Surgery In Cirrhotic Patients Research Articles

Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis

BackgroundFew studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care.MethodsA literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates.ResultsAfter evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31–0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference − 2.04, 95% CI − 3.19 to − 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure.ConclusionIn cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.

How to manage a patient with chronic liver disease undergoing colorectal surgery?

The indications for colorectal surgery in cirrhotic patients have recently been broadened, mostly due to a better understanding and multidisciplinary management of cirrhosis. However, anesthesia and colorectal surgery may both exacerbate deteriorations in liver function in a patient with chronic liver disease such that careful preoperative patient selection remains mandatory. Four scores (i.e., Child-Turcotte-Pugh, the Model for End-Stage Liver Disease, Mayo Risk Score, and (VOCAL)-Penn cirrhosis surgical risk score) are currently available to assess the severity of cirrhosis, determine the risk of decompensation, and to estimate postoperative mortality. For colorectal resection to be safely performed electively in patients with compensated liver disease, optimization of the patient is mandatory in the preoperative setting. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is a promising strategy in patients with portal hypertension, but it requires further evaluation. Similarly, further studies are needed to validate both the feasibility and safety of the laparoscopic approach to colorectal surgery in cirrhotic patients. In summary, preoperative identification and optimization combined with meticulous postoperative care are essential for optimum outcomes in patients with chronic liver disease undergoing colorectal surgery.

Management of Cholelithiasis in Cirrhotic Patients.

Gallstone disease (GD) is a common disease worldwide and has a higher incidence in cirrhotic patients than in the general population. The main indications for cholecystectomy surgery in cirrhotic patients remain symptomatic cholelithiasis and its complications. Over the past two decades, numerous published reports have attested to the feasibility and safety of laparoscopic cholecystectomy in cirrhotic patients. Surgery in patients with liver cirrhosis represents an additional source of stress for an already impaired liver function and perioperative complications are remarkably high compared to non-cirrhotic patients, despite significant advances in surgical management. Therefore, preoperative risk stratification and adequate patient selection are mandatory to minimize postoperative complications. We have conducted a systematic review of the literature over the last 22 years for specific information on indications for surgery in cirrhotic patients and individual percentages of Child-Pugh grades undergoing treatment. There are very few reported cases of cholecystectomy and minimally invasive treatment, such as percutaneous transhepatic cholecystostomy (PTC), in patients with Child-Pugh grade C cirrhosis. With this work, we would like to pay attention to the treatment of cholelithiasis in cirrhotic patients who are still able to undergo cholecystectomy, thus also encouraging this type of intervention in cases of asymptomatic cholelithiasis in patients with Child-Pugh grades A and B.

Enhanced Recovery After Surgery (ERAS) after liver surgery in cirrhotic patients: A systematic review and meta-analysis

Objectives: The beneficial effects on postoperative outcomes of Enhanced Recovery after Surgery (ERAS) in liver surgery are now well established. However, few studies have assessed the applicability of ERAS in liver surgery in cirrhotic patients. The aim of the present systematic review and meta-analysis was to assess the impact of ERAS pathways on outcomes after liver surgery in patients with cirrhosis compared to non-ERAS care.

Helpfulness of the liver disease scores in cardiac surgery for cirrhotic patients.

Liver cirrhosis is a well-known risk factor of mortality after cardiac surgery, but not considered in the widely used EuroSCOREII (ESII). The objective was to analyse the performance of the ESII, the Child-Pugh-Turcotte (CPT) and the Model of End-stage Liver Disease (MELD) scores to predict hospital mortality in cardiac surgery for cirrhotic patients and to analyse the survival according to the preoperative cirrhosis status. Preoperative and cirrhosis characteristics and postoperative outcomes were compared according to hospital mortality. The performance of the 3 scores was analysed by the area under the receiver-operating characteristics (AUC-ROC) by DeLong's method. The survival of the patients who were discharged was analysed by Kaplan-Meier curves according to the preoperative cirrhosis status. Seventy-four patients were included. Observed hospital mortality was 12%, the predictive mortality by ESII was 3.9% ± 5.2%, and AUC-ROC was 0.67 [0.44-0.90]. Only the MELD score was discriminant (AUC-ROC 0.75 [0.57-0.93]). The observed hospital mortality increased by threefold over the ESII (12% versus 3.9%, p < 0.001), except the patients with MELD < 10 for whom hospital mortality was similar as ESII (3% versus 2.6%, p = 0.89). Long-term survival was higher for the MELD < 10 patients. The ESII did not predict hospital mortality after a cardiac surgery in cirrhotic patients and the MELD score should be considered for decision of cardiac intervention in cirrhotic patients.

Bariatric Surgery and Liver Disease: General Considerations and Role of the Gut-Liver Axis.

Weight loss is a therapeutic solution for many metabolic disorders, such as obesity and its complications. Bariatric surgery aims to achieve lasting weight loss in all patients who have failed after multiple dietary attempts. Among its many benefits, it has been associated with the regression of non-alcoholic fatty liver disease (NAFLD), which is often associated with obesity, with evidence of substantial improvement in tissue inflammation and fibrosis. These benefits are mediated not only by weight loss, but also by favorable changes in systemic inflammation and in the composition of the gut microbiota. Changes in microbial metabolites such as short-chain fatty acids (SCFAs), capable of acting as endocrine mediators, and bile acids (BAs) as well as modifications of the gut-brain axis, are among the involved mechanisms. However, not all bariatric surgeries show beneficial effects on the liver; those leading to malabsorption can cause liver failure or a marked worsening of fibrosis and the development of cirrhosis. Nevertheless, there are still many unclear aspects, including the extent of the benefits and the magnitude of the risks of bariatric surgery in cirrhotic patients. In addition, the usefulness and the safety of these procedures in patients who are candidates to or who have undergone liver transplant need solid supporting evidence. This paper aims to review literature data on the use of bariatric surgery in the setting of chronic liver disease.

Cirrhotic Patients Undergoing Cardiac Surgery: Why Not to Develop a More Specific Heart-Liver Score?

Despite not included in the traditional risk scores before surgery, liver cirrhosis, especially in advanced stages, has always influenced strongly final outcome both on short and midterm in patients undergoing cardiac surgery. Growing incidence of non-alcoholic fatty liver disease interlinked with metabolic syndrome and significant advancements in medical therapy have actually increased the likelihood of cardiac surgery in cirrhotic patients. To date, Child-Pugh and MELD scores have been commonly used to predict mortality and postoperative hepatic decompensation, but on the other hand, both traditional risk scores show some limitations for evaluation of hepatopathic patients undergoing specifically cardiac surgery. In this context, a specific Heart-Liver score hasn’t been developed yet in the attempt to outline a patient profile able to face surgery, therefore addressing us to adopt the best strategy possible for each case. If CP class A or low MELD score (<11) patients tolerate cardiac surgery with a mild increase in mortality and morbidity, currently state of art recommends particular caution towards surgery idea in presence of advanced hepatic disease. As far as cardiac surgery represents the unique therapeutic strategy in several life-threatening cases, anyway surgical correction of cardiac pathology won’t guarantee an increased life expectancy in accordance with the persistent liver dysfunction. Hereby, this paper will focus on preoperative parameters that should be considered in the future realization of a Heart-Liver prognostic score for overcoming limitations and difficulties related to the impact of liver disease on final clinical outcome.

Utilization of Laparoscopic Surgery in Cirrhosis of the Liver

Surgery in patients with cirrhosis of the liver is dangerous and risky due to abnormalities in their physiology. However these patients do present with conditions that may require surgical intervention. Laparoscopic surgery is safer for these patients as it mitigates the dangers and complications associated with open surgery, offers shorter operation time and subserves a diagnostic value in its safe use to determine and confirm the pathology of the liver. The aim of this study is to determine if laparoscopic surgery is dangerous or safe for patients with cirrhosis of the liver. A literature review was done using search engines viz Hinari, goggle, high wire press and overview of our experiences in patients in university of medical science teaching hospital Ondo. References to our experiences during our subspecialty training at world laparoscopy hospital New-Delhi were also beneficial in the course of this study. The results show that the technique of laparoscopy in all index cases is more favourable than open surgery in cirrhotic patients. We conclude that cirrhosis of the liver does not contraindicate the procedure of laparoscopy.

What are the Particularities of Splenic Surgery in Cirrhotic Patients?

The aim of this work was to review the entire literature on splenic surgery in cirrhotic patients in order to best define the surgical indications and their management specifics. A review of the international literature published between January 1995 and August 2015 was thus carried out.

What are the Specifics of Abdominal Wall Surgery in Cirrhotic Patients.

The risk of developing an abdominal wall hernia is high in the cirrhotic patient, due to the association of ascites, hypoalbuminemia and amyotrophy in connection with undernutrition frequently associated with cirrhosis. Thus, almost 20% of cirrhotic patients develop an umbilical hernia. Parietal surgery is more at risk in cirrhotic patients and its indications must be discussed on a case-by-case basis. The objective of this work was to review the entire literature on wall surgery in order to best define the surgical indications and the specifics of their management. The bibliographic research was done on Pubmed over the period from January 1995 to December 2019, using French and English as publication languages. The keywords retained were "hernia" [Mesh] and "liver cirrhosis" [Mesh]. In an elective situation, preoperative ascites control is recommended. A parietal prosthesis can be used, even in the case of uninfected ascites, preferably in the retromuscular position. Laparoscopy should be used with caution, due to the bleeding risk. No recommendation can be made on the use of prophylactic intra-abdominal drainage. The literature data do not allow the trans-jugular route portosystemic shunt recommendation, nor the use of a peritoneal-vesical pump to decrease the volume of ascites before parietal surgery in cirrhotic patients.

What are the Particularities of Oesophageal Surgery in Cirrhotic Patients

The aim of this paper was to review the entire literature on esophageal surgery to best define the surgical indications and the specifics of their management. The bibliographic research was carried out on Pubmed between January 1995 and June 2015, using French and English as publication languages.

What are the Particularities of Colorectal Surgery in Cirrhotic Patients.

This work's objective was to review the entire literature on colorectal surgery in order to best define the surgical indications and their management specificities. The literature analysis was carried out according to High Authority for Health (HAS) methodology, by consulting the PubMed database (Medline), from the beginning of January 1995 until the end of June 2015.

Major causes of morbidity after non-transplant surgery in cirrhotic patients

Presenter: Danny Lascano MD | Westchester Medical Center/New York Medical College Background: Surgery on cirrhotics is challenging given the underlying frailty and comorbidities these patients exhibit. There is little data on cirrhotics who undergo non-transplant procedures focusing on their preoperative optimization, intraoperative variables such as fluid resuscitation, and the causes of morbidity and re-admissions after the index procedure. We investigated our experience for cirrhotics who underwent surgery at our institution. Methods: A single surgeon’s experience was queried for cirrhotic patients from 2014-2018. Outcomes measured included pre-operative factors, intraoperative evaluation, and post-operative outcomes. Results: A total of 75 procedures on 66 patients were performed including 57 hernia repairs, 11 liver resections, and 6 cholecystectomies; 50.6% (38/ 75) were Child A and B, 62.7% (47/75) were medically optimized before the procedure, and 40% (30/75) underwent emergent/urgent procedures. There were overall 3 deaths in total at 90 days from fulminant liver failure after liver resection, sepsis from spontaneous bacterial peritonitis, and cardiovascular arrest from unclear etiology. Ninety-day re-admission rates were due to anemia, bleeding, and refractory ascites (32%, 24/75). Ten percent (7/46) made it to transplant after their urgent/elective surgery. On linear regression when controlling for estimated blood loss, Na-MELD, and age, intraoperative albumin was associated with increased length of stay (Beta= 0.381,p< 0.005). On multivariate analysis, the only factor associated with mortality when controlling for operative time and MELD score was American Society of Anesthesiologists (ASA) Score (OR 12.9, p= 0.024). Conclusion: Major morbidity driven by post-operative anemia exists after surgery but mortality was fairly low in this high-risk population. Only 1 death was attributed to surgery specific mortality. Albumin administration was associated with increased length of stay likely because of reasons driven by the need for albumin (e.g. intraoperative hypotension, blood loss). Most importantly, elective surgery allowed patients to avoid complications and make it to transplant for those eligible. More investigation is needed looking at causes of readmission and optimizing intraoperative surgical outcomes, which may be a large cause of the inter-institutional variability in this high-risk population.

Gastroduodenal Surgery in Cirrhotic Patients - Case Series and Literature Review.

Specific risk factors for gastroduodenal surgery in cirrhotic patients have been identified, which dictates for a more personalized management. The retrospective study was conducted between 2012-2019 on twelve patients (7 cases of duodenal ulcer, 2 cases of gastric ulcer and 3 patients with gastric cancer). We took into account a number of possible factors involved in the unfavorable evolution of patients, based on data published in the literature so far. In order to follow the involvement of each factor we compared two groups of patients, one with unfavorable evolutions, exitus and another with favorable evolutions. Emergency surgery, the presence of ascites at the time of intervention, a higher than 30 MELD score, alcoholic cirrhosis, liver encephalopathy and liver failure are common factors that are found in a high percentage (between 75% and 100%) in patients who have had an unfavorable evolution, exitus. The same risk factors are found in much lower percentages in patients who have evolved favorably postoperatively, most between 12.5% and 25%. We analyzed preoperative aspects, surgical approach, complications and risk factors for these patients, compared them with the results of our study and identified future therapeutic possibilities. For CHILD B or C patients, the indication for surgery should be discussed in advance with a multidisciplinary team. Endoscopic submucosal dissection or discontinuation of D2 dissection should be considered in these patients.

What are the Specifics of Biliary Surgery in Cirrhotic Patients?

This work's objective was to review the literature on biliary surgery in order to best define the surgical indications and the specifics of their management. A review of the literature from 1995 to August 2015 was conducted in Pubmed and Google Scholar.

Bariatric Surgery in Cirrhotic Patients: Is It Safe?

IntroductionTen percent of cirrhotic patients are known to have a high risk of postoperative complications. Ninety percent of bariatric patients suffer from non-alcoholic fatty liver disease (NAFLD), and 50% of them may develop non-alcoholic steatohepatitis (NASH) which can progress to cirrhosis. The aim of this study was to assess whether the presence of cirrhosis at the time of bariatric surgery is associated with an increased rate and severity of short- and long-term cirrhotic complications.MethodsA cohort of 110 bariatric patients, between May 2003 and February 2018, who had undergone liver biopsy at the time of bariatric surgery were reassessed for histological outcome and divided into two groups based on the presence (C, n = 26) or absence (NC, n = 84) of cirrhosis. The NC group consisted of NASH (n = 49), NAFLD (n = 24) and non-NAFLD (n = 11) liver histology. Medical notes were retrospectively assessed for patient characteristics, development of 30-day postoperative complications, severity of complications (Clavien-Dindo (CD) classification) and length of stay. The C group was further assessed for long-term cirrhosis-related outcomes.ResultsThe C group was older (52 years vs 43 years) and had lower BMI (46 kg/m2 vs 52 kg/m2) and weight (126 kg vs 145 kg) compared to the NC group (p < 0.05). The C group had significantly higher overall complication rate (10/26 vs 14/84, p < 0.05) and severity of complications (CD class ≥ III, 12% vs 7%, p < 0.05) when compared to the NC group. The length of stay was similar between the two groups (5 days vs 4 days). The C group had significant improvement in model end-stage liver disease scores (7 vs 6, p < 0.01) with median follow-up of 4.5 years (range 2–11 years). There were no long-term cirrhosis-related complications or mortality in our studied cohort (0/26).ConclusionBariatric surgery in cirrhotic patients has a higher risk of immediate postoperative complications. Long-term cirrhosis-related complications or mortality was not increased in this small cohort. Preoperative identification of liver cirrhosis may be useful for risk stratification, optimisation and informed consent. Bariatric surgery in well-compensated cirrhotic patients may be used as an aid to improve long-term outcome.

311 – Non-Emergent Abdominal Surgery in Cirrhotic Patients: A Study of Perioperative Mortality, Morbidity, and Risk Factors in 7,075 Patients in a National Healthcare System

311 – Non-Emergent Abdominal Surgery in Cirrhotic Patients: A Study of Perioperative Mortality, Morbidity, and Risk Factors in 7,075 Patients in a National Healthcare System

Original Study: Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhotic Patients

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) has been suggested to reduce portal hypertension-associated complications in cirrhotic patients undergoing abdominal surgery. The aim of this study was to compare postoperative outcome in cirrhotic patients with and without specific preoperative TIPS placement, following elective extrahepatic abdominal surgery. MethodsPatients were retrospectively included from 2005 to 2016 in four centers. Patients who underwent preoperative TIPS (n = 66) were compared to cirrhotic control patients without TIPS (n = 68). Postoperative outcome was analyzed using propensity score with inverse probability of treatment weighting analysis. ResultsOverall, colorectal surgery accounted for 54% of all surgical procedure. TIPS patients had a higher initial Child-Pugh score (6[5–12] vs. 6[5–9], p = 0.043) and received more beta-blockers (65% vs. 22%, p < 0.001). In TIPS group, 56 (85%) patients managed to undergo planned surgery. Preoperative TIPS was associated with less postoperative ascites (hazard ratio = 0.330 [0.140–0.780]). Severe postoperative complications (Clavien-Dindo > 2) and 90-day mortality were similar between TIPS and no-TIPS groups (18% vs. 23%, p = 0.392, and 7.5% vs. 7.8%, p = 0.644, respectively). ConclusionsPreoperative TIPS placement yielded an 85% operability rate with satisfying postoperative outcomes. No significant differences were found between TIPS and no-TIPS groups in terms of severe postoperative complications and mortality, although TIPS patients probably had worse initial portal hypertension.

Transjugular intrahepatic portosystemic shunt as a bridge to elective abdominal surgery in cirrhotic patients: friend or foe?

Background: While abdominal surgery is associated with higher morbidity and mortality in cirrhotic patients, preoperative TIPS has been suggested as a means to reduce portal hypertension and postoperative complications. This study aims to compare cirrhotic patients with preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement and cirrhotic patients without TIPS, in terms of morbidity and mortality after elective extra hepatic abdominal surgery. Study design: Patients were retrospectively included from 2005 to 2016 in four tertiary referral hospitals. Patients who underwent preoperative TIPS (n=66) were compared to control patients without TIPS (n=68). Postoperative outcome was analyzed using inverse probability of treatment weighting. Results: Ten patients (15%) did not undergo planned surgery after receiving TIPS procedure. Preoperative TIPS placement was associated with less postoperative ascites (HR=0.33, 95 per cent i.c. 0.14 to 0.78) but this did not translate into better postoperative outcomes. Patients with hepatic venous pressure gradient (HVPG) ≤13 mmHg and MELDNa ≤15 seemed to benefit from preoperative TIPS placement in terms of severe postoperative complications (HR=0.21, 0.05 to 1.02 and HR=0.16, 0.03 to 1.05, respectively). TIPS patients in colorectal surgery and HVPG >13 mmHg subgroups required more intraoperative red blood cells transfusions (HR=15.03, 1.71 to 132.17 and HR=4.10 1.16 to 14.47, respectively). Conclusions: Although TIPS placement before elective surgery decreased postoperative ascites, this study failed to demonstrate a benefit in terms of intra and postoperative outcome. Results suggest nevertheless a decrease in severe postoperative complications in patients with mild hepatopathy (HVPG ≤13 mmHg and MELDNa ≤15) but further evaluation is necessary.

Early Abdominal Surgery After Elective Transjugular Intrahepatic Portosystemic Shunt (TIPS) May Increase Morbidity and Mortality Post-Operatively: Case Series of 2 Patients

Background: Abdominal surgery in cirrhotic patients has high morbidity and mortality due to portal hypertension. Preoperative portal decompression by TIPS placement is a logical approach to reduce perioperative complications. However this is controversial. We report outcome of 2 cases of elective TIPS prior to abdominal surgery. Case 1: 60 y/o male with history of decompensated ETOH cirrhosis, Child Pugh C, MELD 16 had elective TIPS prior to surgery for ascending colon adenocarcinoma. Post TIPS hepatic venous pressure gradient (HVPG) decreased from 16 to 6 mmhg. 7 days later patient underwent right hemicolectomy and ileocolonic anastomosis. Intraoperative blood loss was 600 ml. 4 days after surgery patient developed altered mental status (AMS) and sepsis. Work up revealed intra-abdominal abscess from anastomotic leak requiring repeat ex-lap. Subsequent hospital course complicated by septic shock, renal failure, prolonged intubation due to hepatic encephalopathy (HE). Patient went to hospice care and passed away 28 days after initial surgery. Case 2: 70 y/o female with history of decompensated HCV cirrhosis, Child Pugh B, MELD 11 had elective TIPS prior to surgery for cecum adenocarcinoma. Post TIPS HVPG decreased from 14 to 4 mmhg. 3 days later patient underwent right hemicolectomy. Intraoperative blood loss was 50 cc. Postoperative course complicated by HE from use of pain medications. AMS lead to development of aspiration pneumonia. Despite medical optimization with lactulose, Rifaximin and avoiding narcotic she remained encephalopathic. 17 days after surgery TIPS was revised to increase HVPG from 2 to 7 mmhg. HE improved and patient was discharged after 34 days of hospitalization. Discussion: Decompression of portal pressure by TIPS prior to abdominal surgery is expected to improve postoperative outcome. Only retrospective controlled study by Vinet et al1 suggests that elective TIPS within 72±21 days of abdominal surgery has similar outcome compared to those without TIPS. Our patients had increase mortality; morbidity and prolonged hospital stay from early abdominal surgery within 1 week of TIPS placement. We emphasize need for the prospective control study to help determine timing of elective TIPS and assess its effect on outcome of abdominal surgery.