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Perioperative considerations for patients with liver disease

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When a patient with liver disease is evaluated for surgery, evidence should be sought to determine whether an index complication has already occurred. Because the patient in our case study had a cholecystectomy several years before, I would also ask, “What did the surgeon say your liver looked like? Did you have any bleeding problems afterwards? Did you develop ascites?”

It is also important to determine whether portal hypertension is present. For a patient with liver disease, otherwise unexplained thrombocytopenia is a useful indicator of portal hypertension.

Systems for scoring liver disease severity

Even a surgical patient with well-compensated liver disease is at risk for developing complications postoperatively, particularly if abdominal surgery is planned. Risk should be assessed in all patients with liver disease using either the Child-Pugh scoring system or the Model for End-Stage Liver Disease (MELD) scoring system.

The Child-Pugh score , which assigns 1 to 3 points according to the presence/absence and levels of each of five simple factors (bilirubin, albumin, prothrombin time/international normalized ratio [INR], ascites, and encephalopathy stage), has been used for decades to assess the severity of liver disease. Patients with Child-Pugh class A disease (score of 5–6) have well-compensated cirrhosis and good synthetic function, and therefore have essentially no restrictions for undergoing surgery. For patients in Child-Pugh class B (score of 7–9), the risk of perioperative complications and mortality is higher and any major hepatic surgery (such as hepatic resection) should be avoided. Patients with class C cirrhosis (score of 10–15) are not candidates for any major elective surgery and should be considered for liver transplantation referral.

The MELD scoring system was developed more recently and is used to prioritize eligibility for liver transplantation. Calculated using a mathematical formula that incorporates three objective patient variables—
creatinine, bilirubin, and INR—the MELD score correlates very well with prognosis. The score can be calculated by an online MELD calculator such as the one at www.unos.org/resources.2 A patient with a high MELD score is unlikely to survive for more than a few months without liver transplantation; a patient with a low MELD score is likely to survive for at least 12 months. Calculating the MELD score is now one of the first assessments in any patient suspected of having cirrhosis.

Risk factors for complications and death

In a retrospective study to identify factors associated with complications and mortality in surgical patients with cirrhosis, Ziser et al reviewed the records of 733 patients with cirrhosis who underwent surgical procedures (except liver transplantation) at the Mayo Clinic over an 11-year period (1980–1991). 3 The mortality rate within 30 days of surgery was 11.6%. Long-term follow-up showed that most deaths occurred within the first few months after surgery, when many patients succumbed to pneumonia or renal insufficiency.

Univariate analysis of the results identified many patient- and procedure-related factors that were predictive of complications and short- and long-term mortality. Table 1 lists those factors that were found by multivariate analysis to be independently predictive of perioperative complications and of postoperative mortality. 3

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