Surgical Procedures in Patients Awaiting Liver Transplantation: Complications and Impact on the Liver Function

Imke Honerkamp; Lisa Sandmann; Nicolas Richter; Michael P Manns; Torsten Voigtländer; Florian W R Vondran; Thomas von Hahn

doi:10.1016/j.jceh.2021.03.011

Surgical Procedures in Patients Awaiting Liver Transplantation: Complications and Impact on the Liver Function

J Clin Exp Hepatol. 2022 Jan-Feb;12(1):68-79. doi: 10.1016/j.jceh.2021.03.011. Epub 2021 Apr 2.

Authors

Imke Honerkamp¹, Lisa Sandmann¹, Nicolas Richter², Michael P Manns¹, Torsten Voigtländer¹, Florian W R Vondran², Thomas von Hahn^{1

3}

Affiliations

¹ Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany.
² Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, Germany.
³ Department of Gastroenterology, Hepatology and Interventional Endoscopy, Asklepios Hospital Barmbek, Semmelweis University Budapest, Campus Hamburg, Rübenkamp 220, Germany.

Abstract

Background: Potential indications for surgery frequently arise in patients awaiting liver transplantation. There is a risk of hepatic decompensation and death triggered by surgical trauma, but this has not been studied in detail in this unique population. We aimed to quantify the impact of surgical interventions in patients awaiting liver transplantation on hepatic function and identify risk factors for decompensation.

Methods: All surgeries between 2000 and 2018 in patients awaiting liver transplantation in a highvolume German liver transplant center were analyzed retrospectively. Change in liver function measured as indicated by MELD score was assessed and complication rates recorded. The primary endpoint was a composite of an increase in MELD score by > 5 points or death. A logistic regression model was used for multivariate analysis to identify risk factors.

Results: In total, 177 surgical procedures in 148 patients were analyzed. The primary endpoint was reached in 42 cases (23.7%). The overall in-hospital complication rate (including death) was 44.1%. Multivariate analysis identified elevated leukocyte count, perioperative blood transfusion, preoperative presence of ascites, and preoperative circulatory support as independent risk factors for a decline in liver function or death.

Conclusion: Surgery in patients awaiting liver transplantation carries a relevant risk of hepatic decompensation and death that needs to be considered when deciding whether to perform elective surgery prior to or defer until after liver transplantation.

Keywords: ACLF, Acute-on-Chronic Liver Failure; ALT, Alanine transaminase; ASA, American Society of Anesthesiologists physical status classification system; AST, Aspartate transaminase; CHE, Cholinesterase; CRP, C-reactive Protein; HCC, Hepatocellular carcinoma; Hb, Hemoglobin; INR, International Normalized Ratio; MELD; MELD, Model for End-stage Liver Disease; OR, Odds Ratio; SBP, Spontaneous Bacterial Peritonitis; Tsd, Thousand; aPTT, Activated partial thromboplastin time; cirrhosis; dl, Deciliter; g, Gram; i.e., id est; l, Liter; liver transplantation; log, Logarithm; mg, Milligram; min, Minutes; mmol, Millimole; surgery; vs, Versus; waiting list; μl, Microliter.