Presented by:Dr.Sachin Anand Mod By: Dr.

Sanjiv Aneja

INTRODUCTION
Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the ChildTurcottePugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.

Patients with liver disease who require surgery are at greater risk for surgical and anesthesia related complications than those with a healthy liver . The magnitude of the risk depends upon the type of liver disease and its severity, the surgical procedure, and the type of anesthesia.

SCREENING FOR LIVER DISEASE BEFORE SURGERY

Patients undergoing surgery should undergo a history and physical examination to exclude findings or risk factors for liver disease. This may include asking about prior blood transfusions, tattoos, illicit drug use, sexual promiscuity, a family history of jaundice or liver disease, a history of jaundice or fever following anesthesia, alcohol use (current, prior and quantity), and a complete review of current medications.

EXAMINATION
Clinical features suggestive of liver disease ,such as fatigue, pruritus, increased abdominal girth, jaundice, palmar erythema, spider telangiectasias, splenomegaly, and gynecomastia and testicular atrophy in men should be evaluated.

EFFECTS OF ANESTHESIA AND SURGERY ON THE LIVER

The effects of anesthesia and surgery on the liver depend upon the type of anesthesia used, the specific surgical procedures, and the severity of liver disease. In addition, perioperative events, such as hypotension, sepsis, or the administration of hepatotoxic drugs, can compound injury to the liver occurring during the procedure

EFFECT OF LIVER DISEASE ON SURGERY AND ANESTHESIA

The presence of liver disease can increase the risks of surgery and anesthesia in several ways Hepatic dysfunction can significantly impair the metabolism of certain medications used peri-operatively. A hyperdynamic circulation, with elevated cardiac output and decreased systemic vascular resistance. The compensatory inotropic and chronotropic response of the heart to pharmacologic and physiologic stressors, including surgery, is blunted. Induction of anesthesia,hemorrhage, hypoxemia hypotension, use of vasoactive medicationsand even the patients position and the surgical technique usedcan all decrease intraoperative and perioperative oxygen delivery to the liver and increase the risk of hepatic dysfunction

ESTIMATING THE RISK OF SURGERY

Postoperative outcomes are markedly influenced by the severity and nature of the underlying liver disease and the type of surgery being considered Nature of the underlying liver disease Obstructive jaundice risk factors include an initial hematocrit less than 30%, a serum total bilirubin concentration above 11 mg/dl, the presence of malignancy, a serum creatinine concentration higher than 1.4 mg/dl, serum albumin concentration less than 3.0 g/dl, age older than 65 years, aspartate aminotransferase concentration above 90 IU/l, and blood urea nitrogen concentration above 10 mg/dl

Acute hepatitis Patients with acute hepatitis have increased morbidity and mortality associated with surgery. These increases probably occur as a result of the acute hepatocellular injury and associated hepatic dysfunction. As most cases of acute hepatitis are self-limited and symptoms ultimately resolve, elective surgery should be postponed until the patients clinical, bio chemical and histologic parameters return to baseline. overall morbidity and mortality are increased in patients with acute alcoholic hepatitis, and elective surgery is contraindicated in these patients

Chronic hepatitis The etiology of chronic hepatitis does not seem to influence a patients perioperative risk Surgery is considered safe in asymptomatic patients with histologic evidence of mildly active hepatitis, symptomatic patients with histologic evidence of severely active hepatitis have been shown to be at increased risk from surgery increased morbidity and mortality in patients with moderate to severe steatosis (>30%) who underwent major hepatic resection,with mean BMI greater than 30 kg/m2, and pre operative bilirubin levels elevated (mean 2.2 mg/dl), which indicated significant underlying hepatic dysfunction

Cirrhosis In patients with cirrhosis, perioperative risk can be influenced by hepatic dysfunction, Portal hypertension complications such as intraabdominal varices, ascites, renal dysfunction, and portopulmonary hypertension

Severity of the underlying liver disease

An accurate assessment of the extent and severity of the patients underlying liver disease is required for an effective determination of their perioperative risk.
The ChildTurcottePugh (CTP) score the Model for End-stage Liver Disease (MELD) score have both been used for this purpose.

ChildTurcottePugh score The CTP score was the first-described predictorof surgical riskthis score was originally designed by Child and Turcotte to predict mortality after portocaval shunt surgery,
later modified by Pugh et al. to include prothrombin time in place of nutritional status for use in patients undergoing esophageal transections of bleeding varices . Although the CTP score has not been prospectively validated, it has stood the test of time, and has been widely used to assess disease severity in patients with cirrhosis and to predict their risks of perioperative morbidity and mortality for both elective and emergency surgery.

 In cirrhotic patients who undergo abdominal surgery,

CTP classes A, B and C are associated with mortality of 10%, 3031% and 7682%, respectively. The subjective nature of the clinical parameters and the arbitrary cut-off points used for the biochemical parameters limit the accuracy of the CTP score as a predictor of surgical risk. An example of the limitations of the CTP score is shown by the fact that patients with CTP class A cirrhosis can still have ascites, hyperbilirubinemia and portal hypertension.

Model for End-Stage Liver Disease

The MELD score was originally devised as a prognostic

measure of short-term mortality in patients with cirrhosis who were undergoing placement of a transjugular intrahepatic portosystemic shunt. The MELD assigns the patient a score of 840, which is derived from a complex formula that incorporates three biochemical variablesthe serum total bilirubin concentration, serum creatinine concentration, and international normalized ratio. The MELD score has been prospectively validated as a prognostic marker of mortality in patients with cirrhosis, acute variceal bleeding or acute alcoholic hepatitis. A modified MELD score was adopted by the United Network for Organ Sharing in February 2002 for the purposes of donor liver allocation

Model for End-stage Liver Disease score. MELD score = (9.6 loge[creatinine mg/dl]) + (3.8 loge[bilirubin mg/dl]) + (11.2 loge[INR]) + 6.4 The final score is rounded off to the nearest whole number and the maximum score is 40 (scores larger than 40 are assigned a value of 40). For any laboratory values less than 1.0 a value of 1.0 is used. The maximum creatinine concentration is 4.0 mg/dl (creatinine concentrations higher than 4.0 mg/dl are assigned a value of 4.0 mg/dl). If a patient has had dialysis twice within the previous week, the creatinine value is set as 4.0 mg/dl.
.

Other approaches
Alternative approaches used to determine the severity of hepatic disease include liver scintigraphy(using 99mTc-galactosyl-labeled human serum albumin), the indocyanine-green retention test, the aminopyrine breath test, and measurement of the lidocaine metabolite monoethylglycinexylidide. Mainly test hepatic reserve

Type of surgery
Emergency surgery emergency abdominal surgery or surgery as a result of trauma, Patient outcomes worsen with increasing CTP scores. Abdominal surgery Abdominal surgical proceduressuch as gastric bypass, biliary procedures, ulcer surgery and colonic resections. Cholecystectomy, although the risk seems to be highest for those who undergo non laparoscopic and emergency cholecystectomy. pre operative placement of transjugular intrahepatic portosystemic shunts in patients with cirrhosis and portal hypertension, to improve portal hypertension and allow surgery to be successfully completed.

Cardiac surgery
In patients with cirrhosis ,cardiopulmonary bypass has

an increased perioperative risk. study of 18 patients who underwent cardiac surgery with cardiopulmonary bypass demonstrated mortality rates of 0%, 50%, and 100% for patients with CTP classes A, B, and C, cirrhosis, respectively. The increased morbidity and mortality were caused by an elevated incidence of bleeding and sepsis. Another study revealed patients with a CTP score of 8 or higher had significantly higher postoperative mortality than those with a CTP score below 8.

Hepatic resection
Surgical resection of localized hepatocellular carcinoma in patients with cirrhosis raises. concerns about the adequacy of residual hepatic. These patients Have increased rates of perioperative complications, long-term hepatic decompensation, and death following resection, thus patient selection is critical. The absence of portal hypertension measured by hepatic vein catheterization (a hepatic vein pressure gradient <10 mmHg) and a normal serum total bilirubin concentration have been shown to be superior predictors of outcome after surgery, with 5-year survival rates above 70%. an elevated hepatic vein pressure gradient (>10 mmHg) and an elevated total bilirubin concentration of (>1 mg/dl) are associated with 5-year survival rates below 30%, regardless of the patients CTP classification.

RECOMMENDATIONS FOR PREOPERATIVE EVALUATION

General recommendations in the preoperative evaluation of patients with liver disease. CTP class A cirrhosis- Elective surgery can proceed CTP class B cirrhosis, hepatic resection and cardiac surgery should be avoided, and the patients condition should be optimized before elective surgery. CTP class C cirrhosis, elective surgery is contraindicated and non surgical options should be pursued. A patient with a MELD score Below 10 can undergo elective surgery, Caution needs to be exercised for a patient with a MELD score of 1015. MELD score above 15, elective surgery should be avoided and the patients candidacy for liver transplantation should be considered. In particular, the risk of adverse outcomes from orthopedic or urologic procedures is lower than from abdominal or cardiac surgery. Portal hypertension is a superior predictor of poor outcome in patients with cirrhosis who are undergoing hepatic resection, compared CTP score.

Summary
High-risk patients with liver disease for any type of surgery Childs C MELD score greater than 15 Acute liver failure Acute alcoholic hepatitis High serum bilirubin (>11 mg/dL) Portal hypertension with an elevated hepatic vein pressure gradient (>10 mmHg)

Summary
High-risk surgery in patients with liver disease Abdominal surgery Cholecystectomy Colectomy Gastric surgery Liver resection Cardiac surgery Emergent surgery (any type) Surgery with high anticipated blood loss

PREOPERATIVE MANAGEMENT
Clinical manifestation- Management considerations
Nutritional status Maintenance of an adequate protein intake (11.5 g/kg per day). Promotion of a balanced diet Coagulopathy Vitamin K supplementation (oral or parenteral) , Fresh, frozen plasma transfusions Intravenous administration of cryoprecipitate Intravenous administration of recombinant factor VIIa Platelet transfusions Ascites Paracentesis with analysis of ascitic fluid for evidence of infection Dietary sodium restriction (<2 g daily) Oral diuretic therapy with spironolactone and/or furosemide Fluid restriction (if sodium concentration is <120 mmol/l) Avoidance of excessive saline administration Avoidance of NSAIDs

Renal dysfunction Avoidance of nephrotoxic insult Albumin infusion (with paracentesis volumes >5 l)
Portosystemic encephalopathy Correction of reversible metabolic factors Avoidance of sedatives and opioid narcotics, as far as possible Oral lactulose administration, titrated to ~34 bowel movements per day Administration of nonabsorbable antibiotics Decreased protein intake Pulmonary hepatic vascular disorders Supportive care Supplemental oxygen

Thank You