Abstract

Background: Patients with cirrhosis have increased surgical risk compared to the general population. Preoperative optimization by nonsurgical clinicians improves postoperative outcomes after colectomy in studies of patients with major comorbidities, however, data specific to patients with cirrhosis and addressing more diverse surgeries are limited. This study aimed to assess the impact of preoperative primary care provider (PCP) and/or gastroenterology/hepatology (GI/Hep) visits on postoperative mortality in patients with cirrhosis undergoing surgery.

Methods: This was a retrospective cohort study of patients with cirrhosis in the Veterans Health Administration who underwent surgery between 1/2008 and 12/2022. We compared patients with preoperative PCP and/or GI/Hep appointments in the 60 days prior to the surgery with a propensity score (PS) matched group without preoperative appointments. Groups were matched for baseline age, sex, race/ethnicity, liver disease etiology, surgery type (e.g. abdominal wall, major abdominal, orthopedic, etc.), Child-Turcotte-Pugh Score, MELD-Na, and medical comorbidities. We then used Cox regression (CR) and Fine and Gray competing risk (FGCR, transplant as competing event) regression to evaluate the association between preoperative outpatient visit type and postoperative mortality at 6 months.

Results: We compared 1992 patients with cirrhosis who had preoperative PCP/GI/Hep appointments with 1839 PS matched patients with no preoperative appointments, with covariate balance being achieved for all key covariates listed above (p>0.05). Using CR, the hazard of postoperative mortality at 6 months was significantly reduced among patients who had preoperative appointments with GI/Hep + PCP (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.36-0.88; p=0.01), GI/Hep only (HR, 0.67; 95% CI, 0.46-0.96; p=0.02), or PCP only (HR, 0.72; 95% CI, 0.54-0.96; p=0.02) compared to those with no preoperative appointments. Similar results were obtained using FGCR analysis (Figure 1).

Conclusion: Preoperative visits were associated with reduced risk of postoperative mortality in patients with cirrhosis, and greatest risk reduction was observed in patients with both PCP + GI/Hep visits. This suggests that these clinics may contribute to different elements of preoperative optimization that are synergistic. Future studies are needed to identify mechanisms underlying these differences to standardize preoperative optimization strategies.