From the Guidelines
Child-Pugh class C patients are not suitable for surgical therapy due to high operative risk, and alternative treatment options such as supportive care or liver transplantation should be considered. The Child-Pugh classification evaluates liver function based on five parameters: serum bilirubin, serum albumin, prothrombin time/INR, ascites severity, and hepatic encephalopathy grade. Class C patients (scoring 10-15 points) have the highest surgical risk with mortality rates exceeding 50% for major surgeries, as noted in the study by 1.
To assess operative risk for a patient with Child-Pugh class C liver disease, a comprehensive assessment should include both the Child-Pugh score itself and additional risk stratification tools. Beyond the Child-Pugh score, the MELD (Model for End-Stage Liver Disease) score should be calculated using serum creatinine, bilirubin, and INR values, as it often provides better mortality prediction, as discussed in the study by 1.
Key considerations for preoperative optimization include:
- Correcting coagulopathy with vitamin K and possibly fresh frozen plasma
- Managing ascites with diuretics such as spironolactone and furosemide
- Treating encephalopathy with lactulose
- Addressing nutritional deficiencies
- Cardiopulmonary evaluation to assess for portopulmonary hypertension or hepatopulmonary syndrome
For elective procedures in Child-Pugh C patients, consider whether transplantation might be more appropriate than the planned surgery, as the operative mortality risk is extremely high and often prohibitive for all but the most essential procedures, as recommended by 1 and 1.
In summary, the high operative risk associated with Child-Pugh class C liver disease necessitates careful consideration of alternative treatment options and thorough preoperative optimization to minimize morbidity and mortality.
From the Research
Assessing Operative Risk for Child-Pugh Class C Liver Disease
To assess operative risk for a patient with Child-Pugh class C liver disease, several factors must be considered:
- The Child-Pugh classification is a widely used system to assess the severity of liver disease, with class C indicating the most severe disease 2, 3, 4.
- Patients with Child-Pugh class C liver disease are at high risk of postoperative mortality and morbidity, with mortality rates ranging from 44% to 100% in various studies 2, 3, 5.
- The Model for End-Stage Liver Disease (MELD) score is another tool used to predict postoperative mortality in cirrhotic patients, and it has been shown to correlate well with the Child-Pugh score 4.
- A Mayo risk score >15 is also associated with high risk of postoperative mortality, and elective surgery should be deferred in these patients 6.
Preoperative Evaluation and Risk Assessment
Preoperative evaluation and risk assessment are crucial for patients with Child-Pugh class C liver disease:
- Patients should be evaluated for the presence of clinically significant portal hypertension and cirrhosis 6.
- Various risk assessment tools are available, including the Child-Pugh score, MELD score, Mayo risk score, and VOCAL-Penn score 6.
- Perioperative optimization and management of ascites, hepatic encephalopathy, bleeding, liver decompensation, and nutrition should be done with a multidisciplinary approach 6.
Surgical Considerations
Surgical considerations for patients with Child-Pugh class C liver disease include:
- Certain surgeries, such as hepatic resection, intraabdominal, and cardiothoracic surgery, have higher risks than others, such as abdominal wall hernia repair and orthopedic surgery 6.
- Laparoscopic approaches have better outcomes and less risk of liver failure than open surgery 2, 6.
- Minimally invasive alternatives, such as colonic stent placement in case of obstruction, can be considered in high-risk cases 6.