Brief Article
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World J Gastroenterol. Nov 7, 2013; 19(41): 7129-7137
Published online Nov 7, 2013. doi: 10.3748/wjg.v19.i41.7129
Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy
Ayman El Nakeeb, Ahmad M Sultan, Tarek Salah, Mohamed El Hemaly, Emad Hamdy, Ali Salem, Ahmed Moneer, Rami Said, Ahmed AbuEleneen, Mostafa Abu Zeid, Talaat Abdallah, Mohamed Abdel Wahab
Ayman El Nakeeb, Ahmad M Sultan, Tarek Salah, Mohamed El Hemaly, Emad Hamdy, Ali Salem, Ahmed Moneer, Rami Said, Ahmed AbuEleneen, Mostafa Abu Zeid, Talaat Abdallah, Mohamed Abdel Wahab, Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
Author contributions: El Nakeeb A designed the research; El Nakeeb A, Salah T, Salem A, El Hemaly M, Hamdy E, Sultan AM, Moneer A, Said R, AbuEleneen A, Abu Zeid M, Abdallah T and Abdel Wahab M performed the research; El Nakeeb A and Sultan AM analysed the data; El Nakeeb A and Abdallah T wrote the paper.
Correspondence to: Ayman El Nakeeb, MD, Associate Professor of general surgery, Gastroenterology surgical center, Mansoura University, Gehan street, Mansoura 35516, Egypt. elnakeebayman@yahoo.com
Telephone: +20-10-6752021 Fax: +20-50-2251543
Received: June 17, 2013
Revised: August 29, 2013
Accepted: September 3, 2013
Published online: November 7, 2013
Abstract

AIM: To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis.

METHODS: We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient’s score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate.

RESULTS: Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT.

CONCLUSION: Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Keywords: Periampullary tumour, Liver cirrhosis, Portal hypertension, Pancreaticoduodenectomy

Core tip: Traditionally, cirrhosis has been considered a contraindication to major gastrointestinal surgery. Hospital mortality rates have been reported to be 17.5 % to 38% for cirrhotic patients undergoing gastrointestinal surgery. Pancreaticoduodenectomy is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is recommended only in patients with Child A cirrhosis. Cirrhotic patients with portal hypertension were associated with poorer outcome than cirrhotic patients without portal hypertension. Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for radical surgery at high volume centres with available expertise to manage liver cirrhosis.