The Difficult Patient

  • Alberto S. Gallo
  • Courtney Collins


Many patients who require emergent surgery will have pre-existing conditions that may make their care more complicated or require intensive perioperative treatment. This chapter will discuss pathologies such as cirrhosis, pregnancy, anticoagulation and will consider special situations such as the obese and hostile abdomen patients that may require added steps in care to optimize their outcomes. We hope that this overview will help the acute care surgeon better care for these patients and miss pitfalls in their care that could jeopardize their well-being.


Obesity Anticoagulation Cirrhosis Hostile abdomen 


  1. 1.
    Jackson FC, et al. Preoperative management of patients with liver disease. Surg Clin North Am. 1968;48(4):907–30.PubMedCrossRefGoogle Scholar
  2. 2.
    de Goede B, et al. Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review. Best Pract Res Clin Gastroenterol. 2012;26(1):47–59.PubMedCrossRefGoogle Scholar
  3. 3.
    Moore CM, Van Thiel DH. Cirrhotic ascites review: pathophysiology, diagnosis and management. World J Hepatol. 2013;5(5):251–63.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Child CG, Turcotte JG. Surgery and portal hypertension. In: Child CG, editor. The liver and portal hypertension. Philadelphia: Saunders; 1964. p. 50–64.Google Scholar
  5. 5.
    Pugh RN, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Malinchoc M, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31(4):864–71.PubMedCrossRefGoogle Scholar
  7. 7.
    Garrison RN, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg. 1984;199(6):648–55.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Mansour A, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122(4):730–5; discussion 735–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Hanje AJ, Patel T. Preoperative evaluation of patients with liver disease. Nat Clin Pract Gastroenterol Hepatol. 2007;4(5):266–76.PubMedCrossRefGoogle Scholar
  10. 10.
    Arroyo V, Terra C, Gines P. Advances in the pathogenesis and treatment of type-1 and type-2 hepatorenal syndrome. J Hepatol. 2007;46(5):935–46.PubMedCrossRefGoogle Scholar
  11. 11.
    Bleszynski MS, et al. Acute care and emergency general surgery in patients with chronic liver disease: how can we optimize perioperative care? A review of the literature. World J Emerg Surg. 2018;13:32.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Dhiman RK. Gut microbiota and hepatic encephalopathy. Metab Brain Dis. 2013;28(2):321–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Davenport A, et al. Medical management of hepatorenal syndrome. Nephrol Dial Transplant. 2012;27(1):34–41.PubMedCrossRefGoogle Scholar
  14. 14.
    Amarapurkar PD, Amarapurkar DN. Management of coagulopathy in patients with decompensated liver cirrhosis. Int J Hepatol. 2011;2011:695470.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Coakley M, et al. Transfusion triggers in orthotopic liver transplantation: a comparison of the thromboelastometry analyzer, the thromboelastogram, and conventional coagulation tests. J Cardiothorac Vasc Anesth. 2006;20(4):548–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Feltracco P, et al. Perioperative thrombotic complications in liver transplantation. World J Gastroenterol. 2015;21(26):8004–13.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    El-Awadi S, et al. Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective randomized study. Int J Surg. 2009;7(1):66–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003;197(6):921–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Tsugawa K, et al. A comparison of an open and laparoscopic appendectomy for patients with liver cirrhosis. Surg Laparosc Endosc Percutan Tech. 2001;11(3):189–94.PubMedCrossRefGoogle Scholar
  20. 20.
    Patil DH, et al. Comparative modes of action of lactitol and lactulose in the treatment of hepatic encephalopathy. Gut. 1987;28(3):255–9.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Kimer N, et al. Systematic review with meta-analysis: the effects of rifaximin in hepatic encephalopathy. Aliment Pharmacol Ther. 2014;40(2):123–32.PubMedCrossRefGoogle Scholar
  22. 22.
    Belghiti J, Durand F. Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis. 1997;17(3):219–26.PubMedCrossRefGoogle Scholar
  23. 23.
    Kort B, Katz VL, Watson WJ. The effect of nonobstetric operation during pregnancy. Surg Gynecol Obstet. 1993;177(4):371–6.PubMedGoogle Scholar
  24. 24.
    Dewhurst C, Beddy P, Pedrosa I. MRI evaluation of acute appendicitis in pregnancy. J Magn Reson Imaging. 2013;37(3):566–75.PubMedCrossRefGoogle Scholar
  25. 25.
    Gomes M, Matias A, Macedo F. Risks to the fetus from diagnostic imaging during pregnancy: review and proposal of a clinical protocol. Pediatr Radiol. 2015;45(13):1916–29.PubMedCrossRefGoogle Scholar
  26. 26.
    Williams PM, Fletcher S. Health effects of prenatal radiation exposure. Am Fam Physician. 2010;82(5):488–93.PubMedGoogle Scholar
  27. 27.
    Committee on Obstetric Practice and the American Society of Anesthesiologists. Committee opinion no. 696: nonobstetric surgery during pregnancy. Obstet Gynecol. 2017;129(4):777–8.CrossRefGoogle Scholar
  28. 28.
    Juhasz-Boss I, et al. Abdominal surgery in pregnancy--an interdisciplinary challenge. Dtsch Arztebl Int. 2014;111(27–28):465–72.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Moore HB, et al. Effect of pregnancy on adverse outcomes after general surgery. JAMA Surg. 2015;150(7):637–43.PubMedCrossRefGoogle Scholar
  30. 30.
    Cohen-Kerem R, et al. Pregnancy outcome following non-obstetric surgical intervention. Am J Surg. 2005;190(3):467–73.PubMedCrossRefGoogle Scholar
  31. 31.
    McGory ML, et al. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg. 2007;205(4):534–40.PubMedCrossRefGoogle Scholar
  32. 32.
    Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg. 2008;6(4):339–44.PubMedCrossRefGoogle Scholar
  33. 33.
    McGee TM. Acute appendicitis in pregnancy. Aust N Z J Obstet Gynaecol. 1989;29(4):378–85.PubMedCrossRefGoogle Scholar
  34. 34.
    Mazze RI, Kallen B. Appendectomy during pregnancy: a Swedish registry study of 778 cases. Obstet Gynecol. 1991;77(6):835–40.PubMedGoogle Scholar
  35. 35.
    Pearl JP, et al. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc. 2017;31(10):3767–82.PubMedCrossRefGoogle Scholar
  36. 36.
    Hee P, Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy. Int J Gynaecol Obstet. 1999;65(2):129–35.PubMedCrossRefGoogle Scholar
  37. 37.
    Sachs A, et al. Risk factors and risk stratification for adverse obstetrical outcomes after appendectomy or cholecystectomy during pregnancy. JAMA Surg. 2017;152(5):436–41.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Weiner E, et al. Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy. Arch Gynecol Obstet. 2015;292(5):1063–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Jelin EB, et al. Management of biliary tract disease during pregnancy: a decision analysis. Surg Endosc. 2008;22(1):54–60.PubMedCrossRefGoogle Scholar
  40. 40.
    Date RS, Kaushal M, Ramesh A. A review of the management of gallstone disease and its complications in pregnancy. Am J Surg. 2008;196(4):599–608.PubMedCrossRefGoogle Scholar
  41. 41.
    Rollins MD, Chan KJ, Price RR. Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc. 2004;18(2):237–41.PubMedCrossRefGoogle Scholar
  42. 42.
    Pannucci CJ, et al. Individualized venous thromboembolism risk stratification using the 2005 Caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: a meta-analysis. Ann Surg. 2017;265(6):1094–103.PubMedCrossRefGoogle Scholar
  43. 43.
    Berkman ND, et al. Tocolytic treatment for the management of preterm labor: a review of the evidence. Am J Obstet Gynecol. 2003;188(6):1648–59.PubMedCrossRefGoogle Scholar
  44. 44.
    Anderson I, Cifu AS. Management of bleeding in patients taking oral anticoagulants. JAMA. 2018;319(19):2032–3.PubMedCrossRefGoogle Scholar
  45. 45.
    Doherty JU, et al. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017;69(7):871–98.PubMedCrossRefGoogle Scholar
  46. 46.
    Milling TJ Jr, et al. Safety of a four-factor prothrombin complex concentrate versus plasma for vitamin K antagonist reversal: an integrated analysis of two phase IIIb clinical trials. Acad Emerg Med. 2016;23(4):466–75.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Zahir H, et al. Edoxaban effects on bleeding following punch biopsy and reversal by a 4-factor prothrombin complex concentrate. Circulation. 2015;131(1):82–90.PubMedCrossRefGoogle Scholar
  48. 48.
    Eerenberg ES, et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation. 2011;124(14):1573–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Pollack CV Jr, et al. Idarucizumab for dabigatran reversal – full cohort analysis. N Engl J Med. 2017;377(5):431–41.PubMedCrossRefGoogle Scholar
  50. 50.
    Siegal DM, et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. N Engl J Med. 2015;373(25):2413–24.PubMedCrossRefGoogle Scholar
  51. 51.
    Ansell JE, et al. Use of PER977 to reverse the anticoagulant effect of edoxaban. N Engl J Med. 2014;371(22):2141–2.PubMedCrossRefGoogle Scholar
  52. 52.
    Vilahur G, et al. Normalization of platelet reactivity in clopidogrel-treated subjects. J Thromb Haemost. 2007;5(1):82–90.PubMedCrossRefGoogle Scholar
  53. 53.
    Fujikawa T, et al. Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital. J Am Coll Surg. 2013;217(6):1044–53.PubMedCrossRefGoogle Scholar
  54. 54.
    Fang X, Baillargeon JG, Jupiter DC. Continued antiplatelet therapy and risk of bleeding in gastrointestinal procedures: a systematic review. J Am Coll Surg. 2016;222(5):890–905.e11.PubMedCrossRefGoogle Scholar
  55. 55.
    Lewis SR, et al. Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery. Cochrane Database Syst Rev. 2018;7:CD012584.PubMedGoogle Scholar
  56. 56.
    Yeung LYY, et al. Surgeon’s guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation. Trauma Surg Acute Care Open. 2016;1(1):e000022.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    James RF, et al. The role of anticoagulants, antiplatelet agents, and their reversal strategies in the management of intracerebral hemorrhage. Neurosurg Focus. 2013;34(5):E6.PubMedCrossRefGoogle Scholar
  58. 58.
    Fryar CD, Carroll MD, Ogden CL. Prevalence of overweight, obesity, and extreme obesity among adults aged 20 and over: United States, 1960–1962 through 2011–2014. In: National Center for Health Statistics Data, Health E-Stats. 2016. Available at
  59. 59.
    Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg. 2009;250(1):166–72.PubMedCrossRefGoogle Scholar
  60. 60.
    Valentijn TM, et al. The obesity paradox in the surgical population. Surgeon. 2013;11(3):169–76.PubMedCrossRefGoogle Scholar
  61. 61.
    Ferrada P, et al. Obesity does not increase mortality after emergency surgery. J Obes. 2014;2014:492127.PubMedPubMedCentralCrossRefGoogle Scholar
  62. 62.
    Phillips EH, et al. Comparison of laparoscopic cholecystectomy in obese and non-obese patients. Am Surg. 1994;60(5):316–21.PubMedGoogle Scholar
  63. 63.
    Enochsson L, et al. Laparoscopic vs open appendectomy in overweight patients. Surg Endosc. 2001;15(4):387–92.PubMedCrossRefGoogle Scholar
  64. 64.
    Masoomi H, et al. Comparison of laparoscopic versus open appendectomy for acute nonperforated and perforated appendicitis in the obese population. Am J Surg. 2011;202(6):733–8; discussion 738–9.PubMedCrossRefGoogle Scholar
  65. 65.
    Ahmad G, et al. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2015;8:CD006583.PubMedGoogle Scholar
  66. 66.
    Leppaniemi A, Tukiainen E. Planned hernia repair and late abdominal wall reconstruction. World J Surg. 2012;36(3):511–5.PubMedCrossRefGoogle Scholar
  67. 67.
    Fabian TC, et al. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg. 1994;219(6):643–50; discussion 651–3.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

Authors and Affiliations

  • Alberto S. Gallo
    • 1
  • Courtney Collins
    • 2
  1. 1.Baptist Surgical AssociatesBaptist Health LouisvilleLouisvilleUSA
  2. 2.Department of SurgeryThe Ohio State University Wexler Medical CenterColumbusUSA

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