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

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.