Preoperative assessment of the patient with liver disease

Development and validation of a novel nomogram of 1-year mortality in the elderly with hip fracture: a study of the MIMIC-III database

OBJECTIVE

Hip fracture is a prevalent condition with a significant death rate among the elderly. We sought to develop a nomogram-based survival prediction model for older patients with hip fracture.

DESIGN

A retrospective case-control study.

SETTING

The data from Medical Information Mart for Intensive Care III (MIMIC-III V.1.4).

PARTICIPANTS

The clinical features of elderly patients with hip fracture, including basic information, comorbidities, severity score, laboratory tests and therapy, were filtered out based on the MIMIC-III V.1.4.

METHODS AND MAIN OUTCOME MEASURES

All patients included in the study were from critical care and randomly divided into training and validation sets (7:3). On the basis of retrieved data, the least absolute shrinkage and selection operator (LASSO) regression and multiple logistic regression analysis were used to identify independent predictive variables of 1-year mortality, and then constructed a risk prediction nomogram. The predictive values of the nomogram model were evaluated by the concordance indexes (C-indexes), receiver operating characteristic curve, decision curve analysis (DCA) and calibration curve.

RESULTS

A total of 341 elderly patients with hip fracture were included in this study; 121 cases died within 1 year. After LASSO regression and multiple logistic regression analysis, a novel nomogram contained the predictive variables of age, weight, the proportion of lymphocyte count, liver disease, malignant tumour and congestive heart failure. The constructed model proved satisfactory discrimination with C-indexes of 0.738 (95% CI 0.674 to 0.802) in the training set and 0.713 (95% CI 0.608 to 0.819) in the validation set. The calibration curve shows a good degree of fitting between the predicted and observed probabilities and the DCA confirms the model's clinical practicability.

CONCLUSIONS

The novel prediction model provides personalised predictions for 1-year mortality in elderly patients with hip fractures. Compared with other hip fracture models, our nomogram is particularly suitable for predicting long-term mortality in critical patients.

Viscoelastometric versus standard coagulation tests to guide periprocedural transfusion in adults with cirrhosis: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVES

Due to rebalanced haemostasis in cirrhosis, viscoelastometric testing (VET) is more accurate than standard coagulation tests (SCTs) in preprocedural haemostatic evaluation, resulting in decreased unnecessary transfusion. We aimed to determine the impact of VET-guided strategy on postprocedural bleeding, periprocedural transfusion rates and quantities, transfusion-related adverse events (TRAEs), lengths of stay (LOS) and mortality from randomized controlled trials (RCTs) of cirrhotic patients.

METHODS

PubMed and EMBASE were searched for RCTs comparing VET-guided with SCT-guided transfusion in cirrhotic adults undergoing esophagogastroduodenoscopy, liver transplantation or other invasive interventions. Using random-effects models, the pooled risk ratios (RRs) and/or mean differences (MDs) of postprocedural bleeding-free events and the other outcomes were estimated alongside 95% confidence intervals (CIs).

RESULTS

Of seven included RCTs (n = 421; 72.2% men; mean age 49.1 years), VET-guided transfusion did not change postprocedural bleeding-free statuses (RR 1.05; 95% CI 0.94-1.17). However, VET-based algorithms decreased the rates of fresh frozen plasma (FFP; RR 0.52; 95% CI 0.35-0.77) and platelet transfusions (RR 0.34; 95% CI 0.16-0.73), the quantities of transfused FFP (MD -1.39 units; 95% CI -2.18 to -0.60), platelets (MD -1.06 units; 95% CI -2.01 to -0.12) and cryoprecipitate (MD -7.13 units; 95% CI -14.20 to -0.07) and the risk of TRAEs (RR 0.42; 95% CI 0.27-0.65). The overall mortality rates and LOS were not significantly different between two groups.

CONCLUSION

Compared with conventional SCT-guided, VET-guided strategy decreases periprocedural plasma and platelet transfusions and TRAEs, without increasing haemorrhagic complications, LOS or mortality in cirrhosis.

Effects of Underlying Liver Disease on 30-Day Outcomes After Posterior Lumbar Fusion

OBJECTIVE

To examine the effects of underlying liver disease on 30-day postoperative complications after elective posterior lumbar fusion (PLF).

METHODS

We performed a retrospective American College of Surgeons National Surgical Quality Improvement Program study of patients who had undergone elective PLF from 2011 to 2014. The patients were divided into 2 groups stratified by the presence of liver disease, assessed using the Model for End-stage Liver Disease plus sodium score (liver disease, ≥10; no liver disease, <10). The baseline patient and operative characteristics were compared between the 2 groups using univariate analysis. Subsequent multivariate regression analysis adjusted for differences in baseline characteristics was performed to identify 30-day postoperative complications independently associated with liver disease.

RESULTS

Of 2965 patients, 55.9% had underlying liver disease. Those with liver disease were more frequently aged >65 years, male, and underweight or overweight and had had American Society of Anesthesiologists class ≥3, diabetes, pulmonary comorbidity, cardiac comorbidity, renal comorbidity, bleeding disorder, preoperative dyspnea at rest, and a prolonged operative time. On univariate analysis, patients with liver disease had a greater incidence of cardiac complications, pulmonary complications, renal complications, blood transfusion, sepsis, urinary tract infection, and prolonged hospitalization. On adjusted multivariate regression analysis, liver disease was independently associated with renal complications, pulmonary complications, sepsis, urinary tract infection, prolonged hospitalization, and blood transfusion.

CONCLUSIONS

As the long-term survival of patients with liver disease continues to increase, a better understanding of the relationship between liver dysfunction and surgical outcomes is needed. The identification of modifiable risk factors would allow them to be addressed and optimized preoperatively to decrease the incidence and severity of complications and improve patient outcomes after PLF.

Liver disease and mortality among patients with hip fracture: a population-based cohort study

Purpose

The aim of this study was to examine the prognostic impact of liver disease on mortality following hip fracture (HF).

Patients and methods

This nationwide cohort study, based on prospectively collected data retrieved from Danish registries, included all patients diagnosed with incident HF in Denmark during 1996-2013. Patients were classified based on the coexisting liver disease at the time of HF, ie, no liver disease, noncirrhotic liver disease, and liver cirrhosis. We computed 30-day and 31-365-day mortality risks. To compare patients with and without liver disease, we computed mortality adjusted hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) using Cox regression controlled for potential confounders.

Results

Among 152,180 HF patients, 2,552 (1.7%) patients had noncirrhotic liver disease and 1,866 (1.2%) patients had liver cirrhosis. Thirty-day mortality was 9.4% among patients with noncirrhotic liver disease, 12.6% among patients with liver cirrhosis patients, and 9.7% among patients without liver disease. Compared to patients without liver disease, crude and adjusted HRs within 30 days following HF were, respectively, 0.96 (95% CI: 0.85-1.10) and 1.24 (95% CI: 1.09-1.41) for patients with noncirrhotic liver disease and 1.30 (95% CI: 1.14-1.48) and 2.25 (95% CI: 1.96-2.59) for those with liver cirrhosis. Among patients who survived 30 days post-HF, the 31-365-day mortality was 18.5% among patients with noncirrhotic liver disease, 26.4% among patients with liver cirrhosis, and 19.4% among patients without liver disease. Corresponding crude and adjusted HRs were, respectively, 0.95 (95% CI: 0.86-1.04) and 1.08 (95% CI: 0.99-1.20) for patients with noncirrhotic liver disease and 1.40 (95% CI: 1.27-1.54) and 1.91 (95% CI: 1.72-2.12) for those with liver cirrhosis.

Conclusion

Liver disease patients, especially those with liver cirrhosis, had increased 30-day mortality and 31-365-day mortality following HF, compared to patients without liver disease.

The ADOPT-LC score: a novel predictive index of in-hospital mortality of cirrhotic patients following surgical procedures, based on a national survey

AIM

We aimed to develop a model for predicting in-hospital mortality of cirrhotic patients following major surgical procedures using a large sample of patients derived from a Japanese nationwide administrative database.

METHODS

We enrolled 2197 cirrhotic patients who underwent elective (n = 1973) or emergency (n = 224) surgery. We analyzed the risk factors for postoperative mortality and established a scoring system for predicting postoperative mortality in cirrhotic patients using a split-sample method.

RESULTS

In-hospital mortality rates following elective or emergency surgery were 4.7% and 20.5%, respectively. In multivariate analysis, patient age, Child-Pugh (CP) class, Charlson Comorbidity Index (CCI), and duration of anesthesia in elective surgery were significantly associated with in-hospital mortality. In emergency surgery, CP class and duration of anesthesia were significant factors. Based on multivariate analysis in the training set (n = 987), the Adequate Operative Treatment for Liver Cirrhosis (ADOPT-LC) score that used patient age, CP class, CCI, and duration of anesthesia to predict in-hospital mortality following elective surgery was developed. This scoring system was validated in the testing set (n = 986) and produced an area under the curve of 0.881. We also developed iOS/Android apps to calculate ADOPT-LC scores to allow easy access to the current evidence in daily clinical practice.

CONCLUSION

Patient age, CP class, CCI, and duration of anesthesia were identified as important risk factors for predicting postoperative mortality in cirrhotic patients. The ADOPT-LC score effectively predicts in-hospital mortality following elective surgery and may assist decisions regarding surgical procedures in cirrhotic patients based on a quantitative risk assessment.

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.

Management of high grade dysplasia in Barrett's oesophagus with underlying oesophageal varices: A retrospective study

BACKGROUND

Endoscopic treatment of Barrett's oesophagus leading to high grade dysplasia with oesophageal varices may lead to bleeding complications.

AIMS

Estimate effectiveness of endoscopic band-ligation in oesophageal varices patients treated for high grade dysplasia, and compare to endoscopically treated non-oesophageal varices high grade dysplasia patients.

METHODS

Retrospective comparative study. All 8 high grade dysplasia patients with varices who were treated initially with band-ligation at Mayo Clinic between 8/1/1999 and 2/28/2014 were compared with reference group of 52 high grade dysplasia patients treated endoscopically.

RESULTS

One high grade dysplasia patients patient with oesophageal varices (12.5%) achieved complete remission of intestinal metaplasia defined by at least one followup endoscopy with normal biopsies, and 3 (37.5%) achieved complete remission of dysplasia defined by at least one followup endoscopy with non-dysplastic biopsies. 39 (75.0%) endomucosal resection/radiofrequency ablation patients experienced at least one followup endoscopy with normal biopsies, and 49 (94.2%) experienced non-dysplastic biopsies. Both of these endpoints occurred significantly more often in the endomucosal resection/radiofrequency ablation group compared to the high grade dysplasia with oesophageal varices group (p=0.016 and p=0.025, respectively).

CONCLUSIONS

High grade dysplastic Barrett's can be safely managed with band-ligation. However, resolution of Barrett's epithelium is rarely achieved with banding alone.

Allocation of patients with liver cirrhosis and organ failure to intensive care: Systematic review and a proposal for clinical practice

AIM: To propose an allocation system of patients with liver cirrhosis to intensive care unit (ICU), and developed a decision tool for clinical practice.

METHODS: A systematic review of the literature was performed in PubMed, MEDLINE and EMBASE databases. The search includes studies on hospitalized patients with cirrhosis and organ failure, or acute on chronic liver failure and/or intensive care therapy.

RESULTS: The initial search identified 660 potentially relevant articles. Ultimately, five articles were selected; two cohort studies and three reviews were found eligible. The literature on this topic is scarce and no studies specifically address allocation of patients with liver cirrhosis to ICU. Throughout the literature, there is consensus that selection criteria for ICU admission should be developed and validated for this group of patients and multidisciplinary approach is mandatory. Based on current available data we developed an algorithm, to determine if a patient is candidate to intensive care if needed, based on three scoring systems: premorbid Child-Pugh Score, Model of End stage Liver Disease score and the liver specific Sequential Organ Failure Assessment score.

CONCLUSION: There are no established systems for allocation of patients with liver cirrhosis to the ICU and no evidence-based recommendations can be made.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intravenous hypnotic regimens in patients with liver disease; a review article

CONTEXT

The liver as an important organ in the body has many essential functions in physiological processes. One of the major activities of liver is drug metabolism. Hepatic dysfunction affecting hepatic physiological activities, especially drug metabolism can cause many problems during anesthesia and administration of different drugs to patients.

EVIDENCE ACQUISITION

Studies on hepatic disorders and hypnotic anesthetics prescribed in hepatic disorders were included in this review. For this purpose, reliable databases were used.

RESULTS

Anesthesia should be performed with caution in patients with hepatic dysfunction and drugs with long half-life should be avoided in these patients.

CONCLUSIONS

A review of the literature on the use of hypnotic drugs in patients with liver dysfunction showed that some hypnotic drugs used during anesthesia could be safely used in patients with impaired liver function. In these patients, certain drugs should be used with caution.

Preoperative coronary calcium score is predictive of early postoperative cardiovascular complications in liver transplant recipients

BACKGROUND

Coronary computed tomographic angiography (coronary CT) is a non-invasive test for diagnosis of cardiac function. Coronary calcium scores determined by coronary CT are associated with cardiovascular risk factors. However, no studies have investigated the association between coronary calcium scores and cardiovascular complications after liver transplantation (LT). We therefore evaluated the utility of preoperative coronary calcium scores for predicting early postoperative cardiovascular complications in LT recipients.

METHODS

Between 2010 and 2012, 443 LT recipients were analysed retrospectively. Preoperative cardiovascular assessments, including coronary CT, were performed. A coronary calcium score >400 was defined as a positive finding. Predictive factors of early postoperative cardiovascular complications were evaluated by univariate and multivariate analyses. Major cardiovascular complications occurring during a period of 1 month after LT were noted.

RESULTS

Of the 443 patients, 38 (8.6%) experienced one or more cardiovascular complications. Positive coronary CT findings were seen in 11 (2.5%) patients. In the multivariate analysis, a coronary calcium score >400 {odds ratio (OR)=4.62 [95% confidence interval (CI): 1.14-18.72], P=0.032} and female sex [OR=2.76 (1.37-5.57), P=0.005] were predictive of cardiovascular complications.

CONCLUSIONS

A preoperative coronary calcium score of >400 predicted cardiovascular complications occurring 1 month after LT, suggesting that preoperative evaluation of coronary calcium scores could help predict early postoperative cardiovascular complications in LT recipients.

Anesthesia for patients with liver disease

CONTEXT

Liver plays an important role in metabolism and physiological homeostasis in the body. This organ is unique in its structure and physiology. So it is necessary for an anesthesiologist to be familiar with various hepatic pathophysiologic conditions and consequences of liver dysfunction.

EVIDENCE ACQUISITION

WE SEARCHED MEDLINE (PUB MED, OVID, MD CONSULT), SCOPUS AND THE COCHRANE DATABASE FOR THE FOLLOWING KEYWORDS: liver disease, anesthesia and liver disease, regional anesthesia in liver disease, epidural anesthesia in liver disease and spinal anesthesia in liver disease, for the period of 1966 to 2013.

RESULTS

Although different anesthetic regimens are available in modern anesthesia world, but anesthetizing the patients with liver disease is still really tough. Spinal or epidural anesthetic effects on hepatic blood flow and function is not clearly investigated, considering both the anesthetic drug-induced changes and outcomes. Regional anesthesia might be used in patients with advanced liver disease. In these cases lower drug dosages are used, considering the fact that locally administered drugs have less systemic effects. In case of general anesthesia it seems that using inhalation agents (Isoflurane, Desflurane or Sevoflurane), alone or in combination with small doses of fentanyl can be considered as a reasonable regimen. When administering drugs, anesthetist must realize and consider the substantially changed pharmacokinetics of some other anesthetic drugs.

CONCLUSIONS

Despite the fact that anesthesia in chronic liver disease is a scary and pretty challenging condition for every anesthesiologist, this hazard could be diminished by meticulous attention on optimizing the patient's condition preoperatively and choosing appropriate anesthetic regimen and drugs in this setting. Although there are paucity of statistics and investigations in this specific group of patients but these little data show that with careful monitoring and considering the above mentioned rules a safe anesthesia could be achievable in these patients.

A systematic approach to the preoperative medical evaluation of adults

The number, age, and medical complexity of patients undergoing elective noncardiac surgery is rising worldwide. Internists, family physicians, and midlevel providers asked to perform preoperative medical evaluations. However, lack of consensus has led to wide variation in practice in what is included and addressed in these evaluations, and the efficacy of these assessments has been debated. The intended purpose of the evaluation seems to be universally accepted as aiming to assess and identify risks associated with the patient's comorbid medical conditions and the specific surgical procedure. The goal is to minimize those risks. Herein, we propose a systematic approach to the preoperative medical evaluation based on the best available evidence and expert opinion, with an emphasis on identifying all potentially pertinent patient- and surgery-specific risk factors.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

AIM: To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis.

METHODS: We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient’s score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate.

RESULTS: Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT.

CONCLUSION: Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Systemic abnormalities in liver disease

Systemic abnormalities often occur in patients with liver disease. In particular, cardiopulmonary or renal diseases accompanied by advanced liver disease can be serious and may determine the quality of life and prognosis of patients. Therefore, both hepatologists and non-hepatologists should pay attention to such abnormalities in the management of patients with liver diseases.

Long-term outcome in patients with short bowel syndrome after longitudinal intestinal lengthening and tailoring

OBJECTIVES

Longitudinal intestinal lengthening and tailoring (LILT) is a well-established surgical treatment for short bowel syndrome. It has been shown to enhance peristalsis, decrease bacterial overgrowth, and extend mucosal contact time for nutrients. We present the results of a long-term follow-up of patients who underwent LILT and define prognostic parameters for the survival of these patients.

PATIENTS AND METHODS

Between 1987 and 2006, 53 patients underwent LILT in our institution. The main diagnoses were gastroschisis, intestinal volvulus, intestinal atresias, and necrotizing enterocolitis. LILT was performed at a mean age of 24 months (range 4144 months). The follow-up time was 79.76 months (range 6234 months).

RESULTS

After LILT, 41 of 53 patients survived, and 36 of 41 surviving patients were successfully weaned from parenteral nutrition (PN). In long-term follow-up 79% stayed free of PN. The overall survival rate was 77.36%. Weight gain occurred in 58% of the patients after LILT. The quality of life after LILT is on a high level, with most patients having normal physical strength and participating in normal social life and education. Prognostic factors for survival after LILT in short bowel syndrome are length of small intestine (0.06582 + 0.0131 x bowel cm), length of large bowel (P = 0.039), preoperative liver function, and successful weaning from PN within 18 months postoperatively (P = 0.0032).

CONCLUSIONS

Patients undergoing LILT in short bowel syndrome have a high survival rate, weight gain, and a high quality of life. Autologous gastrointestinal reconstruction remains therefore the first choice in the treatment of patients with short bowel syndrome.

Liver protection in the perioperative setting

With recent advances in surgical and anaesthetic management, clinical medicine has responded to societal expectations and the number of operations in patients with a high-risk of perioperative liver failure has increased over the last decades. This review will outline important pathophysiological alterations common in patients with pre-existing liver impairment and thus highlight the anaesthetic challenge to minimise perioperative liver insults. It will focus on the intraoperative balancing act to reduce blood loss while maintaining adequate liver perfusion, the various anaesthetic agents used and their specific effects on hepatic function, perfusion and toxicity. Furthermore, it will discuss advances in pharmacological and ischaemic preconditioning and summarise the results of recent clinical trials.

Preoperative pulmonary assessment of children for liver transplantation

Pulmonary assessment should be part of the preoperative investigation of pediatric patients with chronic liver disease undergoing liver transplantation, as it allows the identification of pulmonary alterations that influence candidacy for transplantation and survival. To describe pulmonary changes found in pediatric patients who were candidates for liver transplantation. Retrospective study of 17 pediatric liver transplant candidates undergoing preoperative pulmonary evaluation assessing pulmonary clinical data, arterial blood gas analysis, CXR, respiratory function test by spirometry, pulmonary scintigraphy, and CEE. Ten patients presented normal chest roentgenograms. The most common radiographic change was interstitial infiltrate in the lung bases. Of the five patients with PaO(2) <70 mmHg, four had cyanosis and dyspnea and two were diagnosed with HPS with intrapulmonary shunt evidenced by contrast echocardiogram. Two patients presented with intrapulmonary shunt but without hypoxemia. Spirometry was normal in six patients, restrictive disturbance was evidenced in one patient, obstructive in three, and combined in two. The most common scintigraphic change was heterogeneous pulmonary perfusion. Pulmonary assessment should be performed routinely in pediatric patients prior to liver transplantation, even in asymptomatic patients. Pulmonary assessment may indicate changes such as HPS that can increase postoperative morbidity/mortality.

Outcomes of patients with cirrhosis undergoing non-hepatic surgery: Risk assessment and management

The reported mortality rates in patients with cirrhosis undergoing various non-transplant surgical procedures range from 8.3% to 25%. This wide range of mortality rates is related to severity of liver disease, type of surgery, demographics of patient population, expertise of the surgical, anesthesia and intensive care unit team and finally, reporting bias. In this article, we will review the pathophysiology, morbidity and mortality associated with non-hepatic surgery in patients with cirrhosis, and then recommend an algorithm for risk assessment and evidence based management strategy to optimize post-surgical outcomes.

Endoscopic therapy in patients with Barrett's esophagus and portal hypertension

BACKGROUND

Endoscopic mucosal resection has been used to stage and treat early neoplasia in Barrett's esophagus. The ability to do this in the setting of portal hypertension has not been reported.

OBJECTIVE

Our purpose was to describe the feasibility and efficacy of endoscopic mucosal resection in patients with portal hypertension and Barrett's esophagus.

DESIGN

Retrospective case series.

SETTING

Two tertiary referral centers.

PATIENTS

Patients with Barrett's esophagus and high-grade dysplasia or adenocarcinoma in the setting of portal hypertension.

INTERVENTION

Endoscopic mucosal resection of endoscopically visible lesions.

MAIN OUTCOME MEASUREMENTS

Complete resection of neoplastic lesion, lack of variceal bleeding.

RESULTS

Four patients were treated with endoscopic mucosal resection a total of 5 times. Endoscopic mucosal resection was successfully performed without significant GI bleeding.

LIMITATIONS

This preliminary case series describes feasibility of the procedure. Whether this can be generalized remains to be determined, although it may be an option in poor surgical candidates.

CONCLUSIONS

Endoscopic mucosal resection appears to be relatively safe in selected patients with portal hypertension and Barrett's esophagus. Further studies are needed to confirm these findings.

Monitoring Hepatic and Renal Function

Liver disease represents a serious risk factor for patients requiring anesthesia and surgery. Even subclinical liver disease increases perioperative morbidity and mortality. Perioperative renal dysfunction and failure have similar implications. Thus, detection of early hepatic and renal dysfunction and monitoring of their progress is essential. This article discusses methods for monitoring hepatic and renal function in patients who have high risk for liver or renal injury in the perioperative period.

The Preoperative Evaluation of the Transplanted Patient for Nontransplant Surgery

With the improved success of solid-organ transplantation, there has been an increased willingness to transplant individuals previously felt to be unsuitable for such procedures. Factors such as age and various medical comorbidities are no longer considered contraindications to transplantation, and hence, an increasing number of recipients may require medical care not specifically related to the transplant. After transplantation, many of these patients may require elective or emergent surgery, making it important for all surgeons to be familiar with the factors that may influence surgical outcomes in this population, asa well asa factors that affect postoperative care. Most transplant centres use a team approach to manage these complex patients, relying on medical professionals experienced in their care and management. Close interaction with the transplant team is likely the single most important step in preparing the transplanted patient for surgery and managing their postoperative care.