What are the recommendations for managing patients with liver cirrhosis undergoing surgical procedures to minimize mortality risk?

From the Guidelines

Patients with liver cirrhosis undergoing surgery should be managed with a comprehensive perioperative approach to minimize mortality risk, focusing on optimization of liver function, careful fluid management, and prevention of complications, as recommended by the Enhanced Recovery After Surgery (ERAS) society guidelines 1.

Key Recommendations

• Preoperative assessment of liver function using Child-Pugh or MELD scores is essential, with elective procedures ideally postponed in patients with Child-Pugh C cirrhosis.
• Optimization before surgery should include:
  • Treating ascites with diuretics (spironolactone 100-400 mg/day with furosemide 40-160 mg/day) and addressing electrolyte imbalances.
  • Correcting coagulopathy with vitamin K (10 mg IV daily for 3 days) and possibly fresh frozen plasma.
  • Preoperative smoking cessation should be counseled at least 4 weeks prior to hepatectomy, and alcohol cessation is recommended for heavy drinkers 4–8 weeks before surgery 1.
• During surgery, careful fluid management is crucial to prevent renal dysfunction, with crystalloids preferred and blood products given as needed to maintain hemoglobin above 7-8 g/dL.
• Postoperatively, close monitoring for complications is necessary, including:
  • Hepatic encephalopathy (treated with lactulose 25-30 mL every 6 hours).
  • Renal dysfunction.
  • Infection.
• Pain management should avoid NSAIDs and utilize opioids cautiously at reduced doses.
• Beta-blockers should be continued perioperatively if the patient is on them for portal hypertension.
• Early oral intake with normal diet should be implemented after hepatectomy, and individualized need for artificial nutrition should be assessed for malnourished patients, patients with complications causing several days of fasting, and patients with liver cirrhosis 1.

Additional Considerations

• The use of minimally invasive surgery, such as laparoscopic liver resection, is recommended when clinically appropriate, as it reduces postoperative length of stay and complication rates 1.
• A multimodal approach to postoperative nausea and vomiting should be used, with patients receiving postoperative nausea and vomiting prophylaxis with at least 2 antiemetic drugs such as dexamethasone and ondansetron 1.
• Early mobilization (out of bed) after liver surgery should be established from the operative day until hospital discharge 1.
• Insulin therapy for maintenance of normoglycemia (<8.3 mmol/l) is recommended 1.

From the Research

Recommendations for Managing Patients with Liver Cirrhosis Undergoing Surgical Procedures

To minimize mortality risk in patients with liver cirrhosis undergoing surgical procedures, several recommendations can be made based on the available evidence:

• Careful evaluation of the patient's liver disease severity and contributing factors such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction is crucial 2, 3, 4.
• Preoperative optimization, including control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation, is essential 3, 4.
• The use of modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can help predict mortality after surgery 3.
• Laparoscopic techniques can improve outcomes in patients with liver cirrhosis undergoing surgical procedures 2, 5.
• In the emergency setting, conservative management is preferred, especially in patients with decompensated liver cirrhosis, alcoholic hepatitis, severe/advanced liver cirrhosis, and significant extrahepatic organ dysfunction 2, 3.

Surgical Considerations

• Surgery should be avoided if possible in patients with acute and alcoholic hepatitis, Child class C cirrhosis, or a MELD score greater than 15 3.
• Patients with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease 3.
• The use of off-pump cardiopulmonary bypass techniques and optimal perfusion modalities can help reduce perioperative complications in cardiac surgery 4.
• Intraoperative management should include the use of safe anesthetic agents, avoidance of hypotension, and careful monitoring of coagulation and bleeding risk 3, 4.

Postoperative Care

• Patients with liver cirrhosis are at higher risk of postoperative complications, including bleeding, sepsis, multisystem organ failure, and hepatic insufficiency 2, 3, 4.
• Close monitoring and management of postoperative complications, including ascites, portal hypertension, and hepatomegaly, are crucial 3, 5.
• The use of nonselective β-blockers, lactulose, and combination aldosterone antagonists and loop diuretics can help manage complications such as variceal bleeding, hepatic encephalopathy, and ascites 6.