Evaluation of patients with liver disease prior to surgery is crucial to estimating perioperative morbidity and mortality and to improving outcomes. The operative risk of liver disease can be related to the rapid changes in liver function that can occur in acute hepatitis or can be related to chronic complications of portal hypertension and parenchymal liver disease in patients with cirrhosis. Therefore, establishment of a risk profile should be based on the etiology of the underlying liver disease and the degree of hepatic decompensation associated with the presence of cirrhosis and portal hypertension. This chapter explains how to assess and prepare patients with liver disease for surgery and provides a framework for predicting operative morbidity and mortality.

Changes in Hepatic Blood Flow

The liver receives a dual blood supply from the portal vein and the hepatic artery. Unlike most other organs, the majority of hepatic oxygen supply in normal individuals is venous via the portal vein. Administration of anesthesia and surgery influences portal and hepatic blood flow. However, when flow through the portal vein is reduced, the hepatic artery vasodilates to increase oxygen supply to the liver. This compensatory vasodilatation appears to be reduced in response to a decrease in portal vein flow caused by changes in hepatic architecture as a result of fibrosis and nodular formation associated with cirrhosis. Due to intraoperative decreases in blood pressure and cardiac output, blood flow in patients with cirrhosis is further decreased in the portal vein and splanchnic vessels. Anesthetics in high doses reduce the hepatic artery’s ability to vasodilate in response to these changes in portal blood flow.

These changes in hepatic blood flow may lead to hepatic ischemia and necrosis induced by hypotension when patients with cirrhosis undergo surgery or receive anesthetic agents. This phenomenon leads to the release of inflammatory mediators resulting in multiorgan system failure. In a study of 733 cirrhosis patients undergoing surgery, Ziser and colleagues found an 11.6% mortality rate. Intraoperative hypotension was among factors found to predict perioperative complications and decreased survival.

Type of Surgery

Postoperative morbidity and mortality in patients with cirrhosis are also influenced by the type of surgery.

Abdominal Surgery

During abdominal surgery, direct trauma due to surgical retraction can lead to hepatic injury. Manipulation of the splanchnic and portal vasculature may also reduce portal or hepatic flow leading to ischemic injury. In particular, patients with Child-Pugh class C cirrhosis who undergo abdominal surgery have been reported to have 75% perioperative mortality.

Cardiovascular Surgery

Cardiovascular surgery, due to effects on portal and hepatic artery blood flow, is also associated with increased perioperative morbidity and mortality. The required perioperative pressor support and prolonged cardiopulmonary bypass are important contributors to hepatic injury.

Emergency Surgery

Many patients who require emergency surgery may be hemodynamically unstable from systemic vasodilation (eg, sepsis) or hypotensive due to hemorrhage (eg, trauma, abdominal surgery), and their outcome is often poor. In a study by Demetriades and colleagues of 46 patients with cirrhosis who underwent emergency laparotomy, the postoperative mortality rate was 45%, which was significantly greater than that for noncirrhotic control patients.

Orthopedic Surgery

There is little information in the literature regarding specific operative risks for patients with cirrhosis who may require surgery for orthopedic problems. Hsieh and colleagues reviewed 38 patients over a 20-year period who underwent hip arthroplasty. The 30-day complication rate was 26.7%. Advanced cirrhosis, age, elevated serum creatinine, low serum albumin, platelet count, ascites, hepatic encephalopathy, and increased operative blood loss were contributory factors to the high complication rate.

Type of Anesthetic

Anesthetic agents may reduce hepatic blood flow by reducing cardiac output. Even spinal and epidural anesthesia may affect hepatic blood flow by reducing the mean arterial pressure. In patients with liver disease, effects on hepatic metabolism may lead to prolonged action of anesthetic agents or production of toxic radicals resulting in increased morbidity and mortality.

Perioperative morbidity and mortality are influenced by the etiology and severity of the patient’s liver disease. The presence of cirrhosis or acute hepatitis at the time of surgery adversely influences the outcome after surgery. Generally, patients with chronic hepatitis from any etiology without features of hepatic decompensation do very well with surgery, and specific precautions are not necessary. However, in patients with acute liver disease and compensated or decompensated cirrhosis, it is critical to assess the perioperative risk as part of informed consent. Acute hepatitis, especially alcoholic hepatitis, and decompensated cirrhosis are absolute contraindications to elective surgery. A number of scoring and staging systems have been suggested as useful in assessing the perioperative risk. However, the Child-Pugh score and the Model for End-Stage Liver Disease (MELD) score are most commonly used in clinical practice. Measurement of the hepatic venous pressure gradient (HVPG) has excellent prognostic value, but its use is confined to a limited number of academic medical centers. A recent study showed that patients with compensated cirrhosis with clinically significant portal hypertension, defined by an HVPG ≥ 10 mm Hg, were at significant risk of developing clinical decompensation defined as the occurrence of ascites, variceal bleeding, or hepatic encephalopathy.

Child-Pugh Score

The Child-Pugh score combines the subjective and objective assessment of liver function (Table 53-1). In a recent study of 33 patients with cirrhosis compared with 31 age- and sex-matched control patients, the Child-Pugh score accurately predicted morbidity after cholecystectomy. In another study of 44 patients with cirrhosis who underwent cardiac surgery, a preoperative Child-Pugh score ≥ 8 was predictive of postoperative mortality. Ziser and colleagues using a large database, found that a high Child-Pugh score was associated with increased perioperative morbidity and mortality. Table 53-2 summarizes the operative mortality risk of patients with different Child-Pugh classes of cirrhosis who undergo abdominal surgery based on two important studies by Garrison and colleagues and Mansour and colleagues.