1. RISK OF SURGERY IN THE PATIENT WITH LIVER DISEASE
Ajay Jain
Gastroenterology Fellow
January 16, 2002

2. CASE ID/CC: 57 F admitted Aug. 28 with L femur # PMHx: HCV Cirrhosis
OGD (1998) Gr II varices
No GI bleed, encephalopathy, SBP
MEDS: nadolol 40 mg OD
spironolactone 100mg OD
furosemide 40 mg OD
Other Hx:
no alcohol abuse

3. CASE
O/E: 110/72,70, 18, afebrile
H&N: scleral icterus, jaundice, spider angiomata
CVS: JVP 3cm ASA, normal S1 S2, no S3 S4, no murmurs, + SOA
PULM: clear
ABDO:distended, bulging flanks, + fluid wave, spleen tip palpable, liver span 8cm, non-tender
NEURO: no asterixis

4. CASE LAB: Hb 97 (MCV 94) Na+ 132 WBC 8.6 Cr 36 Plts 84 Urea 5.1
ALB 18 AST 85
INR ALT 60
T.BILI ALP 253
ABDO U/S:
nodular liver 9cm c/w cirrhosis
spleen 14cm
moderate ascites

5. What recommendations would you provide to the orthopedic surgeon and the patient?

6. Introduction multiple functions of the liver
synthesis of most serum proteins
metabolism of nutrients and drugs
excretion and detoxification of endogenous toxins and exogenous agents
filtering of portal venous blood

7. Introduction
any or all of the functions of the liver may be impaired in patients with liver disease
pharmacokinetic parameters of:
anaesthetics
muscle relaxants
analgesics, and sedatives
can be affected by changes in their
binding to plasma proteins
detoxification
excretion

8. Introduction bleeding risk may be increased due to coagulopathy
susceptibility to infection may be increased due to:
altered functioning of hepatic reticuloendothelial cells
changes in the immune system
portal hypertension

9. Introduction
in the vast majority of patients with liver disease in whom liver function is preserved, the operative risk is not likely to be increased
mild elevations of serum transaminases, alkaline phosphatase, or bilirubin levels are frequent post-operatively
in pts without liver disease, these elevations are usually transient and of no clinical significance

10. Introduction
A diseased liver is particularly susceptible to the hemodynamic changes that accompany surgery
altered hepatic flow may result in hepatic dysfunction in predisposed individuals
Med Clin North Am, 1987
Hepatology, 1991

11. Effects of Anesthesia on the Diseased Liver
anesthesia results in moderate reduction in hepatic arterial blood flow and hepatic oxygen uptake
no clinical significance of these changes seen in healthy volunteers
liver blood flow returns to baseline during surgery
initial hypoperfusion and/or reperfusion injury may contribute to postoperative liver dysfunction

12. Effects of Anesthesia on the Diseased Liver
Volatile Anesthetics (Halothane & Enflurane)
reduce hepatic arterial (HA) blood flow (systemic vasodilatation)
small negative inotropic effect
significant hepatic metabolism (halothane - 20%, enflurane - 3%)
Isoflurane
may actually increase HA blood flow
preferred agent in patients with liver disease
undergo less hepatic metabolism (0.2%)
(corresponds with lower risk of drug-induced hepatitis)
(risk of halothane hepatitis quite low: 1 in )

13. Effects of Anesthesia on the Diseased Liver
Hypercarbia
sympathetic stimulation of splanchnic vasculature, thereby decreasing portal blood flow
pCO2 should be maintained between mmHg during surgery

14. Effects of Anesthesia on the Diseased Liver
Neuromuscular Blocking Agents
prolonged in patients with liver disease due to:
reduced plasma pseudocholinesterase activity
decreased biliary excretion
increased volume of distribution
Atracurium
preferred agent in patients with liver disease
metabolism independent of the liver
Doxacurium
long-acting muscle relaxant
recommended for prolonged procedures including hepatic transplantation

15. Effects of Anesthesia on the Diseased Liver
Narcotics
morphine and meperidine
reduces hepatic blood flow
fentanyl
preferred narcotic agent
Sedatives
diazepam
prolonged metabolism in patients with liver disease
lorazepam
eliminated by glucoronidation without hepatic metabolism
preferred agent

16. Effect of Type of Surgical Procedure on the Diseased Liver
important determinant of post-operative hepatic dysfunction
risk: laparotomy > extra-abdominal surgery
greater reduction in HA blood flow
cholecystectomy, gastric surgery and colectomy associated with high mortality rates in patients with decompensated cirrhosis
morbidity/mortality higher for emergent than elective surgery

17. Effect of Type of Surgical Procedure on the Diseased Liver
Cardiac Surgery (limited experience)
13 pts with alcoholic cirrhosis underwent emergent CABG/valve replacement
post-operative mortality rate
Child’s A: 0 %
Child’s B: 80 %
Ann Thorac Surg, 1998

18. Modified Child-Pugh Score
Points
Parameter
albumin > <28
INR < >2.3
bilirubin (mg/dL) < >3.0
ascites absent slight-mod tense
encephalopathy none Gr. I-II Gr. III-IV
Class A: 5-6 points
Class B: 7-9 points
Class C: points

19. Estimating Operative Risk in Patients with Liver Disease
minimal data on precise estimates of operative risk
most data from small retrospective studies of cirrhotic patients undergoing abdominal surgery
pre-operative risk likely dependent on type of underlying liver disease

20. Contraindications to Elective Surgery in Patients with Liver Disease
Acute viral hepatitis
Acute alcoholic hepatitis
Fulminant hepatic failure
Severe chronic hepatitis
Child’s class C cirrhosis
Severe coagulopathy (PT > 3 sec vs control, Plt<50)
Severe extrahepatic complications
hypoxemia
cardiomyopathy, heart failure
acute renal failure

21. Acute Hepatitis acute hepatitis contraindication to elective surgery
peri-operative mortality rates: 9.5 to 13%
(in icteric patients)
surgery also contraindicated in patients with a histological diagnosis of alcoholic hepatitis
mortality rates as high as 55% reported in patients undergoing open liver biopsy or portosystemic shunt surgery
JAMA, 1963
Br J Surg, 1982

22. Chronic Hepatitis
surgical risk correlate with clinical, biochemical, and histological severity of disease
elective surgery reported to be safe in patients with asymptomatic mild chronic hepatitis

23. Fatty Liver and Non-Alcoholic Steatohepatitis
alcoholic or non-alcoholic fatty liver is not a contraindication to elective surgery
trend toward increased mortality following hepatic resection in patients with moderate to severe steatosis (ie. >30% of hepatocytes containing fat)
J Gastrointest Surg, 1998
period of abstinence from alcohol before surgery advisable

24. Fatty Liver and Non-Alcoholic Steatohepatitis
EFFECT OF PREOPERATIVE ABSTINENCE ON POOR POSTOPERATIVE OUTCOME IN ALCOHOL MISUSERS: RANDOMIZED CONTROLLED TRIAL
(BMJ, 1999)
41 alcoholic (>60g ethanol/d) patients without liver disease undergoing elective colorectal surgery
abstinence from alcohol (n=20) vs continuous drinking (n=21)
Abstinence Continuous
post-op complications % %
post-op myocardial ischemia 23% %
post-op arrhythmias % %

25. Other Causes of Liver Disease
Autoimmune Hepatitis
if in remission, elective surgery well tolerated in patients with compensated liver disease
perioperative administration of “stress” doses of hydrocortisone indicated in patients taking prednisone
Hemochromatosis
monitoring of diabetes in perioperative period
assess for possibility of cardiomyopathy
Wilson’s Disease
neuropsychiatric involvement - interferes with consent
D-pencillamine can impair wound healing - decrease dose in first 1-2 postoperative weeks

26. Cirrhosis
retrospective studies have shown that perioperative mortality and morbidity rates correlate well with the Child-Turcotte-Pugh class of cirrhosis
Alcoholic Cirrhosis (abdominal surgery): Mortality Rates
Child’s A % 10%
Child’s B
Child’s C
some studies have not confirmed predictive value of Child’s classification, mainly due to few Child’s C patients
APACHE III can predict survival in cirrhotic patients admitted to an ICU; yet to be studied in cirrhotics undergoing surgery

27. Resection for Hepatocellular Carcinoma (HCC)
annual incidence of HCC 3 to 5%
perioperative mortality rate for hepatic resection 3 to 16%
postoperative morbidity rates as high as 60%
5 year recurrence rates are as high as 100%
5 year survival rates are no higher than 50%

28. Preoperative Evaluation
1 in 700 otherwise healthy individuals will have abnormal liver function tests
any patient undergoing surgery:
careful history to identify risk factors for liver disease
a history of jaundice or fever after anesthesia
alcohol history and complete review of medications
sx or findings on physical examination suggestive of liver dz
patients with known liver disease:
identify presence of jaundice, ascites, or encephalopathy
complete biochemical assessment of liver function
correct coagulopathy, ascites and encephalopathy

29. Postoperative Period
monitor for signs of liver decompensation including worsening jaundice, encephalopathy and ascites
bilirubin and prothrombin time best measures of hepatic function
renal function important to monitor because of the risk of hepatorenal syndrome
monitoring of serum glucose levels as hypoglycemia often accompanies postoperative hepatic failure

30. CASE - Hospital Course Hospital Day 4
doubling of Cr and urea, small drop in Hb
diagnostic paracentesis c/w SBP ==> ceftriaxone
Hospital Day 6
asterixis
bili 398, INR 1.90, increasing Cr
Hospital Day 9
OGD - Gr III varix - no active bleed

31. CASE - Hospital Course Hospital Day 12
Na+ 122, Cr 170, T.Bili 493, INR 2.2
drowsy
DNR status obtained
Hospital Day 13
hypotensive - Rx with IV fluids
comfort measures
Hospital Day 14
progressive obtundation
glucometer 1.5
expired

32. DISCUSSION