The incidence and outcome of postoperative hepatic encephalopathy in patients with cirrhosis

United European Gastroenterol J. 2021 Jul;9(6):672-680. doi: 10.1002/ueg2.12104. Epub 2021 Jun 8.


Background: Cirrhosis is associated with increased perioperative risks related to hepatic decompensation. However, data are lacking regarding the incidence and outcomes of postoperative hepatic encephalopathy (HE).

Objective: To determine the incidence of HE postoperatively, factors associated with its development, and its association with in-hospital mortality.

Methods: Retrospective cohort study of 583 patients with cirrhosis undergoing non-hepatic surgery over a 10-year period. Outcomes included postoperative HE and in-hospital mortality and were, respectively, evaluated using multi-state modeling and Fine-Gray competing risk regression (with postoperative HE as a time-varying covariate).

Results: Overall, the median Model for End-Stage Liver Disease Sodium was 10, 61.7% had a history of ascites, 49.9% esophageal varices, and 34.6% HE. The most common surgeries including abdominal/non-bowel (33.3%), orthopedic (18.0%), and bowel (12.2%). A total of 42 (7.2%) patients developed HE postoperatively during admission. The cumulative risk of HE was 7.2%, which was most associated with a history of HE, ASA class, postoperative AKI, and postoperative infection. In-hospital mortality occurred in 34 (5.8%) individuals. Only ASA class was independently associated (HR 2.46, 95%CI 1.21-5.02), but there was a trend for postoperative HE (HR 1.71, 95%CI 0.73-3.98).

Discussion: HE is an uncommon but not rare postoperative complication that increases the risk of patient harm. This study implies its development is predictable. Consequently, at-risk patients should have consultation with a hepatologist before undergoing elective surgery.

Keywords: HE; MELD-na; hepatic decompensation; hepatic encephalopathy; manuscript info section: liver cirrhosis; mortality; outcome; perioperative risk; postoperative; surgery.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Ascites / epidemiology*
  • Ascites / etiology
  • Esophageal and Gastric Varices / epidemiology*
  • Esophageal and Gastric Varices / etiology
  • Female
  • Hepatic Encephalopathy / etiology
  • Hepatic Encephalopathy / mortality*
  • Humans
  • Incidence
  • Liver Cirrhosis / complications
  • Liver Cirrhosis / mortality*
  • Liver Cirrhosis / physiopathology
  • Male
  • Michigan / epidemiology
  • Middle Aged
  • Postoperative Period
  • Prognosis
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Time Factors