Surgery in the patient with liver disease

Abstract

Surgery is performed in patients with liver disease more frequently now than in the past, in part because of the long-term survival of patients with cirrhosis. Recent work has focused on estimating perioperative risk in patients with liver disease. Hemodynamic instability in the perioperative period can worsen liver function in patients with liver disease. Operative risk correlates with the severity of the underlying liver disease and the nature of the surgical procedure. Thorough preoperative evaluation is necessary prior to elective surgery. Surgery is contraindicated in patients with certain conditions, such as acute hepatitis, acute liver failure, and alcoholic hepatitis. Estimation of perioperative mortality is inexact because of the retrospective nature of and biased patient selection in available clinical studies. The Child-Pugh classification (Child-Turcotte-Pugh score) and particulary the Model for End-Stage Liver Disease (MELD) score provide reasonable estimations of perioperative mortality but do not replace the need for careful preoperative preparation and postoperative monitoring, as early detection of complications is essential for improving outcomes. Medical therapy for specific manifestations of hepatic disease, including ascites, encephalopathy, and renal dysfunction, should be optimized preoperatively or, if necessary, administered in the postoperative period.

Fig. 1

Relationship between operative mortality and MELD score in 772 patients with cirrhosis who underwent surgery in 1980–1990 and 1994–2004. Panel A: shows 30-day mortality; Panel B: shows 90-day mortality. For patients with a MELD score >8, each one-point increase in the MELD score was associated with a 14% increase in both 30-day and 90-day mortality rates. (From Teh SH, Nagorney DM, Stevens SR, et al. Gastroenterology 2007;132:1261–9, with permission.) MELD, Model for End-Stage Liver Disease.