Abstract
BackgroundColorectal cancer (CRC) is common, with surgery as the main curative treatment. The prevalence of chronic liver disease has increased, but knowledge is limited on postoperative mortality in patients with liver disease who undergo CRC surgery. Hence, we examined 30-day mortality after CRC surgery in patients with liver disease compared to those without liver disease.MethodsWe used medical databases to conduct a nationwide cohort study of all patients undergoing CRC surgery in Denmark from 1996 through 2009. We further identified patients diagnosed with any liver disease before CRC surgery and categorized them into two cohorts: patients with non-cirrhotic liver disease and patients with liver cirrhosis. Patients without liver disease were defined as the comparison cohort. Using the Kaplan-Meier method, we computed 30-day mortality after CRC surgery in each cohort. We used a Cox regression model to compute hazard ratios as measures of the relative risk (RR) of death, controlling for potential confounders including comorbidities. In order to examine the impact of liver disease in different subgroups, we stratified patients by gender, age, cancer stage, cancer site, timing of admission, type of surgery, comorbidity level, and non-hepatic alcohol-related disease.ResultsOverall, 39,840 patients underwent CRC surgery: 369 (0.9%) had non-cirrhotic liver disease and 158 (0.4%) had liver cirrhosis. Thirty-day mortality after CRC surgery was 8.7% in patients without liver disease and 13.3% in patients with non-cirrhotic liver disease (adjusted RR of 1.49 95% confidence interval (CI): 1.12-1.98). Among patients with liver cirrhosis, mortality was 24.1%, corresponding to an adjusted RR of 2.59 (95% CI: 1.86-3.61). The negative impact of liver disease on postoperative mortality was found in all subgroups.ConclusionsPre-existing liver disease was associated with a markedly increased 30-day mortality following CRC surgery.
Highlights
Colorectal cancer (CRC) is common, with surgery as the main curative treatment
Only a few studies have addressed the association between liver disease and mortality following colorectal surgery [5,6,7,8,9,10], and only one focused on mortality after CRC surgery [5]
We identified the diseases in the Charlson Comorbidity Index using International Classification of Diseases (ICD)-8 and ICD-10 diagnosis codes [17], excluding mild and severe liver disease, CRC, CRC metastases, secondary liver cancers, and hepatocellular carcinoma
Summary
The prevalence of chronic liver disease has increased, but knowledge is limited on postoperative mortality in patients with liver disease who undergo CRC surgery. The majority of former studies has been based on data from referral centers [5,8,9] and did not include patients with non-cirrhotic liver disease [5,7,8,9,10] They have been hampered by small study populations [5,8,9], lack of information on comorbidity and surgery [5,8], lack of comparison cohorts of patients without liver disease undergoing same type of surgery [5,8,9], and restriction to in-hospital mortality [7,9,10]. The comorbidity data in former studies were limited by incomplete information as only diagnoses recorded within a short period before surgery were available [6,7,9,10]
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