LA VALUTAZIONE DEL RISCHIO CHIRURGICO. Paolo Caraceni

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1 MONOTEMATICA AISF 2014 Cirrosi epatica: Napoli 10 anni dopo. Napoli, 8-10 Ottobre 2014 LA VALUTAZIONE DEL RISCHIO CHIRURGICO Paolo Caraceni Dipartimento di Scienze Mediche e Chirurgiche Centro di Ricerca Biomedica Applicata (CRBA) Alma Mater Studiorum Università di Bologna

2 Prof. Paolo Caraceni Alma Mater Studiorum Università di Bologna Il sottoscritto dichiara di non aver avuto negli ultimi 12 mesi conflitto d interesse in relazione a questa presentazione e che la presentazione non contiene discussione di farmaci in studio o ad uso off-label

3 CLINICAL SCENARIO 68 years old, Child B8, transient jaundice, gallbladder stones Refraining elective surgery Perform colecistectomy Obstructive jaundice Cholangitis What will kill this patient first: cirrhosis or stones? Which is the risk related to each choice? Acute on Chronic Liver Failure Emergent surgery/endoscopy? (higher risk)

4 CAN LITERATURE HELP US? YES.. BUT WITH MANY LIMITATIONS Most retrospective studies Rare randomized clinical trials Small sample size Selected populations (mostly Child-Pugh A and low MELD) Low-level evidences

5 PATIENT TYPE OF SURGERY PREDICTION OF RISK OF MORTALITY AND MORBIDITY AFTER NON-HEPATIC SURGERY EXPERTISE OF THE SURGICAL AND MEDICAL TEAM

6 PATIENT PREDICTION OF RISK OF MORTALITY AND MORBIDITY AFTER NON-HEPATIC SURGERY

7 SURGICAL RISK IN CIRRHOTIC PATIENTS PATIENT S VARIABLES LIVER DISEASE SEVERITY CO-MORBIDITIES AGE

8 CHRONIC LIVER DISEASE NATURAL HISTORY ASYMPTOMATIC PHASE SYMPTOMATIC PHASE HBV ETOH PORTAL HYPERTENSION CIRCULATORY DYSFUNCTION PRO-INFLAMMATORY STATE NASH HCV OTHERS jaundice ascites variceal bleeding hepatic encephalopathy bacterial infection HCC OLT DEATH CHRONIC HEPATITIS COMPENSATED CIRRHOSIS DECOMPENSATED CIRRHOSIS

9 PROGNOSTIC SCORES IN CIRRHOSIS CHILD-PUGH MELD MELD-BASED INDICES

10 PREDICTION OF SURGICAL RISK IN CIRRHOSIS CHILD-PUGH SCORE 100 POST-OPERATIVE MORTALITY (%) A B C Child-Pugh class De Goede et al., Best Pract Res Clin Gastroenterol, 2012

11 PREDICTION OF SURGICAL RISK IN CIRRHOSIS CHILD-PUGH SCORE 100 POST-OPERATIVE MORBIDITY (%) A B C Child-Pugh class Telem et al., Clin Gastroenterol Hepatol, 2010

12 PREDICTION OF SURGICAL RISK IN CIRRHOSIS MELD SCORE RELATIONSHIP BETWEEN MELD AND POST-OPERATIVE MORTALITY 30 days 90 days Teh et al., Gastroenterology, 2007

13 PREDICTION OF SURGICAL RISK IN CIRRHOSIS MELD SCORE POST-OPERATIVE MORBIDITY (%) <10 10 to to 25 >25 MELD SCORE Telem et al., Clin Gastroenterol Hepatol, 2010

14 PREDICTION OF SURGICAL RISK IN CIRRHOSIS EFFECT OF PORTAL HYPERTENSION A NATIONWIDE COHORT STUDY - ELECTIVE SURGERY IN-HOSPITAL MORTALITY Controls (n= ) Cirrhosis (n=18.335) Cirrhosis with portal hypertension (n=4214) Csikesz et al., Am Coll Surg, 2008

15 PREDICTION OF SURGICAL RISK IN CIRRHOSIS PATIENT VARIABLES INFLUENCING OUTCOME American Society of Anesthesiology, 2010 hyponatremia (< 130 meq/l) low serum albumin (< mg/dl) serum creatinine serum bilirubin ascites etiology of cirrhosis older age ASA score > 2-3..

16 SURGICAL RISK IN CIRRHOSIS SEARCHING FOR A PREDICTION MODEL 772 patients with cirrhosis 426 consecutive patients: consecutive patients: Major surgery 586 patients: digestive (laparatomy) 107 patients: orthopedic 79 patients: cardiovascular Comparison with two control groups 562 cirrhotics seen as outpatients 303 cirrhotics undergone minor surgery (appendicectomy, herniorrhaphy, ) Teh et al., Gastroenterology, 2007

17 SURGICAL RISK IN CIRRHOSIS SEARCHING FOR A PREDICTION MODEL 3 months 1 year 3 years Teh et al., Gastroenterology, 2007

18 SURGICAL RISK IN CIRRHOSIS SEARCHING FOR A PREDICTION MODEL DETERMINANTS OF POSTOPERATIVE MORTALITY AT MULTIVARIATE ANALYSIS MELD SCORE (liver disease severity) ASA SCORE (co-morbidities) AGE Teh et al., Gastroenterology, 2007

19 SURGICAL RISK IN CIRRHOSIS MAYO CLINIC POSTOPERATIVE MORTALITY RISK MODEL Google: surgical risk cirrhosis

20 SURGICAL RISK IN CIRRHOSIS MAYO CLINIC POSTOPERATIVE MORTALITY RISK MODEL MELD day mortality: 6% 3-fold increase Google: surgical risk cirrhosis

21 SURGICAL RISK IN CIRRHOSIS MAYO CLINIC POSTOPERATIVE MORTALITY RISK MODEL LIMITATIONS OF THE STUDY Retrospective Selection bias: sicker patients deferred Most patients had platelet > / L and INR < 1.5 Only 58 out of 772 patients had MELD > 15 Most surgical procedures were intra-abdominal

22 SURGICAL RISK IN CIRRHOSIS RISK ACCORDING TO PATIENT VARIABLES CHILD A no portal hypertension CHILD A with portal hypertension CHILD B CHILD C MELD < 8/10 MELD 8/10 16/18 MELD > 16/18 POST-OPERATIVE MORTALITY RISK MODEL MAYO CLINIC

23 PATIENT TYPE OF SURGERY PREDICTION OF RISK OF MORTALITY AND MORBIDITY AFTER NON-HEPATIC SURGERY

24 PREDICTION OF SURGICAL RISK IN CIRRHOSIS UMBILICAL HERNIA REPAIR A NATIONWIDE COHORT STUDY ( controls vs cirrhotic patients) Carbonell et al, Hernia, 2005

25 PREDICTION OF SURGICAL RISK IN CIRRHOSIS LAPAROSCOPIC COLECISTECTOMY META-ANALYSIS (351 cirrhotic patients) Puggioni and Wong, Liv Intern, J Am Coll Surg 2003

26 PREDICTION OF SURGICAL RISK IN CIRRHOSIS COLORECTAL SURGERY A NATIONWIDE COHORT STUDY ( controls vs cirrhotics without PH vs cirrhotics with PH) Control Cirrhosis without PH Cirrhosis with PH 35,8 Mortality (%) ,6 20, ,1 7,2 1,8 All Elective Non-elective Nguyen et al, Dis Colon Rectum, 2009

27 PREDICTION OF SURGICAL RISK IN CIRRHOSIS CARDIAC SURGERY REVIEW OF THE LITERATURE MORTALITY RISK Modi et al, Inter Cardiovascul Thorac Surg 2010

28 PREDICTION OF SURGICAL RISK IN CIRRHOSIS TYPE OF SURGERY Umbilical and inguinal hernia repair Colorectal surgery Gastrectomy Pancreatic surgery Cardiac surgery Laparoscopic colecistectomy Open colecistectomy Lung surgery Abdominal trauma Orthopedic surgery Laparoscopic Laparotomic Elective Emergency

29 SURGICAL RISK IN CIRRHOSIS RISK ACCORDING TO TYPE OF ELECTIVE SURGERY LOW INTERMEDIATE HIGH UNACCEPTABLE or UKNOWN Abdominal wall surgery CHILD A - no PTH CHILD A - PTH CHILD B CHILD C Laparoscopic colecistectomy CHILD A - no PTH CHILD A - PTH CHILD B CHILD C Open abdomen surgery CHILD A - no PTH CHILD A - PTH CHILD B CHILD C Lung surgery CHILD A - no PTH CHILD A - PTH CHILD B CHILD C Orthopedic surgery CHILD A - no PTH CHILD A - PTH CHILD B CHILD C Cardiac surgery CHILD A - no PTH CHILD A - PTH CHILD B - off pump CHILD B - on pump CHILD C

30 PATIENT TYPE OF SURGERY PREDICTION OF RISK OF MORTALITY AND MORBIDITY AFTER NON-HEPATIC SURGERY EXPERTISE OF THE SURGICAL AND MEDICAL TEAM

31 PREDICTION OF SURGICAL RISK IN CIRRHOSIS HOW TO MINIMIZE RISK Availaibility of less invasive approaches: laparoscopic techniques mini-invasive surgical techniques interventional radiology operative endoscopy Specific surgical expertise with cirrhotic patients MULTIDISCIPLINARY APPROACH High skill surgeon Specific medical expertise in the management of the pre-, peri-, and post-operative periods with cirrhotic patients

32 GRAZIE PER L ATTENZIONE