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Perioperative considerations for patients with liver disease

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References

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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