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Non Hepatic Surgery In Cirrhotics

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MCQ: Models Predicting Outcome of Non-Liver Surgeries in Cirrhotic Patients

Question: Which of the following is not a model predicting the outcome of non-liver surgeries in cirrhotic patients?

a) MELD Na

b) ADOPT-LC

c) VOCAL-Penn

d) CTP

e) none

Correct Answer: e) none

Explanation:

All the listed models are used to predict outcomes in cirrhotic patients undergoing non-liver surgeries:

  • MELD Na: Modified MELD score that includes sodium levels to predict surgical outcomes.
  • ADOPT-LC: A model that incorporates CTP score, age, Charlson comorbidity index, and duration of anesthesia.
  • VOCAL-Penn: A comprehensive model that includes the Mayo risk score, emergency status, and surgery-specific categories to predict postoperative outcomes.
  • CTP (Child-Turcotte-Pugh): A widely used score to assess the severity of liver disease and predict surgical risks.

Cholecystectomy in Cirrhotics: Key Points

  • Increased Risk of Gallstones:
    • Cirrhotic patients have twice the incidence of gallstones compared to the general population due to:
      • Increased intravascular hemolysis
      • Decreased gallbladder motility and emptying
  • Historical Context:
    • In the 1980s, open cholecystectomy in cirrhotic patients had high morbidity (35%) and mortality (25%) rates, primarily due to blood loss, sepsis, and liver failure.
    • Laparoscopic cholecystectomy was initially avoided due to fears of increased bleeding and liver failure but is now shown to have favorable outcomes in CTP class A and B patients.
  • Laparoscopic vs. Open Cholecystectomy:
    • Laparoscopic cholecystectomy offers:
      • Improved visualization
      • Less operative blood loss
      • Shorter operative time
      • Decreased length of hospital stay
    • Studies show higher morbidity (21% vs. 8%), intraoperative bleeding (26% vs. 3%), and open conversion rates (7% vs. 4%) in cirrhotics compared to non-cirrhotics but no difference in mortality.
    • Meta-analysis: Laparoscopic approach is associated with reduced complication rates and shorter hospital stay compared to the open approach.
  • Technical Considerations:
    • Umbilical port placement should avoid venous collaterals and the umbilical vein.
    • Transillumination or preoperative CT may help avoid vascular injury during trocar placement.
    • Instruments like Harmonic Scalpel and LigaSure are useful to control bleeding.
    • Subtotal cholecystectomy may be necessary in cases with large pericholecystic venous collaterals.
    • Direct visualization during trocar removal ensures adequate hemostasis.
    • Conversion to open surgery should be considered if anatomy is unclear.
  • Advanced Cirrhosis (CTP Class C):
    • Cholecystectomy is associated with very poor outcomes in advanced cirrhosis.
    • Alternative interventions:
      • Percutaneous cholecystostomy
      • Endoscopically placed cystic duct stent (less common and limited data)
  • Predictors of Outcomes:
    • Both CTP and MELD scores are valuable for predicting postoperative morbidity and mortality.
    • CTP A and B patients can typically undergo surgery with acceptable outcomes.
    • MELD score cutoff varies, but laparoscopic cholecystectomy is generally safe for patients with MELD < 15.
  • High-Risk Patients:
    • In CTP class C or high MELD score patients, surgery should be deferred if possible, and alternative therapies should be considered as a bridge to surgery when liver function improves.

MCQ: Laparoscopic Cholecystectomy in Cirrhotics

Question: Which of the following is not true about laparoscopic cholecystectomy in cirrhotics?

a) Can be performed in CTP A and B and with MELD < 15

b) Recommended in CTP C symptomatic cholelithiasis in expert centers

c) Umbilical port introduction after other ports

d) Subtotal cholecystectomy - a valid option

Correct Answer: b) Recommended in CTP C symptomatic cholelithiasis in expert centers

Explanation:

  • Option a is correct: Laparoscopic cholecystectomy can indeed be performed in patients with CTP A and B and MELD < 15 with acceptable outcomes.
  • Option c is correct: Introducing the umbilical port after other ports helps avoid venous collaterals and the umbilical vein, which is a recommended approach in cirrhotics.
  • Option d is correct: Subtotal cholecystectomy is a valid option in difficult cases, especially when there are large pericholecystic venous collaterals.
  • Option b is not true: Laparoscopic cholecystectomy is not recommended in CTP C patients due to very poor outcomes. Alternative procedures like percutaneous cholecystostomy are preferred.

Thus, option b is the false statement.

Herniorrhaphy in Cirrhotics: Key Points

  • Incidence and Pathogenesis:
    • Umbilical hernias occur in up to 20% of cirrhotic patients.
    • Causes include:
      • Increased intra-abdominal pressure from ascites.
      • Poor nutritional status leading to decreased abdominal muscle mass and fascial strength.
      • Umbilical vein dilation resulting in enlargement of the preexisting supraumbilical fascial opening.
  • Risks and Complications:
    • In cirrhotic patients, umbilical hernias pose unique risks:
      • Skin ulceration over the hernia can lead to:
        • Leakage of ascites
        • Sac rupture
        • Bacterial peritonitis
        • Evisceration
      • Flood syndrome: Spontaneous umbilical rupture and ascites leak, associated with up to 60% perioperative mortality.
  • Surgical Outcomes:
    • Historically, high mortality rates led to the recommendation against repairing uncomplicated hernias in cirrhotics.
    • Recent data show improved outcomes for elective UHR (Umbilical Hernia Repair), even in cirrhotics with end-stage liver disease.
    • Marsman et al. study: Elective UHR group had no hepatic decompensation or perioperative deaths, while the conservative management group had significantly higher complication rates, including emergency repairs and perioperative deaths.
  • Elective vs. Emergent Repair:
    • Elective UHR is associated with outcomes similar to those in non-cirrhotics, whereas emergent UHR leads to significantly worse outcomes in cirrhotic patients.
    • Perioperative management: TIPS may be considered to reduce refractory ascites before UHR, although specific studies on its efficacy for reducing complications of UHR are lacking.
  • Use of Mesh:
    • The use of nonabsorbable mesh in cirrhotic patients with umbilical hernias is debated, but recent evidence suggests it can be used successfully, even in the presence of ascites.
    • Randomized study (2010): Mesh repair led to a lower recurrence rate compared to suture repair (3% vs. 14%), despite a non-significant increase in surgical site infections.
  • Inguinal Hernia Repair:
    • Outcomes after elective inguinal hernia repair in cirrhotic patients are similar to those in non-cirrhotics.
    • Emergent repair of an incarcerated or strangulated inguinal hernia in cirrhotics results in significantly worse outcomes.
    • Mesh use in inguinal hernia repair is generally safe, with manageable local wound complications.
  • Current Recommendations:
    • Elective hernia repair (umbilical or inguinal) is advisable in cirrhotic patients, provided they are well-compensated, and ascites is controlled, to avoid complications associated with emergent repairs.

Herniorrhaphy in Cirrhotics: Key Points

  • Umbilical Hernias: Occur in up to 20% of cirrhotic patients, caused by ascites, poor nutrition, and umbilical vein dilation.
  • Risks:
    • Skin ulceration can lead to ascites leakage, rupture, and bacterial peritonitis.
    • Flood syndrome (spontaneous rupture) has up to 60% mortality.
  • Surgical Outcomes:
    • Elective UHR has better outcomes than emergent repair.
    • Mesh repair reduces hernia recurrence; infections are manageable.
  • Inguinal Hernia:
    • Elective repair is safe; outcomes worsen significantly with emergent repair.
  • Recommendation:
    • Elective hernia repair is advised in well-compensated cirrhotics [CTP A and B] with controlled ascites.

MCQ: Complications of Umbilical Hernia Repair in Cirrhotic Patients with Ascites

Question: Possible complications of umbilical hernia repair in a cirrhotic patient with marked ascites include all of the following EXCEPT:

a) Hepatic encephalopathy

b) Leakage of ascitic fluid

c) Necrosis of the abdominal wall

d) Variceal bleeding

Correct Answer: a) Hepatic encephalopathy

Explanation:

  • Leakage of ascitic fluid: Common complication that increases the risk of wound infection.
  • Necrosis of the abdominal wall: Can occur due to pressure on the incision and reforming ascites.
  • Variceal bleeding: May result from the interruption of collateral veins during surgery.
  • Hepatic encephalopathy: While possible, it is uncommon unless it occurs secondary to massive variceal bleeding.

Thus, the correct answer is a) Hepatic encephalopathy, as it is not a direct or common complication of umbilical hernia repair in cirrhotic patients with ascites.