Surgery in Patients with Cirrhosis Surgical Symposium 2012 Eugene, Oregon

Transcription

1 Surgery in Patients with Cirrhosis Surgical Symposium 2012 Eugene, Oregon David M. Nagorney, MD Professor of Surgery Mayo Clinic College of Medicine April 28, 2012

2 Pathological Finding Diffuse bridging fibrosis surrounding abnormal regenerative nodules of hepatocytes Reduced hepatocyte mass, altered hepatic blood flow Irreversible, progressive NOT a measure of hepatic function or clinical compensation Cirrhosis

3 Cirrhosis IS NOT Comorbid Condition!

4 Elective Surgery and Mortality 22,569 Cirrhosis & Portal Hypertension Csikesz et al JACS 2009; 208:96

5 Aims Overview natural history of cirrhosis Identify predictors of operative morbidity, mortality and survival, thus, selection Provide information for counseling patients regarding their operative risk Algorithm for operative management - Any non-transplant operation - Hepatic Resection

6 Surgery in Patients with Cirrhosis Does my patient have cirrhosis? Finding Total Patients Cirrhosis Positive LR (95% Cl) P Value Negative LR (95% Cl) P Value Distended abd veins Encephalopathy Ascites Palmar erythema < <.001 Spider nevi < Jaundice Splenomegaly < <.001 Firm liver Hepatomegaly < <.001 Udell et al, JAMA 307: ,2012

7 Surgery in Patients with Cirrhosis Does my patient have cirrhosis?

8 Clinical Course of Cirrhosis Decompensated Compensated Stage 1 Stage 2 Stage 3 Stage 4 NO VARICES NO ASCITES 7% VARICES NO ASCITES 6.6% ASCITES - BLEEDING 7.6% BLEEDING + ASCITES 4.4% 4% 1% 3.4% 20% 57% DEATH D Amico et al, J Hepatol 44:217, 2006

9 D Amico et al J Hepatol 44:217, 2006 Surgery in Patients with Cirrhosis Natural History of Cirrhosis 1.00 Median Survival Compensated Cirrhosis 12 years Yrs Pts at risk Decompensated cirrhosis 2 years

10 D Amico et al, J Hepatol 44:217, 2006 Surgery in Patients with Cirrhosis Natural History by CTP Class CTP A 1 yr 2 yr CTP B 1 yr 2 yr CTP C 1 yr 2 yr

11 Significant Predictors of Decompensation and Death in Cirrhosis CTP Class most robust and consistent CTP Component (each) Age Gender Platelets MELD? D Amico J Hepatol 2006;44:217

12 D Amico et al, J Hepatol 44:217, 2006 Surgery in Patients with Cirrhosis Probability of Decompensation Years Pts at risk

13 Predictors of Decompensation HVPG N = 79 N = 134 MELD N = 154 N = 54 Serum Albumin N = 98 N = 114 Survival (%) mmhg 10 < 4 g/dl < 10 mmhg < 10 4 g/dl Years < 10 mm Hg = 90% compensation Ripoli, Grossman, et al, Gastroenterology 2007;133:481

14 Predictors of Decompensation Summary CPT score accurately stratifies overall mortality for patients with cirrhosis but not decompensation. Currently no metrics accurately identify or predict the frequency and rate of decompensation in patients with compensated cirrhosis.

15 Non-invasive Operative Risk Assessment Liver Focused Cirrhosis Only Scoring Systems - Liver - HCC Quantitation of Hepatic Reserve

16 Quantitation of Hepatic Reserve Indocyanine green clearance Galactose elimination capacity Aminopyrine breath test Drug or amino acid clearance 99m Tc-galactosyl albumin imaging None reliably predictive of outcome Mullin et al Am J Surg 2005;190:87

17 Child-Turcotte-Pugh Class Points Encephalopathy None Moderate Advanced Ascites Absent Controlled Refractory Bilirubin (mg/dl) < > 3 Albumin (Gm/dl) > < 2.8 INR < > 2.3 CTP Class A B C Points

18 MELD Score Model for End-stage Liver Disease MELD = 9.57 x ln (creatinine) x ln (total bilirubin) x ln (INR) Score: 5-40 Exclusion: CRF, BD Obstruction, Calculation Malinchoc et al, Hepatology 2000;31:864

19 CTP Class versus MELD Score CTP MELD Number of variables 5 3 Quantitative variables 3/5 3/3 Derivation of variables Empirical Statistical Variables weighted to their influence No Yes Ceiling effect of quantitative variables Yes No Logarithmic transformation of variables No Yes Needs computation No Yes Variables influenced by clinical judgment Yes No Type of Score Discrete Continuous Durand and Villa, J Hepatol 2005;42:S100

20 Cirrhosis Comparison of Clinical Scoring Scores Objective Parameter Subjective Parameter Parameter Readily Available Prospectively Designed Validated Internally/ Externally IDEAL Yes No Yes Yes Yes/Yes CTP * Yes Yes Yes No Yes/No MELD Yes No Yes Yes Yes/Yes * Ceiling effect: No discrimination between bilirubin of 3 mg and 30 mg/dl * Floor effect: No discrimination between albumin 1.5 g/dl and 2.8 g/dl Kamath and Kim, Hepatology 2007;45:797

21 Nontransplant Operative Mortality by CTP Class 100 Mortality % Garrison Mansour n=50 n=48 n=29 n=33 n=21 n=11 CTP-A CTP-B CTP-C Garrison et al, Ann Surg 1984; 199:648 Mansour et al, Surgery 1997; 122:730

22 MELD and Non-transplant (30 Day) Mortality Any N= Abdominal N= MELD Pr. D. (%) Risk = 1 % / MELD pt for MELD < 20, and 2 % / MELD pt for MELD > 20 Northup et al. Ann Surg 2005:242:244

23 Risk Factors for Mortality after Surgery in Patients with Cirrhosis Teh SH α, Nagorney DM α, Stevens S χ, Offord K χ, Therneau T χ, Plevak D ξ, Talwalkar J, Kim WR, Kamath PS Division of General Surgery α, Biostatistics χ, Anesthesia ξ and Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, USA Gastroenterology 2007;132:

24 MELD Distribution Non-transplant Ops. MELD N = 772 MELD 6-10 N = 432 MELD N = 243 MELD N = 68 MELD N = 15 MELD >25 N = 10 Teh et al, Gastroenterology 2007;132:1261

25 MELD and Postoperative Survival Day 90-Day Long Term 80 Survival (%) (n=432) (n=243) (n=68) (n=15) (n=10) P < P < P < Days Following Surgery Days Following Surgery Years Following Surgery 7-day = ASA Score Teh et al Gastroenterology 2007;132:1261

26 Era and Postoperative Survival 30-Day 90-Day Long Term Survival (%) Era A (n=426) Era B (n=347) 20 0 P < P < Days Following Surgery Days Following Surgery Years Following Surgery Teh et al, Gastroloenterology 2007;132:1261

27 Operative Category, Postoperative Mortality Day Day Survival (%) Dig A (n=373) Dig B (n=214) Ortho (n=107) Cardio (n=79) P = Days Following Surgery Days Following Surgery 0 P = Teh et al Gastroenterology 2007;132;1261

28 Operative Category, Postoperative Mortality 100 Long Term 80 Dig A (n=373) Dig B (n=214) Ortho (n=107) Cardio (n=79) Survival (%) P = Years Following Surgery Teh et al Gastroenterology 2007;132;1261

29 MELD and Postoperative Mortality Day Day Mortality (%) MELD Score MELD Score Teh et al, Gastroenterology 2007;132:1261

30 Predictive Modeling for Risk of Death MELD most powerful predictor Relative risk of death increases by 15% / MELD point from 30 days to 1 yr and by 6% / yr subsequently Clinical adage: For each MELD point 8, mortality risk increases 2%

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32 MELD Score Predicts 3 month survival from INR, bilirubin, and creatinine PSC HCV INR Biliru bin Creati nine MELD Score

33 Hepatic Resection of Hepatocellular Carcinoma in Patients with Cirrhosis: MELD Score Predicts Perioperative Mortality Teh SH, Kamath PS, Christein J, Que F, Donohue J, Cha S *, Kendrick M, Farnell M, Kim RW, Nagorney DM Division of General Surgery, Division of Gastroenterology & Hepatology, Biostatistics * Mayo Clinic College of Medicine, Rochester Teh et al, J Gastro Surg 2005;9:1207

34 CTP vs MELD, Resection of HCC Number of patients CTP A C T P A CTP B Number of patients P= CTP Class MELD Score Teh et al J Gastro Surg 2005;9:1207

35 MELD, Survival after Resection of HCC 100 Percent Survival (n = 37) 9 (n = 45) p = Years from Surgery Date Teh et al, J Gastrol Surg 2005;9:1207

36 MELD, HCC Size and Survival MELD MELD 9 p = 0.02 p = 0.01 Percent Survival cm (n = 20) > 5 cm (n = 17) Percent Survival cm (n=25) > 5cm (n=20) Years from Surgery Date Years from Surgery Date Teh et al, J Gastro Surg 2005;9:1207

37 MELD Profiles After Hepatectomy No Liver Failure N=16 MELD N=164 PRE POD1 POD3 POD5 POD7 Cucchetti et al, J Am Coll Surg 203:670, 2006

38 MELD Profiles After Hepatectomy Liver failure N=31 29% MELD N= % PRE POD1 POD3 POD5 POD7 Cucchetti et al, J Am Coll Surg 203:670, 2006

39 Surgical Resection for HCC with Cirrhosis Risk Score for HCC Resection NIS n=2834 Variable Adjusted OR P (95% CI) Men 1.26 ( ).2413 Age group, y 55 Ref ( ) ( ).2286 > ( ).0006 Charlson comorbidity score 0 Ref ( ) ( ) ( ) <.0001 Procedure type RFA/enucleation Ref Wedge resection 1.80 ( ).0391 Lobectomy 4.03 ( ) <.0001 Nonteaching hospital 1.95 ( ).0019 Estimated Mortality (%) Score Simons et al, Cancer 2010;116:

40 Operative Risk Assessment Summary Increases in CTP class and MELD score correlate with operative morbidity and mortality in patients with cirrhosis. MELD stratifies operative risk more precisely than CTP class and provides a statistical model for counseling patients. MELD identifies patients with cirrhosis at risk of liver failure postoperatively.

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42 References D Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies. J of Hepatology 2006; 44: Aranha GV, Sontag SJ. Cholecystectomy in cirrhotic patients:a formidable operation. Am J Surg.1982; 143: Teh SH, Nagorney DM, Stevens SR, Offord KP, et al. Risk Factors for Mortality After Surgery in Patients with Cirrhosis. Gastroenterology 2007; 132: O Leary JG, Friedman LS. Predicting Surgical Risk in Patients With Cirrhosis: From Art to Science. Editorial. Gastroenterology 2007; 132(4): Malinchoc M, Kamath PS, Gordon FD, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts[comment]. Hepatology 2003;31: Friedman LS. The risk of surgery in patients with liver disease. Hepatology 1999; 29: Cucchetti A, Ercolani G, Vivarelli M, et al. Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis. Liver Transpl 2006; 12: Northup PG, Wanamaker RC, Lee VD, et al. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005; 242: Garrison NR, Cryer HM, Howard DA, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984;199: Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surg 1997; 122: Teh,SH, Christein J, Donohue J, et al. Hepatic resection of hepatocellular carcinoma in patients with cirrhosis: Model of end-stage liver disease (MELD) score predicts perioperative mortality. J Gastrointest Surg 2005; 9(9):

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