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Nationwide volume and mortality after elective surgery in cirrhotic patients
Nicholas G Csikesz1, Louis N Nguyen, Jennifer F Tseng
1Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA, USA.
Insights
Elective surgery outcomes are worse for patients with cirrhosis, even without portal hypertension. Cirrhotic patients face higher mortality, longer stays, and increased costs, necessitating careful surgical decisions.
Area of Science:
- Hepatology and Surgical Outcomes Research
Background:
- Outcomes of elective surgery in patients with cirrhosis remain understudied.
- Cirrhosis and its complications, like portal hypertension, represent significant patient burdens.
Purpose of the Study:
- To evaluate in-hospital mortality and healthcare utilization for elective surgeries in patients with varying degrees of liver disease.
- To compare outcomes between patients with and without cirrhosis, and those with cirrhosis complicated by portal hypertension.
Main Methods:
- Utilized the Nationwide Inpatient Sample (NIS) database from 1998-2005.
- Identified patients undergoing four index elective operations: cholecystectomy, colectomy, abdominal aortic aneurysm repair, and coronary artery bypass grafting.
- Categorized patients into non-cirrhosis (NON-CIRR), cirrhosis (CIRR), and cirrhosis with portal hypertension (PHTN) groups using Elixhauser comorbidity measures.
Main Results:
- Compared 22,569 cirrhotic patients (4,214 with PHTN) against ~2.8 million non-cirrhotic patients.
- Cirrhotic patients were more likely female and less likely to be treated at large hospitals.
- In-hospital mortality, length of stay, and hospital charges significantly increased with liver disease severity for all operations (P < 0.001).
- Adjusted mortality rates showed substantial increases for CIRR and PHTN groups across all procedures, with PHTN patients facing the highest risk.
Conclusions:
- Elective surgery in cirrhotic patients is associated with significantly higher in-hospital mortality, longer hospital stays, and increased total charges, even without portal hypertension.
- The findings underscore the critical need for careful surgical decision-making in cirrhotic patients, given the rising prevalence of hepatitis C and cirrhosis.
- These results highlight the substantial impact of liver disease severity on surgical outcomes and resource utilization.
Background:
The outcomes after elective surgery in patients with cirrhosis have not been well studied.
Study Design:
We used the Nationwide Inpatient Sample (NIS) to identify all patients undergoing elective surgery for four index operations (cholecystectomy, colectomy, abdominal aortic aneurysm repair, and coronary artery bypass grafting) from 1998 to 2005. Elixhauser comorbidity measures were used to characterize patients' disease burden. Three distinct groups were created based on severity of liver disease: patients without cirrhosis (NON-CIRR), those with cirrhosis (CIRR), and patients with cirrhosis complicated by portal hypertension (PHTN). In-hospital mortality was the primary endpoint.
Results:
There were 22,569 patients with cirrhosis (of whom 4,214 had PHTN) who underwent 1 of the 4 index operations compared with approximately 2.8 million patients without cirrhosis having these operations. Patients with CIRR or PHTN were more likely to be women (49.5% versus 44.0%, p < 0.0001) and were less likely to be treated in a large hospital (62.8% versus 67.6%, p < 0.0001) than NON-CIRR patients. Length of hospital stay and total charges per hospitalization increased with severity of liver disease for all operations (p < 0.001, respectively). Adjusted mortality rates increased with increasing liver disease for each operation (cholecystectomy: CIRR hazard ratio [HR] 3.4, 95% CI 2.3 to 5.0; PHTN HR 12.3, 95% CI 7.6 to 19.9; colectomy: CIRR HR 3.7, 95% CI 2.6 to 5.2; PHTN HR 14.3, 95% CI 9.7 to 21.0; coronary artery bypass grafting: CIRR HR 8.0, 95% CI 5.0 to 13.0, PHTN HR 22.7, 95% CI 10.0 to 53.8; abdominal aortic aneurysm: CIRR HR 5.0, 95% CI 2.6 to 9.8, PHTN HR 7.8, 95% CI 2.3 to 26.5).
Conclusions:
In-hospital mortality, length of stay, and total hospital charges are significantly higher after elective surgery in cirrhotic patients, even in the absence of portal hypertension. Careful decision-making about surgery in these patients is critical as the nationwide increase in hepatitis C and cirrhosis continues.
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