Surgery in a patient with liver disease.
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.
['Rai|Rakesh|R|', 'Nagral|Sanjay|S|', 'Nagral|Aabha|A|']
cirrhosis hepatic coagulopathy ABG, arterial blood gas ASA, American Society of Anesthesiologists Anesthesia BNP, brain natriuretic peptide COPD, chronic obstructive pulmonary disease CTP, Child–Turcotte–Pugh CVP, central venous pressure Child–Pugh score FDP, fibrin degradation products FFP, fresh frozen plasma HPS, hepatopulmonary syndrome ICG, indocyanine green ICU, intensive care unit INR, international normalized ratio MELD, model for end-stage liver disease NSAID, nonsteroidal anti-inflammatory drug PICD, paracentesis-induced circulatory dysfunction PT, prothrombin time PTT, partial thromboplastin time SBP, spontaneous bacterial peritonitis TEG, thromboelastogram TIPS, transjugular intrahepatic portosystemic shunt