What is the recommended preoperative risk assessment for patients with chronic liver disease?

Surgical Risk Assessment for Liver Disease Patients

All patients with chronic liver disease being considered for elective extrahepatic surgery should undergo risk stratification using the VOCAL-Penn cirrhosis surgical risk score as the primary tool, supplemented by non-invasive tests (NITs) to assess for compensated advanced chronic liver disease (cACLD)/cirrhosis and clinically significant portal hypertension (CSPH). 1

Initial Risk Stratification Framework

Step 1: Calculate VOCAL-Penn Score

The VOCAL-Penn score should be calculated first as it incorporates multiple critical variables including age, albumin, bilirubin, platelets, obesity, MASLD status, ASA class, emergency status, and surgery type 1. This provides the foundational risk assessment that determines whether to proceed with further evaluation.

Step 2: Rule Out or Confirm cACLD/Cirrhosis Using NITs

Liver stiffness measurement (LSM) by transient elastography is the central tool:

• LSM <10 kPa effectively rules out cACLD, identifying patients with chronic liver disease without significantly increased surgical risk 1
• LSM ≥10 kPa warrants further evaluation for the presence and severity of portal hypertension

Step 3: Assess for Clinically Significant Portal Hypertension (CSPH)

In patients with confirmed cACLD, use the Baveno VII criteria combining LSM and platelet count:

• CSPH ruled out (low risk): LSM <15 kPa AND platelets >150×10⁹/L (sensitivity and negative predictive value >90%) 1
• CSPH highly likely (high risk): LSM >25 kPa in non-obese patients (specificity and positive predictive value >90%) 1
• For obese patients with MASLD: Use the ANTICIPATE-NASH model incorporating BMI for more accurate CSPH prediction 1

For patients in the "grey zone" (unclassifiable by LSM and platelet criteria):

• Add spleen stiffness measurement (SSM): <25 kPa rules out CSPH; >55 kPa rules in CSPH 1
• Or use VITRO (von Willebrand factor-to-platelet ratio): <1.5 rules out CSPH; >25 rules in CSPH 1
• Or apply ANTICIPATE±NASH or NICER models for individual predicted probability of CSPH 1

Step 4: Consider HVPG Measurement in Select Cases

HVPG measurement may be considered in:

• Patients with cACLD who cannot be classified by NITs (grey zone/high uncertainty) 1
• Patients with cACLD with confirmed CSPH or decompensated cirrhosis 1
• Only if HVPG results are expected to impact clinical decision-making 1

HVPG interpretation:

• Risk increases if HVPG >16 mmHg
• High risk if HVPG ≥20 mmHg 1

Preoperative Laboratory Testing

Essential Tests for Patients with Liver Disease

Complete blood count (CBC) is recommended for all patients with liver disease undergoing surgery, regardless of age or surgical grade 2. This identifies anemia, thrombocytopenia (marker of portal hypertension), and potential bleeding risk.

Electrolyte measurement should be obtained for ASA class 2 or 3 patients with liver disease, particularly those undergoing intermediate to major surgery 2.

Risk Interpretation and Decision-Making

Low-Risk Patients (Surgery Generally Safe)

• No cirrhosis (LSM <10 kPa) 1
• Compensated cirrhosis WITHOUT CSPH (LSM <15 kPa AND platelets >150×10⁹/L) 1
• Child-Pugh class A with MELD <10 3

Intermediate-Risk Patients (Surgery Permissible with Caution)

• Compensated cirrhosis WITH CSPH 1
• Child-Pugh class A with MELD 10-15 3
• Avoid liver resection and cardiac surgery in this group 3

High-Risk Patients (Elective Surgery Should Be Deferred)

• Child-Pugh class C 3
• Mayo Risk Score >15 3
• Decompensated cirrhosis with ascites, hepatic encephalopathy, or variceal bleeding 1
• HVPG ≥20 mmHg 1

Critical Caveats and Pitfalls

The VOCAL-Penn score lacks granularity regarding presence/severity of portal hypertension and does not capture severity of decompensation 1. This is why the multimodal approach combining VOCAL-Penn with NITs for CSPH assessment is essential.

Patients with decompensated cirrhosis have the strongest predisposition for complications, determined by severity of decompensation and presence of acute-on-chronic liver failure (ACLF) 1.

Rapid correction of hyponatremia should be avoided perioperatively due to risk of neurological complications 1.

Nerve blocks should be avoided in Child-Pugh B and C cirrhosis due to hemorrhage risk 1.

Surgery-Specific Considerations

Higher-risk procedures: Hepatic resection, intra-abdominal surgery, cardiothoracic surgery 3

Lower-risk procedures: Abdominal wall hernia repair, orthopedic surgery 3

Laparoscopic approaches have better outcomes and lower risk of liver failure compared to open surgery 3.

Perioperative Optimization

Before proceeding with surgery in intermediate-risk patients:

• Optimize nutritional status and address sarcopenia/frailty 4
• Manage portal hypertension (consider TIPS in highly selected cases) 4, 5
• Correct hemostatic abnormalities 4
• Address ongoing etiological drivers (especially alcohol cessation) 5
• Manage varices appropriately 5

All decisions should be made in a multidisciplinary forum with hepatology, surgery, and anesthesiology input, and surgeries should ideally be performed at high-volume centers with expertise in managing cirrhotic patients 4.