Perioperative considerations for patients with liver disease

DISCUSSION

Question from the audience: What are your recommendations regarding platelet transfusion if the platelet count is less than 50,000 in a patient with liver disease?

Dr. Martin: For patients with thrombocytopenia, it is prudent to get the platelet count above 60,000 before any procedure. We will not even do a blind liver biopsy in a patient with a platelet count of less than 60,000.

Question from the audience: A study from the Annals of Surgery concludes that patients with liver disease do poorly with a hemoglobin of less than 10 g/dL. Would you transfuse aggressively before surgery?

Dr. Martin: For a patient with anemia, I don’t like to use aggressive transfusion if cirrhosis is present because the portal pressure may go up and increase the risk of variceal hemorrhage. If there is adequate time for a work-up, one can screen for varices by endoscopy. If there is evidence of overt hepatic decompensation and portal hypertension (esophageal varices, a palpable spleen, and thrombocytopenia), I wouldn’t try to get the hemoglobin much above 10 g/dL.

Question from the audience: How would you modify prophylaxis for deep vein thrombosis following hip or knee replacement surgery in patients with liver disease?

Dr. Martin: I would base it on the INR. Patients who are already mildly coagulopathic tend to be very sensitive to warfarin in the long term. For immediate perioperative prophylaxis, I would not administer anything if the patient had a platelet count below 60,000; otherwise I would probably proceed as usual.

Question from the audience: You said that we shouldn’t operate on patients with acute hepatitis, but we frequently encounter patients with drug-induced hepatitis, such as from anticholesterol drugs. These patients’ ALT and aspartate aminotransferase (AST) levels can remain elevated for 2 or 3 months. How long should we delay surgery? For example, is it dangerous to proceed with a mastectomy a month after discontinuing the drug if the liver enzymes are still around 100 U/L?

Dr. Martin: It’s worth noting that much of the literature on surgery in patients with acute viral hepatitis is 30 or 40 years old. If such a patient had a compelling reason to have surgery, you might wait until the liver enzymes were trending downward and you were confident that the patient was recovering.

Question from the audience: How do you manage patients who have varices or have had variceal bleeding in the past? Many of them are on beta-blockers, such as propranolol, which can cause hypotension intraoperatively.

Dr. Martin: The standard of care is to prescribe beta-blockers for a patient with large varices, or to ablate the varices by endoscopy, which is my practice. In general, I would discontinue propranolol on the morning of surgery. If possible, however, I would have the patient undergo endoscopy before surgery to assess the likelihood of short-term variceal bleeding. If the varices look to be at low risk of bleeding, the beta-blocker can safely be stopped. If they look to be at high risk of bleeding, the surgery should be delayed for a few weeks, if possible, so that the varices can be ablated, which usually takes two or three sessions.

Question from the audience: I deal with many referrals, and I struggle with how aggressive a work-up I should do for patients undergoing elective surgery when a new abnormality is found in one of their liver function tests.

Dr. Martin: I would try to establish whether the abnormality is a chronic problem. Has the patient been told about an abnormal liver test in the past? Ask if the patient has been a blood donor, as measurement of ALT and some hepatitis serologies would have been required. Also ask if he or she has ever taken out a big life insurance policy, which also would have required liver function testing. If the abnormality is chronic, you may proceed with surgery if the bilirubin and INR are normal. In the absence of chronicity, surgery should be delayed for further work-up only in patients with indicators of significant liver disease—either markedly abnormal liver tests, thrombocytopenia, or coagulopathy.

Follow-up question: But patients rarely know whether they’ve had elevated liver enzymes in the past. You said not to worry about enzyme abnormalities unless they are markedly elevated, but how high is that?

Dr. Martin: AST and ALT are indicators of liver injury rather than of synthetic function. The true liver function tests are really albumin, bilirubin, and prothrombin time. Paradoxically, one of the best liver function tests is the platelet count. For me, a red flag for a patient with newly recognized liver disease is any degree of thrombocytopenia or coagulopathy or an elevation of bilirubin above the upper limit of normal. A patient with a platelet count of 90,000 and an INR above 1.2 has significant underlying liver disease, and I would be very concerned. Unless it’s a dire emergency, such a patient would need further evaluation before proceeding with surgery. In contrast, a patient with an ALT of 89, an AST of 65, and normal prothrombin time and platelet count should be safe to proceed to surgery. But such a patient needs an evaluation for liver disease afterward.

Question from the audience: My institution performs many liver resections for metastases or primary liver cancers. Our liver surgeons routinely discontinue statins 2 to 3 weeks before liver surgery, but it has been said at this summit that is not necessary. What’s your opinion?

Dr. Martin: I think that statins get a very bad rap in terms of hepatotoxity. Most patients with metabolic syndrome have hyperlipidemia, which can cause fatty liver disease and hepatic dysfunction. Statins help bring the lipid levels down. Hepatologists do not regard statins as major culprits in causing liver problems. I don’t believe there’s any particular indication to stop them before a patient undergoes hepatic surgery.

Question from the audience: I assess patients 1 or 2 weeks before surgery. For a patient with coagulopathy whom you suspect has underlying liver disease, is there any value in trying to treat the coagulopathy with vitamin K?

Dr. Martin: It can be worthwhile to try 10 mg subcutaneously for 3 days to see whether the situation improves, but if the patient has severe parenchymal liver disease, the vitamin K won’t help much.