoxide poisoning. BMJ : BRITISH MEDICAL JOURNAL 1984; 289:1113. [PMID: 6435797 PMCID: PMC1443239 DOI: 10.1136/bmj.289.6452.1113] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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49
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Strunin L, Davies JM. The liver and anaesthesia. CANADIAN ANAESTHETISTS' SOCIETY JOURNAL 1983; 30:208-17. [PMID: 6831299 DOI: 10.1007/bf03009354] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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