From the Guidelines
Perioperative risk assessment in patients with cirrhosis should begin with a multi-parametric composite assessment of liver function, portal hypertension, extent of hepatectomy, expected volume of the future liver remnant, performance status, and patient’s comorbidities to ensure perioperative mortality is lower than 3% and morbidity is lower than 20%. This approach is supported by the most recent and highest quality study, which emphasizes the importance of a comprehensive evaluation to minimize risks associated with surgery in patients with cirrhosis 1.
Key Components of Risk Assessment
- Liver function assessment using tools such as the Child-Pugh score and Model for End-Stage Liver Disease (MELD) score
- Evaluation of portal hypertension, which is a major predictor of post-hepatectomy liver failure, perioperative mortality, and long-term survival
- Assessment of the expected volume of the future liver remnant, which should be at least 20% in patients without cirrhosis and at least 30%–40% in patients with chronic liver disease and a Child-Pugh A score
- Consideration of the patient’s performance status and comorbidities, which can significantly impact surgical outcomes
Preoperative Optimization
- Correcting coagulopathy with vitamin K, fresh frozen plasma, or platelets as needed
- Managing ascites with diuretics or paracentesis
- Treating encephalopathy
- Addressing nutritional deficiencies
- Evaluating for clinically significant portal hypertension (CSPH) via transjugular pressure measurement (HVPG), imaging, esophagogastroduodenoscopy, endoscopic ultrasound, and MRI or ultrasound-based elastography 1
Surgical Considerations
- The type of surgery impacts risk, with abdominal procedures carrying higher risk than peripheral operations
- Emergency surgery significantly increases mortality regardless of liver function
- Anesthesia approach should minimize hepatic blood flow reduction, with careful medication selection to avoid hepatotoxic agents
- Postoperatively, close monitoring for liver decompensation, infection, renal dysfunction, and bleeding is essential, as these patients have limited physiological reserve to handle surgical stress.
Overall, a thorough and multi-faceted approach to perioperative risk assessment and management is crucial for optimizing outcomes in patients with cirrhosis undergoing surgery, as supported by recent guidelines and studies 1.
From the Research
Assessing Perioperative Risk in Patients with Cirrhosis
To assess perioperative risk in patients with cirrhosis, several factors must be considered, including the severity of liver disease, portal hypertension, and the type of surgery. The following points highlight key considerations and strategies for assessing and managing perioperative risk in these patients:
- Liver Disease Severity: The Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score are commonly used to assess the severity of liver disease in patients with cirrhosis 2. These scores can help predict surgical risk and guide preoperative management.
- Portal Hypertension: Portal hypertension is a significant factor in perioperative risk, particularly for surgeries that may exacerbate portal pressure 3. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement may be considered in selected patients to reduce portal pressure and improve outcomes.
- Surgery Type: The type of surgery is an important determinant of perioperative risk in patients with cirrhosis 4. High-risk surgeries, such as those involving major abdominal or cardiac procedures, require careful consideration and optimization of the patient's condition before proceeding.
- Preoperative Optimization: Preoperative visits with primary care physicians and/or gastroenterologists/hepatologists can improve postoperative outcomes in patients with cirrhosis 5. These visits can help optimize the patient's condition, adjust medications, and perform necessary procedures such as paracentesis.
- Risk Assessment Models: Several risk assessment models are available to aid in the decision-making process, including the CTP score, MELD score, Mayo Risk Score, and VOCAL-Penn Score 2, 6. Each model has its advantages and limitations, and the choice of model should be tailored to the individual patient and surgery type.
- Multidisciplinary Approach: A multidisciplinary approach to preoperative care, involving primary care physicians, gastroenterologists/hepatologists, surgeons, and anesthesiologists, is essential for optimizing outcomes in patients with cirrhosis 5, 6.
Key Considerations for Preoperative Assessment
When assessing patients with cirrhosis for surgery, the following key considerations should be taken into account:
- Coagulation Function: Patients with cirrhosis may have coagulation dysfunction, which can increase the risk of bleeding during surgery 6.
- Malnutrition and Sarcopenia: Malnutrition and sarcopenia are common in patients with cirrhosis and can impact surgical outcomes 2.
- Ascites and Hepatic Encephalopathy: The presence of ascites and hepatic encephalopathy can increase the risk of postoperative complications 3, 5.
- Medication Management: Medications such as diuretics, spontaneous bacterial peritonitis prophylaxis, and hepatic encephalopathy medications may need to be adjusted or initiated preoperatively 5.