Volume 71 - 2008 - Fasc.1 - Symposium
The risk of surgery in patients with cirrhosis
Several reasons result in the finding that patients with cirrhosis need surgery more often than other patients groups. Patients with cirrhosis frequently have comorbidities resulting in gastrointesti- nal, lung or cervical cancer, among others. Independent of cirrho- sis, surgical resection may be the best alternative for a number of those malignancies. Comorbidities may also result in an increased incidence of vascular complications (such as lower extremity ath- erosclerosis and coronary stenosis) some of them being potential indications for surgery. Patients with alcoholic cirrhosis are more frequently subjected to trauma and bone fractures. Ascites leads to umbilical hernia which can be strangulated or ruptured. Emergency surgery may be needed in this context. Finally, a sig- nificant proportion of patients with cirrhosis develop hepatocellu- lar carcinoma (HCC) during the course of the disease. Surgical resection remains a first line option for HCC. While reliable guide- lines have been proposed for surgical resection of HCC and liver transplantation, no precise guidelines are available for other aspects of surgical management during cirrhosis. Specific surgical procedures such as hepatectomy and transplantation are concen- trated in highly specialised centres, where detailed evaluation is relatively easy to obtain. In contrast, more general surgical proce- dures, either abdominal or non abdominal, are performed in var- ious centres, making it more difficult to obtain detailed evaluation and draw recommendations. General surveys are still needed to precisely assess the risk of non-specific surgery in patients with cirrhosis, to identify risk factors and to propose reliable guide- lines. (Acta gastroenterol. belg., 2008, 71, 42-46).
Discussion on “The risk of surgery in patients with cirrhosis" (François Durand)
Discussion held at the BASL Winter Meeting 2006 in Bruges, following the lecture of Prof F. Durand (Hôpital Beaujon, Clichy) on surgical risk factors in cirrhosis. A summary of the most important topics from the discus- sion is given below.
The metabolic syndrome and the liver
Together with the worldwide epidemic proportions of obesity the incidence of 'the metabolic syndrome' is rising across coun- tries. The metabolic syndrome is described as a complex condition that is linked to (intra-abdominal) obesity and is characterized by insulin resistance, dyslipidaemia and hypertension. Several defini- tions for the metabolic syndrome have been suggested, all trying to identify individuals at high risk for both type 2 diabetes and car- diovascular disease. The primary hepatic complication of obesity and insulin resistance is nonalcoholic fatty liver disease (NAFLD). NAFLD is not included as a component of the metabolic syndrome as it is currently defined ; however, data suggest an association. Although the data are mainly epidemiological, the pathogenesis of NAFLD and the metabolic syndrome show common components, with the focus on insulin resistance as a key factor. Even so the treatment of patients with the metabolic syndrome and NAFLD shows a certain degree of similarity, and should focus on the man- agement of associated conditions including obesity, glucose and lipid abnormalities. Lifestyle modifications comprising healthy eating habits and regular exercise are the primary interventions recommended to patients with the metabolic syndrome and those with NAFLD. A pharmacological approach like insulin-sensitizing agents, lipid lowering drugs, antihypertensive drugs and antiobe- sity agents can be successful in the treatment of certain risk fac- tors that are currently clustering with both the metabolic syn- drome and NAFLD. In some cases bariatric surgery may be nec- essary. (Acta gastroenterol. belg., 2008, 71, 48-59).
