D. Hsu1, S. Tohme1, D. Chalhoub2, A. Tsung1 1University Of Pittsburgh,General Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Department Of Epidemiology,Pittsburgh, PA, USA
Introduction: Patients with liver cirrhosis are considered to be at higher risks of developing peri-operative morbidity and mortality. Laparoscopic surgery is considered a safe and feasible alternative to open surgery in cirrhotic patients undergoing cholecystectomy or hepatic resections. However, outcomes after major nonhepatic laparoscopic surgery in cirrhotic patients remain unclear. The aim of this retrospective study was to compare patient characteristics, short term morbidity and mortality between major laparoscopic and open nonhepatic gastrointestinal surgery at a single center in patients with histologically proven cirrhosis.
Methods: Electronic medical records of 4758 patients who were diagnosed with cirrhosis and underwent open or laparoscopic surgery from 1990 to 2014 at University of Pittsburgh Medical Center were reviewed. Out of those patients, 186 patients underwent open and 63 underwent laparoscopic major non-hepatic abdominal surgeries. Demographic information (age, gender, etiology of cirrhosis, MELD score, pre-operative hemoglobin, albumin, and platelets) and peri-operative data (re-admission rate, 90 day morbidity and mortality) were reviewed and analyzed. Adjusted and nonadjusted Cox proportionate hazard ratio was used to compare outcomes.
Results:
With the laparoscopic group compared with the open surgery group, mean age was 55 vs. 59 (p=0.03), MELD score was 5.3 vs. 16.1 (p<0.001), emergent surgery was performed in 11.1% vs. 68.3% (p<0.001). With regards to short term outcomes, operative time was 189 minutes vs. 210 minutes (p = 0.452), hospital stay was 6 days vs. 16 days (P < 0.001), 90 day morbidity grade was 0.3 vs. 3.1 (p<0.001), 90 day readmission rate was 9.5% vs. 21.5% (p=0.05), 90 day mortality rate was 3.2% vs. 45.2% (p<0.001).
We next did subgroup analysis of patients who underwent elective surgery with adjustment of MELD score since the open surgery group were more likely to have more advanced cirrhosis and have emergent surgery performed which likely is behind the significantly worse outcomes. In non-emergent cases and after adjusted for MELD score and age, the hazard ratio for 90 day mortality was 6.2 (95%CI 0.7-52) times greater in open compared to laparoscopic surgery. The hazard ratio for 90 day readmission after adjusting for MELD score was 4 (95%CI 1.2-12.9) times greater in open compared to laparoscopic surgery. In addition, 90 day complication rate after adjusting for MELD score was 16.8 (95%CI 4.1-69.2) times greater in open compared to laparoscopic surgery.
Conclusion: Laparoscopic surgery is more likely to be offered to patients with early stage cirrhosis on an elective basis. Open approach is more likely to be performed in the emergent setting. Laparoscopic surgery has fewer overall postoperative complications, a shorter hospital stay, decreased morbidity and mortality than open surgery even after adjusting for emergency of surgery and degree of cirrhosis.