Preoperative risk assessment for patients with liver disease

Does liver cirrhosis affect the surgical outcome of primary colorectal cancer surgery? A meta-analysis

PURPOSE

The purpose of this meta-analysis was to evaluate the effect of liver cirrhosis (LC) on the short-term and long-term surgical outcomes of colorectal cancer (CRC).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched from inception to March 23, 2021. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of enrolled studies, and RevMan 5.3 was used for data analysis in this meta-analysis. The registration ID of this current meta-analysis on PROSPERO is CRD42021238042.

RESULTS

In total, five studies with 2485 patients were included in this meta-analysis. For the baseline information, no significant differences in age, sex, tumor location, or tumor T staging were noted. Regarding short-term outcomes, the cirrhotic group had more major complications (OR=5.15, 95% CI=1.62 to 16.37, p=0.005), a higher re-operation rate (OR=2.04, 95% CI=1.07 to 3.88, p=0.03), and a higher short-term mortality rate (OR=2.85, 95% CI=1.93 to 4.20, p<0.00001) than the non-cirrhotic group. However, no significant differences in minor complications (OR=1.54, 95% CI=0.78 to 3.02, p=0.21) or the rate of intensive care unit (ICU) admission (OR=0.76, 95% CI=0.10 to 5.99, p=0.80) were noted between the two groups. Moreover, the non-cirrhotic group exhibited a longer survival time than the cirrhotic group (HR=2.96, 95% CI=2.28 to 3.85, p<0.00001).

CONCLUSION

Preexisting LC was associated with an increased postoperative major complication rate, a higher rate of re-operation, a higher short-term mortality rate, and poor overall survival following CRC surgery.

Liver disease and 30-day mortality after colorectal cancer surgery: a Danish population-based cohort study

Background

Colorectal cancer (CRC) is common, with surgery as the main curative treatment. The prevalence of chronic liver disease has increased, but knowledge is limited on postoperative mortality in patients with liver disease who undergo CRC surgery. Hence, we examined 30-day mortality after CRC surgery in patients with liver disease compared to those without liver disease.

Methods

We used medical databases to conduct a nationwide cohort study of all patients undergoing CRC surgery in Denmark from 1996 through 2009. We further identified patients diagnosed with any liver disease before CRC surgery and categorized them into two cohorts: patients with non-cirrhotic liver disease and patients with liver cirrhosis. Patients without liver disease were defined as the comparison cohort. Using the Kaplan-Meier method, we computed 30-day mortality after CRC surgery in each cohort. We used a Cox regression model to compute hazard ratios as measures of the relative risk (RR) of death, controlling for potential confounders including comorbidities. In order to examine the impact of liver disease in different subgroups, we stratified patients by gender, age, cancer stage, cancer site, timing of admission, type of surgery, comorbidity level, and non-hepatic alcohol-related disease.

Results

Overall, 39,840 patients underwent CRC surgery: 369 (0.9%) had non-cirrhotic liver disease and 158 (0.4%) had liver cirrhosis. Thirty-day mortality after CRC surgery was 8.7% in patients without liver disease and 13.3% in patients with non-cirrhotic liver disease (adjusted RR of 1.49 95% confidence interval (CI): 1.12-1.98). Among patients with liver cirrhosis, mortality was 24.1%, corresponding to an adjusted RR of 2.59 (95% CI: 1.86-3.61). The negative impact of liver disease on postoperative mortality was found in all subgroups.

Conclusions

Pre-existing liver disease was associated with a markedly increased 30-day mortality following CRC surgery.

Early and late outcomes of cardiac operations in patients with cirrhosis: a retrospective survival-rate analysis of 47 patients over 8 years

OBJECTIVES

Patients with liver cirrhosis are considered as high-risk population for cardiac surgery. The aim of this study was to review mortality and mid-term outcome of patients with liver cirrhosis requiring coronary artery bypass graft (CABG), valve replacement, or combined procedures.

METHODS

Between July 1997 and December 2006, 47 patients (mean age 65.4 ± 11.7 years) with liver cirrhosis were operated for CABG (21 patients), aortic valve replacement /mitral valve replacement (14 patients), CABG/VR (9 patients) or aortic dissection/tumorexstirpation (3 patients) (group I). Thirty-three patients were classified as Child-Pugh class A (subgroup A), 14 patients as Child-Pugh class B cirrhosis (subgroup B). Postoperative complications/mortality were analyzed retrospectively and compared with a propensity-score pair-matched control group of 47 patients (group II). Follow-up ranged from 0.1 to 11.5 years (mean 3.9 ± 0.25 years) and was complete for 100%.

RESULTS

Necessity of blood products was higher in group I (red cells, fresh frozen plama, platelets; P < 0.01). Chest-tube output (group I 1113 ± 857 vs. group II 849 ± 521; P = 0.15) and re-exploration rate (8.5 vs. 0%; P = 0.11) were slightly accelerated. Ventilation time and ICU-stay was prolonged (P < 0.015). Thirty-day mortality showed 19.1% (group I) versus 8.5% (group II) (P < 0.01), 6.1% (subgroup A) versus 50% (subgroup B) (P < 0.01). Operative risk in subgroup A was not significantly increased compared with control group (P = 0.68). In Child-B operative risk was 15.5-fold higher than in Child-A cirrhosis (P < 0.001). Postcardiotomy syndrome and pleurisy were more frequent in the cirrhosis group (4/47 vs. 0/47; P = 0.11). Actuarial survival after 3, 5 and 8 years was: group I 78.6, 75.6, and 70.2% versus group II 89.1, 85.7, and 85.7% (P = 0.08). Subgroup survival analysis was: group A 90.7, 86.6, and 78.5% versus group B 50, 50, and 50% (P < 0.01).

CONCLUSION

Cardiac surgery can be performed safely in patients with Child-Pugh class A and selected patients with Child-Pugh class B cirrhosis. Mid-term survival-rates within 8 years were not significantly different compared with a propensity-score pair-matched control group without cirrhosis.