1. SURGICAL CLEARANCE IN LIVER DISEASE
Dr. Sawan Bopanna
Preceptor :Dr Shalimar

2. Patients with liver disease presenting for various surgical interventions are increasing
Patients with liver disease form an important subset of surgical candidates
Altered liver function has various implications for those undergoing surgery
Pre-op evaluation of patients with liver disease- common hepatology consult

3. ASSESSING SURGICAL RISK CHALLENGING TASK

4. Effects of surgery and anesthesia on liver disease
OVERVIEW
Effects of surgery and anesthesia on liver disease
Operative risks in various liver diseases
Operative risks in various surgeries
Preoperative risk assessment and clearance for surgery
Surgical risk in patients with obstructive jaundice

5. EFFECT OF SURGERY & ANESTHESIA ON LIVER

6. HEMODYNAMIC CHANGES IN LIVER DISEASE
Liver Disease especially cirrhosis - state of altered hemodynamics
At baseline hepatic perfusion is reduced in cirrhosis:
Peripheral and splanchic vasodilation –reduced effective circulatory volume
Hepatic arterial flow further reduced- altered autoregulation
Portal blood flow is reduced due to increased intrahepatic resistance

7. Decreased hepatic perfusion at baseline makes the diseased liver more susceptible to :
HYPOTENSION
HYPOXEMIA

8. PERIOPERATIVE HYPOTENSION
May occur due to excessive blood loss, intra-operative arrhythmias, and secondary to anesthetic agents
Intermittent positive pressure ventilation and pneumoperitoneum due to laparoscopic surgery mechanically decrease blood flow to the liver
Laparotomy with traction on abdominal viscera causes dilation of splanchnic veins and thereby lower hepatic blood flow
Anesthetic agents including epidural and spinal anesthesia reduce hepatic blood flow by 30-50%

9. RISK FACTORS FOR INTRAOPERATIVE HYPOXEMIA IN PATIENTS WITH LIVER DISEASE
Hepatic hydrothorax
Ascites
Hepatopulmonary syndrome
Portopulmonary hypertension
Ascites and hepatic hydrothorax should be treated before elective surgery
Hepatopulmonary syndrome and portopulmonary hypertension – contraindications to surgery

10. ANESTHETIC RISKS
The risk of surgery cannot be separated from the risk of anesthesia
All volatile anesthetics decrease hepatic blood flow
Advanced liver disease may impair the elimination, prolong half-life and potentiate clinical effects of several drugs
Sedatives, narcotics, and intravenous induction agents must be used with caution in patients with decompensated CLD - may precipitate hepatic encephalopathy

11. OPERATIVE RISKS IN VARIOUS LIVER DISEASES

12. Overview Surgical Risk Cirrhosis Obstructive Jaundice Acute Hepatitis
Chronic Hepatitis

13. Precise estimates of operative risk in patients with well characterized liver disease are few
Most available data derived are from small studies
Mostly retrospective studies of cirrhotic patients who underwent surgery

14. ACUTE HEPATITIS
Operative mortality 10-13% - Data from older studies in patients who underwent laparotomy
Surgery in Acute Hepatitis Causes and Effects Donald D. Harville, MD.JAMA 1963;184(4):
High mortality in patients with alcoholic hepatitis –mortality rates as high as 55%
Surgery is thus contraindicated in patients with acute hepatitis
Can be undertaken after clinical and biochemical resolution of hepatitis

15. CHRONIC HEPATITIS
Surgical risk correlates with clinical, biochemical, and histological severity of disease
Asymptomatic mild chronic hepatitis- not a contraindication for elective surgery
Patients with symptomatic and histologically severe chronic hepatitis have an increased surgical risk
Increased risk if hepatic synthetic function is decreased or portal hypertension is present

16. SURGICAL RISK IN CIRRHOSIS DEPENDS ON
1. Severity of liver disease
2. Nature of the surgical procedure
3. Associated comorbidities

17. ASSESSMENT OF SEVERITY OF LIVER DISEASE FOR SURGICAL CLEARANCE
Child Turcotte Pugh scoring system - most commonly used
Rationale for use of the Child score based on retrospective studies
Predicts postoperative mortality
Child class correlates well with post operative complication including liver failure, worsening encephalopathy, bleeding, infection and ascites

18. Evidence in the form of retrospective studies
MORTALITY RATE
Evidence in the form of retrospective studies
Studies in patients undergoing abdominal surgeries
Garrison RN, Cryer HM, Howard DA, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984;199:648–55
Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 1997;122:730–5
Telem DA, Schiano T, Goldstone R, et al. Factors that predict outcome of abdominal operations in patients with advanced cirrhosis. Clin Gastroenterol Hepatology 2010;8:451–7
Child Class
Garrison et al 1984(%)
Mansour et al
1997(%)
Telem et al
2010(%) A
10 %
10% 2% B
31 %
30%
12% C
76%
82%

19. Lower mortality –attributed to better preoperative management
Morbidity rate still remained high

20. IMPACT OF PORTAL HYPERTENSION
Child A cirrhosis with portal hypertension - mortality rates increase
Similar to Child B cirrhosis - 30%
Reduction in portal pressure by preoperative placement of TIPS - may improve surgical outcome in these patients
Azoulay D, Buabse F, Damiano I, et al. Neoadjuvant transjugular intrahepatic portosystemic shunt: A solution for extrahepaticabdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001;193:46-51

21. Seven cirrhotic patients with severe portal hypertension
Azoulay D, Buabse F, Damiano I, et al. Neoadjuvant transjugular intrahepatic portosystemic shunt: A solution for extrahepaticabdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001;193:46-51
Seven cirrhotic patients with severe portal hypertension
Portal hypertension was the leading cause of surgical contraindication
TIPS to control portal hypertension followed by surgery in 6 of the 7 patients
Surgery was performed with a delay ranging from 1 month to 5 months after TIPS
Operative mortality was seen in only 1 patient

22. TIPS was performed a mean (± SD) of 72±21 days before surgery
Can J Gastroenterol Vol 20 No 6 June 2006
Study evaluated the clinical outcomes of 18 patients with cirrhosis who underwent TIPS
TIPS was performed a mean (± SD) of 72±21 days before surgery
Cirrhotic patients who underwent elective abdominal surgery without preoperative TIPS placement were used as the control group

23. p= 0.58
Study suggested preoperative TIPS did not significantly improve postoperative survival to suggest routine use

24. Emergency surgery increases the perioperative mortality in addition to the Child score
Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 1997;122:730–5.
Child score
Emergency
Elective A
22%
10% B
38%
30% C
100%
82%

25. MELD SCORE TO ASSESS SURGICAL RISK
Has distinct advantages when compared to Child score
It is objective, weights the variables differently and does not rely on arbitrary cut off
Each 1-point increase in MELD score- incremental contribution to operative risk
MELD increases precision in assessing surgical risk

26. 140 surgical procedures were identified and analyzed
140 surgical procedures were identified and analyzed. The 30-day mortality rate was 16.4%
Further subgroup analysis of 67 intra-abdominal surgeries showed an in-hospital mortality of 23.9%.
Linear relationship to mortality, with mortality rising by 1% for each MELD point below 20, and 2% for higher MELD scores (P )
Northup PG, Wanamaker RC, Lee VD et al. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann. Surg. 2005; 242: 244–51
N=140
Died at 30 days
Survived >30 days
P value
Mean admission MELD
23.3(19.6 –27.0)
16.9 (15.6 –18.2)
0.0003
N=67
Died at 30 days
Survived >30 days
P value
Mean admission MELD
24.8 (20.4 –29.3)
16.2( 14.2–18.2) P

27. Large retrospective study
GASTROENTEROLOGY Vol. 132, No. 4
Large retrospective study
772 cirrhotic patients who underwent surgery were included in the study
Digestive(n=586), Orthopedic(n=107), Cardiovascular(n=79)
Control group of patients with cirrhosis included 303 patients undergoing minor surgical procedure and 562 outpatient cirrhotics

28. Patients undergoing major surgery were at increased risk for mortality upto 90 days postoperatively
In the multivariable analysis - significant predictors of mortality
1. MELD score
2. Age
3. ASA class
A single point increase in the MELD score –
14% increase in mortality in the first 30 and 90 postoperative days
15% increase in mortality in the first postoperative year
6% increase in mortality for subsequent years

29. RELATIONSHIP BETWEEN MELD AND MORTALITY
Mortality risk almost linear for MELD scores greater than 8
30 day mortality
60 day mortality
MELD score
Mortality
7 or less
5.7%
8-11
10.3%
12-15
25.4%

30. ASA CLASSIFICATION (AMERICAN SOCIETY OF ANESTHESIOLOGISTS)
Healthy patient II
Mild systemic disease without functional limitation
III
Patient with severe systemic disease with functional limitation IV
Patient with severe systemic disease that is a constant threat to life V
Moribund patient not expected to survive >24 hours with or without surgery
ASA class IV added the equivalent of 5.5 to the prior MELD points
The influence of the ASA class was greatest in the first 7 days after surgery

31. No patient under 30 years of age died and an age greater than 70 years added the equivalent of 3 MELD points to the mortality rate
Emergency surgery was not an independent predictive factor for mortality when the MELD score was considered
A website based calculator was developed which could calculate the mortality risk at different time points based on Age, MELD score and ASA class

32. CTP vs MELD SCORE
World J Gastroenterol 2008 March 21; 14(11):
195 patients with cirrhosis who underwent surgery were reviewed
CTP and MELD scores performed equally in predicting mortality and hepatic decompensation
Though MELD score as its advantages, NO CLEAR RECOMMENDATION can be made regarding use of one over the other, based on current literature

33. MELD + CTP
SURGICAL CLEARANCE
Child C and MELD >14
No surgical intervention
Child B and MELD >8-14
Increased perioperative risk and indication for surgery should be reassessed
Child C and MELD <14
Low perioperative mortality and can be taken up for surgery with low risk

34. PERIOPERATIVE CONSIDERATIONS IN VARIOUS LIVER DISEASES
Chronic HBV/HCV
Carrier states –do not affect surgical risk
Risk increases as biochemical/histologic activity increases
Continue Antiviral therapy
Autoimmune hepatitis
Surgical risk correlates with surgical/histological severity
Increased doses of glucocorticoids may be required
NAFLD
Mortality rate is increased (7-14%) following hepatic resection in moderate to severe steatosis
Hemochromatosis
Cardiomyopathy associated with hemochromatosis increases surgical risk
Wilsons disease
Surgery may precipitate or aggravate neurological disease.
D-pencillamine dose to be reduced as it inhibits healing

35. CONTRAINDICATIONS TO ELECTIVE SURGERY 1. Acute Liver Failure 2
CONTRAINDICATIONS TO ELECTIVE SURGERY 1. Acute Liver Failure 2. Acute Kidney Injury 3. Acute Viral Hepatitis 4. Alcoholic hepatitis 5. Cardiomyopathy 6. Hypoxemia 7. Severe coagulopathy (despite treatment)

36. OPERATIVE RISKS IN VARIOUS SURGERIES

37. CARDIAC SURGERY
Cardiac surgery and other procedures that require use of cardiopulmonary bypass are associated with greater mortality in patients with cirrhosis
Child status
Suman et al(N=44)
(Cleveland Clinic)
Filsoufi et al(N=27)
(Mt Sinai hosp) A
3 %
10 % B
42%
18 % C
100%
67 %

38. ABDOMINAL WALL SURGERY: UMBULICAL HERNIA REPAIR
Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites
Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites Surgery 2011 Sep;150(3):542-6
30 patients underwent operation at a mean age of 58 years
6 were classified as CPT grade A (20%), 19 (63%) as grade B, and 5 (17%) as grade C
No mortality or complications were noted post surgery

39. CHOLECYSTECTOMY IN CIRRHOTICS: OPEN VS LAPAROSCOPIC
Prevalence of gallstones in patients with cirrhosis is estimated at 29–46% and thus is three times as high as those in patients without cirrhosis
Symptomatic gallstones in cirrhotics need to be treated
In the era prior to Lap Cholecystectomy, reported postoperative mortality in patients with cirrhosis undergoing Open Cholecystectomy was 7.5–25.5%

40. Forty-four studies were analyzed
HPB (Oxford) Mar;14(3):153-61
Forty-four studies were analyzed
These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n = 1756) or open (n = 249) cholecystectomy
Mortality rates of 0.74% in laparoscopic cholecystectomy and
2.00% in open cholecystectomy
Meta-analysis of 3 randomized controlled trials were performed(total 220 patients)
Studies were small, heterogeneous in design and include almost exclusively patients with Child–Pugh class A and B disease

41. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC
However, frequencies of postoperative hepatic insufficiency did not differ significantly
In patients with cirrhosis when cholecystectomy is indicated, laparoscopic approach should be considered

42. A meta-analysis of three RCTs involving a total of 220 patients was conducted
Forrest Plots of outcomes:
1.Total postoperative complications
(P = 0.03)
2.Infectious complications
(P = 0.001)
3.Postoperative hepatic insufficiency
(P = 0.40)

43. OBSTRUCTIVE JAUNDICE
Factors affecting morbidity and mortality after obstructive jaundice: review of 373 patients
Gut 1983
Retrospective analysis of 373 patients
Of the 373 patients 281 had a benign and 92 had a malignant cause of obstruction
Three risk factors identified for perioperative death:
Low hematocrit (< 30%)
Elevated serum bilirubin (> 11 mg/dL)
Malignant cause of biliary obstruction
When all 3 present risk of mortality -60%
When none present risk of mortality -5%

44. There was no significant difference in mortality between the 2 groups
Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice
Br J Surg.2013 Nov;100(12): doi: /bjs.9260
Meta-analysis of 6 RCTs
520 patients with malignant or benign obstructive jaundice were included
265 patients had undergone Preoperative Biliary Drainage and 255 patients had no Preoperative Biliary Drainage
There was no significant difference in mortality between the 2 groups
More morbidity among patients who underwent preoperative biliary drainage

45. PBD cannot significantly reduce the postoperative mortality and complications of malignant obstructive jaundice, and therefore should not be used as a preoperative routine procedure for malignant obstructive jaundice
Effect of preoperative biliary drainage on malignant obstructive jaundice: a meta-analysis World J Gastroenterol.2011 Jan 21
There is currently not sufficient evidence to support or refute routine pre-operative biliary drainage for patients with obstructive jaundice. Pre-operative biliary drainage may increase the rate of serious adverse events
Pre-operative biliary drainage for obstructive jaundice Cochrane Database Syst Rev. 2012

46. HEPATIC RESECTION
Post-resectional liver failure has been defined as a prothrombin-time index of less than 50% (INR> 1.7) and serum bilirubin greater than 50 mol/L (>2.9 mg/dL)[“50-50” criteria]
When these criteria are met postoperative mortality is 59% when compared to patients to 1.2% in patients not meeting the above criteria
Sensitivity of 50% and specificity of 96% for prediction of post resection liver failure
van den Broek MA, Olde Damink SW, Dejong CH, et al. Liver failure after partial hepatic resection: definition, pathophysiology, risk factors and treatment. Liver Int 2008;28:767–80

47. Risk Stratification: MELD score
Indication of the extent of hepatectomy for hepatocellular carcinoma on cirrhosis by a simple algorithm based on preoperative variables
Arch Surg 2009
Retrospective study
466 patients who underwent hepatectomy for HCC
29 patients had post hepatectomy liver failure
MELD
PLF
<9
0.4%
9-10
1.2%
>10
15%

48. PERIOPERATIVE ASSESSMENT
Every effort should be undertaken to optimize the condition of a patient with liver disease prior to surgery
Ascites should be treated prior to surgery to avoid respiratory compromise, wound dehiscence or abdominal wall hernia
Volume status and renal function should be optimized to reduce risk of HRS
Nutritional assessment and optimization of nutritional support

49. PREOPEREATIVE EVALUATION OF ASYMPTOMATIC PATIENT WITH ABNORMAL LIVER TEST
Raised ALT/AST
<2x NL
>2xNL or
>1xNL +raised INR
Normal ALP
Bilirubin
INR
H/O of prior liver disease
Imaging and further evaluation
Surgery

50. RAISED ALKALINE PHOSPHATASE
<2x NL
>2x NL
Abnormal GGT/Bilirubin
Normal GGT /
Bilirubin
Further evaluation before surgery
Surgery

51. ANESTHETIC CONSIDERATIONS
The anesthetic agents Halothane and Enflurane
reduce hepatic arterial blood flow
Desflurane and Isoflurane are preferred inhalational anesthetics in chronic liver disease
Intravenous anesthetics have only a modest effect on hepatic blood flow
Neuromuscular blocker action is prolonged due to reduced hepatic clearance
Atracurium is the safest NM blocker in chronic liver disease

52. POSTOPERATIVE ASSESSMENT
Patients with cirrhosis need to be monitored for the development of signs of hepatic decompensation
When any of these indicators is found supportive therapy should be initiated immediately
Monitoring of liver function postoperatively- serum bilirubin and prothrombin time
Glucose monitoring to prevent hypoglycemia
Careful attention should be paid to the assessment of intravascular volume

53. SUMMARY
Patients with chronic liver disease face greater risk of perioperative morbidity and mortality
Risk is greater among patients with cirrhosis
Child-Pugh score has consistently performed well in estimating relative risk or mortality
The best outcomes among Child-Pugh class A patients and poor outcomes for patients with Child-Pugh class C cirrhosis

54. MELD score can predict surgical outcomes
The combination of the Child-Pugh score and the MELD score can guide patients and their surgeons regarding operative risks
Various open abdominal and even cardiac surgeries can be performed in patients of Child A status and MELD score < 8 with low perioperative mortality
In patients with Child C status and MELD score > 14, elective surgeries should be avoided

55. Elective surgery - the procedure should be delayed to allow for a complete evaluation of the severity of liver disease
Optimization of complications such as varices, ascites, and encephalopathy - necessary before surgery
Elective surgery should not be offered to patients with acute liver failure and alcoholic hepatitis

56. Acute Liver Disease
Acute Hepatitis
Acute Liver Failure
Wait till resolves
Consider Transplant

57. Child C/MELD score >14 Consider alternative to surgery
Cirrhosis
Child B/MELD score 8-14
Proceed with caution
Child A/MELD <8
Proceed with surgery
Chronic Liver disease
No Cirrhosis
Proceed with surgery

58. THANK YOU