Is it safer to perform surgery before or after liver transplantation? A case-match study for colorectal and small-bowel surgery.

Aims: Surgical risks are elevated in both patients with cirrhosis and in liver transplant recipients. We aimed to quantify surgical outcomes in comparable patients and procedures.

Methods: This case-control study included liver transplant recipients and cirrhosis patients who underwent small bowel or colorectal surgery. Patients were matched based on Charlson Comorbidity Index (CCI) (± 1), age (± 5 years), and surgical modality. In-hospital mortality, length of hospital stay (LOS), and major morbidity (Dindo-Clavien grade ≥ 3) were used as outcome criteria.

Results: 45 cirrhosis and 45 matched transplant patients were included. Mean age and CCI were 65 years and 6.3, respectively. 38% of all patients underwent emergency surgery. Mortality was significantly higher in the cirrhosis group (38% vs. 11%, p = 0.003). Stratification of cirrhosis patients by MELD revealed no significant difference between patients with MELD ≤ 14 and transplant recipients. However, patients with MELD > 14 exhibited substantially increased mortality (64% vs. 9%, p = 0.07, ns).

Conclusions: Colorectal and small bowel surgery in both cirrhosis and transplant patients carries significant risks. Mortality was significantly higher in cirrhosis patients overall, but data suggests the risk of surgery in cirrhosis patients with MELD scores ≤ 14 might be comparable to transplant patients, while those with MELD scores > 14 are at particular risk. Small sample size and heterogeneity of procedures limit these findings; still, the necessity of surgery in patients with higher MELD should be carefully evaluated, as delaying surgery until after liver transplantation may be safer. WHAT DOES THIS PAPER ADD TO LITERATURE? : This paper contains the largest case-matched comparison of surgery in cirrhosis patients with liver transplant patients. We quantify the risk for small bowel and colorectal surgery in comparable patients for the first time, to assist clinical decision of potentially delaying surgery until after liver transplantation.