Surgical decision making in patients with cirrhosis: a systematic review of the literature

Abstract

Background: The incidence of cirrhosis is increasing and many patients affected by this disease process will require some form of operation (elective vs emergent). In these individuals, the decision making process can be quite demanding. These individuals require adequate assessment for the degree of hepatic dysfunction, extent of both portal hypertension and their comorbidities for perioperative optimization. Some of the common operations performed in patients with cirrhosis involve biliary, colorectal disease and ventral hernias. The primary aim of this study is a systematic review of the literature to determine the decision making process involved with three common emergent surgical cases. Methods: A systematic review of the literature using Pubmed, Medline and Embase was performed. Non case reports and retrospective reviews of patients with cirrhosis undergoing emergency surgery were identified. In addition to the systematic review, 3 specific cases were utilized to highlight the issues involving patients with cirrhosis and common gastrointestinal emergencies. These cases involved patients with cirrhosis who developed: ischemic bowel, acute cholecystitis and an incarcerated umbilical hernia. The decision making aspect in each case involved deciding whether to perform a primary anastomosis post bowel resection versus creation of a stoma, laparoscopic cholecystectomy versus percutaneous drainage and finally the ideal management of an incarcerated umbilical hernia with ascites. Results: High grade evidence for decision making is lacking. In patients with cirrhosis complicated by ischemic bowel, individuals with Child Pugh A or a MELD score <10 display the best outcomes. Whether to create a stoma versus resection and primary anastomosis in end stage liver disease, there is no level 1 evidence to support either. There were no studies identified for this patient population and most studies involved individuals with colorectal disease. However, in the French Association of Surgery series, patients with cirrhosis that had a protective stoma are at risk for stoma complications such as ascites leakage, ascites infection, peristomal varices. There was a 7% fistula rate in individuals with resection and primary anastomosis. Acute cholecystitis in patients with Child Pugh A/B can be treated with laparoscopic cholecystectomy and or subtotal cholecystectomy. For Child Pugh C medical management should be attempted followed by percutaneous transhepatic cholecystostomy tube as necessary. Finally, individuals with an incarcerated umbilical hernia should have emergent surgery and repair of their hernia. Intraoperatively placed closed suction drains can be used to control post-operative ascites and allow for adequate wound healing. Ascites should also be managed aggressively with medical therapy and possible emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS) as necessary. Conclusion: Advanced liver disease complicates many common gastrointestinal surgeries. The decision making process surrounding these operations is far from standardized as high grade evidence recommending optimal management is lacking. Management of cirrhosis in these not un- common emergency settings rely mostly on retrospective data and small cohort studies thus the treatment can vary from surgeon to surgeon.