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Bhalla S, Mcquillen B, Cay E, Reau N. Preoperative risk evaluation and optimization for patients with liver disease. Gastroenterol Rep (Oxf) 2024; 12:goae071. [PMID: 38966126 PMCID: PMC11222301 DOI: 10.1093/gastro/goae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 07/06/2024] Open
Abstract
The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.
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Affiliation(s)
- Sameer Bhalla
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Edward Cay
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nancy Reau
- Internal Medicine, Division of Digestive Diseases, Section of Hepatology, Rush University Medical Center, Chicago, IL, USA
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2
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Ostojic A, Mahmud N, Reddy KR. Surgical risk stratification in patients with cirrhosis. Hepatol Int 2024; 18:876-891. [PMID: 38472607 DOI: 10.1007/s12072-024-10644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.
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Affiliation(s)
- Ana Ostojic
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA.
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3
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Chen T, Wen L, Zhong R, Chen X. General anesthesia in patients with hepatic encephalopathy and acute variceal bleeding undergoing endoscopic treatment: A retrospective study. Medicine (Baltimore) 2023; 102:e34395. [PMID: 37653761 PMCID: PMC10470742 DOI: 10.1097/md.0000000000034395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 09/02/2023] Open
Abstract
The management of cirrhotic patient with encephalopathy and acute variceal bleeding (AVB) remains a clinical challenge with a high mortality. Early endoscopic therapies are frequently applied in patients with AVB. However, the application of general anesthesia in endoscopic surgery for patients with hepatic encephalopathy (HE) is pretty challenging. The present study aimed to evaluate the possible effect of general anesthesia with tracheal intubation on patient complicated with encephalopathy and AVB during endoscopic procedure. Thirty-six cirrhotic patients with encephalopathy and AVB were retrospectively studied, 14 patients underwent endoscopic treatment under general anesthesia with tracheal intubation, and 22 patients received pharmacological treatment, or and endoscopic therapy without general anesthesia served as the control group. Routine clinical and laboratory data were collected. The total mortality rate was 13.9% (5/36), 2 (14.3%) in the anesthesia group, 3 (13.6%) in the control group. The child-Pugh class of death cases were all grade C, 3 (60%) of them were in the stage IV of HE. The stage of HE was all improved in the 2 groups, 12 (85.8 %) patients were totally recovered from consciousness disturbance in the anesthesia group and 16 (72.7 %) in the control group respectively, the difference between the 2 groups was not significant (P>0.05). Except the death cases, there were still 3 patients in the control group had impaired consciousness at discharge. Child-Pugh score, Child-Pugh class and the stage of HE in the anesthesia group were significantly improved at discharge compared with those before operation. General anesthesia does not aggravate the severity of encephalopathy, and endoscopic treatment under general anesthesia with tracheal intubation is effective for HE patients complicated with AVB.
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Affiliation(s)
- Tao Chen
- Department of Digestive Endoscopy Center, Digestive Disease Center, Suining Central Hospital, Suining, China
| | - Lin Wen
- Department of Respiratory and Critical Care Medicine, Jiangyou Second People’s Hospital, Jiangyou, China
| | - Rui Zhong
- Department of Gastroenterology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xia Chen
- Department of Gastroenterology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
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Mansour D, Masson S, Hammond J, Leithead JA, Johnson J, Rahim MN, Douds AC, Corless L, Shawcross DL, Heneghan MA, Tripathi D, McPherson S, Bonner E, Botterill G, West R, Donnelly M, Grapes A, Hollywood C, Ross V. British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 3: special circumstances. Frontline Gastroenterol 2023; 14:474-482. [PMID: 37862443 PMCID: PMC10579550 DOI: 10.1136/flgastro-2023-102432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Part 1 addresses outpatient management of compensated cirrhosis: screening for hepatocellular cancer, varices and osteoporosis, vaccination and lifestyle measures. Part 2 concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. In this, the third part of the guidance, we focus on special circumstances encountered in managing people with cirrhosis, namely surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.
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Affiliation(s)
- Dina Mansour
- Gateshead Health NHS Foundation Trust, Gateshead, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Steven Masson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - John Hammond
- Hepatopancreatobiliary Multidisciplinary team, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Joanna A Leithead
- Addenbrooke's Hospital, Cambridge, UK
- Forth Valley Royal Hospital, Larbert, UK
| | | | | | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital, Kings Lynn, UK
| | - Lynsey Corless
- Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Stuart McPherson
- Newcastle University, Newcastle upon Tyne, UK
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | | | | | | | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
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.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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Morris SM, Abbas N, Osei-Bordom DC, Bach SP, Tripathi D, Rajoriya N. Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach. Expert Rev Gastroenterol Hepatol 2023; 17:155-173. [PMID: 36594658 DOI: 10.1080/17474124.2023.2163627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Sean M Morris
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
| | - Nadir Abbas
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Daniel-Clement Osei-Bordom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Simon P Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Dhiraj Tripathi
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Neil Rajoriya
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Johnson KM, Newman KL, Green PK, Berry K, Cornia PB, Wu P, Beste LA, Itani K, Harris AHS, Kamath PS, Ioannou GN. Incidence and Risk Factors of Postoperative Mortality and Morbidity After Elective Versus Emergent Abdominal Surgery in a National Sample of 8193 Patients With Cirrhosis. Ann Surg 2021; 274:e345-e354. [PMID: 31714310 DOI: 10.1097/sla.0000000000003674] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the incidence and risk factors for mortality and morbidity in patients with cirrhosis undergoing elective or emergent abdominal surgeries. BACKGROUND Postoperative morbidity and mortality are higher in patients with cirrhosis; variation by surgical procedure type and cirrhosis severity remain unclear. METHODS We analyzed prospectively-collected data from the Veterans Affairs (VA) Surgical Quality Improvement Program for 8193 patients with cirrhosis, 864 noncirrhotic controls with chronic hepatitis B infection, and 5468 noncirrhotic controls without chronic liver disease, who underwent abdominal surgery from 2001 to 2017. Data were analyzed using random-effects models controlling for potential confounders. RESULTS Patients with cirrhosis had significantly higher 30-day mortality than noncirrhotic patients with chronic hepatitis B [4.4% vs 1.3%, adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.57-4.98] or with no chronic liver disease (0.8%, aOR 4.68, 95% CI 3.27-6.69); mortality difference was highest in patients with Model for End-stage Liver Disease (MELD) score ≥10. Among patients with cirrhosis, postoperative mortality was almost 6 times higher after emergent rather than elective surgery (17.2% vs. 2.1%, aOR 5.82, 95% CI 4.66-7.27). For elective surgeries, 30-day mortality was highest after colorectal resection (7.0%) and lowest after inguinal hernia repair (0.6%). Predictors of postoperative mortality included cirrhosis-related characteristics (high MELD score, low serum albumin, ascites, encephalopathy), surgery-related characteristics (emergent vs elective, type of surgery, intraoperative blood transfusion), comorbidities (chronic obstructive pulmonary disease, cancer, sepsis, ventilator dependence, functional status), and age. CONCLUSIONS Accurate preoperative risk assessments in patients with cirrhosis should account for cirrhosis severity, comorbidities, type of procedure, and whether the procedure is emergent versus elective.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Lauren A Beste
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, Boston, MA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Patrick S Kamath
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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Cheng C, Wen YW, Tsai CY, Chao YK. Impact of Child-Pugh class A liver cirrhosis on perioperative outcomes of patients with oesophageal cancer: a propensity score-matched analysis. Eur J Cardiothorac Surg 2020; 59:ezaa334. [PMID: 33099615 DOI: 10.1093/ejcts/ezaa334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/29/2020] [Accepted: 08/07/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Advanced-stage (Child-Pugh classes B and C) liver cirrhosis (LC) is a contraindication for oesophagectomy. However, the question as to whether Child-Pugh class A LC may have an impact on perioperative outcomes remains unanswered. This retrospective single-centre study was designed to address this issue. METHODS This was a single-centre, retrospective, propensity-matched study. The perioperative outcomes of patients with Child-Pugh class A LC were compared with those of patients without LC after propensity score matching. RESULTS Out of a cohort consisting of 811 patients, we identified 51 cases with Child-Pugh class A LC. After the application of propensity score matching, the LC and no-LC groups consisted of 50 and 100 patients, respectively. The presence of LC did not compromise the quality of surgical resection as attested to by similar lymph node yields and R0 rates. However, patients with LC patients were more prone to developing postoperative pneumonia (22% vs 9%, P = 0.027), pleural effusion (38% vs 20%, P = 0.018) and chylothorax (10% vs 1%, P = 0.016) and had longer intensive care unit stay (mean: 6.10 vs 2.58 days, P = 0.002) compared with the no-LC group. Multivariable analysis identified thoracic duct ligation [odds ratio (OR) 12.292, P = 0.042] and a higher number of dissected nodes (OR 4.375, P = 0.037) as independent risk factors for chylothorax and pleural effusion, respectively. The detrimental effect of these variables was limited to the LC group. CONCLUSIONS Oesophagectomy portends a higher morbidity in patients with Child-Pugh class A LC. A meticulous management of lymphatic ducts during mediastinal dissection may improve surgical outcomes in this high-risk group.
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Affiliation(s)
- Chuan Cheng
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Wen Wen
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yi Tsai
- Department of General Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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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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Oh SK, Lim BG, Kim YS, Kim SS. Comparison of the Postoperative Liver Function Between Total Intravenous Anesthesia and Inhalation Anesthesia in Patients with Preoperatively Elevated Liver Transaminase Levels: A Retrospective Cohort Study. Ther Clin Risk Manag 2020; 16:223-232. [PMID: 32308400 PMCID: PMC7147612 DOI: 10.2147/tcrm.s248441] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/23/2020] [Indexed: 12/22/2022] Open
Abstract
Background Anesthesia and surgery may deteriorate liver function in patients with elevated liver enzyme levels; therefore, in these patients, choosing anesthetics with less hepatotoxicity is important. Methods This retrospective study investigated the effect of total intravenous anesthesia (TIVA) versus inhalation anesthesia (INHA) on the postoperative liver function in patients with preoperatively elevated liver enzyme levels (aspartate transaminase [AST] or alanine transaminase [ALT] >40 U/L) who underwent non-hepatic surgery under general anesthesia. We compared the changes in enzyme levels within 24 hrs before and after surgery. Results In 730 patients (TIVA: n=138; INHA: n=592), the baseline characteristics were comparable, except for higher comorbidity rates in the TIVA group. The median anesthesia and operation times were significantly longer in the TIVA group because approximately 50% of the TIVA group (vs 19.7% of the INHA group) underwent neurosurgery, which had a relatively longer operation time than other surgeries. Intraoperative hypotensive events and vasopressor use were more frequent in the TIVA group. After 1:4 propensity score matching (TIVA: n=94; INHA: n=376), the baseline characteristics and surgical variables were comparable, except for longer anesthesia time. Before matching, postoperative AST and ALT changes were significantly lower in the TIVA group than in the INHA group. After matching, only the ALT change was significantly lower after TIVA than after INHA [median (interquartile range), -16.7 (-32 to -4) % vs -12.0 (-28.6-6.5) %, P=0.025]. Conclusion TIVA may be safer for patients with preoperatively elevated liver transaminase levels.
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Affiliation(s)
- Seok Kyeong Oh
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Sung Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seong Shin Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Differential significance of early surgical complications for acute and long-term recurrence-free survival following surgical resection of hepatocellular carcinoma: do comorbidities play a role? Eur J Gastroenterol Hepatol 2017; 29:1045-1053. [PMID: 28562395 DOI: 10.1097/meg.0000000000000912] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative complications of Clavien-Dindo grade 3 or more are of prognostic significance in patients who undergo liver resection for hepatocellular carcinoma (HCC). However, perioperative mortality and patient comorbidities represent relevant factors that interfere with postoperative long-term survival. To clarify this, a retrospective single-center study was carried out. PATIENTS AND METHODS Patient data were prospectively collected in a continuously updated liver resection database. Overall, 184 consecutive patients who underwent liver resection for HCC with a curative intent between March 2003 and December 2013 were selected for the study. The patients were assigned to two groups according to the presence or absence of postoperative complications. Pre-existing comorbidities, perioperative mortality, surgical outcome, and long-term survival data were analyzed. RESULTS Postoperative complications requiring revision surgery were identified in 17.4% of the patients. The in-house mortality rate was 4.8%. Compared with patients without complications, patients with complications were older and had significantly more pre-existing comorbidities, more advanced tumors, more intrahepatic metastasis, longer operation times, greater blood loss, and more extensive resections. The overall 5-year survival rates were 40.1 and 52.5% in patients with or without postoperative complications, respectively. The corresponding 5-year recurrence-free survival rates were 46.3 and 46.7% (perioperative mortality excluded). Multivariate analysis showed that elevation of the Charlson Comorbidity Index was associated independently with decreased overall and recurrence-free survival. CONCLUSION In patients with HCC, posthepatectomy complications are confirmed to have predictive value. However, closer analysis and exclusion of perioperative mortality effects show an independent impact of pre-existing comorbidities on long-term overall und recurrence-free survival.
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Wang ZQ, Deng HY, Yang YS, Wang Y, Hu Y, Yuan Y, Wang WP, Chen LQ. Can oesophagectomy be performed for patients with oesophageal carcinoma and concomitant liver cirrhosis? A retrospective study based on a propensity-matched cohort. Interact Cardiovasc Thorac Surg 2017; 25:442-447. [DOI: 10.1093/icvts/ivx132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/04/2017] [Indexed: 12/13/2022] Open
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