Post-operative death—13%

Risk factors predictive of postoperative mortality include elevated bilirubin (p=0.01) and prolonged prothrombin time (p=0.009).

CTP-A patients had significantly better survival rates than combined group of CTP-B and C patients (p=0.008)

Higher mortality for patients undergoing colectomy compared with controls (HR 3.7, 95% CI 2.6 to 5.2)

Presence of portal hypertension confers even higher risk (HR 14.3, 95% CI 9.7 to 21.0)

Patients with cirrhosis and cirrhosis with portal hypertension had higher in-hospital mortality in comparison to patients without cirrhosis (14% and 29% vs 5%, respectively, p<0.0001)

Approximately four-fold higher rate of in-hospital mortality for emergency and urgent procedures in comparison to elective procedures in liver cirrhosis patients

Higher mortality rate of cirrhotic patients with portal hypertension undergoing surgery (HR: 5.8; 95% CI 4.9 to 7.6).

Independent risk factors for mortality were cirrhosis, portal hypertension, old age, colectomy and comorbidities which included cardiovascular disease, chronic kidney disease, paraplegia and malnutrition.

Chronic liver disease patients were identified using clinical characteristic: ascites, oesophageal varices or total bilirubin >34 umol/L.

6.5-fold increased risk of mortality following colorectal operations in chronic liver disease patients.

MELD score >15 associated with higher rates of mortality and complications

Higher 30-day mortality (24.1%) corresponding to adjusted RR of 2.59 (95% CI 1.86 to 3.61)

MELD score >8 influenced overall survival (p<0.001)

Increased risk of in-hospital mortality (adjusted OR 2.05, p<0.001)

No significant increase in postoperative complications (adjusted OR 0.91, p=0.192)

Cirrhotic group experienced more major complications (OR 5.15; p=0.005), higher rates of return to theatre (OR: 2.04; p=0.03), higher short-term mortality (OR: 2.8; p<0.00001) and shorter survival (HR 2.96, p<0.00001)

Overall mortality—54% with bleeding and multiorgan failure being leading causes of death (70%).

Postoperative complications were observed in 10 (25.6%) of patients with 4 (10.3%) hospital deaths.

Forty-four patients received subtotal gastrectomy and 14 received total gastrectomy accompanied by D1 (26 patients) or D2 (32 patients) lymphadenectomy.

Severe postoperative complications occurred in 58.6% of patients and occurred more frequently in CTP-B (p=0.03) or if underwent D2 lymphadenectomy (p=0.015).

Postoperative mortality occurred more frequently in CTP-B patients (p=0.033).

100% mortality was experienced in CTP-C.

Cirrhosis patients experienced more respiratory events (p=0.013), infections (p=0.005) and severe anastomotic complications (p=0.046)

MELD >9 associated with decreased 5 year survival (p=0.004) and MELD score or nine or lower showed outcomes similar to that of non-cirrhotic patients.

Patients with cirrhosis experience higher rates of postoperative complications including postoperative pneumonia (22 vs 9%, p=0.027), pleural effusion (38 vs 20%, p=0.018), chylothorax (10 vs 1%, p=0.016) and had longer intensive care unit (ICU) stay (mean: 6.10 vs 2.58 days, p=0.002) compared with controls

30-day mortality higher in cirrhosis (OR 3.04, 95% CI 1.71 to 5.39) although this was not observed at 90 days (OR 2.84, 95% CI 0.94 to 8.93) or long term (mean follow up - 24-months) (OR 1.70, 95% CI 0.53 to 5.51).

Anastomotic leak occurred at a higher rate in patients with cirrhosis (OR 2.81, 95% CI 1.05 to 7.49).

CTP-A patients were associated with a significantly lower 30-day mortality compared with CTP-B (OR 0.14, 95% CI 0.04 to 0.54).

No difference in mortality (OR 1.73; p=0.33)

Comparing decompensated (n=117) and compensated (n=957) cirrhosis, increased mortality was observed (7.69 vs 0.94%, p<0.001).

397/423 patients with defined CTP class were CTP-A

The weighted pooled proportion of overall complications was 22.14% and all-cause 90-day mortality was 0%.

Significant increase in postoperative complications (p<0.001) but no difference in all-cause 90-day mortality (p=0.1165) compared with controls.

30-day mortality 9% vs 0.3% in cirrhosis and non-cirrhosis patients, respectively.

Laparoscopic appendectomy appeared safer with a mortality of 0.5% in comparison to open appendectomy with mortality of 3.2%)

Evidence was graded as very low quality for all outcomes.

Mortality quoted to be 6% (n=191).

Patients with cirrhosis are eight times more like to die after surgery compared with patients without cirrhosis

Randomised controlled trial (16—elective repair, 18—conservative management)

After 24 months, 8 (50%) assigned to elective repair, in comparison to 14 (77.8%) assigned to conservative treatment had no significant difference in morbidity.

Elective repair in cirrhosis is associated with similar outcomes in patients without cirrhosis.

Cirrhotic patients were more likely to undergo emergency repair (26% vs 4.8%; p<0.0001), concomitant bowel resection (8.8% vs 0.8%; p<0.0001), return to theatre (7.9% vs 2.5%, p=0.0006) and increased length of stay (4 vs 2 days; p=0.01)

In total, 30 patients (6 CTP-A, 19 CTP-B and 5 CTP-C) with a median MELD score was 12 (IQR 8–16).

Elective umbilical hernia repair is safe with no post-operative intensive care admissions and only 2 of 30 patients died; neither of deaths were attributable to umbilical hernia repair.

Cirrhotics had a higher age distribution (p<0.0001) underwent ICU admission more commonly (15.9% vs 6%; p<0.0001), had a longer length of stay (5.4 vs 3.7 days), and higher morbidity (16.5% vs 13.8%; p=0.008), and mortality (2.5% vs 0.2%; p<0.0001) compared with non-cirrhotics.

Mortality was seven-fold higher in patients undergoing emergency repair (3.8% vs 0.5%; p<0.0001)

Elective hernia repair was successful in 12 out of 17 patients without complications and recurrence. 3/17 wound related problems and 4/17 had recurrence.

Conservative management was only successful in 23%; 10/13 attended hospitals for incarceration of which 6 required emergency hernia repairs. Two patients managed conservatively died from complications of umbilical hernia.

A total of 246 patients (57 underwent elective hernia repair and 189 who opted for ‘wait and see’ approach) were included in the study. Of the latter, 43 (22.7%) patients required emergency hernia repair due to complications such as ascites leakage due to skin rupture in hernia site (n=28), incarceration (n=7), small bowel strangulation (n=5), and extensive skin necrosis or ulceration (n=3).

MELD score >11 (HR 7.8; p=0.011) and emergency hernia repair (HR 5.35; p=0.005) were identified as risk factors for 30-day mortality.

Morbidity (9.1–16.7%) is not significantly higher than patients without cirrhosis

Overall mortality ranging from <1% to 2.7%

Cumulative recurrence rates were not significantly different between cirrhosis and non-cirrhosis group (p=0.87)

Inguinal hernioplasty in patients with cirrhosis is a safe procedure and improves quality of life.

1 year survival was 68 vs 81% (p<0.001) in cirrhosis for CABG and valve surgery

Overall postoperative mortality—17%

CTP-A—no increased mortality when undergoing elective cardiac surgery

CTP-B and C—mortality rate 50%–100% after cardiopulmonary bypass

CTP score reporting 30-day mortality noted to be 9%, 37% and 52% for CTP class A, B and C, respectively.

One-year mortality was reported to be 27.2%, 66.2% and 78.9%, respectively, for CTP class A, B and C, respectively.

Increased mortality was observed for both CABG (OR 5.19, p<0.0001) and valve surgery (OR 7.49, p<0.0001) in comparison to controls.

Higher rates of complications (bleeding, respiratory, renal, infections) in patients with liver dysfunction and CABG.

Nineteen of the studies evaluated mortality with 354 patients in CTP-A, 205 in CTP-B and 33 in CTP-C.

Mean mortality rates were 20.58%, 43.58% and 56.48% for patients in class A, B and C, respectively (p<0.01 for comparisons between each class).

Major postoperative morbidity with rates up to 60%, 100% and 100% for CTP-A, B and C, respectively.

Aortic valve surgery in-hospital mortality was 16 vs 5% in controls (OR 3.6, p<0.0001) and greater rate of complications (55% vs 45% for controls).

Risk factors of mortality included congestive cardiac failure, fluid and electrolyte disturbances, pulmonary circulation disorder and weight loss.

CTP-B and MELD>10—associated with reduced survival

Significant difference in 2-year survival (77.4% vs 97.8%; p=0.03)

Complication rates, decompensation and/or death in up to 80% of cirrhosis patients after emergency THA due to a fracture.

Primary THA or TKA can be safely performed electively in CTP-A and CTP-B patients

Cirrhosis was associated with increased rate of major complications (3.7% vs 2.3%; OR 1.23, 95% CI 1.13 to 1.33; p<0.001) Higher risk of periprosthetic joint infection compared with controls, minor medical complications (13.5% vs 7.4%; OR 1.52, 95% CI 1.45 to 1.59, p<0.001), transfusion (2.8% vs 1.4%; OR 1.66, 95% CI 1.51 to 1.81, p<0.001), encephalopathy (1.0% vs 0.2%; OR 3.00, 95% CI 2.55 to 3.51, p<0.001), DIC (<0.001) within 90 days

Alcohol and viral aetiologies were associated with increased rate of major complications.

Increased postoperative infection rates of 0.5% (p<0.001) and perioperative mortality of 4.1% (p<0.001).

Frequent need for revision surgery at 4% (p<0.001).

Aetiology of need for revision surgery included periprosthetic infection (70%), aseptic loosening (13%), instability (13%), periprosthetic fracture (2%) and linear wear (2%).