Clinical Challenges in Emergency General Surgery: Cirrhotic Patients

Behind The Knife: The Surgery Podcast

Medicine, Health & Fitness, Education, Science

4.8 • 1.4K Ratings

🗓️ 3 April 2023

⏱️ 34 minutes

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Summary

Please join Drs. Graham Skelhorne-Gross, Jordan Nantais and Ashlie Nadler from our Emergency General Surgery Team for a discussion on cirrhotic patients.

Child-Pugh Score (https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality)
· Bilirubin, albumin, INR, ascites, encephalopathy
· Used to predict operative mortality based on cirrhosis severity
· Mortality in EGS:
- Child-Pugh A: 10% electively and 22% emergently
- Child-Pugh B: 30% electively and 38% emergently
- Child-Pugh C: 80% electively and up to 100% emergently

Model for End Stage Liver Disease (MELD) (https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld?utm_source=site&utm_medium=link&utm_campaign=meld_12_and_older)
· creatinine, bilirubin, INR, and sodium
· MELD < 20 – 1% increase in mortality with each point increase
· MELD > 20 – 2% increase in mortality with each point increase

Pre-operative Planning
· Identification of cirrhosis with physical examination, bloodwork and imaging
· Involvement of other medical services (internal medicine, hepatology, ICU) as needed
· Cirrhosis optimization, if possible
· Abdominal wall mapping

Unexpected Intraoperative Finding

Communicate unexpected findings to the operative team and think of additional adjuncts you may need such as additional ports, topical hemostatic agents or energy devices.
Think about why you are in the OR. If its an elective situation and can wait, consider bailing. If its emergent, you may have to do something more definitive.
Exposure may be a challenge, you may have to alter your typical approach including where the assistant grabs and retracts. Extra hands are helpful.
Bleeding can be a big deal. If possible, map out the abdominal wall ahead of time with cross-sectional imaging. Stay away from varices around the umbilicus or porta

Ventral Hernia + Cirrhosis
· Ideally, control ascites pre-operatively, if you can’t consider leaving drains
· Small (< 2cm) hernias close primarily
· Larger (>2cm) hernias repair with mesh unless infected filed (controversial)
· Minimally invasive repairs can be performed

Benign Biliary Disease + Cirrhosis
· Incidence of gallstones is 4-5 times higher in cirrhotic patients
· Prophylactic laparoscopic cholecystectomy (LC) generally not done
· LC generally considered acceptable in CP A or B but not C (exceptions: HD instability, gangrenous cholecystitis, hemorrhagic cholecystitis)
· Cholecystostomy and ERCP are safe

References:

Bleszynski, M. et. Al. Acute care and emergency general surgery in patients with chronic liver disease: how can be optimize perioperative care? A review of the literature. 2018. World Journal of Emergency Surgery; 13:32

Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122:730–5.

Yeom SK, Lee CH, Cha SH, Park CM. Prediction of liver cirrhosis, using diagnostic imaging tools. World J Hepatol. 2015 Aug 18;7(17):2069-79. doi: 10.4254/wjh.v7.i17.2069. PMID: 26301049; PMCID: PMC4539400.

Jain D, Mahmood E, V-Bandres M, Feyssa E. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Ann Gastroenterol. 2018 May-Jun;31(3):330-337. doi: 10.20524/aog.2018.0249. Epub 2018 Mar 15. PMID: 29720858; PMCID: PMC5924855.

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Transcript

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0:23.0	Cash podcast 23 all lowercase and take your business to the next level today.
0:35.0	Behind the night, the surgery podcast.
0:38.0	Relevant and engaging content designed to help you dominate the day.
0:44.0	Have you been working hard to dominate your surgical residency?
0:55.0	Do you want to help others to dominate no matter what stage of training they're in?
0:59.0	Hi to all of our BTK listeners.
1:01.0	My name is Nina Clark, General Surgery resident at the University of Washington.
1:05.0	And I'm Jessica Mallard, General Surgery resident at the University of Michigan.
1:09.0	We both have had the privilege of working as behind-the-knife education college for the past year.
1:13.0	And we're excited to continue growing our team.
1:16.0	Are you a surgical resident interested and enthusiastic about surgical education?
1:20.0	BTK is offering a two-year surgical education fellowship starting July 1st, 2023 and ending June 30th, 2025.
1:28.0	Only residents who are starting a two-year block, a professional development time,
1:33.0	away from full-time clinical activity will be considered.
1:36.0	And you have to ensure that your institution and mentor a proof of this fellowship.
1:40.0	Fellows will be deeply involved in the BTK activities.
1:44.0	The two of us have worked on an absite revamp, not tying video series,
	...

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