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Duan M, Cao L, Lu M, Zhang T, Ji Q, Guo X, Guo Z, Wu Q, Liu Y, Gong J, Zhu W, Li Y. Prophylactic Intra-abdominal Drainage is Associated With Lower Postoperative Complications in Patients With Crohn's Disease: A Randomized Controlled Trial. Surg Innov 2024; 31:157-166. [PMID: 38339842 DOI: 10.1177/15533506241232598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Prophylactic intraoperative drains have been shown not superior for patients underwent intestinal surgery. However, for patients with Crohn's disease (CD), this needs further exploration. METHODS In this pilot study, CD patients were randomly assigned to drain (n = 50) and no-drain (n = 50) groups. The primary endpoint was the rate of postoperative prolonged ileus (PPOI). The secondary endpoints were postoperative abdominal ascites, postoperative systemic inflammatory response syndrome (SIRS) and C-reactive protein (CRP) levels. RESULTS The incidences of PPOI and postoperative abdominal ascites were significantly lower in the drain group (12% vs 44%; 0% vs 24%, both P < .05). Postoperative SIRS incidence and CRP levels were significantly increased in the no-drain group [36% vs 10%; 54.9 vs 34.3 mg/L, both P < .05]. In multivariate analysis, prophylactic drainage was the independent protective factor for PPOI and postoperative LOS. CONCLUSIONS Prophylactic drainage may be associated with improved clinical outcomes in CD patients.
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Affiliation(s)
- Ming Duan
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Mengjie Lu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qing Ji
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Xian Guo
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qiong Wu
- Department of Scientific Research and Training, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing, China
| | - Yuxiu Liu
- Data and Statistics Division, Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Takai K, Saeki M, Takaoka S, Tada Y, Fujimura R, Harada T, Yamauchi T, Kumano H. Negative pressure wound therapy for prolonged surgical wound healing after brachiobasilic arteriovenous fistula creation in a patient with end-stage liver failure. J Vasc Access 2024; 25:327-330. [PMID: 35708249 DOI: 10.1177/11297298221106102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A 54-year-old male patient diagnosed with hepatorenal syndrome caused by decompensated alcoholic cirrhosis was referred for arteriovenous fistula (AVF) creation after initiation of hemodialysis. A brachiobasilic arteriovenous fistula (BBAVF) was created because neither forearm had suitable vasculature. Large-volume serous effusion from the incision persisted postoperatively, and we started negative pressure wound therapy (NPWT) for wound protection. The effusion volume decreased gradually; however, up to 80 ml of discharge continued daily. Re-operation was performed 35 days after the initial operation, followed by continued NPWT. The wound was almost healed 85 days after the primary surgery. We present a case of severe surgical wound complication after AVF creation in a patient with hemostatic and coagulation disorders and malnutrition caused by end-stage hepatic failure. We confirmed the usefulness of NPWT for excessive surgical wound effusion and the adequacy of BBAVF for vascular access.
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Affiliation(s)
- Kanako Takai
- Department of Critical Care Medicine, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
| | - Maki Saeki
- Nursing Department, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
| | - Seiji Takaoka
- Department of Nephrology, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
| | - Yusuke Tada
- Department of Critical Care Medicine, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
| | - Ryuta Fujimura
- Department of Nephrology, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
| | - Tamaki Harada
- Department of Nephrology, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
| | - Takashi Yamauchi
- Department of Cardiovascular Surgery, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
| | - Hodaka Kumano
- Department of Critical Care Medicine, Higashiosaka City Medical Center, Higashiosaka, Osaka Prefecture, Japan
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The Management of Postoperative Cognitive Dysfunction in Cirrhotic Patients: An Overview of the Literature. Medicina (B Aires) 2023; 59:medicina59030465. [PMID: 36984466 PMCID: PMC10053389 DOI: 10.3390/medicina59030465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Background and objectives: Postoperative cognitive dysfunction (POCD) represents a decreased cognitive performance in patients undergoing general anesthesia for major surgery. Since liver cirrhosis is associated with high mortality and morbidity rates, cirrhotic patients also assemble many risk factors for POCD. Therefore, preserving cognition after major surgery is a priority, especially in this group of patients. The purpose of this review is to summarize the current knowledge regarding the effectiveness of perioperative therapeutic strategies in terms of cognitive dysfunction reduction. Data Collection: Using medical search engines such as PubMed, Google Scholar, and Cochrane library, we analyzed articles on topics such as: POCD, perioperative management in patients with cirrhosis, hepatic encephalopathy, general anesthesia in patients with liver cirrhosis, depth of anesthesia, virtual reality in perioperative settings. We included 115 relevant original articles, reviews and meta-analyses, and other article types such as case reports, guidelines, editorials, and medical books. Results: According to the reviewed literature, the predictive capacity of the common clinical tools used to quantify cognitive dysfunction in cirrhotic settings is reduced in perioperative settings; however, novel neuropsychological tools could manage to better identify the subclinical forms of perioperative cognitive impairments in cirrhotic patients. Moreover, patients with preoperative hepatic encephalopathy could benefit from specific preventive strategies aimed to reduce the risk of further neurocognitive deterioration. Intraoperatively, the adequate monitoring of the anesthesia depth, appropriate anesthetics use, and an opioid-sparing technique have shown favorable results in terms of POCD. Early recovery after surgery (ERAS) protocols should be implemented in the postoperative setting. Other pharmacological strategies provided conflicting results in reducing POCD in cirrhotic patients. Conclusions: The perioperative management of the cognitive function of cirrhotic patients is challenging for anesthesia providers, with specific and targeted therapies for POCD still sparse. Therefore, the implementation of preventive strategies appears to remain the optimal attitude. Further research is needed for a better understanding of POCD, especially in cirrhotic patients.
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van Beekum CJ, Beckmann C, Semaan A, Manekeller S, Matthaei H, Braun L, Willis MA, Kalff JC, Vilz TO. Predictors of Morbidity and Mortality After Colorectal Surgery in Patients With Cirrhotic Liver Disease–A Retrospective Analysis of 54 Cases at a Tertiary Care Center. Front Med (Lausanne) 2022; 9:886566. [PMID: 35814748 PMCID: PMC9257019 DOI: 10.3389/fmed.2022.886566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDespite various existing scores that predict morbidity and mortality of patients with cirrhotic liver disease (CLD), data on specific risk stratification of patients with CLD undergoing colorectal surgery (CRS) are rare. The aim of this study was to assess in-hospital morbidity and mortality of patients with liver cirrhosis scheduled for CRS, with specific focus on possible pitfalls of surgery in this special cohort.MethodsBetween 1996 and 2018, 54 patients with CLD undergoing CRS were identified and included in this study cohort. Postoperative morbidity and mortality were assessed using the Clavien/Dindo (C/D) classification as well as by type of complication. Univariate and multivariate analyses were performed to analyze the predictive factors for increased postoperative morbidity.ResultsOf the patients, 37% patients died during the procedure or postoperatively. Major complications were seen in 23.1% of patients (>C/D IIIb). Patients with Child B or C cirrhosis as well as patients undergoing emergency surgery experienced significantly more major complications (p = 0.04 and p = 0.023, respectively). The most common complications were bleeding requiring blood transfusion (51.1%) and cardiocirculatory instability due to bleeding or sepsis (44.4%). In 53.7% of patients, an anastomosis was created without a protective ostomy. Anastomotic leakage occurred in 20.7% of these patients. Multivariate analysis showed that a primary anastomosis without a protective ostomy was the strongest risk factor for major complications (p = 0.042).DiscussionMorbidity and mortality after CRS in patients with CLD remains high and is not only influenced by liver function but also by surgical variables. Considering the high rate of anastomotic leakage, creating a protective or definitive ostomy must be considered with regard to the underlying pathology, the extent of CLD, and the patient's condition. Moreover, our data suggest that surgery in these most fragile patients should be performed only in experienced centers with immediate contact to hepatologists and experts in hemostasis.
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Chang J, Meinke J, Geck M, Hebest M, Böhling N, Dolscheid-Pommerich R, Stoffel-Wagner B, Kristiansen G, Overhaus M, Peyman LO, Klein S, Uschner FE, Brol MJ, Vilz TO, Lingohr P, Kalff JC, Jansen C, Strassburg CP, Wehner S, Trebicka J, Praktiknjo M. Extrahepatic Surgery in Cirrhosis Significantly Increases Portal Pressure in Preclinical Animal Models. Front Physiol 2021; 12:720898. [PMID: 34489738 PMCID: PMC8418541 DOI: 10.3389/fphys.2021.720898] [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: 06/05/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Liver cirrhosis is a relevant comorbidity with increasing prevalence. Postoperative decompensation and development of complications in patients with cirrhosis remains a frequent clinical problem. Surgery has been discussed as a precipitating event for decompensation and complications of cirrhosis, but the underlying pathomechanisms are still obscure. The aim of this study was to analyze the role of abdominal extrahepatic surgery in cirrhosis on portal pressure and fibrosis in a preclinical model. Methods: Compensated liver cirrhosis was induced using tetrachlormethane (CCL4) inhalation and bile duct ligation (BDL) models in rats, non-cirrhotic portal hypertension by partial portal vein ligation (PPVL). Intestinal manipulation (IM) as a model of extrahepatic abdominal surgery was performed. 2 and 7 days after IM, portal pressure was measured in-vivo. Hydroxyproline measurements, Sirius Red staining and qPCR measurements of the liver were performed for evaluation of fibrosis development and hepatic inflammation. Laboratory parameters of liver function in serum were analyzed. Results: Portal pressure was significantly elevated 2 and 7 days after IM in both models of cirrhosis. In the non-cirrhotic model the trend was the same, while not statistically significant. In both cirrhotic models, IM shows strong effects of decompensation, with significant weight loss, elevation of liver enzymes and hypoalbuminemia. 7 days after IM in the BDL group, Sirius red staining and hydroxyproline levels showed significant progression of fibrosis and significantly elevated mRNA levels of hepatic inflammation compared to the respective control group. A progression of fibrosis was not observed in the CCL4 model. Conclusion: In animal models of cirrhosis with continuous liver injury (BDL), IM increases portal pressure, and development of fibrosis. Perioperative portal pressure and hence inflammation processes may be therapeutic targets to prevent post-operative decompensation in cirrhosis.
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Affiliation(s)
- Johannes Chang
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Jonathan Meinke
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Moritz Geck
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Marc Hebest
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Nina Böhling
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | | | | | | | - Marcus Overhaus
- Department of Visceral Surgery, Malteser Hospital Sankt Hildegardis, Cologne, Germany
| | - Leon O Peyman
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Sabine Klein
- Translational Hepatology, Department of Internal Medicine 1, University of Frankfurt, Frankfurt, Germany
| | - Frank E Uschner
- Translational Hepatology, Department of Internal Medicine 1, University of Frankfurt, Frankfurt, Germany
| | - Maximilian J Brol
- Translational Hepatology, Department of Internal Medicine 1, University of Frankfurt, Frankfurt, Germany
| | - Tim O Vilz
- Department of Surgery, University of Bonn, Bonn, Germany
| | | | - Jörg C Kalff
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Sven Wehner
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Jonel Trebicka
- Translational Hepatology, Department of Internal Medicine 1, University of Frankfurt, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Michael Praktiknjo
- Department of Internal Medicine 1, Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
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