Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials

Surgical Considerations in Portal Hypertension

This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.

Surgical risk stratification in patients with cirrhosis

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.

Non-operative management of cirrhotic patients with acute calculous cholecystitis: How effective is it?

INTRODUCTION

Nonoperative management (NOM) of acute calculous cholecystitis (ACC) in patients with cirrhosis was proposed. We examined the outcomes of cirrhotic patients with ACC treated with cholecystectomy compared to NOM.

METHODS

We analyzed the 2017-Nationwide Readmissions Database including cirrhotic patients with ACC. Patients were stratified: cholecystectomy, percutaneous cholecystostomy (PCT), and antibiotics only.

PRIMARY OUTCOMES

complications, failure of NOM.

SECONDARY OUTCOMES

mortality, length of stay (LOS), and charges.

RESULTS

3454 patients were identified. 1832 underwent cholecystectomy, 360 PCT, and 1262 were treated with antibiotics. PCT patients had higher mortality 16.9% vs. the antibiotics group 10.9% vs. cholecystectomy group 4.2%. PCT patients had longer LOS, but lower charges compared to the operative group. Failure of NOM was 28.2%. On regression, PCT was associated with mortality.

CONCLUSION

ACC remains a morbid disease in cirrhosis patients. One in three failed NOM, had longer LOS, and higher mortality. Further studies are warranted to identify predictors of NOM failure.

LEVEL OF EVIDENCE

Level III, prognostic.

Retrospective comparison of clinical outcomes of ultrasound-guided percutaneous cholecystostomy in patients with and without coagulopathy: a single center's experience

PURPOSE

To compare the complication rate and clinical outcomes for percutaneous cholecystostomy (PC) in patients with or without coagulopathy.

MATERIALS AND METHODS

We retrospectively reviewed electronic medical chart of patients who underwent ultrasound-guided PC with a 8.5-F drainage tube for acute cholecystitis between November 2003 and March 2017. We divided the patients into two groups: patients with coagulopathy (international normalized ratio > 1.5 or platelet count < 50 × 109/L or with a history of anticoagulant medication in preceding 5 days) and patients without coagulopathy. Duration of drainage, duration of hospital stay, 30-day mortality and complication rates were compared between these two groups. Student's t test, Chi-square test or Fisher's exact test was used for bivariate analyses. Age, age-adjusted Charlson Comorbidity Index (ACCI) and sepsis-adjusted complication rates were also compared.

RESULTS

In total, 141 patients had PC (mean age was 73.3 years [SD 13.3]; range 33-96 years; 94 men and 47 women). Fifty-two patients (36.9%) had coagulopathy and 89 patients (63.1%) were without any history of coagulopathy. Hemorrhagic complication rate was 3.5% (5 out of 141 patients, including 4 with coagulopathy and 1 without). One patient with coagulopathy died due to the hemorrhage. Duration of drainage was longer in patients with coagulopathy than patients without coagulopathy (20.0 days vs. 14.8 days; P = 0.033). No significant difference was observed with regard to duration of hospital stay (32.3 days vs. 25.6 days; P = 0.103) and 30-day mortality (7.7% vs. 1.1%; P = 0.062). The overall complication rate did not significantly differ (9.6% and 11.2%; P = 0.763), nor did age, ACCI or sepsis-adjusted complications.

CONCLUSION

Clinical outcomes and complications rates after PC did not statistically differ between patients with and without coagulopathy, but there was a tendency of higher risk of hemorrhage in coagulopathy patients. Therefore, the indication of this procedure should be carefully determined.

Cholecystectomy in patients with cirrhosis: a population-based cohort study from England

BACKGROUND

This population-based cohort study aimed to determine postoperative outcomes after emergency and elective cholecystectomy in patients with cirrhosis.

METHODS

Linked electronic healthcare data from England were used to identify all patients undergoing cholecystectomy between January 2000 and December 2017. Length of stay (LOS), re-admission, case fatality and the odds ratio of 90-day mortality were calculated for patients with and without cirrhosis, adjusting for age, sex and co-morbidity using logistic regression.

RESULTS

Of the total 69,141 eligible patients who underwent a cholecystectomy, 511 (0.74%) had cirrhosis. In patients without cirrhosis 86.55% underwent a laparoscopic procedure compared with 57.53% in patients with cirrhosis (p < 0.0001). LOS was longer in those with cirrhosis (3 IQR 1-8 vs 1 IQR 1-3 days,p < 0.0001). 90-day re-admission was greater in patients with cirrhosis, 36.79% compared with 14.95% in those without cirrhosis. 90-day case fatality after elective cholecystectomy in patients with and without cirrhosis was 2.79% and 0.43%; and 12.82% and 2.39% following emergency cholecystectomy. This equated to a 3-fold (OR 3.22, IQR 1.72-6.02) and a 4-fold (OR 4.52, IQR 2.46-8.33) increased odds of death at 90-days following elective and emergency cholecystectomy after adjusting for confounders.

CONCLUSION

Patients with cirrhosis undergoing cholecystectomy have an increased 90-day risk of postoperative mortality, which is significantly worse after emergency procedures.

Should All Minimal Access Surgery Be Robot-Assisted? A Systematic Review into the Musculoskeletal and Cognitive Demands of Laparoscopic and Robot-Assisted Laparoscopic Surgery

BACKGROUND

Surgeons are among the most at risk of work-related musculoskeletal health decline because of the physical demands of surgery, which is also associated with cognitive fatigue. Minimally invasive surgery offers excellent benefits to patients but the impact of robotic or laparoscopic surgery on surgeon well-being is less well understood. This work examined the musculoskeletal and cognitive demands of robot-assisted versus standard laparoscopic surgery.

METHODS

Medline, Embase and Cochrane databases were systematically searched for 'Muscle strain' AND 'musculoskeletal fatigue' AND 'occupational diseases' OR 'cognitive fatigue' AND 'mental fatigue' OR 'standard laparoscopic surgery' AND 'robot-assisted laparoscopic surgery'. Primary outcomes measured were electromyographic (EMG) activity for musculoskeletal fatigue and questionnaires (NASA-TLX, SMEQ, or Borg CR-10) for cognitive fatigue. A systematic review was conducted in accordance with the Synthesis Without Meta-analysis (SWiM) Guidelines. The study was preregistered on Prospero ID: CRD42020184881.

RESULTS

Two hundred and ninety-eight original titles were identified. Ten studies that were all observational studies were included in the systematic review. EMG activity was consistently lower in robotic than in laparoscopic surgery in the erector spinae and flexor digitorum muscles but higher in the trapezius muscle. This was associated with significantly lower cognitive load in robotic than laparoscopic surgery in 7 of 10 studies.

CONCLUSIONS

Evidence suggests a reduction in musculoskeletal demands during robotic surgery in muscles excluding the trapezius, and this is associated with most studies reporting a reduced cognitive load. Robotic surgery appears to have less negative cognitive and musculoskeletal impact on surgeons compared to laparoscopic surgery.

Comparison of Omental Patch Closure Versus Simple Closure for Laparoscopic Repair of Perforated Peptic Ulcer: A Systematic Review and Meta-Analysis

AIMS

To evaluate comparative outcomes of laparoscopic repair of perforated peptic ulcer with omental patch versus without omental patch.

METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic repair of perforated peptic ulcer (PPU) with and without omental patch were included. Operative time, postoperative complications, re-operation and mortality were the evaluated outcome parameters for the meta-analysis. Revman 5.3 was used for data analysis.

RESULTS

Four observational studies reporting a total number of 438 patients who underwent laparoscopic repair of PPU with (n = 268) or without (n = 170) omental patch were included. Operative time was significantly shorter in no-omental patch group (NOP) when compared to omental patch group (P = .02). There was no significant difference in the risk of postoperative ileus (Odd ratio (OR) .76, P = .61), leakage (OR 1.17, P = .80), wound infection (OR 1.89, P = .34), intra-abdominal abscess (OR 1.17, P = .87), re-operation (OR .00, P = .94) and mortality (OR .55, P = .48). Moreover, length of hospital stay was comparable between the two groups (P = .81).

CONCLUSION

Laparoscopic repair of PPU with or without omental patch have comparable postoperative complications and mortality rate. However, considering the shorter operative time, no-omental patch approach is an attractive and more favourable choice. Well-designed randomized controlled trials are needed to investigate this comparison.

Mortality Following Appendicectomy in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis

Introduction

With the global prevalence of liver cirrhosis rising, this systematic review aimed to define the perioperative risk of mortality in these patients following appendicectomy.

Methods

Systematic searches of Medline, EMBASE, Cochrane Library databases, ICTRP, and Clinical trials.gov were undertaken to identify studies including patients with cirrhosis undergoing appendicectomy, published since database inception to March 2021. Studies had to report mortality. Two review authors independently identified eligible studies and extracted data. Pooled analysis of in-patient and 30-day mortality was performed.

Results

Of the 948 studies identified, four were included and this comprised three nationwide database studies (USA and Denmark) and one multi-centre observational study (Japan). A total of 923 patients had cirrhosis and 167,211 patients did not. In-patient mortality ranged from 0 to 1.7% in patients with cirrhosis and 0.17 to 0.3% in patients without. 30-day mortality was 9% in patients with cirrhosis compared to 0.3% in those without. One study stratified cirrhotic patients into compensated and decompensated groups. In patients with compensated cirrhosis, mortality following laparoscopic appendicectomy (0.5%) was significantly lower than open appendicectomy (3.2%). The meta-analysis highlighted a tenfold increase in perioperative mortality in cirrhotic patients (OR 9.92 (95% CI 4.67 to 21.06, I2 = 28%). All studies reported an increased length of stay in patients with cirrhosis.

Conclusion

This review suggests that appendicectomy in the cirrhotic population is associated with increased mortality. LA may be safer in this population. Lack of information on cirrhosis severity and failure to control for age and co-morbidities make the results difficult to interpret. Further large population-based studies are required.

Gallstone Disease in Cirrhosis-Pathogenesis and Management

Gallstones are more common in patients with cirrhosis of the liver, and the incidence increases with severity of liver disease. Pigment stones are the most frequent type of gallstones (GSs) in cirrhotics, and majority remain asymptomatic. Hepatitis C virus infection and nonalcoholic fatty liver disease are the underlying etiologies of liver diseases that most often associated with GSs. Multiple altered mechanisms in cirrhosis such as chronic hemolysis due to hypersplenism, reduced bile acid synthesis and transport, decreased cholesterol secretion, decreased apolipoprotein A-I and A-II secretion, gallbladder hypo-motility, autonomic dysfunction, and portal hypertension collectively lead to increased risk of lithogenesis. Asymptomatic GSs should be followed up closely and offered laparoscopic cholecystectomy once symptomatic in Child-Pugh class A and B patients. The model for the end-stage liver disease score is the best predictor of the outcome after cholecystectomy. In patients of Child-Pugh class C, conservative or minimally invasive approaches should be used to treat complications of GSs.

Surgical Risk Assessment in Patients with Chronic Liver Diseases

Chronic liver diseases (CLD) is one of the leading causes of morbidity and mortality. The overall life span of patients with CLD has increased and so is the number of surgical procedures these patients undergo. Pathophysiological and hemodynamic changes in cirrhosis make these patients more susceptible to hypotension and hypoxia during surgery. They also have a high risk of drug induced liver injury, renal dysfunction and post-operative liver decompensation. Patients with CLD planned for elective or semi-elective surgery should undergo detailed preoperative risk assessment. Patients should be evaluated for the presence of clinically significant portal hypertension and cirrhosis. In the absence of both cirrhosis and clinically significant portal hypertension, patients with CLD can undergo surgery with minimal or low risk. Various risk assessment tools available for patients with advanced CLD are-CTP score, MELD Score, Mayo risk score, VOCAL-Penn score. A Child class C and/or Mayo risk score >15 in general is associated with high risk of post-operative mortality and elective surgery should be deferred in these patients. In patients with Child class, A and MELD 10-15 surgery is permissible with caution (except liver resection and cardiac surgery) while in Child A and MELD <10 surgery is well tolerated. VOCAL-Penn score is a new promising tool and can be the better alternative of CTP, MELD, and Mayo risk score models but more prospective studies with large patients' population are warranted. Certain surgeries like Hepatic resection, intraabdominal, and cardiothoracic have higher risk than abdominal wall hernia repair and orthopedic surgery. Laparoscopic approaches have better outcomes and less risk of liver failure than open surgery. Minimally invasive alternatives like colonic stent placement in case of obstruction can be considered in high-risk cases. Perioperative optimization and management of ascites, HE, bleeding, liver decompensation, and nutrition should be done with multidisciplinary approach. Patients with cirrhosis undergoing high risk elective surgery can develop liver failure in post-operative period and should be evaluated and counseled for liver transplantation if not contraindicated.

Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery?

Acute cholecystitis and several gallbladder stone-related conditions, such as impacted common bile duct stones, cholangitis, and biliary pancreatitis, are common medical conditions in daily practice. An early cholecystectomy or drainage procedure with delayed cholecystectomy is the current standard of treatment based on published clinical guidelines. Cirrhosis is not only a condition of chronically impaired hepatic function but also has systemic effects in patients. In cirrhotic individuals, several predisposing factors, including changes in the bile acid composition, increased nucleation of bile, and decreased motility of the gallbladder, contribute to the formation of biliary stones and the possibility of symptomatic cholelithiasis, which is an indication for surgical treatment. In addition to these predisposing factors for cholelithiasis, systemic effects and local anatomic consequences related to cirrhosis lead to anesthesiologic risks and perioperative complications in cirrhotic patients. Therefore, the treatment of the aforementioned biliary conditions in cirrhotic patients has become a challenging issue. In this review, we focus on cholecystectomy for cirrhotic patients and summarize the surgical indications, risk stratification, surgical procedures, and surgical outcomes specific to cirrhotic patients with symptomatic cholelithiasis.

The role of the laparoscopic approach in two-stage hepatectomy for colorectal liver metastases: a single-center experience

BACKGROUND

In selected patients, laparoscopic liver surgery for the treatment of colorectal liver metastases (CRLM) leads to better short-term outcomes and comparable oncologic outcomes in comparison with an open approach. However, its role in two-stage hepatectomy (TSH) remains poorly explored.

METHODS

A single-center retrospective study was performed to evaluate the role of laparoscopic liver resection (LLR) in the first and second stage of TSH. Demographic data, comorbid factors, perioperative outcomes, and short-term outcomes were evaluated.

RESULTS

Between September 2011 and May 2020, 23 patients were planned to undergo a TSH. The first stage hepatectomy (FSH) was performed laparoscopically in 22 patients (96%) without need for conversion. The median blood loss was 50 cc (IQR 30-100 cc) and postoperative length of hospital stay was 4 days (IQR 2.5-5 days). R0 resections were obtained in 18 FSHs (78%), while all others were R1 vascular (22%). Fourteen patients (61%) underwent a second stage hepatectomy (SSH). All SSHs were anatomically major hepatectomies. SSH was performed laparoscopically in 7 patients (50%), with need for conversion in 1 case (14%). The median blood loss was slightly lower in the open liver resection (OLR) group compared to the LLR group (200 cc (IQR 110-375 cc) vs. 240 cc (IQR 150-400 cc), respectively. The median postoperative length of hospital stay was 3 days shorter in the LLR group compared to the OLR group (4 days (IQR 3.5-4 days) vs. 7 days (IQR 4.5-8.5 days), respectively).

CONCLUSIONS

The already proven advantages of LLR in the treatment of CRLM favor the role of a laparoscopic approach in TSH for CRLM. In first stage minor or technically major hepatectomy, LLR is progressively becoming the gold standard. Laparoscopic second stage anatomically major hepatectomy is feasible in experienced hands, but should be limited to selected cases and should be performed in expert centers.

Laparoscopic cholecystectomy in patients with portal cavernoma without portal vein decompression

Introduction

Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC.

Patients and Methods

Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips.

Results

Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130-250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four.

Conclusion

LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.

Anesthesia for the Patient with Severe Liver Failure

The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.

Trends in surgical volume and in-hospital mortality among United States cirrhosis hospitalizations

Background

In the aging population of patients with cirrhosis in the United States, there is a potentially increased need for surgical procedures. However, individuals with cirrhosis have increased perioperative risk relative to patients without cirrhosis. We sought to quantify temporal trends in cirrhosis surgical procedures and in-hospital mortality in relation to surgical procedure type, elective admission status and compensated vs. decompensated status.

Methods

We performed a retrospective cohort study of cirrhosis hospitalizations between 2005 and 2014 using the National Inpatient Sample. Surgical procedures of interest included cholecystectomy, hernia repair, and major abdominal, orthopedic and cardiovascular surgery. We plotted trends in volume and in-hospital mortality by procedure type, and used linear regression to test the significance of trends.

Results

While the number of cirrhosis hospitalizations increased over time, the number of surgeries per 1000 admissions decreased (b=-1.454, P<0.001). When stratified by elective admission status, elective major orthopedic surgeries significantly increased over time (b=177.9; P<0.001). In-hospital mortality rates for most surgeries were significantly higher in the non-elective vs. elective setting (each P<0.001). In patients with compensated cirrhosis, there was a significant increase in the number of orthopedic (b=272.4; P<0.001) and hernia repair surgeries over time (b=191.1; P<0.001). Overall, there was significantly greater in-hospital mortality among patients with decompensated cirrhosis (each P<0.05). Q. Please mention the exact P-value unless <0.001

Conclusions

Despite an increasing number of cirrhosis hospitalizations, the decreasing relative number of cirrhosis surgeries may indicate progressive surgical risk aversion. Future cirrhosis surgical risk scores should consider surgical procedure type, elective/non-elective status, and decompensation status.

Lights off, camera on! Laparoscopic cholecystectomy improves outcomes in cirrhotic patients with acute cholecystitis

BACKGROUND

The best surgical approach to treat acute cholecystitis (AC) in cirrhotic patients is controversial. This study aimed to evaluate treatment options in cirrhotic patients with AC. We hypothesized that laparoscopic cholecystectomy (LC) would lead to better clinical outcomes when compared to non-operative management (NOM) and open cholecystectomy (OC), independent of the severity of liver cirrhosis.

METHODS

Patients from the National Inpatient Sample diagnosed with AC were stratified into no cirrhosis (NC), compensated cirrhosis (CC), and decompensated cirrhosis (DC) and analyzed according to treatment: NOM, OC, and LC. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), cost, and surgical complications. Univariate and multivariate analyses using generalized linear models were performed. A P < 0.05 was deemed significant.

RESULTS

Of 1 367 495 AC patients, 49 030 (3.6%) had cirrhosis; 23 260 had CC, and 25 770 had DC. LC (12 080 in CC group and 4840 in DC group) was accompanied by significantly lower mortality, HLOS, complications, and cost when compared to OC and NOM. OC was significantly associated with higher mortality, increased HLOS, total cost, and postoperative complications, independent of the presence or severity of cirrhosis.

CONCLUSIONS

LC in cirrhotic patients leads to superior outcomes compared to OC and NOM regardless of the severity of cirrhosis.

Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions

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.

Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease

BACKGROUND

Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD).

STUDY DESIGN

We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs.

RESULTS

Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001).

CONCLUSIONS

Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.

A Potential Role for Robotic Cholecystectomy in Patients with Advanced Liver Disease: Analysis of the NSQIP Database

Robotic surgery has been widely adopted by many specialties, including hepatobiliary surgery. However, robotic procedures generally require longer operative times and are costlier than their laparoscopic counterparts. The role for robotic cholecystectomy (RC), particularly in patients with advanced liver disease, has not been established. A retrospective analysis of the NSQIP database was performed, focusing on patients with chronic liver disease who underwent cholecystectomy. Patients were categorized based on their model for end-stage liver disease (MELD) score and the type of surgical procedure: open, laparoscopic, or RC. Rates of a variety of postoperative complications including length of stay (LOS) were analyzed. In patients with a MELD score of 21 to 30, open cholecystectomy was associated with a long hospital LOS (3 vs 1 vs 1; P 20.01). RC was equivalent to laparoscopic cholecystectomy in terms of perioperative mortality for higher MELD score patients but was associated with lower conversion rates and overall LOS. This data suggests that RC should be considered in patients with advanced liver disease needing cholecystectomy.

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study

With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients.

METHODS

We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99.

RESULTS

The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

CONCLUSION

LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

Anesthesia for the Patient with Severe Liver Failure

The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study

With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients.

METHODS

We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99.

RESULTS

The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

CONCLUSION

LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

Current status of postoperative infections after digestive surgery in Japan: The Japan Postoperative Infectious Complications Survey in 2015

AIM

To survey postoperative infections (PI) after digestive surgery.

METHODS

This survey, conducted by the Japan Society of Surgical Infection, included patients undergoing digestive surgery at 28 centers between September 2015 and March 2016. Data collected included patient background characteristics, type of surgery, contamination status, and type of PI, including surgical site infection (SSI), remote infection (RI), and antimicrobial-resistant (AMR) bacterial infections and colonization.

RESULTS

Postoperative infections occurred in 10.7% of 6582 patients who underwent digestive surgery (6.8% for endoscopic surgery and 18.7% for open surgery). SSI and RI, including respiratory tract infection, urinary tract infection, antibiotic-associated diarrhea, drain infection, and catheter-related bloodstream infection, occurred in 8.9% and 3.7% of patients, respectively. Among all PI, 13.2% were overlapping infections. The most common overlapping infections were incisional and organ/space SSI, which occurred in 4.2% of patients. AMR bacterial infections occurred in 1.2% of patients after digestive surgery and comprised 11.5% of all PI. Rate of AMR bacterial colonization after digestive surgery was only 0.3%.

CONCLUSION

Periodic surveillance of PI, including AMR bacteria, is necessary for a detailed evaluation of nosocomial infections.

Operative Considerations for the General Surgeon in Patients with Chronic Liver Disease

Chronic liver disease remains a prevalent and challenging comorbidity in the American population at large. Scarring and fibrosis cause physical and physiological changes that may prove challenging in both medical and surgical management. However, because there has been relevant improvements in preoperative diagnostic, perioperative hepatologic, and intensive care management, as well as in surgical techniques, patients with cirrhosis can safely be operated on but patient selection remains vital. Patients with chronic liver disease may present to a general surgeon for evaluation of a number of elective or emergent surgical conditions. Here, we review current literature on the perioperative management and operative strategies of seemingly routine general surgery issues and provide a review of the pathophysiology associated with chronic liver disease.

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.

Hepatic Pedicle Occlusion with the Pringle Maneuver During Difficult Laparoscopic Cholecystectomy Reduces the Conversion Rate

BACKGROUND

In the presence of cholecystitis or portal hypertension, hemorrhage is common during laparoscopic cholecystectomy (LC) because the vessels of Calot's triangle are fragile and tortuous. Bleeding can obstruct surgical field visibility and increase conversion rates and risk of common bile duct injury. The Pringle maneuver is a simple occlusion approach that could limit blood flow from the hepatic pedicle, thus controlling bleeding to provide a clear surgical field to reduce conversion rate. In this study, we aimed to investigate the feasibility, effectiveness and safety of hepatic pedicle occlusion with the Pringle maneuver during difficult LC.

METHODS

From 2011 to 2015, LC with hepatic pedicle occlusion by the Pringle maneuver was performed in 67 patients (Pringle group). Another group of 67 cases with matched clinical parameters where LC was performed without the Pringle maneuver (non-Pringle group) was retrieved from a database to serve as the control group.

RESULTS

The Pringle group had a significantly lower conversion rate (1.49% vs. 11.9%; P = 0.038), less blood loss (37.5 ± 24.1 mL vs. 94.5 ± 67.8 mL; P = 0.002), shorter postoperative hospitalization (2.5 ± 1.4 days vs. 3.5 ± 2.5 days; P = 0.005), and lower cost ($1343 ± $751 USD vs. $1674 ± $609 USD; P = 0.024) than non-Pringle group. There was one case each of bile duct injury and readmission within 30 days because of bile leakage in the non-Pringle group, but none in the Pringle group.

CONCLUSIONS

Hepatic pedicle occlusion could provide a clear surgical field and enable the recognition of structures during LC. The Pringle maneuver offers a feasible and safe approach to lower conversion rates in difficult LC.

Comparison Between Outcomes of Laparoscopic Cholecystectomy in Patients With Liver Cirrhosis or With Normal Liver Function

Objective and Background:

The safety of laparoscopic cholecystectomy in patients with Child–Pugh A and B cirrhosis is well-established, but perioperative complications are frequently observed in patients with cirrhosis. Technical challenges of this operation in cirrhotic patients remain in need of resolution.

Methods:

Twenty-one patients preoperatively diagnosed as having cirrhosis underwent laparoscopic cholecystectomy mainly using the French approach and were retrospectively reviewed. Their clinicopathologic characteristics were compared with 74 continuous patients with gallstone but no cirrhosis who underwent laparoscopic cholecystectomy using the American approach.

Results:

Most cirrhotic patients (19/21, 90.5%) had a chronic liver disease such as hepatitis B/C, alcoholic hepatitis, or primary biliary cholangitis. On imaging, the Chilaiditi sign and gallbladder bed pocket score, previously proposed to be informative in these patients, were significantly higher in the cirrhosis group than in the no cirrhosis group. Although the Child–Pugh score was higher in patients with cirrhosis, the model for end-stage liver disease (MELD) score was similar for the 2 groups. There were no differences in the operation time or the amount of intraoperative blood transfused. Postoperative hospital stay and postoperative morbidity rates were significantly greater in the cirrhosis group, although severe complications with a Clavien–Dindo score ≥ IIIa occurred in only 1 patient in each group.

Conclusions:

The safety of laparoscopic cholecystectomy in cirrhotic patients was confirmed. Because the gallbladder is completely covered in patients with cirrhosis, the French style approach, which enables surgeons to more easily access the gallbladder pocket, is assumed to be one of the operative options.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.

[Laparoscopic cholecystectomy in patients with liver cirrhosis]

AIM

To assess efficacy and safety of laparoscopic cholecystectomy in patients with liver cirrhosis.

MATERIAL AND METHODS

46 patients with liver cirrhosis Child-Pugh class A and B underwent laparoscopic cholecystectomy for the period from August 2001 to December 2015. Indications for surgery were acute calculous cholecystitis in 21 (45.6%) patients and chronic calculous cholecystitis in 25 (54.4%) patients.

RESULTS

Mean surgery time was 75 minutes. Conversion to open surgery was required in 2 patients. Postoperative complications including bleeding, liver dysfunction, ascites, wound complications were observed in 11 (23.9%) patients. There were no deaths. Mean hospital-stay time was 2.5 days.

CONCLUSION

Laparoscopic cholecystectomy may be successfully performed in carefully selected patients with compensated cirrhosis. The advantages of minimally invasive technique are less blood loss, surgery time and hospital-stay.

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.

Living donor liver transplantation indicated for compensated liver cirrhosis with symptomatic gallstone diseases: report of two cases

BACKGROUND

Surgical interventions for symptomatic gallstone disease could be dangerous in patients with severe comorbid conditions including liver cirrhosis. Here, we report our experience of living donor liver transplantation (LDLT) indicated for two patients with liver cirrhosis complicated with gallstone diseases.

CASE 1

A 70-year-old woman with a history of hepatitis C virus infection was diagnosed as symptomatic choledocholithiasis. She had open cholecystectomy and choledochotomy with choledocholithotomy, which complicated with postoperative liver failure. Her Child-Pugh score increased from 7 to 12 points and Model for End-Stage Liver Disease (MELD) score from 11 to 36. She underwent LDLT, using the right lobe graft donated by her 47-year-old daughter. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 27.

CASE 2

A 46-year-old man with a history of hepatitis B virus infection was diagnosed as cholecystitis. He had cholecystostomy without any complications and his Child-Pugh score remained to be 9 and MELD score 17, followed by LDLT using the right lobe graft donated by his 45-year-old wife. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 44.

CONCLUSION

LDLT is one of treatment options when patients with Child-Pugh B cirrhosis accompanied with gallstone diseases, likely to be deteriorating their liver functions in the near future.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Is Cirrhosis a Contraindication to Laparoscopic Cholecystectomy?

Laparoscopic cholecystectomy is the gold standard treatment for the vast majority of patients with symptomatic cholelithiasis. Although cirrhotic patients are twice as likely to develop gallstones as compared with noncirrhotic patients, cirrhosis has historically been considered a relative, if not absolute, contraindication to laparoscopic cholecystectomy. More recently a number of authors have reported on the safety of laparoscopic cholecystectomy in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of laparoscopic cholecystectomy in cirrhotic patients as compared with noncirrhotics at a large liver transplant center. A retrospective longitudinal cohort study was conducted of all laparoscopic cholecystectomies performed by our surgical group between August 2002 and April 2011. Of 63 patients undergoing laparoscopic cholecystectomy, 32 (51%) were cirrhotic. Of the 30 for whom a Child score could be calculated, 11 (34%) were Child A, 14 (44%) were Child B, and five (16%) were Child C. The morbidity rate was 33 per cent and mortality rate was 2 per cent. Length of stay, conversion rates, 30-day readmission rates, and morbidity and mortality rates were not significantly different between the cirrhotic and noncirrhotic groups. There was a trend toward higher complication rates in Child C cirrhotics. Our results indicate that laparoscopic cholecystectomy can be performed with acceptable morbidity and mortality in carefully selected cirrhotic patients.

"One-off" complete radiofrequency ablation of hepatocellular carcinoma adjacent to the gallbladder by a novel laparoscopic technique without gallbladder isolation

The main objective of this study is to assess the feasibility and safety of treating hepatocellular carcinoma (HCC) proximal to the gallbladder using laparoscopic radiofrequency ablation (RFA). Surgical ablation of tumor located adjacent to the gallbladder may damage the gallbladder wall, even with a laparoscope and this ablation method is not precise and incomplete and is frequently combined with alcohol injections with need for further RFA treatment. Four patients were included in this study, with typical HCC where the tumor was present on the left, right, or bed side surrounding the gallbladder. The gallbladder was not separated or removed during larascopic inspection. In the RFA treatment procedure, the tumor lesion was pre-heated for 10 min, and heating was continued for 20 min. The integrity of the gallbladder wall was properly maintained. A follow-up to check for possible local recurrence was carried out 1 year after the RFA. The goal of "one-off" tumor complete RFA is to achieve thorough ablation of the tumor in a single treatment and limiting the possibility of recurrence within 6 months. Seven days after RFA, liver functions of all the patients returned to near-preoperative levels. The patients experienced slight pain in the upper right abdomen, which disappeared in 2-3 days. Results of B ultrasound on days 3-5 showed thickening of the periphery of the ablation area, without significant effusion. Enhanced CT on day 3 showed that RFA low-density area completely covered the lesions. No significant abnormality was observed in the gallbladder and its vicinity. One month after the surgery, B ultrasound and CT examination revealed no significant abnormalities. All patients had an intact gallbladder, and no extrahepatic or intrahepatic bile duct dilatation occurred. There was no evidence of damage to the bile duct or the vessels. Follow-up for 18-32 months found that all patients were in good condition. "One-off" complete RFA can be safely implemented to ablate HCC close to the gallbladder with the assistance of a laparoscope while maintaining integrity and continuity of the gallbladder, and without the need for secondary treatments.

Gallstones in patients with liver cirrhosis: Incidence, etiology, clinical and therapeutical aspects

Gallstones occur in about one third of the patients having liver cirrhosis. Pigment gallstones are the most frequent type, while cholesterol stones represent about 15% of all stones in cirrhotics. Increased secretion of unconjugated bilirubin, increased hydrolysis of conjugated bilirubin in the bile, reduced secretion of bile acids and phospholipds in bile favor pigment lithogenesis in cirrhotics. Gallbladder hypomotility also contributes to lithogenesis. The most recent data regarding risk factors for gallstones are presented. Gallstone prevalence increases with age, with a ratio male/female higher than in the general population. Chronic alcoholism, viral C cirrhosis, and non-alcoholic fatty liver disease are the underlying liver diseases most often associated with gallstones. Gallstones are often asymptomatic, and discovered incidentally. If asymptomatic, expectant management is recommended, as for asymptomatic gallstones in the general population. However, a closer follow-up of these patients is necessary in order to earlier treat symptoms or complications. For symptomatic stones, laparoscopic cholecystectomy has become the therapy of choice. Child-Pugh class and MELD score are the best predictors of outcome after cholecystectomy. Patients with severe liver disease are at highest surgical risk, therefore gallstone complications should be treated using noninvasive or minimally invasive procedures, until stabilization of the patient condition.

Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk

Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.

Quality and safety of minimally invasive surgery: past, present, and future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

Laparoscopic versus open liver resection: a meta-analysis of long-term outcome

BACKGROUND

Laparoscopic liver resection is growing in popularity, but the long-term outcome of patients undergoing laparoscopic liver resection for malignancy has not been established. This paper is a meta-analysis and compares the long-term survival of patients undergoing laparoscopic (LHep) versus open (OHep) liver resection for the treatment of malignant liver tumours.

METHODS

A PubMed database search identified comparative human studies analysing LHep versus OHep for malignant tumours. Clinical and survival parameters were extracted. The search was last conducted on 18 March 2012.

RESULTS

In total, 1002 patients in 15 studies were included (446 LHep and 556 OHep). A meta-analysis of overall survival showed no difference [1-year: odds ratio (OR) 0.71, 95% confidence interval (CI) 0.42 to 1.20, P = 0.202; 3-years: OR 0.76, 95% CI 0.56 to 1.03, P = 0.076; 5-years: OR 0.8, 95% CI 0.59 to 1.10, P = 0.173]. Subset analyses of hepatocellular carcinoma (HCC) and colorectal metastases (CRM) were performed. There was no difference in the 1-, 3-, and 5-year survival for HCC or in the 1-year survival for CRM, however, a survival advantage was found for CRM at 3 years (LHep 80% versus OHep 67.4%, P = 0.036).

CONCLUSIONS

Laparoscopic surgery should be considered an acceptable alternative for the treatment of malignant liver tumours.

Early mortality and long-term survival after abdominal surgery in patients with liver cirrhosis

BACKGROUND

Patients with liver cirrhosis have an increased risk of postoperative mortality. In addition, cirrhotic patients per se have a reduced life expectancy. Little is known about the combined effect of these factors on long-term outcomes after surgery. We thus evaluated early -and long-term survival in patients with cirrhosis who underwent abdominal surgery.

METHODS

We evaluated 30- and 90-day mortality as well as long-term survival after 212 general surgical procedures performed in 194 patients with liver cirrhosis. Risk factors for early and late mortality were assessed by uni- and multivariate methods. To avoid multicollinearity of data, different models (Child Turcotte Pugh [CTP], model for end-stage liver disease [MELD], or American Society of Anesthesiologists [ASA] score) were used in multivariate analysis.

RESULTS

The 30- and 90-day mortality rates were 20% and 30%, respectively. CTP, MELD, and ASA were all independently associated with 30- and 90-day mortality. Although emergency operations and intraoperative transfusions independently influenced 30-day mortality, 90-day mortality also was influenced by the extent of the procedure and thrombocytopenia. Survival after surgery (n = 180) was 54% after one and 25% after 5 years (median survival 1.24 years). Long-term survival was independently influenced by CTP, MELD, ASA, hyponatremia, emergency operations, thrombocytopenia, and underlying malignancies. Survival in patients discharged after surgery (n = 140) was 69% after 1 and 33% after 5 years (median survival 2.8 years). Survival after discharge was independently influenced by MELD, CTP, hyponatremia, underlying malignant disease, and (partially) by serum creatinine. The inclusion of serum sodium into MELD scores did not further facilitate prediction of early and late mortality.

CONCLUSION

A high postoperative mortality as well as a strongly reduced survival even after hospital discharge contribute to the very poor life expectancy in patients with liver cirrhosis requiring general surgery. Postoperative outcome is influenced by liver function, comorbidity and "surgical" factors such as the need for blood transfusion and emergent or major operations. However, after hospital discharge, "surgical" factors did not influence survival.

Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis

BACKGROUND

Open cholecystectomy (OC) is often preferred over laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and portal hypertension, but evidence is lacking to support this practice. This meta-analysis aimed to clarify which surgical technique is preferable for symptomatic cholecystolithiasis in patients with liver cirrhosis.

METHODS

A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and October 2011 were identified from MEDLINE, Embase and the Cochrane Library. Randomized clinical trials (RCTs) comparing outcomes of OC versus LC for cholecystolithiasis in patients with liver cirrhosis were included. The quality of the RCTs was assessed using the Jadad criteria.

RESULTS

Following review of 1422 papers by title and abstract, a meta-analysis was conducted of four RCTs comprising 234 surgical patients. They provided evidence of at least level 2b on the Oxford Level of Evidence Scale, but scored poorly according to the Jadad criteria. Some 97·0 per cent of the patients had Child-Turcotte-Pugh (CTP) grade A or B liver cirrhosis. In all, 96·6 per cent underwent elective surgery. No postoperative deaths were reported. LC was associated with fewer postoperative complications (risk ratio 0·52, 95 per cent confidence interval (c.i.) 0·29 to 0·92; P = 0·03), a shorter hospital stay (mean difference -3·05 (95 per cent c.i. -4·09 to -2·01) days; P < 0·001) and quicker resumption of a normal diet (mean difference -27·48 (-30·96 to -23·99) h; P < 0·001).

CONCLUSION

Patients with CTP grade A or B liver cirrhosis who undergo LC for symptomatic cholecystolithiasis have fewer overall postoperative complications, a shorter hospital stay and resume a normal diet more quickly than those who undergo OC.

Surgery in a patient with liver disease

Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.