Umbilical Hernia and Cirrhosis - Department of Surgery … Hernia and Cirrhosi… · P OSTOPERATIVE COURSE - SYSTEMS N: ... P. ATHOPHYSIOLOGY OF. C. ... Umbilical hernia repair in

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

www.downstatesurgery.org

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


PATIENT PRESENTATION 98.5 95 143/78 16 100%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. Non-reducible. Non-tender.

Bilateral inguinal hernias, fluid filled


PATIENT PRESENTATION CBC: 5.1/12.2/37.1/53 BMP: 136/4.4/103/27/34/1.3/224 8.6/2.2/4.0 LFTs: 8.6/2.5/51/50/88/2.7 Coags: 16.3/27.8/1.8











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


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 97.8 83 18 134/78 99% Creatinine 1.3 1.0 Bilirubin 2.7 4.1 INR 1.8 2.3 Pt became encephalopathic Ammonia 160 Son elected to consent to surgery the following

morning, taken to surgery emergently


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


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


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 re-intubations


POSTOPERATIVE COURSE - SYSTEMS Heme

Initially on HSQ for DVT ppx Vitamin K POD 8 pt had coffee-ground NGT aspirate and

dropped Hct 30 22. 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


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 1.2-1.5 until POD 7, increased to 2, 3, 5

Na peaked at 154 on POD 4, NS initially to ½ NS @ maintenance rate

Lasix IV and spironolactone NG for ascites, albumin given daily with lasix, no return of ascitic distension


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



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?


PATHWAY Pt in need of non-hepatic surgery

H&P

No evidence of liver disease or cirrhosis

Continue pre-operative assessment

GET SURGERY

Suspicious for liver disease

Characterize • LFTs • Serology • Imaging

Risk Stratification • Risk Score • Other Patient Factors • Surgery Type

Acceptable Risk

Optimize

SURGERY

Unacceptable Risk

Pursue alternative therapy

Manage post-operative care



H&P



GET SURGERY




Acceptable Risk

Optimize

SURGERY

Unacceptable Risk




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


Normal System


Cirrhosis 1. Intrahepatic –

NO decreased, TXA increased (+ Scarification)

NO TXA


Cirrhosis 1. Intrahepatic –

NO decreased, TXA increased (+ Scarification)

2. Collateral flow 3. Splanchnic

circulation becomes vasodilatory to compensate (with decrease in systemic)

NO TXA

NO TXA


Principal effects: Hyperdynamic

cardiac function with little reserve

Maximized hepatic circulation with little reserve

Decreased renal blood flow

NO TXA

NO TXA


Effects on Kidney? Decreased blood

flow Activation of

Renin-Angiotensin-Aldosterone

Non-osmotic release of vasopressin


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)


NO TXA

NO TXA

Compensation vs Decompensation


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


OPTIMIZATION BY SYSTEMS Cardiac – Hyper-dynamism

Pre-operative Cardiac assessment Awareness of lack of reserve

Post-operative Avoid inotropic agents


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


OPTIMIZATION BY SYSTEMS Hepatorenal Syndrome

Overwhelming activation of renin-angiotensin-aldosterone system

Difficult to reverse High mortality


OPTIMIZATION BY SYSTEMS Hepatorenal Syndrome

Treatment Terlipressin – splanchnic vasoconstriction Albumin+octreotide+midodrine RRT - failure


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


OPTIMIZATION BY SYSTEMS Neurologic

Pre-operative Consider diagnosis of hepatic encephalopathy Lactulose, rifaximin, serial ammonia measurements

unhelpful Avoidance of sedation

Post-operative Same


OPTIMIZATION BY SYSTEMS Coagulation Synthetic (factors) + consumptive (platelets)

Pre-operative Vitamin K FFP and platelets No benefit of rfVII

Post-operative Same


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


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



H&P



GET SURGERY



Risk Stratification • Other Patient Factors • Risk Score • Surgery Type

Acceptable Risk

Optimize

SURGERY

Unacceptable Risk




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


OTHER PATIENT FACTORS


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


OTHER PATIENT FACTORS Hepatopulmonary Syndrome Algorithm


RISK SCORES: CHILD-TURCOTTE-PUGH 1964 - Child & Turcotte Mortality after shunting surgery for portal htn Variables, original:

Albumin Bilirubin Encephalopathy Ascites Nutritional status


RISK SCORES: CHILD-TURCOTTE-PUGH 1973 - 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


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


1997 92 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


RISK SCORES: CHILD-TURCOTTE-PUGH MDCalc


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


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


RISK SCORES: MELD

Validation with 4 larger data sets (n=282 to n=1179)

Mortality overall, unrelated to undergoing a procedure

Allogenic transplant allocation


RISK SCORES: MELD MDCalc


RISK SCORES: MELD


RISK SCORES: MELD

2004 - prospective 40 patients undergoing elective (n=24) or

emergent (n=16) surgical procedures CTP and MELD


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)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43

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


RISK SCORES - WHAT TO USE?


RISK SCORES - WHAT TO USE?

2007 - retrospective 772 cirrhotic patients undergoing

digestive(n=586), orthopedic (n=107) or cardiac surgery (n=79)

Multivariable analysis (w/ statistics)





IS THAT IT? Pt in need of non-hepatic surgery

H&P



GET SURGERY




Acceptable Risk

Optimize

SURGERY

Unacceptable Risk




SURGERY SPECIFIC FACTORS Type of surgery has significant impact



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?


UMBILICAL HERNIA


UMBILICAL HERNIA


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


UMBILICAL HERNIA


UMBILICAL HERNIA


UMBILICAL HERNIA


UMBILICAL HERNIA


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


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


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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Umbilical Hernia and Cirrhosis - Department of Surgery … Hernia and Cirrhosi… · P OSTOPERATIVE COURSE - SYSTEMS N: ... P. ATHOPHYSIOLOGY OF. C. ... Umbilical hernia repair in