Predictors of Negative Intraoperative Findings at Emergent Laparotomy in Patients with Cirrhosis

Elliot B. Tapper, Vilas Patwardhan, Laura M. Mazer, Byron Vaughn, Gail Piatkowski, Amy R. Evenson, Raza Malik

Research output: Contribution to journalArticlepeer-review

1 Scopus citations

Abstract

Background: Emergent surgery in the setting of decompensated cirrhosis is highly morbid. We sought to determine the clinical factors associated with negative intraoperative findings at emergent laparotomy.

Methods: We performed a retrospective cohort study of consecutive inpatients with a diagnosis of cirrhosis (ICD-9 571) admitted to the Beth Israel Deaconess Medical Center (Boston, MA) who underwent emergent, nonhepatic, abdominal surgery between May 6, 2005 and September 3, 2012.

Results: Eighty-six patients with cirrhosis were included with a mean model for end-stage liver disease score of 21.3 ± 7.95 and a 90-day mortality rate of 39.5 %. Twelve (16.2 %) patients had negative laparotomies. Negative intraoperative findings were independently associated with (1) paracentesis prior to a preoperative diagnosis of perforated viscus (P = 0.006), (2) development of an indication for emergent surgery after 24 h into hospital admission for another reason (P = 0.020), and (3) a preoperative diagnosis of bowel ischemia (P = 0.005), with odds ratios of 10.1 (CI 1.92–66.83), 5.80 (CI 1.32–33.39), and 11.1 (CI 2.08–77.4), respectively. Free air on computed tomography (CT) imaging was found in 64.3 % (9/14) of patients who had a paracentesis within the preceding 48 h compared to 10.1 % (7/72) among patients who did not undergo a paracentesis (P < 0.001). Only 45 % of patients with free air following a paracentesis had positive findings at laparotomy compared to 100 % in those without a preceding paracentesis (P = 0.038). Negative laparotomy was independently predictive of in-hospital mortality (OR 4.7; P = 0.034).

Conclusion: The possibility of a negative laparotomy is suggested by preoperative clinical factors. In particular, free air following a paracentesis does not necessarily indicate that operative intervention is required. Consideration of close observation before laparotomy in these patients is reasonable.

Original languageEnglish (US)
Pages (from-to)1777-1783
Number of pages7
JournalJournal of Gastrointestinal Surgery
Volume18
Issue number10
DOIs
StatePublished - Oct 1 2014

Keywords

  • Acute-on-chronic liver failure
  • Bowel ischemia
  • Liver disease
  • Paracentesis

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