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Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: An updated review. Clin Res Hepatol Gastroenterol 2023; 47:102205. [PMID: 37678609 DOI: 10.1016/j.clinre.2023.102205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.
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Affiliation(s)
- Ahmed Bedewy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Postal Code: 11795, Cairo, Egypt.
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2
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Wagner A, Wostrack M, Hartz F, Heim J, Hameister E, Hildebrandt M, Meyer B, Winter C. The role of extended coagulation screening in adult cranial neurosurgery. BRAIN & SPINE 2023; 3:101756. [PMID: 37383462 PMCID: PMC10293229 DOI: 10.1016/j.bas.2023.101756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality. Research question We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage. Methods A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage. Results The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p = .546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p = .023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p = .034). Differences in mean intraoperative blood loss were not significant with 528 ml in the study cohort and 486 ml in the control cohort (p = .376). Conclusion Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Frederik Hartz
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Johannes Heim
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Erik Hameister
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Martin Hildebrandt
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Christof Winter
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
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Delta De Ritis Ratio Is Associated with Worse Mortality Outcomes in Adult Trauma Patients with Moderate-to-Severe Traumatic Brain Injuries. Diagnostics (Basel) 2022; 12:diagnostics12123004. [PMID: 36553011 PMCID: PMC9776494 DOI: 10.3390/diagnostics12123004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
This study aimed to investigate whether changes in the De Ritis ratio (DRR) can be used to stratify the mortality risk of patients with moderate-to-severe traumatic brain injury (TBI). This retrospective study reviewed data for 1347 adult trauma patients (134 deaths and 1213 survival) with moderate-to-severe TBI between 1 January 2009, and 31 December 2020, from the registered trauma database. The outcomes of the patients allocated into the two study groups were compared based on the best Delta DRR (ΔDRR) cutoff point. The first and second DRR of patients who died were significantly higher than those of patients who survived. Elevation of DRR 72-96 h later was found for patients who died, but not for those who survived; the ΔDRR of the patients who died was significantly higher than that of those who survived (1.4 ± 5.8 vs. -0.1 ± 3.3, p = 0.004). Multivariate logistic regression analysis revealed that ΔDRR was a significant independent risk factor for mortality in these patients. Additionally, a ΔDRR of 0.7 was identified as the cutoff value for mortality stratification of adult trauma patients at high risk of mortality with moderate-to-severe TBI.
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Chang TW, Lin KTR, Tsai ST, Lee CH. The emergent neurosurgical outcome of spontaneous intracranial hemorrhage in patients with chronic liver disease. Tzu Chi Med J 2022; 35:58-61. [PMID: 36866341 PMCID: PMC9972939 DOI: 10.4103/tcmj.tcmj_54_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 11/04/2022] Open
Abstract
Objectives The influence of chronic liver disease (CLD) on emergent neurosurgical outcomes in patients with spontaneous intracerebral hemorrhage (ICH) remains unclear. CLD is usually associated with coagulopathy and thrombocytopenia, which contribute to a high rebleeding rate and poor prognosis after surgery. This study aimed to confirm the outcomes of spontaneous intracranial hemorrhage in patients with CLD after emergent neurosurgery. Materials and Methods We reviewed the medical records of all patients with spontaneous ICH from February 2017 to February 2018 at the Buddhist Tzu Chi Hospital, Hualien, Taiwan. This study was approved by the Review Ethical Committee/Institutional Board Review of Hualien Buddhist Tzu Chi Hospital (IRB111-051-B). Patients with aneurysmal subarachnoid hemorrhage, tumors, arteriovenous malformations, and those younger than 18 years were excluded. Duplicate electrode medical records were also removed. Results Among the 117 enrolled patients, 29 had CLD and 88 did not. There were no significant differences in essential characteristics, comorbidities, biochemical profile, Glasgow coma scale (GCS) score at admission, or ICH sites. The length of hospital stay (LOS) and length of intensive care unit stay (LOICUS) are significantly longer in the CLD group (LOS: 20.8 vs. 13.5 days, P = 0.012; LOICUS: 11 vs. 5 days, P = 0.007). There was no significant difference in the mortality rate between the groups (31.8% vs. 28.4%, P = 0.655). The Wilcoxon rank-sum test for liver and coagulation profiles between survivors and the deceased revealed significant differences in the international normalized ratio (P = 0.02), including low platelet counts (P = 0.03) between survivors and the deceased. A multivariate analysis of mortality found that every 1 mL increase in ICH at admission increased the mortality rate by 3.9%, and every reduction in GCS at admission increased the mortality rate by 30.7%. In our subgroup analysis, we found that the length of ICU stay and LOS are significantly longer in patients with CLD who underwent emergent neurosurgery: 17.7 ± 9.9 days versus 7.59 ± 6.68 days, P = 0.002, and 27.1 ± 7.3 days versus 16.36 ± 9.08 days, P = 0.003, respectively. Conclusions From our study's perspective, emergent neurosurgery is encouraged. However, there were more prolonged ICU and hospital stays. The mortality rate of patients with CLD who underwent emergent neurosurgery was not higher than that of patients without CLD.
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Affiliation(s)
- Tze-Wei Chang
- Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kuan-Ting Robin Lin
- Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Sheng-Tzung Tsai
- Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Chien-Hui Lee
- Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan,Address for correspondence: Dr. Chien-Hui Lee, Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien, Taiwan. E-mail:
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Shin HJ, Ha SW, Kim SW. Delayed Onset Acute Subdural Hematoma after Burr Hole Drainage in a Patient with Chronic Subdural Hematoma and Liver Cirrhosis. Korean J Neurotrauma 2021; 17:156-161. [PMID: 34760827 PMCID: PMC8558012 DOI: 10.13004/kjnt.2021.17.e15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/10/2021] [Accepted: 05/25/2021] [Indexed: 11/15/2022] Open
Abstract
Although acute intracranial bleeding after burr hole drainage for chronic subdural hematoma (SDH) is rare, it could still occur and is associated with a poor clinical outcome. Although rare, most of them occur immediately or within a few days after drainage, especially in patients who are on antiplatelet drugs or anticoagulants. We report an unusual case of delayed-onset acute SDH that developed 14 days after burr hole drainage of chronic SDH in a 54-year-old man with liver cirrhosis and thrombocytopenia. The possible pathophysiological mechanisms of this rare entity are discussed, and the relevant literature is reviewed.
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Affiliation(s)
- Hyun Jae Shin
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Sang Woo Ha
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Seok Won Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
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Jo HH, Min C, Kyoung DS, Park MA, Kim SG, Kim YS, Chang Y, Jeong SW, Jang JY, Lee SH, Kim HS, Jun BG, Kim YD, Cheon GJ, Yoo JJ. Adverse outcomes after surgeries in patients with liver cirrhosis among Korean population: A population-based study. PLoS One 2021; 16:e0253165. [PMID: 34125860 PMCID: PMC8202950 DOI: 10.1371/journal.pone.0253165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/30/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients with liver cirrhosis have an increased risk of in-hospital mortality or postoperative complication after surgery. However, large-scale studies on the prognosis of these patients after surgery are lacking. The aim of the study was to investigate the adverse outcomes of patients with liver cirrhosis after surgery over five years. Methods and findings We used the Health Insurance Review and Assessment Service-National Inpatient Samples (HIRA-NIS) between 2012 and 2016. In-hospital mortality and hospital stay were analyzed using the data. Mortality rates according to the surgical department were also analyzed. Of the 1,662,887 patients who underwent surgery, 16,174 (1.0%) patients had cirrhosis. The in-hospital mortality (8.0% vs. 1.0%) and postoperative complications such as respiratory (6.0% vs. 5.3%) or infections (2.8% vs. 2.4%) was significantly higher in patients with cirrhosis than in those without cirrhosis. In addition, the total hospitalization period and use of the intensive care unit were significantly higher in patients with liver cirrhosis. In propensity score matching analysis, liver cirrhosis increased the risk of adverse outcome significantly [adjusted OR (aOR) 1.67, 95% CI 1.56–1.79, P<0.001], especially in-hospital mortality. In liver cirrhosis group, presence of decompensation or varices showed significantly increased postoperative complication or mortality. Adverse outcomes in patients with cirrhosis was the highest in patients who underwent otorhinolaryngology surgery (aOR 1.86), followed by neurosurgery (aOR 1.72), thoracic and cardiovascular surgery (aOR 1.56), and plastic surgery (aOR 1.36). Conclusion The adverse outcomes of patients with cirrhosis is significantly high after surgery, despite advances in cirrhosis treatment.
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Affiliation(s)
- Hyun Ho Jo
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Changwook Min
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | | | - Min-Ae Park
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Korea
| | - Sang Gyune Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Young Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Soung Won Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jae Young Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Sae Hwan Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Hong Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Baek Gyu Jun
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Seoul, Korea
| | - Young Don Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Seoul, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung Asan Hospital, Seoul, Korea
| | - Jeong-Ju Yoo
- Department of Gastroenterology and Hepatology, Soonchunhyang University School of Medicine, Seoul, Korea
- * E-mail:
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Kwon HM, Jun IG, Kim KS, Moon YJ, Huh IY, Lee J, Song JG, Hwang GS. Rupture Risk of Intracranial Aneurysm and Prediction of Hemorrhagic Stroke after Liver Transplant. Brain Sci 2021; 11:brainsci11040445. [PMID: 33807191 PMCID: PMC8066281 DOI: 10.3390/brainsci11040445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 01/23/2023] Open
Abstract
Postoperative hemorrhagic stroke (HS) is a rare yet devastating complication after liver transplantation (LT). Unruptured intracranial aneurysm (UIA) may contribute to HS; however, related data are limited. We investigated UIA prevalence and aneurysmal subarachnoid hemorrhage (SAH) and HS incidence post-LT. We identified risk factors for 1-year HS and constructed a prediction model. This study included 3544 patients who underwent LT from January 2008 to February 2019. Primary outcomes were incidence of SAH, HS, and mortality within 1-year post-LT. Propensity score matching (PSM) analysis and Cox proportional hazard analysis were performed. The prevalence of UIAs was 4.63% (n = 164; 95% confidence interval (CI), 3.95–5.39%). The 1-year SAH incidence was 0.68% (95% CI, 0.02–3.79%) in patients with UIA. SAH and HS incidence and mortality were not different between those with and without UIA before and after PSM. Cirrhosis severity, thrombocytopenia, inflammation, and history of SAH were identified as risk factors for 1-year HS. UIA presence was not a risk factor for SAH, HS, or mortality in cirrhotic patients post-LT. Given the fatal impact of HS, a simple scoring system was constructed to predict 1-year HS risk. These results enable clinical risk stratification of LT recipients with UIA and help assess perioperative HS risk before LT.
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Mendoza-Avendaño M, Ramírez-Carvajal A, Barreto-Herrera I, Muñoz-Báez K, Ramos-Villegas Y, Shrivastava A, Janjua T, Moscote-Salazar LR, Agrawal A. Approach to Emergent Neurotrauma-related Neurosurgical Procedures in Patients with Hepatic Disease. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1725215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractLiver diseases constitute a group of pathologies of extraordinary importance, because of the large number of patients who suffer from these as well as the consequences that they can have on these individuals if they undergo any surgical procedure. Therefore, these patients have greater risk of suffering unfavorable outcomes than a healthy person undergoing emergency neurosurgical procedures (ENP) for neurotrauma. For this reason, there is a need to classify these patients according to their surgical risk based on risk factors secondary to the concurrent hepatic derangements. Among the possible tools that allow us to stage patients with liver disease are the Child–Turcotte–Pugh (CTP) and model for end-stage liver disease (MELD) scales, which have proven utility in effectively predicting the outcomes, including morbidity and mortality in hepatic disease patients who are undergoing surgery. They also help to predict the risk of complications such as intracranial hemorrhage secondary to coagulopathy due to hepatic derangement.
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Affiliation(s)
- María Mendoza-Avendaño
- Faculty of Medicine, Center for Biomedical Research, University of Cartagena, Cartagena, Colombia
| | - Ana Ramírez-Carvajal
- Faculty of Medicine, Center for Biomedical Research, University of Cartagena, Cartagena, Colombia
| | - Iván Barreto-Herrera
- Faculty of Medicine, Center for Biomedical Research, University of Cartagena, Cartagena, Colombia
| | - Karen Muñoz-Báez
- Faculty of Medicine, Center for Biomedical Research, University of Cartagena, Cartagena, Colombia
| | - Yancarlos Ramos-Villegas
- Faculty of Medicine, Center for Biomedical Research, University of Cartagena, Cartagena, Colombia
| | - Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Tariq Janjua
- Intensive Care Department, Regions Hospital, Saint Paul, Minnesota, United States
| | | | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Lagman C, Nagasawa DT, Azzam D, Sheppard JP, Chen CHJ, Ong V, Nguyen T, Prashant GN, Niu T, Tucker AM, Kim W, Kaldas FM, Pouratian N, Busuttil RW, Yang I. Survival Outcomes After Intracranial Hemorrhage in Liver Disease. Oper Neurosurg (Hagerstown) 2020; 16:138-146. [PMID: 29767779 DOI: 10.1093/ons/opy096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Survival outcomes for patients with liver disease who suffer an intracranial hemorrhage (ICH) have not been thoroughly investigated. OBJECTIVE To understand survival outcomes for 3 groups: (1) patients with an admission diagnosis of liver disease (end-stage liver disease [ESLD] or non-ESLD) who developed an ICH in the hospital, (2) patients with ESLD who undergo either operative vs nonoperative management, and (3) patients with ESLD on the liver transplant waitlist who developed an ICH in the hospital. METHODS We retrospectively reviewed hospital charts from March 2006 through February 2017 of patients with liver disease and an ICH evaluated by the neurosurgery service at a single academic medical center. The primary outcome was survival. RESULTS We included a total of 53 patients in this study. The overall survival for patients with an admission diagnosis of liver disease who developed an ICH (n = 29, 55%) in the hospital was 22%. Of those patients with an admission diagnosis of liver disease, 27 patients also had ESLD. Kaplan-Meier analysis found no significant difference in survival for ESLD patients (n = 33, 62%) according to operative status. There were 11 ESLD patients on the liver transplant waitlist. The overall survival for patients with ESLD on the liver transplant waitlist who suffered an in-hospital ICH (n = 7, 13%) was 14%. CONCLUSION ICH in the setting of liver disease carries a grave prognosis. Also, a survival advantage for surgical hematoma evacuation in ESLD patients is not clear.
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Affiliation(s)
- Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Daniel T Nagasawa
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Daniel Azzam
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Cheng Hao Jacky Chen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Vera Ong
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Tianyi Niu
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Alexander M Tucker
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Won Kim
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Fady M Kaldas
- Department of Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Nader Pouratian
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Ronald W Busuttil
- Department of Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California.,Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California.,Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California.,UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
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Yeap MC, Chen CC, Liu ZH, Hsieh PC, Lee CC, Liu YT, Yi-Chou Wang A, Huang YC, Wei KC, Wu CT, Tu PH. Postcranioplasty seizures following decompressive craniectomy and seizure prophylaxis: a retrospective analysis at a single institution. J Neurosurg 2019; 131:936-940. [PMID: 30239312 DOI: 10.3171/2018.4.jns172519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 04/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranioplasty is a relatively simple and less invasive intervention, but it is associated with a high incidence of postoperative seizures. The incidence of, and the risk factors for, such seizures and the effect of prophylactic antiepileptic drugs (AEDs) have not been well studied. The authors' aim was to evaluate the risk factors that predispose patients to postcranioplasty seizures and to examine the role of seizure prophylaxis in cranioplasty. METHODS The records of patients who had undergone cranioplasty at the authors' medical center between 2009 and 2014 with at last 2 years of follow-up were retrospectively reviewed. Demographic and clinical characteristics, the occurrence of postoperative seizures, and postoperative complications were analyzed. RESULTS Among the 583 patients eligible for inclusion in the study, 247 had preexisting seizures or used AEDs before the cranioplasty and 336 had no seizures prior to cranioplasty. Of these 336 patients, 89 (26.5%) had new-onset seizures following cranioplasty. Prophylactic AEDs were administered to 56 patients for 1 week after cranioplasty. No early seizures occurred in these patients, and this finding was statistically significant (p = 0.012). Liver cirrhosis, intraoperative blood loss, and shunt-dependent hydrocephalus were risk factors for postcranioplasty seizures in the multivariable analysis. CONCLUSIONS Cranioplasty is associated with a high incidence of postoperative seizures. The prophylactic use of AEDs can reduce the occurrence of early seizures.
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Chen CC, Chen SW, Tu PH, Huang YC, Liu ZH, Yi-Chou Wang A, Lee ST, Chen TH, Cheng CT, Wang SY, Chou AH. Outcomes of chronic subdural hematoma in patients with liver cirrhosis. J Neurosurg 2019; 130:302-311. [PMID: 29393757 DOI: 10.3171/2017.8.jns171103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE: Burr hole craniostomy is an effective and simple procedure for treating chronic subdural hematoma (CSDH). However, the surgical outcomes and recurrence of CSDH in patients with liver cirrhosis (LC) remain unknown. METHODS: A nationwide population-based cohort study was retrospectively conducted using data from the Taiwan National Health Insurance Research Database. The study included 29,163 patients who underwent first-time craniostomy for CSDH removal between January 1, 2001, and December 31, 2013. In total, 1223 patients with LC and 2446 matched non-LC control patients were eligible for analysis. All-cause mortality, surgical complications, repeat craniostomy, extended craniotomy, and long-term medical costs were analyzed. RESULTS: The in-hospital mortality rate (8.7% vs 3.1% for patients with LC and non-LC patients, respectively), frequency of hospital admission, length of ICU stay, number of blood transfusions, and medical expenditures of patients with LC who underwent craniostomy for CSDH were considerably higher than those of non-LC control patients. Patients with LC tended to require an extended craniotomy to remove subdural hematomas in the hospital or during long-term follow-up. The surgical outcome worsened with an increase in the severity of LC. CONCLUSIONS: Even for simple procedures following minor head trauma, LC remains a serious comorbidity with a poor prognosis.
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Affiliation(s)
| | - Shao-Wei Chen
- Divisions of2Thoracic and Cardiovascular Surgery and
| | | | | | | | | | | | - Tien-Hsing Chen
- 3Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch and Linkou Medical Center, Taoyuan City, Taiwan
| | - Chi-Tung Cheng
- 4Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University; and
| | - Shang-Yu Wang
- 4Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University; and
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Seno S, Tomura S, Ono K, Tanaka Y, Ikeuchi H, Saitoh D. Poor prognostic factors in elderly patients aged 75 years old or older with mild traumatic brain injury. J Clin Neurosci 2019; 67:124-128. [PMID: 31221574 DOI: 10.1016/j.jocn.2019.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/09/2019] [Indexed: 10/26/2022]
Abstract
The incidence of traumatic brain injury (TBI) in elderly patients is increasing. We retrospectively investigated the poor prognostic factors at discharge in elderly patients aged 75 years or older admitted to hospital with mild TBI. We continuously enrolled 83 patients aged 75 years or older with mild TBI, in a private general Japanese hospital. The Glasgow Coma Scale scores on admission were within the range of 13-15. Patients with good recovery or moderate disability were included in the "good outcome" group, and those with severe disability, in a persistent vegetative state, or who died were included in the "poor outcome" group. We performed statistical analyses using 8 parameters. We conducted a univariate analysis on each item. Next, we conducted a logistic regression analysis on variables where the p < 0.20 in the univariate analysis. Elderly patients had a poor prognosis when they had dementia (odds ratio [OR]: 20.357, 95% confidence interval [CI]: 2.075-199.683, p = 0.010), cancer (OR: 14.005, 95% CI: 1.262-154.444, p = 0.032), or a history of antithrombotic therapy before admission (OR: 6.673, 95% CI: 1.072-41.526, p = 0.042). When elderly patients aged 75 years or older with mild TBI have the 3 poor prognostic factors of dementia, cancer, or a history of antithrombotic therapy, their outcomes might be worse compared to other elderly patients. Elderly patients who have these factors should be carefully managed.
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Affiliation(s)
- Soichiro Seno
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan; Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan.
| | - Satoshi Tomura
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan
| | - Kenichiro Ono
- Department of Neurosurgery, Mishuku Hospital, Tokyo, Japan
| | - Yoshihiro Tanaka
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Hisashi Ikeuchi
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan; Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
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The Effect of Underlying Liver Disease on Perioperative Outcomes Following Craniotomy for Tumor: An American College of Surgeons National Quality Improvement Program Analysis. World Neurosurg 2018; 115:e85-e96. [DOI: 10.1016/j.wneu.2018.03.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 01/10/2023]
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14
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Lagman C, Nagasawa DT, Sheppard JP, Jacky Chen CH, Nguyen T, Prashant GN, Niu T, Tucker AM, Kim W, Pouratian N, Kaldas FM, Busuttil RW, Yang I. End-Stage Liver Disease in Patients with Intracranial Hemorrhage Is Associated with Increased Mortality: A Cohort Study. World Neurosurg 2018; 113:e320-e327. [DOI: 10.1016/j.wneu.2018.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/03/2018] [Accepted: 02/05/2018] [Indexed: 12/15/2022]
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Pintea B, Baumert B, Kinfe TM, Gousias K, Parpaley Y, Boström JP. Early motor function after local treatment of brain metastases in the motor cortex region with stereotactic radiotherapy/radiosurgery or microsurgical resection: a retrospective study of two consecutive cohorts. Radiat Oncol 2017; 12:177. [PMID: 29132382 PMCID: PMC5683312 DOI: 10.1186/s13014-017-0917-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/31/2017] [Indexed: 11/25/2022] Open
Abstract
Background We compared the functional outcome and influential factors of two standard treatment modalities for central cerebral metastases: electrophysiological-controlled microsurgical resection (MSR) and stereotactic radiotherapy/stereotactic radiosurgery (SRT/SRS). Methods We performed a database search for central metastasis treatments during the period from January 2008 to September 2012 in two clinical registers: 1) register for intraoperative neuromonitoring (Department of Neurosurgery), and 2) prospective database for SRT/SRS (Department of Radiotherapy). Neurological status before and after treatment, Karnofsky performance index (KPI), histology, tumor localization and volume, and oncological status were standardized and pooled together for analysis. Muscle strength was graded on a scale of 0–5. Results We identified 27 MSR and 41 SRT/SRS cases from 68 treatments. The MSR-treated patients had significant less muscle strength in the upper and lower extremities before and after the treatment as compared to the patients receiving SRT/SRS. Muscle strength of the extremities did not change for patients receiving SRT/SRS, while MSR patients had significant improvement in lower extremity muscle strength (p = 0.05) and a non-significant improvement in the upper extremities. MSR showed significant improvement in hemiparesis as compared to radiotherapy, but this was accompanied with a significant deterioration of extremity muscle strength after surgery, as compared to SRT/SRS (improvement p = 0.04, deterioration p = 0.10). Conclusion Electrophysiologically guided microsurgery of central metastases had a significantly better functional outcome regarding hemiparesis. However, there was also a trend for less secondary neurological deterioration after SRT/SRS. Trial registration ISRCTN81776764. Retrospectively Registered 27 July 2017.
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Affiliation(s)
- Bogdan Pintea
- Department of Neurosurgery, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany. .,Department of Neurosurgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Brigitta Baumert
- Department of Radiosurgery and Stereotactic Radiotherapy, MediClin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany
| | - Thomas Mehari Kinfe
- Department of Neurosurgery, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Konstantinos Gousias
- Department of Neurosurgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Yaroslav Parpaley
- Department of Neurosurgery, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany
| | - Jan Patrick Boström
- Department of Neurosurgery, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.,Department of Radiosurgery and Stereotactic Radiotherapy, MediClin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany
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Abbas N, Makker J, Abbas H, Balar B. Perioperative Care of Patients With Liver Cirrhosis: A Review. Health Serv Insights 2017; 10:1178632917691270. [PMID: 28469455 PMCID: PMC5398291 DOI: 10.1177/1178632917691270] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 11/29/2016] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Naeem Abbas
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Naeem Abbas, Divisions of Gastroenterology and Hepatology, Department of Medicine, Bronx-Lebanon Hospital Center, 1650 Selwyn Ave, Suite 10C, Bronx, NY 10457, USA.
| | - Jasbir Makker
- Division of Gastroenterology, Bronx-Lebanon Hospital Center, Bronx, NY, USA
| | - Hafsa Abbas
- Department of Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
| | - Bhavna Balar
- Division of Gastroenterology, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Cheng CY, Ho CH, Wang CC, Liang FW, Wang JJ, Chio CC, Chang CH, Kuo JR. One-Year Mortality after Traumatic Brain Injury in Liver Cirrhosis Patients--A Ten-Year Population-Based Study. Medicine (Baltimore) 2015; 94:e1468. [PMID: 26448001 PMCID: PMC4616736 DOI: 10.1097/md.0000000000001468] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/07/2015] [Accepted: 08/07/2015] [Indexed: 12/15/2022] Open
Abstract
This study investigated the 1-year mortality of patients who underwent brain surgery following traumatic brain injury (TBI) who also had alcoholic and/or nonalcoholic liver cirrhosis (LC) using a nationwide database in Taiwan. A longitudinal cohort study matched by propensity score with age, gender, length of ICU stay, HTN, DM, MI, stroke, HF, renal diseases, and year of TBI diagnosis in TBI patients with alcoholic and/or nonalcoholic LC and TBI patients without LC was conducted using the National Health Insurance Research Database in Taiwan between January 1997 and December 2007. The main outcome studied was 1-year mortality. In total, 7296 subjects (2432 TBI patients with LC and 4864 TBI patients without LC) were enrolled in this study. The main findings were (1) TBI patients with LC had a higher 1-year mortality (52.18% vs 30.61%) and a 1.75-fold increased risk of mortality (95% CI 1.61-1.90) compared with non-LC TBI patients, (2) renal diseases and HF are risk factors, but hypertension could be a protective factor in cirrhotic TBI patients, and (3) TBI patients with non-alcoholic LC and the coexistence of alcoholic and nonalcoholic LC had higher 1-year mortality compared with TBI patients with alcoholic cirrhosis. This study showed that patients with LC who have undergone brain surgery might have higher risk of 1-year mortality than those without LC. In addition, nonalcoholic and the coexistence of alcoholic and nonalcoholic LC show higher 1-year mortality risk than alcoholic in TBI patients with LC, especially in those with comorbidities of hypertension, diabetes mellitus, and stroke.
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Affiliation(s)
- Chieh-Yang Cheng
- From the Departments of Neurosurgery (C-YC, C-CW, C-CC, C-HC, J-RK); Medical Research, Chi-Mei Medical Center, Tainan, Taiwan (C-HH, J-JW, J-RK); Departments of Biotechnology (J-RK); ChildCare, Southern Taiwan University of Science and Technology, Tainan, Taiwan (C-CW); Departments of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan (F-WL); and Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan (C-HH)
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Chen CC, Huang YC, Yeh CN. Neurosurgical procedures in patients with liver cirrhosis: A review. World J Hepatol 2015; 7:2352-7. [PMID: 26413225 PMCID: PMC4577643 DOI: 10.4254/wjh.v7.i21.2352] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/22/2015] [Accepted: 08/30/2015] [Indexed: 02/06/2023] Open
Abstract
Liver cirrhosis, a devastating liver fibrosis caused by hepatitis/inflammation or tumors, is a major comorbid factor in known surgery fields, such as cardiovascular and abdominal surgeries. It is important to review possible comorbid results in neurosurgical procedures in cirrhotic patients. In the reviewed literature, Child-Pugh and model for end-stage liver disease scores are commonly used in the assessment of surgical risks for cirrhotic patients undergoing abdominal, cardiovascular or neurosurgical procedures. The major categories of neurosurgery are traumatic brain injury (TBI), spontaneous intracranial hemorrhage (SICH), brain tumors, and spinal instrumentation procedures. TBI was reported with surgical mortality as high as 34.5% and a complication rate of 87.2%. For SICH, mortality ranged from 22.7% to 47.0%, while complications were reported to be 43.2%. Less is discussed in brain tumor patients; still the postoperative hemorrhage rate approached 26.7%. In spinal fusion instrumentation procedures, the complication rate was as high as 41.0%. Preoperative assessment and correction could possibly decrease complications such as hemorrhage, wound infection and other cirrhosis-related complications (renal, pulmonary, ascites and encephalopathy). In this study, we reviewed the neurosurgical-related literature with regard to liver cirrhosis as a prognostic factor influencing neurosurgical outcomes.
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Affiliation(s)
- Ching-Chang Chen
- Ching-Chang Chen, Yin-Cheng Huang, Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Yin-Cheng Huang
- Ching-Chang Chen, Yin-Cheng Huang, Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chun-Nan Yeh
- Ching-Chang Chen, Yin-Cheng Huang, Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
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Shi HY, Hwang SL, Lee IC, Chen IT, Lee KT, Lin CL. Trends and outcome predictors after traumatic brain injury surgery: a nationwide population-based study in Taiwan. J Neurosurg 2014; 121:1323-30. [PMID: 25280095 DOI: 10.3171/2014.8.jns131526] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors sought to analyze trends in hospital resource utilization and mortality rates in a population of patients who had received traumatic brain injury (TBI) surgery. METHODS This nationwide population-based cohort study retrospectively analyzed 18,286 patients who had received surgical treatment for TBI between 1998 and 2010. The multiple linear regression model and Cox proportional hazards model were used for multivariate assessment of outcome predictors. RESULTS The prevalence rate of surgical treatment for patients with TBI gradually but significantly (p < 0.001) increased by 47.6% from 5.0 per 100,000 persons in 1998 to 7.4 per 100,000 persons in 2010. Age, sex, Deyo-Charlson comorbidity index score, hospital volume, and surgeon volume were significantly associated with TBI surgery outcomes (p < 0.05). Over the 12-year period analyzed, the estimated mean hospital treatment cost increased 19.06%, whereas the in-hospital mortality rate decreased 10.9%. The estimated mean time of overall survival after TBI surgery (± SD) was 83.0 ± 4.2 months, and the overall in-hospital and 1-, 3-, and 5-year survival rates were 74.5%, 67.3%, 61.1%, and 57.8%, respectively. CONCLUSIONS These data reveal an increased prevalence of TBI, especially in older patients, and an increased hospital treatment cost but a decreased in-hospital mortality rate. Health care providers and patients should recognize that attributes of the patient and of the hospital may affect hospital resource utilization and the mortality rate. These results are relevant not only to other countries with similar population sizes but also to countries with larger populations.
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Affiliation(s)
- Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics and
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Han MS, Moon KS, Lee KH, Cho SB, Lim SH, Jang WY, Jung TY, Kim IY, Jung S. Brain metastasis from hepatocellular carcinoma: the role of surgery as a prognostic factor. BMC Cancer 2013; 13:567. [PMID: 24289477 PMCID: PMC3879022 DOI: 10.1186/1471-2407-13-567] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 11/27/2013] [Indexed: 02/06/2023] Open
Abstract
Background The incidence of brain metastasis from hepatocellular carcinoma (HCC) is expected to increase as a result of prolonged survival due to the recent advances in HCC treatment. However, there is no definite treatment strategy for brain metastasis from HCC mainly due to its rarity and dismal prognosis. To provide helpful recommendations in treatment of brain metastasis from HCC, the authors aimed to identify prognostic factors that influence survival rates with a review of the recently published data. Methods Thirty-three cases of brain metastasis, whose incidence was 0.65%, were selected from a total of 5015 HCC patients and reviewed retrospectively in terms of clinical and radiological features. Results Median overall survival time after diagnosis of brain metastasis was 10.4 weeks (95% confidence interval [CI], 5.1-15.7 weeks) with 1-, 6- and 12-month survival rates, of 79%, 24% and 6%, respectively. Median survival of the patients treated with surgical resection or surgical resection followed by whole-brain radiation therapy (WBRT) (25.3 weeks; range, 15.8-34.8 weeks) was longer than that of the patients treated with gamma knife surgery (GKS), WBRT, or GKS followed by WBRT (10.4 weeks; range, 7.5-13.3 weeks) as well as that of patients treated with only steroids (1 week; range, 0.0-3.3 weeks) (p < 0.001). Child-Pugh’s classification A group had a longer median survival time than Child-Pugh’s classification B or C group (14.4 weeks vs 8.4 weeks, p = 0.038). RPA class I & II group had also a longer median survival time than RPA class III group did (13.4 weeks vs 2.4 weeks, p = 0.001). Surgical resection (hazard ratio [HR] 0.23, 95% CI 0.08-0.66, p = 0.006) and good liver function at the time of brain metastasis (HR 0.25, 95% CI 0.09-0.69, p = 0.007) were found to be the powerful prognostic factors for favorable survival in the multivariate analysis. In addition, presence of intratumoral hemorrhage was a statistically significant prognostic factor for survival. Conclusion Although HCC patients with brain metastasis showed a very dismal prognosis, surgical intervention was shown to lead to relative prolongation of the survival time, especially in those with preserved hepatic function.
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Affiliation(s)
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Gwangju, South Korea.
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Early mortality and long-term survival after abdominal surgery in patients with liver cirrhosis. Surgery 2013; 155:623-32. [PMID: 24468037 DOI: 10.1016/j.surg.2013.11.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 11/15/2013] [Indexed: 02/07/2023]
Abstract
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.
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Yeh CC, Liao CC, Chang YC, Jeng LB, Yang HR, Shih CC, Chen TL. Adverse outcomes after noncardiac surgery in patients with diabetes: a nationwide population-based retrospective cohort study. Diabetes Care 2013; 36:3216-21. [PMID: 23990518 PMCID: PMC3781492 DOI: 10.2337/dc13-0770] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate whether diabetes affects perioperative complications or mortality and to gauge its impact on medical expenditures for noncardiac surgeries. RESEARCH DESIGN AND METHODS With the use of reimbursement claims from the Taiwan National Health Insurance system, we performed a population-based cohort study of patients with and without diabetes undergoing noncardiac surgeries. Outcomes of postoperative complications, mortality, hospital stay, and medical expenditures were compared between patients with and without diabetes. RESULTS Diabetes increased 30-day postoperative mortality (odds ratio 1.84 [95% CI 1.46-2.32]), particularly among patients with type 1 diabetes or uncontrolled diabetes and patients with preoperative diabetes-related comorbidities, such as eye involvement, peripheral circulatory disorders, ketoacidosis, renal manifestations, and coma. Compared with nondiabetic control patients, coexisting medical conditions, such as renal dialysis (5.17 [3.68-7.28]), liver cirrhosis (3.59 [2.19-5.88]), stroke (2.87 [1.95-4.22]), mental disorders (2.35 [1.71-3.24]), ischemic heart disease (2.08 [1.45-2.99]), chronic obstructive pulmonary disease (1.96 [1.29-2.97]), and hyperlipidemia (1.94 [1.01-3.76]) were associated with mortality for patients with diabetes undergoing noncardiac surgery. Patients with diabetes faced a higher risk of postoperative acute renal failure (3.59 [2.88-4.48]) and acute myocardial infarction (3.65 [2.43-5.49]). Furthermore, diabetes was associated with prolonged hospital stay (2.30 [2.16-2.44]) and increased medical expenditures (1.32 [1.25-1.40]). CONCLUSIONS Diabetes increases postoperative 30-day mortality, complications, and medical expenditures in patients undergoing in-hospital noncardiac surgeries.
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