Along with the general burden of disease affecting patients with cirrhosis, this group has an elevated risk of perioperative morbidity and mortality compared to individuals without cirrhosis. In a recent narrative review based on 87 studies spanning 1998-2018, the authors reported that perioperative mortality rates are 2-10 times greater in patients with vs without cirrhosis, with varying rates based on the severity of liver dysfunction.1
The range of “effects of hepatic dysfunction on anatomy, physiology, and metabolism in cirrhosis present unique perioperative challenges including the accurate assessment of perioperative risk, the impact of anesthesia, risks unique to each surgical procedure, and post-operative care,” wrote Kira L. Newman, MD, PhD, an internal medicine resident at the University of Washington in Seattle, and colleagues.1
They examined the available evidence regarding these challenges in cirrhotic patients undergoing non-hepatic surgery specifically, noting that there is scant data to “guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion.” Selected points from the review are summarized below.
In addition to the standard preoperative assessments, it is critical to evaluate the severity of liver dysfunction as indicated by factors including portal hypertension, which “may increase the liver’s susceptibility to hemodynamic changes during surgery [and] cause hepatic ischemia and decompensation,” as explained in the paper.1 Along with a thorough physical exam, clinicians “may consider an esophagogastroduodenoscopy to screen for varices and/or portal gastropathy and an ultrasound or computed tomography scan to assess for ascites, splenomegaly, and portosystemic collaterals.”
Preoperative management of cirrhosis-associated conditions
Guidelines from the American Association for the Study of Liver Diseases recommend upper endoscopy to screen for esophageal varices before elective surgery.2 For patients with medium or large varices, initiating a non-selective beta blocker a few days before surgery may reduce portal venous pressure and thus the risk of variceal bleeding.1 If the patient is already taking carvedilol, this should suffice and there is no need to switch to a non-selective beta blocker.
Guidelines recommend optimal ascites control before surgery to limit the “risk of peritoneal infection, ascitic fluid leak from surgical sites, and would dehiscence in abdominal surgery,” wrote Newman, et al.1,3 Salt and fluid restriction, the use of diuretics, and paracentesis may be required, and preoperative transjugular intrahepatic portosystemic shunt (TIPS) represents another option for management of large-volume ascites.
Clinicians should aim to correct encephalopathy with lactulose (orally or via enema) and/rifaximin before elective surgical procedures. The use of serum ammonia level to diagnose and titrate treatment is not advised, as it has shown poor correlation with the presence of hepatic encephalopathy.1
Ideally, coagulopathy should be assessed via thromboelastography where available.1,4 Other options to treat coagulopathy, each with their own risks and need for monitoring, include fresh frozen plasma (with central venous pressure monitoring due to the risk of fluid overload and pulmonary congestion), vitamin K (in case malnutrition is contributing to coagulopathy), cryoprecipitate (in patients with fluid overload), coagulation factors such as fibrinogen concentrate, and several other therapies.1,4
Malnutrition and sarcopenia
Estimated prevalence rates of malnutrition and sarcopenia in patients with cirrhosis are 80% and 25%-70%, respectively.1 Even those with normal or elevated body mass index may have sarcopenia, which is linked with a 3 times greater risk of mortality in cirrhotic patients, as well as delayed wound healing and poor outcomes in patients undergoing surgery. Those who need help maintaining their weight and adequate dietary intake may require nutritional counseling, which has been found to be associated with improved surgical outcomes.1
Newman, et al, also note the need to manage or address immunologic and inflammatory dysfunction, concomitant hepatitis B and C virus infections, current alcohol use, and alterations in medication metabolism.1
“To adequately estimate post-operative mortality, we need models that incorporate cirrhosis-related, surgery-related, and comorbidity-related predictors,” the study authors stated.1 “Such models do not currently exist.” The most commonly used systems to predict postoperative morbidity and mortality in patients with cirrhosis include the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD).4
Perioperative mortality and morbidity in patients with cirrhosis are influenced by the type, complexity, and urgency of surgery. For example, colorectal resection has one of the highest postoperative mortality rates (13%-26%) among gastrointestinal surgeries, while elective abdominal hernia repair has one of the lowest mortality rates (typically 0%). Additionally, various studies have demonstrated that postoperative mortality rates are 4 to >10 times higher in cirrhotic patients undergoing emergent vs elective surgery.1
Intraoperative and postoperative considerations
Considerations for intraoperative care include the need for invasive blood pressure monitoring, especially for patients with advanced cirrhosis; transesophageal echocardiography for high-risk procedures; and selection of anesthetic strategies that align with the “overarching interoperative goals… to maintain hepatic blood flow and oxygen supply and to minimize exposure to hepatoxic medications.”1
Postoperatively, patients should be monitored and treated as needed to reduce the risk of complications such as encephalopathy, renal dysfunction, spontaneous bacterial peritonitis, and venous thromboembolism. For “patients who are potential transplant candidates and require a prior non-urgent operation, it is reasonable to complete a transplant workup before surgery to expedite listing for an organ in case of postoperative hepatic failure,” as stated in the review.1
Dr Newman was interviewed for further discussion on the topic.
What are some of the main risk factors for increased perioperative morbidity and mortality in patients with cirrhosis?
Dr Newman: Some of the most significant risk factors for increased perioperative morbidity and mortality in patients with cirrhosis are severity of liver dysfunction, medical comorbidities, and whether the surgery is emergent or elective. Emergent surgery is associated with especially poor outcomes in patients with cirrhosis.
What are some ways in which these risks can be assessed and managed?
Dr Newman: Preoperative planning is especially important for patients with cirrhosis. This includes allowing enough time for medical optimization while still providing prompt management of time-sensitive conditions. Delaying some types of surgery for too long may put patients at risk for crises that require emergent intervention, which increases the risk of poor outcomes.
What are other key considerations for clinicians regarding this topic?
Dr Newman: For many patients with well-compensated cirrhosis and low MELD scores, elective surgery is reasonable to consider. Cirrhosis alone should not disqualify a patient as an operative candidate.
What should be the focus of future research in this area?
Dr Newman: There is a need for well-designed prospective studies of perioperative management and surgical techniques in patients with cirrhosis. There is also a need for the development of better perioperative risk calculators that can be applied to patients with cirrhosis.
1. Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative evaluation and management of patients with cirrhosis: risk assessment, surgical outcomes, and future directions [published online July 31, 2019] Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2019.07.051
2. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65(1):310-335.
3. Northup PG, Friedman LS, Kamath PS. AGA clinical practice update on surgical risk assessment and perioperative management in cirrhosis: expert review. Clin Gastroenterol Hepatol. 2019 Mar;17(4):595-606.