PSH 2017

Peshawar Meeting November 2017

EVERYDAY CHALLENGES IN
CLINICAL PRACTICE
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Surgical Risk
Assessment in patients
with Liver Disease
DR ZABIH ULLAH
MBBS, FCPS( GASTROENTEROLOGY)
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Objectives

 Review basic principles of pre op assessment of patients with

liver disease
 Effects of anesthesia and surgery on the liver
 Estimation of operative risk
 Risk associated with specific types of Surgery
 Discuss strategies to optimize pre op management of liver
diseases
 Choice of sedation for surgery
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SCREENING FOR LIVER
DISEASE BEFORE SURGERY 
 HISTORY
 prior blood transfusions
 tattoos
 illicit drug use
 sexual promiscuity
 family history of jaundice or liver disease
 history of jaundice or fever following anesthesia
 alcohol use (current, prior and quantity)
 complete review of current medications
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Clinical features

 Increased abdominal girth

 Jaundice
 Palmar erythema
 Spider telangiectasias
 Splenomegaly
 Gynecomastia and testicular atrophy in men
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Effects of anesthesia on the liver

Hepatic ischemia: elevated transaminases
Cirrhosis
Hyperdynamic circulation with decreased blood flow to liver
More susceptible to hypoxemia and hypotension
 Surgical factors contributing to hepatic ischemia:
 Hypotension, hemorrhage, vasoactive medications
 Positive pressure ventilation
 Pneumoperitoneum during laparoscopic cases
 Traction on abdominal viscera
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Metabolism of medications

 Volume of distribution of medications is increased in cirrhotic

patients.
 Inhaled anesthetic choice
 Halothane dcrease hepatic blood flow and can cause
hepatotoxicity
 Isoflurane, sevoflorane and desflorane has less effect on hepatic
blood flow and hepatotoxicity
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Metabolism of medications

 Atracurium/cisatracurium preferred—not excreted by liver or

kidney

 Sedatives and narcotics can precipitate hepatic encephalopathy

and prolong periods of depressed consciousness.
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Whatare the postoperative

concerns
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Coagulopathy

 Decreased production of clotting factors

 Depletion of vitamin K stores
 Increased fibrinolytic activity
 Thrombocytopenia
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Ascites

 Hepatic hydrothorax—respiratory complications

 Wound complications
 Hernia
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Hepatic encephalopathy

 Precipitating factors in post operative period

 Volume contraction
 Hypokalemia
 Infection
 Bleeding
 Medications
Renal Dysfunction

 Potential causes:
 Intravascular volume depletion
 Nephrotoxicity
 ATN
 Hepatorenal syndrome (HRS)
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Pulmonary complications
 Ascites and hepatic hydrothorax
 Increased risk of aspiration
 Pneumonia
 ARDS
 Ventilation dependence
 Hepatopulmonary syndrome:
 Triad of liver disease, increased AA gradient and intrapulmonary
shunting
 Platypnea
 Orthodeoxia
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EFFECTS OF ANESTHESIA AND
SURGERY ON THE LIVER 
 Depends upon:
 Type of anesthesia used
 specific surgical procedures
 severity of liver disease.
 Perioperative events
 hypotension
 sepsis
 Administration of hepatotoxic drugs
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ESTIMATING SURGICAL RISK 

 Appraisal of the severity of liver disease

 The urgency of surgery (and alternatives to surgery)
 Coexisting medical illness.
 Surgical risk assessment is less relevant if immediate
surgery is required to prevent death.
 Elective procedures
 Risk assessment
 Optimization of the patient's medical status
 Consideration of alternative approaches.
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Study Design Flaws

 Mostly small studies

 Retrospective
 Clinical experience
 Arbitrary parameters
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Contraindications for elective surgery

 Acute hepatitis
 Alcoholic hepatitis
 Abstinence from alcohol for at least 12 weeks
 improves hepatic inflammation and hyperbilirubinemia
 Reassess after 12 weeks
 Acute liver failure

HARVILLE DD, SUMMERSKILL WH. Surgery in acute hepatitis. Causes and effects. JAMA 1963;
184:257.

Greenwood SM, Leffler CT, Minkowitz S. The increased mortality rate of open liver biopsy in
alcoholic hepatitis. Surg Gynecol Obstet 1972; 134:600.

Powell-Jackson P, Greenway B, Williams R. Adverse effects of exploratory laparotomy in patients

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PATIENTS AT VARIABLE
INCREASED RISK 
 The risk of surgery in patients with cirrhosis depends
 the severity of disease,
 the clinical setting
 type of surgical procedure
SCORING SYSTEMS TO ASSESS
SURGERY RISK
1. CTP
2. MELD
3. ASA
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Child-Turcotte-Pugh score
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ASA Classification
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 In a retrospective study of 261 patients (45 with cirrhosis and 216

matched controls without cirrhosis) undergoing cardiac surgery
between 1992 and 2009,
 CP < 8 : 95 % survival rate at 90 days
 CP > 8 : 30 % survival rate at 90 days

Macaron C, Hanouneh IA, Suman A, et al.. Clin Gastroenterol Hepatol 2012; 10:535.
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MELD score 

 MELD is supplanting the CP classification as the principal method

for determining surgical risk
 The MELD score, American Society of Anesthesiologists (ASA)
class, and age predicted mortality in a study of 772 patients with
cirrhosis who underwent major digestive, orthopedic, or
cardiovascular surgery.
 The MELD score was the best predictor of 30- and 90-day
mortality. Mortality at 30 days ranged from 6 percent (MELD
score, <8) to more than 50 percent (MELD score, >20) and
correlated linearly with the MELD score.

Teh SH, Nagorney DM, Stevens SR, et al. Gastroenterology 2007;

132:1261.
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 Increased risk of mortality up to 90 days postoperatively

 Mortality rates
 MELD <7: 5.7%
 MELD 8-11: 10.3%
 MELD 12-15: 25.4%
 ASA class IV adds 5.5 MELD points. ASA class V = 100% mortality
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 MELD < 10 : elective surgery

 MELD 10 to 15 : elective surgery with caution
 MELD >15 : should not undergo elective surgery

Hanje AJ, Patel T..Nat Clin Pract Gastroenterol Hepatol 2007; 4:266.
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 Obstructive jaundice — 
 Increased risk of perioperative complications
 Infections
 stress ulceration
 DIC
 wound dehiscence
 renal failure

Grande L, Garcia-Valdecasas JC, Fuster J, et al.. Br J Surg 1990;

77:440.
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 An overall mortality rate of 9 percent was found in a large

retrospective study that included 373 patients undergoing
surgery for obstructive jaundice.
 Multivariate analysis identified three predictors of
postoperative mortality:
 An initial hematocrit value <30 percent
 An initial serum bilirubin level >11 mg/dL (200 micromoles/L)
 A malignant cause of obstruction (eg, pancreatic carcinoma
or cholangiocarcinoma)
 All three factors +ive Mortality 60 %
 All three factors -ive Mortality 5 %

Dixon JM, Armstrong CP, Duffy SW, Davies GC. Gut 1983; 24:845.
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 A number of interventions have been attempted to reduce

morbidity and mortality in these patients:
 Perioperative administration of broad-spectrum intravenous
antibiotics
 External biliary drainage via a transhepatic approach
 Endoscopic biliary drainage
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 Limited evidence suggests that the administration of bile

salts or lactulose to patients with obstructive jaundice can
prevent both the endotoxemia and the exaggerated renal
vasoconstriction

Pain JA, Cahill CJ, Gilbert JM, et al. Br J Surg 1991; 78:467.
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 Cardiac surgery —
  Cardiac surgery is associated with increased mortality in patients
with cirrhosis compared to other surgical procedures

Csikesz NG, Nguyen LN, Tseng JF, Shah SA. J Am Coll Surg 2009; 208:96.
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 9 studies involving 210 patients with cirrhosis

 Mortality : 17 %.
 CP A: 5%
 CP B : 35%
 CP C : 70%
 MELD score has not been adequately studied as a prognostic
tool for patients undergoing cardiac surgery.

Modi A, Vohra HA, Barlow CW. Interact Cardiovasc Thorac Surg 2010; 11:630.
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 Risk factors for hepatic decompensation

 total time of cardiopulmonary bypass
 use of nonpulsatile as opposed to pulsatile cardiopulmonary bypass
 need for perioperative pressor support
 Thus, the least invasive options
 Angioplasty,
 Valvuloplasty
 Minimally invasive revascularization techniques, should be
considered in patients with advanced cirrhosis who require invasive
intervention for cardiac disease

Gaudino M, Santarelli P, Bruno P, et al. Am J Cardiol 1997;

80:1351.
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 Hepatic resection —
 RESIDUAL VOLUME NEEDED
 Normal Liver 25%
 Cirrhotic liver 40%

Cooper A, Aloia T..Transl Cancer Res 2013; 2:450.

 Risk factors for hepatic decompensation
 CTP
 MELD
 BILIRUBIN
 PT
 Portal Hypertension
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 A database study of 587 patients who underwent hepatic

resection concluded that the Child-Turcotte-Pugh score and ASA
score were better predictors of morbidity and mortality than the
MELD

Schroeder et al Ann Surg 2006; 243:373.

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 Clinically significant portal hypertension

 Gastroesophageal varices OR
 Platelet < 100,000/mL with splenomegaly
 clinical decompensation after surgery
 3 & 5 year mortality
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 Trauma — 
 Trauma patients found to have cirrhosis at laparotomy are at
increased risk for morbidity and mortality.
 In one study, the overall mortality rate was 45 percent,
significantly higher than of a matched control population (24
percent)

Demetriades D, Constantinou C, Salim A, et al..J Am Coll Surg 2004; 199:538.

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 Abdominal surgery —
 In patients undergoing cholecystectomy, a laparoscopic approach is
associated with lower mortality rates than an open approach and
can be performed in patients with CP class A and B cirrhosis and
MELD scores up to 13

Laurence JM, Tran PD, Richardson AJ, et al. HPB (Oxford) 2012; 14:153.
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 Colorectal surgery, primarily for diverticular disease and

colorectal cancer, is associated with mortality rates as high as 26
percent in patients with cirrhosis

Bhangui P, Laurent A, Amathieu R, Azoulay D. J Hepatol 2012; 57:874.

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 Less invasive approaches such as stent placement to relieve

obstruction should be considered when possible.

Cho SW, Bhayani N, Newell P, et al. Arch Surg 2012; 147:864.

 Elective umbilical hernia repair can be performed with excellent
outcomes, even in patients with CP class C cirrhosis
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 Patients with minimally increased risk —

 Mild to moderate chronic liver disease without cirrhosis
 Mild chronic hepatitis
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 Fatty liver and nonalcoholic steatohepatitis 

 Increased mortality following hepatic resection has been

observed in those with moderate to severe steatosis (>30
percent of hepatocytes containing fat

 NASH is associated with increased morbidity following hepatic

resection

Behrns KE, Tsiotos GG, DeSouza NF, et al. J Gastrointest Surg 1998;
2:292.
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 Recommending a period of abstinence from alcohol prior to

surgery is advisable for all patients with the histologic
appearance of steatohepatitis or those who are suspected of
excessive alcohol consumption

Zimmerman HJ, Maddrey WC. Hepatology 1995; 22:767.

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 Autoimmune hepatitis — 
 Elective surgery is usually well tolerated in patients with autoimmune
hepatitis who have compensated liver disease.
 Perioperative "stress" doses of hydrocortisone should be given to
patients taking prednisone.
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 Hemochromatosis —
 Evaluation for complications
 Diabetes
 Cardiomyopathy

Farrell FJ, Nguyen M, Woodley S, et al. Hepatology 1994; 20:404.

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 Wilson disease —
 Patients with Wilson disease who have neuropsychiatric
involvement may not be able to provide informed consent.
 Surgery can precipitate or aggravate neurologic symptoms
 D-penicillamine interferes with the crosslinking of collagen and
may impair wound healing
 the dose should be decreased prior to surgery and during the
first one to two postoperative weeks

Yarze JC, Martin P, Muñoz SJ, Friedman LSAm J Med 1992; 92:643.
OPTIMIZING MEDICAL
THERAPY
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COAGULOPATHY

 Management of haemostatic abnormalities in patients with cirrhosis

 optimize the platelet count
 optimize fibrinogen level
 optimize renal function
 avoid the INR values to guide therapy
 A prolonged bleeding time can be treated with desmopressin
 (DDAVP).
 Optimal surgical technique and maintenance of low central venous
pressure may reduce blood loss and may be more important than
attempting to correct the prothrombin time
Alkozai EM, Lisman T, Porte RJ. Clin Liver Dis 2009; 13:145.
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Take Home Points

 Medical therapy should be optimized in all patients

 Operative mortality can be estimated based upon the CTP, MELD,
ASA, Age and co-morbidities
 Elective surgery not be performed in patients with
 Acute or fulminant hepatitis
 Alcoholic hepatitis,
 Child-Pugh class C or MELD score >15 cirrhosis,
 Severe coagulopathy
 Severe extrahepatic manifestations of liver disease (such as hypoxia,
cardiomyopathy, or acute renal failure)
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 Surgery is generally well tolerated

 CTP A and MELD <10
 Mild chronic liver disease without cirrhosis
 Surgery is generally permissible
 CTP B and MELD 10 to 15 except those undergoing extensive
hepatic resection or cardiac surgery) who have undergone
thorough preoperative preparation
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THANK YOU