How do I assess medical fitness for surgery in a patient with chronic liver disease, including Child‑Pugh classification, Model for End‑Stage Liver Disease (MELD) score, and peri‑operative optimization?

Medical Fitness for Surgery in Chronic Liver Disease

Assessment Framework

Patients with chronic liver disease require systematic evaluation of liver function, portal hypertension status, and future liver remnant volume before any surgical intervention, with Child-Pugh Class A and MELD <10 representing the safest surgical candidates. 1, 2, 3

Core Assessment Components

1. Liver Function Stratification

Child-Pugh Classification:

• Child-Pugh Class A (5-6 points): Surgery is well tolerated with perioperative mortality <3% 1, 2, 3
• Child-Pugh Class B (7-9 points): Surgery permissible only for highly selected patients with normal liver function tests and no portal hypertension; otherwise defer elective procedures 1, 2, 4
• Child-Pugh Class C (10-15 points): Elective surgery should be avoided due to prohibitively high mortality risk 2, 4, 5

MELD Score Thresholds:

• MELD <10: Surgery well tolerated 3, 4
• MELD 10-15: Surgery permissible with caution (except liver resection and cardiac surgery) 4
• MELD >15 or Mayo risk score >15: High postoperative mortality risk; defer elective surgery 4, 5

2. Portal Hypertension Evaluation

Mandatory assessments include: 1, 3

• Upper endoscopy to identify esophagogastric varices
• Cross-sectional imaging (CT/MRI) for splenomegaly, abdominal collaterals
• Laboratory markers: Thrombocytopenia (platelet count <150,000/μL suggests portal hypertension)
• Liver stiffness measurement by transient elastography (VCTE): values >12-14 kPa predict significant risk of post-hepatectomy liver failure 1, 6

Clinical significance: Clinically significant portal hypertension (HVPG >10 mmHg) increases risk of hepatic decompensation and portal hypertensive bleeding, though limited resection may be feasible with mild portal hypertension if liver function is preserved 1

3. Additional Functional Assessment Tools

Indocyanine Green (ICG) Retention Test: 1

• ICG-R15 <20-25%: Major resection acceptable
• ICG-R15 <30-35%: Limited resection/segmentectomy acceptable
• ICG-R15 >35%: High risk for post-hepatectomy liver failure

ALBI Grade: Provides improved liver functional estimation compared to Child-Pugh alone, particularly useful for borderline cases 1

Hepatic Resection-Specific Criteria

Future Liver Remnant (FLR) Requirements

Calculate FLR/total liver volume ratio using CT volumetry: 1, 3, 6

• Normal liver: FLR ≥20% required
• Chronic liver disease/Child-Pugh A: FLR ≥30-40% required
• More advanced cirrhosis: FLR ≥40% required

Portal vein embolization (PVE) indications: 1

• Consider when FLR is below threshold values in otherwise suitable candidates
• Minimum hypertrophy criteria: >10% increase in patients with fibrosis/cirrhosis, >5% in normal liver
• Only indicated for Child-Pugh A patients without significant portal hypertension

Optimal Tumor Characteristics for Resection

Ideal candidates: 1

• Solitary tumors without major vascular invasion
• Absence of extrahepatic metastasis
• No tumor invasion of portal vein or hepatic veins/inferior vena cava

Perioperative Optimization Strategy

Preoperative Correction

Laboratory targets: 3, 7

• INR <1.5 (consider vitamin K supplementation)
• Albumin optimization through nutritional support
• Electrolyte correction (particularly hyponatremia)
• Creatinine monitoring for renal dysfunction

Ascites management: 4, 7

• Control ascites with diuretics (spironolactone ± furosemide)
• Consider large-volume paracentesis if tense ascites present
• Avoid surgery with uncontrolled ascites due to increased leak and infection risk

Nutritional support: 3, 7

• Adequate protein intake (1.2-1.5 g/kg/day)
• Correction of vitamin deficiencies (particularly vitamin K, thiamine, folate)
• Consider branched-chain amino acid supplementation

Intraoperative Considerations

Anesthetic selection: 7

• Safe agents: Isoflurane, propofol
• Avoid: NSAIDs (renal dysfunction risk), benzodiazepines (encephalopathy risk)
• Maintain adequate blood pressure to prevent hepatic hypoperfusion

Surgical technique optimization: 1

• Laparoscopic approaches preferred when feasible (lower risk of liver failure than open surgery) 4
• Intermittent hilar clamping (Pringle maneuver) to minimize blood loss
• Low central venous pressure maintenance
• Minimize blood transfusion requirements

Postoperative Monitoring

Daily surveillance for post-hepatectomy liver failure: 3

• Monitor bilirubin, INR, creatinine
• Watch for ascites development and hepatic encephalopathy
• Infection surveillance (wound, pneumonia, urinary tract)

Surgery Type-Specific Risk

Higher risk procedures: 4

• Hepatic resection (highest risk)
• Intra-abdominal surgery
• Cardiothoracic surgery

Lower risk procedures: 4

• Abdominal wall hernia repair
• Orthopedic surgery

Consider minimally invasive alternatives (e.g., colonic stent placement for obstruction) in high-risk patients 4

Critical Decision Algorithm

1. Calculate Child-Pugh score and MELD score 2, 3, 4
2. Assess for portal hypertension (endoscopy, imaging, platelets, liver stiffness) 1, 3
3. For hepatic resection: Calculate FLR ratio and consider ICG-R15 testing 1, 3
4. Apply risk stratification:
   • Child A + MELD <10 + no significant portal hypertension = Proceed with surgery
   • Child A + MELD 10-15 + mild portal hypertension = Proceed with caution (avoid major resection)
   • Child B/C or MELD >15 = Defer elective surgery; consider transplant evaluation 2, 4

Common Pitfalls to Avoid

• Do not rely on imaging alone to exclude cirrhosis; morphologic features appear only in advanced disease 6
• Do not assume normal INR means normal hemostasis; consider thromboelastography for global assessment 7
• Do not proceed with major hepatectomy without adequate FLR, even in Child-Pugh A patients 1, 6
• Do not overlook unrecognized cirrhosis; obtain preoperative biopsy if extent of parenchymal disease unclear and major resection planned 6