Comorbidity and survival of Danish cirrhosis patients: a nationwide population-based cohort study

Patients with liver cirrhosis have a high mortality, not just from cirrhosis-related causes, but also from other causes. This observation indicates that many patients with cirrhosis have other chronic diseases, yet the prognostic impact of comorbidities has not been examined. Using data from a nationwide Danish population-based hospital registry, we identified patients who were diagnosed with cirrhosis between 1995 and 2006 and computed their burden of comorbidity using the Charlson comorbidity index. We compared survival between comorbidity groups, adjusting for alcoholism, sex, age, and calendar period. We also examined the risks of cirrhosis-related and non-cirrhosis-related death using data from death certificates and identified a matched comparison cohort without cirrhosis from the Danish population. We included 14,976 cirrhosis patients, 38% of whom had one or more comorbidities. The overall 1-year survival probability was 65.5%; the 10-year survival probability was 21.5%. Compared with patients with a Charlson comorbidity index of 0, the mortality rate was increased 1.17-fold in patients with an index of 1 [95% confidence interval (CI), 1.11-1.23], 1.51-fold in patients with an index of 2 (95% CI, 1.42-1.62), and two-fold in patients with an index of 3 or higher (95% CI, 1.85-2.15). In the first year of follow-up, but not later, comorbidity increased the risk of cirrhosis-related death, and this was consistent with an apparent synergy between the cirrhosis and comorbidity effects on mortality in the same period. CONCLUSION: Our findings demonstrate that comorbidity is an important prognostic factor for patients with cirrhosis. Successful treatment of comorbid diseases in the first year after diagnosis may substantially reduce the mortality rate.     

Mortality after a cholecystectomy: a population-based study

Background

The trade-off between the benefits of surgery for gallstone disease for a large population and the risk of lethal outcome in a small minority requires knowledge of the overall mortality.

Methods

Between 2007 and 2010, 47 912 cholecystectomies for gallstone disease were registered in the Swedish Register for Cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) (GallRiks). By linkage to the Swedish Death Register, the 30-day mortality after surgery was determined. The age- and sex-standardized mortality ratio (SMR) was estimated by dividing the observed mortality with the expected mortality rate in the Swedish general population 2007. The Charlson Comorbidity Index (CCI) was estimated by International Classification of Diseases (ICD) codes retrieved from the National Patient Register.

Results

Within 30 days after surgery, 72 (0.15%) patients died. The 30-day mortality was close [SMR = 2.58; 95% confidence interval (CI): 2.02–3.25] to that of the Swedish general population. In multivariable logistic regression analysis, predictors of 30-day mortality were age >70 years [odds ratio (OR) 7.04, CI: 2.23–22.26], CCI > 2 (OR 1.93, CI: 1.06–3.51), American Society of Anesthesiologists (ASA) > 2 (OR 13.28, CI: 4.64–38.02), acute surgery (OR 10.05, CI:2.41–41.95), open surgical approach (OR 2.20, CI: 1.55–4.69) and peri-operative complications (OR 3.27, CI: 1.74–6.15).

Discussion

Mortality after cholecystectomy is low. Co-morbidity and peri-operative complications may, however, increase mortality substantially. The increased mortality risk associated with open cholecystectomy could be explained by confounding factors influencing the decision to perform open surgery.     

Laparoscopic cholecystectomy in patients with liver cirrhosis

BACKGROUND: Initially considered a contraindication to the surgical laparoscopy, cirrhosis have been an occasional discovery during this procedure. Until now many series reported in the literature suggest that the majority of the surgeons still consider cirrhosis as contraindication to the laparoscopic cholecystectomy. AIM: To evaluate our experience in laparoscopic treatment of the cholelithiasis in cirrhotic patient. PATIENTS AND METHODS: Six hundred and four patients with symptomatic cholelithiasis were operated on Clinical and Surgical Gastroenterology Unit, "Santa Casa de Misericórdia de Porto Alegre", Porto Alegre, RS, Brazil, during the period from May 1993 to May 2000. Of these, 10 (1,6%) presented hepatic cirrhosis. The patients' age was between 22 and 69 years (average of 50,4 +/- 18,1). Eight patients (80%) were female. The alcohol was the etiological factor in four, chronic hepatitis B and C, primary biliary cirrhosis and of alfa-1 antitripsin deficiency in one patient each. In two patient the causal agent was not identified. RESULTS: Cholecystectomy was accomplished in all patients and in seven also diagnostic hepatic biopsy. In two (20%) the surgery was converted. The result of the intraoperative cholangiography was normal in all cases. In seven patients the postoperative was uneventfull. Clinically controlled ascite was observed in two (20%). Both were Child A at the moment of the surgery. The last patient, Child C, died. He presented irreversible hepatic failure. CONCLUSIONS: Despite larger experience still should be acquired, it seems that laparoscopic is a safe approach in well compensated cirrhotic patients with symptomatic cholelithiasis. In Child C patients we believed that all of the efforts should be driven to the improvement of the hepatic function or a less invasive method such as cholecystostomy.     

Outcome after cholecystectomy in the elderly: a population-based register study

Objective: The decision to perform surgery in elderly is usually based on a complex consideration of benefit versus risk, which makes it difficult to perform controlled trials. The aim of this study was to assess the safety of cholecystectomy in patients aged?80 years and above. Methods: The study was based on the Swedish National Register for Gallstone Surgery and ERC (GallRiks) 2006–2011. The cohort was cross-linked with the Swedish Patient Register in order to obtain data on previous medical history and postoperative events. Date and cause of death were obtained from the Central Death Register. All events with an ICD code indicating myocardial infarct, cerebrovascular insult or pulmonary embolism within 30 days postoperatively were considered to be a cardiovascular event. Poisson regression was used to calculate the 30-day age- and sex-adjusted standardised mortality ratio (SMR). Results: Altogether 1961 procedures in patients aged?80 years and above were registered. A cardiovascular event within 30 days after the procedure was registered in 56 (0.20%) of the cases. Mortality within 30 days was n?=?56 (0.20%). The SMR was 4.07 (CI 3.07–5.28). In univariate regression analyses, no factor was found to significantly predict a postoperative cardiovascular event. Gallstone disease without secondary complication, and open approach were associated with increased risk for death within 30 days after surgery in both univariate and multivariate regression analyse (p?Conclusion: Cholecystectomy seems to be a relatively safe procedure in patients aged 80 years or older. Minimally invasive techniques may reduce the risk of postoperative death.     

Laparoscopic left lateral sectionectomy: a population-based study

Background

Laparoscopic left lateral sectionectomy (LLS) has now become standard practice. However, published series are small and retrospective. The aim was to compare at a national level the use and short-term outcome of laparoscopic and open LLS.

Laparoscopic cholecystectomy for acute cholecystitis in the elderly: a retrospective study

BACKGROUND/AIMS: Laparoscopic cholecystectomy for acute cholecystitis in the elderly remains a subject almost unstudied. A first study performed at Brugmann hospital broached the subject, but was rather unsatisfying. In fact, it showed that, except for a shorter hospital stay, laparoscopic cholecystectomy didn't have any advantages over open cholecystectomy. In view of the perfection in surgical technique and of the rapidity of management, we have analyzed our new results and compared them to the ones of our former study. METHODOLOGY: In this current study we included patients aged over 75 years and with histologically proven acute cholecystitis. As such, we retrospectively studied 20 patients undergoing cholecystectomy from 1997 to 2002. Sixteen patients (80%) underwent laparoscopic cholecystectomy whereas 4 (20%) were considered unable to withstand the laparoscopic approach because of hemodynamic instability, they underwent open cholecystectomy. RESULTS: Age, APACHE-II scoring, white blood cell counts and CRP were more important in the laparotomy group, but there was no difference in terms of local and general complication or mortality rates between the two groups. CONCLUSIONS: Comparing the results with those of the first study (1991-1997), we established that the laparoscopic approach is very well indicated in the geriatric population. Also, the laparoscopy has been applied more appropriately, seen that our conversion rate dropped to zero. Still, open cholecystectomy proves to be indicated in critically ill patients.     

Pneumocystis jirovecii pneumonia in autoimmune rheumatic diseases: a nationwide population-based study

Clinical Rheumatology - To compare Pneumocystis jirovecii pneumonia (PJP) risk between patients with autoimmune rheumatic diseases (ARD) and the general population We identified patients with ARD...     

Liver cirrhosis in selected autoimmune diseases: a nationwide cohort study in Taiwan

The association between autoimmune diseases and liver cirrhosis has rarely been explored in Asian populations, an endemic area of viral hepatitis. The aim of this study was to investigate the comparative risk of liver cirrhosis among a group of selective autoimmune diseases in Taiwanese patients and to identify groups of high risk. This retrospective study was a nationwide, population-based study and used Taiwan’s National Health Insurance Research Database. A total of 29,856 patients with definite diagnosis of selected autoimmune diseases (Registry of Taiwan Catastrophic Illness Database, ACR classification) at the starting time point of January 1, 2005, were enrolled in this study. After tracked for a 5-year period, the endpoints were diagnosis of liver cirrhosis (in accordance with International Classification of Diseases, Ninth Revision, Clinical Modification, ICD-9-CM codes 571). The control group was composed of other patients in the same database and consisted of randomly selected 753,495 sex- and age-matched non-autoimmune disease patients. The Cox proportional hazard regression model was used to calculate the risk of liver cirrhosis after adjusting for certain variables such as comorbidity, living area, and socioeconomic status. Among the patients with selected autoimmune diseases, 1987 liver cirrhosis were observed. Patients with psoriasis had a significantly increased risk of liver cirrhosis (HR 1.87, 95 % CI 1.25–2.81) than control group without psoriasis. The risk of liver cirrhosis was significantly lower in patients with rheumatoid arthritis (HR 0.29, 95 % CI 0.19–0.44). There is a gradient of risk of liver cirrhosis among the autoimmune diseases; the specific risks need to be investigated on the basis of hypotheses. Conventional immunosuppressive drug administration should be carefully implemented by regular monitoring of liver condition in order to avoid causing an adverse effect of chronic liver fibrosis.     

Laparoscopic cholecystectomy; a retrospective 10-year study

BACKGROUND/AIMS: To evaluate results of laparoscopic cholecystectomies realized in our department and to compare results concerning local and general complications with those reported in the literature. METHODOLOGY: We analyzed retrospectively all the 1255 laparoscopic cholecystectomies realized in our department between January 95 and December 2004. Local and general complications were analyzed. Mean age was 55.6 (21-94) years, sex ratio (F/M) was 3.9. Common bile duct stones were extracted by endoscopic retrograde endoscopy (ERCP) before surgery or by choledochotomy (less than 1% of cases). The operation was performed with 4 trocars, as described by Dubois. RESULTS: Conversion rate was 1.95%. Mean postoperative hospitalization duration was2.7 days. Morbidity was 5.8% with equal repartition between local and general complications. Therevere 2 common bile duct injuries (0.16%). Six patients suffered from residual bile duct stone after cholecystectomy; 5 were treated by ERCP and 1 by choledochotomy. Three patients died (0.24%) after general complications. CONCLUSIONS: Laparoscopic cholecvstectomv is a common operation with potential possible dramatic complications. We think that a radiological study of the biliary tract must be performed before surgery to avoid mistakes during the operation.     

Short-term postoperative outcomes after liver resection in the elderly patient: a nationwide population-based study

BackgroundLiver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.MethodsIn this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.ResultsIn total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02–1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.ConclusionThirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.