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Perioperative considerations for patients with liver disease

November 1, 2009|Cleveland Clinic Journal of Medicine
Paul Martin, MD, MPH
Author and Disclosure Information

Paul Martin, MD
Professor of Medicine and Chief, Division of Hepatology, University of Miami Miller School of Medicine, Miami, FL

Correspondence: Paul Martin, MD, Chief, Division of Hepatology, University of Miami Miller School of Medicine, P.O. Box 016960, Miami, FL 33101–6960; pmartin2@med.miami.edu

Dr. Martin has indicated that he has no financial relationships with commercial interests that have a direct bearing on the subject matter of this article.

This article was developed from an audio transcript of Dr. Martin’s lecture at the 4th Annual Perioperative Medicine Summit. The transcript was edited by the Cleveland Clinic Journal of Medicine staff for clarity and conciseness, and was then reviewed, revised, and approved by Dr. Martin.

ABSTRACT

In surgical patients with underlying chronic liver disease, surgical outcomes correlate with hepatocellular function. The risk of surgery in such patients should be assessed preoperatively using the Child-Pugh or Model for End-Stage Liver Disease (MELD) severity scoring systems. Patients with severe liver disease (eg, Child-Pugh class C) should not undergo any elective surgery and should be evaluated for liver transplantation. In patients who can proceed with surgery, coagulopathy should be corrected preoperatively and careful fluid management is required intraoperatively to avoid hypotension. Renal insufficiency (as evidenced by elevated creatinine) may indicate that hepatorenal syndrome has developed and carries a poor prognosis.

KEY POINTS

  • Patients with acute hepatitis should delay elective surgery until after their hepatitis resolves.
  • Patients with chronic liver disease who have developed any index complication—variceal hemorrhage, ascites, hepatic encephalopathy, or jaundice—are at increased risk for postoperative complications and death.
  • The Child-Pugh and MELD scores appear to be comparably effective in predicting surgical outcomes in patients with liver disease.
  • Cardiac surgery with cardiopulmonary bypass and abdominal surgery are particularly high-risk procedures in patients with liver disease.
  • If cholecystectomy is indicated in a patient with compensated liver disease, laparoscopy should be the initial approach, with conversion to an open procedure only if necessary.

Risk factors have strong cumulative power

The study by Ziser et al also underscored the cumulative effect of risk factors, as the probability of developing a perioperative complication increased dramatically with the number of risk factors (as identified by multiavariate analysis) that a patient had, as follows3:

  • 9.3% risk of complications with 1 risk factor
  • 14.5% risk with 2 factors
  • 33.5% risk with 3 factors
  • 63.0% risk with 4 or 5 factors
  • 73.3% risk with 6 factors
  • 100% risk with 7 or 8 factors.

Postoperative complications: Beware hepatorenal syndrome

The most common postoperative complications in the study by Ziser et al were pneumonia, other infections, ventilation dependency, and ascites.3

Possibly the most ominous perioperative complication in a patient with liver disease is the onset of renal insufficiency, which may be precipitated by a number of factors, including nephrotoxic drugs and intraoperative hypotension. Renal insufficiency is usually a predictor of markedly reduced survival and a sign that hepatorenal syndrome may have developed.

Hepatorenal syndrome, which occurred in 3.3% of patients in the analysis by Ziser et al,3 is the presence of renal failure in a patient with cirrhosis. It is characterized by advanced liver failure and severe sinusoidal portal hypertension. The renal failure is said to be “functional” because significant histological changes are absent on kidney biopsy. Marked arteriolar vasodilation occurs in the extrarenal circulation with renal vasoconstriction leading to reduced glomerular filtration.

IMPORTANCE OF SURGICAL PROCEDURE TYPE

In addition to the patient-specific risk factors discussed above, certain surgical procedures deserve special consideration in patients with liver disease.

Cholecystectomy: Open vs closed

Patients with liver disease have the same indication for cholecystectomy as anyone else does: symptomatic gallstone disease. Patients with cirrhosis who are found to have incidental gallstones on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic, as liver function may deteriorate after surgery.

For a patient with liver disease undergoing cholecystectomy, a common concern is whether an open or closed procedure should be done. Conventional wisdom had been that a patient with underlying liver disease (particularly cirrhosis) should have an open procedure so that the surgeon could more easily control bleeding, but that notion has changed in recent years with evidence supporting the safety of a laparoscopic approach in patients with liver disease.

One study supporting this new strategy is a retrospective review of 50 patients who had undergone cholecystectomy for symptomatic gallstone disease at the Mayo Clinic between 1990 and 1997.4 The procedure was open in half of the patients and laparoscopic in the other half. All patients had Child-Pugh class A or B cirrhosis. The indications for surgery were acute cholecystitis, biliary colic, or pancreatitis, and the number of patients with each of these indications was comparable between the open-surgery and laparoscopy groups. Three patients who initially underwent laparoscopy were converted to open cholecystectomy: two for bleeding and one for poor access. The study found that laparoscopic cholecystectomy was associated with statistically significant reductions in operating room time, blood loss, and length of hospital stay. No deaths occurred in either group. The authors concluded that laparoscopic cholecystectomy is safe in patients with cirrhosis and offers several advantages over an open surgical approach.

In light of these findings and other recent evidence, laparoscopic cholecystectomy should be recommended for patients with liver disease unless they have ascites or other evidence of overt hepatic decompensation, in which case cholecystectomy itself is contraindicated.

Cardiac surgery with bypass poses extra risk

Patients with liver disease undergoing open heart surgery with cardiopulmonary bypass are at especially high risk because of the effect on hepatic hemodynamics. This risk was demonstrated in a retrospective review of all patients with cirrhosis who underwent cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic from 1992 to 2002.5 Of the 44 patients identified, 12 (27%) developed hepatic decompensation and 7 (16%) died. Hepatic decompensation was a major factor in all the deaths.

The MELD and Child-Pugh scores correlated well with one another in this study and were highly associated with hepatic decompensation and death. The best cutoff values for predicting mortality and hepatic decompensation were found to be a score greater than 7 in the Child-Pugh system and a score greater than 13 in the MELD system. (For context, receipt of a donor liver via a transplant list in the United States requires a MELD score of at least 15.) The study confirmed that the Child-Pugh score, which is easy to determine at the bedside, remains a reliable predictor of poor outcomes.5

CASE REVISITED: POSTOPERATIVE LIVER FUNCTION DECLINE―HOW SERIOUS IS IT?

Our patient undergoes the CABG procedure, and 3 days later you are asked to see him. According to the sub-intern, although the surgery was successful, the patient is now “in liver failure.” After hearing this news, the family is anxious to discuss liver transplantation.

On examination, the patient is alert and extubated, so he is clearly not encephalopathic. His wound is clean and shows no sign of infection. He appears to be mildly icteric, and he may have some ascites, based on mild flank dullness.

His laboratory test results are as follows:

  • Bilirubin, 3.1 mg/dL (normal range, 0.3–1.2)
  • INR, 1.2 (0.9–1.2)
  • Alanine aminotransferase (ALT), 300 U/L (10–40)
  • Creatinine, 0.9 mg/dL (0.6–1.2).

Although the bilirubin and ALT are elevated, it is notable that the creatinine is normal. This pattern is not uncommon after elective surgery in a patient with underlying cirrhosis. Renal dysfunction is the biggest concern in the perioperative management of a patient with liver disease, as it is an indicator that the patient may develop overt hepatic decompensation. Likely reasons for the patient’s ALT elevation are the effects of cardiopulmonary bypass and possible intraoperative hypotension.

The family needs to be told that the patient is not in liver failure and that it is best to wait with the expectation that he will do fine unless other complications supervene.

You advise cautious diuresis, and the ALT falls over the next few days. The bilirubin declines to 2.0 mg/dL. At this point, you advise discharge planning.

One need not wait for the bilirubin to return to normal: after an acute hepatic insult such as ischemic hepatitis or intraoperative hypotension, bilirubin is the last indicator to improve. Bilirubin is in part albumin-bound, and the half-life of albumin is 18 days, so a patient can remain icteric for some time after the rest of the liver function tests have returned to normal.

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