Specialized care improves outcomes for patients with cirrhosis who require general surgical operations


Autoři: Joshua K. Kays aff001;  Daniel P. Milgrom aff001;  James R. Butler aff001;  Tiffany W. Liang aff001;  Nakul P. Valsangkar aff001;  Brandon Wojcik aff001;  C. Corbin Frye aff001;  Mary A. Maluccio aff001;  Chandrashekhar A. Kubal aff001;  Leonidas G. Koniaris aff001
Působiště autorů: Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States of America aff001
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223454

Souhrn

Background

General surgical operations on patients with cirrhosis have historically been associated with high morbidity and mortality rates. This study examines a contemporary series of patients with cirrhosis undergoing general surgical procedures.

Methods

A retrospective evaluation of 358 cirrhotic patients undergoing general surgical operations at a single institution between 2004–2015 was performed. Thirty- and 90-day mortality along with complications and subsequent transplantation rates were examined.

Results

358 cirrhotic patients were identified. The majority were Child-Turcotte-Pugh class (CTP) A (55.9%) followed by class B (32.4%) and class C (11.7%). Mean MELD score differed significantly between the groups (8.7 vs. 12.1 vs. 20.1; p<0.001). The most common operations were herniorrhaphy (29.9%), cholecystectomy (19.3%), and liver resection (14.5%). The majority of cases were performed semi-electively (68.4%), however, within the CTP C patients most cases were performed emergently (73.8%). Thirty and 90-day mortality for all patients were 5% and 6%, respectively. Mortality rates increased from CTP A to CTP C (30 day: 3.0% vs. 5.2% vs. 14.3%; p = 0.01; 90 day: 4.5% vs. 6.9% vs. 16.7%; p = 0.016). Additionally, 30-day mortality (12.8% vs. 2.3%; p<0.001), 90 day mortality (16.0% vs. 3.4%; p<0.001) were higher for emergent compared to elective cases. A total of 13 (3.6%) patients underwent transplantation ≤ 90 days from surgery. No elective cases resulted in an urgent transplantation.

Conclusion

Performing general surgical operations on cirrhotic patients carries a significant morbidity and mortality. This contemporary series from a specialized liver center demonstrates improved outcomes compared to historical series. These data strongly support early referral of cirrhotic patients needing general surgical operation to centers with liver expertise to minimize morbidity and mortality.

Klíčová slova:

Abdominal surgery – Cirrhosis – Death rates – Digestive system procedures – Liver diseases – Liver transplantation – Morbidity – Surgical and invasive medical procedures


Zdroje

1. National Institute of Health National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts for Cirrhosis. https://www.niddk.nih.gov/health-information/liver-disease/cirrhosis/definition-facts. Accessed on June 8, 2018. Updated March 2018.

2. Scaglione S, Kliethermes S, Cao G, Shoham D, Durazo R, Luke A, et al. The epidemiology of cirrhosis in the United States: a population-based study. J Clin Gastroenterol. 2015;49: 690–696. doi: 10.1097/MCG.0000000000000208 25291348

3. Younossi ZM, Stepanova M, Afendy M, Fang Y, Youssef Y, Mir H, et al. Changes in the prevalence of the most common causes of chronic liver disease in the United States from 1988 to 2008. Clin Gastroenterol Hepatol. 2011;9: 521–530

4. Mansour A, Watson W, Shaynai V, Pickleman J. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997.122: 730–736. doi: 10.1016/s0039-6060(97)90080-5 9347849

5. Garrison RN, Cryer HM, Howard DA, Polk HC Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg. 1984;199: 648–655. doi: 10.1097/00000658-198406000-00003 6732310

6. Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders. 1964:50–64.

7. Pugh RNH, Lyon-Murray IM, Dawson JL, Pietroni and Williams R. Transection of the oesophagus for bleeding oesophageal varices. Brit J Surg. 1973;60: 646–649. doi: 10.1002/bjs.1800600817 4541913

8. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33:464–470. doi: 10.1053/jhep.2001.22172 11172350

9. Markar SR, Karthikesalingam A, Thrumurthy S, Low DE. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000–2011. J Gastrointest Surg. 2012;16: 1055–1063. doi: 10.1007/s11605-011-1731-3 22089950

10. Alsfasser G, Kittner J, Eisold S, Klar E. Volume-outcome relationship in pancreatic surgery: the situation in Germany. Surgery. 2012;152: S50–S55. doi: 10.1016/j.surg.2012.05.011 22763260

11. Nguyen NT, Paya M, Stevens CM, Mavandadi S, Zainabadi K, Wilson SE. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann Surg. 2004;240: 586–594. doi: 10.1097/01.sla.0000140752.74893.24 15383786

12. Birkmeyer JD, Finlayson EVA, Birkmeyer C. Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative. Surgery. 2001;130: 415–422. doi: 10.1067/msy.2001.117139 11562662

13. Gutierrez JP, Perez EA, Moffar FL, Livingstone AS, Franceschi D, and Koniaris LG. Should soft tissue sarcomas be treated at high-volume centers? An analysis of 4205 patients. Ann Surg. 2007;245: 952–958. doi: 10.1097/01.sla.0000250438.04393.a8 17522521

14. Ghaferi A, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Medical Care. 2011;49: 1076–1081. doi: 10.1097/MLR.0b013e3182329b97 22002649

15. “About BMI”. Healthy Weight. Center for Disease Control and Prevention. 29 August 2017. Accessed 9 June 2018.

16. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240: 205–213. doi: 10.1097/01.sla.0000133083.54934.ae 15273542

17. Schell MT, Barcia A, Spitzer AL, Harris HW. Pancreaticoduodenectomy: volume is not associated within an academic health care system. HPB Surg. 2008: 825940 doi: 10.1155/2008/825940 18475317

18. Joseph B, Morton JM, Hernandez-Boussard T, Rubinfeld I, Faraj C, Velanovich V. Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection. J Am Coll Surg. 2009;208: 520–527. doi: 10.1016/j.jamcollsurg.2009.01.019 19476785

19. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364: 2128–2137. doi: 10.1056/NEJMsa1010705 21631325

20. Kays JK, Liang TW, Zimmers TA, Milgrom DP, Abduljabar H, Young A, et al. Sarcopenia is a significant predictor of mortality after abdominal aortic aneurysm repair. JCSM Clinical Reports. 2018;3:e00053. 30984911

21. Cheung MC, Yang R, Byrne MM, Solorzano CC, Nakeeb A, Koniaris LG. Are patients of low socioeconomic status receiving suboptimal management for pancreatic adenocarcinoma? Cancer. 2010;116: 723–733. doi: 10.1002/cncr.24758 19998350

22. Yang R, Cheung MC, Byrne MM, Huang Y, Nguyen D, Lally BE, et al. Do racial or socioeconomic disparities exist in lung cancer treatment? Cancer. 2010;116: 2437–2447. doi: 10.1002/cncr.24986 20209616

23. Zielsdorf SM, Kubasiak JC, Janssen I, Myers JA, Luu MB. A NSQIP analysis of MELD and perioperative outcomes in general surgery. The American Surgeon. 2015;81:7 55–759.

24. del Olmo JA, Flor-Lorente B, Flor-Civera B, Rodriguez F, Serra MA, Escudero A, et al. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg. 2003;27: 647–652. doi: 10.1007/s00268-003-6794-1 12732995

25. Doberneck RC, Sterling WA Jr, Allison DC. Morbidity and mortality after operation in nonbleeding cirrhotic patients. Am J Surg. 1983;146: 306–309. doi: 10.1016/0002-9610(83)90402-6 6604465

26. de Goede B, Klitsie PJ, Lange JF, Metselarr HJ, Kazemier G. Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis; a systematic review. Best Pract Res Clin Gastroeneterol. 2012;26: 47–59.

27. Ziser A, Plevak DJ, Wiesner RH, Rakela J, Offord KP, and Brown DL. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Anesthesiology. 1999;90: 42–53. doi: 10.1097/00000542-199901000-00008 9915311

28. Andraus W, Pinheiro RS, Lai Q, Haddad LBP, Nacif LS, D’Albuquerque LAC, et al. Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality. BMC Surg. 2015; 15:65. doi: 10.1186/s12893-015-0052-y 25990110

29. Neeff H, Mariaskin D, Spangenberg HC, Hopt UT, Makowiec F. Perioperative mortality after non-hepatic general surgery in patients with liver cirrhosis: an analysis of 138 operations in the 2000s using Child and MELD scores. J Gastrointestin Surg. 2011;15: 1–11.


Článek vyšel v časopise

PLOS One


2019 Číslo 10