Risk factors for mortality after surgery in patients with cirrhosis
ABSTRACT Current methods of predicting risk of postoperative mortality in patients with cirrhosis are suboptimal. The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. The aim of this study was to determine the risk factors for postoperative mortality in patients with cirrhosis.
Patients with cirrhosis (N = 772) who underwent major digestive (n = 586), orthopedic (n = 107), or cardiovascular (n = 79) surgery were studied. Control groups of patients with cirrhosis included 303 undergoing minor surgical procedures and 562 ambulatory patients. Univariate and multivariable proportional hazards analyses were used to determine the relationship between risk factors and mortality.
Patients undergoing major surgery were at increased risk for mortality up to 90 days postoperatively. By multivariable analysis, only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, <8) to more than 50% (MELD score, >20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period.
MELD score, age, and American Society of Anesthesiologists class can quantify the risk of mortality postoperatively in patients with cirrhosis, independently of the procedure performed. These factors can be used in determining operative mortality risk and whether elective surgical procedures can be delayed until after liver transplantation.
Article: Model for End-stage Liver Disease.[Show abstract] [Hide abstract]
ABSTRACT: Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15-20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score.
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ABSTRACT: To assess safety and outcomes (metabolic and liver) of bariatric surgery in patients with cirrhosis with or without portal hypertension. This study is a retrospective review of 14 patients with Child's A cirrhosis with or without portal hypertension who were prospectively enrolled from February 23, 2009, through November 9, 2011, with 6- to 24-month follow-up after bariatric surgery (11 patients underwent sleeve gastrectomy [78.6%] and 3 gastric bypass [21.4%]). Four patients had portal hypertension detected by esophagogastroduodenoscopy. The mean patient age was 55.5 years, and 10 of 14 patients were women. The mean weight decreased from 125±18 to 94±17 at 1 year (P<.001) and 93±17 kg at 2 years (P<.001) postsurgery. The prevalence of diabetes decreased from 10 of 14 patients to 4 of 12 (P=.01) and 1 of 6 (P=.02) at 1 and 2 years postsurgery. The frequency of dyslipidemia and hypertension decreased but was not statistically significant; however, the number of medications required to control them decreased. Hepatic steatosis was detected by perioperative liver biopsy in 13 of 14 patients (5%-30% steatosis in 6 patients, 31%-60% in 6, and >60% in 1). At 1 year postsurgery, only 1 of 8 patients who underwent follow-up ultrasound imaging showed evidence of steatosis. The bilirubin level was above 2 mg/dL in 1 patient at 1 year postsurgery. One patient had encephalopathy at 2 years postsurgery. None of the patients developed peri- or postoperative bleeding or surgical complications. Bariatric surgery in patients with compensated cirrhosis even with mild portal hypertension is well tolerated and safe with minimal risk of postoperative complications if performed in a large referral center. This population can experience the beneficial effects of weight loss and improved metabolic syndrome, as well as reduced hepatic steatosis. Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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ABSTRACT: Hepatosplanchnic circulation receives almost half of cardiac output and is essential to physiologic homeostasis. Liver cirrhosis is estimated to affect up to 1% of populations worldwide, including 1.5% to 3.3% of intensive care unit patients. Cirrhosis leads to hepatosplanchnic circulatory abnormalities and end-organ damage. Sepsis and cirrhosis result in similar circulatory changes and resultant multi-organ dysfunction. This review provides an overview of the hepatosplanchnic circulation in the healthy state and in cirrhosis, examines the signaling pathways that may play a role in the physiology of cirrhosis, discusses the physiology common to cirrhosis and sepsis, and reviews important issues in management.