Peri-operative Evaluation of

the Cirrhotic Patient

Dr César YAGHIHépato-Gastroentérologue

Hôtel-Dieu de FranceUniversité Saint Josephcesar.yaghi@usj.edu.lb

Introduction

Greater risk for surgical and anesthesia related complications

Risk depends

• Type of liver disease and its severity

• The surgical procedure

• The type of anesthesia.

ESTIMATING SURGICAL RISK

LIVER DISEASE TYPE OF SURGERY MORTALITY PROGNOSTIC FACTORS

Nonlaparoscopic biliary surgery 20% Ascites, prothrombin time, alb

Peptic ulcer surgery 54% Prothrombin time,systolic blo

pressure, hemoglobin

Umbilical herniorrhaphy 13% Urgent surgery

Colectomy 24% Hepatic encephalopathy,

ascites,albumin, hemoglobin

Emergency abdominal surgery 57%

Abdominal surgery for trauma 47% Child Pugh class, urgent surg

Laparoscopic cholecystectomy 0.9%1, 6%

Emergency cardiac surgery 80% Child Pugh class

Elective cardiac surgery 3%–46% Child Pugh score

Knee replacement 0%

Transurethral resection of the prostate 6.7%

Chronic hepatitis Various types 0%

Hepatitis C Laparoscopic cholecystectomy 0%

ser, Avishai; Plevak, David; Wiesner, Russell; Rakela, Jorge; Offord, Kenneth

Brown, David

Anesthesiology. 90(1):42-53, January 1999.

r, Avishai; Plevak, David; Wiesner, Russell; Rakela, Jorge; Offord, Kenneth;

Brown, David

Anesthesiology. 90(1):42-53, January 1999.

By multivariate analys

the risk factors were:

1. Male gender

2. Child-Pugh score

3. Presence of ascite

4. Cryptogenic cirrho

5. Creatinine

6. preoperative infect

7. ASA physical statu

score

8. Surgery on the

respiratory system

risk factors

59 patients had 0

173 had 1 214 had 2

Assessing Liver Function

Equation du score MELD

MELD score = (9.6 loge[creatinin mg/dL]) + (3.8 loge[bilirubin mg/dL]) + (11.2

e[INR]) + 6.4

MELD < 10 - Low risk

MELD = 10 -15 - Intermediate risk

Operative Mortality in Cirrhotics in relation to Child

Score and Type of surgery

Author Surgery Year Child A Child B Child

Garrison Abdominal 1984 10% 31% 76%

Mansour Abdominal elective 1997 10% 30% 82%

Mansour Abdominal emergency 1997 22% 38% 100%

Bizouarn Cardiac 1999 11% 18% 67%

Gervaz Cancer du colon 2003 6% 13% 28%

Hayashida Cardiac 2004 6% 67% 100%

Benmalek Abdominal 2004 5% 10% > 50%

Pre-operative MELD score for predicting

post-operative risk

MELD > 8 identifies risks of morbidity and mortality post

cholecystectomy

800 cirrhotic patients evaluating causes de morbidity and

mortality following major abdominal, orthopedic, or cardiac

surgery

– MELD correlated with short and long term mortality

– Each increase in the score of 1 unit (above 8) was

associated with an increase in mortality of 14% at 30 and

90 days

http://www.uptodate.com/contents/calculator-mortality-risk-in-post-operat

Mortality and Morbidity related to hepatic

resection in Cirrhosis patients

Authors Year Patients Liver Failure Bleeding Sepsis Complications M

Doberneck 1982Cirrhose Chirurgie variée

(n=102)43(42.2) 9(8.8) 19(18.6) 48(47.1)

Yanaga 1985 Cirrhose (n=103) 19 (12.6) NR 16 (16.8) 29 (28.2)

Nagasue 1985 Cirrhose et CHC (n=101) 10 (9.8) 10 (9.8) 4 (4.2) 32 (31.7)

Bismuth 1986 Cirrhose et CHC (n=35) 15 (42.5) NR NR 20 (47.2)

Gozetti 1987 Cirrhose (n=25) 3 (12) 1 (4) NR NR

1995Cirrhose résections

majeures (n=54)NR 4 (7.4) 18 (33) 27 (50)

Estimation des volumes hépatiques

dans la stratégie des hépatectomies

Relationship Between CT Volumetry and Functional Liver Volume Using

Technetium-99m Galactosyl Serum Albumin Scintigraphy

(A) CT scan and (B) 99mTc-GSA scintigraphy

Hepatic volume measured by CT-vol and 99mTc-GSA scintigraphy was significantly

Estimation des volumes hépatiques

dans la stratégie des hépatectomies

Residual Hepatic Volume

An acceptable residual volume in healthy individuals

is around 20% of the initial hepatic voloume, which

should be equivalent to 2 segments at least.

In patients with underlying liver disease:

– The minimal functional liver volume is estimated to

30 - 60% in chronic hepatitis, fatty liver or post-

chemotherapy.

– The residual volume should be 40 - 70% in patients

with cirrhosis

Pre-operative Portal Embolisation

The aim of Pre-operative Portal Embolisation is to

increase the residual hepatic volume and decrease

the incidence of post-operative liver failure.

2-8 weeks after PE, controloateral segment

hypertrophy reported increment of 20-46%

Hemi-hepatectomy was possible in 70-100% of

patients

3 and 5 years-survival respectively 61.2% and 43.7%

Contraindication for PVE

Tumors invading the portal vein

Portal hypertension (blocked to free hepatic vein pressure gradient

over12mm HG)

Coagulation disorders (PT<60%, plateled count <50G/l)

Even if a previous TACE may improve results of PVE , a minimum of

weeks delay between TACE and PVE is recommended.

In patients with cirrhosis,

• The decision is based on liver volumes with or without estimation o

the overall liver function by indocyanin green retention rate at 15

minutes (ICCG 15).

• A residual liver volume of 40% is recommended when the ICCG 15

between 10% and 20%. When the ICCG 15 is above 20%, a volum

of 50% is recommended

Assessing Liver Function

Indocyanine green clearance

– [ICG] plasma > 15% , 15 minutes after injection of 0.5 mg/kg ICG is considered abnormal

– Limited Correlation with Child Pugh score

Morbidité associée avec:

TP diminué

Une incidence de gestes

chirurgicaux concomitants

Une durée d’ischémie plus

prolongée

Durée opératoire prolongée

Saignement opératoire important

Besoins en transfusion

En analyse multivariée:

TP OR= 0.94

Duree operatoire OR=1.29

Optimizing Medical Therapy

Correction Prothrombin time

• Correction with vitamin K and fresh frozen plasma to achieve a

prothrombin time within three seconds of normal prior to surgery.

• Recombinant factor VIIA, (high cost, transient effect, associated

risk of thromboembolism).

Platelets: 50-100K (100K for cardiovascular and neurosurgery) A

prolonged bleeding time can be treated with diamino-8-D-arginine

vasopressin (DDAVP)

Optimal surgical technique / low central venous pressure may reduc

blood loss

Ascites: to reduce the chance of wound dehiscence and abdominal

wall herniation.

• Electrolyte abnormalities, (hypokalemia, metabolic

alkalosis) to decrease cardiac arrhythmias and hepatic

encephalopathy.

• Renal function

• Gastroesophageal varices : appropriate prophylactic

treatment.

• Malnutrition : Perioperative nutritional support : reduce

postoperative complications and short-term mortality

• calories equal to 1.2 times the estimated resting energ

expenditure and a 1 g/kg per day of protein.

Optimizing Medical Therapy

dans la survenue d’une insuffisance hépatique

• Volume hépatique résiduel

• Hypotension

• Ischémie hépatiqueOpératoire

• Sepsis

• HypotensionPost-

opératoire

• Age

• Cholestase

• Cirrhose

• Diabète

• Nutrition

• Chimiothérapie

Patient

Régression

Hépatique

Régéné

Hépat

Insuffisance

Hépatique

Inhibition de la

régénération

hépatique

Atteinte des hépatocytes

Influence des infections sur la régénération

hépatique après hépatectomie

Sepsis

Hypotension Ischémie

Anomalies des Ć de Kupfer

Diminution de la clairance des

bactériesportales

Risque de défaillance

multi-viscérale

Augmentation TNF-α

Apoptose

Regulation TGF-β

Atteintehépatocytaire

directe

Inhibition de la prolifération

hépatocytaire

Atteinte Hépatiquet altération de l

régénération

Conclusion

• Medical therapy should be optimized in all patients

• Operative mortality can be estimated based upon the Child

classification and the MELD score and taking into

consideration other factors such as the patient's age, ASA

score, and additional comorbidities.

• Elective or semi-urgent surgery not be performed in patients

with acute or fulminant hepatitis, alcoholic hepatitis, severe

chronic hepatitis, Child class C or MELD >15 cirrhosis, severe

coagulopathy, or severe extrahepatic manifestations of liver

disease (such as hypoxia, cardiomyopathy, or acute renal

failure)