Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions

Abstract

Background and aims: Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures.

Methods: We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review.

Results: Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate.

Conclusions: Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.

Keywords: Liver Cirrhosis; Perioperative Management; Perioperative Risk Assessment; Surgery Outcomes.

Figure 1.

Metabolic, anatomic, and physiologic changes in cirrhosis and potential surgical consequences. Abbreviations: aPTT=activated partial thromboplastin time, AKI=acute kidney injury, ARDS=acute respiratory distress syndrome, ATN=acute tubular necrosis, PT=prothrombin time.

Figure 2.

Postoperative mortality in patients with cirrhosis depends on cirrhosis-related, surgery-related and comorbidity-related factors. These factors need to be combined in multivariable models to enable accurate estimates of postoperative mortality in individual patients undergoing a specific surgery – but such models have not yet been developed. Accurate estimates of postoperative mortality can be used to optimize patient selection and perioperative care.