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Kling SM, Taylor GA, Peterson NR, Patel T, Fagenson AM, Poggio JL, Ross HM, Pitt HA, Lau KN, Philp MM. Colectomy in patients with liver disease: albumin-bilirubin score accurately predicts outcomes. J Gastrointest Surg 2024; 28:843-851. [PMID: 38522642 DOI: 10.1016/j.gassur.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/17/2024] [Accepted: 03/09/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction. METHODS All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score. RESULTS Of 86,273 patients identified, 48% (N = 41,624) were Albumin-Bilirubin Grade 1, 45% (N = 38,370) Grade 2 and 7% (N = 6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001). CONCLUSION Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.
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Affiliation(s)
- Sarah M Kling
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - George A Taylor
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Nicholas R Peterson
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Takshaka Patel
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Alexander M Fagenson
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Juan Lucas Poggio
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States; Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States
| | - Howard M Ross
- Department of Surgery, Hackensack University Medical Center, Hackensack, New Jersey, United States
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, United States
| | - Kwan N Lau
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States; Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States
| | - Matthew M Philp
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States; Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, United States.
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Patel S, Brennan K, Zhang L, Djerboua M, Nanji S, Merchant S, Flemming J. Colorectal Cancer in Individuals with Cirrhosis: A Population-Based Study Assessing Practice Patterns, Outcomes, and Predictors of Survival. Curr Oncol 2023; 30:9530-9541. [PMID: 37999110 PMCID: PMC10670829 DOI: 10.3390/curroncol30110690] [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: 10/03/2023] [Revised: 10/28/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023] Open
Abstract
Those with cirrhosis who develop colorectal cancer (CRC) are an understudied group who may tolerate treatments poorly and are at risk of worse outcomes. This is a retrospective cohort study of 842 individuals from Ontario, Canada, with a pre-existing diagnosis of cirrhosis who underwent surgery for CRC between 2009 and 2017. Practice patterns, overall survival, and short-term morbidity and mortality were assessed. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (52%) and alcohol-associated liver disease (29%). The model for end-stage liver disease score (MELD-Na) was available in 42% (median score of 9, IQR7-11). Preoperative radiation was used in 62% of Stage II/III rectal cancer patients, while postoperative chemotherapy was used in 42% of Stage III colon cancer patients and 38% of Stage II/III rectal cancer patients. Ninety-day mortality following surgery was 12%. Five-year overall survival was 53% (by Stages I-IV, 66%, 55%, 50%, and 11%, respectively). Those with alcohol-associated cirrhosis (HR 1.8, 95% CI 1.5-2.2) had lower survival than those with NAFLD. Those with a MELD-Na of 10+ did worse than those with a lower MELD-Na score (HR 1.9, 95% CI 1.4-2.6). This study reports poor survival in those with cirrhosis who undergo treatment for CRC. Caution should be taken when considering aggressive treatment.
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Affiliation(s)
- Sunil Patel
- Department of Surgery, Queen’s University, Kingston, ON K7L 2V7, Canada
- Cancer Care and Epidemiology, Queens Cancer Research Institute, Kingston, ON K7L 3N6, Canada
| | - Kelly Brennan
- Department of Surgery, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Lisa Zhang
- Department of Surgery, Ottawa University, Ottawa, ON K1H 8L6, Canada
| | | | - Sulaiman Nanji
- Department of Surgery, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Shaila Merchant
- Department of Surgery, Queen’s University, Kingston, ON K7L 2V7, Canada
- Cancer Care and Epidemiology, Queens Cancer Research Institute, Kingston, ON K7L 3N6, Canada
| | - Jennifer Flemming
- Cancer Care and Epidemiology, Queens Cancer Research Institute, Kingston, ON K7L 3N6, Canada
- Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
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5
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Kazi A, Finco TB, Zakhary B, Firek M, Gerber A, Brenner M, Coimbra R. Acute Colonic Diverticulitis and Cirrhosis: Outcomes of Laparoscopic Colectomy Compared with an Open Approach. J Am Coll Surg 2020; 230:1045-1053. [PMID: 32229299 DOI: 10.1016/j.jamcollsurg.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The impact of cirrhosis on outcomes of acute colonic diverticulitis (ACD) has been studied infrequently. We investigated the effect of cirrhosis on outcomes of surgical patients with ACD treated by either an open or laparoscopic approach. METHODS A cross-sectional study was performed using the Nationwide Inpatient Sample 2012 to 2014. Patients with ACD were stratified into compensated and decompensated cirrhosis for comparisons of demographic characteristics, hospital length of stay, complications, mortality, and cost. Groups were stratified according to surgical treatment: open colectomy and laparoscopic colectomy. A comparative effectiveness analysis of outcomes was performed between the 2 surgical treatments. Univariate comparisons between groups and multivariate regression analysis were performed to identify risk factors for mortality and specific complications. RESULTS Of 1,172,875 patients hospitalized with the diagnosis of ACD during the study period, 1,145 were cirrhotic. The majority were male (59%). There were 660 compensated cirrhotic patients and 485 decompensated cirrhotic patients and all underwent either open (n = 875) or laparoscopic colectomy (n = 270). Consistently, marked increases in mortality, hospital length of stay, and cost were observed in decompensated cirrhotic patients regardless of the type of treatment. Laparoscopic colectomy was accompanied by shorter hospital length of stay, lower costs, and significantly decreased mortality rate compared with open colectomy in compensated and decompensated cirrhotic patients. CONCLUSIONS The presence of cirrhosis markedly impacts outcomes in patients with ACD, leading to prolonged hospitalization, higher cost, and increased complications and deaths. Laparoscopic colectomy is associated with better outcomes in patients requiring surgical management, including those with decompensated cirrhosis.
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Affiliation(s)
- Albert Kazi
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Tiago B Finco
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Matthew Firek
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Ari Gerber
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Megan Brenner
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA; Department of Surgery, University of California Riverside, Riverside, CA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA; Department of Surgery, Loma Linda University, Loma Linda, CA.
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6
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Kruger AJ, Mumtaz K, Anaizi A, Modi RM, Hussan H, Zhang C, Hinton A, Conwell DL, Krishna SG, Stanich PP. Cirrhosis Is Associated with Increased Mortality in Patients with Diverticulitis: A Nationwide Cross-Sectional Study. Dig Dis Sci 2017; 62:3149-3155. [PMID: 28986716 DOI: 10.1007/s10620-017-4782-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/25/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diverticulitis in patients with cirrhosis has been associated with higher surgical mortality, but no prior studies evaluate non-surgical treatment results. AIMS Our aim was to compare the outcomes of hospitalization for diverticulitis in patients with and without cirrhosis. METHODS We utilized the Nationwide Inpatient Sample (2007-2013) for patients with and without cirrhosis hospitalized for diverticulitis. Patients were further stratified by the presence of compensated versus decompensated cirrhosis. Validated ICD-9 codes captured patients and surgical procedures. Multivariate logistic regression models were fit. The primary outcomes of interest were mortality and surgical intervention rates. RESULTS There were 1,555,469 patients hospitalized for diverticulitis without cirrhosis, and 7523 patients hospitalized for diverticulitis with cirrhosis. On multivariate analysis, patients with cirrhosis had an increased mortality rate (OR 2.28; 95% CI 1.48-3.5). There were no significant differences in surgical interventions. Subgroup multivariate analyses of compensated cirrhosis (n = 6170) and decompensated cirrhosis (n = 1353) revealed that decompensated cirrhosis had an increased mortality rate (OR 4.99; 95% CI 2.48-10.03) when compared to patients without cirrhosis, whereas those with compensated cirrhosis did not (OR 1.67; 95% CI 0.96-2.91). Those with compensated cirrhosis underwent less surgical interventions (OR 0.82; 95% CI 0.67-0.99) compared to those without cirrhosis. Patients with diverticulitis and cirrhosis had increased costs and lengths of hospitalization. CONCLUSION Presence of cirrhosis in patients hospitalized for diverticulitis is associated with an increased mortality rate. These are novel findings, and future clinical studies should focus on improving diverticulitis outcomes in this group.
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Affiliation(s)
- Andrew J Kruger
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Ahmad Anaizi
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Rohan M Modi
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hisham Hussan
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Cheng Zhang
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Alice Hinton
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA.,Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 200, Columbus, OH, 43210, USA.
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