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

Klein, Leah Maria; Chang, Johannes; Gu, Wen; Manekeller, Steffen; Jansen, Christian; Lingohr, Philipp; Praktiknjo, Michael; Kalf, Jörg C.; Schulz, Martin; Spengler, Ulrich; Strassburg, Christian P.; Cárdenas, Andrés; Arroyo, Vicente; Trebicka, Jonel

doi:10.1002/lt.25675

Cited by 29 publications

(41 citation statements)

References 12 publications

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“…Complications of liver cirrhosis such as portal hypertension, ascites, malnutrition, renal dysfunction, or coagulopathy in addition to operative trauma and general anesthesia provoke various complications, resulting in a prolonged hospital stay and higher costs. The increased risk of mortality in patients with LC is the consequence of elevated bacterial infection rates, higher bleeding complications, and postoperative development of acute-on-chronic liver failure (ACLF) [ 7 ]. The surgical outcome depends on the severity of the underlying LC and the operative procedure [ 8 , 9 ].…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease—A Retrospective Analysis of 76 Cases in a Tertiary Center

Wetterkamp

Beekum

Willis

et al. 2020

Biology

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(1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were “additional surgery” (OR 5.3) and “bowel anastomosis” (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients’ outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.

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Section: Introductionmentioning

confidence: 99%

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease—A Retrospective Analysis of 76 Cases in a Tertiary Center

Wetterkamp

Beekum

Willis

et al. 2020

Biology

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“…Recently, we showed that the outcome in patients with cirrhosis undergoing either surgery or TIPS is mainly determined by ACLF itself. ( 9 , 10 ) In the case of gastrointestinal bleeding, we demonstrated that TIPS improves survival and the rebleeding rate in patients with ACLF. ( 10 ) Currently, the Child‐Turcotte‐Pugh (CTP) score and Model for End‐stage Liver Disease (MELD), among others, ( 11 , 12 ) are the most commonly applied prognostic models to stratify patient outcome after surgery or TIPS.…”

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confidence: 91%

Elective Surgery but not Transjugular Intrahepatic Portosystemic Shunt Precipitates Acute‐On‐Chronic Liver Failure

et al. 2021

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Acute-on-chronic liver failure (ACLF) is a syndrome associated with organ failure and high short-term mortality. Presence of ACLF at interventions, such as surgery or transjugular intrahepatic portosystemic shunt (TIPS), has been shown to determine outcome, but those interventions have also been attributed to precipitate ACLF in different studies. However, dedicated investigation for the risk of ACLF development in these interventions, especially in elective settings, has not been conducted. Patients with cirrhosis undergoing elective surgery were propensity score matched and compared to patients receiving TIPS. The primary endpoint was ACLF development within 28 days after the respective procedure. The secondary endpoint was 3-month and 1-year mortality. In total, 190 patients were included. Within 28 days, ACLF developed in 24% of the surgery and 3% of the TIPS cohorts, with the highest ACLF incidence between 3 and 8 days. By day 28 after the procedure, ACLF improved in the TIPS cohort. In both cohorts, patients developing ACLF within 28 days after surgery or TIPS placement showed significantly worse survival than patients without ACLF development at follow-up. After 12 months, mortality was significantly higher in the surgery cohort compared to the TIPS cohort (40% vs. 23%, respectively; P = 0.031). Regression analysis showed a European Foundation Chronic Liver Failure Consortium acute decompensation (CLIF-C AD) score ≥50 and surgical procedure as independent predictors of ACLF development. CLIF-C AD score ≥50, C-reactive protein, and ACLF development within 28 days independently predicted 1-year mortality. Conclusion: Elective surgical interventions in patients with cirrhosis precipitate ACLF development and ultimately death, but TIPS plays a negligible role in the development of ACLF. Elective surgery in patients with CLIF-C AD ≥50 should be avoided, while the window of opportunity would be CLIF-C AD <50. (Hepatology Communications 2021;0:1-13).C irrhosis is the common end stage of chronic liver disease. Unstable clinical courses of disease may occur after the development of acute decompensation (AD). However, AD can progress to acute-on-chronic liver failure (ACLF), a specific syndrome characterized by the development of organ

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“…Even though there has been substantial progress in the fields of hepatology and surgery in managing patients with cirrhosis, surgery-associated AD and mortality remains high and correlates with severity of liver disease (Friedman, 2010 ; de Goede et al, 2012 ). Recently, the role of surgery as a precipitating event for ACLF development has been characterized, resulting in high rates of ACLF development even after electively performed surgical procedures (Klein et al, 2020 ; Chang et al, 2021 ). Therefore, in many hospitals, with the presence of cirrhosis especially in advanced stages is considered a contraindication for all kinds of surgery.…”

Section: Introductionmentioning

confidence: 99%

Extrahepatic Surgery in Cirrhosis Significantly Increases Portal Pressure in Preclinical Animal Models

et al. 2021

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Background: Liver cirrhosis is a relevant comorbidity with increasing prevalence. Postoperative decompensation and development of complications in patients with cirrhosis remains a frequent clinical problem. Surgery has been discussed as a precipitating event for decompensation and complications of cirrhosis, but the underlying pathomechanisms are still obscure. The aim of this study was to analyze the role of abdominal extrahepatic surgery in cirrhosis on portal pressure and fibrosis in a preclinical model.Methods: Compensated liver cirrhosis was induced using tetrachlormethane (CCL4) inhalation and bile duct ligation (BDL) models in rats, non-cirrhotic portal hypertension by partial portal vein ligation (PPVL). Intestinal manipulation (IM) as a model of extrahepatic abdominal surgery was performed. 2 and 7 days after IM, portal pressure was measured in-vivo. Hydroxyproline measurements, Sirius Red staining and qPCR measurements of the liver were performed for evaluation of fibrosis development and hepatic inflammation. Laboratory parameters of liver function in serum were analyzed.Results: Portal pressure was significantly elevated 2 and 7 days after IM in both models of cirrhosis. In the non-cirrhotic model the trend was the same, while not statistically significant. In both cirrhotic models, IM shows strong effects of decompensation, with significant weight loss, elevation of liver enzymes and hypoalbuminemia. 7 days after IM in the BDL group, Sirius red staining and hydroxyproline levels showed significant progression of fibrosis and significantly elevated mRNA levels of hepatic inflammation compared to the respective control group. A progression of fibrosis was not observed in the CCL4 model.Conclusion: In animal models of cirrhosis with continuous liver injury (BDL), IM increases portal pressure, and development of fibrosis. Perioperative portal pressure and hence inflammation processes may be therapeutic targets to prevent post-operative decompensation in cirrhosis.

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

Cited by 29 publications

References 12 publications

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease—A Retrospective Analysis of 76 Cases in a Tertiary Center

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease—A Retrospective Analysis of 76 Cases in a Tertiary Center

Elective Surgery but not Transjugular Intrahepatic Portosystemic Shunt Precipitates Acute‐On‐Chronic Liver Failure

Extrahepatic Surgery in Cirrhosis Significantly Increases Portal Pressure in Preclinical Animal Models

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