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Wang SY, Yeh CN, Jan YY, Chen MF. Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery? Gut Liver 2021; 15:517-527. [PMID: 32921635 PMCID: PMC8283297 DOI: 10.5009/gnl20052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/19/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Acute cholecystitis and several gallbladder stone-related conditions, such as impacted common bile duct stones, cholangitis, and biliary pancreatitis, are common medical conditions in daily practice. An early cholecystectomy or drainage procedure with delayed cholecystectomy is the current standard of treatment based on published clinical guidelines. Cirrhosis is not only a condition of chronically impaired hepatic function but also has systemic effects in patients. In cirrhotic individuals, several predisposing factors, including changes in the bile acid composition, increased nucleation of bile, and decreased motility of the gallbladder, contribute to the formation of biliary stones and the possibility of symptomatic cholelithiasis, which is an indication for surgical treatment. In addition to these predisposing factors for cholelithiasis, systemic effects and local anatomic consequences related to cirrhosis lead to anesthesiologic risks and perioperative complications in cirrhotic patients. Therefore, the treatment of the aforementioned biliary conditions in cirrhotic patients has become a challenging issue. In this review, we focus on cholecystectomy for cirrhotic patients and summarize the surgical indications, risk stratification, surgical procedures, and surgical outcomes specific to cirrhotic patients with symptomatic cholelithiasis.
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Affiliation(s)
- Shang Yu Wang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yi Yin Jan
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Miin Fu Chen
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Zhao JJ, Syn NL, Chong C, Tan HL, Ng JYX, Yap A, Kabir T, Goh BKP. Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients. Surgery 2021; 170:994-1003. [PMID: 34023139 DOI: 10.1016/j.surg.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/17/2021] [Accepted: 04/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another. METHODS To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis. RESULTS Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928). CONCLUSION Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.
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Affiliation(s)
- Joseph J Zhao
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore. http://twitter.com/ARWMD
| | - Nicholas L Syn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore. http://twitter.com/ARWMD
| | - Cheryl Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Julia Yu Xin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ashton Yap
- Townsville Hospital, Queensland, Australia
| | - Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Hepatopancreatobiliary Service, Department of General Surgery, Sengkang General Hospital, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore.
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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: 39] [Impact Index Per Article: 9.8] [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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Schizas D, Katsaros I, Karatza E, Kykalos S, Spartalis E, Tsourouflis G, Dimitroulis D, Nikiteas N. Concomitant Laparoscopic Splenectomy and Cholecystectomy: A Systematic Review of the Literature. J Laparoendosc Adv Surg Tech A 2020; 30:730-736. [PMID: 32202962 DOI: 10.1089/lap.2020.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Concomitant laparoscopic splenectomy and cholecystectomy (CLSC) is performed for concurrent pathologies of the spleen and gallbladder. This systematic review aimed to evaluate the available evidence on its indications, operative technique, and outcomes. Materials and Methods: The PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: December 6, 2019) for studies reporting on CLSC. The National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was utilized for the evaluation of eligible articles. Results: Eight studies met inclusion criteria and concerned collectively 108 patients (53 males and 55 females) with a mean age of 27.02 ± 20.48 years (mean, SD). The most common surgery indications were hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%). Laparoscopic cholecystectomy preceded splenectomy in the majority of cases (75%). A five-trocar approach was most frequently (89.8%) utilized. The mean operation duration was 170.18 ± 53.07 minutes (mean, SD). Resected spleen weight was 601.82 ± 386.02 g (mean, SD) and had a length of 18.74 ± 5.3 cm (mean, SD). The conversion rate was 2.7%, while 20.4% of included cases experienced postoperative complications. Most frequent ones included pulmonary infection (6.5%) and portal/splenic vein thrombosis (4.6%). No postoperative death was recorded. Mean hospitalization period was 5.43 ± 3.18 days (mean, SD). Conclusions: CLSC is a safe and feasible operation for simultaneous diseases of the spleen and gallbladder that require elective procedures. High-quality clinical trials are essential to further elucidate clinical evidence and standardize operative technique.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery and National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Ioannis Katsaros
- First Department of Surgery and National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Elli Karatza
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Stylianos Kykalos
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Eleftherios Spartalis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Gerasimos Tsourouflis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Nikolaos Nikiteas
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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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: 0.3] [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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7
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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: 3.4] [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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8
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Liu Q, Li XL, Liu JJ, Song XH, Jiang XY, Li W, Zhang H, Pan CQ. Efficacy and safety of endometrial ablation for treating abnormal uterine bleeding in pre- and postmenopausal women with liver cirrhosis. J Obstet Gynaecol Res 2016; 42:1753-1760. [PMID: 27647778 DOI: 10.1111/jog.13124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/15/2016] [Accepted: 07/06/2016] [Indexed: 12/15/2022]
Abstract
AIM Abnormal uterine bleeding (AUB) occurs in 10-30% of women of reproductive age and up to 61% of cirrhotic women. We evaluated the efficacy and safety of endometrial ablation (NovaSure therapy) for AUB in cirrhotic women. METHODS This prospective, two-arm, observational study enrolled patients for NovaSure treatment, and they were followed for 12 months. Primary measurements were the amenorrhea rate and changes of pictorial blood loss assessment chart (PBLAC) scores at 1-month post-therapy. Key secondary end-points included the longevity of amenorrhea at 12 months, safety profile, and progression of cirrhosis. RESULTS Among 88 women, 26 were cirrhotic and 62 were non-cirrhotic. At 1-month post-NovaSure treatment, a significant reduction of mean PBLAC scores was observed in cirrhotic patients compared to those at baseline (0.4 ± 1.3 vs 215.2 ± 410.9, P < 0.001), and the amenorrhea rate was 88.5%. The efficacy outcomes of the PBLAC scores and amenorrhea rate were maintained until the end of the 12-month follow-up. A significant improvement in quality of life scores was observed 1-month post-therapy compared to those at baseline (5.4 ± 3.1 vs 20.5 ± 5.5, P < 0.001). Patients' satisfaction rates were 100% and 92.31% at 6 and 12 months, respectively. The aforementioned outcomes were comparable with those in non-cirrhotic patients. No significant progression of cirrhosis or safety concern was reported. CONCLUSION Cirrhotic patients on NovaSure therapy had a high rate of amenorrhea 1-month post-treatment, which maintained longevity for 12 months. The safety profile was similar to that in non-cirrhotic patients.
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Affiliation(s)
- Qing Liu
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiu-Lan Li
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Ji-Juan Liu
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Hong Song
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Ying Jiang
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Department of Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Hua Zhang
- Department of Obstetrics and Gynecology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Calvin Q Pan
- Center for Major Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Division of Gastroenterology and Hepatology, Department of Medicine, NYU Langone Medical Center, New York University School of Medicine, New York, USA
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Lopez-Delgado JC, Ballus J, Esteve F, Betancur-Zambrano NL, Corral-Velez V, Mañez R, Betbese AJ, Roncal JA, Javierre C. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol 2016; 22:2657-2667. [PMID: 26973406 PMCID: PMC4777990 DOI: 10.3748/wjg.v22.i9.2657] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/30/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.
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10
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Laparoscopic common bile duct exploration in cirrhotic patients with choledocholithiasis. Surg Laparosc Endosc Percutan Tech 2015; 25:64-68. [PMID: 24732744 DOI: 10.1097/sle.0000000000000018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although laparoscopic common bile duct exploration (LCBDE) has become the standard procedure for most choledocholithiasis patients, the application of this procedure to liver cirrhosis is still in debate. The aim of current study was to evaluate the feasibility and safety of LCBDE in choledocholithiasis patients with compensated liver cirrhosis. MATERIALS AND METHODS From January 2006 to December 2012, 346 LCBDE performed in our hospital. According to previous defined liver condition, the patients were divided into group A (liver cirrhosis, n=132) and group B (without cirrhosis, n=214). The perioperative data for the 2 groups were retrospectively reviewed and compared. RESULTS LCBDE was successfully completed in 326 patients. Conversion from laparoscopic to open surgery was necessary for 20 patients (5.7%) mainly because of hemorrhage (5, 25%) and severe adhesions (8, 40%); a T-tube was placed in 211 patients (64.7%), and primary closure was done in 115 (35.3%). There was significant difference for groups A and B in term of intraoperative blood loss (85 vs. 35 mL; P<0.01). However, the 2 groups showed no significant differences with respect to mean operation time (2.1 vs. 1.9 h; P=0.07), complication rates (10.6% vs. 8.8%; P=0.6), and mean hospital stay (4.2 vs. 4.0 d; P=0.6), conversion rate (5.3% vs. 6.1%; P=0.77), and retained choledocholithiasis rate (8.3% vs. 7.1%; P=0.65). There was no mortality in both the groups. CONCLUSION LCBDE is a feasible, effective, and safe surgical procedure for choledocholithiasis patients with compensated cirrhosis.
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Abstract
BACKGROUND AND AIMS Although laparoscopic common bile duct exploration (LCBDE) has become the standard procedure for most choledocholithiasis patients, the application of this procedure to liver cirrhosis is still in debate. The aim of the current study was to evaluate the feasibility and safety of LCBDE in choledocholithiasis patients with compensated liver cirrhosis. PATIENTS AND METHODS From January 2006 to December 2012, 346 LCBDEs were performed in our hospital. According to the previously defined liver condition, the patients were divided into group A (liver cirrhosis, n=132) and group B (without cirrhosis, n=214). The perioperative data for the 2 groups were retrospectively reviewed and compared. RESULTS LCBDE was successfully completed in 326 patients. Conversion from laparoscopic to open surgery was necessary for 20 patients (5.7%) mainly because of hemorrhage (5, 25%) and severe adhesions (8, 40%). A T-tube was placed in 211 patients (64.7%), and primary closure was performed in 115 (35.3%) patients. There was a significant difference for groups A and B in terms of intraoperative blood loss (85 vs. 35 mL; P<0.01). However, the 2 groups showed no significant differences with respect to the mean operation time (2.1 vs. 1.9 h; P=0.07), complication rates (10.6% vs. 8.8%; P=0.6), mean hospital stay (4.2 vs. 4.0 d; P=0.6), conversion rate (5.3% vs. 6.1%; P=0.77), and retained choledocholithiasis rate (8.3% vs. 7.1%; P=0.65). There was no mortality in both groups. CONCLUSIONS LCBDE is a feasible, effective, and safe surgical procedure for choledocholithiasis patients with compensated cirrhosis.
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12
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Bielefeldt K, Saligram S, Zickmund SL, Dudekula A, Olyaee M, Yadav D. Cholecystectomy for biliary dyskinesia: how did we get there? Dig Dis Sci 2014; 59:2850-63. [PMID: 25193389 DOI: 10.1007/s10620-014-3342-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/19/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction. METHODS We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction. RESULTS Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function. CONCLUSION Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.
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Affiliation(s)
- Klaus Bielefeldt
- Divisions of Gastroenterology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA, 15213, USA,
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13
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Abstract
Gastrointestinal surgery is feasible in patients with Child A cirrhosis, but is associated with higher morbidity and mortality. Hernia repair, biliary and colonic surgery are the most frequently performed interventions in this context. Esophageal and pancreatic surgery are more controversial and less frequently performed. For patients with decompensated liver function (Child B or C patients), the indications for surgery should be discussed by a multi-specialty team including the hepatologist, anesthesiologist, surgeon; liver function should be optimized if possible. During emergency surgery, histologic diagnosis of cirrhosis should be confirmed by liver biopsy because the histologic diagnosis has therapeutic and prognostic implications. The management of patients with Child A cirrhosis without portal hypertension is little different from the management of patients without cirrhosis. However, the management of patients with Child B or C cirrhosis or with portal hypertension is more complex and requires an accurate assessment of the balance of benefit vs. risk for surgical intervention on a case-by-case basis.
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Affiliation(s)
- C Sabbagh
- Department of digestive and oncological surgery, hôpital Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France
| | - D Fuks
- Department of digestive and oncological surgery, hôpital Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France
| | - J-M Regimbeau
- Department of digestive and oncological surgery, hôpital Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France.
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Parks KR, Kuo YH, Davis JM, O’ Brien B, Hagopian EJ. Laparoscopic versus open liver resection: a meta-analysis of long-term outcome. HPB (Oxford) 2014; 16:109-18. [PMID: 23672270 PMCID: PMC3921005 DOI: 10.1111/hpb.12117] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 03/19/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic liver resection is growing in popularity, but the long-term outcome of patients undergoing laparoscopic liver resection for malignancy has not been established. This paper is a meta-analysis and compares the long-term survival of patients undergoing laparoscopic (LHep) versus open (OHep) liver resection for the treatment of malignant liver tumours. METHODS A PubMed database search identified comparative human studies analysing LHep versus OHep for malignant tumours. Clinical and survival parameters were extracted. The search was last conducted on 18 March 2012. RESULTS In total, 1002 patients in 15 studies were included (446 LHep and 556 OHep). A meta-analysis of overall survival showed no difference [1-year: odds ratio (OR) 0.71, 95% confidence interval (CI) 0.42 to 1.20, P = 0.202; 3-years: OR 0.76, 95% CI 0.56 to 1.03, P = 0.076; 5-years: OR 0.8, 95% CI 0.59 to 1.10, P = 0.173]. Subset analyses of hepatocellular carcinoma (HCC) and colorectal metastases (CRM) were performed. There was no difference in the 1-, 3-, and 5-year survival for HCC or in the 1-year survival for CRM, however, a survival advantage was found for CRM at 3 years (LHep 80% versus OHep 67.4%, P = 0.036). CONCLUSIONS Laparoscopic surgery should be considered an acceptable alternative for the treatment of malignant liver tumours.
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Affiliation(s)
- Kevin Ryan Parks
- Department of Surgery, Jersey Shore University Medical Center
- Department of Surgery, Robert Wood Johnson Medical SchoolNew Brunswick, NJ, USA
| | - Yen-Hong Kuo
- Office of Academic Affairs, Jersey Shore University Medical CenterNeptune
- Department of Surgery, Robert Wood Johnson Medical SchoolNew Brunswick, NJ, USA
| | - John Mihran Davis
- Department of Surgery, Jersey Shore University Medical Center
- Department of Surgery, Robert Wood Johnson Medical SchoolNew Brunswick, NJ, USA
| | | | - Ellen J Hagopian
- Department of Surgery, Jersey Shore University Medical Center
- Department of Surgery, Robert Wood Johnson Medical SchoolNew Brunswick, NJ, USA
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Wang MJ, Li JL, Zhou J, Wu Z, Peng B. Consecutive laparoscopic gallbladder and spleen resections in cirrhotic patients. World J Gastroenterol 2014; 20:546-554. [PMID: 24574724 PMCID: PMC3923030 DOI: 10.3748/wjg.v20.i2.546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/08/2013] [Accepted: 11/30/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the feasibility, safety, and effectiveness of consecutive laparoscopic cholecystectomy (LC) plus splenectomy (LS) in liver cirrhosis patients.
METHODS: From 2003 to 2013, 17 (group 1) patients with liver cirrhosis complicated by hypersplenism and symptomatic gallstones were treated with combined LC and LS, while 58 (group 2) patients with liver cirrhosis and hypersplenism received LS alone. An additional 14 (group 3) patients who received traditional open procedures during the same period were included as controls. Data were retrospectively collected and reviewed in regard to demographic characteristics and preoperative, intraoperative and postoperative features. Differences between the three groups were assessed by statistical analysis.
RESULTS: The three groups showed no significant differences in the demographic characteristics or preoperative status. However, the patients treated with LC and LS required significantly longer operative time, shorter postoperative stay as well as shorter time of return to the first oral intake, and suffered less intraoperative blood loss as well as fewer postoperative surgical infections than the patients treated with traditional open procedures (group 1 vs group 3, P < 0.05 for all). The patients treated with LC and LS showed no significant differences in the intraoperative and postoperative variables from those treated with LS alone (group 1 vs group 2). All patients showed significant improvements in the haematological responses (preoperative period vs postoperative period, P < 0.05 for all). None of the patients treated with LC and LS presented with any gallstone-associated symptoms following discharge, while the patients treated with the traditional open procedures expressed complaints of discomfort related to their surgical incisions.
CONCLUSION: Consecutive LC and LS is an appropriate treatment option for liver cirrhosis patients with gallstones and hypersplenism, especially for those with Child-Pugh A and B.
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Abstract
BACKGROUND AND OBJECTIVES Due to the concern of risk of intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered a contraindication for laparoscopic cholecystectomy (LC). This article intends to review the literature and underline the various approaches to dealing with this technically challenging procedure. METHODS A Medline search of major articles in the English literature on LC in cirrhotic patients over a 16-y period from 1994 to 2011 was reviewed and the findings analyzed. A total of 1310 cases were identified. RESULTS Most the patients who underwent LC were in Child-Pugh class A, followed by Child-Pugh classes B and C, respectively. The overall conversion rate was 4.58%, and morbidity was 17% and mortality 0.45%. Among the patients who died, most were in Child-Pugh class C, with a small number in classes B and A. The cause of death included, postoperative bleeding, liver failure, sepsis, duodenal perforation, and myocardial infarction. A meta-analysis of 400 patients in the literature, comparing outcomes of patients undergoing LC with and without cirrhosis, revealed higher conversion rate, longer operative time, higher bleeding complications, and overall increased morbidity in patients with cirrhosis. Safe LC was facilitated by measures that included the use of ultrasonic shears and other hemostatic measures and using subtotal cholecystectomy in patients with difficult hilum and gallbladder bed. CONCLUSIONS Laparoscopic cholecystectomy can be safely performed in cirrhotic patients, within Child-Pugh classes A and B, with acceptable morbidity and conversion rate.
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Chmielecki DK, Hagopian EJ, Kuo YH, Kuo YL, Davis JM. Laparoscopic cholecystectomy is the preferred approach in cirrhosis: a nationwide, population-based study. HPB (Oxford) 2012; 14:848-53. [PMID: 23134187 PMCID: PMC3521914 DOI: 10.1111/j.1477-2574.2012.00562.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/06/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM To assess the impact of open versus laparoscopic surgery in cirrhotic patients undergoing a cholecystectomy using the Nationwide Inpatient Sample (NIS). METHODS All patients with cirrhosis who underwent a cholecystectomy (open or laparoscopic) between 2003 and 2006 were queried from the NIS. Associated complications including infection, transfusion, reoperation, liver failure and mortality were determined. RESULTS A total of 3240 patients with cirrhosis underwent a cholecystectomy: 383 patients underwent an open cholecystectomy (OC) whereas 2857 patients underwent a laparoscopic cholecystectomy (LC), which included 412 patients converted (LCC) from a LC to an OC. Post-operative infection was higher in OC as opposed to a laparoscopic cholecystectomy (TLC) or LCC (3.5% versus 0.7% versus 0.2%, P < 0.0001). The need for a blood transfusion was significantly higher in the OC and LCC groups as compared with the TLC group (19.2% versus 14.4% versus 6.2%, P < 0.0001). Reoperation was more frequent after OC or LCC versus TLC (1.5% versus 2.5% versus 0.8%, P = 0.007). In-hospital mortality was higher after OC as compared with TLC and LCC (8.3% versus 1.3% versus 1.4%, P < 0.0001). CONCLUSION Patients with cirrhosis have increased in-hospital morbidity and mortality after an open as opposed to a laparoscopic or conversion to an open cholecystectomy. LC should be the preferred initial approach in cirrhotic patients.
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Affiliation(s)
- David K Chmielecki
- Department of Surgery and Office of Clinical Research, Jersey Shore University Medical Center, Robert Wood Johnson Medical SchoolNeptune, NJ, USA
| | - Ellen J Hagopian
- Department of Surgery and Office of Clinical Research, Jersey Shore University Medical Center, Robert Wood Johnson Medical SchoolNeptune, NJ, USA
| | - Yen-Hong Kuo
- Department of Surgery and Office of Clinical Research, Jersey Shore University Medical Center, Robert Wood Johnson Medical SchoolNeptune, NJ, USA
| | - Yen-Liang Kuo
- Department of Surgery, Pingtung Christian HospitalPingtung, Taiwan
| | - John M Davis
- Department of Surgery and Office of Clinical Research, Jersey Shore University Medical Center, Robert Wood Johnson Medical SchoolNeptune, NJ, USA
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de Goede B, Klitsie PJ, Hagen SM, van Kempen BJH, Spronk S, Metselaar HJ, Lange JF, Kazemier G. Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis. Br J Surg 2012; 100:209-16. [PMID: 23034741 DOI: 10.1002/bjs.8911] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Open cholecystectomy (OC) is often preferred over laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and portal hypertension, but evidence is lacking to support this practice. This meta-analysis aimed to clarify which surgical technique is preferable for symptomatic cholecystolithiasis in patients with liver cirrhosis. METHODS A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and October 2011 were identified from MEDLINE, Embase and the Cochrane Library. Randomized clinical trials (RCTs) comparing outcomes of OC versus LC for cholecystolithiasis in patients with liver cirrhosis were included. The quality of the RCTs was assessed using the Jadad criteria. RESULTS Following review of 1422 papers by title and abstract, a meta-analysis was conducted of four RCTs comprising 234 surgical patients. They provided evidence of at least level 2b on the Oxford Level of Evidence Scale, but scored poorly according to the Jadad criteria. Some 97·0 per cent of the patients had Child-Turcotte-Pugh (CTP) grade A or B liver cirrhosis. In all, 96·6 per cent underwent elective surgery. No postoperative deaths were reported. LC was associated with fewer postoperative complications (risk ratio 0·52, 95 per cent confidence interval (c.i.) 0·29 to 0·92; P = 0·03), a shorter hospital stay (mean difference -3·05 (95 per cent c.i. -4·09 to -2·01) days; P < 0·001) and quicker resumption of a normal diet (mean difference -27·48 (-30·96 to -23·99) h; P < 0·001). CONCLUSION Patients with CTP grade A or B liver cirrhosis who undergo LC for symptomatic cholecystolithiasis have fewer overall postoperative complications, a shorter hospital stay and resume a normal diet more quickly than those who undergo OC.
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Affiliation(s)
- B de Goede
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, The Netherlands
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Laurence JM, Tran PD, Richardson AJ, Pleass HCC, Lam VWT. Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials. HPB (Oxford) 2012; 14:153-61. [PMID: 22321033 PMCID: PMC3371197 DOI: 10.1111/j.1477-2574.2011.00425.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholecystectomy is associated with increased risks in patients with cirrhosis. The well-established advantages of laparoscopic surgery may be offset by the increased risk for complications relating particularly to portal hypertension and coagulopathy. METHODS A systematic search was undertaken to identify studies comparing open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) in patients with cirrhosis. A meta-analysis was performed of the available randomized controlled trials (RCTs). RESULTS Forty-four studies were analysed. These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n= 1756) or open (n= 249) cholecystectomy, with mortality rates of 0.74% and 2.00%, respectively. A meta-analysis of three RCTs involving a total of 220 patients was conducted. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC. However, frequencies of postoperative hepatic insufficiency did not differ significantly. CONCLUSIONS There are few RCTs comparing OC and LC in patients with cirrhosis. These studies are small, heterogeneous in design and include almost exclusively patients with Child-Pugh class A and B disease. However, LC appears to be associated with shorter operative time, reduced complication rates and reduced length of hospital stay.
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Affiliation(s)
- Jerome M Laurence
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
| | - Peter D Tran
- Department of Surgery, Liverpool HospitalSydney, NSW, Australia
| | - Arthur J Richardson
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
| | - Henry C C Pleass
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
| | - Vincent W T Lam
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
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Abstract
INTRODUCTION Historically the presence of liver cirrhosis has been an absolute or relative contraindication to laparoscopic cholecystectomy (LC). Accumulating experience in LC has resulted in an increasing number of investigators reporting that LC can be safely performed in cirrhotic patients. The aim of this study was to report the efficacy and safety of LC in the treatment of symptomatic cholelithiasis in cirrhotic patients, and a review of the literature in the matter. METHODS Between January 2006 and July 2010, from 503 patients under LC, we reviewed 43 cirrhotic patients of Child-Pugh Classification A, B, and C, with symptomatic gallstones. RESULTS Conversion to an open procedure was necessary in 5 patients due to multiple factors. The mean operative time and length of hospital stay were significantly longer and higher in cirrhotic group (P<0.05). Postoperative complications were observed in 37.2% of patients. Trocar site hematoma (P=0.02), wound complications (P=0.02), and intra-abdominal collection (P=0.01) occurred more frequently in patients with cirrhosis (Child B and C class) than in patients without cirrhosis. One case of continuing hemorrhage from the gallbladder bed required a reoperation for hemostasis. Two patients with Child-Pugh class C and 1 patient with class B cirrhosis developed ascites after surgery; 1 patient with Child-Pugh class A had bile leakage. No deaths occurred. CONCLUSIONS LC is an effective and safe procedure and should be the treatment of choice for symptomatic cholelithiasis or cholecystitis in patients with compensated cirrhosis.
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de Goede B, Klitsie PJ, Lange JF, Metselaar HJ, Kazemier G. Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review. Best Pract Res Clin Gastroenterol 2012; 26:47-59. [PMID: 22482525 DOI: 10.1016/j.bpg.2012.01.010] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/17/2012] [Accepted: 01/17/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study is to review systematically morbidity and mortality after non-hepatic surgery in patients with liver cirrhosis. METHODS Comprehensive searches were conducted in PubMed, Embase and the Cochrane Library for articles using the words: liver failure, hepatic insufficiency, liver cirrhosis, cirrhosis, cirrhotic, surgical procedures, operative complications, operative mortality, postoperative complications, surgical complication, surgical risk, hernia. RESULTS Forty-six articles were selected from 5247 included after the initial search. Level of evidence provided in the articles varied greatly. Non-hepatic surgery of patients with cirrhosis resulted in increased postoperative morbidity and mortality compared to similar surgery for non-cirrhotic patients. Cholecystectomy and umbilical and inguinal hernia correction were associated with the lowest increased morbidity and mortality while pancreatic surgery, cardiovascular, and trauma surgery correlated with the highest. The preoperative model for end stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores appeared to be predictive of postoperative risks. Portal hypertension and surgery in the emergency setting were associated with extra increased mortality and morbidity rates. CONCLUSION This systematic review of the literature showed that in patients with liver cirrhosis who undergo non-hepatic surgery, postoperative morbidity and mortality rates varied greatly depending on severity of the cirrhosis and the surgical procedure. However, the majority of procedures can be safely performed in patients with low MELD scores or CTP A cirrhosis without portal hypertension.
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Affiliation(s)
- B de Goede
- Erasmus University Medical Center, Department of Surgery, Medical Center, Rotterdam, The Netherlands
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Single-port laparoscopic hepatectomy: technique, safety, and feasibility in a clinical case series. Surg Endosc 2011; 26:1696-701. [PMID: 22179479 DOI: 10.1007/s00464-011-2095-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 11/20/2011] [Indexed: 12/26/2022]
Abstract
BACKGROUND The recent use of single-port-access surgery in cholecystectomy and other abdominal surgeries has confirmed its safety and validity as a treatment option. However, few reports have described the use of complete single-port access surgeries in hepatectomy for neoplasms. METHODS The authors performed single-port laparoscopic hepatectomy (SLH) for eight patients (5 patients with hepatocellular carcinoma, 1 patient with metastatic liver tumor, 1 patient with endocrine liver tumor, and 1 patient with hemangioma). Furthermore, in terms of Child-Pugh classification, five patients were in category A, two in category B, and one in category C. The patients were eligible for SLH if they had solitary tumors measuring 3 cm or smaller on the caudal surface of the liver. The lesion was approached through a 20-mm supraumbilical incision using a single-port access device. RESULTS No patient experienced intraoperative complications that required additional port access and conversion to laparotomy. The operative time was 148 min (range, 141-235 min). The postoperative course of the patients was uneventful, and they were discharged an average of 6.2 days (range, 3-11 days) after the operation. Approximately 2 weeks after discharge, the patients experienced no wound pain or liver dysfunction. CONCLUSION The SLH technique is a safe and feasible procedure for a specific group of candidates, including patients with high-grade liver dysfunction.
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Bernardo WM, Aires FT. A colecistectomia laparoscópica é segura em pacientes com cirrose hepática? Rev Assoc Med Bras (1992) 2011. [DOI: 10.1590/s0104-42302011000400005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Bernardo WM, Aires FT. Is laparoscopic cholecystectomy safe in patients with liver cirrhosis? Rev Assoc Med Bras (1992) 2011. [DOI: 10.1016/s0104-4230(11)70076-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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