Abstract
Simple SummaryIt is well known that the incidence of liver cirrhosis is increasing and it negatively affects outcome after surgery. While there are several studies investigating the influence of liver cirrhosis on colorectal, hepatobiliary, or hernia surgery, data about its impact on small bowel surgery are completely lacking. Therefore, a retrospective analysis over a period of 17 years was performed including 76 patients with liver cirrhosis and small bowel surgery. Postsurgical complications were analyzed, and 38 parameters as possible predictive factors for a worse outcome were investigated. We observed postsurgical complications in over 90% of the patients; in over 50%, the complications were classified as severe. When subdividing postoperative complications, bleeding, respiratory problems, wound healing disorders and anastomotic leakage, hydropic decompensation, and renal failure were most common. The most important predictive factors for those complications after uni- and multivariate analysis were portal hypertension, poor liver function, emergency or additional surgery, ascites, and high ASA score. We, therefore, recommend treatment of portal hypertension before small bowel surgery to avoid extension of the operation to other organs than the small bowel and in case of ascites to evaluate the creation of an anastomosis stoma instead of an unprotected anastomosis to prevent leakages.(1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were “additional surgery” (OR 5.3) and “bowel anastomosis” (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients’ outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.
Highlights
Liver cirrhosis (LC) is the common final stage of various chronic liver injuries such as viral or autoimmune hepatitis, alcoholic liver disease, and non-alcoholic steatohepatitis (NASH) caused by metabolic diseases or obesity [1,2,3].The prevalence of LC has increased in the past decades while the life expectancy of patients suffering from LC improved since the introduction of novel therapies of viral hepatitis and optimized treatment strategies of comorbidities of cirrhotic liver disease
We identified the model of end-stage liver disease (MELD) score
While postoperative mortality for non-cirrhotic patients undergoing hernia repair, cholecystectomy, or bile duct exploration varies between 0.7% and 3.5%, it significantly increases in patients with LC to 8.3% in hernia repair and up to 25% in bile duct exploration, depending on the remaining liver function assessable as
Summary
Liver cirrhosis (LC) is the common final stage of various chronic liver injuries such as viral or autoimmune hepatitis, alcoholic liver disease, and non-alcoholic steatohepatitis (NASH) caused by metabolic diseases or obesity [1,2,3].The prevalence of LC has increased in the past decades while the life expectancy of patients suffering from LC improved since the introduction of novel therapies of viral hepatitis and optimized treatment strategies of comorbidities of cirrhotic liver disease. Liver cirrhosis (LC) is the common final stage of various chronic liver injuries such as viral or autoimmune hepatitis, alcoholic liver disease, and non-alcoholic steatohepatitis (NASH) caused by metabolic diseases or obesity [1,2,3]. The increased risk of mortality in patients with LC is the consequence of elevated bacterial infection rates, higher bleeding complications, and postoperative development of acute-on-chronic liver failure (ACLF) [7]. While postoperative mortality for non-cirrhotic patients undergoing hernia repair, cholecystectomy, or bile duct exploration varies between 0.7% and 3.5%, it significantly increases in patients with LC to 8.3% in hernia repair and up to 25% in bile duct exploration, depending on the remaining liver function assessable as
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