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 follows 3:
- 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.