What are the preoperative considerations for patients with hepatic encephalopathy undergoing surgery?

Preoperative Considerations for Patients with Hepatic Encephalopathy

For patients with hepatic encephalopathy undergoing surgery, comprehensive preoperative optimization focusing on nutritional status, medication management, and prevention of precipitating factors is essential to reduce morbidity and mortality.

Nutritional Assessment and Optimization

• A thorough nutritional assessment is mandatory prior to all hepatic surgery in patients with hepatic encephalopathy 1
• Malnourished patients (weight loss >10% or >5% over 3 months, reduced BMI, or low fat-free mass index) should receive enteral supplementation for at least 7-14 days before surgery 1
• For severely malnourished patients (>10% weight loss), surgery should be postponed for at least 2 weeks to improve nutritional status 1
• Preoperative fasting should be limited to 6 hours for solids and 2 hours for liquids 1
• Carbohydrate loading is recommended the evening before surgery and 2-4 hours before anesthesia to improve insulin resistance 1

Medication Management

• Long-acting anxiolytic drugs should be avoided, particularly in elderly patients, as they can worsen hepatic encephalopathy by impairing psychomotor function 1
• Preoperative gabapentinoids and NSAIDs are not recommended 1
• Acetaminophen dosage should be adjusted according to the extent of liver resection 1
• Continue rifaximin therapy if the patient is already on it, as it helps maintain lower ammonia levels 2, 3
• Steroid administration (methylprednisolone 500 mg) is recommended before surgery, except in diabetic patients 1

Prevention of Precipitating Factors

• Identify and address all potential precipitating factors of hepatic encephalopathy before surgery 4:
  • Treat any ongoing infections
  • Correct electrolyte imbalances, particularly hyponatremia and hypokalemia
  • Ensure adequate hydration status
  • Address any gastrointestinal bleeding
  • Manage constipation with appropriate bowel regimen

Thromboprophylaxis

• Low molecular weight heparin or unfragmented heparin should be started postoperatively to reduce thromboembolic risk 1
• Intermittent pneumatic compression devices should be used to further reduce thromboembolic risk 1

Biliary Drainage

• Biliary drainage is recommended in cholestatic liver disease (bilirubin >50 mmol/L) 1
• For perihilar cholangiocarcinoma, percutaneous biliary drainage is preferred over endoscopic drainage 1
• Surgery should ideally be postponed until bilirubin levels drop below 50 mmol/L 1

Substance Cessation

• Smoking cessation should be counseled at least 4 weeks prior to surgery 1
• Alcohol cessation is recommended for heavy drinkers (>24 g/day for women and >36 g/day for men) 4-8 weeks before surgery 1

Antimicrobial Prophylaxis

• Antibiotic prophylaxis (e.g., cefazolin) should be administered within 60 minutes before surgical incision 1
• For complex liver surgery with biliary reconstruction, targeted antibiotic regimen based on preoperative bile culture may be recommended 1
• Skin preparation with chlorhexidine-alcoholic solution is preferred over povidone-iodine solution 1

Surgical Approach

• When clinically appropriate and with trained teams, laparoscopic liver resection is recommended as it reduces postoperative length of stay and complication rates 1
• This approach may be particularly beneficial for patients with hepatic encephalopathy as it can lead to faster recovery and less metabolic stress 1

Special Considerations for Hepatic Encephalopathy

• Patients with Child-Pugh Class C hepatic impairment have significantly higher drug exposure (21-fold higher) compared to healthy subjects, requiring careful medication dosing 2
• Monitor for signs of elevated intracranial pressure, which may require specific management strategies 4
• Consider continuous renal replacement therapy for patients with elevated ammonia levels 4
• Ensure correction of hyponatremia is gradual to avoid central pontine myelinolysis 4

By addressing these preoperative considerations systematically, the risk of perioperative complications and hepatic encephalopathy exacerbation can be significantly reduced, leading to improved surgical outcomes in this high-risk population.