Surgical Risk Assessment in Patients with Chronic Liver Diseases

Abstract

Chronic liver diseases (CLD) is one of the leading causes of morbidity and mortality. The overall life span of patients with CLD has increased and so is the number of surgical procedures these patients undergo. Pathophysiological and hemodynamic changes in cirrhosis make these patients more susceptible to hypotension and hypoxia during surgery. They also have a high risk of drug induced liver injury, renal dysfunction and post-operative liver decompensation. Patients with CLD planned for elective or semi-elective surgery should undergo detailed preoperative risk assessment. Patients should be evaluated for the presence of clinically significant portal hypertension and cirrhosis. In the absence of both cirrhosis and clinically significant portal hypertension, patients with CLD can undergo surgery with minimal or low risk. Various risk assessment tools available for patients with advanced CLD are-CTP score, MELD Score, Mayo risk score, VOCAL-Penn score. A Child class C and/or Mayo risk score >15 in general is associated with high risk of post-operative mortality and elective surgery should be deferred in these patients. In patients with Child class, A and MELD 10-15 surgery is permissible with caution (except liver resection and cardiac surgery) while in Child A and MELD <10 surgery is well tolerated. VOCAL-Penn score is a new promising tool and can be the better alternative of CTP, MELD, and Mayo risk score models but more prospective studies with large patients' population are warranted. Certain surgeries like Hepatic resection, intraabdominal, and cardiothoracic have higher risk than abdominal wall hernia repair and orthopedic surgery. Laparoscopic approaches have better outcomes and less risk of liver failure than open surgery. Minimally invasive alternatives like colonic stent placement in case of obstruction can be considered in high-risk cases. Perioperative optimization and management of ascites, HE, bleeding, liver decompensation, and nutrition should be done with multidisciplinary approach. Patients with cirrhosis undergoing high risk elective surgery can develop liver failure in post-operative period and should be evaluated and counseled for liver transplantation if not contraindicated.

Keywords: ASA, American Society of Anaesthesiologists; CLD, Chronic liver disease; CTP, Child-Turcotte-Pugh; Cirrhosis; HCC, Hepatocellular carcinoma; HVPG, hepatic venous pressure gradient; MELD, Model for end stage liver disease; NASH, Non-alcoholic steatohepatitis; ROTEM, rotational thromboelastometry; Surgery in cirrhosis; Surgical risk assessment; TEG, Thromboelastography; VOCAL-Penn score, Veterans Outcomes and Costs Associated with Liver Disease-Penn score.

Figure 1

Algorithm for surgical risk assessment in patients with chronic liver disease. CBC, Complete blood count; KFT, Kidney function test; LFT, Liver function test; PT-INR, Prothrombin Time-International normalization ratio; TEG, Thromboelastography; CSPH, clinically significant portal hypertension; CTP, Child Turcotte Pugh; MELD, Model for end stage for liver disease.