To the Editor:
We read with great interest the results of comparing postoperative complications of non-liver surgery in patients with chronic liver disease(CLD) and those without chronic liver disease. We wish to congratulate Oliver et al. [Citation1]. for completing such a pivotal study. As indicated, this first retrospective study demonstrated that compared with non-CLD patients, CLD patients undergoing non-hepatic surgery had more comorbidities. However, some issues merit further discussion.
First, the authors did not specifically classify the types of chronic liver diseases, such as chronic viral hepatitis, alcoholic steatohepatitis, and nonalcoholic steatohepatitis [Citation2, Citation3]. Different chronic liver diseases have different clinical manifestations and treatments. The authors relied on the Model for End Stage Liver Disease(MELD) scoring model to stratify chronic liver disease. MELD score can help clinicians to stratify the risk of patients with end-stage liver disease, choose more reasonable and effective intervention methods, and improve the treatment effect [Citation4]. But for well-compensated patients with early liver disease, it had little application value. If based on specific chronic liver disease types, MELD score can more accurately judge the liver function of patients.
Second, the data analysis results of the article showed that patients with chronic liver disease had higher postoperative mortality and postoperative complications than patients without chronic liver disease. However, the authors did not explore the mechanisms underlying chronic liver disease and postoperative mortality and complications. The results of the article showed that the most common postoperative complications in patients with chronic liver disease include hemorrhage, renal failure, and coma, which were performance of postoperative liver failure. Previous studies have shown that liver failure is caused by a variety of factors, the core of which was a large number of hepatocyte necrosis caused by host immune activation [Citation5]. Scholars put forward the triple-whammy theory, including immune damage, hypoxia-ischemia and endotoxemia [Citation6]; in terms of postoperative deep vein thrombosis, the incidence of chronic liver disease cohort was significantly higher than that of non-chronic liver disease cohort(P < 0.05), which may be caused by abnormal coagulation function in patients with chronic liver disease; studies have shown that in liver disease, due to liver cell damage or necrosis, liver synthesis of coagulation factors and anticoagulation factors such as protein C and antithrombin-3 decrease, these decreased plasma levels of factors lead to abnormal coagulation function indicators [Citation7]. On the other hand, the results of the article showed that patients with chronic liver disease had a significantly higher probability of postoperative bleeding(P < 0.05). This may be due to thrombocytopenia in patients with chronic liver disease. In theory, both decreased platelet production and increased consumption can lead to thrombocytopenia. The mechanism of thrombocytopenia in patients with liver disease is complex and is the result of a combination of factors, including spleen block, decreased thrombopoietin production, increased platelet destruction, and myelosuppression [Citation8]. Therefore, research on the mechanism of chronic liver disease and postoperative complications will be helpful for perioperative prevention and treatment.
Finally, the article did not discuss in detail the specific perioperative management measures for patients with chronic liver disease. For different chronic liver disease patients, we should carry out individualized preoperative prevention work and postoperative treatment measures according to different postoperative complications. In addition to the prevention of deep vein thrombosis mentioned in the article, patients with liver disease often had abnormal nutrient metabolism, and appropriate enteral nutrition preparations and parenteral nutrition support should be selected after surgery, which will help improve the nutritional and immune status of patients [Citation9]. At the same time, the datas in the article showed that patients with liver disease had a higher risk of developing pneumonia after surgery. Preoperative smoking cessation, respiratory function assessment, and postoperative nebulization can help improve pneumonia. Pneumonia infection may be related to factors such as decreased immune resistance in patients with chronic hepatitis and traumatic operations [Citation10]. Appropriate antibiotic therapy should be selected according to drug sensitivity results such as sputum culture. On the other hand, when patients with chronic liver disease develop liver failure after surgery, artificial liver is an important means of clinical treatment of liver failure at this stage [Citation11].
For the perioperative management of patients with chronic liver disease, it is necessary to take effective measures to improve the clinical treatment effect.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
- Oliver JB, Merchant AM, Koneru B. The impact of chronic liver disease on postoperative outcomes and resource utilization. J Invest Surg. 2021;34(6):617–626. doi:10.1080/08941939.2019.1676846.
- Shiha G, Mousa N. Non-alcoholic steatohepatitis or metabolic-associated fatty liver: time to change. Hepatobiliary Surg Nutr. 2021;10(1):123–125. doi:10.21037/hbsn-20-438.
- Kim HS, El-Serag HB. Tenofovir vs. entecavir in reducing hepatocellular carcinoma risk in patients with chronic HBV infection?-Still an unsolved question. Hepatobiliary Surg Nutr. 2021;10(1):119–122. doi:10.21037/hbsn-2020-3.
- Ge J, Kim WR, Lai JC, Kwong AJ. Beyond MELD" - Emerging strategies and technologies for improving mortality prediction, organ allocation and outcomes in liver transplantation. J Hepatol. 2022;76(6):1318–1329. doi:10.1016/j.jhep.2022.03.003.
- Moolenaar LR, de Waard NE, Heger M, et al. Liver injury and acute liver failure after bariatric surgery: an overview of potential injury mechanisms. J Clin Gastroenterol. 2022;56(4):311–323. doi:10.1097/mcg.0000000000001662.
- Hirao H, Nakamura K, Kupiec-Weglinski JW. Liver ischaemia-reperfusion injury: a new understanding of the role of innate immunity. Nat Rev Gastroenterol Hepatol. 2022;19(4):239–256. doi:10.1038/s41575-021-00549-8.
- Luther J, Friedman LS. Management of thrombocytopenia and coagulopathy in patients with chronic liver disease undergoing therapeutic endoscopic interventions. Clin Liver Dis. 2022;26(1):1–12. doi:10.1016/j.cld.2021.08.002.
- Afdhal N, McHutchison J, Brown R, et al. Thrombocytopenia associated with chronic liver disease. J Hepatol. 2008;48(6):1000–1007. doi:10.1016/j.jhep.2008.03.009.
- Chen L, Chen X, Li G. Nutritional management after hepatopancreatobiliary surgery. Hepatobiliary Surg Nutr. 2021;10(2):273–275. doi:10.21037/hbsn-2021-10.
- Xu L, Ying S, Hu J, et al. Pneumonia in patients with cirrhosis: risk factors associated with mortality and predictive value of prognostic models. Respir Res. 2018;19(1):242. doi:10.1186/s12931-018-0934-5.
- García Martínez JJ, Bendjelid K. Artificial liver support systems: what is new over the last decade? Ann Intensive Care. 2018;8(1):109. doi:10.1186/s13613-018-0453-z.