General Considerations
- Complications: Worsening ascites, jaundice, encephalopathy, renal dysfunction, electrolyte abnormalities, increased risk of infection, hemorrhage, and death.
- Data Source: Most of the evidence-base is derived from patients with advanced liver disease and cirrhosis, and the majority of studies involve patients undergoing cardiovascular or abdominal surgeries.
- Estimator of Surgical mortality risk: Child-Turcotte-Pugh classification or MELD score.
- Bottom Line: Advance planning for elective surgery is key. In general, patients with advanced liver disease make poor operative candidates due to a high risk of decompensated cirrhosis and death in the post-operative period.
Preoperative Assessment
- Patients with mild to moderate liver disease without cirrhosis generally tolerate surgery well.
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RISK FACTORS FOR MORBIDITY AND MORTALITY |
CONTRAINDICATIONS TO NONEMERGENT SURGERY |
|
Hypoalbuminemia Hypoxemia Encephalopathy Emergency surgery Portal hypertension Anemia Ascites Trauma Infection Malnutrition Type of surgery: hepatic, abdominal or cardiac |
Acute or fulminant liver failure Acute viral or alcoholic hepatitis Acute kidney injury Cardiomyopathy Hypoxemia Uncorrected coagulopathy
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Predicting Mortality
|
CHILD-PUGH SCORE |
|
|
A |
Okay for elective surgery |
|
B |
Caution with elective surgery, estimated mortality for noncardiac surgery as high as 30%. Cardiovascular surgery NOT recommended |
|
C |
Elective and Cardiovascular surgery NOT recommended |
|
D |
Elective and Cardiovascular surgery NOT recommended |
|
MELD SCORE |
|
|
<10 |
Okay for elective surgery |
|
10-15 |
Undergo elective surgery with caution |
|
> 15 |
Avoid elective surgery (operative mortality 60-80%) |
Medical Optimization
Optimization of the following may help to mitigate overall risk:
- Renal function
- Ascites (TIPS may be considered in carefully selected scenarios, data only from small case series, no robust clinical trials to examine role of TIPS in elective surgery)
- Encephalopathy
- Electrolytes (e.g., normalizing K, addressing metabolic alkalosis)
- Coagulopathy: correct with vitamin K and/or FFP
- Detection and treatment of active infections
- Nutrition
Bhangui P, Laurent A, Amathieu R, Azoulay D. Assessment of risk for non-hepatic surgery in cirrhotic patients. J.Hepatol. 2012 10;57(4):874-884.
Rai R, Nagral S, Nagral A. Surgery in a Patient with Liver Disease. Journal of Clinical and Experimental Hepatology 2012 9;2(3):238-246.
Friedman, LS. The risk of surgery in patients with liver disease. Hepatology 1999;29:1617.
O'Leary, JG, Yachimski, PS, Friedman, LS. Surgery in the patient with liver disease. Clin Liver Dis 2009;13:211.
Telem, DA, Schiano, T, Goldstone, R, et al. Factors that predict outcome of abdominal operations in patients with advanced cirrhosis. Clin Gastroenterol Hepatol 2010;8:451.
Teh, SH, Nagorney, DM, Stevens, SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007;132:1261.
Hanje, AJ, Patel, T. Preoperative evaluation of patients with liver disease. Nat Clin Pract Gastroenterol Hepatol 2007; 4:266.