Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Colectomy for benign or malignant disease may be elective, urgent, or emergent. Data suggest successively worse outcomes for nonelective colectomy. Limited data exist regarding the contribution of high area deprivation index and care fragmentation to nonelective colectomy.

Determine the association between area deprivation and nonelective colectomy in the Veterans Health Administration and assess whether accounting for differences in care fragmentation alters the association across indications and for benign and malignant conditions separately.

Retrospective cohort with multivariable multinomial logit models to evaluate associations between high-deprivation care fragmentation and the adjusted odds of nonelective colectomy. We calculated total, direct, and indirect effects to assess whether the association varied by levels of care fragmentation.

Veterans receiving care in the private sector and Veterans Health Administration.

Veterans aged 65 years or older undergoing colectomy between 2013 and 2019 were included.

Colectomy case acuity.

We identified 6538 colectomy patients, of whom 3006 (46.0%) were identified for malignancy. The odds of emergent colectomy were higher for patients in high-deprivation areas when the indication was for benign pathology (adjusted OR 1.51; 95% CI, 1.15-2.00). For malignant indications, there was no association between high deprivation and nonelective colectomy. More fragmented care was associated with higher odds of urgent and emergent colectomy for both benign and malignant indications, but the association between deprivation and nonelective colectomy did not vary by care fragmentation.

Inherent to large administrative retrospective databases.

Veterans living in high-deprivation areas are at higher risk for emergent colectomy for benign conditions. Care fragmentation is also associated with a higher risk of emergent colectomy across indications. Efforts to reduce care fragmentation and promote early detection of IBD and diverticular disease in high-deprivation neighborhoods may lower the risk for nonelective colectomy in veterans. See Video Abstract .

ANTECEDENTES:La colectomía por enfermedad benigna o maligna puede ser electiva, urgente o de emergencia. Los datos sugieren resultados cada vez peores para la colectomía no electiva. Existen pocos datos sobre la contribución del alto índice de privación de área y la fragmentación de la atención a la colectomía no electiva.OBJETIVO:Determinar la asociación entre la privación de área y la colectomía no electiva en la Administración de Salud de Veteranos (VHA) y evaluar si tener en cuenta las diferencias en la fragmentación de la atención altera la asociación entre las indicaciones y para las condiciones benignas y malignas por separado.DISEÑO:Cohorte retrospectiva con modelos logit multinomiales multivariables para evaluar las asociaciones entre la alta fragmentación de la atención por privación y las probabilidades ajustadas de colectomía no electiva. Calculamos los efectos totales, directos e indirectos para evaluar si la asociación variaba según los niveles de fragmentación de la atención.ESCENARIO:Veteranos que reciben atención en el sector privado y la VHA.PACIENTES:Veteranos ≥ 65 años sometidos a colectomía entre 2013 y 2019.

Gravedad de los casos de colectomíaRESULTADOS:Identificamos 6538 pacientes de colectomía, de los cuales 3006 (46,0%) fueron por neoplasia maligna. Las probabilidades de colectomía de emergencia fueron mayores para los pacientes en áreas de alta privación cuando la indicación fue por patología benigna (aOR 1,51 IC del 95% 1,15, 2,00). Para las indicaciones malignas, no hubo asociación entre la alta privación y la colectomía no electiva. La atención más fragmentada se asoció con mayores probabilidades de colectomía urgente y de emergencia tanto para indicaciones benignas como malignas, pero la asociación entre la privación y la colectomía no electiva no varió según la fragmentación de la atención.LIMITACIONES:Inherentes a las grandes bases de datos administrativas retrospectivas.CONCLUSIONES:Los veteranos que viven en zonas de alta pobreza tienen un mayor riesgo de colectomía de urgencia por afecciones benignas. La fragmentación de la atención también se asocia con un mayor riesgo de colectomía de urgencia en todas las indicaciones. Los esfuerzos para reducir la fragmentación de la atención y promover la detección temprana de la enfermedad inflamatoria intestinal y la enfermedad diverticular en barrios de alta pobreza pueden reducir el riesgo de colectomía no electiva en los veteranos. (Traducción-Dr Yolanda Colorado ).

The incidence of hepatocellular carcinoma (HCC) is on the rise worldwide, due to the increasing prevalence of liver diseases associated with metabolic dysfunction and better management of cirrhosis and its complications. The diversification of HCC treatments has recently increased, with the choice of strategy based on HCC characteristics, liver function and comorbidities. The combination of new therapies has transformed the prognosis, with up to 70% survival at 5 years.

The aim of this review was to analyse the most recent data on preoperative evaluation, peri-operative anaesthetic management of liver resection, liver transplantation and other types of procedures, and to highlight the multidisciplinary aspect of such management.

The importance of preanaesthetic evaluation will depend largely on the procedure proposed, associated co-morbidities and the stage of liver disease. This assessment should verify stabilisation of all comorbidities, and evaluate the degree of portal hypertension, cirrhosis severity and sarcopenia. Liver resection and liver transplantation for HCC present specific surgical challenges, and minimally invasive techniques improve recovery. Nonsurgical procedures considered as therapeutic (ablation) or standby (regional embolisation) are diverse, and all expose patients to specific intra-anaesthetic complications, sometimes requiring intensive care management. Peri-operative anaesthetic strategies deployed in the management of liver resection or nonsurgical procedures involve specific management of fluids, coagulation, narcosis and analgesia, which can impact on patients' overall, and cancer prognosis. Lastly, new down-staging strategies combining several types of procedure and possibly immunotherapy, also call for collegial reflection on posthepatic transplant immunosuppression, which must remain tailored to each individual patient.

Heart disease is becoming more and more common in modern society because of factors like stress, inadequate diets, etc. Early identification of heart disease risk factors is essential as it allows for treatment plans that may reduce the risk of severe consequences and enhance patient outcomes. Predictive methods have been used to estimate the risk factor, but they often have drawbacks such as improper feature selection, overfitting, etc. To overcome this, a novel Deep Red Fox belief prediction system (DRFBPS) has been introduced and implemented in Python software. Initially, the data was collected and preprocessed to enhance its quality, and the relevant features were selected using red fox optimization. The selected features analyze the risk factors, and DRFBPS makes the prediction. The effectiveness of the DRFBPS model is validated using Accuracy, F score, Precision, AUC, Recall, and error rate. The findings demonstrate the use of DRFBPS as a practical tool in healthcare analytics by showing the rate at which it produces accurate and reliable predictions. Additionally, its application in healthcare systems, including clinical decisions and remote patient monitoring, proves its real-world applicability in enhancing early diagnosis and preventive care measures. The results prove DRFBPS to be a potential tool in healthcare analytics, providing a strong framework for predictive modeling in heart disease risk prediction.

The association between cirrhosis and post-operative breast cancer outcomes has not been explored. We evaluated the association between cirrhosis and surgical outcomes in female patients with breast cancer.

We performed a retrospective population-based cohort study of female patients undergoing surgery for breast cancer between 2007 and 2018 using health administrative data from Ontario, Canada. Patients were stratified by cirrhosis status. Overall survival (OS) was described using the Kaplan-Meier method and the association between cirrhosis and long-term cancer-specific mortality (CSM) was evaluated using adjusted competing risks regression and subdistribution hazard ratios (sHR).

A total of 902 patients with breast cancer and cirrhosis were compared to 81,514 patients with breast cancer without cirrhosis. The median age at diagnosis was 65 years vs 61 years in patients with and without cirrhosis, respectively (p < .001). The most common etiologies of cirrhosis were metabolic dysfunction-associated steatotic liver disease (n = 595, 66%) and alcohol-associated (n = 143, 16%) liver disease. The median model for end-stage liver disease sodium score was 8 (IQR 6-11, n = 215). Furthermore, cirrhosis was associated with a twofold higher 90-day rate of post-operative mortality (RR 2.82; 95% CI 1.49-5.33). OS was lower in patients with cirrhosis (HR 1.41, 95% CI 1.26-1.58); however, there was no association with CSM (sHR 1.11, 95% CI 0.93-1.32).

This large population-based study demonstrates that patients with cirrhosis have lower OS compared to those without cirrhosis; however, there is no difference in CSM. Their outcomes remain favorable, and they should be considered for curative-intent therapies.

Dissemination of organisms from the gut microbiota is a major contributor to sepsis and critical illness. Patients with cirrhosis are prone to systemic infections and are commonly prescribed the carbohydrate lactulose to manage hepatic encephalopathy (HE) 1 . Commensal metabolism of lactulose is believed to reduce pathobiont colonization through short-chain fatty acid production, but its direct effects on gut pathobionts remain unexplored 2 . Here, we show that lactulose consumption unexpectedly selects for mutations in Escherichia coli lactose (lac) operon regulation, enhancing its metabolic fitness and colonization capacity. This is mediated by selection for constitutive expression of the lac operon through mutations in its regulatory components. Using in vitro systems, murine models, and clinical samples, we demonstrate that these mutations enable E. coli to exploit lactulose as a carbon source, bypassing host carbohydrate metabolism and increasing its intestinal colonization. Despite its long-standing use in HE treatment, we find that lactulose has a paradoxical association with risk of infection hospitalization in patients with cirrhosis in a large epidemiologic study. The emergence of lactulose-adapted E. coli strains could be suppressed by a dietary oligosaccharide that competitively inhibits lactulose uptake. These findings reveal a mechanism by which dietary substrates exert selective pressure on the microbiome, with implications for diet-based strategies to modulate microbial evolution and infection risk.

Acute-on-chronic liver failure (ACLF) is a specific, but complex and multifactorial form of acute decompensation (AD) of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure and high short-term mortality. In daily clinical practice, patients with liver cirrhosis and decompensation have indications for different medical procedures such as endoscopies, interventional treatments like transjugular intrahepatic portosystemic shunt (TIPS) or even surgical procedures. In these situations, clinicians often need to balance the expected benefits of such procedures with the risks of causing acute decompensation or ACLF. This review summarizes the evidence of medical procedures and their role in precipitating or preventing ACLF and highlights the aspects to consider during patient selection.

This consensus statement gives practical advice for the safe management of patients with harmful alcohol intake undergoing elective and emergency surgery. The wide spectrum of alcohol-related organ dysfunction observed in this cohort of patients may have a profound impact on care, and the additional effects of alcohol withdrawal may further exacerbate postoperative morbidity and mortality.

A working party was assembled based on clinical and/or academic expertise in the area. Recommendations were formulated using a modified Delphi process. An initial list of recommendations was produced following targeted literature reviews for all relevant phases of patient care throughout the peri-operative pathway. These recommendations were distributed among the authors who rated each as 'include', 'exclude'; or 'revise'. Recommendations with ≥ 75% inclusion decision were included.

The working party produced a list of 10 key peri-operative management recommendations. These include recommendations on how to screen effectively for excessive alcohol usage in the surgical population. To achieve this, a validated point-of-care tool is used with additional weighting provided by considering surgical urgency. This is combined with the use of scoring systems to facilitate decisions regarding peri-operative care including postoperative location. This document also provides clear explanation of the physiological and pharmacological issues relating to alcohol excess, highlighting the direct effects of alcohol and its secondary effects on organ systems.

This consensus statement offers strategies and solutions to minimise the impact of harmful alcohol intake on the safe conduct of anaesthesia.

Despite the extensive research on hepatocellular carcinoma (HCC) exploring various treatment strategies, the survival outcomes have remained unsatisfactory. The aim of this research was to evaluate the ability of machine learning (ML) methods in predicting the survival probability of HCC patients. The study retrospectively analyzed cases of patients with stage 1-4 HCC. Demographic, clinical, pathological, and laboratory data served as input variables. The researchers employed various feature selection techniques to identify the key predictors of patient mortality. Additionally, the study utilized a range of machine learning methods to model patient survival rates. The study included 393 individuals with HCC. For early-stage patients (stages 1-2), the models reached recall values ​​of up to 91% for 6-month survival prediction. For advanced-stage patients (stage 4), the models achieved accuracy values ​​of up to 92% for 3-year overall survival prediction. To predict whether patients are ex or not, the accuracy was 87.5% when using all 28 features without feature selection with the best performance coming from the implementation of weighted KNN. Further improvements in accuracy, reaching 87.8%, were achieved by applying feature selection methods and using a medium Gaussian SVM. This study demonstrates that machine learning techniques can reliably predict survival probabilities for HCC patients across all disease stages. The research also shows that AI models can accurately identify a high proportion of surviving individuals when assessing various clinical and pathological factors.

Background: Liver function and the presence of portal hypertension, as well as the urgency and type of surgery, are prognostic factors in advanced chronic liver disease (ACLD) patients undergoing extrahepatic major surgeries. Emergent surgery in ACLD patients has 4-10 times higher mortality rates than elective surgery. However, perioperative management improvements have been made in recent years. Methods: This is a retrospective, observational, and unicentric study of 482 patients with ACLD who underwent major surgery from 2010 to 2019. We compared baseline characteristics and postoperative mortality according to the presence of ascites, the emergency, and the surgery period. Results: In total, 140 (29%) patients had ascites, and 191 (39.6%) underwent urgent surgeries. The 90-day mortality was 2.8-fold higher in patients with ascites [HR (95%CI) 2.8 (1.6-5.0); p = 0.001] and 3-fold higher in urgent surgeries [3.0 (1.6 - 5.5); p < 0.001)]. Urgent surgeries in patients with ascites revealed the highest mortality risk [6.3 (2.7-14.8); p < 0.001)], which persisted in current (2015-2019) surgeries [12.8 (2.9-56.5); p = 0.001)]. Portal hypertension was meaningful in patients undergoing abdominal surgery. Conclusions: ascites and emergent surgery increase the mortality risk of patients with ACLD despite the recent perioperative improvements.

In cirrhotic patients, portal hypertension increases mortality after surgery. We evaluated the impact of pre-operative transjugular intrahepatic portosystemic shunt (TIPS) on the outcomes of bariatric surgery in cirrhosis.

Multicentric retrospective cohort. The decision for TIPS placement has been made according to hepatic venous pressure gradient (HVPG) values and centers' policy. The primary outcome: 1-year decompensation-free survival; secondary outcomes: 1-year acute-on-chronic liver failure (ACLF) and survival.

Fifty-three patients were included (2010-2022): 92% Child-Pugh A, MELD score 8, age 55 years, BMI 38.3 ± 13 kg/m2, 9 (18%) had TIPS. At baseline, patients with TIPS had more esophageal varices (89% vs 10%, p < 0.001), more previous decompensations (22% vs 0%, p = 0.002), and a higher HVPG (14 vs 7 mmHg, p < 0.001). All patients in the TIPS group had clinically significant portal hypertension vs 11% of patients without TIPS, p < 0.001. One-year decompensation-free survival was 77.8% and 93.2% in patients with and without TIPS, p = 0.064. ALCF occurred in 3 patients (6.8%) without TIPS and none with TIPS. All patients were alive 1 year after surgery.

In patients with cirrhosis and clinically significant portal hypertension (CSPH) undergoing bariatric surgery, TIPS placement was safe and had similar outcomes after surgery as patients without TIPS.

This review assesses the outcomes of coronary interventions in patients with liver cirrhosis and coronary artery disease (CAD), focusing on the clinical challenges posed by cirrhosis-related hemodynamic and coagulopathic changes. It highlights essential considerations for managing these patients, who have an increased risk of adverse events during coronary procedures.

Recent studies have shown that patients with liver cirrhosis undergoing PCI experience significantly higher mortality rates compared to non-cirrhotic patients, particularly in the context of STEMI and NSTEMI. Coagulopathy and thrombocytopenia increase the risk of bleeding and vascular complications during interventions. Radial access has been suggested as a safer alternative to femoral access in these patients due to reduced bleeding complications. Additionally, contrast-induced nephropathy (CIN) is a prevalent risk, with cirrhotic patients demonstrating higher rates of acute kidney injury post-PCI. Preventive strategies such as minimizing contrast exposure and utilizing intravascular ultrasound (IVUS) are recommended. Managing CAD in cirrhotic patients requires careful consideration of their unique pathophysiological state. Higher in-hospital mortality, bleeding risks, and vascular complications necessitate tailored procedural strategies, such as radial access and contrast minimization. The balance between thrombotic and bleeding risks is critical in decision-making, with IVUS and hydration strategies being promising approaches. Further research is required to optimize treatment protocols and improve long-term outcomes for this high-risk population.

Corticosteroids are recommended by multiple society guidelines for the treatment of severe alcohol-associated hepatitis (AH). However, their use remains controversial due to inconsistent studies regarding their survival benefit.

This was a retrospective cohort study of first-time hospitalizations for severe AH (Maddrey discriminant function ≥ 32) admitted to the Veterans Health Administration between January 3, 2005, and December 5, 2020, (i) evaluating the effect of corticosteroid therapy on all-cause survival, (ii) characterizing the clinical and psychosocial factors associated with corticosteroid use, and (iii) determining the effect of duration of corticosteroid therapy on all-cause survival among treatment-responsive patients (Lille score < 0.45).

During the study period, 2,618 patients were admitted with severe AH, of whom 1,083 (41.37%) received corticosteroids. Although corticosteroids were significantly associated with improved all-cause survival in the unadjusted model ( P = 0.022), no survival benefit was observed in the adjusted model after accounting for baseline and admission characteristics (adjusted hazard ratio [aHR] = 1.01, P = 0.818). Psychiatry consultation was the only factor evaluated that was protective against mortality (aHR = 0.67, P < 0.001). Among the 428 patients (49.7%) responsive to corticosteroids, duration of therapy was not associated with overall survival on unadjusted ( P = 0.696) or adjusted models (aHR = 1.12, P = 0.710 for a ≥28-day course compared with a ≤7-day reference).

Despite being recommended by clinical guidelines for severe AH, corticosteroids have low utilization with no survival benefit after accounting for differences in patient characteristics and practice patterns. Among patients with treatment response per the Lille score, no difference was observed in overall survival between shorter and longer durations of corticosteroid therapy.

In patients with noncirrhotic chronic extrahepatic portal vein obstruction (EHPVO), data on the morbimortality of abdominal surgery are scarce.

We retrospectively analyzed the charts of 76 patients (78 interventions) with EHPVO undergoing abdominal surgery within the Vascular Disease Interest Group network. Fourteen percent of the patients had ≥1 major bleeding (unrelated to portal hypertension) and 21% had ≥1 Dindo-Clavien grade ≥3 postoperative complications within 1 month after surgery. Fifteen percent had ≥1 portal hypertension-related complication within 3 months after surgery. Three patients died within 12 months after surgery. An unfavorable outcome (ie, ≥1 abovementioned complication or death) occurred in 37% of the patients and was associated with a history of ascites and with nonwall, noncholecystectomy surgical intervention: 17% of the patients with none of these features had an unfavorable outcome, versus 48% and 100% when one or both features were present, respectively. We then compared 63/76 patients with EHPVO with 126 matched (2:1) control patients without EHPVO but with similar surgical interventions. As compared with control patients, the incidence of major bleeding ( p <0.001) and portal hypertension-related complication ( p <0.001) was significantly higher in patients with EHPVO, but not that of grade ≥3 postoperative complications nor of death. The incidence of unfavorable postoperative outcomes was significantly higher in patients with EHPVO than in those without (33% vs. 18%, p =0.01).

Patients with EHPVO are at high risk of major perioperative or postoperative bleeding and postoperative complications, especially in those with ascites or undergoing surgery other than wall surgery or cholecystectomy.

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Introduction and Objectives: Osteoporotic hip fractures in cirrhotic subjects are associated with increased post-fracture mortality. Our aim was to identify unfavorable factors that were associated with increased post-fracture mortality. Patients and Methods: We employed a retrospective evaluation of the short- and long-term prognosis of cirrhotic patients that were admitted with a hip fracture to our institution. Results: A total of 77 cirrhotic and 81 control patients were included. The majority of the patients who died either during the initial three months or during one year of follow-up after the hip fracture were cirrhotic. The patients that did not survive the three-month period suffered from decompensated cirrhosis. The variables that were associated upon multivariate analysis with increased one-year all-cause mortality in both the control and cirrhotic patients were the presence of either cirrhosis, congestive heart failure or low hemoglobin levels upon admission. The variables that were associated upon univariate analysis with increased one-year all-cause mortality only in the cirrhotic patients were the patient's age, the presence of hepatic encephalopathy, as well as the levels of serum albumin, PT (in %) and FIB-4. Our multivariate analysis disclosed that the admission level of PT (in %) was the only parameter that was associated with one-year all-cause mortality among the cirrhotic patients (adjusted OR 0.962, CI: 0.928-0.996, p = 0.029). Conclusions: Patients with decompensated cirrhosis are at an increased risk of dying during the first year after an osteoporotic hip fracture. Cirrhotic patients with osteoporosis who are at risk of hip fractures should be identified and measures to prevent this complication should be implemented.

Prognosticating survival among patients with HCC and cirrhosis must account for both the tumor burden/stage, as well as the severity of the underlying liver disease. Although there are many staging systems used to guide therapy, they have not been widely adopted to predict patient-level survival after the diagnosis of HCC. We sought to develop a score to predict long-term survival among patients with early- to intermediate-stage HCC using purely objective criteria.

Retrospective cohort study among patients with HCC confined to the liver, without major medical comorbidities within the Veterans Health Administration from 2014 to 2023. Tumor data were manually abstracted and combined with clinical and laboratory data to predict 5-year survival from HCC diagnosis using accelerated failure time models. The data were randomly split using a 75:25 ratio for training and validation. Model discrimination and calibration were assessed and compared to other HCC staging systems.

The cohort included 1325 patients with confirmed HCC. A risk score using baseline clinical, laboratory, and HCC-related survival had excellent discrimination (integrated AUC: 0.71 in the validation set) and calibration (based on calibration plots and Brier scores). Models had superior performance to the BCLC and ALBI scores and similar performance to the combined BCLC-ALBI score.

We developed a risk score using purely objective data to accurately predict long-term survival for patients with HCC. This score, if validated, can be used to prognosticate survival for patients with HCC, and, in the setting of liver transplantation, can be incorporated to consider the net survival benefit of liver transplantation versus other curative options.

Cirrhosis patients are at increased risk for postoperative complications. It remains unclear whether preoperative nonsurgical clinician visits improve postoperative outcomes. We assessed the impact of preoperative primary care physician (PCP) and/or gastroenterologist/hepatologist (GI/Hep) visits on postoperative mortality in cirrhosis patients undergoing surgery and explored differences in medication changes and paracentesis rates as potential mediators.

This was a retrospective cohort study of cirrhosis patients in the Veterans Health Administration who underwent surgery between 2008 and 2016. We compared 1982 patients with preoperative PCP and/or GI/Hep visits with 1846 propensity-matched patients without preoperative visits. We used Cox regression and Fine and Gray competing risk regression to evaluate the association between preoperative visit type and postoperative mortality at 6 months.

Patients with preoperative GI/Hep and PCP visits had a 45% lower hazard of postoperative mortality compared with those without preoperative visits (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.35-0.87). A smaller effect size was noted with GI/Hep preoperative visit alone (HR, 0.69; 95% CI, 0.48-0.99) or PCP visit alone (HR, 0.70; 95% CI, 0.53-0.93). Patients with preoperative PCP/GI/Hep visits were more likely to have diuretics, spontaneous bacterial peritonitis prophylaxis, and hepatic encephalopathy medications newly initiated and/or dose adjusted and more likely to receive preoperative paracentesis as compared with those without preoperative visits.

Preoperative PCP/GI/Hep visits are associated with a reduced risk of postoperative mortality with the greatest risk reduction observed in those with both PCP and GI/Hep visits. This synergistic effect highlights the importance of a multidisciplinary approach in the preoperative care of cirrhosis patients.

Risk for colorectal cancer may accumulate through multiple environmental factors. Understanding their effects, along with genetics, age, and family history, could allow improvements in clinical decisions for screening protocols. We aimed to extend the previous work by recalibrating an environmental risk score (e-Score) for colorectal cancer among a sample of US veteran participants of the Million Veteran Program.

Demographic, lifestyle, and colorectal cancer data from 2011 to 2022 were abstracted from survey responses and health records of 227,504 male Million Veteran Program participants. Weighting for each environmental factor's effect size was recalculated using Veterans Affairs training data to create a recalibrated e-Score. This recalibrated score was compared with the original weighted e-Score in a validation sample of 113,752 (n cases = 590). Nested multiple logistic regression models tested associations between quintiles for recalibrated and original e-Scores. Likelihood ratio tests were used to compare model performance.

Age (P < 0.0001), education (P < 0.0001), diabetes (P < 0.0001), physical activity (P < 0.0001), smoking (P < 0.0001), NSAID use (P < 0.0001), calcium (P = 0.015), folate (P = 0.020), and fruit consumption (P = 0.019) were significantly different between colorectal cancer case and control groups. In the validation sample, the recalibrated e-Score model significantly improved the base model performance (P < 0.001), but the original e-Score model did not (P = 0.07). The recalibrated e-Score model quintile 5 was associated with significantly higher odds for colorectal cancer compared with quintile 1 (Q5 vs. Q1: 1.79; 95% CI, 1.38-2.33).

Multiple environmental factors and the recalibrated e-Score quintiles were significantly associated with colorectal cancer cases.

A recalibrated, veteran-specific e-Score could be used to help personalize colorectal cancer screening and prevention strategies.

Advanced-stage liver cancers are associated with poor prognosis and have limited treatment options, often leading the patient to hospice care. Percutaneous intratumoral injection of anticancer agents has emerged as a potential alternative to systemic therapy to overcome tumor barriers, increase bioavailability, potentiate immunotherapy, and avoid systemic toxicity, which advanced-stage cancer patients cannot tolerate. Here, an injectable OncoGel (OG) comprising of a nanocomposite hydrogel loaded with an ionic liquid (IL) is developed for achieving a predictable and uniform tumor ablation and long-term slow release of anticancer agents into the ablation zone. Rigorous mechanical, physiochemical, drug release, cytotoxicity experiments, and ex vivo human tissue testing identify an injectable version of the OG with bactericidal properties against highly resistant bacteria. Intratumoral injection of OG loaded with Nivolumab (Nivo) and doxorubicin (Dox) into highly malignant tumor models in mice, rats, and rabbits demonstrates enhanced survival and tumor regression associated with robust tissue ablation and drug distribution throughout the tumor. Mass cytometry and proteomic studies in a mouse model of colorectal cancer that often metastasizes to the liver indicate an enhanced anticancer immune response following the intratumoral injection of OG. OG may augment immunotherapy and potentially improve outcomes in liver cancer patients.

Perioperative risks associated with acute hepatitis, cirrhosis, and chronic kidney disease are substantial and prevalence of underlying chronic kidney or liver disease is rising; surgeries in these populations have accordingly become more common. Optimal perioperative management in both cases is paramount; this article focuses on understanding disease pathophysiology, a targeted preoperative evaluation, accurate estimation of perioperative risk, and anticipation and management of common postoperative complications.

Hypoalbuminemia is a common complication in patients with chronic kidney disease (CKD) and is associated with various adverse clinical events. Currently, there are few studies focused on identifying risk factors and constructing models for hypoalbuminemia in patients with CKD stages 3 and 4. This study aims to identify independent risk factors for hypoalbuminemia in patients with CKD stages 3 and 4 and construct a nomogram for predicting the risk of hypoalbuminemia in these patients.

A total of 237 patients with CKD stages 3 and 4 treated at Anning First People's Hospital from January to December 2023 were included. Univariate and bidirectional stepwise multivariate logistic regression analyses were used to identify independent risk factors for hypoalbuminemia in these patients. Based on the results of logistic regression analyses, a nomogram was constructed. The model performance was assessed using area under the receiver operator characteristic curve, calibration curves, and decision curve analysis.

Hemoglobin, red blood cells, serum sodium, and serum calcium were identified as independent risk factors for hypoalbuminemia in these patients. The contributions of each independent risk factor to hypoalbuminemia were visualized in a nomogram. The area under the receiver operator characteristic curve of the model was 0.819, indicating good discrimination. The calibration curves showed good agreement between predicted and observed outcomes. The decision curve analysis also verified that the model had the good clinical utility.

Hemoglobin, red blood cells, serum sodium, and serum calcium were identified as independent risk factors of hypoalbuminemia in patients with CKD stages 3 and 4. The nomogram exhibits good discrimination, calibration, and clinical utility, offering a reliable tool for the early prediction and identification of hypoalbuminemia in these patients.

Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.

Oesophageal disorders and chronic liver disease are common worldwide and significantly impact quality of life. The intricate link between these conditions, including how oesophageal disorders like GERD, Barrett's oesophagus and oesophageal cancer affect and are affected by chronic liver disease, remains poorly understood.

To review the relationship between oesophageal disorders and chronic liver disease, evaluating epidemiology, pathophysiology and therapeutic factors.

We reviewed the literature on the relationship between oesophageal disorders and chronic liver disease, including cirrhosis, using the PubMed database RESULTS: Oesophageal disorders such as gastroesophageal reflux disease, Barrett's oesophagus, oesophageal cancer, oesophageal motor disorders and oesophageal candidiasis are prevalent among individuals with cirrhosis, exacerbating the burden of liver disease. These diseases have a multifaceted symptomatology and pathogenic basis, posing a significant challenge in cirrhotic patients that necessitates careful diagnosis and management. Additionally, therapies frequently used for these diseases, such as proton pump inhibitors, require careful consideration in cirrhotic patients due to potential adverse effects and altered pharmacokinetics. Managing oesophageal disorders in cirrhotic patients requires a cautious approach due to possible interactions with medications and the risk of adverse effects. Furthermore, symptoms associated with these conditions are often exacerbated by common interventions in patients with cirrhosis, such as band ligation for oesophageal varices.

Oesophageal disorders are common in cirrhosis and increase the disease burden. These conditions require careful management due to complex symptoms and treatment risks. Proton pump inhibitors and other therapies must be used cautiously, as cirrhosis interventions can worsen symptoms.

Acute-on-chronic liver failure (ACLF), usually precipitated by alcohol misuse or viral reactivation, is characterised by rapid onset and usually reversible liver failure. Various definitions of ACLF have been proposed and widely used across the globe, including those by APASL, COSSH, EASL-CLIF, Japanese experts, and NACSELD. Although all the definitions have several similarities and connote high short-term mortality, a clear and standardised definition is still lacking, hampering research in this key area. In this review, we discuss the similarities and differences among various definitions and propose steps to harmonise EASL-CLIF, APASL, NACSELD, Japanese, and Chinese definitions of ACLF.

This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.

To evaluate the correlation between non-tumoral liver volume (NTLV) by computed tomography (CT) volumetry and indocyanine green retention at 15 minutes (ICG-r15%), Child-Pugh score (CTP) and model for end-stage liver diseases (MELD) score in cirrhotic patients having hepatocellular carcinoma (HCC) (group A) and in cirrhotics without HCC (group B).

As many as 111 consecutive patients with liver cirrhosis, who underwent triple-phase CT abdomen, were retrospectively included in our study. They were classified into group A (cirrhosis with HCC, n = 69) and group B (cirrhosis only, n = 42). Segmental liver volume, tumor and NTLV were calculated using Myrian XP-Liver segmentation software. In group B, NTLV was the same as the total liver volume (TLV). The correlation of NTLV with ICG-r15%, CTP and MELD scores was analyzed using appropriate correlation tests for each group.

NTLV had a good and significant negative correlation with ICG-r15% (ρ =  - 512; p < 0.001) in group A, but not in group B. It also had a significant negative correlation with CTP (ρ =  - 251; p = 0.038) and MELD (ρ =  - 323; p = 0.007) scores only in group A. Furthermore, ICG-r15% had a good and significant positive correlation with CTP and MELD scores in both groups (p < 0.05).

NTLV showed a significant negative correlation with ICG-r15% in cirrhotic patients with HCC, but not in cirrhotic patients without HCC. Therefore, CT volumetry can be a valuable tool to predict the functional hepatic volume in patients of cirrhosis with HCC subjected for hepatectomy, where a facility of ICG-r15% is not available. However, further studies are needed to validate our findings in cirrhotic only patients.

The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.

Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context.

The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients.

Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care.

The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

This review explores the intricacies of evaluating cirrhotic patients for liver resection while exploring how to extend surgical intervention to those typically excluded by the Barcelona Clinic Liver Cancer (BCLC) criteria guidelines by focusing on the need for robust preoperative assessment and innovative surgical strategies. Cirrhosis presents unique challenges and complicates liver resection due to the altered physiology of the liver, portal hypertension, and liver decompensation. The primary objective of this review is to discuss the current approaches in assessing the suitability of cirrhotic patients for liver resection and aims to identify which patients outside of the BCLC criteria can safely undergo liver resection by highlighting emerging strategies that can improve surgical safety and outcomes.

Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.

Those with cirrhosis who require emergency colorectal surgery are at risk for poor outcomes. Although risk predictions models exists, these tools are not specific to colorectal surgery, nor were they developed in a contemporary setting. Thus, the objective of this study was to assess the outcomes in this population and determine whether cirrhosis etiology and/or the Model for End Stage Liver Disease (MELD-Na) is associated with mortality.

This population-based study included those with cirrhosis undergoing emergent colorectal surgery between 2009 and 2017. All eligible individuals in Ontario were identified using administrative databases. The primary outcome was 90-day mortality.

Nine hundred and twenty-seven individuals (57%) (male) were included. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (50%) and alcohol related (32%). Overall 90-day mortality was 32%. Multivariable survival analysis demonstrated those with alcohol-related disease were at increased risk of 90-day mortality (hazards ratio [HR] 1.53, 95% confidence interval [CI] 1.2-2.0 vs. NAFLD [ref]). Surgery for colorectal cancer was associated with better survival (HR 0.27, 95%CI 0.16-0.47). In the subgroup analysis of those with an available MELD-Na score (n = 348/927, 38%), there was a strong association between increasing MELD-Na and mortality (score 20+ HR 6.6, 95%CI 3.9-10.9; score 10-19 HR 1.8, 95%CI 1.1-3.0; score <10 [ref]).

Individuals with cirrhosis who require emergent colorectal surgery have a high risk of postoperative complications, including mortality. Increasing MELD-Na score is associated with mortality and can be used to risk stratify individuals.

Hepatocellular carcinoma (HCC) with high Ki67 protein expression, the most commonly used cell proliferation marker, is associated with an aggressive biologic phenotype; however, conventional immunostaining is hampered by variability in institutional protocol, specific antibody probe, and by assessor subjectivity. To this end, we hypothesized that Ki67 gene (MKi67) expression would identify highly proliferative HCC, and clarify its association with oncologic outcome, tumor progression, and immune cell population in the tumor microenvironment (TME). Furthermore, we sought to identify the cell-cycle gene expression profile that confers this aggressive phenotype.

A total of 473 HCC patients with clinicopathological data associated with transcriptome were selected for this study: 358 patients from The Cancer Genome Atlas (TCGA) as the testing cohort, and 115 from GSE76427 as the validation cohort. Each cohort was divided into a highly proliferative group (MKi67-high) and the low MKi67 group (MKi67-low) by the median of Ki67 gene (MKi67) expression levels.

MKi67-high HCC patients had worse disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS) independent of histological grade in the TCGA cohort. MKi67 expression correlated with histological grade and tumor size. MKi67 expression increased throughout the HCC carcinomatous sequence from normal liver, cirrhotic liver, early HCC, and advanced HCC. MKi67-high HCC was associated with higher intratumor heterogeneity, homologous recombination deficiency, and altered fraction as well as intratumoral infiltration of T helper type 1 (Th1) and Th2 cells, but lower interferon-gamma response and M2 macrophage infiltration. Cell proliferation-related gene sets in the Hallmark collection (E2F targets, G2M checkpoint, Myc target v1 and mitotic spindle), MTORC1 signaling, DNA repair, PI3K MTOR signaling, and unfolded protein response were all enriched in the MKi67-high HCC (false discovery rate (FDR) < 0.25).

High MKi67 gene expression identified highly proliferative HCC with aggressive biology involving classical pathways in cell cycle regulation and DNA repair, as well as poor overall oncologic outcomes. This suggests potential for personalized treatment strategies, but validation and refinement of these observations require further research to elucidate the underlying mechanisms and validate therapeutic targeting of these pathways in MKi67-high HCC tumors.

Obesity is an independent risk factor for the development of hepatocellular carcinoma (HCC) and may influence its outcomes. However, after diagnosis of HCC, like other malignancies, the obesity paradox may exist where higher body mass index (BMI) may in fact confer a survival benefit. This is frequently observed in patients with advanced HCC and cirrhosis, who often present late with advanced tumor features and cancer related weight loss.

To explore the relationship between BMI and survival in patients with cirrhosis and HCC.

This is a retrospective cohort study of over 2500 patients diagnosed with HCC between 2009-2019 at two United States academic medical centers. Patient and tumor characteristics were extracted manually from medical records of each institutions' cancer registries. Patients were stratified according to BMI classes: < 25 kg/m2 (lean), 25-29.9 kg/m2 (overweight), and > 30 kg/m2 (obese). Patient and tumor characteristics were compared according to BMI classification. We performed an overall survival analysis using Kaplan Meier by the three BMI classes and after adjusting for Milan criteria. A multivariable Cox regression model was then used to assess known risk factors for survival in patients with cirrhosis and HCC.

A total of 2548 patients with HCC were included in the analysis of which 11.2% (n = 286) were classified as non-cirrhotic. The three main BMI categories: Lean (n = 754), overweight (n = 861), and obese (n = 933) represented 29.6%, 33.8%, and 36.6% of the total population overall. Within each BMI class, the non-cirrhotic patients accounted for 15% (n = 100), 12% (n = 94), and 11% (n = 92), respectively. Underweight patients with a BMI < 18.5 kg/m2 (n = 52) were included in the lean cohort. Of the obese cohort, 42% (n = 396) had a BMI ≥ 35 kg/m2. Out of 2262 patients with cirrhosis and HCC, 654 (29%) were lean, 767 (34%) were overweight, and 841 (37%) were obese. The three BMI classes did not differ by age, MELD, or Child-Pugh class. Chronic hepatitis C was the dominant etiology in lean compared to the overweight and obese patients (71%, 62%, 49%, P < 0.001). Lean patients had significantly larger tumors compared to the other two BMI classes (5.1 vs 4.2 vs 4.2 cm, P < 0.001), were more likely outside Milan (56% vs 48% vs 47%, P < 0.001), and less likely to undergo transplantation (9% vs 18% vs 18%, P < 0.001). While both tumor size (P < 0.0001) and elevated alpha fetoprotein (P < 0.0001) were associated with worse survival by regression analysis, lean BMI was not (P = 0.36).

Lean patients with cirrhosis and HCC present with larger tumors and are more often outside Milan criteria, reflecting cancer related cachexia from delayed diagnosis. Access to care for hepatitis C virus therapy and liver transplantation confer a survival benefit, but not overweight or obese BMI classifications.