How to optimize a patient with liver cirrhosis (cirrhosis) for surgical procedures?

From the Guidelines

Optimizing a cirrhosis patient for surgery requires a comprehensive approach that prioritizes 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%.

Preoperative Assessment

Begin with a thorough preoperative assessment including Child-Pugh or MELD scoring to quantify liver dysfunction severity, as mortality increases significantly with higher scores 1.

• Include at least volumetry, indocyanine green liver retention test, and one laboratory value-based test (e.g., Child-Pugh, model for end-stage liver disease [MELD], albumin-bilirubin [ALBI], aspartate aminotransferase-to-platelet ratio index) for risk assessment in all liver resection candidates.
• In case a major hepatectomy is planned, scintigraphy should also be added.

Management of Coagulopathy and Bleeding Risk

Correct coagulopathy with vitamin K (10mg IV daily for 3 days) and consider fresh frozen plasma (for INR >1.5) or platelets (for counts <50,000/μL), but routine use of fresh frozen plasma to decrease the rate of procedure-related clinically relevant bleeding is not recommended 1.

• Infusion of platelet concentrates or use of TPO-R agonists is not recommended when platelet count is above 50 × 10^9/L or when bleeding can be treated by local haemostasis.
• In patients undergoing high-risk procedures in whom local haemostasis is not possible and platelet count is between 20 × 10^9/L and 50 × 10^9/L, infusion of platelet concentrates or TPO-R agonists should not be routinely performed but may be considered on a case-by-case basis.

Ascites and Hepatic Encephalopathy Management

Address ascites with sodium restriction (2g/day), diuretics (spironolactone 100-400mg/day with furosemide 40-160mg/day), and paracentesis if needed to reduce respiratory compromise and wound complications.

• Manage hepatic encephalopathy with lactulose (30ml orally three times daily, titrated to 2-3 soft bowel movements daily) and rifaximin (550mg twice daily).

Nutrition and Fluid Management

Optimize nutrition with 1.2-1.5g/kg/day protein intake and consider branched-chain amino acid supplementation.

• Ensure euvolemia while avoiding excessive fluid administration.

Perioperative Care

Prophylaxis against infection is crucial, particularly with albumin (1.5g/kg at anesthesia induction and 1g/kg postoperatively) for procedures with high bleeding risk.

• Choose anesthetic agents with minimal hepatic metabolism (sevoflurane, desflurane) and adjust medication dosages according to liver function.
• Postoperatively, monitor closely for bleeding, infection, renal dysfunction, and encephalopathy.
• Patients with clinically significant portal hypertension (defined as HVPG >10 mmHg) or Child-Pugh class B are at higher risk and require careful consideration 1.

From the Research

Preoperative Optimization for Cirrhosis Patients

To optimize cirrhosis patients for surgery, several factors need to be considered, including the severity of liver disease, presence of comorbidities, and type of surgical procedure. The following are key points to consider:

• Accurate assessment of liver function using scoring systems such as the Child-Pugh score 2 or the Model for End-Stage Liver Disease (MELD) score 3
• Identification and management of comorbidities, such as ascites, encephalopathy, and renal dysfunction 2, 3
• Optimization of medical therapy preoperatively, including diuretics for ascites and lactulose for encephalopathy 2, 3
• Correction of coagulopathy using pharmacologic adjuncts 2
• Consideration of alternative treatments, such as transjugular intrahepatic portosystemic shunt (TIPS), for patients with portal hypertensive bleeding 2

Risk Assessment and Prediction

Several risk prediction tools are available to estimate perioperative mortality in cirrhosis patients, including:

• Child-Turcotte-Pugh score 4, 2, 3
• Model for End-Stage Liver Disease-Sodium (MELD-Na) score 4
• Mayo Risk Score 4
• VOCAL-Penn Score 4 These tools can help identify patients at high risk of postoperative complications and guide preoperative optimization and postoperative monitoring.

Surgical Considerations

Surgery in cirrhosis patients requires careful consideration of the type of procedure, anesthetic technique, and postoperative care. Key points to consider include:

• Avoiding surgery in patients with acute hepatitis, acute liver failure, or alcoholic hepatitis 3
• Using careful hemodynamic monitoring to avoid worsening liver function 3
• Providing close postoperative monitoring for early detection of complications 3
• Considering alternative treatments, such as TIPS, for patients with portal hypertensive bleeding 2