Abdominal hernias in cirrhotic patients: Surgery or conservative treatment? Results of a prospective cohort study in a high volume center: Cohort study

Outcomes of peritoneal dialysis in cirrhosis: A systematic review and meta-analysis

BACKGROUND

Cirrhosis and end-stage kidney disease (ESKD) are significant global health concerns, contributing to high mortality and morbidity. Haemodialysis (HD) is frequently used to treat ESKD in patients with cirrhosis. However, it often presents challenges such as haemodynamic instability during dialysis sessions, leading to less than optimal outcomes. Peritoneal dialysis (PD), while less commonly used in cirrhotic patients, raises concerns about the risks of peritonitis and mortality. Our systematic review and meta-analysis aimed to assess outcomes in PD patients with cirrhosis.

METHODS

We executed a comprehensive search in Ovid MEDLINE, EMBASE and Cochrane databases up to 25 September 2023. The search focused on identifying studies examining mortality and other clinical outcomes in ESKD patients with cirrhosis receiving PD or HD. In addition, we sought studies comparing PD outcomes in cirrhosis patients to those without cirrhosis. Data from each study were aggregated using a random-effects model and the inverse-variance method.

RESULTS

Our meta-analysis included a total of 13 studies with 15,089 patients. Seven studies compared ESKD patients on PD with liver cirrhosis (2753 patients) against non-cirrhosis patients (9579 patients). The other six studies provided data on PD (824 patients) versus HD (1943 patients) in patients with cirrhosis and ESKD. The analysis revealed no significant difference in mortality between PD and HD in ESKD patients with cirrhosis (pooled odds ratio (OR) of 0.77; 95% confidence interval (CI), 0.53-1.14). In PD patients with cirrhosis, the pooled OR for peritonitis compared to non-cirrhosis patients was 1.10 (95% CI: 1.03-1.18). The pooled ORs for hernia and chronic hypotension in cirrhosis patients compared to non-cirrhosis controls were 2.48 (95% CI: 0.08-73.04) and 17.50 (95% CI: 1.90-161.11), respectively. The pooled OR for transitioning from PD to HD among cirrhotic patients was 1.71 (95% CI: 0.76-3.85). Mortality in cirrhosis patients on PD was comparable to non-cirrhosis controls, with a pooled OR of 1.05 (95% CI: 0.53-2.10).

CONCLUSIONS

Our meta-analysis demonstrates that PD provides comparable mortality outcomes to HD in ESKD patients with cirrhosis. In addition, the presence of cirrhosis does not significantly elevate the risk of mortality among patients undergoing PD. While there is a higher incidence of chronic hypotension and a slightly increased risk of peritonitis in cirrhosis patients on PD compared to those without cirrhosis, the risks of hernia and the need to transition from PD to HD are comparable between both groups. These findings suggest PD as a viable and effective treatment option for ESKD patients with cirrhosis.

Predictive value of hematological parameters in cirrhotic patients with open umbilical hernia repair

PURPOSE

Patients with liver cirrhosis sometimes suffer from high recurrence rates and postoperative complications. We previously reported that platelet-related hematological parameters are associated with the outcomes after incisional herniorrhaphy, and aim to evaluate the predictive value of these criteria in cirrhotic patients undergoing open umbilical herniorrhaphy.

METHODS

This is a retrospective study. The data of 95 cirrhotic patients undergoing open umbilical herniorrhaphy were analyzed. Patients were grouped based on the recurrence and defined hematological values. Platelet-multiple-lymphocyte index (PLM), neutrophil-leukocyte ratio, lymphocyte-monocyte ratio, platelet-neutrophil ratio, systemic immune-inflammation index, and aspartate aminotransferase-leukocyte ratio values were calculated based on preoperative blood analyses. The outcomes were obtained from hospital records and follow-up calls to patients.

RESULTS

Using cutoff values acquired by the Youden Index, we found a PLM value < 27.9, and the history of inguinal herniorrhaphy were revealed to be statistically significant in the recurrence based on univariant and multivariant analyses (p < 0.05). We further divided patients into two groups based on the cutoff value of PLM and found that a PLM value < 27.9 was significantly associated with the recurrence of incisional hernias (p = 0.018) and the occurrence of postoperative foreign sensation (p = 0.044), and tended to result in other postoperative complications such as cardiopathy, respiratory infection, hypoproteinemia, and hepatic diseases (p = 0.089).

CONCLUSION

The preoperative hematological values, especially PLM, may indicate the outcomes in cirrhotic patients after open umbilical herniorrhaphy. Accurate identification of risks may alert the intraoperative and postoperative care for patients.

Impact of nonmalignant ascites on outcomes of open inguinal hernia repair in the USA

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.

Preoperative Optimization for Abdominal Wall Reconstruction

Patients requiring abdominal wall reconstruction may have medical comorbidities and/or complex defects. Comorbidities such as smoking, diabetes, obesity, cirrhosis, and frailty have been associated with an increased risk of postoperative complications. Prehabilitation strategies are variably associated with improved outcomes. Large hernia defects and loss of domain may present challenges in achieving fascial closure, an important part of restoring abdominal wall function. Prehabilitation of the abdominal wall can be achieved with the use of botulinum toxin A, and preoperative progressive pneumoperitoneum.

Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery

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.

Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach

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.

Cirrhosis and hernia repair in a cohort of 6352 patients in a tertiary hospital: Risk assessment and survival analysis

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.

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

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.

Umbilical hernia repair in patients with cirrhosis: who, when and how to treat

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.

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

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.

Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial)

Purpose

To establish optimal management of patients with an umbilical hernia complicated by liver cirrhosis and ascites.

Methods

Patients with an umbilical hernia and liver cirrhosis and ascites were randomly assigned to receive either elective repair or conservative treatment. The primary endpoint was overall morbidity related to the umbilical hernia or its treatment after 24 months of follow-up. Secondary endpoints included the severity of these hernia-related complications, quality of life, and cumulative hernia recurrence rate.

Results

Thirty-four patients were included in the study. Sixteen patients were randomly assigned to elective repair and 18 to conservative treatment. After 24 months, 8 patients (50%) assigned to elective repair compared to 14 patients (77.8%) assigned to conservative treatment had a complication related to the umbilical hernia or its repair. A recurrent hernia was reported in 16.7% of patients who underwent repair. For the secondary endpoint, quality of life through the physical (PCS) and mental component score (MCS) showed no significant differences between groups at 12 months of follow-up (mean difference PCS 11.95, 95% CI − 0.87 to 24.77; MCS 10.04, 95% CI − 2.78 to 22.86).

Conclusion

This trial could not show a relevant difference in overall morbidity after 24 months of follow-up in favor of elective umbilical hernia repair, because of the limited number of patients included. However, elective repair of umbilical hernia in patients with liver cirrhosis and ascites appears feasible, nudging its implementation into daily practice further, particularly for patients experiencing complaints.

Trial registration

Clinicaltrials.gov, NCT01421550, on 23 August 2011.

First case report of spigelian hernia containing the appendix after liver transplantation: Another cause for chronic abdominal pain

INTRODUCTION

Abdominal ventral hernias are common in chronic liver disease due to increased abdominal pressure and sarcopenia. Following liver transplantation, diagnosis of chronic abdominal pain is challenging because it may relate to immunosuppression, scaring or opportunistic infections.

PRESENTATION OF CASE

A 62 years-old male presented with chronic abdominal pain one year following liver transplantation due to hepatocellular carcinoma. After work-up he was diagnosed with a Spigelian hernia containing the appendix. We did hernia repair with mesh but appendectomy was not performed since it showed no signs of inflammation. On follow-up the patient had complete resolution of the pain.

DISCUSSION

This is the first case of spigelian hernia containing the appendix following liver transplantation. Mesh repair can be safely performed in this setting but incidental appendectomy is controversial due to higher morbidity and mortality. In this case report we discuss the relationship between liver transplantation, abdominal hernias and the pitfalls of incidental appendectomy.

CONCLUSION

Uncommon ventral hernias are a possible cause for chronic abdominal pain after surgery and should be investigated with imaging studies. Mesh repair is safe but incidental appendectomy in the immunosuppressed is not encouraged due to increased morbidity.