Open Access

The critically ill patient after hepatobiliary surgery

  • Stephen P Povoski1, 5,
  • Robert J Downey1, 2, 4,
  • Paul S Dudrick1, 6,
  • Yuman Fong1, 3,
  • William R Jarnigan1, 3,
  • Jeffrey S Groeger2 and
  • Leslie H Blumgart1, 3
Critical Care19993:139

DOI: 10.1186/cc367

Received: 14 April 1999

Accepted: 23 September 1999

Published: 13 October 1999

Abstract

Background

We analyzed the causes and results of utilization of critical careservices in the special care unit in patients after surgical proceduresperformed by the hepatobiliary surgical service during a 23-month period.

Results

Thirty-two of 537 patients (6.0%) required postoperative admissionto the special care unit. Twenty-one patients were admitted directly fromoperating room or from recovery room because of inability to wean fromventilator (n = 10), hypovolemic shock (n = 4), myocardialischemia or infarction (n = 2), sepsis (n = 2), uppergastrointestinal bleeding (n = 2), and acute renal failure (n=1). Eleven postoperative patients were admitted from floor care forrespiratory failure (n = 4), cardiac dysrhythmia or infarction(n = 4), sepsis (n = 2), and upper gastrointestinal bleeding(n = 1). Thirty-eight per cent of patients (n = 12) admitted tothe special care unit after surgery died. By multivariate analysis, totalpostoperative stay in the special care unit that was greater than median totalduration of stay of 4.5 days was the only independent predictor of mortality(P = 0.041).

Conclusions

Respiratory failure was the predominant component of allcomplications after hepatobiliary surgery. No clinically useful predictors ofeventual outcome could be identified.

Keywords

critical care hepatobiliary surgery morbidity mortality pancreatic surgery

Introduction

Postoperative morbidity and mortality after hepatobiliary operations, especially in cancer patients, has traditionally been perceived as being high. Prior reports, however, have failed to identify a predominant class of complications, such that interventions could be undertaken that might be able to reduce the incidence of these complications. Prior reports have focused on subgroups of operations within the family of all hepatobiliary procedures, such as hepatic resection [1,2,3,4,5], proximal bile duct resection [6,7], pancreatic resection [8,9], and biliary-enteric bypass [10]. There are no prior reports on the utilization and outcomes of critical care services required in the management of all patients who experience complications after hepatobiliary surgery at a single institution. This paper reviews the complications leading to the utilization of critical care services after all hepatobiliary procedures performed over a 23-month period by a team of specialized surgeons, nurses, anesthesiologists, and internists who comprise the Hepatobiliary Disease Management Team of the Memorial Sloan-Kettering Cancer Center.

Materials and methods

Between February 2, 1994 and December 28, 1995, all patients admitted to the Hepatobiliary Surgical Service at Memorial Sloan-Kettering Cancer Center were identified from the institutional database and the hepatobiliary database. For these patients, the following variables were collected from the Institutional Database: admitting diagnosis, operative procedure(s) performed, whether admission to the special care unit (SCU) was required, and outcome. For all patients undergoing hepatobiliary surgical procedures and admitted to the SCU during their hospital course, multiple preoperative, intraoperative, and postoperative variables were collected by retrospective chart review.

Patients undergoing hepatic, biliary, or pancreatic resection by the Hepatobiliary Surgical Service are routinely monitored during emergence from anesthesia in the postanesthesia care unit (PACU) for the first postoperative night, and, if stable the following morning, are transferred to floor care for further postoperative care. In this study, time in the PACU was not counted as utilization of the critical care services. Total duration of SCU stay was defined as the total number of days (consecutive or nonconsecutive) spent in the SCU during a hospital admission. Postoperative death was defined as death within 30 days postoperatively or before discharge from the hospital.

Statistical analysis

Results are expressed as the mean ± standard deviation, median(range), or as the number and percentage of the total number of patients forcategoric variables. One-way analysis of variance was used for comparison ofall continuous variables. Pearson's χ2 analysis orFisher's exact test, when appropriate, were used for univariatecomparisons for all categoric variables analyzed. When multiple categoricvariables were determined to be statistically significant by univariateanalysis, they were then entered into a logistic regression model formultivariate analysis to determine independent predictors of outcome. Thesoftware program SPSS for Windows (version 8.0; SPSS Incorporated, Chicago,Illinois, USA) was utilized for all statistical analyses. P ≤0.05 was considered statistically significant.

Results

Study population

Between February 2, 1994 and December 28, 1995, 1048 patients wereadmitted to the Hepatobiliary Surgical Service (admitting physicians LHB andYF) at Memorial Sloan-Kettering Cancer Center. Of these, 32 out of 537 patients(6.0%) undergoing surgical treatment were admitted to the SCU, whereas four outof 511 patients (0.8%) who were receiving medical treatment only were admittedto the SCU. No single surgical procedure was associated with a higher frequencyof SCU utilization than other procedures (data not shown).

Preoperative variables

The mean age of the 32 patients (22 males, 10 females) admitted tothe SCU for postoperative care was 63.2 ± 12.2 years (median 66 years, range30-84years). The admitting diagnoses are summarized in Table 1. Eighteen patients had a history of cardiac disease, 10 werejaundiced in the preoperative period, 10 underwent preoperative biliaryinstrumentation, nine underwent preoperative biliary drainage, five had ahistory of cirrhosis and/or portal hypertension, four had a history of chronicobstructive pulmonary disease, and three had a history of viral hepatitis.

Mean preoperative laboratory values of those 32 patients admitted tothe SCU for postoperative care were as follows: albumin 3.5 ± 0.7g/dl(normal range 4.0-5.2 g/dl), prothrombin time 12.6 ± 1.1s (normal range<13.1s), total bilirubin 3.5 ± 6.4 mg/dl (normal range 0–1.0 mg/dl),creatinine 1.1 ± 0.3 mg/dl (normal range 0.6–1.3 mg/dl), and white blood cellcount 9228 ± 6452 cells/mm3 (normal range5000–10000 cell/mm3).

Operative variables

A summary of the operations performed on those 32 patients admittedpostoperatively to the SCU is shown in Table 2. Twenty-six patients were operated upon electively and six patients emergently. Sixteen patients underwent resection of malignant disease with curative intent,six underwent treatment for benign disease, six had palliative operations, andfour received treatment for complications of a surgical procedure performedduring a previous hospital admission. Mean operating time was 232 ± 116 min(median 210 min, range 37–493 min), mean intraoperative blood loss was 2064 ±2271 cm3 (median 1100 cm3, range 0–9000cm3),mean transfusion of red blood cells was 3.4 ± 4.7 units (median 2 units,range 0–18 units), and mean intraoperative fluid administration was 5369 ±3922 cm3 (median 4300 cm3, range 400–20600 cm3). During their postoperative course, seven patients required second procedures(two drainage intraabdominal abscesses, two tracheostomies, one repair ofbleeding peptic ulcer, one repair of postoperative intraabdominal bleed, onerepeat pancreatic debridement), two patients required a third procedure (onerepeat pancreatic debridement, one removal of intra-abdominal packing andclosure of abdomen), and one patient required a fourth procedure(thoracotomy/decortication for empyema).

Postoperative variables and complications

The mean total stay in the SCU was 11.2 ± 17.6days (median4.5 days, range 1–78 days). The mean postoperative duration of hospital stay was28.2 ± 36.3 days (median 15.5 days, range 4–177 days). Twenty-one patientswere admitted to the SCU directly from the operating room, or the followingmorning from the PACU. The reason for admission to the SCU in these 21 patientswas inability to wean from the ventilator (n = 10), hypovolemic shock(n = 4), myocardial ischemia/infarction (n = 2), ongoing septicshock (n = 2), ongoing upper gastrointestinal bleeding (n = 2),and acute renal failure (n = 1). Eleven patients were admitted to theSCU from floor care at a later time during their postoperative course. Thereasons for admission to the SCU in these 11 patients were respiratory failure(n = 4), cardiac dysrhythmia/infarction (n = 4), septic shock(n = 2), and upper gastrointestinal bleeding (n = 1). Tenpatients required readmission to the SCU after being transferred to floor care(five because of upper gastrointestinal bleeding, five because of respiratoryfailures), four patients required a third SCU admission (all because ofrespiratory failures), and two patients requiring a fourth SCU admission (bothbecause of intra-abdominal abscesses/sepsis). A comprehensive list of allpostoperative complications seen is shown in Table 3.

High and low postoperative laboratory values

Mean high and low postoperative laboratory values of the 32 patientsadmitted to the SCU in the postoperative period and the mean days on which theyoccurred were as follows: lowest albumin value 2.1 ± 0.4 g/dl on day 13(± 25 days), highest prothrombin time 16.7 ± 3.0s on day 13 (± 28days), highest total bilirubin value 6.9 ± 6.3 mg/dl on day 15 (± 34days), highest creatinine value of 1.9 ± 1.0 mg/dl on day 13 (± 17days), and highest white blood cell count of 20547 ±8467 cells/mm3 on day 9 (± 13 days).

Postoperative mortality

The overall postoperative mortality of all patients operated on bythe Hepatobiliary Surgical Service was 3.2% (17 out of 537 patients). Twelve ofthe 32 patients (37.5%) admitted to the SCU during their postoperative coursedied, compared with five out of 505 (1.0%) patients never admitted to the SCUduring their postoperative course (P < 0.001). Neither thepreoperative diagnosis (Table 1) nor the operationperformed (Table 2) appear to be associated with an increased risk of SCUdeath. At the time of death, eight out of the 12 patients (67%) had respiratoryfailure, five patients (42%) had hepatic failure, and three patients (25%) hadacute renal failure. Additionally, five out of the 12 patients (42%) wereseptic, two patients (17%) had persistent coagulopathy and ongoing uppergastrointestinal bleeding, and two patients (17%) died of acute cardiopulmonaryarrest of undetermined etiology. Overall, three out of the 12 patients (25%)had multiple organ system failure.

Mean total postoperative duration of stay in the SCU wassignificantly longer (P = 0.035) for nonsurvivors (20.0 ± 23.8days) than for survivors (6.2 ± 10.2 days). Univariate analysisdemonstrated that mortality was significantly increased for patients who hadmedian total postoperative duration of stay in the SCU that was greater thanthe overall median duration of stay of 4.5 days (P = 0.009) and forpatients who had more than two SCU admissions during their hospitalization(P = 0.014). However, multivariate analysis of these variablessuggested that only a median total postoperative duration of stay in the SCU ofgreater than the median total duration of stay of 4.5 days was an independentpredictor of postoperative mortality (P = 0.041). Postoperativemortality did not depend on the total postoperative duration of stay, or on thenumber of times a patient was taken to the operating room.

Preoperative and intraoperative variables were analyzed (Table4 as potential predictors of postoperative mortalityamong patients admitted to the SCU. A history of viral hepatitis(P = 0.044) was determined to be significantly associated withpostoperative mortality among patients admitted to the SCU by univariateanalysis. By univariate analysis, the association of history ofcirrhosis/portal hypertension with postoperative mortality was determined toapproach statistical significance (P = 0.053) among patients admitted tothe SCU. Multivariate analysis of those two variables revealed that neither ahistory of viral hepatitis and a history of cirrhosis/portal hypertension wasan independent predictor of postoperative mortality among patients admitted tothe SCU.

Preoperative and postoperative laboratory values (mean±standard deviation) in survivors (n = 20) and non-survivors (n= 12) were analyzed as potential predictors of postoperative mortality amongpatients admitted to the SCU (Table 5). In nonsurvivorspreoperative prothrombin time was significantly higher, preoperative albuminwas nearly significantly lower (P = 0.056), postoperative prothrombintime was significantly higher (P = 0.021), postoperative albumin levelswere nearly significantly lower (P = 0.055), and postoperative whiteblood cell count was significantly higher (P = 0.020).

Postoperative variables were analyzed as potential predictors ofpostoperative mortality among patients admitted to the SCU (Table6). By univariate analysis, a patient with postoperativepneumonia (P = 0.002), hepatic failure (P = 0.004), orrespiratory failure (P = 0.009) was statistically more likely to diethan patients with other complications. However, multivariate analysis of thesethree postoperative complications failed to disclose any independent predictorof postoperative mortality.
Table 1

Diagnoses of those 32 patients who required critical care services during postoperative care and number of deaths by diagnosis

Diagnosis

Diagnosis [% (n)]

Deaths (n)

Hepatocellular carcinoma

25 (8)

3

Pancreatic/peripancreatic malignancy

13 (4)

1

Colorectal hepatic metastases

9 (3)

1

Noncolorectal hepatic metastases

9 (3)

1

Cholangiocarcinoma

8 (3)

2

Benign biliary disease

6 (2)

0

Acute necrotizing pancreatitis

6 (2)

1

Polycystic disease of the liver

6 (2)

1

Bleeding peptic ulcer disease

6 (2)

1

Perforated peptic ulcer disease

3 (1)

1

Abdominal wall dehisence

3 (1)

0

Empyema

3 (1)

0

Table 2

Type of operations performed on 32 patients admitted requiringcritical care service during postoperative care and the number of postoperativedeaths by type of operation

Type of operation

Type of operation [% (n)]

Deaths (n)

Hepatic resection

47 (15)

5

Biliary enteric bypass

13 (4)

2

Pancreatic resection

9 (3)

1

Peptic ulcer operation

9 (3)

2

Extrahepatic bile duct resection

6 (2)

0

Acute pancreatitis operation

6 (2)

1

Combined hepatic and pancreatic resection

3 (1)

1

Abdominal wall dehisence

3 (1)

0

Thoracotomy and decortication

3 (1)

0

Table 3

Postoperative complications in those 32 patients who requiredcritical care services during postoperative care

Postoperative complications

Patients [n (%)]

Respiratory failure

16 (50)

Acute renal failure

9 (28)

Bacteremia

9 (28)

Pneumonia

8 (25)

Upper gastrointestinal bleeding

8 (25)

Hepatic failure

5 (16)

Cardiac dysarrhythmias

5 (16)

Intraabdominal abscess

5 (16)

Urinary tract infection

4 (13)

Wound infection

3 (9)

Myocardial ischemia/infarction

3 (9)

Central line infection

2 (6)

Intra-abdominal bleeding

1 (3)

Empyema

1 (3)

Table 4

Potential preoperative and intraoperative variables associated withpostoperative mortality by univariate and multivariate analyses in those 32patients who required critical care services during postoperative care

Variables

Univariate (P)

Multivariate (P)

Preoperative variables

  

   Age

0.999

   Sex

0.119

   History of cirrhosis/portal hypertesion

0.053

0.194

   History of viral hepatitis

0.044

0.802

   History of jaundice

0.703

   History of cardiac disease

0.718

   Diabetes mellitus

0.999

   Chronic obstructive pulmonary disease

0.999

   Preoperative biliary instrumentation

0.703

   Preoperative biliary drainage

0.999

   Diagnosis

  

       Hepatocellular carcinoma

0.999

       Pancreatic/peripancreatic malignancy

0.999

       Colorectal hepatic metastases

0.999

       Noncolorectal hepatic metastases

0.999

       Cholangiocarcinoma

0.540

       Benign biliary disease

0.516

       Polycystic disease of the liver

0.999

       Other disease

0.999

Intraoperative variables

  

   Operative time

0.999

   Blood loss

0.999

   Intravenous fluids

0.999

   Transfusion of red blood cells

0.724

   Elective versus emergency case

0.647

   Resected for cure versus palliation

0.999

   Hepatic resection

0.726

   Biliary enteric bypass

0.620

   Pancreatic resection

0.999

   Peptic ulcer operation

0.540

   Extrahepatic bile duct resection

0.516

   Combined hepatic/pancreatic resection

0.375

   Other operations

0.999

Table 5

Preoperative and postoperative laboratory values in surviving andnonsurviving patients requiring critical care services during postoperativecare

Laboratory values

All patients (n = 32)

Survivors (n = 20)

Nonsurvivors (n = 12)

P value

Preoperative

    

   Albumin (g/dl)

  3.5 ± 0.7

  3.7 ± 0.7

  3.2 ± 0.7

0.056

   Prothrombin time (s)

12.6 ± 1.1

12.2 ± 0.9

13.1 ± 1.2

0.025

   Total bilirubin (mg/dl)

  3.5 ± 6.4

  4.5 ± 7.6

  1.8 ± 3.4

0.263

   Creatinine (mg/dl)

  1.1 ± 0.3

  1.1 ± 0.3

  1.0 ± 0.4

0.263

   White blood cells (cells/mm³)

9228 ± 6452

8005 ± 3384

11267 ± 9501

0.170

Postoperative

    

   Albumin low (g/dl)

2.1 ± 0.4

2.2 ± 0.5

1.9 ± 0.4

0.055

   Prothrombin time high (s)

16.7 ± 3.0

15.8 ± 2.6

18.3 ± 3.1

0.021

   Total bilirubin high (mg/dl)

6.9 ± 6.3

6.9 ± 7.5

6.9 ± 3.6

0.998

   Creatinine high (mg/dl)

1.9 ± 1.0

1.6 ± 0.8

2.2 ± 1.3

0.102

   White blood cells high (cells/mm³)

20547 ± 8467

17905 ± 6055

24950 ± 10240

0.020

Values are expressed as means ± standard deviation.

Table 6

Potential postoperative complications associated with postoperativemortality by univariate and multivariate analyses in those 32 patients whorequired critical care services during postoperative care

Postoperative complications

Univariate (P)

Multivariate (P)

Respiratory failure

0.009

0.093

Bacteremia

0.696

Pneumonia

0.002

0.239

Upper gastrointestinal bleeding

0.116

Acute renal failure

0.696

Hepatic failure

0.004

0.863

Cardiac dysarrhythmias

0.130

Intra–abdominal abscess

0.999

Wound infection

0.999

Urinary tract infection

0.136

Myocardial ischemia/infarction

0.274

Central line infection

0.999

Intra-abdominal bleeding

0.999

Empyema

0.375

Values are expressed as means ± standard deviation.

Discussion

There is relatively incomplete information available within the literature as to the causes and outcomes of utilization of critical care services for patients undergoing hepatobiliary surgery. In the present paper, we have reviewed the Memorial Sloan-Kettering Cancer Center experience during the period of February 2, 1994 to December 28, 1995. Firstly, this study was initiated to help to determine the causes of major morbidity and mortality after hepatobiliary surgery, such that we might alter our patient care in order to avoid similar complications in the future. Secondly, this study was initiated to help to evaluate possible predictors of survival once a major complication had arisen, such that guidance could be given to clinicians caring for such patients in determining the likelihood of ultimate survival of such events.

Over a 23-month period, 6.0% of patients operated upon by the Hepatobiliary Surgical Service at Memorial Sloan-Kettering Cancer Center required critical care services. Information on similar critical care services utilized by comparable hepatobiliary services at other institutions is not available in the surgical literature; however, this appears to be an appropriate level of care, because the mortality of patients treated postoperatively with floor care alone was only 1% (five out of 505 patients). The fact that the mortality of hepatobiliary patients, once admitted to the SCU, was 37.5% (12 out of 32 patients) may be taken to suggest that patients might have been kept for inappropriately long periods on floor care before being admitted to a critical care setting, or that the problems that arose were poorly treated in the critical care setting, or that the problems that arose were beyond the ability of critical care medicine to salvage. The latter explanation seems to be the most probable.

The causes for admission to a critical care setting were varied. Three findings from the present results appear to be worth further discussing, however. First, more than 50% of the patients requiring a SCU admission suffered respiratory failure. It is possible that instituting an improved preoperative evaluation of pulmonary function, as well as instituting a pulmonary rehabilitation program, might help to reduce this excessive rate of respiratory failure. Second, the intraoperative blood loss among patients requiring a SCU admission was approximately 2000cm3 and the intraoperative blood transfusion requirement among patients requiring a SCU admission was 3.4 units of packed red blood cells. Both of these values are well above the median values of 645 cm3 of intraoperative blood loss and less than one unit of packed red blood cells for intraoperative blood transfusion recorded for 496 patients undergoing hepatic resection at our own institution [11]. Third, 10 out of 32 patients requiring a SCU admission underwent preoperative biliary drainage procedures, which is above the rate for all patients undergoing hepatobiliary surgery. Our own institutional data have shown that previously drained patients with tumors causing proximal or distal obstruction of the biliary tree who undergo surgical resection or surgical bypass suffer increased intraoperative blood loss [12], as well as increased postoperative infectious complications [13,14,15,16]. Those organisms responsible for the postoperative infectious complications were the same as those organisms isolated from intraoperative bile cultures [14,16,17,18]. This suggests that the potential benefit of preoperative drainage of the biliary tree before surgical resection is questionable and needs to be evaluated further.

On univariate analysis, we found an association of a history of viral hepatitis with postoperative mortality (P = 0.044) and a near association of a history of cirrhosis (with or without portal hypertension) with postoperative mortality (P = 0.053). These findings confirm the prior reports of Bozzetti et al [1] and Lehnert and Herfarth [19]. Likewise, we found that preoperative prothrombin time was significantly (P = 0.025) higher in the nonsurviving patients versus the surviving patients who required postoperative critical care utilization, and preoperative albumin was nearly significantly (P = 0.056) lower in the nonsurviving patients versus the surviving patients who required postoperative critical care utilization. These findings confirm the prior reports of Nagino et al [6], Su et al [7], and Lehnert and Herfarth [19]. Although these associations were not independent predictors of postoperative mortality on multivariate analysis, these associations suggest the importance of hepatic function and hepatic reserve in pre-operative patient selection for hepatobiliary surgery, as has been previously established by the Child–Turcotte–Pugh grading system for severity of liver disease [20,21]. None of the thirty-two patients requiring postoperative SCU admission had ascites or were encephalopathic preoperatively. Therefore, preoperative prothrombin time and preoperative albumin, as well as a history of viral hepatitis and/or a history of cirrhosis with or without portal hypertension, may be taken to indicate a need for heightened alertness to the possibility of the need for critical care services after significant hepatobiliary surgery.

Once admitted to the critical care unit, postoperative mortality increased with increasing duration of stay, with patients whose SCU stays exceeded 4.5 days doing significantly worse. Beyond this association of survival and duration of SCU stay, we were unable to establish any distinct individual markers to help determine the appropriateness of continuing aggressive care of critically ill patients. However, if markers could be identified, then the determination of the time at which aggressive critical care becomes futile could be established. This would ultimately better assist the critical care staff in advising the patient or proxy as to when survival is unlikely, and all subsequent decisions about pursuing further aggressive interventions could be made with this in mind.

Declarations

Acknowledgements

The authors gratefully acknowledge Ruth L Sun (HepatobiliaryDatabase Manager) and Frank M Lewis (Systems Development Data Administrator)for their assistance in identifying patients and collecting data from thehepatobiliary and institutional databases, respectively.

Authors’ Affiliations

(1)
Department of Surgery, Memorial Sloan-KetteringCancer Center
(2)
Division of Thoracic Surgery, Memorial Sloan-KetteringCancer Center
(3)
Division of Hepatobiliary Surgery, Memorial Sloan-KetteringCancer Center
(4)
Division of Critical Care Medicine, Memorial Sloan-KetteringCancer Center
(5)
Department of Surgery, Section of Surgical Oncology, West VirginiaUniversity
(6)
Department of Surgery, Section of Surgical Oncology, University ofTennessee

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