Thank you for this well thought out and referenced response to our article [Citation1, Citation2]. We are excited that our work has sparked discussion and further exploration and welcome the opportunity to address the issues brought up by the authors.
We did not specify or stratify our results based on cause of chronic liver disease (CLD). We recognize this as a limitation of our paper as this is not data available in the National Surgical Quality Improvement Program (NSQIP) database. In fact, we utilized surrogates to classify patients as CLD as this is not a field explicitly captured by the database. This is a limitation experienced by other authors who also utilized NSQIP [Citation3, Citation4]. However, compared to a recent article that utilized the Veterans Affairs Quality Improvement Program (VASQIP) database, the precursor to NSQIP, that identified cirrhotic patients with outside data, we found similar outcomes [Citation5]. The letter to the editor [Citation2] also critiqued the utilization of MELD score; however, this has been found to be correlated with post-operative outcomes, outperforming many other measures [Citation5, Citation6]. While we acknowledge that the manifestations and treatments of CLD do vary based on the etiology, whether this is applicable to how the cause of CLD impacts non-hepatic surgery is unclear. Most articles that look at the impact of CLD in surgical outcomes do not make any distinction based on the etiology [Citation6], but this could be an area of further investigation.
We welcome the expanded exploration and theories into the underlying causes of the poorer surgical outcomes [Citation2]. As the authors may be aware, there are limitations to the word and page counts which limited our ability to explore all topics of interest. While the discussion is a place to try to explain findings, caution must always be expressed in trying to imply causation to correlations seen in an observational study. We agree with the proposed mechanisms and believe this is a welcome addition to the literature and adjunct to our paper, and welcome further experimental data to prove these correlations as well.
The final critique is regarding the lack of specific perioperative management measures for patients with chronic liver disease. The authors discuss several measures they perform at their center, as well as generalized guidelines such as optimizing nutrition, selecting appropriate antibiotics, and smoking cessation that are applicable and important [Citation2]. This highlights the point we did focus on in our article that these patients should be cared for in centers with the expertise for caring for CLD when possible, including transplant centers or those with dedicated departments and wards of liver surgery. Things like artificial liver support [Citation7] and transjugular intrahepatic portal systemic shunt [Citation8] are two examples of advanced care that could improve post operative outcomes that would only be available at such centers.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
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- Lahat E, Lim C, Bhangui P, et al. Transjugular intrahepatic portosystemic shunt as a bridge to non-hepatic surgery in cirrhotic patients with severe portal hypertension: a systematic review. HPB (Oxford). 2018;20(2):101–109. doi:10.1016/j.hpb.2017.09.006.