American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

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Liver, Part II

Liver Part IIVol. 46, No. 4, 2020 

  • General Aspects of Liver Injury
  • Cystic Diseases of the Liver
  • Liver Abscesses
  • Benign Liver Tumors
  • Liver Metastases Management
  • Non-CRLM, Non-Neuroendocrine Metastases Management

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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Haffner MR, Le HV, Saiz AM Jr, et al. Postoperative in-hospital morbidity and mortality of patients with COVID-19 infection compared with patients without COVID-19 infection. JAMA Netw Open. 2021;4(4):e215697. Published 2021 Apr 1. doi:10.1001/jamanetworkopen.2021.5697

Commentary by: Reynold Henry, MD, MPH; and Kenji Inaba, MD, FRCSC, FACS

As society settles into a third year of the COVID-19 pandemic, the broad effects of this disease throughout medicine are slowly being elucidated. For surgeons, it remains unclear whether infection results in worse outcomes in the perioperative setting, although several small studies and metanalyses have demonstrated various concerning findings.1–3 Better powered studies could help create a risk modeling framework for surgeons, particularly in the ambulatory setting where delays in procedures have untoward consequences.4

Haffner et al. utilized the Vizient Clinical Data Base (CDB), a voluntary private database tool used primarily by institutions to compare quality metrics using other hospitals as a benchmark, to compare outcomes between COVID-19 negative and positive adult surgical patients.5 Outcomes of interest included mortality and hospital length of stay, as well as complications, hospital-acquired conditions and patient safety indicators as defined by the database. Matching was performed 1:1 based on age and case mix index.

Overall, matched COVID+ patients undergoing surgery were noted to have greater mortality (85.2 percent vs. 92.9 percent). There was no significant difference noted in complication rates and lengths of stay. However, hospital-acquired conditions were more common in COVID+ patients (2.0 percent vs. 0.8 percent), as were patient safety indicators (3.3 percent vs. 2.4 percent). The authors also performed subgroup analyses based on hospital type (public, private and non-profit) and found greater mortality in public and non-profit facilities but not in private ones. When compared by hospital type, there was also notably no difference in outcomes for COVID+ surgery patients.

The results of this large retrospective analysis should be taken with caution. While it is the largest study of its kind, it also has several limitations. The method of matching is simplistic, controlling for only two variables. Age and case mix index does not resolve the urgency of the case (emergent, urgent, elective), patient co-morbid conditions, physiologic status, or the severity of the COVID infection, all of which may act as confounders. Additionally, subgroup analysis was not performed regarding the procedure performed or the anesthesia technique used. An aesthetic plastic surgery procedure performed under monitored anesthesia will likely have a different impact from COVID than a damage control laparotomy performed under general anesthesia.

Additionally, the cause of death was not elucidated and is critical for understanding the impact of COVID on surgery. It is unclear whether the cause of death was the COVID infection, the condition requiring surgery, or an intersection of the two. This makes it very difficult to draw conclusions regarding whether semi-urgent elective cases should be performed or deferred until the resolution of the infection.

As surgeons of every specialty grapple with this unprecedented pandemic, the path forward cannot and should not become "business as usual." Prior smaller studies have shown similar findings in mortality and have demonstrated various other concerning results, such as increased incidence of thrombotic and pulmonary complications.6,7 The authors of this study should be congratulated for using an actively updated database such as the CDB, and their findings should spur further investigation into disciplinary subgroups. While definitive recommendations are not possible at this time, we must work towards better evidence-based guidelines so that surgeons can have informed conversations with their patients regarding these tangible risks.


  1. Carrier FM, Amzallag É, Lecluyse V, et al. Postoperative outcomes in surgical COVID-19 patients: a multicenter cohort study. BMC Anesthesiol. 2021;21(1):15. Published 2021 Jan 12. doi:10.1186/s12871-021-01233-9
  2. Wang K, Wu C, Xu J, et al. Factors affecting the mortality of patients with COVID-19 undergoing surgery and the safety of medical staff: A systematic review and meta-analysis. EClinicalMedicine. 2020;29:100612. doi:10.1016/j.eclinm.2020.100612
  3. Clement ND, Hall AJ, Makaram NS, et al. IMPACT-Restart: the influence of COVID-19 on postoperative mortality and risk factors associated with SARS-CoV-2 infection after orthopaedic and trauma surgery. Bone Joint J. 2020;102-B(12):1774-1781. doi:10.1302/0301-620X.102B12.BJJ-2020-1395.R2
  4. The Lancet Rheumatology. Too long to wait: the impact of COVID-19 on elective surgery. Lancet Rheumatol. 2021;3(2):e83. doi:10.1016/S2665-9913(21)00001-1
  5. Haffner MR, Le HV, Saiz AM Jr, et al. Postoperative in-hospital morbidity and mortality of patients with COVID-19 infection compared with patients without COVID-19 infection. JAMA Netw Open. 2021;4(4):e215697. Published 2021 Apr 1. doi:10.1001/jamanetworkopen.2021.5697
  6. Doglietto F, Vezzoli M, Gheza F, et al. Factors associated with surgical mortality and complications among patients with and without Coronavirus disease 2019 (COVID-19) in Italy. JAMA Surg. 2020;155(8):691-702. doi:10.1001/jamasurg.2020.2713
  7. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study [published correction appears in Lancet. 2020 Jun 9;:]. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X



Recommended Reading

The SRGS Recommended Reading List is a summary of the most pertinent articles cited in each issue; the editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstracts on PubMed, and free full texts are available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. Mar 2017;82(3):605-617.

Article summary: Cannon and coauthors reviewed the elements of damage control resuscitation and described a practice guideline that emphasized a balanced approach to hemorrhage resuscitation using plasma, red cells, and platelets.

Roediger R, Lisker-Melman M. Pyogenic and amebic infections of the liver. Gastroenterol Clin North Am. Jun 2020;49(2):361-377.

Article summary: This review article provided useful information regarding the pathophysiology, diagnosis, and management of liver abscesses.

Cloyd JM, Wiseman JT, Pawlik TM. Surgical management of pancreatic neuroendocrine liver metastases. J Gastrointest Oncol. Jun 2020;11(3):590-600.

Article summary: Neuroendocrine tumors are a heterogeneous group of neoplasms with variable clinical characteristics and prognoses. The most common site of metastasis is the liver. This article reviews the diagnosis and management of neuroendocrine liver metastases.