Aspartate transaminase to platelet ratio index and Model for End-Stage Liver Disease scores are associated with morbidity and mortality after endovascular aneurysm repair among patients with liver dysfunction

Minimally invasive umbilical hernia repair is safe for patients with liver dysfunction: A propensity-score-matched analysis of approach and outcomes using ACS-NSQIP

BACKGROUND

Umbilical hernias are highly prevalent in patients with liver dysfunction, ascites, and cirrhosis. This patient population carries significant perioperative risk and poses significant challenges because of their comorbidities. Literature suggests that elective repair of umbilical hernias can lead to better outcomes by reducing the risk of ascitic leak and compromised bowel. Medical optimization followed by open repair has been the standard approach; however, little is known about whether a laparoscopic approach may be equivalent or superior.

METHODS

We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021 for umbilical hernia repairs in patients with liver dysfunction, as defined per the aspartate aminotransferase to platelet ratio index ≥1. We compare operative outcomes for open and laparoscopic repair, adjusting for confounders using propensity score matching and stratifying by case acuity.

RESULTS

We identified 1,983 patients with liver dysfunction who underwent umbilical hernia repair. Most patients (86%) were operated via an open approach rather than laparoscopy. Operative outcomes between the laparoscopy and open group were comparable regarding mortality and serious complications. Notably, length of stay and need for blood transfusion intraoperatively or postoperatively were reduced in the laparoscopy group (P < .001). These findings remained significant after subgroup analysis with propensity matching stratified by elective and emergency case types.

CONCLUSION

Minimally invasive umbilical hernia repair in liver dysfunction is as safe and, in some metrics, superior to open technique. We found no difference in mortality although hospital stays and the need for blood transfusions were lower in the laparoscopy groups. Prospective randomized trials are needed to validate these findings further.

Quercetin inhibits hepatotoxic effects by reducing trimethylamine-N-oxide formation in C57BL/6J mice fed with a high L-carnitine diet

L-Carnitine can be metabolized to trimethylamine (TMA) by gut microbiota and further converted into trimethylamine N-oxide (TMAO) in the liver, leading to liver damage. This study aimed to investigate the protective effect of quercetin against high L-carnitine-induced liver toxicity in mice. 3% L-carnitine drinking water was used to feed mice in this study. The formation of TMAO in the blood circulation of the tested mice was down-regulated following quercetin treatment. Administration of quercetin could also effectively antagonize the liver injury caused by high L-carnitine intake, which was proved by the decreased serum AST and ALT activities and the reduced levels of inflammatory liver cytokines (IL-1, IL-6, TNF-α, and TNF-β). Moreover, quercetin exhibited a rebalancing effect on dyslipidemia (TC, TG, HDL, and LDL) and antioxidant abilities (SOD, GSH-Px, MDA, and RAHFR) in L-carnitine-treated mice. The results of hepatic H&E and Oil Red O staining further verified the liver injury of high L-carnitine-treated mice and the protective effects of quercetin. These findings suggested that quercetin could attenuate the hepatotoxic effects of the mice fed with a high L-carnitine diet via inhibiting the circulating TMAO formation.

Biomarkers in EndoVascular Aneurysm Repair (EVAR) and Abdominal Aortic Aneurysm: Pathophysiology and Clinical Implications

Circulating biomarkers have been recently investigated among patients undergoing endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Considering the plethora of small descriptive studies reporting potential associations between biomarkers and clinical outcomes, this review aims to summarize the current literature considering both the treated disease (post EVAR) and the untreated disease (AAA before EVAR). All studies describing outcomes of tissue biomarkers in patients undergoing EVAR and in patients with AAA were included, and references were checked for additional sources. In the EVAR scenario, circulating interleukin-6 (IL-6) is a marker of inflammatory reaction which might predict postoperative morbidity; cystatin C is a promising early marker of post-procedural acute kidney injury; plasma matrix metalloproteinase-9 (MMP-9) concentration after 3 months from EVAR might help in detecting post-procedural endoleak. This review also summarizes the current gaps in knowledge and future direction of this field of research. Among markers used in patients with AAA, galectin and granzyme appear to be promising and should be carefully investigated even in the EVAR setting. Larger prospective trials are required to establish and evaluate prognostic models with highest values with these markers.

Assessment of Liver Function for Evaluation of Short- and Long-Term Outcomes in Type B Aortic Dissection Patients Undergoing Thoracic Endovascular Aortic Repair

Background and Aims: Patients with decreased liver function suffer from poor outcomes when undergoing procedures. We aimed to explore the impact of liver fibrosis identified by aspartate transaminase-to-platelet ratio index (APRI) and poor liver functional reserve assessed by a model of end-stage liver disease (MELD) and albumin-bilirubin(ALBI) score on the prognosis of patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR). Methods: A retrospective analysis of a prospectively maintained database from 2010 to 2017 was performed. APRI > 0.5 was used to identify those with significant liver fibrosis. Logistic and Cox regression analyses were performed to investigate the association between liver fibrosis, MELD, and ALBI with adverse events. Results: TEVAR was performed on 812 TBAD patients including 35 with liver fibrosis and 777 without. Twenty-four (3.0%) patients deceased during hospitalization and 69 (8.8%) patients died after a median 48.2 months follow-up. Multivariable analysis revealed that liver fibrosis, MELD, and ALBI were independently associated with in-hospital [fibrosis: odds ratio (OR) 23.73, 95% confidence interval (CI) 8.89-63.33, P < 0.001; MELD: OR 1.08, 95% CI 1.03-1.14, P = 0.003; ALBI: OR 4.45; 95% CI 1.56-12.67, P = 0.005] and follow-up mortality [fibrosis: hazard ratio (HR) 4.69, 95% CI 1.93-11.42, P = 0.001; MELD: HR 1.07, 95% CI 1.04-1.10, P < 0.001; ALBI: HR 2.88, 95% CI 1.53-5.43, P = 0.001]. The association was further corroborated by a subgroup analysis. Conclusion: Liver fibrosis and poor liver functional reserve could significantly increase the morbidity and mortality after TEVAR. APRI, MELD, and ALBI should be calculated and routinely used for preoperative risk stratification. Strict preoperative preparation and elaborate postoperative care are necessary to improve these patients' prognosis.

Liver Disease is Associated with Increased Mortality and Major Morbidity After Infra-Inguinal Bypass but not After Endovascular Intervention

OBJECTIVE

Liver disease increases mortality after abdominal surgery, including endovascular aortic aneurysm repair. However, its effect on mortality and morbidity after endovascular and open management of peripheral vascular disease has not been widely evaluated.

METHODS

The National Surgical Quality Improvement Program was used to evaluate patients undergoing infra-inguinal bypass and endovascular intervention (2005 - 2016). Aspartate aminotransferase to platelet ratio (APRI score) is a non-invasive tool recommended by the World Health Organisation to identify liver disease and was calculated for all patients. A ratio of > 0.5 was used to identify patients with liver fibrosis. Demographics, comorbidities, and 30 day outcomes were evaluated for patients with and without liver fibrosis. A subgroup analysis was completed in patients with APRI scores > 0.5, to evaluate the effect of increasing Model for End-Stage Liver Disease (MELD) scores on outcomes. Multivariable regression was used to account for differences in baseline factors.

RESULTS

In total, 17 603 patients underwent infra-inguinal bypasses. Fibrosis was associated with higher mortality (3.8% vs. 2.4%; p < .001), major complications (23% vs. 20%; p = .020), pulmonary (5.1% vs. 2.9%; p < .001), and renal complications (1.9% vs. 1.1%; p = .007) after bypass. These differences persisted following multivariable adjustment. Altogether, 7 830 patients underwent endovascular intervention. Fibrosis was also associated with higher mortality (4.7% vs. 2.2%; p < .001), pulmonary (3.9% vs. 2.5%; p = .022), and renal complications (1.9% vs. 0.8%; p = .003) after endovascular intervention. After adjustment, only renal complications persisted. In a subgroup analysis of patients with liver fibrosis, morbidity (31% vs. 17%; p < .001) and mortality (7.2% vs. 1.8%; p < .001) increased after bypass among those with MELD scores > 15 but not after endovascular intervention.

CONCLUSION

Liver fibrosis was associated with higher 30 day mortality and major complications after infra-inguinal bypass, with outcomes worsening as MELD scores increased. Surgeons may consider an endovascular first approach in managing peripheral arterial disease among those with liver fibrosis.