Surgery in a patient with liver disease

Abstract

Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.

Keywords: ABG, arterial blood gas; ASA, American Society of Anesthesiologists; Anesthesia; BNP, brain natriuretic peptide; COPD, chronic obstructive pulmonary disease; CTP, Child–Turcotte–Pugh; CVP, central venous pressure; Child–Pugh score; FDP, fibrin degradation products; FFP, fresh frozen plasma; HPS, hepatopulmonary syndrome; ICG, indocyanine green; ICU, intensive care unit; INR, international normalized ratio; MELD, model for end-stage liver disease; NSAID, nonsteroidal anti-inflammatory drug; PICD, paracentesis-induced circulatory dysfunction; PT, prothrombin time; PTT, partial thromboplastin time; SBP, spontaneous bacterial peritonitis; TEG, thromboelastogram; TIPS, transjugular intrahepatic portosystemic shunt; cirrhosis; coagulopathy; hepatic.