RISK STRATIFICATION IN CIRRHOSIS: FOCUS ON UMBILICAL HERNIA Sam Hawkins MD PGY5

Transcription

1 RISK STRATIFICATION IN CIRRHOSIS: FOCUS ON UMBILICAL HERNIA Sam Hawkins MD PGY5

2 PATIENT PRESENTATION 73M w/ Hep B Cirrhosis, HTN, DM II Liver disease followed at OSH x2 years (when moved from China), on tenofivir, lasix Known umbilical hernia, acute onset of pain at hernia site x1d Constipation, obstipation, nausea & vomiting x1d

3 PATIENT PRESENTATION / %RA NAD, AAOx3 Abdomen distended with fluid wave Umbilical hernia with erythematous appearing skin and 2x3 scab at apex. Hernia fluid filled with palpable indurated mass within. Nonreducible. Non-tender. Bilateral inguinal hernias, fluid filled

4 PATIENT PRESENTATION CBC: 5.1/12.2/37.1/53 BMP: 136/4.4/103/27/34/1.3/ /2.2/4.0 LFTs: 8.6/2.5/51/50/88/2.7 Coags: 16.3/27.8/1.8

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14 PATIENT PRESENTATION Discussion with patient and son at bedside including significant risks of surgery DNR/DNI status Refusal of surgery Admitted NGT/NPO Serial abdominal exams

15 PATIENT PRESENTATION HD 1-3 pt did not improve and hernia became increasingly discolored, tense, and painful Patient expressed desire for surgery at night, added on for following day /78 99% Creatinine Bilirubin INR Pt became encephalopathic Ammonia 160 Son elected to consent to surgery the following morning, taken to surgery emergently

16 OPERATIVE COURSE Opened hernia sac immediate release of large ascites and obvious necrotic small bowel Hernia defect 1cm, opened to deliver dilated and collapsed small bowel, viable in both directions from defect (opened to approx 6 cm) Removed ascites (total 8L by end of case) Resected 25cm small bowel side-to-side stapled anastomosis Closed defect w/ running #1 prolene Skin left open and packed Operative time: 2h Given 4u FFP, 1000 crystaloid EBL 100, UOP 300 Taken to SICU intubated

17 POSTOPERATIVE COURSE - OVERVIEW POD 0-2: critical POD 3-11: progression to multi-organ failure POD 12: family elected against escalation of care and made DNR status, to maintain abx and ETT, institute comfort care POD 15: expired in PM

18 POSTOPERATIVE COURSE - SYSTEMS N: non-responsive off sedation lactulose POD 4 responsive with agitation POD 10 increasingly obtunded off sedation until expiration C: initially NT/NTC POD 4 hypertensive with new onset afib w/ RVR amiodarone gtt + metoprolol POD 10 switched to metoprolol, rate maintained in afib P/ID: initially kept intubated POD 3 failed SBT CXR after fever demonstrates bilateral infiltrates resp cx w/ MSSA and enterobacter abx initiated and maintained until expiration multiple self-extubations with successful reintubations

19 POSTOPERATIVE COURSE - SYSTEMS Heme Initially on HSQ for DVT ppx Vitamin K POD 8 pt had coffee-ground NGT aspirate and dropped Hct INR 3.1, platelets 38 (ranged throughout admission 20-50) Transfused PRBC, platelets, FFP, HSQ d/c d Intermittent coffee-ground emesis, no additional drop in Hct or PRBC transfusions

20 POSTOPERATIVE COURSE - SYSTEMS Renal/Fluids 8L ascites drained intraop 1u albumin in PACU Normotensive over POD 0-3, became hypertensive controlled with metoprolol until expiration BUN/Crt 40/1.2 BUN increased over 10 days to 120s, Crt stable until POD 7, increased to 2, 3, 5 Na peaked at 154 on POD 4, NS initially to ½ maintenance rate Lasix IV and spironolactone NG for ascites, albumin given daily with lasix, no return of ascitic distension

21 POSTOPERATIVE COURSE - SYSTEMS GI Trickle feeds from POD1 advanced to goal feeds with hepatic formula Bilirubin post-op stable at 4-5 until POD 8 increased to 10 then 20

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23 OVERVIEW Pathophysiology of Cirrhosis Pre-operative and Post-operative considerations Risk stratification Patient specific factors Contraindications to surgery Scoring systems CTP, MELD, is there a right score to use? Surgery specific factors Umbilical hernia as special case?

24 PATHWAY Pt in need of non-hepatic surgery H&P Suspicious for liver disease Characterize LFTs Serology Imaging Risk Stratification Risk Score Other Patient Factors Surgery Type No evidence of liver disease or cirrhosis Continue preoperative assessment GET SURGERY Unacceptable Risk Pursue alternative therapy Acceptable Risk Optimize SURGERY Manage postoperative care

25 PATHWAY Pt in need of non-hepatic surgery H&P Suspicious for liver disease Characterize LFTs Serology Imaging Risk Stratification Risk Score Other Patient Factors Surgery Type No evidence of liver disease or cirrhosis Continue preoperative assessment GET SURGERY Unacceptable Risk Pursue alternative therapy Acceptable Risk Optimize SURGERY Manage postoperative care

26 PATHOPHYSIOLOGY OF CIRRHOSIS Portal Hypertension Hemodynamics circulating volume and pressure Cardiac function hyperdynamism Renal function Ascites Liver Function Synthetic Coagulation Metabolic Toxins, pharmacology Nutrition Infectious disease

27 Normal System

28 Cirrhosis 1. Intrahepatic NO decreased, TXA increased (+ Scarification) NO TXA

29 NO TXA NO TXA Cirrhosis 1. Intrahepatic NO decreased, TXA increased (+ Scarification) 2. Collateral flow 3. Splanchnic circulation becomes vasodilatory to compensate (with decrease in systemic)

30 NO TXA Principal effects: Hyperdynamic cardiac function with little reserve Maximized hepatic circulation with little reserve Decreased renal blood flow NO TXA

31 Effects on Kidney? Decreased blood flow Activation of Renin- Angiotensin- Aldosterone Non-osmotic release of vasopressin

32 Effects on Kidney? Decreased blood flow Activation of Renin- Angiotensin-Aldosterone Non-osmotic release of vasopressin renal hypoperfusion sodium retention (fluid overload) free-water retention in excess of sodium retention (hyponatremia)

33 Compensation vs Decompensation NO TXA NO TXA

34 PATHOPHYSIOLOGY OF CIRRHOSIS Ascites 10% in cirrhosis 60% 3 year survival after onset Hemodynamic consequences Increased splanchnic flow + increased portal pressure Capillary permeability increases Hypoalbuminemia

35 OPTIMIZATION BY SYSTEMS Cardiac Hyper-dynamism Pre-operative Cardiac assessment Awareness of lack of reserve Post-operative Avoid inotropic agents

36 OPTIMIZATION BY SYSTEMS Renal Pre-operative Renal function studies Assessment for hepatorenal syndrome Judicious use of diuretics for ascites and lactulose for encephalopathy (volume) Albumin vs crystaloid Post-operative Monitoring for HRS Albumin vs crystaloid

37 OPTIMIZATION BY SYSTEMS Hepatorenal Syndrome Overwhelming activation of renin-angiotensinaldosterone system Difficult to reverse High mortality

38 OPTIMIZATION BY SYSTEMS Hepatorenal Syndrome Treatment Terlipressin splanchnic vasoconstriction Albumin+octreotide+midodrine RRT - failure

39 OPTIMIZATION BY SYSTEMS Ascites Pre-operative Diuretic therapy- spironolactone and furosemide Large Volume Paracentesis (LVP) Albumin administration with LVP Screening for SBP Post-operative Same Paracentesis Induced Circulatory Dysfunction Fluid shift vs vasodilation Hypovolemia and R-A-A activation Volume expansion >5L w/ albumin

40 OPTIMIZATION BY SYSTEMS Neurologic Pre-operative Consider diagnosis of hepatic encephalopathy Lactulose, rifaximin, serial ammonia measurements unhelpful Avoidance of sedation Post-operative Same

41 OPTIMIZATION BY SYSTEMS Coagulation Synthetic (factors) + consumptive (platelets) Pre-operative Vitamin K FFP and platelets No benefit of rfvii Post-operative Same

42 OPTIMIZATION BY SYSTEMS Nutrition Pre-operative, Post-operative Maximize nutrition, no good evidence for hepatic formulas (including low-nitrogen) Infectious Disease SBP Sepsis No difference in GDT in cirrhotic - harder Inotropes less effective Lactate metabolism

43 OPTIMIZATION Cardiac Avoidance of inotropes Neuro Encephalopathy - lactulose Renal Hyponatremia fluid restriction HRS albumin, terlipressin, octreotide+midodrine Ascites Diuretics, LVP w/ albumin Coagulopathy Vitamin K, platelets and FFP Awareness of the precariousness of cirrhotic physiology, readiness to act

44 PATHWAY Pt in need of non-hepatic surgery H&P Suspicious for liver disease Characterize LFTs Serology Imaging Risk Stratification Other Patient Factors Risk Score Surgery Type No evidence of liver disease or cirrhosis Continue preoperative assessment GET SURGERY Unacceptable Risk Pursue alternative therapy Acceptable Risk Optimize SURGERY Manage postoperative care

45 WHY RISK STRATIFY? Patients with cirrhosis need surgery Umbilical hernia Gallbladder Colon Cardiac Emergency surgical conditions Liver surgery and transplantation Patients with cirrhosis do worse The effects of surgery (and other stressors) are complicated and unpredictable 7

46 OTHER PATIENT FACTORS

47 OTHER PATIENT FACTORS Hepatopulmonary Syndrome Up to 50% of cirrhotic patients Significant increase in mortality Median survival 11 months No studies on effect on post-op mortality Irreversible cause of hypoxia

48 OTHER PATIENT FACTORS Hepatopulmonary Syndrome Algorithm

49 RISK SCORES: CHILD-TURCOTTE-PUGH Child & Turcotte Mortality after shunting surgery for portal htn Variables, original: Albumin Bilirubin Encephalopathy Ascites Nutritional status

50 RISK SCORES: CHILD-TURCOTTE-PUGH Pugh et al Transection of the oesophagus for bleeding oesophageal varices (BJS) Mortality after surgery for bleeding varices Variables, updated: Albumin Bilirubin Encephalopathy Ascites Nutritional status Prothrombin time

51 RISK SCORES: CHILD-TURCOTTE-PUGH Ease of use, simplicity 40 years and 100s of papers Ruptured esophageal varices Subclinical encephalopathy Hepatocellular carcinoma Alcoholic cirrhosis Decompensated HCV-related cirrhosis Primary sclerosing cholangitis Primary biliary cirrhosis Budd Chiari syndrome Liver surgery and transplant Mortality after non-hepatic surgery

52 patients with cirrhosis undergoing emergent or elective surgery 54 variables evaluated retrospectively CTP score most predictive of mortality The study thought of as the validation study as the mortality figures mirror those from original paper

53 RISK SCORES: CHILD-TURCOTTE-PUGH MDCalc

54 RISK SCORES: CHILD-TURCOTTE-PUGH Disadvantages: Ascites and encephalopathy are SUBJECTIVE Validation has been mainly in RETROSPECTIVE studies with SMALL study populations Variables NOT WEIGHTED CAUSE of cirrhosis not included SURGERY type not included

55 RISK SCORES: MELD MELD: Model for End-stage Liver Disease 2000 retrospective 231 patients who underwent TIPS Cox-proportio (statistics) 3 weighted variables: bilirubin, INR, creatinine

56 RISK SCORES: MELD Validation with 4 larger data sets (n=282 to n=1179) Mortality overall, unrelated to undergoing a procedure Allogenic transplant allocation

57 RISK SCORES: MELD MDCalc

58 RISK SCORES: MELD

59 RISK SCORES: MELD prospective 40 patients undergoing elective (n=24) or emergent (n=16) surgical procedures CTP and MELD

60 RISK SCORES: MELD Advantages: All variables are OBJECTIVE Validation for overall mortality risk has utilized LARGE study populations Variables WEIGHTED MELD = 3.78 ln[serum bilirubin (mg/dl)] ln[inr] ln[serum creatinine (mg/dl)] Disadvantages Assessment of mortality in cirrhotic patients after surgery continued to rely on SMALL data sets CAUSE of cirrhosis not included SURGERY type not included

61 RISK SCORES - WHAT TO USE?

62 RISK SCORES - WHAT TO USE? retrospective 772 cirrhotic patients undergoing digestive(n=586), orthopedic (n=107) or cardiac surgery (n=79) Multivariable analysis (w/ statistics)

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66 IS THAT IT? Pt in need of non-hepatic surgery H&P Suspicious for liver disease Characterize LFTs Serology Imaging Risk Stratification Risk Score Other Patient Factors Surgery Type No evidence of liver disease or cirrhosis Continue preoperative assessment GET SURGERY Unacceptable Risk Pursue alternative therapy Acceptable Risk Optimize SURGERY Manage postoperative care

67 SURGERY SPECIFIC FACTORS Type of surgery has significant impact

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69 UMBILICAL HERNIA Significant problem in cirrhotics 20% prevalence, 40-50% in setting of ascites Enlarge over time Skin breakdown and necrosis SBP What role do risk scores play? Surgery for UH an exception to these scores?

70 UMBILICAL HERNIA

71 UMBILICAL HERNIA

72 UMBILICAL HERNIA 32,033 patients who underwent abdominal wall hernias between 1999 and 2004 (excluding inguinal) 1197 cirrhotic patients Emergency surgery performed in 60% of cirrhotics (vs 30% non-cirrhotics) Does not include table comparison between study groups

73 UMBILICAL HERNIA

74 UMBILICAL HERNIA

75 UMBILICAL HERNIA

76 UMBILICAL HERNIA

77 SUMMARY 1 Pre- and Post-operative issues in cirrhotics 1. There are dysfunctions related to cirrhosis that deserve special attention 2. Awareness of the precariousness of cirrhotic physiology, readiness to act

78 SUMMARY 2 Risk stratification for cirrhotic patients undergoing non-hepatic surgery includes 1. Review and consider contraindications to elective surgery, including HPS 2. Calculation of a risk score, of which the Mayo Clinic augmented MELD appears the most robust 3. Consideration of surgery specific data on morbidity and mortality

79 SUMMARY 3 Umbilical hernia repair in cirrhotic patients Is safe, with acceptable morbidity and mortality When performed under elective conditions, has comparable morbidity and mortality to non-cirrhotics Should be performed when found to avoid the increase in mortality under emergent conditions Can probably be performed using synthetic mesh

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