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Wang SY, Yeh CN, Jan YY, Chen MF. Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery? Gut Liver 2021; 15:517-527. [PMID: 32921635 PMCID: PMC8283297 DOI: 10.5009/gnl20052] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/19/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Acute cholecystitis and several gallbladder stone-related conditions, such as impacted common bile duct stones, cholangitis, and biliary pancreatitis, are common medical conditions in daily practice. An early cholecystectomy or drainage procedure with delayed cholecystectomy is the current standard of treatment based on published clinical guidelines. Cirrhosis is not only a condition of chronically impaired hepatic function but also has systemic effects in patients. In cirrhotic individuals, several predisposing factors, including changes in the bile acid composition, increased nucleation of bile, and decreased motility of the gallbladder, contribute to the formation of biliary stones and the possibility of symptomatic cholelithiasis, which is an indication for surgical treatment. In addition to these predisposing factors for cholelithiasis, systemic effects and local anatomic consequences related to cirrhosis lead to anesthesiologic risks and perioperative complications in cirrhotic patients. Therefore, the treatment of the aforementioned biliary conditions in cirrhotic patients has become a challenging issue. In this review, we focus on cholecystectomy for cirrhotic patients and summarize the surgical indications, risk stratification, surgical procedures, and surgical outcomes specific to cirrhotic patients with symptomatic cholelithiasis.
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Affiliation(s)
- Shang Yu Wang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yi Yin Jan
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Miin Fu Chen
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Adiamah A, Ban L, Hammond J, Jepsen P, West J, Humes DJ. Mortality After Extrahepatic Gastrointestinal and Abdominal Wall Surgery in Patients With Alcoholic Liver Disease: A Systematic Review and Meta-Analysis. Alcohol Alcohol 2021; 55:497-511. [PMID: 32558895 DOI: 10.1093/alcalc/agaa043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/26/2020] [Accepted: 04/28/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS This meta-analysis aimed to define the perioperative risk of mortality in patients with alcoholic liver disease (ALD) undergoing extrahepatic gastrointestinal surgery. METHODS Systematic searches of Embase, Medline and CENTRAL were undertaken to identify studies reporting about patients with ALD undergoing extrahepatic gastrointestinal surgery published since database inception to January 2019. Studies were only considered if they reported on mortality as an outcome. Pooled analysis of mortality was stratified as benign and malignant surgery and specific operative procedures where feasible. RESULTS Of the 2899 studies identified, only five studies met inclusion criteria, representing cholecystectomy (one study), umbilical hernia repair surgery (one study) and oesophagectomy (three studies). The total number of patients with ALD in these studies was 172. Therefore, any study on liver disease patients undergoing extrahepatic surgery that crucially included a subset with alcohol aetiology was included as a secondary analysis even though they failed to stratify mortality by underlying aetiology. The total number of studies that met this expanded inclusion criteria was 62, reporting on 37,703 patients with liver disease of which 1735 (4.5%) had a definite diagnosis of ALD. Meta-analysis of proportions of in-hospital mortality in patients with ALD undergoing upper gastrointestinal cancer surgery (oesophagectomy) was 23% [95% confidence interval (CI) 14-35%, I2 = 0%]. In-hospital mortality following oesophagectomy in liver disease patients of all aetiologies was lower, 14% (95% CI 9-21%, I2 = 41.1%). CONCLUSION Postoperative in-hospital mortality is high in patients with liver disease and ALD in particular. However, the currently available evidence on ALD is limited and precludes definitive conclusions on postoperative mortality risk.
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Affiliation(s)
- Alfred Adiamah
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK
| | - Lu Ban
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK
| | - John Hammond
- Division of Hepatobiliary and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology and Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark ,8200
| | - Joe West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
| | - David J Humes
- Nottingham Digestive Diseases Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
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3
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Abstract
Patients with portal hypertension will increasingly present for nontransplant surgery because of the increasing incidence of, and improving long-term survival for, chronic liver disease. Such patients have increased perioperative morbidity and mortality caused by the systemic pathophysiology of liver disease. Preoperative assessment should identify modifiable causes of liver injury and distinguish between compensated and decompensated cirrhosis. Risk stratification, which is crucial to preparing patients and their families for surgery, relies on scores such as Child-Turcotte-Pugh and Model for End-stage Liver Disease to translate disease severity into quantified outcomes predictions. Risk factors for postoperative complications should also be recognized.
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Affiliation(s)
- Melissa Wong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Transplant Center, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, The Dumont-UCLA Transplant Center, 757 Westwood Blvd, Suite 8236, Los Angeles, CA 90095, USA.
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Okamuro K, Cui B, Moazzez A, Park H, Putnam B, Virgilio CD, Neville A, Singer G, Deane M, Chong V, Kim DY. Laparoscopic Cholecystectomy is Safe in Emergency General Surgery Patients with Cirrhosis. Am Surg 2019. [DOI: 10.1177/000313481908501015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic ( P < 0.001), had a higher incidence of preadmission antithrombotic therapy use ( P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups ( P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.
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Affiliation(s)
- Kyle Okamuro
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Brian Cui
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Ashkan Moazzez
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Hayoung Park
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Brant Putnam
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Chris De Virgilio
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Angela Neville
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - George Singer
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Molly Deane
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Vincent Chong
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y. Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
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5
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Northup PG, Friedman LS, Kamath PS. AGA Clinical Practice Update on Surgical Risk Assessment and Perioperative Management in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2019; 17:595-606. [PMID: 30273751 DOI: 10.1016/j.cgh.2018.09.043] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Lawrence S Friedman
- Departments of Medicine, Harvard Medical School, Tufts University School of Medicine, Newton-Wellesley Hospital, Rochester, Minnesota; Massachusetts General Hospital, Boston, Massachusetts, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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Adamson DT, Bozeman MC, Benns MV, Burton A, Davis EG, Jones CM. Operative Considerations for the General Surgeon in Patients with Chronic Liver Disease. Am Surg 2019. [DOI: 10.1177/000313481908500236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chronic liver disease remains a prevalent and challenging comorbidity in the American population at large. Scarring and fibrosis cause physical and physiological changes that may prove challenging in both medical and surgical management. However, because there has been relevant improvements in preoperative diagnostic, perioperative hepatologic, and intensive care management, as well as in surgical techniques, patients with cirrhosis can safely be operated on but patient selection remains vital. Patients with chronic liver disease may present to a general surgeon for evaluation of a number of elective or emergent surgical conditions. Here, we review current literature on the perioperative management and operative strategies of seemingly routine general surgery issues and provide a review of the pathophysiology associated with chronic liver disease.
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Affiliation(s)
- Dylan T. Adamson
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Matthew C. Bozeman
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Matthew V. Benns
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Alison Burton
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Eric G. Davis
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Christopher M. Jones
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
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7
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Rädle J, Mönch C. Perioperatives Management bei Patienten mit Leberzirrhose. DER GASTROENTEROLOGE 2017; 12:464-476. [DOI: 10.1007/s11377-017-0192-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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8
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Gallstones in Patients with Chronic Liver Diseases. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9749802. [PMID: 28251162 PMCID: PMC5306972 DOI: 10.1155/2017/9749802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/11/2017] [Indexed: 12/16/2022]
Abstract
With prevalence of 10-20% in adults in developed countries, gallstone disease (GSD) is one of the most prevalent and costly gastrointestinal tract disorders in the world. In addition to gallstone disease, chronic liver disease (CLD) is also an important global public health problem. The reported frequency of gallstone in chronic liver disease tends to be higher. The prevalence of gallstone disease might be related to age, gender, etiology, and severity of liver disease in patients with chronic liver disease. In this review, the aim was to identify the epidemiology, mechanisms, and treatment strategies of gallstone disease in chronic liver disease patients.
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9
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Lopez-Delgado JC, Ballus J, Esteve F, Betancur-Zambrano NL, Corral-Velez V, Mañez R, Betbese AJ, Roncal JA, Javierre C. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol 2016; 22:2657-2667. [PMID: 26973406 PMCID: PMC4777990 DOI: 10.3748/wjg.v22.i9.2657] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/30/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.
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10
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Abstract
Gastrointestinal surgery is feasible in patients with Child A cirrhosis, but is associated with higher morbidity and mortality. Hernia repair, biliary and colonic surgery are the most frequently performed interventions in this context. Esophageal and pancreatic surgery are more controversial and less frequently performed. For patients with decompensated liver function (Child B or C patients), the indications for surgery should be discussed by a multi-specialty team including the hepatologist, anesthesiologist, surgeon; liver function should be optimized if possible. During emergency surgery, histologic diagnosis of cirrhosis should be confirmed by liver biopsy because the histologic diagnosis has therapeutic and prognostic implications. The management of patients with Child A cirrhosis without portal hypertension is little different from the management of patients without cirrhosis. However, the management of patients with Child B or C cirrhosis or with portal hypertension is more complex and requires an accurate assessment of the balance of benefit vs. risk for surgical intervention on a case-by-case basis.
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Affiliation(s)
- C Sabbagh
- Department of digestive and oncological surgery, hôpital Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France
| | - D Fuks
- Department of digestive and oncological surgery, hôpital Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France
| | - J-M Regimbeau
- Department of digestive and oncological surgery, hôpital Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France.
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11
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Im GY, Lubezky N, Facciuto ME, Schiano TD. Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk. Clin Liver Dis 2014; 18:477-505. [PMID: 24679507 DOI: 10.1016/j.cld.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.
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Affiliation(s)
- Gene Y Im
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Nir Lubezky
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Marcelo E Facciuto
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Thomas D Schiano
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA.
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12
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Shrikhande SV, Gaikwad V, Purohit D, Goel M. Major abdominal cancer resections in cirrhotic patients: how frequent is postoperative hepatocellular decompensation? Indian J Gastroenterol 2014; 33:258-64. [PMID: 24214581 DOI: 10.1007/s12664-013-0426-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/14/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND The reported incidence of postoperative liver failure in cirrhotic patients is highly varied with diverse risk factors identified to predict risk, mainly drawn from organ or disease-specific studies. We aimed to assess risk factors for the development of postoperative liver failure in a specific cohort of patients with cirrhosis undergoing abdominal cancer resection. METHODS From November 2007 to October 2012, 30 cirrhotic patients who underwent curative resection for abdominal cancer were analyzed. The postoperative trends in liver function were followed and the incidence of postoperative liver failure was demonstrated. RESULTS Among the 30 patients, the tumors were located in the stomach (n = 5), pancreas (n = 5), colon/rectum (6), liver (n = 11), gallbladder (n = 1), and retroperitoneum (n = 2). Eighteen (60 %) patients experienced postoperative liver failure of which 7 (23 %) patients required deviation from the clinical course or management. There was one mortality due to grade C liver failure and hepatorenal syndrome. On multivariate analysis, only age (>55 years) was found to be statistically significant to predict postoperative liver failure (p = 0.024). CONCLUSION Liver dysfunction remains a major problem during the postoperative phase of major gastrointestinal cancer resections. However, less than one fourth of well-selected patients will develop significant postoperative liver failure. This incidence may be further reduced if the selection is restricted to younger patients.
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Affiliation(s)
- Shailesh Vinayak Shrikhande
- Division of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, 400 012, India,
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13
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Rebibo L, Gerin O, Verhaeghe P, Dhahri A, Cosse C, Regimbeau JM. Laparoscopic sleeve gastrectomy in patients with NASH-related cirrhosis: a case-matched study. Surg Obes Relat Dis 2013; 10:405-10; quiz 565. [PMID: 24355322 DOI: 10.1016/j.soard.2013.09.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 08/28/2013] [Accepted: 09/27/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) is a validated procedure for the surgical treatment of morbid obesity. Cirrhosis is often considered a relative contraindication to elective extrahepatic surgery. The objective of this study was to evaluate the morbidity related to SG performed in cirrhotic patients compared with noncirrhotic patients. METHODS Between March 2004 and January 2013, we included all patients with cirrhosis undergoing SG (13 patients). These patients (SG-cirrhosis group) were matched in terms of preoperative data (age, gender, body mass index, and co-morbidities) on a 1:2 basis, with 26 noncirrhotic patients (SG group) selected from a population of 750 patients. Cirrhosis was diagnosed postoperatively on histologic exam. The primary endpoint was the overall postoperative complication rate. Secondary endpoints were operating time, revisional surgery rate, gastric fistula and bleeding rates, postoperative mortality, and weight loss over a 24-month period. RESULTS The SG-cirrhosis group consisted of 13 patients with a median age of 52 years. All patients in the SG-cirrhosis group were Child A. Etiology of cirrhosis was related to NASH in 93.3%. Median operating time in the SG-cirrhosis group and SG group was 75 minutes versus 80 minutes (P = .59). No postoperative mortality was observed in either group. The overall postoperative complication rate was 7.7% versus 7.7% (P = 1). The major complication rate was 0% versus 7.7% (P = .22), and the postoperative gastric fistula rate was 0% versus 3.8% (P = .47). No complications related to cirrhosis were reported. CONCLUSION SG can be performed in Child A cirrhosis with no increased risk of postoperative complications and no specific complications related to cirrhosis. Weight loss for patients with cirrhosis undergoing SG is similar to that observed in noncirrhotic patients.
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Affiliation(s)
- Lionel Rebibo
- Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Olivier Gerin
- Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Pierre Verhaeghe
- Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Abdennaceur Dhahri
- Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Cyril Cosse
- Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France.
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14
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Abstract
BACKGROUND AND OBJECTIVES Due to the concern of risk of intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered a contraindication for laparoscopic cholecystectomy (LC). This article intends to review the literature and underline the various approaches to dealing with this technically challenging procedure. METHODS A Medline search of major articles in the English literature on LC in cirrhotic patients over a 16-y period from 1994 to 2011 was reviewed and the findings analyzed. A total of 1310 cases were identified. RESULTS Most the patients who underwent LC were in Child-Pugh class A, followed by Child-Pugh classes B and C, respectively. The overall conversion rate was 4.58%, and morbidity was 17% and mortality 0.45%. Among the patients who died, most were in Child-Pugh class C, with a small number in classes B and A. The cause of death included, postoperative bleeding, liver failure, sepsis, duodenal perforation, and myocardial infarction. A meta-analysis of 400 patients in the literature, comparing outcomes of patients undergoing LC with and without cirrhosis, revealed higher conversion rate, longer operative time, higher bleeding complications, and overall increased morbidity in patients with cirrhosis. Safe LC was facilitated by measures that included the use of ultrasonic shears and other hemostatic measures and using subtotal cholecystectomy in patients with difficult hilum and gallbladder bed. CONCLUSIONS Laparoscopic cholecystectomy can be safely performed in cirrhotic patients, within Child-Pugh classes A and B, with acceptable morbidity and conversion rate.
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15
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Bhangui P, Laurent A, Amathieu R, Azoulay D. Assessment of risk for non-hepatic surgery in cirrhotic patients. J Hepatol 2012; 57:874-84. [PMID: 22634123 DOI: 10.1016/j.jhep.2012.03.037] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 03/08/2012] [Accepted: 03/10/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta -The Medicity, Delhi NCR, India
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16
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Weingarten TN, Swain JM, Kendrick ML, Charlton MR, Schroeder BJ, Lee REC, Narr BJ, Ribeiro TCR, Schroeder DR, Sprung J. Nonalcoholic steatohepatitis (NASH) does not increase complications after laparoscopic bariatric surgery. Obes Surg 2012; 21:1714-20. [PMID: 21948267 DOI: 10.1007/s11695-011-0521-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Advanced liver disease is associated with increased risk for postoperative complications. It is not well known whether the presence of nonalcoholic steatohepatitis (NASH) in morbidly obese patients contributes to the rate of postoperative complications. The main objective was to study the association between NASH and postoperative complications in bariatric patients. METHODS A total of 340 contemporary sequential patients who underwent laparoscopic bariatric operations and who had intraoperative liver biopsies were studied. The rates of severe postoperative complications were compared across three patient groups-those with (1) no liver disease or with simple steatosis, (2) mild nonalcoholic NASH [steatosis with necroinflammation and mild fibrosis (stage 0-1)], and (3) advanced NASH [steatosis, necroinflammation, and more advanced fibrosis (stage ≥ 2)]. RESULTS Of 340 patients, 141 (42%) had no NASH, and 151 (44%) and 48 (14%) had mild and advanced NASH, respectively. Superobesity (P = 0.037), diabetes (P < 0.001), and cerebrovascular disease (P = 0.013) had highest frequencies in patients with advanced NASH. Hypertension was highly prevalent in cohort (57%) but similarly distributed across three groups. Forty-five patients experienced at least one complication (pulmonary 4, cardiovascular 8, surgical 16, and acute kidney injury 21). The complications rate did not differ significantly across NASH categories. Median hospital stay was 3 days (IQR 2, 3), and it was not associated with NASH severity. There were no 30-day postoperative deaths. CONCLUSIONS Despite the high prevalence of NASH among morbidly obese surgical patients, this condition was not associated with increased risk for postoperative complications. Postoperative acute kidney injury was the most frequent single complications.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Laurence JM, Tran PD, Richardson AJ, Pleass HCC, Lam VWT. Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials. HPB (Oxford) 2012; 14:153-61. [PMID: 22321033 PMCID: PMC3371197 DOI: 10.1111/j.1477-2574.2011.00425.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholecystectomy is associated with increased risks in patients with cirrhosis. The well-established advantages of laparoscopic surgery may be offset by the increased risk for complications relating particularly to portal hypertension and coagulopathy. METHODS A systematic search was undertaken to identify studies comparing open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) in patients with cirrhosis. A meta-analysis was performed of the available randomized controlled trials (RCTs). RESULTS Forty-four studies were analysed. These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n= 1756) or open (n= 249) cholecystectomy, with mortality rates of 0.74% and 2.00%, respectively. A meta-analysis of three RCTs involving a total of 220 patients was conducted. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC. However, frequencies of postoperative hepatic insufficiency did not differ significantly. CONCLUSIONS There are few RCTs comparing OC and LC in patients with cirrhosis. These studies are small, heterogeneous in design and include almost exclusively patients with Child-Pugh class A and B disease. However, LC appears to be associated with shorter operative time, reduced complication rates and reduced length of hospital stay.
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Affiliation(s)
- Jerome M Laurence
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
| | - Peter D Tran
- Department of Surgery, Liverpool HospitalSydney, NSW, Australia
| | - Arthur J Richardson
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
| | - Henry C C Pleass
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
| | - Vincent W T Lam
- Department of Surgery, Westmead HospitalSydney, NSW, Australia,Discipline of Surgery, Faculty of Medicine, University of SydneySydney, NSW, Australia
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18
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Eaton JE, Thackeray EW, Lindor KD. Likelihood of malignancy in gallbladder polyps and outcomes following cholecystectomy in primary sclerosing cholangitis. Am J Gastroenterol 2012; 107:431-9. [PMID: 22031356 DOI: 10.1038/ajg.2011.361] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Patients with primary sclerosing cholangitis (PSC) have an increased risk for gallbladder cancer. We aimed to define the postoperative outcomes in PSC patients after cholecystectomy and determine if size of a gallbladder lesion on imaging predicts the presence of neoplasia. METHODS We conducted a retrospective review of patients with PSC who underwent cholecystectomy at Mayo Clinic between 1 January 1995 and 31 December 2008. Patients with a prior history of a liver transplant or cholangiocarcinoma were excluded. RESULTS A total of 57 patients were included in our primary analysis during the early postoperative period. The most common indication for undergoing a cholecystectomy was the presence of a gallbladder polyp or mass. The sensitivity and specificity of a gallbladder lesion of 0.80 cm and the presence of gallbladder neoplasia was 100% (95% confidence interval (CI) 77-100%) and 70% (95% CI 35-93%), respectively. Of the patients, 23 (40%) had an early postoperative complication. The Child-Pugh score was the only predictor of postoperative outcomes in the multivariate model (odds ratio 1.78, 95% CI 1.11-3.12, P=0.02). CONCLUSIONS Cholecystectomy in patients with PSC is associated with a high morbidity. Gallbladder polyps <0.80 cm are unlikely to be malignant and observation of these small polyps should be considered. A higher Child-Pugh score was associated with early postoperative complications.
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Affiliation(s)
- John E Eaton
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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19
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Abstract
INTRODUCTION Historically the presence of liver cirrhosis has been an absolute or relative contraindication to laparoscopic cholecystectomy (LC). Accumulating experience in LC has resulted in an increasing number of investigators reporting that LC can be safely performed in cirrhotic patients. The aim of this study was to report the efficacy and safety of LC in the treatment of symptomatic cholelithiasis in cirrhotic patients, and a review of the literature in the matter. METHODS Between January 2006 and July 2010, from 503 patients under LC, we reviewed 43 cirrhotic patients of Child-Pugh Classification A, B, and C, with symptomatic gallstones. RESULTS Conversion to an open procedure was necessary in 5 patients due to multiple factors. The mean operative time and length of hospital stay were significantly longer and higher in cirrhotic group (P<0.05). Postoperative complications were observed in 37.2% of patients. Trocar site hematoma (P=0.02), wound complications (P=0.02), and intra-abdominal collection (P=0.01) occurred more frequently in patients with cirrhosis (Child B and C class) than in patients without cirrhosis. One case of continuing hemorrhage from the gallbladder bed required a reoperation for hemostasis. Two patients with Child-Pugh class C and 1 patient with class B cirrhosis developed ascites after surgery; 1 patient with Child-Pugh class A had bile leakage. No deaths occurred. CONCLUSIONS LC is an effective and safe procedure and should be the treatment of choice for symptomatic cholelithiasis or cholecystitis in patients with compensated cirrhosis.
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20
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Gerges SS, Seleem MI, Ahmed AE, Eldin SS, El-Atrebi KA, Abdel Baky AM, Halim GW. Laparoscopic cholecystectomy in liver cirrhosis patients: An Egyptian experience. SURGICAL PRACTICE 2012. [DOI: 10.1111/j.1744-1633.2011.00574.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Dalvi AN, Thapar PM, Narawane NM, Shukla RN. Laparoscopic Heller's cardiomyotomy in cirrhosis with oesophageal varices. J Minim Access Surg 2011; 6:46-9. [PMID: 20814511 PMCID: PMC2924548 DOI: 10.4103/0972-9941.65164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 01/29/2010] [Indexed: 11/16/2022] Open
Abstract
Surgical intervention in cirrhosis of liver with portal hypertension is associated with increased morbidity and mortality. This is attributed to liver decompensation, intra-operative bleeding, prolonged operative time, wound related and anaesthesia complications. Laparoscopic surgery in cirrhosis is advantageous but is associated with technical challenges. We report one such case of hepatitis C cirrhosis with oesophageal varices and symptomatic achalasia cardia, who was successfully treated by laparoscopic cardiomyotomy after thorough preoperative workup and planning. In the review of literature on pubmed, no such case is reported.
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Affiliation(s)
- Abhay N Dalvi
- Department of Minimal Invasive Surgery, Jupiter Hospital, Thane, Maharashtra, India
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22
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Hamad MA, Thabet M, Badawy A, Mourad F, Abdel-Salam M, Abdel-Rahman MET, Hafez MZED, Sherif T. Laparoscopic versus open cholecystectomy in patients with liver cirrhosis: a prospective, randomized study. J Laparoendosc Adv Surg Tech A 2010; 20:405-9. [PMID: 20518688 DOI: 10.1089/lap.2009.0476] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Gallstones are more common in patients with liver cirrhosis than in healthy individuals. Higher morbidity and mortality were reported in cirrhotic patients with either laparoscopic or open cholecystectomy. The aim of this study was to compare laparoscopic and open cholecystectomy in cirrhotic patients with symptomatic cholelithiasis in a prospective, randomized manner. MATERIALS AND METHODS Thirty patients with symptomatic cholelithiasis associated with Child-Pugh class A or B liver cirrhosis were prospectively and randomly grouped equally to either laparoscopic or open cholecystectomy. The two groups were compared regarding operative time, morbidity, mortality, postoperative liver function, and hospital stay. RESULTS The two groups were comparable regarding demographic data, preoperative and postoperative Child-Pugh scoring, mean operative time (57.3 minutes for laparoscopic and 48.5 for open), and complications (33.3% for each). Hospital stay was shorter for the laparoscopic group. One conversion (6.7%) to open surgery was reported. No periopertive mortality occurred in either group. CONCLUSIONS For Child-Pugh class A and B cirrhotics, laparoscopic cholecystectomy is comparable to the open approach regarding operative time, morbidity, mortality, and effect on liver function, but with shorter hospital stay. Considering the other well-documented advantages of the laparoscopic approach, namely, less pain, earlier mobilization and feeding, and better cosmoses, laparoscopic cholecystectomy would be the first choice in cirrhotic patients.
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Affiliation(s)
- Mostafa A Hamad
- Department of Surgery, Assiut University Hospital, Assiut, Egypt.
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23
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Abstract
BACKGROUND AND OBJECTIVES Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at a tertiary care hospital in Pakistan. METHODS From January 2003 to December 2005, a retrospective study was conducted at SU IV, Liaquat University of Medical & Health Sciences Jamshoro. All the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study. RESULTS Of 250 patients undergoing laparoscopic cholecystectomy, 20 (12.5%) were cirrhotic. Of these 20, 12 (60%) were Childs group A and 8 (40%) were group B. Thirty percent were hepatitis B positive, and 70% were hepatitis C positive. Preoperative diagnosis of cirrhosis was possible in 80% of cases, and 20% were diagnosed during surgery. Morbidity rate was 15% and mortality rate was 0%. Two patients developed postoperative ascites, and mean hospital stay was 2.8+/-0.1 days. Of the 20 cases, 2 (10%) were converted to open cholecystectomy. The mean operation time was 70.2+/-32.54 minutes. CONCLUSION Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.
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Affiliation(s)
- Abdul Razaque Shaikh
- Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, Sindh, Pakistan.
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Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child-Pugh classification in predicting outcome. Surg Endosc 2009; 24:407-12. [PMID: 19551433 DOI: 10.1007/s00464-009-0588-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Revised: 05/04/2009] [Accepted: 05/30/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is a challenging procedure in patients with cirrhosis. This study aims to evaluate the safety and outcome of laparoscopic cholecystectomy in patients with cirrhosis and examines the value of model for end-stage liver disease (MELD) score and Child-Pugh classification in predicting morbidity. MATERIALS AND METHODS From January 1995 to July 2008, 220 laparoscopic cholecystectomies were performed in cirrhotic, Child-Pugh class A and B patients. Indications included symptomatic gallbladder disease and cholecystitis. MELD score ranged between 8 and 27. Child-Pugh class and MELD score were preoperatively calculated and associated with postoperative results. Data regarding patients and surgical outcome were retrospectively analyzed. RESULTS No deaths occurred. Postoperative morbidity occurred in 19% of the patients and included hemorrhage, wound complications, and intra-abdominal collections controlled conservatively. Intraoperative difficulty due to liver bed bleeding was experienced in 19 patients. Conversion to open cholecystectomy was necessary in 12 cases. Median operative time was 95 min. Median hospital stay was 4 days. Patients with preoperative MELD score above 13 showed a tendency for higher complication rate postoperatively. Child-Pugh classification did not seem to predict morbidity effectively. CONCLUSION Laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child-Pugh A and B and symptomatic cholelithiasis with acceptable morbidity. Some of its advantages are shorter operative time and reduced hospital stay. MELD score seems to predict morbidity more accurately than Child-Pugh classification system.
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25
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Operative risks of digestive surgery in cirrhotic patients. ACTA ACUST UNITED AC 2009; 33:555-64. [PMID: 19481892 DOI: 10.1016/j.gcb.2009.03.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 03/25/2009] [Indexed: 12/13/2022]
Abstract
Digestive surgery in cirrhotic patients has long been limited to the treatment of disorders related to the liver disease (portal hypertension, hepatocellular carcinoma and umbilical hernia). The improvement in cirrhotic patient management has allowed an increase in surgical procedures for extrahepatic indications. The aim of this study was to evaluate the operative risks of such surgical procedures. Extrahepatic surgery in cirrhotic patients is associated with high mortality and morbidity. Emergency surgery, gastrointestinal tract opening (esophagus, stomach and colon), <30 g/L serum albumin, transaminase levels more than three times the upper limit of normal, ascites, and intraoperative transfusions are the main risk factors for postoperative death. In Child A patients, the operative risk of elective surgery is moderate and surgical indications are not altered by the presence of cirrhosis. The laparoscopic approach should be recommended because of the potentially lower morbidity. In Child C patients, operative mortality is often higher than 40%; surgical indications must remain exceptional and non operative management has to be preferred. In Child B patients, preoperative improvement of liver function is mandatory for lower risk surgery.
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Frye JW, Perri RE. Perioperative risk assessment for patients with cirrhosis and liver disease. Expert Rev Gastroenterol Hepatol 2009; 3:65-75. [PMID: 19210114 DOI: 10.1586/17474124.3.1.65] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis are at an increased risk of complications of operative procedures. There is a growing understanding of the nature of the risks that cirrhotic patients experience, as well as more precise and objective tools to gauge the patients at risk for surgical complications. Surgical procedures that are common and high risk for patients with cirrhosis are cardiac surgery, cholecystectomy and hepatic resections, as well as other abdominal surgeries and orthopedic surgeries. The physicians who care for patients with cirrhosis who require a surgical procedure can apply an understanding of the type of surgery anticipated with knowledge of the severity of the patient's liver disease to predict those patients at risk for operative morbidity and mortality. A sound knowledge of the specific operative risks faced by patients with cirrhosis should prompt the clinician to take steps to prevent these complications.
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Affiliation(s)
- Jeanetta W Frye
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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27
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Déry L, Galambos Z, Kupcsulik P, Lukovich P. [Cirrhosis and cholelithiasis. Laparoscopic or open cholecystectomy?]. Orv Hetil 2009; 149:2129-34. [PMID: 18977740 DOI: 10.1556/oh.2008.28450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
UNLABELLED Recently laparoscopic cholecystectomy has become the standard operation in case of cholelithiasis. The range of contraindications has decreased, a previous abdominal surgery, a severe cholecystitis or gravidity are not self-evident contraindications any more. The advantages and benefits of laparoscopic interventions in patients with hepatic cirrhosis are doubtful. PATIENTS AND METHODS Between 1996--2006, 52 patients were analyzed at the I. Department of Surgery of Semmelweis University in a retrospective study who underwent operations on hepatic cirrhosis and cholelithiasis. The female/male ratio was 2.7/1 and the mean age was 58.5 (31-87). The patients were classified according to the Child-Pugh score: A = 36, B = 14, C = 2. 23 traditional, open (OC) and 29 laparoscopic (LC) cholecystectomy were performed, in 4 out of the latter operations conversion had to be done. RESULTS In Child A and B cirrhotic patients the mean operative time was 86.5 minutes in the case of LC, whereas with the open intervention it was 86.21 minutes. In Child C cirrhotic patients, open cholecystectomy was performed in both cases, the average operative time was 81.5 minutes. Postoperative complications (Child A, B) occurred in 8 cases (LC/1), (OC/7), while in Child C patients in two cases. The average hospital stay was 7.6 (LC) and 12.45 (OC) days, respectively. The same with Child C patients increased to 28 days. In the postoperative phase 4 patients died: all of them had open cholecystectomy, suffered from Child B and Child C class hepatic cirrhosis, respectively, and they developed hepatorenal syndrome that could not be treated. CONCLUSION The results show that LC is a safe procedure in well-compensated Child A and B cirrhotic patients. Although hepatic cirrhosis greatly increases the surgical risks, as well as the likelihood of complications, and it also necessitates longer operative time and longer hospital stay, it is recommended that cirrhotic patients with symptomatic cholelithiasis should clearly be operated on.
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Affiliation(s)
- Levente Déry
- Semmelweis Egyetem, Altalános Orvostudományi Kar, I. Sebészeti Klinika, Budapest.
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Mancero JMP, D'Albuquerque LAC, Gonzalez AM, Larrea FIS, de Oliveira e Silva A. Laparoscopic cholecystectomy in cirrhotic patients with symptomatic cholelithiasis: a case-control study. World J Surg 2008; 32:267-70. [PMID: 18064516 DOI: 10.1007/s00268-007-9314-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In this study we retrospectively evaluated a group of symptomatic cirrhotic (n=30) and non-cirrhotic (n=60) patients submitted to laparoscopic cholecystectomy (LC) in a public hospital in Brazil. METHODS The groups were compared for surgical time, duration of hospitalization after surgery, period of permanence in the intensive care unit (ICU), use of blood derivatives, mortality rates, and transoperative and post-surgery complications. Other parameters, such as hepatic reserve capacity and presence of ascites, were also analyzed. RESULTS Twenty-three (76.7%) of the patients of the cirrhosis group (CG) were classified as Child-Pugh A, and seven (23.3%) were Child-Pugh B. Six of them (20%) had ascites. Differences between the two groups included surgery time (p=0.008), duration of hospitalization (p=0.014), and post-surgery (p=0.000) or ambulatory (p=0.008) complications. The worst results were observed among Child B patients and in those with ascites. Blood derivatives were used in only 3.3% of the CG patients. No cases of conversion to laparotomy were observed among the two groups of patients included in this study, nor were there any deaths. CONCLUSIONS These results indicate that videolaparoscopic cholecystectomy may be safely performed in public hospitals in Brazil, with low levels of complications, no associated mortality, and no need for blood derivatives.
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Bingener J, Cox D, Michalek J, Mejia A. Can the MELD Score Predict Perioperative Morbidity for Patients with Liver Cirrhosis Undergoing Laparoscopic Cholecystectomy? Am Surg 2008. [DOI: 10.1177/000313480807400215] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender ( P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic ( P = 0.52). MELD and Child's score correlated well ( P < 0.001); however, the risk of complication was not related to the MELD ( P = 0.94) or Child-Pugh-Turcotte score ( P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.
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Affiliation(s)
| | - Diane Cox
- From the Departments of Surgery and Transplant Center and
| | - Joel Michalek
- Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Curro G, Baccarani U, Adani G, Cucinotta E. Laparoscopic cholecystectomy in patients with mild cirrhosis and symptomatic cholelithiasis. Transplant Proc 2007; 39:1471-3. [PMID: 17580164 DOI: 10.1016/j.transproceed.2007.01.086] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 01/29/2007] [Indexed: 12/24/2022]
Abstract
BACKGROUND Our goal was to support the emerging opinion that laparoscopic cholecystectomy is safe and well tolerated in selected cirrhotic patients with indications for surgery. We present our experience with 50 laparoscopic cholecystectomies performed on patients with mild cirrhosis. METHODS We retrospectively reviewed and analyzed the outcomes of 50 laparoscopic cholecystectomies performed between January 1995 and May 2006 in patients with Child-Pugh A and B cirrhosis. RESULTS Laparoscopic cholecystectomy was uneventful for 35 cirrhotic patients. Conversion to an open procedure was necessary in two Child-Pugh B patients with chronic cholelcystitis. One Child-Pugh B cirrhotic patient required blood transfusion. Postoperative complications occurred in 12 patients, including hemorrhage, wound infection, intra-abdominal collection, and cardiopulmonary complications. The mean postoperative stay was 5 days (range, 3 to 13). No deaths occurred. CONCLUSIONS Laparoscopic cholecystectomy is a safe procedure in well-selected Child-Pugh A and B cirrhotic patients and should be the gold standard for patients with mild cirrhosis and symptomatic cholelithiasis.
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Affiliation(s)
- G Curro
- Department of Human Pathology, University of Messina, Strada Panoramica 30/A, Messina 98168, Italy.
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31
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da Silveira EBV. Outcome of cirrhotic patients undergoing cholecystectomy: applying Bayesian analysis in gastroenterology. J Gastroenterol Hepatol 2006; 21:958-62. [PMID: 16724978 DOI: 10.1111/j.1440-1746.2006.04227.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Cholelithiasis is a common finding in patients with cirrhosis. Previous studies showed that open cholecystectomy (OC) carries a high risk of postoperative complications and deaths in cirrhotic patients. Laparoscopic cholecystectomy (LC) has significantly decreased hospital stay and postoperative morbidity in non-cirrhotic patients. The aim of this study was to evaluate the outcomes of cirrhotic patients after LC and OC in a tertiary center. METHODS The outcomes of 33 cirrhotic patients matched by age and sex to 66 non-cirrhotic controls who underwent cholecystectomy were assessed using Bayesian analysis. Both non-informative and informative priors were used to calculate posterior distributions for parameters under investigation. RESULTS Twenty-four (72%) cirrhotic patients had LC and 9 (27%) OC. A similar percentage of patients in the control group underwent LC (78%) and OC (21%). Emergent cholecystectomy was not different between cirrhotic and controls (95% credible interval [CrI]-0.35, 0.02). Mean blood loss, duration of surgery and conversion rate was not different between cirrhotic and controls, but cirrhotic patients had a longer length of hospital stay than controls (CrI 0.88, 4.71). Cirrhotic patients undergoing LC had lower volume of blood loss (CrI -363.85 mL, -49.28 mL), shorter duration of surgery (CrI -79.82 min, -19.74 min), lower amount of intravenous fluid during surgery (CrI -1532.9 mL, -495.4 mL) and shorter hospital stay (CrI -11.14 days, -1.20 days) than cirrhotic patients undergoing OC. Child-Pugh class B class and admission diagnosis of biliary pancreatitis were associated with a longer hospital stay. CONCLUSION Laparoscopic cholecystectomy is a safe and effective alternative to OC in Child-Pugh class A and B cirrhotic patients undergoing elective or emergent cholecystectomy. Although outcomes of cirrhotic patients undergoing LC and OC in a tertiary center are not different, LC is associated with less intraoperative bleeding, shorter duration of surgery and fewer days of in-hospital care.
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Affiliation(s)
- Eduardo B V da Silveira
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.
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Abstract
Conditions that necessitate surgery frequently arise in patients with chronic liver disease and cirrhosis. Because cirrhosis has the ability to cause physiologic derangements in every organ system in the body, clinicians face significant challenges in preoperative preparation of the patient with cirrhosis in order to decrease postoperative morbidity and mortality. Emergent operations add an extra dimension of complexity to the clinical picture, due to limited preoperative time to prepare the patient with cirrhosis for surgery. In cases of severely decompensated cirrhosis, clinicians should have in their armamentarium possible alternatives to surgery that can be used to temporize the emergent nature of the disease and improve patient outcomes. The classification of cirrhotic liver disease by Child and Turcotte was initially utilized to predict mortality in patients undergoing surgically placed shunts for portal hypertensive bleeding. Subsequent studies have pointed to the fact that other general and thoracic surgery procedures can be assigned predicted mortality rates according to a similar classification scheme, the modified Child-Pugh score. Patients with cirrhosis facing surgery should undergo a careful history and physical examination and should be accurately placed into a designated Child-Pugh category. Because the modified Child-Pugh class is the most reliable determinant of postoperative morbidity and mortality, every attempt should be made to upgrade a patient's class in a favorable direction prior to surgery. Patients should be carefully evaluated for the presence of ascites and dietary alterations. In addition, medical management with diuretics should be employed to prevent postoperative ascites leak and possible infectious complications including bacterial peritonitis. Perhaps one of the most feared complications in the patient with cirrhosis facing surgery is hemorrhage. Because the liver is vital in maintenance of coagulation homeostasis, several pharmacologic adjuncts may be administered to correct any coagulopathy in the peri-operative period. Several diseases such as cholelithiasis and peptic ulcer disease are known to be more prevalent in the cirrhotic patient, and clinicians treating these diseases should have a thorough understanding of the pathophysiology of cirrhosis and portal hypertension. Patients with cirrhosis and portal hypertensive bleeding that are considered good surgical candidates (ie, Child-Pugh class A) may benefit from surgical portasystemic shunt in contrast to angiographically placed portacaval shunt (ie, transjugular intrahepatic portosystemic shunt ) due to the lack of durable patency and cost effectiveness in the latter. In patients with cirrhosis awaiting orthotopic liver transplantation, TIPS may be a lifesaving temporizing technique that is utilized as a bridge to transplantation.
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Affiliation(s)
- Christopher L Bell
- Department of Surgery, Methodist Hospital of Dallas, 221 West Colorado Blvd., Pavilion I, Suite 100, Dallas, TX 75208, USA
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Schiff J, Misra M, Rendon G, Rothschild J, Schwaitzberg S. Laparoscopic cholecystectomy in cirrhotic patients. Surg Endosc 2005; 19:1278-81. [PMID: 16021366 DOI: 10.1007/s00464-004-8823-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 03/02/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND Due to unacceptable increases in intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered to be a contraindication for laparoscopic cholecystectomy (LC). However, recent advances have now made it increasingly possible for experienced surgeons to perform LC on this high-risk population. The aim of this study was to evaluate the impact of the coagulopathy associated with cirrhosis on the performance and results of LC. We hypothesized that the factors leading to hemorrhage, rather than Child's classification, would drive operating time and resource utilization. METHODS Between 1 July 1996 and 30 June 2003, 1,285 cholecystectomies were performed. Thirty one of these patients had evidence of cirrhosis at the time of operation. The 31 patients were divided into high, (low platelets, prolonged International Normalized Ratio) (n = 18), intermediate, (abnormal liver function tests, normal clotting) (n = 5), and low, (normal platelets, normal clotting, and normal liver function tests) (n = 8) surgical risk categories for further analysis. Based on the Child-Turcotte-Pugh (CTP) classification of cirrhosis, there were three grade C and 28 grade A or grade B patients. RESULTS There were 24 LC, three of which were started laparoscopically and then converted to open, and four open cholecystectomies. Operating room time ranged from 79 to 450 min, with the extent of coagulopathy correlating with the length of time needed to achieve satisfactory hemostasis. Median length of stay postoperatively in the high-risk group was 2 days (range, 0-20). Nine of the cholecystectomies were performed on an outpatient basis. One patient received a liver transplantation 5 months post-LC. There were no operative deaths, bile duct injuries, or returns to the operating room for bleeding. Blood product usage correlated with preexisting coagulopathy. CONCLUSIONS Currently, the classification of cirrhotic patients is normally done using the CTP score. However, preoperative platelet levels and INR more accurately predict the difficulty of cholecystectomy than CTP score, because intraoperative hemorrhage is the primary concern in these patients. This study demonstrates that preoperative degree of coagulopathy, and not Child's class, should guide the surgeon's approach and expectations when LC is performed in a cirrhotic patient.
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Affiliation(s)
- J Schiff
- Department of Surgery and Paul Pierce Center for Minimally Invasive Surgery, Tufts-New England Medical Center, 750 Washington Street, Box 1047, Boston, MA 02111, USA
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Cobb WS, Heniford BT, Burns JM, Carbonell AM, Matthews BD, Kercher KW. Cirrhosis is not a contraindication to laparoscopic surgery. Surg Endosc 2004; 19:418-23. [PMID: 15624057 DOI: 10.1007/s00464-004-8722-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2004] [Accepted: 10/12/2003] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cirrhosis of the liver contributes significantly to morbidity and mortality in abdominal surgery. The proven benefits of laparoscopy seem especially applicable to patients with this complex disease. This study evaluates the safety and efficacy of laparoscopic procedures in a series of consecutively treated patients with biopsy-proven cirrhosis. METHODS The medical records of all patients with biopsy-proven cirrhosis undergoing laparoscopic surgery at the authors' medical center between January 2000 and December 2003 were retrospectively reviewed. RESULTS A total of 50 patients (27 men and 23 women) underwent 52 laparoscopic procedures. Among these 50 patients were 39 patients with Child-Pugh classification A cirrhosis, 10 with classification B, and 1 with classification C, who underwent a variety of laparoscopic procedures including cholecystectomy (n = 22), splenectomy (n = 18), colectomy (n = 4), diagnostic laparoscopy (n = 3), ventral hernia repair (n = 1), Nissen fundoplication (n = 1), Heller myotomy (n = 1), Roux-en-Y gastric bypass (n = 1), and radical nephrectomy (n = 1). There were two conversions (4%) to an open procedure. The mean operative time was 155 min. Estimated blood loss averaged 124 ml for all procedures, and 20 patients (40%) required perioperative transfusion of blood products. One patient required a single blood transfusion postoperatively because of anemia. No one experienced hepatic decompensation. Overall morbidity was 16%. There were no deaths. The mean length of hospitalization was 3 days. CONCLUSIONS Although technically challenging because portal hypertension, varices, and thrombocytopenia frequently coexist, basic and advanced laparoscopic procedures are safe for patients with mild to moderate cirrhosis of the liver.
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Affiliation(s)
- W S Cobb
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, MEB 601, Charlotte, NC 28203, USA
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Perkins L, Jeffries M, Patel T. Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis. Clin Gastroenterol Hepatol 2004; 2:1123-8. [PMID: 15625658 DOI: 10.1016/s1542-3565(04)00547-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis have an increased risk for cholelithiasis but also have an increased risk for morbidity and mortality after cholecystectomy. Current preoperative assessment of surgical risk is imprecise. Our aims were to identify preoperative factors that would accurately predict the risk for cholecystectomy in patients with cirrhosis. METHODS Preoperative clinical or biochemical parameters were determined for 33 patients with cirrhosis and 31 age- and sex-matched patients without cirrhosis. The use of these parameters and of the Child-Pugh and model for end-stage liver disease (MELD) scores as preoperative predictors of outcome after surgery were assessed. RESULTS There were 2 deaths, both in cirrhotic patients. The overall risk for morbidity or mortality was increased in cirrhotic patients compared with controls. Postoperative morbidity was significantly associated with preoperative increases of international normalized ratio >1.2, bilirubin >1.0 mg/dL, creatinine >1.4 mg/dL, and a decreased platelet count <150 x 10(3) /mL. The MELD and Child-Pugh scores accurately predicted postoperative morbidity, with an area under the curve of 0.938 and 0.839, respectively. A preoperative MELD score of > or =8 had a sensitivity of 91% and a specificity of 77% for predicting postoperative morbidity. Persons with a MELD score of > or =8 had increased 30- and 90-day global charges and increased blood product usage. CONCLUSIONS Preoperative biochemical parameters, international normalized ratio, bilirubin, platelets, and creatinine can predict increased morbidity in cirrhotic patients. A MELD score of > or =8 identifies a group at high risk for postoperative morbidity after cholecystectomy.
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Affiliation(s)
- Linda Perkins
- division of Gastroenterology, Scott and White Clinic, Texas A&M University System Health Science Center, Temple, Texas 76508, USA
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Richardson JD, Cocanour CS, Kern JA, Garrison RN, Kirton OC, Cofer JB, Spain DA, Thomason MH. Perioperative risk assessment in elderly and high-risk patients. J Am Coll Surg 2004; 199:133-46. [PMID: 15217641 DOI: 10.1016/j.jamcollsurg.2004.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2002] [Revised: 02/20/2004] [Accepted: 02/24/2004] [Indexed: 12/20/2022]
Affiliation(s)
- J David Richardson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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Abstract
OBJECTIVE To review the characteristic features of patients with advanced liver disease that may lead to increased perioperative morbidity and mortality rates. DESIGN Literature review. RESULTS Patients with end-stage liver disease are at high risk of major complications and death following surgery. The most common complications are secondary to acute liver failure and include severe coagulopathy, encephalopathy, adult respiratory distress syndrome, acute renal failure, and sepsis. The degree of malnutrition, control of ascites, level of encephalopathy, prothrombin time, concentration of serum albumin, and concentration of serum bilirubin predict the risk of complications and death following surgery. Other determinants of adverse outcome include emergency surgery, advanced age, and cardiovascular disease. Portal hypertension is a prominent feature of advanced liver disease, and it predisposes the patient to variceal hemorrhage, hepatorenal syndrome, hepatopulmonary syndrome, and uncontrolled ascites. Portal hypertension can be ameliorated by percutaneous or surgical portasystemic shunting procedures. If well-defined contraindications are not present, patients with advanced liver disease should be evaluated for orthotopic liver transplantation from a cadaver donor or possible living-related liver transplantation. CONCLUSIONS Optimal preparation, which addresses the common features of advanced liver disease, may decrease the risk of complications or death following surgery. Preparation should include correcting coagulopathy, minimizing preexisting encephalopathy, preventing sepsis, and optimizing renal function.
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Affiliation(s)
- Richard A Wiklund
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND Few articles address the issue of LC in patients with cirrhosis. Existing articles are retrospective and with small sample sizes, which makes it difficult to draw conclusions about indications and complications with LC in this setting. STUDY DESIGN An extensive search of the Medline, Embase, and Cochrane databases using the terms "laparoscopic cholecystectomy" and "cirrhosis" or "cirrhotic" was conducted. The data from each study were extracted, combined with those of similar studies, and analyzed. RESULTS Twenty-five publications (400 patients with cirrhosis undergoing LC) from 1993 to 2001 were identified. Four articles compared LC with open cholecystectomy in patients with cirrhosis, and six compared patients with cirrhosis to patients without cirrhosis. Patients were primarily in Child-Pugh class A or B, with only six patients in Child-Pugh class C. Compared with patients without cirrhosis, patients with cirrhosis had higher conversion rates (7.06% versus 3.64%, p = 0.024), operative times (98.2 minutes versus 70 minutes, p = 0.005), bleeding complications (26.4% versus 3.1%, p < 0.001), and overall morbidity (20.86% versus 7.99%, p < 0.001). Acute cholecystitis was evident in 47% of patients with cirrhosis versus 14.7% of patients without cirrhosis (p < 0.001). When LC was compared with open cholecystectomy in patients with cirrhosis, LC was associated with less operative blood loss (113 mL versus 425.2 mL, p = 0.015), operative time (123.3 minutes versus 150.2 minutes, p < 0.042), and length of hospital stay (6 days versus 12.2 days, p < 0.001). CONCLUSIONS Patients with cirrhosis undergo cholecystectomies for more emergent reasons and have higher morbidity. The laparoscopic approach offers advantages of less blood loss, shorter operative time, and shorter length of hospitalization in patients with cirrhosis. Prospective studies will establish which factors affect outcomes and determine the appropriateness of LC in Child's-Pugh class C cirrhosis.
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del Olmo JA, Flor-Lorente B, Flor-Civera B, Rodriguez F, Serra MA, Escudero A, Lledó S, Rodrigo JM. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg 2003; 27:647-52. [PMID: 12732995 DOI: 10.1007/s00268-003-6794-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cirrhosis of the liver appears to have an unfavorable prognosis in the surgical patient. The aim of this study was to determine risk factors for morbidity and mortality in patients with cirrhosis undergoing nonhepatic surgery. We studied 135 patients with liver cirrhosis undergoing nonhepatic procedures and 86 controls matched by age, sex, and preoperative diagnosis. Preoperative, intraoperative, and postoperative variables associated with 30-day mortality and morbidity were assessed by univariate and multivariate analyses. Patients with cirrhosis showed higher blood transfusion requirements, longer length of hospital stay, and a higher number of complications than controls. The mortality rate was 16.3% in cirrhotics and 3.5% in controls. By univariate analysis, the need for transfusions, prothrombin time, and Child-Pugh score were significantly associated with postoperative liver decompensation, whereas duration of surgery, prothrombin time, Child-Pugh score, cirrhosis-related complications, and general complications were significantly associated with mortality. In the multivariate analysis, Child-Pugh score (odds ratio [OR] 24.4; 95% confidence interval [CI] 5.5 to 106); duration of surgery (OR 5; 95% CI 1.2 to 15.6), and postoperative general complications (OR 3.7; 95% CI 3.4 to 6.4) were independent predictors of mortality. Patients with cirrhosis undergoing nonhepatic operations are at significant risk of perioperative complications leading to death. Independent variables associated with perioperative mortality include preoperative Child-Pugh score, the duration of surgery, and the presence of postoperative general complications.
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Affiliation(s)
- Juan A del Olmo
- Service of Hepatology, Hospital Clinico Universitario, Avenida Blasco Ibáñez 17, E-46010 Valencia, Spain.
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Fontes PRO, de Mattos AA, Eilers RJ, Nectoux M, Pinheiro JOP. [Laparoscopic cholecystectomy in patients with liver cirrhosis]. ARQUIVOS DE GASTROENTEROLOGIA 2002; 39:212-6. [PMID: 12870079 DOI: 10.1590/s0004-28032002000400002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Initially considered a contraindication to the surgical laparoscopy, cirrhosis have been an occasional discovery during this procedure. Until now many series reported in the literature suggest that the majority of the surgeons still consider cirrhosis as contraindication to the laparoscopic cholecystectomy. AIM To evaluate our experience in laparoscopic treatment of the cholelithiasis in cirrhotic patient. PATIENTS AND METHODS Six hundred and four patients with symptomatic cholelithiasis were operated on Clinical and Surgical Gastroenterology Unit, "Santa Casa de Misericórdia de Porto Alegre", Porto Alegre, RS, Brazil, during the period from May 1993 to May 2000. Of these, 10 (1,6%) presented hepatic cirrhosis. The patients' age was between 22 and 69 years (average of 50,4 +/- 18,1). Eight patients (80%) were female. The alcohol was the etiological factor in four, chronic hepatitis B and C, primary biliary cirrhosis and of alfa-1 antitripsin deficiency in one patient each. In two patient the causal agent was not identified. RESULTS Cholecystectomy was accomplished in all patients and in seven also diagnostic hepatic biopsy. In two (20%) the surgery was converted. The result of the intraoperative cholangiography was normal in all cases. In seven patients the postoperative was uneventfull. Clinically controlled ascite was observed in two (20%). Both were Child A at the moment of the surgery. The last patient, Child C, died. He presented irreversible hepatic failure. CONCLUSIONS Despite larger experience still should be acquired, it seems that laparoscopic is a safe approach in well compensated cirrhotic patients with symptomatic cholelithiasis. In Child C patients we believed that all of the efforts should be driven to the improvement of the hepatic function or a less invasive method such as cholecystostomy.
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Affiliation(s)
- Paulo Roberto Ott Fontes
- Serviço de Gastroenterologia Clínica e Cirúrgica, Complexo Hospitalar da Santa Casa de Porto Alegre, Porto Alegre, Brasil.
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Tuech JJ, Pessaux P, Regenet N, Rouge C, Bergamaschi R, Arnaud JP. Laparoscopic cholecystectomy in cirrhotic patients. Surg Laparosc Endosc Percutan Tech 2002; 12:227-31. [PMID: 12193815 DOI: 10.1097/00129689-200208000-00005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since 1992, laparoscopic cholecystectomy has been the treatment of choice for symptomatic gallstones. The advantages of laparoscopic cholecystectomy for most patients have been extensively published. However, its benefits and successful use in patients with cirrhosis are less well documented. The aim of this study was to determine the efficacy and safety of laparoscopic cholecystectomy in cirrhotic patients. We did a retrospective review of the records of 26 consecutive laparoscopic cholecystectomy procedures performed on cirrhotic patients between January 1992 and September 2000. Twenty-two patients were classified as having Child's class A cirrhosis, and 4 patients were classified as having Child's class B. No patients were classified as having Child's class C cirrhosis. There were 20 men and 6 women, with a mean age of 57 years (range, 37-76). All procedures were completed laparoscopically. There was histologic confirmation of cirrhosis in all patients. The mean operative time was 126 minutes (range, 60-184). The mean estimated blood loss was 110 mL (range, 40-380). Complications occurred in 7 patients (27%). No operative mortality occurred in this study. The mean length of hospital stay was 5 days (range, 3-14). Our results and the results of others show that laparoscopic cholecystectomy in cirrhotic patients seems to be safe in selected Child-Pugh class A and B patients with compensated cirrhosis. Cholecystectomy remains a high-risk procedure in cirrhotic patients, and indications for cholecystectomy should be evaluated carefully. Controlled trials are required to confirm the safety of this procedure, and further studies are also required to evaluate the management of gallbladder disease in patients with Child-Pugh class C cirrhosis.
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Affiliation(s)
- Jean-Jacques Tuech
- Department of Digestive Surgery, Angers University Hospital, 4 rue Larrey, CHU, 49000 Angers, France
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Buckles DC, Lindor KD, Larusso NF, Petrovic LM, Gores GJ. In primary sclerosing cholangitis, gallbladder polyps are frequently malignant. Am J Gastroenterol 2002; 97:1138-42. [PMID: 12014717 DOI: 10.1111/j.1572-0241.2002.05677.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The management of gallbladder polyps/masses in patients with primary sclerosing cholangitis (PSC) (i.e., cholecystectomy vs observation) remains problematic. Given the risk of biliary tract cancer in PSC in the face of the benign nature of most gallbladder polyps in the general population, our aim was to determine the prevalence of gallbladder cancer in PSC patients with a gallbladder mass who had undergone cholecystectomy. METHODS The case records of all patients with PSC undergoing a cholecystectomy at the Mayo Clinic between 1977-1999 were reviewed. RESULTS Of the 102 patients with PSC who underwent a cholecystectomy, 14 of 102 (13.7%) had a gallbladder mass. In the subset of patients with gallbladder masses, eight of 14 (57%) had adenocarcinomas (seven primary adenocarcinomas and one metastatic cholangiocarcinoma); the other six had benign masses (five adenomas and one cholesterol polyp). In those patients with benign masses, 33% had associated epithelial cell dysplasia; in patients with primary gallbladder cancers, 57% had associated dysplasia. The patients with primary gallbladder adenocarcinoma had a favorable outcome after cholecystectomy, with a 36-month survival of 66%. CONCLUSIONS In conclusion, gallbladder neoplasms in PSC patients are malignant in approximately 40-60% of the cases. The presence of gallbladder epithelial cell dysplasia suggests a dysplasia-carcinoma sequence in PSC similar to that observed in ulcerative colitis. Consideration should be given to performing a cholecystectomy in PSC patients with gallbladder polyps. If a cholecystectomy is not performed, careful interval follow-up is warranted.
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Affiliation(s)
- Daniel C Buckles
- Division of Gastroenterology and Hepatology, Mayo Medical School, Clinic, and Foundation, Rochester, Minnesota 55905, USA
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Ziser A, Plevak DJ. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Curr Opin Anaesthesiol 2001; 14:707-11. [PMID: 17019169 DOI: 10.1097/00001503-200112000-00018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Several studies have demonstrated increased morbidity and mortality in patients with cirrhosis undergoing anesthesia and surgery. Cirrhosis is a chronic liver disease, which may affect all body systems. The severity of the disease, assessed by the Child-Pugh classification, has a substantial effect on patient outcome. The extent of surgery and co-morbid conditions also have a major impact. In the past few years, changes have been made in the diagnosis, preoperative preparation, surgical and anesthetic management and perioperative care of patients with liver disease. The aim of this review is to examine whether these changes have resulted in improved perioperative outcomes.
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Affiliation(s)
- A Ziser
- Department of Anesthesiology, Rambam Medical Center and the Technion Faculty of Medicine, Haifa, Israel.
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