Cirrhosis patients are at increased risk for postoperative complications. It remains unclear whether preoperative nonsurgical clinician visits improve postoperative outcomes. We assessed the impact of preoperative primary care physician (PCP) and/or gastroenterologist/hepatologist (GI/Hep) visits on postoperative mortality in cirrhosis patients undergoing surgery and explored differences in medication changes and paracentesis rates as potential mediators. This was a retrospective cohort study of cirrhosis patients in the Veterans Health Administration who underwent surgery between 2008 and 2016. We compared 1982 patients with preoperative PCP and/or GI/Hep visits with 1846 propensity-matched patients without preoperative visits. We used Cox regression and Fine and Gray competing risk regression to evaluate the association between preoperative visit type and postoperative mortality at 6 months. Patients with preoperative GI/Hep and PCP visits had a 45% lower hazard of postoperative mortality compared with those without preoperative visits (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.35–0.87). A smaller effect size was noted with GI/Hep preoperative visit alone (HR, 0.69; 95% CI, 0.48–0.99) or PCP visit alone (HR, 0.70; 95% CI, 0.53–0.93). Patients with preoperative PCP/GI/Hep visits were more likely to have diuretics, spontaneous bacterial peritonitis prophylaxis, and hepatic encephalopathy medications newly initiated and/or dose adjusted and more likely to receive preoperative paracentesis as compared with those without preoperative visits. Preoperative PCP/GI/Hep visits are associated with a reduced risk of postoperative mortality with the greatest risk reduction observed in those with both PCP and GI/Hep visits. This synergistic effect highlights the importance of a multidisciplinary approach in the preoperative care of cirrhosis patients.

中文翻译：

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术前肝病学和初级保健就诊可改善接受手术的肝硬化患者的术后结果


肝硬化患者术后并发症的风险增加。目前尚不清楚术前非手术临床医生就诊是否可以改善术后结果。我们评估了术前初级保健医生 (PCP) 和/或胃肠病专家/肝病专家 (GI/Hep) 就诊对接受手术的肝硬化患者术后死亡率的影响，并探讨了药物变化和腹腔穿刺率作为潜在中介因素的差异。这是一项针对退伍军人健康管理局 2008 年至 2016 年间接受手术的肝硬化患者的回顾性队列研究。我们将 1982 名术前接受过 PCP 和/或 GI/Hep 就诊的患者与 1846 名未接受术前就诊的倾向匹配患者进行了比较。我们使用 Cox 回归和 Fine and Gray 竞争风险回归来评估术前就诊类型与术后 6 个月死亡率之间的关联。与术前未就诊的患者相比，术前接受过 GI/Hep 和 PCP 就诊的患者术后死亡风险降低了 45%（风险比 [HR]，0.55；95% 置信区间 [CI]，0.35–0.87）。单独进行 GI/Hep 术前访视（HR，0.69；95% CI，0.48-0.99）或单独进行 PCP 访视（HR，0.70；95% CI，0.53-0.93）时，效果较小。与术前未就诊的患者相比，术前就诊的 PCP/GI/Hep 患者更有可能服用利尿剂、自发性细菌性腹膜炎预防、新开始使用和/或调整剂量的肝性脑病药物，并且更有可能接受术前腹腔穿刺术。术前 PCP/GI/Hep 就诊与术后死亡率风险降低相关，在同时进行 PCP 和 GI/Hep 就诊的患者中观察到风险降低幅度最大。 这种协同效应凸显了多学科方法在肝硬化患者术前护理中的重要性。