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)
Objectives
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 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
Clinical features
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 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 with

unsuspected liver disease. Br J Surg 1982; 69:449.
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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
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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.
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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
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 Obstructive jaundice —
 Increased risk of perioperative complications
 Infections
 stress ulceration
 DIC
 wound dehiscence
 renal failure
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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 %
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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
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 Cardiac surgery —
 Cardiac surgery is associated with increased mortality in patients
with cirrhosis compared to other surgical procedures
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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.
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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
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 Hepatic resection —
 RESIDUAL VOLUME NEEDED
 Normal Liver 25%
 Cirrhotic liver 40%
 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)
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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
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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
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 Less invasive approaches such as stent placement to relieve

obstruction should be considered when possible.
 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
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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
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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
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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
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
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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