Symptomatische Cholelithiasis beim Patienten mit Leberzirrhose€¦ · Symptomatische...

Symptomatische Cholelithiasis beim Patienten mit Leberzirrhose

Vanessa Banz

Departement Viszerale Chirurgie und Medizin Inselspital Bern

Universitätsklinik für Viszerale Chirurgie und Medizin www: viszerale.ch

Cholecystectomy in cirrhotic patients?


Theodor Kocher 1907


Mortality in patients with liver cirrhosis

• Gastric resection up to 54%

• Cardiac surgery up to 31%

• Colectomy up to 24%

• Open cholecystectomy up to 17%


Pathophysiology: impaired liver function

• Low hepatic reserve

• Bleeding (portal hyptertension)

• Shunting of blood

• Hemodynamic changes

• Splanchnic vasodilation

• Anaesthetic agents

• Infection

Hepatic

ischemia

Hepatic

decompensation


Risk factors: Patient

Hepatic

• Child-score

• MELD score

Extrahepatic

• Cardiac

• Renal

• Anemia

• Infection

• Malnutrition


Friedman LS et al. Trans Am Clin Climatol Assoc 2010

Risk stratification: Mortality and Child class


Risk stratification according to the MELD score

30-day mortality 90-day mortality


• Incidence: 1/3 of all patients

• Pigment gallstones

• Changes in bile

• Gallbladder hypomotility

• Risk factors: age / more advanced liver disease

• Additional risk factors: alcoholic, viral C, fatty liver disease

Cholelithiasis in liver cirrhosis:

a relevant problem?

Acalovschi M et al World J Gastroenterol 2014


Treatment options for symptomatic

cholelithiasis in liver cirrhosis


• 1980’s: discouraging results, don’t attempt!

• 1992 NIH Consensus paper: no lap. CHE in

patients with end-stage liver disease and portal

hypertension

• 2012 retrospective cohort study: 2857 lap. CHE &

383 open CHE in cirrhotic patients

Laparoscopic cholecystectomy in

cirrhotic patients

Chmielecki D et al HPB 2012


- postop. Infections 0.6 vs. 3.5%

- postop. Hemorrhage 3.9 vs 6.6%

- RBC transfusion 7.4 vs 19.2%

- Liver failure 1.4 vs 7.0%

- No difference in reop. rate


cirrhotic patients

Chmielecki D et al HPB 2012


• Less blood loss

• Shorter OR time

• Shorter hospital stay

• Fewer complications

• Quicker normal diet


cirrhotic patients

De Goede B et al Br J Surg 2013


ERCP vs lap. Bile duct exploration

in cirrhotic patients

ERCP

• 538 ERCP in 328 patients

• 80 patients Child C

• Adverse events A:B:C

6.1%: 11.4%: 11.3%

• Caveat: high grade

encephalopathy

• Safely do-able

LCBDE

• 132 cirrhotic patients

• Increased blood loss

compared to non-cirrhotic

patients

• Similar OR time

• Similar complication rate

• Similar rate retained stones

• Feasible

Qiu J et al, J Clin Gastroenterol 2015 Adler D et al, Gastrointest Endosc 2015


• 30 articles, systematic review

• >70% laparoscopic, 20% primarily open, 8%

conversions

• Reasons for subtotal CHE: severe cholecystitis,

cirrhosis with portal hypertension, empyema /

perforated gallbladder

• Overall low morbidity / mortality

• Higher risk of bile leaks (18%)

• Acceptable technique in “risk” settings

“Subtotal” Cholecystectomy?

Elshaer M et al, JAMA Surg 2015


Preoperative TIPS: Safer surgery?


Preoperative TIPS: Safer surgery

• Candidates

- Child A and early Child B patients

- Significant ascites ± extensive abdominal varices

• Intervention safe in expert hands

- 2-4 weeks prior to surgery

• Reduced:

- Risk of bleeding

- Ascites


Prolonged antibiotics

Optimization

nutritional status

Correction coagulopathy/ascites

Restriction of sedatives

Avoid nephrotoxic substances


• Expectant management for asymptomatic stones

• Prophylactic or concomitant cholecystectomy?

• Symptomatic stones EARLY treatment

• Surgery versus interventional treatment

• Preferred method: laparoscopic cholecystectomy

Conclusions

NO!


Best treatment for symptomatic

cholecystolithiasis in cirrhotics?

Symptomatische Cholelithiasis beim Patienten mit Leberzirrhose€¦ · Symptomatische...

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