Colectomy in patients with liver disease: albumin-bilirubin score accurately predicts outcomes

BACKGROUND

Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction.

METHODS

All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score.

RESULTS

Of 86,273 patients identified, 48% (N = 41,624) were Albumin-Bilirubin Grade 1, 45% (N = 38,370) Grade 2 and 7% (N = 6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001).

CONCLUSION

Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.

Totally extraperitoneal repair of groin hernia in liver transplant patients: a case series study (TOHER)

PURPOSE

The present study aims to describe the feasibility and the postoperative results of groin hernia repair in liver transplant patients using a totally extra-peritoneal (TEP) repair approach.

METHODS

From May 2022 to March 2023, liver transplant patients with groin hernia underwent TEP groin hernia repair, by the single common senior experimented surgeon. Background information, intraoperative findings, postoperative complications, postoperative pain, health, and well-being were registered.

RESULTS

Thirteen TEP approach groin hernioplasties were performed in 10 patients, completing the procedure in all cases without the need for conversion either to open or transabdominal preperitoneal approaches. 70% of surgical explorations revealed multiple hernia defects: lateral hernias in all patients, medial defects in 62%, and femoral defects in 30.8%. Median hospital stay was 1 day [range (0.3)], with 30% treated as outpatients. Post-surgical complications occurred in 30% of cases: 1 hematoma and 2 seromas. Postoperative pain and physical functioning scored 100 (IQR 44) and 90 (IQR 15), respectively.

CONCLUSION

TEP groin hernioplasty is safe and feasible for liver transplant patients, with low complication rates, short hospital stays, and a significant proportion treated as outpatients. The posterior approach allows comprehensive repair of myopectineal defects, crucial due to associated hernial defects.

High-risk liver patients are not associated with adverse events following pancreaticoduodenectomy

INTRODUCTION

Pancreaticoduodenectomy performed with underlying hepatic disease has been reported to have increased adverse events postoperatively. This study aimed to further evaluate that association.

METHODS

Retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) main and targeted pancreatectomy registries for 2014-2016. High-risk liver patients were defined by MELD scores, received neoadjuvant chemotherapy, and had hepatosteatosis; two separate subgroups of MELD ≥9 and ≥ 11. High-risk liver patients were then compared to control cases via propensity score matching.

RESULTS

There were 156 and 132 cases that met the high-risk liver criteria for the MELD cutoffs of ≥9 and ≥ 11 respectively. Propensity score matching left 2527 cases for final adjusted analysis. On both univariate and multivariate analysis high-risk liver patients were not associated with increased adverse events following Whipple resection. Lack of association with increased adverse events held for both the ≥9 and ≥ 11 MELD score cohorts.

CONCLUSION

High-risk liver patients defined by MELD scores, neoadjuvant chemotherapy utilization, and hepatosteatosis were not associated with any increased incidence of adverse events following pancreaticoduodenectomy. Patients with underlying high-risk liver disease in this study did not appear to pose as a contraindication for oncologic resection of pancreatic adenocarcinoma.

Interfacility Transfer for Nonelective Cholecystectomy in High MELD Patients: An ACS-NSQIP Analysis

INTRODUCTION

Interfacility transfer to a referral center is often considered for patients with liver disease undergoing nonelective cholecystectomy given management complexities and perioperative risk. We sought to determine the association between the Model for End Stage Liver Disease (MELD) score, transfer frequency, and outcomes in those patients using a national database.

MATERIALS AND METHODS

The ACS-NSQIP participant use files were queried for nonelective open or laparoscopic cholecystectomy from 2016 to 2018. Patients were grouped according to low (6-11), intermediate (12-18), or high (>18) MELD. In the high MELD group, patient characteristics and outcomes were compared between transferred and nontransferred patients and multivariate regression was performed to evaluate independent predictors of outcomes. Outcomes included in-hospital mortality, complications, length-of-stay (LOS), and 30-d reoperation and readmission.

RESULTS

30,171 subjects were included. Transfer was more likely as MELD increased (19.5% high versus 12.1% low, P < 0.001). High MELD patients had increased LOS, reoperation, readmission, and mortality rates compared to low MELD. In high MELD patients (n = 1016), those transferred were more likely older, white, obese, and septic. Transferred patients had increased mortality (7.6% versus 4.2%, P = 0.044), LOS, reoperation, and complications. After controlling for differences between transferred and nontransferred patients, transfer status was not independently associated with mortality (OR = 1.593, P = 0.177), postoperative complications or LOS, but was associated with increased risk for reoperation. Sepsis and laparoscopic surgery were independently associated with higher and lower mortality, respectively.

CONCLUSIONS

Transfer status is not independently associated with mortality, postoperative complications, or prolonged LOS, suggesting patients with advanced liver disease undergoing acute cholecystectomy may not benefit from interfacility transfer.

Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients

BACKGROUND

We hypothesize that patients with compensated cirrhosis undergoing elective UHR have an improved mortality compared to those undergoing emergent UHR.

METHOD

The NIS was queried for patients undergoing UHR by CPT code, and ICD-10 codes were used to define separate patient categories of non-cirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC).

RESULTS

A total of 32,526 patients underwent UHR, 97% no cirrhosis, 1.1% compensated cirrhosis, 1.7% decompensated cirrhosis. On logistic regression, cirrhosis was found to be independently associated with mortality (OR 2.841, CI 2.14-3.77). On subset analysis of only cirrhosis patients, elective repair was found to be protective from mortality (OR 0.361, CI 0.15-0.87, p = 0.02).

CONCLUSIONS

In this retrospective review, cirrhosis as well as emergent UHR in cirrhotic patients were independently associated with mortality. More specifically, electively (rather than emergently) repairing an umbilical hernia in cirrhotic patients was independently associated with a 64% reduction in mortality.

Open inguinal hernia repair outcomes in liver transplant recipients versus patients with cirrhosis

PURPOSE

Patients with liver cirrhosis (LC) are at an increased risk for postoperative complications after open inguinal hernia repair (OIHR). It is possible that orthotopic liver transplant (OLT) recipients may have better outcomes, given reversal of liver failure pathophysiology. Therefore, we sought to compare mortality risk, complications, length of stay (LOS), and cost associated with OIHR in OLT recipients versus LC.

METHODS

From the National Inpatient Sample (NIS), using ICD-9 codes, we found 83 OLT recipients and 764 patients with LC who underwent OIHR between 2002 and 2014. We used logistic, negative binomial, and multiple linear regression models to compare peri-operative mortality risk, postoperative complications, and LOS, and cost associated with OIHR in OLT recipients versus LC patients. Models were adjusted for patient demographic and clinical characteristics, and hospital factors.

RESULTS

OLT recipients were younger (58 vs 61, p = 0.02), more likely to be privately insured (42.0% vs 24.6%, p = 0.006), less likely to have ascites at time of surgery (5.1% vs 18.9%, p = 0.003), and have surgery at large (84.3% vs 65.2%, p = 0.01) and teaching hospitals (84.2% vs 47.9%, p < 0.001). There were no mortalities among OLT recipients, but 19 (2.5%) deaths among LC patients. OLT recipients had a similar risk of overall complications (adjusted odds ratio aOR = 0.71 1.30 2.41) and hospital-associated costs (adjusted cost ratio = 0.71 0.88 1.09). However, LOS was significantly different with OLT recipients having shorter LOS (adjusted LOS ratio = 0.56 0.70 0.89).

CONCLUSION

Delaying OIHR in patients with LC until after OLT decreases LOS and may carry decreased mortality.

Preoperative Evaluation Before Noncardiac Surgery

The medical complexity of surgical patients is increasing and medical specialties are frequently asked to assist with the perioperative management surgical patients. Effective pre-anesthetic medical evaluations are a valuable tool in providing high-value, patient-centered surgical care and should systematically address risk assessment and identify areas for risk modification. This review outlines a structured approach to the pre-anesthetic medical evaluation, focusing on the asymptomatic patient. It discusses the evidence supporting the use of perioperative risk calculation tools and focused preoperative testing. We also introduce important key topics that will be explored in greater detail in upcoming reviews in this series.

Model for End-Stage Liver Disease Sodium as a Predictor of Surgical Risk in Cirrhotic Patients With Ascites

BACKGROUND

The Model for End-Stage Liver Disease Sodium (MELD-Na) incorporates hyponatremia into the MELD score and has been shown to correlate with surgical outcomes. The pathophysiology of hyponatremia parallels that of ascites, which purports greater surgical risk. This study investigates whether MELD-Na accurately predicts morbidity and mortality in patients with ascites undergoing general surgery procedures.

MATERIALS AND METHODS

We used the National Surgical Quality Improvement Program database (2005-2014) to examine the adjusted risk of morbidity and mortality of cirrhotic patients with and without ascites undergoing inguinal or ventral hernia repair, cholecystectomy, and lysis of adhesions for bowel obstruction. Patients were stratified by the MELD-Na score and ascites. Outcomes were compared between patients with and without ascites for each stratum using low MELD-Na and no ascites group as a reference.

RESULTS

A total of 30,391 patients were analyzed. Within each MELD-Na stratum, patients with ascites had an increased risk of complications compared with the reference group (low MELD-Na and no ascites): low MELD-Na with ascites odds ratio (OR) 4.33 (95% confidence interval [CI] 1.96-9.59), moderate MELD-Na no ascites OR 1.70 (95% CI 1.52-1.9), moderate MELD-Na with ascites OR 3.69 (95% CI 2.49-5.46), high MELD-Na no ascites OR 3.51 (95% CI 3.07-4.01), and high MELD-Na ascites OR 7.18 (95% CI 5.33-9.67). Similarly, mortality risk was increased in patients with ascites compared with the reference: moderate MELD-Na no ascites OR 3.55 (95% CI 2.22-5.67), moderate MELD-Na ascites OR 13.80 (95% CI 5.65-33.71), high MELD-Na no ascites OR 8.34 (95% CI 5.15-13.51), and high MELD-Na ascites OR 43.97 (95% CI 23.76-81.39).

CONCLUSIONS

MELD-Na underestimates morbidity and mortality risk for general surgery patients with ascites.

Relationship Between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study

OBJECTIVE

The aim of this study was to establish the relationship between postoperative pain and 30-day postoperative complications.

BACKGROUND

Only scarce data are available on the association between postoperative pain and a broad range of postoperative complications in a large heterogeneous surgical population.

METHODS

Having postoperative pain was assessed in 2 ways: the movement-evoked pain score on the Numerical Rating Scale (NRS-MEP) and the patients' opinion whether the pain was acceptable or not. Outcome was the presence of a complication within 30 days after surgery. We used binary logistic regression for the total population and homogeneous subgroups to control for case complexity. Results for homogeneous subgroups were summarized in a meta-analysis using inverse variance weighting.

RESULTS

In 1014 patients, 55% experienced moderate-to-severe pain on the first postoperative day. The overall complication rate was 34%. The proportion of patients experiencing postoperative complications increased from 0.25 [95% confidence interval (CI) = 0.21-0.31] for NRS-MEP = 0 to 0.45 (95% CI = 0.36-0.55) for NRS-MEP = 10. Patients who found their pain unacceptable had more complications (adjusted odds ratio = 2.17 (95% CI = 1.51-3.10; P < 0.001)). Summary effect sizes obtained with homogeneous groups were similar to those obtained from the total population who underwent very different types of surgery.

CONCLUSIONS

Higher actual postoperative pain scores and unacceptable pain, even on the first postoperative day, are associated with more postoperative complications. Our findings provide important support for the centrality of personalized analgesia in modern perioperative care.

Pain therapy to reduce perioperative complications

The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.

Surgery in Patients with Portal Hypertension

Patients with portal hypertension will increasingly present for nontransplant surgery because of the increasing incidence of, and improving long-term survival for, chronic liver disease. Such patients have increased perioperative morbidity and mortality caused by the systemic pathophysiology of liver disease. Preoperative assessment should identify modifiable causes of liver injury and distinguish between compensated and decompensated cirrhosis. Risk stratification, which is crucial to preparing patients and their families for surgery, relies on scores such as Child-Turcotte-Pugh and Model for End-stage Liver Disease to translate disease severity into quantified outcomes predictions. Risk factors for postoperative complications should also be recognized.

Specialized care improves outcomes for patients with cirrhosis who require general surgical operations

Background

General surgical operations on patients with cirrhosis have historically been associated with high morbidity and mortality rates. This study examines a contemporary series of patients with cirrhosis undergoing general surgical procedures.

Methods

A retrospective evaluation of 358 cirrhotic patients undergoing general surgical operations at a single institution between 2004–2015 was performed. Thirty- and 90-day mortality along with complications and subsequent transplantation rates were examined.

Results

358 cirrhotic patients were identified. The majority were Child-Turcotte-Pugh class (CTP) A (55.9%) followed by class B (32.4%) and class C (11.7%). Mean MELD score differed significantly between the groups (8.7 vs. 12.1 vs. 20.1; p<0.001). The most common operations were herniorrhaphy (29.9%), cholecystectomy (19.3%), and liver resection (14.5%). The majority of cases were performed semi-electively (68.4%), however, within the CTP C patients most cases were performed emergently (73.8%). Thirty and 90-day mortality for all patients were 5% and 6%, respectively. Mortality rates increased from CTP A to CTP C (30 day: 3.0% vs. 5.2% vs. 14.3%; p = 0.01; 90 day: 4.5% vs. 6.9% vs. 16.7%; p = 0.016). Additionally, 30-day mortality (12.8% vs. 2.3%; p<0.001), 90 day mortality (16.0% vs. 3.4%; p<0.001) were higher for emergent compared to elective cases. A total of 13 (3.6%) patients underwent transplantation ≤ 90 days from surgery. No elective cases resulted in an urgent transplantation.

Conclusion

Performing general surgical operations on cirrhotic patients carries a significant morbidity and mortality. This contemporary series from a specialized liver center demonstrates improved outcomes compared to historical series. These data strongly support early referral of cirrhotic patients needing general surgical operation to centers with liver expertise to minimize morbidity and mortality.

The Effects of Liver Disease on Surgical Outcomes Following Adult Spinal Deformity Surgery

BACKGROUND

As the prevalence of chronic liver disease continues to rise in the United States, understanding the effects of liver dysfunction on surgical outcomes has become increasingly important. The objective of this study was to assess the effects of chronic liver disease on 30-day complications following adult spinal deformity (ASD) surgery.

METHODS

We performed a retrospective cohort study of 2337 patients in the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program database who underwent corrective ASD surgery. Patients with liver disease were identified based on a Model for End-Stage Liver Disease-Na score ≥10. A univariate analysis was performed to compare 30-day postoperative complications between patients with and without liver disease. A multivariate regression analysis adjusting for differences in baseline patient characteristics was performed to identify complications that were associated with liver disease.

RESULTS

Patients with liver disease had a significantly greater incidence of postoperative pulmonary complications (6.3% vs. 2.9%; P < 0.001), blood transfusion (34.6% vs. 24.0%; P < 0.001), sepsis (2.2% vs. 0.9%; P = 0.011), prolonged hospitalization (19.0% vs. 8.0%; P < 0.001), as well as any 30-day complication (45.4% vs. 29.4%; P < 0.001). The multivariate regression analysis identified liver disease as a risk factor for prolonged hospitalization (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.64-2.84; P < 0.001), pulmonary complications (OR 1.78; 95% CI 1.16-2.74; P = 0.009), blood transfusion (OR 1.67; 95% CI 1.36-2.05; P < 0.001), and any 30-day complication (OR 1.43; 95% CI 1.15-1.77; P = 0.001).

CONCLUSIONS

The multisystem pathophysiology of liver dysfunction predisposes patients to postoperative complications following ASD surgery. A multidisciplinary approach in surgical planning and preoperative optimization is needed to minimize liver disease-related complications and improve patient outcomes.

Hernia Management in Cirrhosis: Risk Assessment, Operative Approach, and Perioperative Care

BACKGROUND

The rising incidence of liver disease has complicated the management of common surgical pathologies. Hernias, in particular, are problematic given the shortage of high-quality data and differing expert opinions. We aim to provide a narrative review of hernia management in cirrhosis as a first step toward developing evidence-based recommendations for the care of these patients.

MATERIALS AND METHODS

A literature review using separate search strings was conducted for PubMed and Cochrane Central Register of Controlled Trials databases. Review articles, conference abstracts, randomized clinical trials, and observational studies were included. Articles without a focus on patients with end-stage liver disease were excluded. Manuscripts were selected based on relevance to perioperative risk assessment, medical optimization, surgical decision-making, and considerations of hernia repair in patients with cirrhosis.

RESULTS

The existing literature is varied with regard to focus and quality of data. Of the 4516 articles identified, 51 full-text articles were selected for review. In general, there is evidence to suggest that individuals with compensated cirrhosis may successfully undergo and benefit from hernia repair. Patients at high risk for decompensated cirrhosis may be best served by nonoperative management.

CONCLUSIONS

Carefully selected patients with cirrhosis may proceed with herniorrhaphy. A multidisciplinary approach is essential to provide high-quality care and improve outcomes.

Predication of post-operative outcome of colectomy in ulcerative colitis patients using Model of End-Stage Liver Disease Score

PURPOSE

Model of End-Stage Liver Disease (MELD) score was developed to predict mortality in patients with liver disease. The aim of this study was to investigate the relationship between preoperative MELD score and 30-day surgical outcomes using the American College of Surgeons National Surgical Quality Improvement Program.

METHODS

Patients with ulcerative colitis (UC) (ICD: 556.X) who underwent colectomy were identified from NSQIP 2005 to 2013. The primary outcomes were bleeding complications, and overall morbidity and mortality.

RESULTS

A total of 7534 UC patients undergoing colectomy were identified. Patients with a higher MELD score had a longer hospital stay; more bleeding; and cardiac, respiratory, renal, thromboembolic, and septic complications as well as mortality. Patients were stratified into 4 groups by MELD score: < 7, 7-11, 12-15, and > 15 and a stratified multivariate analysis was done. Patients with a MELD score 12-15 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-1.3) and MELD > 15 (OR 2.6, 95%CI 1.5-4.7) were at significant risk for bleeding complication. Apart from the MELD score, the presence of ascites (OR 2.5, 95%CI 1.2-5.1) or varices (OR 1.0, 95%CI 1.01-1.03) was also significantly associated with post-operative bleeding complication. MELD 12-15 and MELD > 15 were also found to be risk factors for overall morbidity (OR 5.3, 95%CI 1.8-15.7; OR 10.3, 95%CI 3.6-29.7, respectively) and mortality (OR 3.3, 95%CI 1.3-8.4; OR 5.9, 95%CI 2.4-14.6, respectively).

CONCLUSION

UC patients with a higher MELD score were associated with a higher post-colectomy morbidity and mortality. MELD score > 11 was an independent indicator for post-operative bleeding, and overall complications and mortality.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program

INTRODUCTION

Chronic liver disease is prevalent in obese patients presenting for bariatric surgery and is associated with increased postoperative morbidity and mortality (M&M). There are no comparative studies on the safety of different types of bariatric operations in this subset of patients.

OBJECTIVE

The aim of this study is to compare the 30-day postoperative M&M between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-Y-gastric bypass (LRYGB) in the subset of patients with a model of end-stage liver disease (MELD) score ≥ 8.

METHODS

Data for LSG and LRYGB were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2012 and 2013. MELD score was calculated using serum creatinine, bilirubin, INR, and sodium. Postoperative M&M were assessed in patients with a score ≥ 8 and compared for the type of operation. This was followed by analysis for MELD subcategories. Multiple logistic regression was performed to adjust for confounders.

RESULTS

Out of 34,169, 9.8% of cases had MELD ≥ 8 and were included. Primary endpoint, 30-day M&M, was significantly lower post-LSG (9.5%) compared to LRYGB (14.7%); [AOR = 0.66(0.53, 0.83)]. Superficial wound infection, prolonged hospital stay, and unplanned readmission were more common in LRYGB. M&M post-LRYGB (30.6%) was significantly higher than LSG (15.7%) among MELD15-19 subgroup analysis.

CONCLUSION

LRYGB is associated with a higher postoperative risk than LSG in patients with MELD ≥ 8. The difference in postoperative complications between procedures was magnified with higher MELD. This suggests that LSG might be a safer option in morbidly obese patients with higher MELD scores, especially above 15.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Glutathione species and metabolomic prints in subjects with liver disease as biological markers for the detection of hepatocellular carcinoma

BACKGROUND

The incidence of liver disease is increasing in USA. Animal models had shown glutathione species in plasma reflects liver glutathione state and it could be a surrogate for the detection of hepatocellular carcinoma (HCC).

METHODS

The present study aimed to translate methods to the human and to explore the role of glutathione/metabolic prints in the progression of liver dysfunction and in the detection of HCC. Treated plasma from healthy subjects (n = 20), patients with liver disease (ESLD, n = 99) and patients after transplantation (LTx, n = 7) were analyzed by GC- or LC/MS. Glutathione labeling profile was measured by isotopomer analyzes of ²H₂O enriched plasma. Principal Component Analyzes (PCA) were used to determined metabolic prints.

RESULTS

There was a significant difference in glutathione/metabolic profiles from patients with ESLD vs healthy subjects and patients after LTx. Similar significant differences were noted on patients with ESLD when stratified by the MELD score. PCA analyses showed myristic acid, citric acid, succinic acid, l-methionine, d-threitol, fumaric acid, pipecolic acid, isoleucine, hydroxy-butyrate and glycolic, steraric and hexanoic acids were discriminative metabolites for ESLD-HCC⁺ vs ESLD-HCC^- subject status.

CONCLUSIONS

Glutathione species and metabolic prints defined liver disease severity and may serve as surrogate for the detection of HCC in patients with established cirrhosis.

Update in perioperative medicine: practice-changing evidence published in 2015

Evidence in perioperative medicine is published in a wide variety of journals, given the multidisciplinary nature of its practice which spans medicine and its subspecialties, as well as surgery and anesthesiology. It can be difficult to identify new and important evidence, as perioperative practice continues to evolve in multiple areas such as medication management, anticoagulation and cardiac risk stratification, among others. New, high-quality evidence is published each year, and must be placed into the context of not only existing literature, but also practical real-world patient care. We sought to systematically identify, critically evaluate and concisely summarize the practice implications of 10 articles published in 2015 for the practicing perioperative clinician.