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Review
. 2024 Jun;18(3):876-891.
doi: 10.1007/s12072-024-10644-y. Epub 2024 Mar 12.

Surgical risk stratification in patients with cirrhosis

Ana Ostojic  1 , Nadim Mahmud #  2 , K Rajender Reddy #  3
Affiliations
Review

Surgical risk stratification in patients with cirrhosis

Ana Ostojic et al. Hepatol Int. 2024 Jun.

Abstract

Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.

Keywords: Child–Turcotte–Pugh classification; Hepatic surgery; Liver cirrhosis; MELD; Mayo risk model; Non-hepatic surgery; Surgical risk; Surgical risk assessment; VOCAL-Penn score.

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Conflict of interest statement

Ana Ostojic declares that he has no conflict of interest. Nadim Mahmud declares support from Grifols (investigator-initiated research) K. Rajender Reddy Advisory Board: Mallinckrodt, Spark Therapeutics, Novo Nordisk, Bio Vie. Grant Support (Paid to the University of Pennsylvania): Mallinckrodt, BMS, Intercept, Bio Vie, Sequana, Grifols, HCC-TARGET, NASH-TARGET, Exact Sciences, Camurus, B and D Device, DSMB: Novartis, Genkyotex, Astra Zeneca.

Figures

Fig. 1
Fig. 1
Perioperative risk factors in patient with liver cirrhosis undergoing surgery
Fig. 2
Fig. 2
Perioperative optimization of patients with liver cirrhosis
Fig. 3
Fig. 3
Algorithm for preoperative assessment of patient with cirrhosis before elective surgery
Fig. 4
Fig. 4
Interactions between patient (cirrhosis)-related and surgery-related risk factors
See this image and copyright information in PMC

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