Perioperative Care of Patients With Liver Cirrhosis: A Review

Abbas, Naeem; Makker, Jasbir; Abbas, Hafsa; Balar, Bhavna

doi:10.1177/1178632917691270

Cited by 59 publications

(65 citation statements)

References 104 publications

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“…Prior to the implantation of the alfapump, the diagnosis of RA should be carefully reviewed by a hepatologist, as many of these patients still have potential for improvement with conservative measures, ie optimisation of nutrition (low salt diet and adequate protein intake, compensation for selective deficits, eg zinc) and diuretic therapy (with a combination of an aldosterone antagonist and a loop diuretic). Optimisation of nutrition is also beneficial for the reduction of perioperative complication what has been shown in several other surgical fields …”

Section: Discussionmentioning

confidence: 95%

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

Stirnimann¹,

Berg²,

Zeuzem³

et al. 2017

Aliment Pharmacol Ther

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SummaryBackgroundRefractory ascites (RA) is a frequent complication of cirrhosis, requiring large volume paracentesis or placement of a transjugular intrahepatic portosystemic shunt (TIPSS). The automated low‐flow ascites pump (alfapump, Sequana Medical AG, Zurich, Switzerland) is an innovative treatment option for patients with RA.AimTo assess safety and efficacy of this treatment in patients with a contraindication to TIPSS.MethodsFifty‐six patients (43 males; mean age 62 years) from centres in Germany, Switzerland, UK and Spain were included and followed for up to 24 months. Complications, device deficiencies, paracentesis frequency and patient survival were recorded.ResultsAt the time of this analysis, 3 patients completed the 24‐month observation period, monitoring of 3 was ongoing, 9 underwent liver transplantation, 17 patients were withdrawn due to serious adverse events and 23 patients died. Most frequently observed technical complication was blocking of the peritoneal catheter. Twenty‐three pump‐related reinterventions (17 patients) and 12 pump exchanges (11 patients) were required during follow‐up. The pump system was explanted in 48% of patients (in 17 patients due to serious adverse events, in 9 at the time of liver transplantation and in 1 due to recovery from RA). Median frequency of paracentesis dropped from 2.17 to 0.17 per month.ConclusionsThe alfapump can expand therapeutic options for cirrhotic patients with RA. Continuous drainage of ascites in a closed loop automated system led to significant reduction in paracentesis frequency. Technical and procedural improvements are required to reduce the rate of adverse events and reinterventions. https://clinicaltrials.gov/ct2/show/NCT01532427

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Section: Discussionmentioning

confidence: 95%

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

Stirnimann¹,

Berg²,

Zeuzem³

et al. 2017

Aliment Pharmacol Ther

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“…In a number of patients (40%), no precipitating event was identified, whereas in others, more than 1 precipitating event occurred . Surgical interventions, in particular, have been considered to be responsible for deterioration in patients with cirrhosis . However, to date, there are no reports on the prevalence and risk factors for the development of ACLF after surgery.…”

Section: Discussionmentioning

confidence: 99%

“…On the other hand, the effect of AD and the development of ACLF at surgery on the outcome of the patients have not been adequately described even though there has been substantial progress in both hepatology and surgery in managing patients with cirrhosis . The currently applied prognostic factors for outcomes after surgery are still the Child‐Pugh and the Model for End‐Stage Liver Disease (MELD) scores, whereas the concepts of AD and ACLF have not yet been introduced in the perioperative management of patients with cirrhosis.…”

mentioning

confidence: 99%

The Development and Outcome of Acute‐on‐Chronic Liver Failure After Surgical Interventions

Klein¹,

Chang²,

et al. 2019

Liver Transpl

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Acute-on-chronic liver failure (ACLF) is a syndrome with high short-term mortality. Precipitating events, including hemorrhage and infections, contribute to ACLF development, but the role of surgery remains unknown. We investigated the development of ACLF in patients with cirrhosis undergoing surgery. In total, 369 patients with cirrhosis were included in the study. The clinical and laboratory data were collected prior to and on days 1-2, 3-8, and 9-28, and at 3 and 12 months after surgery. Surgery type was classified as limited or extensive, as well as liver and nonliver surgery. A total of 39 patients had baseline ACLF. Surgery was performed during acute decompensation in 35% of the rest of the 330 patients, and 81 (24.5%) developed ACLF within 28 days after surgery. Surrogate markers of systemic inflammation were similar in patients who developed ACLF or not. Age, sex, serum sodium, baseline bacterial infection, and abdominal nonliver surgery were independent predictors for the development of ACLF after surgery. Patients who developed ACLF within 28 days after surgery had a higher mortality at 3, 6, and 12 months. Survival did not differ between patients with ACLF at surgery and those developing ACLF after surgery. Development of ACLF within 28 days after surgery and elevated alkaline phosphatase and international normalized ratio were independent predictors of 90-day mortality. Independent predictors of 1-year all-cause mortality were alkaline phosphatase, Model for End-Stage Liver Disease score, and preoperative hepatic encephalopathy, whereas nonliver surgery was associated with improved survival. ACLF frequently develops in patients with cirrhosis undergoing surgery, especially in those with active bacterial infection, lower serum sodium, and kidney or coagulation dysfunction. Prognoses of ACLF both at and after surgery are similarly poor. Patients with cirrhosis should be carefully managed perioperatively.Liver Transplantation 26 227-237 2020 AASLD.

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“…This apparent discordance results from the fact that the removal of thrombopoietin from the circulation is made through its internalization in megakaryocytes and platelets, including those which are pooled in the spleen (9). In liver cirrhosis, platelets also show quantitative changes besides decreasing in number (10).…”

Section: Discussionmentioning

confidence: 99%

The risk of bleeding and encephalopathy in surgical patients with liver cirrhosis

Banu¹,

Salvatore²,

Merlo³

et al. 2019

JMMS

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Liver cirrhosis is a disease with an increasing incidence. Surgical procedures in patients with cirrhosis are also increasing, due to a longer life expectancy in these patients and also to the improvement of therapeutic and diagnostic resources.Digestive hemorrhage in the cirrhotic patient requires emergency medical intervention (intensive therapy, endoscopic or even surgical approaches), being at the same time a factor that precipitates episodes of encephalopathy, i.e. the conventional complication of cirrhosis. Hepatic encephalopathy represents one of the most severe clinical events of cirrhosis, being associated with high morbidity and mortality. The causes of hepatic encephalopathy are briefly presented in this paper. Therapeutic approaches currently available consist in the administration of non-absorbable disaccharides such as lactulose and non-absorbable antibiotics such as rifaximin. New therapeutic perspectives are under evaluation, e.g. ammonia scavengers and the modulation of gut microbiota.Clotting disorders in patients with liver cirrhosis are more severe as the disease progresses and involves complex mechanisms, as presented in this review. The correction of possible disorders of hemostasis should be promptly made as a sine qua non condition prior to surgery.

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Perioperative Care of Patients With Liver Cirrhosis: A Review

Cited by 59 publications

References 104 publications

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

The Development and Outcome of Acute‐on‐Chronic Liver Failure After Surgical Interventions

The risk of bleeding and encephalopathy in surgical patients with liver cirrhosis

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