Adverse Outcomes in Patients With Chronic Liver Disease Undergoing Colorectal Surgery

Colorectal Cancer in Individuals with Cirrhosis: A Population-Based Study Assessing Practice Patterns, Outcomes, and Predictors of Survival

Those with cirrhosis who develop colorectal cancer (CRC) are an understudied group who may tolerate treatments poorly and are at risk of worse outcomes. This is a retrospective cohort study of 842 individuals from Ontario, Canada, with a pre-existing diagnosis of cirrhosis who underwent surgery for CRC between 2009 and 2017. Practice patterns, overall survival, and short-term morbidity and mortality were assessed. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (52%) and alcohol-associated liver disease (29%). The model for end-stage liver disease score (MELD-Na) was available in 42% (median score of 9, IQR7-11). Preoperative radiation was used in 62% of Stage II/III rectal cancer patients, while postoperative chemotherapy was used in 42% of Stage III colon cancer patients and 38% of Stage II/III rectal cancer patients. Ninety-day mortality following surgery was 12%. Five-year overall survival was 53% (by Stages I-IV, 66%, 55%, 50%, and 11%, respectively). Those with alcohol-associated cirrhosis (HR 1.8, 95% CI 1.5-2.2) had lower survival than those with NAFLD. Those with a MELD-Na of 10+ did worse than those with a lower MELD-Na score (HR 1.9, 95% CI 1.4-2.6). This study reports poor survival in those with cirrhosis who undergo treatment for CRC. Caution should be taken when considering aggressive treatment.

Colorectal Surgery in Patients with Liver Cirrhosis: A Systematic Review

BACKGROUND

Colorectal surgery in patients with liver cirrhosis poses a significant challenge due to the associated peri-operative morbidity and mortality risks. The aim of this systematic review was to evaluate the outcomes in this cohort of patients following colorectal surgery.

METHODS

The PubMed, Embase and Cochrane databases and references were searched up to October 2022 using the PRISMA guidelines. The data collated included: patient demographics, pathology or type of colorectal operation performed, severity of liver cirrhosis, post-operative complication rates, mortality rates and prognostic factors. A quality assessment of included studies was performed with the Newcastle-Ottawa scale.

RESULTS

Sixteen studies reporting the outcomes of colorectal surgery in patients with liver cirrhosis were identified, including the results of 8646 patients. The indications, pathologies and/or type of operations varied. The overall complication rate ranged from 29 to 75%, minor complication ranged 14.5-37% and major complication ranged 6.7-59.3%. The mortality rates ranged from 0 to 37%.

CONCLUSION

Colorectal surgery in patients with liver cirrhosis still carries considerable morbidity and mortality rates. This group of patients needs to be managed in a multidisciplinary setting to achieve excellent outcomes. Future research should focus on uniform definitions to enable interpretable outcomes.

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.

Characteristics Associated With Failure to Rescue After Open Abdominal Aortic Aneurysm Repair

INTRODUCTION

Failure to Rescue (FTR), defined as mortality following a complication of care, is an important indicator of hospital care quality. Understanding risk factors associated with FTR in the elective Abdominal Aortic Aneurysm (AAA) population may help surgeons prevent operative mortality.

METHODS

Elective open AAA repairs (2008-2018) were identified from Cerner's HealthFacts database using ICD-9 and ICD-10 diagnosis and procedure codes. Patient, hospital, and encounter characteristics were analyzed. Multivariate logistic regression models determined the relative contribution of patient and encounter characteristics leading to FTR.

RESULTS

For 1761 patients who underwent open repair for nonruptured AAA, overall mortality was 6.1%. Of patients with one or more complications (40%), mortality was 9.6%, increasing to 21.5% for patients with ≥4 major complications. Complications of care most associated with death were myocardial infarction (MI), gastrointestinal (GI) bleeding, and pulmonary failure. After multivariable adjustment, FTR was associated with advanced age (odds ratio [OR] 1.19 for 5 y, 95% confidence interval [CI] 1.06-1.34); female sex (OR 1.74, 95% CI 1.12-2.70); congestive heart failure (OR 1.65, 95% CI 1.00-2.73); peptic ulcer disease (OR 3.99, 95% CI 1.18-13.5); diabetes (OR 4.90, 95% CI 1.90-12.6), and the number of complications of care.

CONCLUSIONS

Complications of care were common following open elective AAA repair. The complications with the highest mortality included MI, GI bleeding, and respiratory failure. FTR was associated with female sex, comorbidities, and increasing numbers of complications of care. Often, the lowest occurring complications had the highest FTR. Adopting gender-specific assessment tools, a protocol-driven approach for perioperative GI prophylaxis, and preoperative MI risk mitigation may lead to reduced FTR.

The Management of Postoperative Cognitive Dysfunction in Cirrhotic Patients: An Overview of the Literature

Background and objectives: Postoperative cognitive dysfunction (POCD) represents a decreased cognitive performance in patients undergoing general anesthesia for major surgery. Since liver cirrhosis is associated with high mortality and morbidity rates, cirrhotic patients also assemble many risk factors for POCD. Therefore, preserving cognition after major surgery is a priority, especially in this group of patients. The purpose of this review is to summarize the current knowledge regarding the effectiveness of perioperative therapeutic strategies in terms of cognitive dysfunction reduction. Data Collection: Using medical search engines such as PubMed, Google Scholar, and Cochrane library, we analyzed articles on topics such as: POCD, perioperative management in patients with cirrhosis, hepatic encephalopathy, general anesthesia in patients with liver cirrhosis, depth of anesthesia, virtual reality in perioperative settings. We included 115 relevant original articles, reviews and meta-analyses, and other article types such as case reports, guidelines, editorials, and medical books. Results: According to the reviewed literature, the predictive capacity of the common clinical tools used to quantify cognitive dysfunction in cirrhotic settings is reduced in perioperative settings; however, novel neuropsychological tools could manage to better identify the subclinical forms of perioperative cognitive impairments in cirrhotic patients. Moreover, patients with preoperative hepatic encephalopathy could benefit from specific preventive strategies aimed to reduce the risk of further neurocognitive deterioration. Intraoperatively, the adequate monitoring of the anesthesia depth, appropriate anesthetics use, and an opioid-sparing technique have shown favorable results in terms of POCD. Early recovery after surgery (ERAS) protocols should be implemented in the postoperative setting. Other pharmacological strategies provided conflicting results in reducing POCD in cirrhotic patients. Conclusions: The perioperative management of the cognitive function of cirrhotic patients is challenging for anesthesia providers, with specific and targeted therapies for POCD still sparse. Therefore, the implementation of preventive strategies appears to remain the optimal attitude. Further research is needed for a better understanding of POCD, especially in cirrhotic patients.

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.

The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization

BACKGROUND

Multiple studies have shown high rates of postoperative morbidity and mortality in individuals with chronic liver disease (CLD). However, analyses from comparisons with individuals without CLD are not available. Such analyses might provide opportunities to improve outcomes.

METHODS

Data from The National Surgical Quality Improvement Program (NSQIP) from 2008 to 2011 were analyzed comparing CLD patients undergoing non-liver surgery propensity matched to those without CLD. Patients with CLD were stratified by Model of End Stage Liver Disease (MELD) scores <15 and ≥15. Primary outcome was all cause mortality, and secondary outcomes were composite and individual morbidity, hospital length of stay, readmission, reoperation, and discharge destination. Odds ratios (OR) were calculated, and length of hospital stay was estimated using Poisson regression.

RESULTS

There were 6,209 patients with CLD (4,013 with low MELD, 2,196 with high MELD) matched to 18,627 patients without. Patients with CLD had 1.8- and 3.3-times higher odds of mortality (95% CI 1.6-2.1 for Low MELD (10.6%), 2.9-3.8 for high MELD (35.2%), and 1.8- and 2.2-times higher odds of any morbidity (1.6-1.9 and 1.9-2.4). Complications specific to CLD were increased based on MELD specifically coma (OR 1.6, 0.9-2.9 for Low MELD, 2.2, 1.5-3.2 for High MELD), renal failure (OR 1.4, 1.1-1.8 and 2.4, 2.0-2.9), and bleeding (OR 1.7, 1.5-1.9 and 2.0, 1.8-2.3). They also had a 20% and 80% longer length of stay, 2.2- and 3.4-times higher odds of being discharged somewhere other than home, 1.7- and 1.6-times higher odds of readmission, and 1.5- and 1.6-times higher odds of reoperation.

CONCLUSION

Patients with CLD have significantly higher odds of mortality and morbidity, which is increased with a higher MELD. Interventions that decrease those morbidities are needed and have the potential to decrease mortality and resource utilization.

[Palliative Surgery in Colorectal Cancer - Which Factors Should Influence the Choice of the Surgical Procedure?]

BACKGROUND

The surgical procedure for patients with colorectal cancer (CRC) in the palliative situation cannot be adequately standardised. The present study was initiated to identify criteria for the decision for resection of the malignancy with or without anastomosis.

PATIENTS/MATERIAL AND METHODS

In a unicentric retrospective analysis, 103 patients after palliative resection with or without anastomosis due to CRC were examined. Using univariate and logistic regression analysis, the influence of a total of 40 factors on postoperative morbidity and mortality was assessed.

RESULTS

In 46 cases, resection with primary anastomosis and in 57 cases a discontinuity resection was performed. Postoperative morbidity was 44.7% and mortality 17.5%. After one-stage resection with anastomosis, nicotine abuse (OR 4.2; p = 0.044), hypalbuminaemia (OR 4.0; p = 0.012), ASA score > 2 (OR 3.7; p = 0.030) and liver remodelling/cirrhosis (OR 3.6; p = 0.031) increased the risk for postoperative complications. Hypalbuminaemia (OR 1.8; p = 0.036), cachexia (OR 1.8; p = 0.043), anaemia (OR 1.5; p = 0.038) and known alcohol abuse (OR 1.9; p = 0.023) were identified as independent risk factors for early postoperative mortality. After discontinuity resection, renal failure (OR 2.1; p = 0.042) and cachexia (OR 1.5; p = 0.045) led to a significant increase in the risk of postoperative morbidity, alcohol abuse (OR 1.8; p = 0.041) in mortality. Hypalbuminaemia (OR 2.8; p = 0.019) and an ASA score > 2 (OR 2.6; p = 0.004) after resection and reconstruction increased the risk of major complications according to Clavien-Dindo, while pre-existing renal failure (OR 1.6; p = 0.023) increased the risk after discontinuity resection. In univariate analysis, an ASA score > 2 (p = 0.038) after simultaneous tumour resection and reconstruction, and urgent surgery in both groups with or without primary anastomosis were additionally identified as significant parameters with a negative influence on mortality (p = 0.010 and p = 0.017).

CONCLUSION

Palliative resections of colorectal carcinomas have high morbidity and mortality. Especially in cases of pre-existing alcohol abuse and/or urgent indication for surgery, more intensive monitoring should be performed. In the case of anaemia, cachexia, hypalbuminemia and an ASA score > 2, discontinuity resection may be the more appropriate procedure.

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease-A Retrospective Analysis of 76 Cases in a Tertiary Center

Simple Summary

It is well known that the incidence of liver cirrhosis is increasing and it negatively affects outcome after surgery. While there are several studies investigating the influence of liver cirrhosis on colorectal, hepatobiliary, or hernia surgery, data about its impact on small bowel surgery are completely lacking. Therefore, a retrospective analysis over a period of 17 years was performed including 76 patients with liver cirrhosis and small bowel surgery. Postsurgical complications were analyzed, and 38 parameters as possible predictive factors for a worse outcome were investigated. We observed postsurgical complications in over 90% of the patients; in over 50%, the complications were classified as severe. When subdividing postoperative complications, bleeding, respiratory problems, wound healing disorders and anastomotic leakage, hydropic decompensation, and renal failure were most common. The most important predictive factors for those complications after uni- and multivariate analysis were portal hypertension, poor liver function, emergency or additional surgery, ascites, and high ASA score. We, therefore, recommend treatment of portal hypertension before small bowel surgery to avoid extension of the operation to other organs than the small bowel and in case of ascites to evaluate the creation of an anastomosis stoma instead of an unprotected anastomosis to prevent leakages.

Abstract

(1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were “additional surgery” (OR 5.3) and “bowel anastomosis” (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients’ outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

Non-Hepatic Abdominal Surgery in Patients with Cirrhotic Liver Disease

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.

Model for End-Stage Liver Disease Underestimates Morbidity and Mortality in Patients with Ascites Undergoing Colectomy

BACKGROUND

The Model for End-Stage Liver Disease (MELD) score and ascites correlate with surgical morbidity and mortality. However, the MELD score does not account for ascites. We sought to evaluate whether the MELD score accurately risk stratifies patients with ascites.

METHODS

We analyzed the American College of Surgeons National Surgical Quality Improvement Program (2005-2014) to examine the risk-adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing colectomy for diverticulitis. Patients were stratified by MELD score, and the presence of ascites and outcomes were compared between patients with and without ascites to the reference group of low MELD and no ascites. Multivariable logistic regression was used to control for demographic factors and comorbidities.

RESULTS

A total of 16,877 colectomies were analyzed. For each MELD stratum, patients with ascites have increased risk of complications compared to those without ascites (P < 0.05 unless indicated): low MELD ascites OR 1.13, P = 0.69, moderate MELD no ascites OR 1.37, moderate MELD ascites OR 2.06, high MELD no ascites OR 1.93, and high MELD ascites OR 3.54. These trends hold true for mortality: low MELD ascites OR 2.91, P = 0.063, moderate MELD no ascites OR 1.47, moderate MELD ascites OR 5.62, high MELD no ascites OR 3.04, and high MELD ascites OR 9.91.

CONCLUSION

Ascites predicts an increased risk for postoperative morbidity and mortality for cirrhotic patients undergoing colectomy for all MELD classifications. These findings suggest that the MELD score significantly underestimates postoperative risk as it does not account for ascites.

Short-term postoperative outcomes of colorectal cancer among patients with chronic liver disease: a national population-based study

OBJECTIVE

Patients with colorectal carcinoma (CRC) with pre-existing chronic liver disease (CLD) had a significantly higher 30-day mortality after CRC surgery compared with healthy controls. This study investigated the factors associated with postoperative complications and in-hospital mortality in patients with CRC with coexisting CLD (excluding cirrhosis) who underwent colorectal surgery.

DESIGN

A retrospective, observational, population-based study.

SETTING

Data were sourced from the National Inpatient Sample database, a part of the Healthcare Cost and Utilisation Project.

PARTICIPANTS

This study analysed 7463 inpatients with CRC who underwent colorectal surgery on admission between 2005 and 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint of this study was the prevalence of postoperative complications, and the secondary endpoint was in-hospital mortality.

RESULTS

In the CLD group, 36.27% of patients had chronic hepatitis C, 28.36% had non-alcoholic fatty liver disease and 31.19% had other types of CLD. The median hospital stay was 7.0 (5.0-10.0) days in patients with no postoperative complications vs 17.0 (10.0-26.0) days, 8.0 (6.0-12.0) days, 8.0 (6.0-17.0) days, 9.0 (8.0-14.0) days and 10.5 (7.0-17.0) days for patients with postoperative infection, postoperative bleeding, cardiac arrest/heart failure, respiratory complications and digestive complications, respectively (all p<0.05). The presence of CLD was significantly associated with higher risk of postoperative bleeding (adjusted OR (aOR)=1.64, 95% CI 1.15 to 2.34, p=0.007). The presence of CLD (aOR=1.98, 95% CI 1.39 to 2.82, p<0.001) and length of hospital stay (aOR=1.06, 95% CI 1.04 to 1.08, p<0.001) were significantly associated with higher risk of in-hospital mortality. However, hyperlipidaemia was associated with a significantly lower risk of mortality (aOR=0.46, 95% CI 0.28 to 0.75, p=0.002).

CONCLUSIONS

Postoperative complications prolonged the length of hospital stay. The presence of CLD and hyperlipidaemia were important factors impacting postoperative complications and in-hospital mortality in patients with CRC with underlying CLD.

Safety of laparoscopic resection for colorectal cancer in patients with liver cirrhosis: A retrospective cohort study

BACKGROUND

Patients with liver cirrhosis represent a high risk group for colorectal surgery. The safety and effectiveness of laparoscopy in colorectal surgery for cirrhotic patients is not clear. The aim of this study was to compare the outcomes of laparoscopic colorectal surgery with those of open procedure for colorectal cancer in patients with liver cirrhosis.

MATERIALS AND METHODS

A total of 62 patients with cirrhosis who underwent radical resections for colorectal cancer from 2005 to 2014 were identified retrospectively from a prospective database according to the technique adopted (laparoscopic or open). Short- and long-term outcomes were compared between the two groups.

RESULTS

Comparison of laparoscopic group and open group revealed no significant differences at baseline. In the laparoscopic group, the laparoscopic surgery was associated with reduced estimated blood loss (136 vs. 266 ml, p = 0.015), faster first flatus (3 vs. 4 days, p = 0.002) and shorter days to first oral intake (4 vs. 5 days, p = 0.033), but similar operative times (p = 0.856), number of retrieved lymph nodes (p = 0.400) or postoperative hospital stays (p = 0.170). Despite the similar incidence of overall complications between the two groups (50.0% vs. 68.8%, p = 0.133), we observed lower morbidities in laparoscopic group in terms of the rate of Grade II complication (20.0% vs. 50.0%, p = 0.014). Long-term of overall and Disease-free survival rates did not differ between the two groups.

CONCLUSION

Laparoscopic colorectal surgery appears to be a safe and less invasive alternative to open surgery in some elective cirrhotic patients in terms of less blood loss or early recovery and does not result in additional harm in terms of the postoperative complications or long-term oncological outcomes.

Ascites: A marker for increased surgical risk unaccounted for by the model for end-stage liver disease (MELD) score for general surgical procedures

BACKGROUND

Ascites and the Model for End-Stage Liver Disease score have both been shown to independently correlate with surgical morbidity and mortality. We evaluated if incorporating the presence of ascites changed postoperative risk as assessed by the Model for End-Stage Liver Disease score.

METHODS

Data originated from the National Surgical Quality Improvement Program database from 2005-2014. Patients undergoing hernia repair, adhesiolysis, and cholecystectomy were included. Univariate analysis and logistic regression stratified by Model for End-Stage Liver Disease score and presence of ascites was performed.

RESULTS

A total of 30,391 patients were analyzed. When compared to low Model for End-Stage Liver Disease stratum without ascites, the presence of ascites predicted increased risk for complications (low Model for End-Stage Liver Disease with ascites odds ratio 3.22, 95% confidence interval [2.00-5.18], moderate Model for End-Stage Liver Disease with ascites odds ratio 3.70, 95% confidence interval [2.64-5.19], high Model for End-Stage Liver Disease with ascites odds ratio 6.38, 95% confidence interval [4.39-9.26]). These findings hold true for mortality as well (low Model for End-Stage Liver Disease with ascites odds ratio 9.40 95% confidence interval [3.53-25.01], moderate Model for End-Stage Liver Disease with ascites odds ratio 15.24 95% confidence interval [8.17-28.45], high Model for End-Stage Liver Disease with ascites odds ratio 28.56 95% confidence interval [15.43-52.88]).

CONCLUSIONS

Ascites increased the risk of morbidity and mortality across multiple general surgery operations. Model for End-Stage Liver Disease may underestimate surgical risk in patients with ascites. Predictive models inclusive of ascites may more accurately predict the perioperative risk of these complex patients.

Perioperative management of liver surgery-review on pathophysiology of liver disease and liver failure

An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.

Oncologic and surgical outcomes in colorectal cancer patients with liver cirrhosis: A propensity-matched study

The management of colorectal cancer in patients with liver cirrhosis requires a thorough understanding of both diseases. This study evaluated the effect of liver cirrhosis on oncologic and surgical outcomes and prognostic factors in colorectal cancer patients. Fifty-five consecutive colorectal cancer patients with liver cirrhosis underwent colorectal resection (LC group). Using a prospectively maintained database, these patients were matched 1:4 using propensity scoring with R programming language, package "MatchIt" and "optmatch" by sex, age, cancer location, and tumor stage with 220 patients without liver cirrhosis (non-LC group), resulting in 275 patients. The 5-year overall survival (OS) was significantly worse in the LC group than in the non-LC group (46.7% vs. 76.2% respectively, P < 0.001); however, the 5-year proportion of recurrence free (PRF) rates were similar (73.1% vs. 84.5% respectively, P = 0.094). On multivariate analysis of the LC group, tumor-node-metastasis (TNM) stage ≥III disease, venous invasion, and a model for end-stage liver disease plus serum sodium (MELD-Na) score >10 were prognostic factors for OS. However, the OS was not different between the LC group with MELD-Na score ≤10 and the non-LC group (5-year OS rate, TNM stage ≤II, 85.7 vs 89.5%, p = 0.356; TNM stage ≥III, 41.1 vs 66.2%, p = 0.061). Colorectal cancer patients with liver cirrhosis have poorer OS compared to those without liver cirrhosis; however, the PRF rates are similar. It might be due to the mortality from the liver, and surgical treatment should be actively considered for patients with MELD-Na score <10.

Perioperative Care of Patients With Liver Cirrhosis: A Review

The incidence of cirrhosis is rising, and identification of these patients prior to undergoing any surgical procedure is crucial. The preoperative risk stratification using validated scores, such as Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease, perioperative optimization of hemodynamics and metabolic derangements, and postoperative monitoring to minimize the risk of hepatic decompensation and complications are essential components of medical management. The advanced stage of cirrhosis, emergency surgery, open surgeries, old age, and coexistence of medical comorbidities are main factors influencing the clinical outcome of these patients. Perioperative management of patients with cirrhosis warrants special attention to nutritional status, fluid and electrolyte balance, control of ascites, excluding preexisting infections, correction of coagulopathy and thrombocytopenia, and avoidance of nephrotoxic and hepatotoxic medications. Transjugular intrahepatic portosystemic shunt may improve the CTP class, and semielective surgeries may be feasible. Emergency surgery, whenever possible, should be avoided.

Liver Cirrhosis/Severe Fibrosis Is a Risk Factor for Anastomotic Leakage after Colorectal Surgery

Purpose. Liver cirrhosis associated with high perioperative morbidity/mortality. This retrospective study determines whether liver cirrhosis represents a risk factor for anastomotic leakage after colonic anastomosis or not. Methods. Based on a prospective database with all consecutive colorectal resections performed at the authors' institution from 07/2002 to 07/2012 (n = 2104) all colonic and rectal anastomoses were identified (n = 1875). A temporary loop ileostomy was constructed in 257 cases (13.7%) either due to Mannheimer Peritonitis-Index > 29 or rectal anastomosis below 6 cm from the anal verge. More than one-third of the patients (n = 691) had postoperative contrast enema, either at the occasion of another study or prior to closure of ileostomy. The presence of liver cirrhosis and the development of anastomotic leakage were assessed by chart review. Results. The overall anastomotic leakage rate was 2.7% (50/1875). In patients with cirrhosis/severe fibrosis, the anastomotic leakage rate was 12.5% (3/24), while it was only 2.5% (47/1851) in those without (p = 0.024). The difference remained statistically significant after correction for confounding factors by multivariate analysis. Conclusion. Patients with liver cirrhosis/severe fibrosis have an increased risk of leakage after colonic anastomosis.

Should We Use the Model for End-Stage Liver Disease (MELD) to Predict Mortality After Colorectal Surgery?

We sought to determine the accuracy of the Model for End-Stage Liver Disease and the Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator in patients with ascites who underwent colorectal surgery. The National Surgical Quality Improvement Program database was queried for patients with ascites who underwent a major colorectal operation. Predicted 90-day mortality rate based on the Model for End-Stage Liver Disease and 30-day mortality based on the Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator were compared with observed 30-day mortality. The cohort contained 3137 patients with ascites who underwent a colorectal operation. The Model for End-Stage Liver Disease predicted that 252 (8 %) of patients with ascites undergoing colorectal operations would die within 90 days postoperatively, yet we observed 821 deaths (26 % mortality) within 30 days after surgery (p < 0.001). The Mayo Clinic Postoperative Mortality Risk in Patients with Cirrhosis Calculator predicted that 491 (16.6 % mortality) of patients with ascites undergoing colorectal operations would die within 30 days postoperatively, yet we observed 707 (23.9 % mortality) at 30 days (p < 0.01). We concluded that the current risk prediction models significantly under predict mortality in patients with ascites who underwent colorectal surgery.

Management of colorectal cancer in patients with cirrhosis: A retrospective, case-matched study of short- and long-term outcomes

BACKGROUND

Few studies have assessed access to postoperative chemotherapy and survival in cirrhotic patients with colorectal cancer. Aim of this study was to analyse short and long-term outcomes in these patients compared to non-cirrhotics.

METHODS

A retrospective, single-centre, comparative, case-matched study comparing 40 cirrhotic patients who had undergone colorectal resection between January 2006 and January 2014, and a matched cohort of 80 non-cirrhotic patients. Data collection included rate of postoperative outcomes, chemotherapy regimen, overall and disease-free 3-year survival.

RESULTS

Cirrhotics had more major postoperative complications than non-cirrhotics (57.5% vs. 26.5%, respectively; p=0.002) but no difference in anastomotic leakage (p=0.1); a higher mortality rate (p=0.0006) was observed in Child-Pugh class B patients. Cirrhotics had no difference in adjuvant chemotherapy rate compared to non-cirrhotics (55% vs. 65%, respectively p=0.8); 3-year overall survival was 71% in the Child A group vs. 92% in non-cirrhotics (p=0.03).

CONCLUSION

Despite a higher postoperative complication rate and a lower overall survival of cirrhotic patients compared to non-cirrhotics, cirrhosis had no impact on oncological outcomes and access/tolerance to postoperative chemotherapy. Thus cirrhosis should not be considered as a contraindication to curative treatment of colon cancer.

Coexisting liver disease is associated with increased mortality after surgery for diverticular disease

BACKGROUND

Coexistence of liver disease in patients undergoing surgery for diverticular disease (DD) may increase the risk of postoperative complications, but the evidence is limited.

AIM

To investigate the impact of liver disease on mortality and reoperation rates following surgery for DD.

METHODS

We performed a cohort study based on medical databases of all patients undergoing surgery for DD in Denmark during 1977-2011, categorizing them into three cohorts according to history of liver disease: patients with non-cirrhotic liver disease, those with liver cirrhosis, and those without liver disease (comparison cohort). Using the Kaplan-Meier method, we computed mortality in each cohort for 0-30, 31-60, and 61-90 days following surgery for DD. We used a Cox regression model to compute hazard ratios as measures of the relative risk (RR) of death, controlling for potential confounders, including other comorbidities. In addition, we assessed the reoperation rate within 30 days of initial surgery.

RESULTS

Of 14,408 patients undergoing surgery for DD, 233 (1.6 %) had non-cirrhotic liver disease and 91 (0.6 %) had liver cirrhosis. Thirty-day mortality was 9.9 % in patients without liver disease and 14.6 % in patients with non-cirrhotic liver disease [adjusted RR = 1.64 (95 % confidence interval [CI] 1.16-2.31)]. Among patients with liver cirrhosis, mortality was 24.2 % [adjusted RR = 2.70 (95 % CI 1.73-4.22)]. Liver cirrhosis had an impact on mortality up to 60 days after surgery for DD. The reoperation rate was approximately 10 % in each cohort.

CONCLUSION

Preexisting liver disease has a major impact on postoperative mortality following surgery for DD.

Clinical registries and quality measurement in surgery: a systematic review

BACKGROUND

Surgical clinical registries provide clinical information with the intent of measuring and improving quality. This study aimed to describe how surgical clinical registries have been used to measure surgical quality, the reported findings, and the limitations of registry measurements.

METHODS

Medline, CINAHL, and Cochrane were queried for English articles with the terms: "registry AND surgery AND quality." Eligibility criteria were studies explicitly assessing quality measurement with registries as the primary data source. Studies were abstracted to identify registries, define registry structure, uses for quality measurement, and limitations of the measurements used.

RESULTS

A total of 111 studies of 18 registries were identified for data abstraction. Two registries were financed privately, and 5 registries were financed by a governmental organization. Across registries, the most common uses of process measures were for monitoring providers and as platforms for quality improvement initiatives. The most common uses of outcome measures were to improve quality modeling and to identify preoperative risk factors for poor outcomes. Eight studies noted improvements in risk-adjusted mortality with registry participation; one found no change. A major limitation is bias from context and means of data collection threatening internal validity of registry quality measurement. Conversely, the other major limitation is the cost of participation, which threatens the external validity of registry quality measurement.

CONCLUSION

Clinical registries have advanced surgical quality definition, measurement, and modeling as well as having served as platforms for local initiatives for quality improvement. The implication of this finding is that subsidizing registry participation may improve data validity as well as engage providers in quality improvement.

Colorectal surgery in cirrhotic patients

Patients with cirrhosis have a greater risk of morbidity and mortality following colorectal surgery. Therefore, preoperative medical optimization and risk assessment using criteria such as the MELD score are vital in preventing complications. Some risk factors include age, urgency of surgery, and ASA score. Postoperative morbidity and mortality are related to portal hypertension, ascites, infection, and anastomotic and stomal complications. This review highlights the assessment of risk and perioperative management of cirrhotic patients undergoing colorectal 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.

Pulmonary complications after elective liver transplantation-incidence, risk factors, and outcome

After liver transplantation (LT), postoperative pulmonary complications (PPC) occur in approximately 35% to 50% of the recipients. Among these PPC, pneumonia is the most frequently encountered. Pulmonary dysfunction has also been widely reported among patients awaiting LT. The links between this dysfunction and PPC have not been clearly established. In this present cohort study, we evaluated the incidence and profile of post-LT pneumonia and identified potential preoperative risk factors.

METHODS

The postoperative clinical course of 212 liver transplant recipients between January 2008 and April 2010 was analyzed. These patients were treated in a single intensive care unit and received standardized postoperative care.

RESULTS

During the postoperative period, 47 (22%) patients developed pneumonia, of whom 20 (43%) developed respiratory failure requiring mechanical ventilation. Univariate analysis showed that several preoperative factors (age of recipient, model for end-stage liver disease score, indication for LT, platelet count, and restrictive lung pattern revealed by preoperative pulmonary function tests) and the transfusion (blood units and fresh frozen plasma units) during the operative period were associated with pneumonia. Using multivariate analysis by logistic regression, only a restrictive lung pattern (odds ratio=3.14; 95% confidence interval, 1.51-6.51; P=0.002) and the international normalized ratio measured prior LT (OR=4.95; 95% confidence interval, 1.86-8.59; P=0.0004) were independent predictors of pneumonia after LT.

CONCLUSION

Pneumonia is common among patients undergoing LT and is a major cause of morbidity. A restrictive pattern on preoperative pulmonary testing and a higher international normalized ratio measured prior LT were associated with more risk of postoperative pneumonia.

Anesthetic considerations for the patient with liver disease

PURPOSE OF REVIEW

An increasing number of patients requiring surgery are presenting with chronic or end stage liver disease. The management of these patients demands anesthesiologists with in-depth knowledge of the consequences of hepatic dysfunction, the effects on other organs, the risk of surgery, and the impact of anesthesia.

RECENT FINDINGS

Chronic or end stage liver disease is associated with an increased risk of perioperative morbidity and mortality. It is essential to preoperatively assess possible hepatic encephalopathy, pleural effusions, hepatopulmonary syndrome, hepatopulmonary hypertension, hepatorenal syndrome, cirrhotic cardiomyopathy, and coagulation disorders. The application of two scoring systems, that is, Child-Turcotte-Pugh and model for end stage liver disease, helps to estimate the risk of surgery. The use of propofol is superior to benzodiazepines as intravenous narcotics. Although enflurane and halothane are discouraged for maintenance of anesthesia, all modern volatile anesthetics appear comparable with respect to outcome. Fentanyl, sufentanil, and remifentanil as opioids and cis-atracurium for relaxation may be the best choices in liver insufficency. Regional anesthesia is valuable for postoperative pain management.

SUMMARY

Current studies have employed different anesthetic approaches in the preoperative and intraoperative management in order to improve outcomes of patients with liver disease.