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Skovsen AP, Jensen TK, Gögenur I, Tolstrup MB. A high rate of mortality in liver cirrhosis patients after emergency abdominal surgery. Eur J Trauma Emerg Surg 2025; 51:117. [PMID: 39982478 PMCID: PMC11845415 DOI: 10.1007/s00068-025-02787-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2024] [Accepted: 02/02/2025] [Indexed: 02/22/2025]
Abstract
PURPOSE In the elective setting, there are high mortality rates for patients with liver cirrhosis after surgery. Few studies focus on emergency surgery. This study investigates mortality and morbidity of patients with cirrhosis undergoing emergency abdominal surgery. METHODS In a database established at two Copenhagen University Hospitals (Herlev and North Zealand), including all patients operated in an emergency setting (n = 1116), including all patients with known cirrhosis at time of surgery. Postoperative complications, and mortality rates were evaluated by a matched case-control method, matching cases and controls according to surgical procedure, age, sex and American Society of Anaesthesiologists-class (ASA). Medical and surgical complications were classified according to the Clavien-Dindo classification. RESULTS In the study, 24 patients with cirrhosis and 48 matched controls were evaluated. The 30-day mortality was 37.5% for patients with cirrhosis and 12.5% for controls (OR 4.2, 95% CI [1.28, 13.80], p = 0.014) and 90-day mortality was 62.5% for patients with cirrhosis compared to 18.8% for controls (OR 7.22, 95% CI [2.41, 21.68], p < 0.001). For patients with cirrhosis 58.3% had surgical complications compared to 31.3% for the controls (p = 0.027). The reoperation rate was 45.8% in the cirrhosis group and 22.9% in the control group (p = 0.047). The days-alive-out-of-hospital at 90-days (DAOH-90) was 9 days in the cirrhosis group and 78 days in the control group (p < 0.001). CONCLUSION This retrospective study shows that patients with cirrhosis have significantly higher mortality rates after emergency surgery, more surgical complications and reoperations, and reduced DAOH-90.
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Affiliation(s)
- Anders Peter Skovsen
- Department of Surgery, Copenhagen University Hospital North Zealand, Dyrehavevej 29, Hillerød, 3400, Denmark.
| | - Thomas Korgaard Jensen
- Department of Surgery, Copenhagen University Hospital Herlev, Herlev Ringvej 75, Herlev, 2730, Denmark
| | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Lykkebaekvej 1, Koege, 4600, Denmark
| | - Mai-Britt Tolstrup
- Department of Surgery, Copenhagen University Hospital North Zealand, Dyrehavevej 29, Hillerød, 3400, Denmark
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Bhalla S, Mcquillen B, Cay E, Reau N. Preoperative risk evaluation and optimization for patients with liver disease. Gastroenterol Rep (Oxf) 2024; 12:goae071. [PMID: 38966126 PMCID: PMC11222301 DOI: 10.1093/gastro/goae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 07/06/2024] Open
Abstract
The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.
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Affiliation(s)
- Sameer Bhalla
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Edward Cay
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nancy Reau
- Internal Medicine, Division of Digestive Diseases, Section of Hepatology, Rush University Medical Center, Chicago, IL, USA
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3
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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.
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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.
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Adiamah A, Rashid A, Crooks CJ, Hammond J, Jepsen P, West J, Humes DJ. The impact of urgency of umbilical hernia repair on adverse outcomes in patients with cirrhosis: a population-based cohort study from England. Hernia 2024; 28:109-117. [PMID: 38017324 PMCID: PMC10891219 DOI: 10.1007/s10029-023-02898-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/18/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Umbilical hernia is common in patients with cirrhosis; however, there is a paucity of dedicated studies on postoperative outcomes in this group of patients. This population-based cohort study aimed to determine the outcomes after emergency and elective umbilical hernia repair in patients with cirrhosis. METHODS Two linked electronic healthcare databases from England were used to identify all patients undergoing umbilical hernia repair between January 2000 and December 2017. Patients were grouped into those with and without cirrhosis and stratified by severity into compensated and decompensated cirrhosis. Length of stay, readmission, 90-day case fatality rate and the odds ratio of 90-day postoperative mortality were defined using logistic regression. RESULTS In total, 22,163 patients who underwent an umbilical hernia repair were included and 297 (1.34%) had cirrhosis. More patients without cirrhosis had an elective procedure, 86% compared with 51% of those with cirrhosis (P < 0.001). In both the elective and emergency settings, patients with cirrhosis had longer hospital length of stay (elective: 0 vs 1 day, emergency: 2 vs 4 days, P < 0.0001) and higher readmission rates (elective: 4.87% vs 11.33%, emergency:11.39% vs 29.25%, P < 0.0001) than those without cirrhosis. The 90-day case fatality rates were 2% and 0.16% in the elective setting, and 19% and 2.96% in the emergency setting in patients with and without cirrhosis respectively. CONCLUSION Emergency umbilical hernia repair in patients with cirrhosis is associated with poorer outcomes in terms of length of stay, readmissions and mortality at 90 days.
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Affiliation(s)
- A Adiamah
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - A Rashid
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C J Crooks
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - J Hammond
- Division of Hepatobiliary and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle Upon Tyne, NE7 7DN, UK
| | - P Jepsen
- Department of Hepatology and Gastroenterology and Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
| | - D J Humes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
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Shahait A, Pearl A, Saleh KJ. Outcomes of Colectomy in United States Veterans With Cirrhosis: Predicting Outcomes Using Nomogram. J Surg Res 2024; 293:570-577. [PMID: 37832308 DOI: 10.1016/j.jss.2023.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION With growing incidence of liver cirrhosis worldwide, there is more need for a risk assessment tool to aid in perioperative management of cirrhotic patients undergoing colorectal procedures. We aim to assess the association of open (OC) versus laparoscopic (LC) approach with colorectal procedures' outcomes and develop an easy-to-use nomogram to predict outcomes. METHODS We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent colorectal procedures from 2008 to 2015. Model for End-stage Liver Disease score was calculated as well as five-items modified frailty index. The chi-square test was utilized to analyze categorical variables. Two-sided unpaired Student's t-test or Mann-Whitney U-test were used for numerical variables as appropriate. Multivariate logistic regression adjusting for demographics, comorbidities, and other preoperative factors was used to analyze postoperative outcomes. A predictive nomogram was constructed and internally validated. RESULTS A total of 731 patients were identified. Overall, complications occurred in 48.2% of patients, and 30-d mortality was 24.8%, with 57.5% were performed emergently. Malignant neoplasm was the most common indication (25.4%). LC was performed in 22.4%, with shorter operative time, less blood transfusions, shorter length of stay, and lower morbidity compared to OC. Overall, Model for End-stage Liver Disease score was an independent factor of mortality, while laparoscopic approach had a protective effect on morbidity. An easy-to-use nomogram was generated for morbidity and 30-d mortality with calculated area under cure of 74.5% and 77.9%, respectively, indicating reliability. CONCLUSIONS Although colectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing colectomy is proposed.
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Affiliation(s)
- Awni Shahait
- Departement of Surgery, Southern Illinois University School of Medicine, Carbondale, Illinois; Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan.
| | - Adam Pearl
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Khaled J Saleh
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, Michigan
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Kerekes DM, Sznol JA, Khan SA, Becher RD. Impact of nonmalignant ascites on outcomes of open inguinal hernia repair in the USA. Hernia 2023; 27:1497-1506. [PMID: 37029887 DOI: 10.1007/s10029-023-02790-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/02/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE Studies on inguinal hernia repair in patients with ascites are limited, small, and inconsistent, exacerbating a challenging clinical dilemma for surgeons. To fill this gap in the literature, this retrospective cohort study used a national US database to examine the impact of ascites on the outcomes of open inguinal herniorrhaphy. METHODS Patients who underwent open inguinal herniorrhaphy between 2005 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Two groups were defined by the presence or absence of nonmalignant preoperative ascites. Ascites patients were propensity matched 1:10 with non-ascites patients. Surgical outcomes at 30 days for the matched groups, stratified by electiveness of procedure, were compared, with the primary end points of mortality and the NSQIP composite outcome "serious complication". RESULTS The study included 682 patients with ascites. Compared to matched controls, those with ascites had significantly increased odds of mortality (OR 3.3, 95% CI 1.5-7.0) after elective repair, but not after nonelective repair. Ascites was associated with increased odds of serious complication after both elective (OR 1.7, 1.2-2.3) and nonelective (OR 2.0, 1.3-3.0) surgery. Among ascites patients, age ≥ 65 years was associated with increased mortality (risk-adjusted OR 3.8, 1.2-14.4) and serious complication (OR 2.2, 1.2-3.9). CONCLUSION In this largest study to date on patients with ascites undergoing open inguinal herniorrhaphy, ascites increased the odds of mortality after elective repair and of serious complication after elective and nonelective repair. Age ≥ 65 was a risk factor for poor outcome. Inguinal herniorrhaphy is fraught with complications in this population.
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Affiliation(s)
- D M Kerekes
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA.
| | - J A Sznol
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA
| | - S A Khan
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA
| | - R D Becher
- Department of Surgery, Yale School of Medicine, 20 York St, New Haven, CT, 06510, USA
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Snitkjær C, Christoffersen MW, Gluud LL, Kimer N, Helgstrand F, Jensen KK, Henriksen NA. Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities-A Nationwide Cohort Study. World J Surg 2023; 47:2733-2740. [PMID: 37202491 DOI: 10.1007/s00268-023-07047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Umbilical hernia is a frequent condition in patients with cirrhosis. The aim of the study was to evaluate the risks associated with umbilical hernia repair in patients with cirrhosis in the elective and emergency setting. Secondly, to compare patients with cirrhosis with a population of patients with equally severe comorbidities but without cirrhosis. METHODS Patients with cirrhosis who underwent umbilical hernia repair from January 1, 2007, to December 31, 2018, were included from the Danish Hernia Database. A control group of patients with a similar Charlson score (≥ 3) without cirrhosis was generated using propensity score matching. The primary outcome was postoperative re-intervention within 30 days following hernia repair. Secondary outcomes were mortality within 90 days and readmission within 30 days following hernia repair. RESULTS A total of 252 patients with cirrhosis and 504 controls were included. Emergency repair in patients with cirrhosis was associated with a significantly increased rate of re-intervention (54/108 (50%) vs. 24/144 (16.7%), P < 0.001), 30-day readmission rate (50/108 (46.3%) compared with elective repair vs. 36/144 (25%) (P < 0.0001)), and 90-day mortality (18/108 (16.7%) vs. 5/144 (3.5%), P < 0.001). Patients with cirrhosis were more likely to undergo a postoperative re-intervention compared with comorbid patients without cirrhosis (OR = 2.10; 95% CI [1.45-3.03]). CONCLUSION Patients with cirrhosis and other severe comorbidity undergo emergency umbilical hernia repair frequently. Emergency repair is associated with increased risk of poor outcome. Patients with cirrhosis undergo a postoperative reintervention more frequently than patients with other severe comorbidity undergoing umbilical hernia repair.
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Affiliation(s)
- Christian Snitkjær
- Abdominalcenter, University of Copenhagen, Herlev Hospital, 2730, Herlev, Denmark.
| | - Mette W Christoffersen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lise Lotte Gluud
- Gastro Unit, Medical Division, University Hospital Hvidovre, Copenhagen, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, University Hospital Hvidovre, Copenhagen, Denmark
| | | | - Kristian Kiim Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nadia A Henriksen
- Abdominalcenter, University of Copenhagen, Herlev Hospital, 2730, Herlev, Denmark
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Cichos KH, Jordan E, Niknam K, Chen AF, Hansen EN, McGwin G, Ghanem ES. Child-Pugh Class B or C Liver Disease Increases the Risk of Early Mortality in Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty Regardless of Treatment Status. Clin Orthop Relat Res 2023; 481:2016-2025. [PMID: 36961471 PMCID: PMC10499110 DOI: 10.1097/corr.0000000000002631] [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: 09/15/2022] [Revised: 01/20/2023] [Accepted: 02/28/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Patients with hepatitis C virus (HCV) undergoing primary elective total joint arthroplasty (TJA) are at increased risk of postoperative complications. Patients with chronic liver disease and cirrhosis, specifically Child-Pugh Class B and C, who are undergoing general surgery have high 2-year mortality risks, approaching 60% to 80%. However, the role of Child-Pugh and Model for End-Stage Liver Disease classifications of liver status in predicting survivorship among patients with HCV undergoing elective arthroplasty has not been elucidated. QUESTION/PURPOSE What factors are independently associated with early mortality (< 2 years) in patients with HCV undergoing arthroplasty? METHODS We performed a retrospective study at three tertiary academic medical centers and identified patients with HCV undergoing primary elective TJA between January 2005 and December 2019. Patients who underwent revision TJA and simultaneous primary TJA were excluded. A total of 226 patients were eligible for inclusion in the study. A further 25% (57) were excluded because they were lost to follow-up before the minimum study requirement of 2 years of follow-up or had incomplete datasets. After the inclusion and exclusion criteria were applied, the final cohort consisted of 75% (169 of 226) of the initial patient population eligible for analysis. The mean follow-up duration was 53 ± 29 months. We compared confounding variables for mortality between patients with early mortality (16 patients) and surviving patients (153 patients), including comorbidities, HCV and liver characteristics, HCV treatment, and postoperative medical and surgical complications. Patients with early postoperative mortality were more likely to have an associated advanced Child-Pugh classification and comorbidities including peripheral vascular disease, end-stage renal disease, heart failure, and chronic obstructive pulmonary disease. However, both groups had similar 90-day and 1-year medical complication risks including myocardial infarction, stroke, pulmonary embolism, and reoperations for periprosthetic joint infection and mechanical failure. A multivariable regression analysis was performed to identify independent factors associated with early mortality, incorporating all significant variables with p < 0.05 present in the univariate analysis. RESULTS After accounting for significant variables in the univariate analysis such as peripheral vascular disease, end-stage renal disease, heart failure, chronic obstructive pulmonary disease, and liver fibrosis staging, Child-Pugh Class B or C classification was found to be the sole factor independently associated with increased odds of early (within 2 years) mortality in patients with HCV undergoing elective TJA (adjusted odds ratio 29 [95% confidence interval 5 to 174]; p < 0.001). The risk of early mortality in patients with Child-Pugh Class B or C was 64% (seven of 11) compared with 6% (nine of 158) in patients with Child-Pugh Class A (p < 0.001). CONCLUSION Patients with HCV and a Child-Pugh Class B or C at the time of elective TJA had substantially increased odds of death, regardless of liver function, cirrhosis, age, Model for End-Stage Liver Disease level, HCV treatment, and viral load status. This is similar to the risk of early mortality observed in patients with chronic liver disease undergoing abdominal and cardiac surgery. Surgeons should avoid these major elective procedures in patients with Child-Pugh Class B or C whenever possible. For patients who feel their arthritic symptoms and pain are unbearable, surgeons need to be clear that the risk of death is considerably elevated. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Kyle H. Cichos
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric Jordan
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kian Niknam
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Antonia F. Chen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Erik N. Hansen
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elie S. Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Shahait A, Mesquita-Neto JWB, Weaver D, Mostafa G. Outcomes of umbilical hernia repair in cirrhotic veterans: a VASQIP study. Langenbecks Arch Surg 2023; 408:246. [PMID: 37358646 DOI: 10.1007/s00423-023-02984-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE Umbilical hernia repair (UHR) in cirrhotics with ascites is a challenging problem associated with increased morbidity and mortality. This study examines the outcomes of UHR in veterans, comparing those undergoing elective versus emergent repair. METHODS VASQIP was queried for all UHRs during the period 2008-2015. Data collection included demographics, operative details, Model for End-stage Liver Disease (MELD) score, and postoperative outcomes. Univariate and multivariate regression analyses were performed, and a p value of ≤ 0.05 was considered significant. RESULTS A total of 383 patients were included in the analysis. Overall, mean age was 58.9, 99.0% were males, mean body mass index (BMI) was 26.7 kg/m2, 98.2% had American Society of Anesthesiologists (ASA) classification ≥ III, and 87.7% had independent functional status. More than 1/3 the patients underwent emergent UHR (37.6%). Compared with the elective UHR group, who underwent emergent repair were older, more likely to be functionally dependent, higher MELD score. Hypoalbuminemia, emergency repair and MELD score were found to be independent predictors of poor outcomes. CONCLUSION UHR in cirrhotic veterans has worse outcomes when performed emergently. Diagnosis should be followed by medical optimization and elective repair, rather than waiting for an emergent indication in > 1/3 of patients.
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Affiliation(s)
- Awni Shahait
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA.
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA.
| | - Jose Wilson B Mesquita-Neto
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Donald Weaver
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Gamal Mostafa
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
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Kaltenbach MG, Mahmud N. Assessing the risk of surgery in patients with cirrhosis. Hepatol Commun 2023; 7:e0086. [PMID: 36996004 PMCID: PMC10069843 DOI: 10.1097/hc9.0000000000000086] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/17/2023] [Indexed: 03/31/2023] Open
Abstract
Patients with cirrhosis have an increased perioperative risk relative to patients without cirrhosis. This is related to numerous cirrhosis-specific factors, including severity of liver disease, impaired synthetic function, sarcopenia and malnutrition, and portal hypertension, among others. Nonhepatic comorbidities and surgery-related factors further modify the surgical risk, adding to the complexity of the preoperative assessment. In this review, we discuss the pathophysiological contributors to surgical risk in cirrhosis, key elements of the preoperative risk assessment, and application of risk prediction tools including the Child-Turcotte-Pugh score, Model for End-Stage Liver Disease-Sodium, Mayo Risk Score, and the VOCAL-Penn Score. We also detail the limitations of current approaches to risk assessment and highlight areas for future research.
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Affiliation(s)
- Melissa G. Kaltenbach
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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12
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Biolato M, Vitale F, Galasso T, Gasbarrini A, Grieco A. Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines. World J Gastrointest Surg 2023; 15:127-141. [PMID: 36896308 PMCID: PMC9988645 DOI: 10.4240/wjgs.v15.i2.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Federica Vitale
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Tiziano Galasso
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
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13
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Morris SM, Abbas N, Osei-Bordom DC, Bach SP, Tripathi D, Rajoriya N. Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach. Expert Rev Gastroenterol Hepatol 2023; 17:155-173. [PMID: 36594658 DOI: 10.1080/17474124.2023.2163627] [Citation(s) in RCA: 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.
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Affiliation(s)
- Sean M Morris
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
| | - Nadir Abbas
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Daniel-Clement Osei-Bordom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Simon P Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Dhiraj Tripathi
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Neil Rajoriya
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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14
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Comparison of human acellular amniotic membranes with acellular amniotic membranes pretreated with MPLA for repair of fascia in rats. Cell Tissue Bank 2022; 24:495-501. [DOI: 10.1007/s10561-022-10049-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022]
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15
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Pipek LZ, Cortez VS, Taba JV, Suzuki MO, do Nascimento FS, de Mattos VC, Moraes WA, Iuamoto LR, Hsing WT, Carneiro-D’Albuquerque LA, Meyer A, Andraus W. Cirrhosis and hernia repair in a cohort of 6352 patients in a tertiary hospital: Risk assessment and survival analysis. Medicine (Baltimore) 2022; 101:e31506. [PMID: 36397364 PMCID: PMC9666189 DOI: 10.1097/md.0000000000031506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The prevalence of hernias in patient with cirrhosis can reach up to 40%. The pathophysiology of cirrhosis is closely linked to that of the umbilical hernia, but other types are also common in this population. The aim of this study is to evaluate factors that influence in the prognosis after hernia repair in patients with cirrhosis. A historical cohort of 6419 patients submitted to hernia repair was gathered. Clinical, epidemiological data and hernia characteristics were obtained. For patient with cirrhosis, data from exams, surgery and follow-up outcomes were also analyzed. Survival curves were constructed to assess the impact of clinical and surgical variables on survival. 342 of the 6352 herniated patients were cirrhotic. Patient with cirrhosis had a higher prevalence of umbilical hernia (67.5% × 24.2%, P < .001) and a lower prevalence of epigastric (1.8% × 9.0%, P < .001) and lumbar (0% × 0.18%, P = .022). There were no significant differences in relation to inguinal hernia (P = .609). Ascites was present in 70.1% of patient with cirrhosis and its prevalence was different in relation to the type of hernia (P < .001). The survival curve showed higher mortality for emergency surgery, MELD > 14 and ascites (HR 12.6 [3.79-41.65], 4.5 [2.00-10.34], and 6.1 [1.15-20.70], respectively, P < .05). Hernia correction surgery in patient with cirrhosis has a high mortality, especially when performed under urgent conditions associated with more severe clinical conditions of patients, such as the presence of ascites and elevated MELD.
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Affiliation(s)
| | | | - João Victor Taba
- Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | | | | | | | | | - Leandro Ryuchi Iuamoto
- Center of Acupuncture, Department of Orthopaedics and Traumatology, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Wu Tu Hsing
- Center of Acupuncture, Department of Orthopaedics and Traumatology, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Alberto Meyer
- Department of Gastroenterology, Hospital das Clínicas, HCFMUSP, São Paulo, Brazil
- *Correspondence: Alberto Meyer, Avenida Doutor Arnaldo, 455, São Paulo 05403-000, Brazil (e-mail: )
| | - Wellington Andraus
- Department of Gastroenterology, Hospital das Clínicas, HCFMUSP, São Paulo, Brazil
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16
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Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease. Eur J Gastroenterol Hepatol 2022; 34:1060-1066. [PMID: 36062496 DOI: 10.1097/meg.0000000000002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. METHODS A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan-Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. RESULTS One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). CONCLUSIONS Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.
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17
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Seppey R, Benjamin A, Lambrakis P. A novel approach to managing ruptured umbilical hernias in cirrhosis. ANZ J Surg 2022; 92:2524-2528. [DOI: 10.1111/ans.17936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/15/2022] [Accepted: 07/14/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Romain Seppey
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
| | - Aditya Benjamin
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
| | - Paul Lambrakis
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
- School of Medicine University of New South Wales Sydney New South Wales Australia
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18
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Johnson KM, Newman KL, Berry K, Itani K, Wu P, Kamath PS, Harris AHS, Cornia PB, Green PK, Beste LA, Ioannou GN. Risk factors for adverse outcomes in emergency versus nonemergency open umbilical hernia repair and opportunities for elective repair in a national cohort of patients with cirrhosis. Surgery 2022; 172:184-192. [PMID: 35058058 DOI: 10.1016/j.surg.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Whether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair. METHODS Veterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair. RESULTS Among 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years. CONCLUSIONS Nonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Kira L Newman
- Gastroenterology Fellowship Program, University of Michigan Medical School, Ann Arbor, MI
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, MA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, and Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Lauren A Beste
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle WA and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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19
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Bronswijk M, Jaekers J, Vanella G, Struyve M, Miserez M, van der Merwe S. Umbilical hernia repair in patients with cirrhosis: who, when and how to treat. Hernia 2022; 26:1447-1457. [PMID: 35507128 DOI: 10.1007/s10029-022-02617-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/09/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past. METHODS The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia. RESULTS Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances. CONCLUSION Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.
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Affiliation(s)
- M Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium.,Imelda GI Clinical Research Center, Bonheiden, Belgium
| | - J Jaekers
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - G Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Struyve
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - S van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Laboratory of Hepatology, CHROMETA Department, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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20
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The impact of compensated and decompensated cirrhosis on the postoperative outcomes of patients undergoing hernia repair: a propensity score-matched analysis of 2011-2017 US hospital database. Eur J Gastroenterol Hepatol 2021; 33:e944-e953. [PMID: 34974467 DOI: 10.1097/meg.0000000000002321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Since there is clinical overlap between populations with cirrhosis and those who require hernia repair (i.e. due to stretching of abdominal walls), we systematically evaluate the effects of cirrhosis on post-hernia repair outcomes. METHODS 2011-2017 National Inpatient Sample was used to identify patients who underwent hernia repair (included: inguinal, umbilical, and other abdominal hernia repairs). The population was stratified into those with compensated cirrhosis (CC), decompensated cirrhosis (DC), and no cirrhosis; hepatic decompensation was defined as those with portal hypertension, ascites, and varices. The propensity score was used to match the no-cirrhosis controls to CC and DC using the 1:1 nearest neighbor mechanism. Endpoints included mortality, length of stay, costs, and complications. RESULTS Postmatch, there were 392/446 CC/DC with equal number controls in those undergoing inguinal hernia repair, 714/1652 CC/DC with equal number controls in those undergoing umbilical hernia repair, and 784/702 CC/DC. In multivariate, for inguinal repair, there was no difference in mortality [CC vs. no-cirrhosis aOR 2.61, 95% confidence interval (CI) 0.50-13.52; DC vs. no-cirrhosis: aOR 1.75, 95% CI 0.84-3.63]. For umbilical repair, there was no difference in mortality for CC vs. no-cirrhosis: aOR 0.94, 95% CI 0.36-2.42); however, DC had higher mortality (aOR 2.86, 95% CI 1.76-4.63) when comparing DC vs. no-cirrhosis. For other abdominal repairs, there was no difference in mortality for CC vs. no-cirrhosis (aOR 1.10, 95% CI 0.54-2.23); however, DC had higher mortality (P < 0.001, aOR 2.58, 95% CI 1.49-4.46) when comparing DC vs. no-cirrhosis. CONCLUSION This study demonstrates that the presence of DC affects postoperative survival in patients undergoing umbilical or other abdominal hernia repair surgery.
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21
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Johnson KM, Newman KL, Green PK, Berry K, Cornia PB, Wu P, Beste LA, Itani K, Harris AHS, Kamath PS, Ioannou GN. Incidence and Risk Factors of Postoperative Mortality and Morbidity After Elective Versus Emergent Abdominal Surgery in a National Sample of 8193 Patients With Cirrhosis. Ann Surg 2021; 274:e345-e354. [PMID: 31714310 DOI: 10.1097/sla.0000000000003674] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the incidence and risk factors for mortality and morbidity in patients with cirrhosis undergoing elective or emergent abdominal surgeries. BACKGROUND Postoperative morbidity and mortality are higher in patients with cirrhosis; variation by surgical procedure type and cirrhosis severity remain unclear. METHODS We analyzed prospectively-collected data from the Veterans Affairs (VA) Surgical Quality Improvement Program for 8193 patients with cirrhosis, 864 noncirrhotic controls with chronic hepatitis B infection, and 5468 noncirrhotic controls without chronic liver disease, who underwent abdominal surgery from 2001 to 2017. Data were analyzed using random-effects models controlling for potential confounders. RESULTS Patients with cirrhosis had significantly higher 30-day mortality than noncirrhotic patients with chronic hepatitis B [4.4% vs 1.3%, adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.57-4.98] or with no chronic liver disease (0.8%, aOR 4.68, 95% CI 3.27-6.69); mortality difference was highest in patients with Model for End-stage Liver Disease (MELD) score ≥10. Among patients with cirrhosis, postoperative mortality was almost 6 times higher after emergent rather than elective surgery (17.2% vs. 2.1%, aOR 5.82, 95% CI 4.66-7.27). For elective surgeries, 30-day mortality was highest after colorectal resection (7.0%) and lowest after inguinal hernia repair (0.6%). Predictors of postoperative mortality included cirrhosis-related characteristics (high MELD score, low serum albumin, ascites, encephalopathy), surgery-related characteristics (emergent vs elective, type of surgery, intraoperative blood transfusion), comorbidities (chronic obstructive pulmonary disease, cancer, sepsis, ventilator dependence, functional status), and age. CONCLUSIONS Accurate preoperative risk assessments in patients with cirrhosis should account for cirrhosis severity, comorbidities, type of procedure, and whether the procedure is emergent versus elective.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Lauren A Beste
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, Boston, MA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Patrick S Kamath
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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22
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Yane Y, Kawamura J, Ushijima H, Yoshioka Y, Kato H, Ueda K. Hybrid method using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia in a patient with liver cirrhosis and severe varicose veins: A case report. Int J Surg Case Rep 2021; 85:106207. [PMID: 34343796 PMCID: PMC8349998 DOI: 10.1016/j.ijscr.2021.106207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Cirrhosis is a significant determinant of postoperative morbidity and mortality. Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment of inguinal hernia because of the substantial recurrence rate and high postoperative morbidity and mortality. However, hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with severe liver cirrhosis. No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. PRESENTATION OF CASE A 62-year-old man with a history of chronic C-type liver cirrhosis (Child-Pugh classification C) and hepatocellular carcinoma was referred to us for surgical treatment of an irreducible right inguinal hernia. An abdominal computed tomography (CT) scan revealed that the small intestine had herniated into the scrotum and severe abdominal wall varicose veins due to liver cirrhosis. We performed a hybrid method that combines examination laparoscopy and Lichtenstein's technique to observe the abdominal cavity and to avoid the risks due to severe varicosis of the inferior epigastric vein. DISCUSSION There have been some reports of inguinal hernia with cirrhosis and ascites, but no reports of incarcerated inguinal hernia with abdominal wall varicose veins. In the present case, we chose a laparoscopic approach to observe the abdominal cavity to confirm intestinal necrosis. Hybrid surgery using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia could be performed safely. CONCLUSION Hybrid surgery using laparoscopy and Lichtenstein's technique may be an effective method for patients with incarcerated inguinal hernia with end-stage cirrhosis and severe abdominal varicosis.
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Affiliation(s)
- Yoshinori Yane
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan.
| | - Junichiro Kawamura
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Hokuto Ushijima
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Yasumasa Yoshioka
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Hiroaki Kato
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
| | - Kazuki Ueda
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Osaka, Japan
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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.
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Affiliation(s)
- Alfred Adiamah
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK
| | - Lu Ban
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK
| | - John Hammond
- Division of Hepatobiliary and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology and Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark ,8200
| | - Joe West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
| | - David J Humes
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
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Oliver JB, Merchant AM, Koneru B. The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization. J INVEST SURG 2021; 34:617-626. [PMID: 31661332 DOI: 10.1080/08941939.2019.1676846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have shown high rates of postoperative morbidity and mortality in individuals with chronic liver disease (CLD). However, analyses from comparisons with individuals without CLD are not available. Such analyses might provide opportunities to improve outcomes. METHODS Data from The National Surgical Quality Improvement Program (NSQIP) from 2008 to 2011 were analyzed comparing CLD patients undergoing non-liver surgery propensity matched to those without CLD. Patients with CLD were stratified by Model of End Stage Liver Disease (MELD) scores <15 and ≥15. Primary outcome was all cause mortality, and secondary outcomes were composite and individual morbidity, hospital length of stay, readmission, reoperation, and discharge destination. Odds ratios (OR) were calculated, and length of hospital stay was estimated using Poisson regression. RESULTS There were 6,209 patients with CLD (4,013 with low MELD, 2,196 with high MELD) matched to 18,627 patients without. Patients with CLD had 1.8- and 3.3-times higher odds of mortality (95% CI 1.6-2.1 for Low MELD (10.6%), 2.9-3.8 for high MELD (35.2%), and 1.8- and 2.2-times higher odds of any morbidity (1.6-1.9 and 1.9-2.4). Complications specific to CLD were increased based on MELD specifically coma (OR 1.6, 0.9-2.9 for Low MELD, 2.2, 1.5-3.2 for High MELD), renal failure (OR 1.4, 1.1-1.8 and 2.4, 2.0-2.9), and bleeding (OR 1.7, 1.5-1.9 and 2.0, 1.8-2.3). They also had a 20% and 80% longer length of stay, 2.2- and 3.4-times higher odds of being discharged somewhere other than home, 1.7- and 1.6-times higher odds of readmission, and 1.5- and 1.6-times higher odds of reoperation. CONCLUSION Patients with CLD have significantly higher odds of mortality and morbidity, which is increased with a higher MELD. Interventions that decrease those morbidities are needed and have the potential to decrease mortality and resource utilization.
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Affiliation(s)
- Joseph B Oliver
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
- Department of Surgery, East Orange Veterans Affairs Hospital, East Orange, NJ, USA
| | - Aziz M Merchant
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Baburao Koneru
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
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Alvaro D, Caporaso N, Giannini EG, Iacobellis A, Morelli M, Toniutto P, Violi F. Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia. Eur J Clin Invest 2021; 51:e13508. [PMID: 33539542 PMCID: PMC8244048 DOI: 10.1111/eci.13508] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gaps of knowledge still exist about the potential association between severe thrombocytopenia and increased risk of procedure-associated bleeding in patients with liver disease. METHODS In this narrative review, we aimed at examining the association between procedure-related bleeding risk and platelet count in patients with cirrhosis and severe thrombocytopenia in various settings. We updated to 2020 a previously conducted literature search using MEDLINE/PubMed and EMBASE. The search string included clinical studies, adult patients with chronic liver disease and thrombocytopenia undergoing invasive procedures, any interventions and comparators, and haemorrhagic events of any severity as outcome. RESULTS The literature search identified 1276 unique publications, and 15 studies met the inclusion criteria and were analysed together with those identified by the previous search. Most of the new studies included in our analysis did not assess the association between post-procedural bleeding risk and platelet count alone in patients with chronic liver disease. Furthermore, some results could have been biased by prophylactic platelet transfusions. A few studies found that severe thrombocytopenia may be predictive of bleeding following percutaneous liver biopsy, dental extractions, percutaneous ablation of liver tumours and endoscopic polypectomy. CONCLUSIONS Currently available literature cannot support definitive conclusions about the appropriate target platelet counts to improve the risk of bleeding in cirrhotic patients who underwent invasive procedures; moreover, it showed enormous variability in the use of prophylactic platelet transfusions.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Nicola Caporaso
- Department of Clinical Medicine and SurgeryUniversity of Naples 'Federico II'NaplesItaly
| | - Edoardo Giovanni Giannini
- Gastroenterology UnitDepartment of Internal MedicineUniversity of Genoa, IRCCS‐Ospedale Policlinico San MartinoGenoaItaly
| | - Angelo Iacobellis
- Division of GastroenterologyFondazione IRCCS Casa Sollievo della SofferenzaFoggiaItaly
| | | | - Pierluigi Toniutto
- Hepatology and Liver Transplantation UnitAzienda Sanitaria Universitaria IntegrataAcademic HospitalUdineItaly
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Kykalos S, Machairas N, Ntikoudi E, Dorovinis P, Molmenti EP, Sotiropoulos GC. Inguinal Hernias in Cirrhotic Patients: From Diagnosis to Treatment. Surg Innov 2021; 28:620-627. [PMID: 33599535 DOI: 10.1177/1553350621995058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cirrhosis has a strong association with abdominal wall hernias, especially in the presence of concomitant ascites. Major predisposing factors for hernia formation in this particular group of patients include increased intra-abdominal pressure and decreased muscle mass due to poor nutrition. Management of these patients is highly challenging and requires an experienced multidisciplinary surgical and medical approach. The aim of our review is to clarify crucial diagnostic and management approaches. Crucial medical and technical issues on this topic are widely discussed with special focus on indication, timing, and type of surgical repair, with an additional reference to the actual role of laparoscopy.
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Affiliation(s)
- Stylianos Kykalos
- Department of Propaedeutic Surgery, 68993National and Kapodistrian University of Athens, Medical School Athens, Laiko General Hospital, Greece
| | - Nikolaos Machairas
- Department of Propaedeutic Surgery, 68993National and Kapodistrian University of Athens, Medical School Athens, Laiko General Hospital, Greece
| | | | - Panagiotis Dorovinis
- Department of Propaedeutic Surgery, 68993National and Kapodistrian University of Athens, Medical School Athens, Laiko General Hospital, Greece
| | - Ernesto P Molmenti
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Georgios C Sotiropoulos
- Department of Propaedeutic Surgery, 68993National and Kapodistrian University of Athens, Medical School Athens, Laiko General Hospital, Greece
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Young S, Larson L, Bermudez J, Mohei H, Rostambeigi N, Golzarian J, Mahgoub A. Evaluation of the frequency and factors predictive of hernia incarceration following transjugular intrahepatic portosystemic shunt placement. Clin Radiol 2021; 76:287-293. [PMID: 33549300 DOI: 10.1016/j.crad.2020.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 12/30/2020] [Indexed: 02/07/2023]
Abstract
AIM To examine the frequency and predictive factors for bowel incarceration following transjugular intrahepatic portosystemic shunts (TIPS) placement to treat refractory cirrhosis-induced ascites. MATERIALS AND METHODS Ninety-nine patients with known hernias at the time of TIPS placement were identified. Their electronic medical records were reviewed and pertinent pre-procedural, procedural, and outcome variables were recorded. Patients were divided between those that suffered incarceration (study group) and a control group of those with a hernia who did not suffer incarceration. RESULTS Twelve of the 99 patients (12.1%) suffered hernia incarceration, of which seven (7.1%) suffered incarceration in the first 90 days. One patient who suffered incarceration ultimately died from complications of the incarceration. When comparing all patients who suffered incarceration to controls, incarceration patients were found to have significantly higher albumin levels (mean 3.13 versus 2.73, p=0.02). When just considering those who had incarcerations in the first 90 days to controls, incarceration patients were less likely to have improvement in their ascites (p=0.04). CONCLUSIONS Incarcerated hernias occur frequently after TIPS placement and can lead to significant morbidity and mortality. Clinicians should be aware of this complication and counsel patients on presenting symptoms prior to placement.
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Affiliation(s)
- S Young
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA.
| | - L Larson
- Department of Medicine, Division of Gastroenterology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - J Bermudez
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - H Mohei
- Department of Medicine, Division of Gastroenterology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - N Rostambeigi
- Department of Radiology, Division of Interventional Radiology, Washington University, 5110 S Kingshighway Blvd, St Louis, MO 63110, USA
| | - J Golzarian
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - A Mahgoub
- Department of Medicine, Division of Gastroenterology, Baylor Scott and White, 3410 Worth St, Ste 860, Dallas, TX 75246, USA
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Salah D, Algharabawy WS. Ultrasound-guided transverse abdominis plane and ilioinguinal-iliohypogastric nerve block versus illioinguinal- illiohypogastric nerve block for inguinal hernia repair in patients with liver cirrhosis. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1863021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Dina Salah
- Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Sayed Algharabawy
- Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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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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Hill CE, Olson KA, Roward S, Yan D, Cardenas T, Teixeira P, Coopwood BT, Trust M, Aydelotte J, Ali S, Brown C. Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients. Am J Surg 2020; 220:1402-1404. [PMID: 32988606 DOI: 10.1016/j.amjsurg.2020.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/08/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND We hypothesize that patients with compensated cirrhosis undergoing elective UHR have an improved mortality compared to those undergoing emergent UHR. METHOD The NIS was queried for patients undergoing UHR by CPT code, and ICD-10 codes were used to define separate patient categories of non-cirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC). RESULTS A total of 32,526 patients underwent UHR, 97% no cirrhosis, 1.1% compensated cirrhosis, 1.7% decompensated cirrhosis. On logistic regression, cirrhosis was found to be independently associated with mortality (OR 2.841, CI 2.14-3.77). On subset analysis of only cirrhosis patients, elective repair was found to be protective from mortality (OR 0.361, CI 0.15-0.87, p = 0.02). CONCLUSIONS In this retrospective review, cirrhosis as well as emergent UHR in cirrhotic patients were independently associated with mortality. More specifically, electively (rather than emergently) repairing an umbilical hernia in cirrhotic patients was independently associated with a 64% reduction in mortality.
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Affiliation(s)
- Charles E Hill
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA.
| | - Kristofor A Olson
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Simin Roward
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Derek Yan
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Tatiana Cardenas
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Pedro Teixeira
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Ben T Coopwood
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Marc Trust
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Jayson Aydelotte
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Sadia Ali
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Carlos Brown
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
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Siegel N, DiBrito S, Ishaque T, Kernodle AB, Cameron A, Segev D, Adrales G, Garonzik-Wang J. Open inguinal hernia repair outcomes in liver transplant recipients versus patients with cirrhosis. Hernia 2020; 25:1295-1300. [PMID: 32857237 DOI: 10.1007/s10029-020-02290-8] [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: 06/19/2020] [Accepted: 08/18/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Patients with liver cirrhosis (LC) are at an increased risk for postoperative complications after open inguinal hernia repair (OIHR). It is possible that orthotopic liver transplant (OLT) recipients may have better outcomes, given reversal of liver failure pathophysiology. Therefore, we sought to compare mortality risk, complications, length of stay (LOS), and cost associated with OIHR in OLT recipients versus LC. METHODS From the National Inpatient Sample (NIS), using ICD-9 codes, we found 83 OLT recipients and 764 patients with LC who underwent OIHR between 2002 and 2014. We used logistic, negative binomial, and multiple linear regression models to compare peri-operative mortality risk, postoperative complications, and LOS, and cost associated with OIHR in OLT recipients versus LC patients. Models were adjusted for patient demographic and clinical characteristics, and hospital factors. RESULTS OLT recipients were younger (58 vs 61, p = 0.02), more likely to be privately insured (42.0% vs 24.6%, p = 0.006), less likely to have ascites at time of surgery (5.1% vs 18.9%, p = 0.003), and have surgery at large (84.3% vs 65.2%, p = 0.01) and teaching hospitals (84.2% vs 47.9%, p < 0.001). There were no mortalities among OLT recipients, but 19 (2.5%) deaths among LC patients. OLT recipients had a similar risk of overall complications (adjusted odds ratio aOR = 0.71 1.30 2.41) and hospital-associated costs (adjusted cost ratio = 0.71 0.88 1.09). However, LOS was significantly different with OLT recipients having shorter LOS (adjusted LOS ratio = 0.56 0.70 0.89). CONCLUSION Delaying OIHR in patients with LC until after OLT decreases LOS and may carry decreased mortality.
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Affiliation(s)
- N Siegel
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD, 21205, USA
| | - S DiBrito
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD, 21205, USA
| | - T Ishaque
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD, 21205, USA
| | - A B Kernodle
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD, 21205, USA
| | - A Cameron
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD, 21205, USA
| | - D Segev
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD, 21205, USA
| | - G Adrales
- Department of Minimally Invasive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - J Garonzik-Wang
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD, 21205, USA.
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Abdominal Pain in a Patient With Ascites. J Emerg Med 2020; 59:710-711. [PMID: 32712038 DOI: 10.1016/j.jemermed.2020.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
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Tennakoon L, Baiu I, Concepcion W, Melcher ML, Spain DA, Knowlton LM. Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease. Am Surg 2020; 86:665-674. [PMID: 32683972 DOI: 10.1177/0003134820923304] [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: 12/24/2022]
Abstract
BACKGROUND Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD). STUDY DESIGN We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs. RESULTS Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001). CONCLUSIONS Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.
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Affiliation(s)
- Lakshika Tennakoon
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Ioana Baiu
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Waldo Concepcion
- 6429 Department of Surgery, Division of Abdominal Transplantation, Stanford University Medical Center, Stanford, CA, USA
| | - Marc L Melcher
- 6429 Department of Surgery, Division of Abdominal Transplantation, Stanford University Medical Center, Stanford, CA, USA
| | - David A Spain
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Lisa M Knowlton
- 6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA
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Kumar A, Pol MM. Laparoscopic total extraperitoneal (TEP) mesh repair for femoral hernia in a patient of child B liver cirrhosis with ascites. A case report. Int J Surg Case Rep 2020; 72:298-300. [PMID: 32563089 PMCID: PMC7305352 DOI: 10.1016/j.ijscr.2020.05.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 11/04/2022] Open
Abstract
Minimal access laparoscopic techniques may be performed safely in patients with femoral hernia with liver cirrhosis. Minimal access technique provide less postoperative pain, lower recurrence and early discharge. Extraperitoneal approaches are safe in hernia patients with ascites associated with liver failure. Improved anesthetic techniques and improved medications have improved outcomes of surgery in patients with liver cirrhosis. Introduction Femoral hernia is infrequently encountered in surgical practice and is even rare in patients with liver cirrhosis. Recurrent pain adds to the existing morbidity and affects the quality of life of these patients. Management of such cases had rather high rates of morbidity and mortality owing to hepatic decompensation. However, more recent studies have shown a significant improvement of the quality of life and improved rates of morbidity in cirrhotic patients with inguinal hernias post repair. These studies all included open hernia repair with preperitoneal approach with improved results in terms of morbidity and lower rates of recurrence postoperatively. However, when compared to laparoscopic repairs these have more postoperative complications, complication related re-operations, pain and recurrence rates. Keeping these in mind, the laparoscopic approach was considered in our patient which has not been described yet in literature for femoral hernia. The report is in line with the SCARE criteria. (Agha et al. (2018) [1]) The case report is registered with research registry (UID researchregistry5467). Presentation of case A 40 year old female patient with Child B cirrhosis of liver with ascites was operated for a symptomatic left uncomplicated femoral hernia using standard three port laparoscopic total extraperitoneal repair with prolene mesh. She was discharged on postoperative day 2. She developed ascitic leak from the hypogastric port site in the late postoperative period which was managed conservatively. The patient has remained stable without recurrence at one year follow up. Conclusion Laparoscopic TEP may be a safe option with no major adverse events in symptomatic femoral hernias. Further studies are needed to ascertain its role.
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Affiliation(s)
- Aditya Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Manjunath Maruti Pol
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
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Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients. J Visc Surg 2020; 158:27-37. [PMID: 32553558 DOI: 10.1016/j.jviscsurg.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites. METHODS Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival. RESULTS Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group. CONCLUSION Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.
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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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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
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Henriksen NA, Kaufmann R, Simons MP, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Montgomery A. EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances. BJS Open 2020; 4:342-353. [PMID: 32207571 PMCID: PMC7093793 DOI: 10.1002/bjs5.50252] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/26/2019] [Indexed: 01/11/2023] Open
Abstract
Background Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management. Methods The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed. Results Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence. Conclusion This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.
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Affiliation(s)
- N A Henriksen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - R Kaufmann
- Erasmus University Medical Centre, Rotterdam, the Netherlands.,Tergooi, Hilversum, the Netherlands
| | - M P Simons
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - F Berrevoet
- Department of General and Hepato-Pancreato-Biliary Surgery, Gent University Hospital, Gent, Belgium
| | - B East
- Third Department of Surgery, Motol University Hospital, Prague, Czech Republic.,First and Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - J Fischer
- University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - W Hope
- New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - D Klassen
- Department of Surgery, Dalhousie University, Halifax, Canada
| | - R Lorenz
- Praxis 3+CHIRURGEN, Berlin, Germany
| | - Y Renard
- Department of Digestive Surgery, Robert Debré University Hospital, Reims, France
| | - M A Garcia Urena
- Henares University Hospital, Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain
| | - A Montgomery
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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Li J, Shao X, Cheng T, Ji Z. Inguinal hernia repair in cirrhotic patients with ascites. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2020. [DOI: 10.4103/ijawhs.ijawhs_11_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Pinheiro RS, Andraus W, Waisberg DR, Nacif LS, Ducatti L, Rocha-Santos V, Diniz MA, Arantes RM, Lerut J, D'Albuquerque LAC. Abdominal hernias in cirrhotic patients: Surgery or conservative treatment? Results of a prospective cohort study in a high volume center: Cohort study. Ann Med Surg (Lond) 2019; 49:9-13. [PMID: 31853365 PMCID: PMC6911966 DOI: 10.1016/j.amsu.2019.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/13/2019] [Indexed: 01/15/2023] Open
Abstract
Background Surgical treatment of abdominal hernias in cirrhotics is often delayed due to the higher morbidity and mortality associated with the underlying liver disease. Some patients are followed conservatively and only operated on when complications occur (“wait and see” approach). The aim of this study is to compare outcomes of cirrhotic patients undergoing conservative non-operative care or elective hernia repair. Methods A prospective observational study including 246 cirrhotic patients with abdominal hernia was carried out. Patients were given the option to select their treatment: elective hernia repair or conservative non-operative care. Demographics, characteristics of underlying liver disease, type of hernia, complications and mortality were analyzed. During follow-up of patients who opted for the “wait and see” approach, emergency hernia repair was performed in case of hernia complications. Results Elective hernia repair was performed in 57 patients and 189 patients were kept in conservative care, of which 43 (22.7%) developed complications that required emergency hernia repair. Elective surgery provided better five-years survival than conservative care (80% vs. 62%; p = 0.012). Multivariate analysis identified multiples hernias [Hazards Ratio (HR):6.7, p < 0.001] and clinical follow-up group (HR 3.62, p = 0.005) as risk factors for mortality. Among patients undergoing surgical treatment, multivariate analysis revealed MELD>11 (HR 7.8; p = 0.011) and emergency hernia repair (HR 5.35; p = 0.005) as independent risk factors for 30-day mortality. Conclusions Elective hernia repair offers an acceptable morbidity and ensures longer survival. “Wait and see” approach jeopardizes cirrhotic patients and should be avoided, given the higher incidence of emergency surgery due to hernia complications.
Prospective study comparing “wait and see” approach with elective surgical repair of abdominal hernias in cirrhotic patients. About 22.7% (n = 43) of patients under conservative treatment developed hernia complications requiring emergency hernia repair. Five-year survival was higher in elective repair group than in conservative treatment (80% vs. 62%; p = 0.012). Among patients undergoing hernia repair MELD>11 and emergency surgery were independent risk factors for 30-day mortality. “Wait and see” approach jeopardizes cirrhotic patients, as a high incidence of emergency surgery negatively impact survival.
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Affiliation(s)
- Rafael Soares Pinheiro
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Wellington Andraus
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Daniel Reis Waisberg
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Lucas Souto Nacif
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Liliana Ducatti
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Vinicius Rocha-Santos
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Márcio A Diniz
- Biostatistics and Bioinformatics Research Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, United States
| | - Rubens Macedo Arantes
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Jan Lerut
- Starzl Unit of Abdominal Transplantation, University Hospital of Saint Luc, Université Catholique Louvain, Brussels, Belgium
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Abstract
Patients with portal hypertension will increasingly present for nontransplant surgery because of the increasing incidence of, and improving long-term survival for, chronic liver disease. Such patients have increased perioperative morbidity and mortality caused by the systemic pathophysiology of liver disease. Preoperative assessment should identify modifiable causes of liver injury and distinguish between compensated and decompensated cirrhosis. Risk stratification, which is crucial to preparing patients and their families for surgery, relies on scores such as Child-Turcotte-Pugh and Model for End-stage Liver Disease to translate disease severity into quantified outcomes predictions. Risk factors for postoperative complications should also be recognized.
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Affiliation(s)
- Melissa Wong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Transplant Center, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, The Dumont-UCLA Transplant Center, 757 Westwood Blvd, Suite 8236, Los Angeles, CA 90095, USA.
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Wang H, Fu J, Qi X, Sun J, Chen Y. Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in patients with liver cirrhosis accompanied by ascites. Medicine (Baltimore) 2019; 98:e17078. [PMID: 31651835 PMCID: PMC6824811 DOI: 10.1097/md.0000000000017078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 07/21/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022] Open
Abstract
To investigate the feasibility, efficacy, and safety of laparoscopic totally extraperitoneal (TEP) repair in patients with inguinal hernia accompanied by liver cirrhosis.Between October 2015 and May 2018, 17 patients with liver cirrhosis who underwent TEP repair were included in this study. The baseline characteristics, perioperative data, and recurrence were retrospectively reviewed.Seventeen patients with a mean duration of 18.23 ± 16.80 months were enrolled. All TEP repairs were successful without conversion to trans-abdominal pre-peritoneal (TAPP) surgery or open repair, but 4 patients had peritoneum rupture during dissection. The mean operation time was 54.23 ± 10.51 minutes for unilateral hernia and 101.25 ± 13.77 minutes for bilateral hernias. We found 2 cases with contralateral inguinal hernia and 2 cases with obturator hernia during surgery. The rate of complication was 17.65% (3/17), 2 of 3 cases were Child-Turcotte-Pugh C with large ascites. During a follow-up of 19.29 ± 9.01 months, no patients had recurrence and chronic pain, but 2 patients died because of the progression of underlying liver disease.Early and elective inguinal hernia repair is feasible and effective for patients with liver cirrhosis. TEP is a feasible and safe repair option for cirrhotic patients in experienced hands.
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Kim SW, Kim MA, Chang Y, Lee HY, Yoon JS, Lee YB, Cho EJ, Lee JH, Yu SJ, Yoon JH, Park KJ, Kim YJ. Prognosis of surgical hernia repair in cirrhotic patients with refractory ascites. Hernia 2019; 24:481-488. [PMID: 31512088 DOI: 10.1007/s10029-019-02043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Abdominal wall hernias are common in patients with ascites. Elective surgical repair is recommended for the treatment of abdominal wall hernias. However, surgical hernia repair in cirrhotic patients with refractory ascites is controversial. In this study, we aimed to evaluate the outcomes of elective surgical hernia repair in patients with liver cirrhosis with and without refractory ascites. METHOD From January 2005 to June 2018, we retrospectively reviewed the records of consecutive patients with liver cirrhosis who underwent a surgical hernia repair. RESULTS This study included 107 patients; 31 patients (29.0%) had refractory ascites. Preoperatively, cirrhotic patients with refractory ascites had a higher median model for end-stage liver disease (MELD) score (13.0 vs 11.0, P = 0.001) than those without refractory ascites. The 30-day mortality rate (3.2% vs 0%, P = 0.64) and the risk of recurrence (hazard ratio 0.410; 95% CI 0.050-3.220; P = 0.39) did not differ significantly between cirrhotic patients with refractory ascites and cirrhotic patients without refractory ascites. Among cirrhotic patients with refractory ascites, albumin (P = 0.23), bilirubin (P = 0.37), creatinine (P = 0.97), and sodium levels (P = 0.35) did not change significantly after surgery. CONCLUSION In advanced liver cirrhosis patients with refractory ascites, hernias can be safely treated with elective surgical repair. Mortality rate within 30 days did not differ by the presence or absence of refractory ascites. Elective hernia repair might be beneficial for treatment of abdominal wall hernia in cirrhotic patients with refractory ascites.
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Affiliation(s)
- S W Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - M A Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Y Chang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - H Y Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, South Korea
| | - J S Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Y B Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - E J Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - J-H Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - S J Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - J-H Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - K J Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Y J Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea. .,Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Futagawa Y, Yanaga K, Kosuge T, Suka M, Isaji S, Hirano S, Murakami Y, Yamamoto M, Yamaue H. Outcomes of pancreaticoduodenectomy in patients with chronic hepatic dysfunction including liver cirrhosis: results of a retrospective multicenter study by the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:310-324. [PMID: 31017730 DOI: 10.1002/jhbp.630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Yasuro Futagawa
- Department of Surgery The Jikei University School o f Medicine 3‐25‐8 Nishishimbashi, Minato‐ku Tokyo105‐8461Japan
| | - Katsuhiko Yanaga
- Department of Surgery The Jikei University School o f Medicine 3‐25‐8 Nishishimbashi, Minato‐ku Tokyo105‐8461Japan
| | - Tomoo Kosuge
- Department of Surgery Sangenjaya Daiichi Hospital Tokyo Japan
| | - Machi Suka
- Department of Public Health and Environmental Medicine The Jikei University School of Medicine Tokyo Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic and Transplant Surgery Mie University Graduate School of Medicine Mie Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II Hokkaido University Faculty of Medicine Hokkaido Japan
| | - Yoshiaki Murakami
- Department of Surgery Institute of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Masakazu Yamamoto
- Department of Surgery Institute of Gastroenterology Tokyo Women's Medical University Tokyo Japan
| | - Hiroki Yamaue
- Second Department of Surgery Wakayama Medical University School of Medicine Wakayama Japan
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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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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.
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Hickman L, Tanner L, Christein J, Vickers S. Non-Hepatic Abdominal Surgery in Patients with Cirrhotic Liver Disease. J Gastrointest Surg 2019; 23:634-642. [PMID: 30465191 PMCID: PMC7102012 DOI: 10.1007/s11605-018-3991-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Abstract
Cirrhotic liver disease is an important cause of peri-operative morbidity and mortality in general surgical patients. Early recognition and optimization of liver dysfunction is imperative before any elective surgery. Patients with MELD <12 or classified as Child A have a higher morbidity and mortality than matched controls without liver dysfunction, but are generally safe for elective procedures with appropriate patient education. Patients with MELD >20 or classified as Child C should undergo transplantation before any elective procedure given mortality exceeds 40%. Laparoscopic procedures are feasible and safe in cirrhotic patients.
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Affiliation(s)
- Laura Hickman
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - John Christein
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Selwyn Vickers
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
- Dean's Office, UAB School of Medicine, FOT 1203, 510 20th Street South, Birmingham, AL, 35233, USA.
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Schwab R, Germer CT, Lang H. Relevante Nebenerkrankungen zu Notfallindikationen und Notfalloperationen in der Viszeral- und Allgemeinchirurgie. NOTFÄLLE IN DER ALLGEMEIN- UND VISZERALCHIRURGIE 2019. [PMCID: PMC7121273 DOI: 10.1007/978-3-662-53557-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Die Adipositas ist eine über das Normalmaß hinausgehende Vermehrung des Körperfetts und wird über den Body-Mass- Index (BMI = kg/m) bestimmt. Ab einem BMI von 30 kg/m liegt definitionsgemäß eine Adipositas vor. Der Krankheitswert ergibt sich aus der Assoziation von Folgeerkrankungen, deren Risiko mit der Prävalenzdauer und dem Schweregrad der Adipositas ansteigt (Tab. 28.1). Dabei korreliert das kardiovaskuläre Risiko besonders mit dem Vorliegen einer viszeralen Adipositas (>88/102 cm Taillenumfang bei Frauen/ Männern). Die Prävalenz der Adipositas steigt in Deutschland kontinuierlich an. Derzeit ist knapp ein Viertel der deutschen Bevölkerung als adipös einzustufen.
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Affiliation(s)
- Robert Schwab
- grid.493974.40000 0000 8974 8488BundeswehrZentralkrankenhaus Koblenz, Koblenz, Deutschland
| | | | - Hauke Lang
- grid.410607.4Universitätsmedizin Mainz, Mainz, Deutschland
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Petro CC, Haskins IN, Perez AJ, Tastaldi L, Strong AT, Ilie RN, Tu C, Krpata DM, Prabhu AS, Eghtesad B, Rosen MJ. Hernia repair in patients with chronic liver disease - A 15-year single-center experience. Am J Surg 2019; 217:59-65. [PMID: 30343877 DOI: 10.1016/j.amjsurg.2018.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/04/2018] [Accepted: 10/12/2018] [Indexed: 12/28/2022]
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