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Operative risks of digestive surgery in cirrhotic patients

Gastroentérologie Clinique et Biologique (2009) xxx, xxx—xxx
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Operative risks of digestive surgery in
cirrhotic patients

Risque opératoire du patient cirrhotique en chirurgie digestive
R. Douard , C. Lentschener , Y. Ozier , B. Dousset
a Service de chirurgie digestive et endocrinienne, hôpital Cochin, Assistance publique—Hôpitaux de Paris,faculté de médecine Paris Descartes, 27, rue du Faubourg Saint-Jacques, 75014 Paris, Franceb Service d'anesthésie—réanimation, hôpital Cochin, Assistance publique—Hôpitaux de Paris,faculté de médecine Paris-Descartes, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France Digestive surgery in cirrhotic patients has long been limited to the treatment of dis- orders related to the liver disease (portal hypertension, hepatocellular carcinoma and umbilicalhernia). The improvement in cirrhotic patient management has allowed an increase in surgicalprocedures for extrahepatic indications. The aim of this study was to evaluate the operativerisks of such surgical procedures. Extrahepatic surgery in cirrhotic patients is associated withhigh mortality and morbidity. Emergency surgery, gastrointestinal tract opening (esophagus,stomach and colon), < 30 g/L serum albumin, transaminase levels more than three times theupper limit of normal, ascites, and intraoperative transfusions are the main risk factors forpostoperative death. In Child A patients, the operative risk of elective surgery is moderate andsurgical indications are not altered by the presence of cirrhosis. The laparoscopic approachshould be recommended because of the potentially lower morbidity. In Child C patients, oper-ative mortality is often higher than 40%; surgical indications must remain exceptional and nonoperative management has to be preferred. In Child B patients, preoperative improvement ofliver function is mandatory for lower risk surgery.
2009 Elsevier Masson SAS. All rights reserved.
La chirurgie digestive chez le cirrhotique a longtemps été limitée au traitement des conséquences de la maladie hépatique (hypertension portale, carcinome hépatocellulaire,hernie ombilicale). L'amélioration de la prise en charge des cirrhotiques a permis une aug-mentation du nombre d'interventions réalisées pour des indications extrahépatiques. Le butde ce travail a été de faire le point sur le risque opératoire du cirrhotique dans ces indica-tions chirurgicales. La chirurgie extrahépatique chez le patient cirrhotique est associée à destaux élevés de mortalité et de morbidité élevés. Une intervention en urgence, une interven-tion portant sur le tube digestif (œsophage, estomac, côlon), une hypoalbuminémie inférieure à30 g/L, des transaminases supérieures à trois fois la limite supérieure de la normale, la présence ∗ Corresponding author.
E-mail address: (B. Dousset).
0399-8320/$ – see front matter 2009 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Douard R, et al. Operative risks of digestive surgery in cirrhotic patients. GastroenterolClin Biol (2009), doi:

R. Douard et al.
d'une ascite et l'existence de transfusions peropératoires sont les principaux facteurs de risquede mortalité postopératoire. Chez les malades Child A, le risque opératoire en chirurgie élec-tive est modéré et les indications chirurgicales ne sont pas modifiées par la cirrhose. La voied'abord laparoscopique doit être privilégiée car elle pourrait diminuer la morbidité. Chez lesmalades Child C, la mortalité opératoire dépasse souvent 40 % ; les indications chirurgicalesdoivent rester exceptionnelles et il faut privilégier les traitements non opératoires. Pour lesmalades Child B, il faut différer l'intervention et améliorer la fonction hépatique pour diminuerle risque opératoire.
2009 Elsevier Masson SAS. Tous droits réservés.
Digestive surgery in cirrhotic patients has long been limitedto the treatment of disorders related to the liver disease;portal hypertension, hepatocellular carcinoma and umbili-cal hernia. Improvement in cirrhotic patient managementhas improved patient survival and so more and more cir-rhotic patients are proposed for surgery. In this population,the number of surgical procedures for extrahepatic diseasehas consequently increased in a similar proportion. Althoughpostoperative morbidity and mortality are higher than gen-erally observed, few studies have examined the specific risksof digestive surgery in the cirrhotic patient. The purposeof this study was to review our knowledge of the opera-tive risk of digestive surgery in the cirrhotic patient. Theoperative risk related to hepatic surgery and portal hyper-tension will not be discussed in this review because they aredirectly related to the liver disease and its consequences.
We will first discuss the overall operative risk in the cir-rhotic patient and then examine the specific consequencesof surgery in this population before analyzing the different From Northup et al. mortality rate in the types of surgery individually.
140 study cirrhotic patients at 30-day follow-up after generalsurgery according to the model for end-stage liver disease(MELD) score. The MELD score takes into account the inter- Surgical risk in the cirrhotic patient
national normalized ratio, total bilirubin and serum creatininelevel.
Operative mortality in the cirrhotic patient is correlatedwith the severity of liver failure, irrespective of the scoreused to assess surgical risk The Child-Pugh ( cirrhotic patient undergoing general surgery procedures and model for end-stage liver disease (MELD) scores Operative risk is higher in patients with sev- initially correlated with operative mortality for portal caval eral factors The risk of postoperative death, even for a anastomosis, can be transposed to general operative risk major operation, in cirrhotic patients free of ascites, liver for cirrhotic patients. More recently, Ziser et al. confirmed failure and acute alcoholic hepatitis, and who have a normal these data and identified eight factors significantly corre- prothrombin level, is the same as observed in noncirrhotic lated with postoperative morbidity and mortality in the patients with the same pathological condition Organ failure in the operated cirrhotic patient
Child-Pugh classification Hemodynamics
Irrespective of the etiology, cirrhotic patients present a
hyperkinetic hemodynamic situation associating elevated heart flow rate, low systemic blood pressure and low left Serum bilirubin (␮mol/L) ventricle afterload associated with splanchnic vasodilata- Serum albumin (g/L) tion This splanchnic vasodilation ‘‘steals'' vascular flow from other vital territories such as the renal circulation The Child-Pugh score is the sum of points (5—15). The Child-Pugh Perioperative infusion of vasopressive amines may be stage is established from the Child-Pugh score: A: 5 or 6 points; necessary to counterbalance the loss of volumetric con- B: 7—9 points; C: 10—15 points. For primary biliary cirrhosis, the trol triggered by the surgery. Perioperative hemodynamic points for serum bilirubin are as follows: 1 point for <70 ␮mol/L, variations may disclose an alcohol-related dilated cardiomy- 2 points for 70 to 170 ␮mol/L and 3 points for >170 ␮mol/L.
opathy (low cardiac output and/or rythm disorders) or Please cite this article in press as: Douard R, et al. Operative risks of digestive surgery in cirrhotic patients. GastroenterolClin Biol (2009), ARTICLE IN PRESS
Digestive surgery and cirrhosis Factors associated with postoperative complication in cirrhotic patients Mortality at 30 days (%) Mortality at 6 months (%) Child-Pugh score: 7—10 Elevated serum creatinine Chronic respiratory disease Preoperative infection Upper digestive bleeding Low interoperative blood pressure Cryptogenetic cirrhosis cirrhotic cardiomyopathy (left ventricular dysfunction) effective A deficit in factors I, II, V, VII, IX, X due to Pulmonary artery hypertension, defined as a mean pul- defective hepatic synthesis is correlated with the severity monary arterial pressure ≥ 25 mmHg, associated with a of liver failure. Apparently primary fibrinolysis is usually normal wedge pressure can coexist with cirrhosis. The risk a complication, especially of infection. Hypercoagulation is severe intra- and postoperative heart failure due to right markers are common in patients with cirrhosis, who are ventricle failure. The prevalence of coronary artery disease susceptible to thromboembolic complications is high in the cirrhotic population, where diabetes, alcoholabuse and smoking are common Malnutrition
Malnutrition is a common finding in cirrhotic patients
and is correlated with the severity of liver failure. Dex- Hypoxemia has been noted in 15 to 45% of cirrhotic patients trose infusions may reveal deficiency in trace elements and generally related to pleural effusion associated with vitamins Today, clinicians consider that cirrhosis does ascites The hepatopulmonary syndrome is defined by not preclude renutrition but have been unable to formally hypoxemia associated with an oxygen alveolar-arterial gra- demonstrate an advantage in terms of postoperative mor- dient without cardiac anomalies. The causal mechanism is the shunt provoked by the dilation of the pulmonary precap-illary arterioles. A spontaneous ventilation hyperoxemia test Infections in the operated cirrhotic patient
can be used to assess the correction of the hypoxemia and Preexisting infection is an independent variable associated quantify the shunt, predictive of postventilatory weaning with postoperative morbidity (74%) and mortality at 30 days and postoperative respiratory tolerance (49%) and 6 months (60%) in the operated cirrhotic patientSystematic search for infection and preoperative treat- Renal function and ascites
ment are thus mandatory in the cirrhotic patient. Cirrhosis is Renal blood flow declines proportionally with the sever- not an independent factor for operative site infection, irre- ity of the cirrhosis-related hyperkinetic syndrome In spective of the type of surgery (contaminated or not) patients with liver failure, lean body mass is often dimin- It is, however, a risk factor for infections distant from the ished and glomerular filtation can be greatly reduced despite operative site Consequently, the same antibiotic pro- a normal serum creatinine level Serum levels must be phylaxis must be scheduled for the cirrhotic patient as for assayed repeatedly in cirrhotic patients receiving nephro- the noncirrhotic patient with the same surgical risk toxic drugs In a surgery context, blood or digestive steady rise in medicalization of cirrhotic patients has led fluid losses, constitution of a third sector, evacuation of to a high prevalence of multiresistant germs, irrespective abundant ascites, aggressive diuretic treatment and inap- of the site of infection Nasal and rectal swabs might propriate fluid and electrolyte restriction may aggravate the be helpful in detecting carriers of multiresistant bacteria impact of the hyperkinetic syndrome on the kidneys inducing among previously medicalized cirrhotic patients In the functional renal failure Ascites is a frequent compli- cirrhotic patient, the frequency of postoperative infections cation of abdominal surgery in the cirrhotic patient is associated with translocation of gastrointestinal tract The ascitic fluid arises via a diminution of the circulating bacteria into the general blood stream, blood transfusion, volume There is no evidence supporting the hypothesis duration of surgery, severity of liver failure and insufficient that postoperative restriction of fluid intake prevents post- antibiotic therapy Preoperative decontamination operative ascites There is no evidence that exsudative of the digestive tract has not been found to decrease the effusion associated with digestive resection and postopera- rate of postoperative infections tive chylous ascites are specific for this population Quantitative changes in the synthesis of binding proteins cir- Splenic sequestration of platelets leads to various degrees culating in the blood stream leads to an increase in the of thrombopenia. Circulating platelets are functionally concentration of pharmacologically active free fraction of Please cite this article in press as: Douard R, et al. Operative risks of digestive surgery in cirrhotic patients. GastroenterolClin Biol (2009), doi: ARTICLE IN PRESS
R. Douard et al.
certain drugs, including antibiotics The distribution vol- fat-free diet supplemented with medium chain triglycerides ume of certain drugs can be increased as a result of fluid may be insufficient. Drainage (or iterative puncture) may and electrolyte retention Drug administration must be be needed, combined with exclusive parenteral nutrition to halt the production of this chylous ascites in 4 to 6 weeks.
Anesthesia and postoperative analgesia
No anesthesia protocol has been proven superior in the Renal failure is observed in nearly 10% of operated cir- operated cirrhotic patient Locoregional and peridural rhotic patients may present functional renal failure anesthesia and analgesia should be discussed for patients a hepatorenal syndrome associated with severe liver with normal coagulation factors and a platelet count above failure renal failure subsequent to acute tubular 100,000/mm3 who would not be expected to develop necrosis related to severe infection or multiorgan failure. It major fibrinolysis postoperatively. Acetaminophen should be is associated with ascites in 60% of patients and an infectious used prudently Nefopam is not submitted to hepatic syndrome in 50%. These associations show that the renal metabolism; its efficacy in relieving postoperative pain has failure is generally the consequence of other complications been demonstrated for major digestive surgery Care- (dehydration, infection, multiorgan failure).
ful titration of analgesic and secondary effects is requiredfor morphine prescription Inhibition of prostaglandin synthesis in the kidneys by administration of nonsteroidal Postoperative infection affects 13 to 40% of operated anti-inflammatory drugs (NSAID) is a cause of renal ischemia cirrhotic patients The rate is higher if the gas- by reduced blood flow NSAID should be proscribed for trointestinal tract has been opened In the cirrhotic cirrhotic patients with ascites patient, infections occur more readily late after surgery andgenerally do not involve the operative site. The most com- Chronic viral hepatitis B and C
mon localizations include the lung (8%) and the urinary tract Viral disease can be associated with renal failure, or infected ascites, sometimes associated with septicemia systemic hypertension, pulmonary vasculitis, cryoglobu- The risk of spontaneous bacteriemia is higher linemia, peripheral neuropathy, thyroid dysfunction and in cirrhotic patients and increases further in the event of thrombopenic purpura. The secondary effects of certain postoperative liver failure antiviral agents should be taken into account, e.g. epilep-sia, depression, leukothrombopenia with infection and risk Complications involving the abdominal wall
of hemolysis with ribavirin Ascites leakage through the abdominal wall is observedin 2% of operated patients, even if abdominal drainage is Specific postoperative complications
installed. This leakage favors infections and evisceration.
Abdominal drainage may be insufficient to avoid this leakage but significantly increases the risk of ascites infection Postoperative ascites is one of the main complications Abdominal drainage can, however, avoid excessive accu- observed in cirrhotic patients undergoing abdominal surgery.
mulation of ascites which would exaggerate the leakage The prevalence is greater than 20% The risk of post- favoring the constitution of pseudocellulitis due to infiltra- operative ascites is significantly increased by the presence tion of the subcutaneous tissues and evisceration.
of intraoperative ascites and installation of drainage. The An expert consensus recommends a solid suture of the risk differs depending on the type of abdominal surgery; abdominal wall using a slow resorbing thread and tight clo- it is lower after parietal and biliary surgery. Postoperative sure of the teguments using a cutaneous overcast stitch.
ascites in a cirrhotic patient can be divided into three cat- Depending on the procedure performed and the anticipated egories. Type I is correlated with liver failure. It is favored risk of postoperative ascites, it is recommended either to by postoperative fluid and electrolyte retention and readily avoid drainage or to drain with a sterile aspiration system.
responds to treatment. Type II ascites is defined as unremit-ting and difficult to treat. More commonly observed after supramesocolonic surgery (gastrectomy), this type of ascites This complication is observed in 10% of operated cirrhotic would be related to section of the lymphatic vessels drain- patients but in only 5% of those undergoing abdominal ing the liver and overloaded with interstitial fluid because of surgery Because of this high rate special pre- and the portal hypertension This is a lymphatic ascites of postoperative measures are warranted to prevent digestive hepatic origin producing a clear effusion with high protein bleeding related to portal hypertension, i.e. betablockers content, high lymphocyte count and a normal triglyceride and/or endoscopic treatment, depending on the size of level, similar to the ascites observed after liver transplanta- the varices and the past history of rupture of esophageal tion Type III postoperative ascites is a chylous effusion varices In the cirrhotic patient, there is a higher risk of related to the extravasation of lymphatic fluid rich in bleeding from gastroduodenal stress ulcers; favoring factors triglycerides arising from the interruption of the mesenteric are severe sepsis, prolonged mechanical ventilation, liver lymphatic flow because of the surgical section of the mesen- failure and abdominal surgery Several studies have teric or periaortic lymphatic vessels It can be observed demonstrated an increased risk of nosocomial pneumopathy after pancreatic, colonic or small bowel surgery. There is no related to the use of antisecretory agents (compared with relationship between the severity of the liver failure and sucralfate) by alkalinization and colonization of the gastric the development of chylous ascites. Treatment is difficult; Please cite this article in press as: Douard R, et al. Operative risks of digestive surgery in cirrhotic patients. GastroenterolClin Biol (2009), ARTICLE IN PRESS
Digestive surgery and cirrhosis Severe liver failure
umbilical hernia and 2% after elective surgery Mortality Severe liver failure is the most common complication, the was zero in the two most recent studies reported by expert cause of nearly 50% of postoperative deaths centers and including 39 and 40 patients undergoing surgery For the majority of patients, severe liver failure develops in for umbilical hernia a context of preoperative liver failure after an emergencyintervention opening the gastrointestinal tract. Prothrombin below 50% and total serum bilirubin > 50 ␮mol/L on the 5th Surgery should be proposed solely for postoperative day would be the best sign of postoperative inguinal hernias and incisional hernia which become symp- liver failure This 50-50 rule was defined for patients tomatic or complicated. For patients with a moderately undergoing liver resection of healthy or pathological liv- altered liver function (Child A or B), cure for inguinal her- ers but not for patients undergoing extrahepatic surgery.
nia can be achieved with acceptable morbidity In It is difficult to differentiate liver failure from multiorgan the presence of ascites, the same precautions must be taken failure, common in this context.
as for umbilical hernias. The French Association of Surgeryreported a series of 38 inguinal hernias (one case of prosthe- Surgery of the abdominal wall
sis interposition) and 23 incisional hernias (nine prosthesisinterpositions and two peritoneojugular shunts) Mor- Hernias and incisional hernias are more common in the cir- tality was 5.7% (91% elective surgery). The recurrence rate rhotic patient than in the general population. Abdominal was 8 to 10% recurrence being favored by weak wall distention caused by the ascites and the loss of muscle mass structure and ascites.
secondary to the poor nutritional status are the main risk Irrespective of the type of parietal hernia or evisceration, factors In the cirrhotic patient, the rate of abdominal an extraperitoneal interposition prosthesis should be used in wall hernia is 16% and reaches 24% in the presence of ascites cirrhotic patients because of the higher risk of recurrence.
More than half of all hernias are umbilical; the Furthermore, prostheses with a very low infectious risk are rate is 4-fold higher in patients with ascites. Umbilical her- available. This approach is however debatable if the patient nias are also favored by Cruveilhier-Baumgarten syndrome presents a complication (strangulation, rupture), cutaneous (renewed patency of the umbilical vein). Treatments for lesions or an infected ascites. If the ascites proves to be inguinal hernia and incisional hernia must be distinguished unresponsive to treatment, a TIPS would probably be the from the treatment of umbilical hernia more specific to the best solution since indications for peritoneojugular shunt cirrhotic patient.
have disappeared. Should a cirrhotic patient on the livertransplantation list present a hernia or incisional hernia freeof complications, treatment may be delayed until the trans- plantation procedure, although a TIPS while on the waiting Indications retained for treating an umbilical hernia are list might be useful to prevent the development of parietal functional impairment and presence of a complication: voluminous herniation, strangulation, rupture, cutaneous The operative technique should prefer oblique or lesions. Strangulation, rare in patients with ascites, is transversal approaches, using a multilayer wall closure with favored by a sudden drop in the volume of the effusion due to slow resorption thread and overcast stitches to limit the risk an umbilical rupture, evacuating puncture, vigorous medical of ascites leakage and evisceration. If possible, drainage treatment or installation of a peritoneojugular shunt should be avoided, but when necessary, using a minimally The goal is to treat the ascites before undertaking surgery.
traumatic technique with sterile aspiration. There is no con- Specific complications after surgical treatment of an umbil- traindication for laparoscopy in a cirrhotic patient ical hernia are ascites, renal failure, wall infection, liverfailure and recurrent hernia. Ascitis is the main cause ofrecurrent parietal deficiency; 71% versus 4% without ascites The predominant role of ascites in the developmentof postoperative complications explains why a simultane- ous peritoneojugular shunt has been proposed in the event Biliary surgery in cirrhotic patients is mainly represented of refractory ascites or when an emergency treatment is by gallstone. Incidence is increased because of the hyper- required, despite the estimated 14% risk of infection splenism and the subsequent hemolysis. Prevalence of More recently, a small series of three cirrhotic patients who gallstones in the cirrhotic patient is higher than in the gen- underwent emergency surgery for a ruptured or strangu- eral population, reaching 17 to 28% Cirrhosis, with lated umbilical hernia reported treatment by parietal repair cardiovascular disease, is the main risk factor for postchole- and installation of a transjugular intrahepatic portosystemic cystectomy mortality. A recent meta-analysis demonstrated shunt (TIPS) on days 2, 0 and 2 of the herniorrhaphy that, on average, cholecystectomy is performed in cirrhotic These data, based on the efficacy of TIPS for the treat- patients in more urgent situations and with higher morbidity ment of refractory ascites suggest that TIPS should be Laparoscopic cholecystectomy is currently the pre- preferred over peritoneojugular shunt for the treatment of ferred technique for cirrhotic patients Complications umbilical hernia in patients with refractory ascites.
include ascites, liver failure, infection, kidney failure, diges- In the series reported by the French Association of tive bleeding and operative site bleeding. Morbidity is Surgery, which included 81 patients who underwent surgical related to the indication, the severity of the liver fail- treatment of an umbilical hernia, overall mortality was 5%: ure, blood transfusion and surgical approach. There were 11% after emergency surgery for ruptured or strangulated no deaths in a study comparing the results of laparoscopic Please cite this article in press as: Douard R, et al. Operative risks of digestive surgery in cirrhotic patients. GastroenterolClin Biol (2009), doi: ARTICLE IN PRESS
R. Douard et al.
cholecystectomy (n = 26) with open cholecystectomy (n = 24) of 52 cirrhotic patients who underwent endoscopic sphinc- in Child A or B patients The conversion rate for terotomy for common bile duct stones Considering this the laparoscopic procedures was 12%, with significantly evidence, several teams have proposed balloon endoscopic decreased morbidity (19% versus 67%, p = 0.001) and lower sphincteroclasia to avoid the risk of bleeding in cirrhotic risk of transfusion (0% versus 33%, p = 0.008) Laparo- patients, particularly Child C patients scopic cholecystectomy in Child A or B patients is feasible For the Child A or B patient, stones in the common with a conversion rate of 5 to 9%, 5 to 10% morbidity bile duct should be treated by endoscopic sphinctero- and 0 to 1% mortality In the cirrhotic patient, tomy followed by laparoscopic cholecystectomy. Endoscopic laparoscopy is associated, as in the noncirrhotic patient, sphincteroclasia would appear to be the best alternative for with less blood loss, shorter operative time and shorter hos- Child C patients, without secondary cholecystectomy.
pital stay Some authors suggested that in thecirrhotic patient preoperative coagulation disorders would be more predictive of difficult operation and complicationsfor laparoscopic cholecystectomy than the Child score. Oth- Excepting the survey published by the French Association of ers have proposed subtotal cholecystectomy in this Surgery data are lacking on the specificity of pancre- context of increased risk of hemorrhage, especially for acute atic surgery in the cirrhotic patient. In the published series, or chronic cholecystitis. On the contrary, for the Child C 35 patients underwent surgery for chronic (n = 17) or acute patient, cholecystectomy is associated with a prohibitive (n = 3) pancreatitis, a malignant tumor (n = 14) or a benign death rate of 23 to 50% severe liver failure, acute tumor (n = 1). The procedures were resection (n = 9; left cholecystitis and emergency surgery are common in this pancreatectomy: 3, pancreaticoduodenectomy: 2, ampul- type of patient. Most authors agree that medical treat- lectomy: 2, atypical resection for acute pancreatitis: 2) and ment should be proposed in this type of situation. If the derivations (n = 26; digestive = 7, biliodigestive: 13, pancre- medical approach is unsuccessful, or should pyocholecystitis aticodigestive: 10). The transfusion rate was 44%, morbidity develop, percutaneous cholecystostomy could be a solution 51% and mortality 20%. All three patients who had an emer- The cholecystotomy should ideally be performed via gency procedure died. All deaths occurred in patients whose a transhepatic approach after transfusion of platelets and gastrointestinal tract was opened. The univariate analysis coagulation factors; percutaneous drainage of the ascites identified emergency procedure and elevated transaminase may be associated or precede the operation.
level as independently predictive of death.
Laparoscopic cholecystectomy is the procedure of choice The findings suggest endoscopic (stent, endoscopic cys- for the Child A or B patient with symptomatic gallstones or togastrostomy, ampullectomy) and radiologic (percutaneous acute cholecystitis morbidity is 10 to 15%, mortality 0 drainage of pancreatic abscesses) treatments should be pre- to 1% and conversion rate 5 to 9%. For the Child C patient, ferred in cirrhotic patients with an inflammatory disease or medical treatment should be proposed and, if necessary, tumor of the pancreas. The rare indications for resection combined with percutaneous cholecystostomy.
should be reserved for elective procedures in Child-Pugh Apatients without elevated transaminases.
Common bile duct stones
Treatment of stones in the common bile duct is more diffi-
cult in the cirrhotic patient because the procedure involves
cholecystectomy and extraction of the stone from the bileduct. Stone extraction is difficult because of the portal Studies on gastric surgery in the cirrhotic patient have hypertension and the risk of injuring neighboring varices or focused on the treatment of complications of peptic ulcers triggering hemobilia with the extraction instruments. In the and gastric cancers.
series reported by the French Association of Surgery, morbid- Peptic ulcers appear to be more common in cirrhotic ity in 31 patients undergoing surgery for a common bile duct patients, affecting 8 to 20% of patients The propor- stone was 29%, with 9.6% mortality. In a series of 87 cirrhotic tion of cirrhotic patients among patients with peptic ulcer patients who underwent surgery for gallstones (n = 53) or appears to be higher than the equivalent proportion in the common bile duct stones (n = 34), morbidity was 15% and general population: 9% among patients with hemorrhagic mortality 4.5%. Two factors had a significant impact on mor- ulcer, 6% among patients with a perforated ulcer and 8% bidity and mortality: Child-Pugh stage C (morbidity 32%, among patients aged 65 years-old and over with a symp- mortality 12%) and presence of a stone in the common duct tomatic ulcer The mortality of emergency surgery for (morbidity 24%, mortality 9%) Another team compared complicated peptic ulcer in the cirrhotic patient is very surgery (n = 9) versus endoscopic sphincterotomy (n = 7) for high, ranging from 23 to 64% Prognostic fac- this indication. Mortality was 44% versus 14.3% (p < 0.01) and tors impacting mortality are severity of the liver failure and morbidity 66% versus 14% (p < 0.01) with a mean blood loss presence of ascitis With the advent of proton of 1576 mL after surgery highlighting the benefits for endo- pump inhibitors, eradication of Helicobacter pylori and the scopic sphincterotomy Another study confirmed these development of endoscopic hemostasis techniques, the effi- findings and reported 67% morbidity after surgery versus 22% cacy of simple suture of the perforation in a patient with after endoscopic sphincterotomy with no significant differ- peritonitis due to the perforated ulcer has been demon- ence for mortality Endoscopic sphincterotomy has thus strated, dramatically reducing the indications for surgery become the gold standard for common bile duct stones, fol- and gastric resections for hemorrhagic ulcers. Excepting rare lowed by elective laparoscopic cholecystectomy. The risks cases, emergency surgery for complicated ulcers does not must not however be overlooked; mortality was 7% in a series require resection, although the gastrointestinal tract must Please cite this article in press as: Douard R, et al. Operative risks of digestive surgery in cirrhotic patients. GastroenterolClin Biol (2009), ARTICLE IN PRESS
Digestive surgery and cirrhosis be opened. Two controlled studies have demonstrated the • pleural effusion (26%); efficacy of laparoscopic suture of perforated ulcers • anastomotic fistula (24%); by extrapolation, laparoscopic suture of perforated ulcers • infection (22%); can be proposed for cirrhotic patients.
• renal failure (17%).
Two series from Japan have reported results of surgi- cal treatment of gastric cancer in cirrhotic patients. The Twelve patients (26%) died. Factors predictive of fatal first was a series of 37 operated patients (24 superficial can- outcome included liver failure (prothombin < 60%, serum cers); morbidity was 20%, mortality 0%, and 5-year actuarial albumin < 30 g/L, serum bilirubin > 35 ␮mol/L), transfusion survival 51% The second study included 39 operated of more than three packed cell units and anastomotic fis- patients (28 superficial cancers); morbidity was 26%, mortal- tula. These findings illustrate the risks of esophagectomy in ity 10.3% and 5-year acturarial survival 64% for superficial the cirrhotic patient; mortality is greater than 20% and the cancers and 14% for invasive cancers Causes of late rate of anastomotic leakage greater than 20%. This surgery death were mainly related to the liver disease.
should be reserved for Child-Pugh A5 patients with T1-T3 N0 The series of 66 operated cirrhotic patients with gas- tumors who are free of ascites and transaminase elevation.
tric disease reported by the French Association of Surgery For all other patients, non-surgical treatment with exclusive included patients with a noncomplicated benign disease chemoradiotherapy should be proposed (n = 12), hemorrhagic or perforated ulcer (n = 35), malignanttumor (n = 17) or another disease (n = 2). Mortality was 23%, significantly higher in patients with ascites and low serumalbumin; mortality was not affected by gastric disease orby type of surgery (simple suture, vagotomy, gastrectomy).
Particularities of colorectal cancer in the cirrhotic
Overall morbidity was 56%, most deaths related to ascites, infection, and renal failure Hepatic metastasis is less frequent in cirrhotic patients than For perforated ulcers in the cirrhotic patient, laparo- non-cirrhotic patients For patients with chronic scopic suture is the treatment of choice. In the event of viral hepatitis B, colorectal cancer-related survival is longer a hemorrhagic ulcer, endoscopic hemostasis should be fol- than in noncirrhotic patients due to the lower rate of liver lowed, if necessary, by surgery in order to maximize elective involvement Reporting experience of the Mayo clinic, procedures. Direct hemostasis with arterial ligature and Gervaz et al. observed a lower rate of hepatic vagotomy should be preferred over vagotomy-antrectomy.
metastasis in cirrhotic patients (10%) and noted that survival In cirrhotic patients, who have a gastric cancer, surgery is a in these patients was long enough for hepatic metastases to very high risk option in the presence of ascites, hypoalbu- develop. An alteration of the extracellular matrix stim- minemia, and Child-Pugh stage C. For stage A and B patients, ulation of the Kupffer cells defective angiogenesis it would be preferable to propose type D1 dissection and to and presence of spontaneous portalcaval shunts avoid dissection of the hepatic pedicle because of the risk been proposed to explain this lower risk of hepatic metasta- of type II lymphatic ascites.
sis. Because of the different prognostic course of colorectalcancer, Child-Pugh stage remains the main prognostic factorfor long-term survival of these patients.
Indications for surgery in the cirrhotic patient
Seven percent of patients with cancer of the esophagus Two main series have reported results of colorectal cancer also have cirrhosis Overall morbidity after esophageal in cirrhotic patients: the Mayo clinic series the surgery in the operated cirrhotic patient is twice that French Association of Surgery series The Mayo clinic observed in the noncirrhotic patient: 17 to 21% versus 3 reported 72 operated cirrhotic patients with colorectal can- to 8% Mortality does not appear to be affected cer: Child A (43%), Child B (42%), Child C (15%). Mortality was by the type of operation; the rate of esophagogastric fis- 13% and morbidity 46%. Fistulae developed in 3%. Cirrhosis- tulization ranges from 9 to 11% Morbidity, especially related complications were mainly secondary to liver failure lung disease, is significantly increased by cirrhosis and included infection and digestive bleeding. Factors pre- Mortality is correlated with preoperative liver failure, pro- dictive of postoperative death were elevated serum bilirubin thrombin < 60%, presence of ascites and hypoalbuminemia and low prothrombin level. Ten percent of the patients The risk of postoperative liver failure is higher in developed liver metastases. Overall 1, 2 and 3-year survivals the event of acute alcoholic hepatitis; it is recommended were 69, 49 and 35%. Survival was better in Child A patients to wait until transaminase levels return to normal before than Child B or C patients. Multivariate analysis identified attempting surgery. For most teams, the presence of Child B serum albumin and prothormbin level as affecting survival.
or C cirrhosis proscribes surgery The series of 53 patients Conversely, Tumor Node Metastasis (TNM) staging had no undergoing esophageal surgery reported by the French Asso- impact on survival, suggesting that the prognosis in these ciation of Surgery included 46 patients who had elective patients depends mainly on liver function.
resections followed by esophagogastric anastomosis; 26% of In the French Association of Surgery series, 54 cirrhotic the patients had ascites and 81% received a blood transfu- patients underwent colorectal surgery: 11 for divertic- sion. Complications developed in 72% of patients: ular disease and 19 for other diseases. An emergencyprocedure was necessary for 17 patients for peritonitis • ascites (39%); (n = 10), obstruction (n = 5), hemorrhage (n = 2). Among the • pneumopathy (30%); 56 patients who had a resection-anastomosis, 7% developed Please cite this article in press as: Douard R, et al. Operative risks of digestive surgery in cirrhotic patients. GastroenterolClin Biol (2009), doi: ARTICLE IN PRESS
R. Douard et al.
a fistula. Overall morbidity was 51%, mainly ascites and exceptional. Nonoperative endoscopic or percutaneous radi- infection. Overall mortality was 23%. Emergency surgery ological treatments should be preferred.
and presence of intraoperative ascites were predictive of For Child B patients, a precise assessment of the liver fail- operative death. It should be remembered, however, that ure and the operative risks as a function of the projected in the cirrhotic patient a protective stomy has specific operation is required to adapt management practices. The complications including ascites leakage, ascites infection, operative risk may be reduced by improving liver function, stomial disinsertion, peristomial hernia, peristomial eviscer- reducing the ascites, improving the nutritional status and ation and peristomial varices normalizing elevated transaminase levels; surgery may have Colorectal surgery in the cirrhotic patient is associated to be delayed but not proscribed. The presence of por- with higher morbidity and mortality than in the noncirrhotic tal hypertension with esophageal varices ≥ grade 2 warrants patient. Factors predictive of operative mortality are those primary prophylaxis with betablockers. If the postopera- of surgery in the cirrhotic patient: emergency procedure, tive risk of hemorrhage is considered high, or if there serum albumin < 30 g/L, presence of ascites, low prothrom- is a contraindication for betablockers, prophylactic elas- bin These factors are included in Child-Pugh staging tic ligation of the esophageal varices may be proposed.
allowing the distinction of two categories of patients: Child A Persistence of refractory ascites or severe portal hyperten- patients who can undergo elective surgery with an expected sion (history of digestive bleeding by rupture of esophageal postoperative period comparable to noncirrhotic patients varices and ≥ grade 2 varices) despite well-conducted medi- and Child C patients with a high operative mortality (40—50 cal treatment may require preoperative TIPS, which, in this %) for which surgery should be undertaken only exception- indication, should replace the peritoneojugular shunt ally. For Child B patients, the degree of liver failure must In emergency situations, it is best, whenever possi- be assessed carefully; correction of an ascites, with TIPS if ble, to defer surgery of the cirrhotic patient, preferring necessary, may delay surgery.
a semi-elective intervention. Intensive care and nonoper-ative treatments would be more advisable in these high-riskpatients.
Regarding surgical technique for open procedures, oblique or transversal approaches are preferable. A multiple In the cirrhotic patient, extrahepatic surgery is associ- plane closure of the abdominal wall using slow absorption ated with higher morbidity and mortality. In the series thread and overcast stitches is advisable to reduce the risk of of the French Association of Surgery which collected data ascites leakage, evisceration, incisional hernia and drainage on 760 patients, including a very large majority of Child A should, whenever possible, be avoided. If necessary, non- patients, overall mortality was 14%. Factors predictive of traumatic minimal aspiration drainage can be used. Despite operative mortality were emergency procedure, operation the lack of solid evidence, it is probably useful to pre- involving the digestive tract (esophagus, stomach, colon), pare the colon to reduce the risk of bacterial contamination serum albumin < 30 g/L, transaminase level more than three for esophageal, gastric or colorectal surgery. Rigorous sur- times above the upper limit of normal, presence of ascites gical technique with special attention to hemostasis and and intraoperative blood transfusion lymphostasis is necessary; for cancer surgery, where the Can the operative risk be reduced for the cirrhotic prognosis is probably more related to the cirrhosis than the patient undergoing digestive surgery? cancer, there is evidence in the literature arguing against It is important to carefully search for cirrhosis before extensive nodal dissection.
undertaking abdominal surgery. The problematic is sim- Hepatotoxic and nephrotoxic agents should be avoided ple when the cirrhosis is known, for carriers of hepatitis for anesthesia and perioperative intensive care; it is C virus, or when chronic alcohol abuse is obvious. For approximately 20% of patients, however, cirrhosis may go tors (prothrombin level < 50%, fibrinogen < 1 g/L), schedule unrecognized and be discovered intraoperatively. Focus platelet transfusion when the platelet count is less than should be placed on asymptomatic patients whose imag- 50,000/mm3, and maintain intra- and postoperative sys- ing work-up displays splenomegaly, hepatic dysmorphism or temic, renal and hepatic hemodynamics, even at the cost spontaneous portosystemic shunts as well as patients with of aggravating postoperative ascites if necessary. Intensive an isolated thrombopenia, sometimes the inaugural sign of care must focus on nutritional status and identification and well-compensated cirrhosis A FibroScan can be useful rapid treatment of infections, crucial challenges for the before surgery; its contribution should be assessed postoperative outcome of the cirrhotic patient.
Three factors known to aggravate the operative risk should be identified: ascites, serum albumin < 30 g/L,transaminase elevation. For Child A patients, the operative Conflict of interests
risk of elective surgery is acceptable and surgical indicationsneed not be changed from those proposed for non-cirrhotic patients, if management is carefully adapted. The laparo-scopic approach should be preferred because it reduces therisk of bleeding, respiratory disorders, infection and abdom- inal wall defects as well as the prevalence of postoperativeascites.
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Top 10 Tips for Defending Mass Torts in New Jersey by James J. Ferrelli and Alyson B. Walker New Jersey is home to many mass torts—asbestos, hormone replacementtherapy (HRT), NuvaRing, Vioxx, Fosamax, Accutane, and Bextra/Celebrex—toname just a few. With plaintiffs filing numerous cases in the Garden State, it'seasy to fall into the mindset that New Jersey is for plaintiffs. But don't get caughtin that trap and become complacent, filing rote motions and litigating onautopilot. With the right strategy and tactics, New Jersey can be for defendantstoo. Here are our top 10 tips for defending mass torts in New Jersey: