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PSH 2017
Peshawar Meeting November 2017 EVERYDAY CHALLENGES IN CLINICAL PRACTICE
Surgical Risk Assessment in patients with Liver Disease DR ZABIH ULLAH
MBBS, FCPS( GASTROENTEROLOGY)
PSH 2017
Objectives
Review basic principles of pre op assessment of patients with liver disease
Effects of anesthesia and surgery on the liver
Estimation of operative risk
Risk associated with specific types of Surgery
Discuss strategies to optimize pre op management of liver diseases
Choice of sedation for surgery
PSH 2017
SCREENING FOR LIVER DISEASE BEFORE SURGERY
HISTORY
prior blood transfusions
tattoos
illicit drug use
sexual promiscuity
family history of jaundice or liver disease
history of jaundice or fever following anesthesia
alcohol use (current, prior and quantity)
complete review of current medications
PSH 2017
Clinical features
Increased abdominal girth
Jaundice
Palmar erythema
Spider telangiectasias
Splenomegaly
Gynecomastia and testicular atrophy in men
PSH 2017
PSH 2017
PSH 2017
Effects of anesthesia on the liver Hepatic ischemia: elevated transaminases Cirrhosis
Hyperdynamic circulation with decreased blood flow to liver More susceptible to hypoxemia and hypotension
Surgical factors contributing to hepatic ischemia:
Hypotension, hemorrhage, vasoactive medications
Positive pressure ventilation
Pneumoperitoneum during laparoscopic cases
Traction on abdominal viscera
PSH 2017
Metabolism of medications
Volume of distribution of medications is increased in cirrhotic patients.
Inhaled anesthetic choice
Halothane dcrease hepatic blood flow and can cause hepatotoxicity
Isoflurane, sevoflorane and desflorane has less effect on hepatic blood flow and hepatotoxicity
PSH 2017
Metabolism of medications
Atracurium/cisatracurium preferred—not excreted by liver or kidney
Sedatives and narcotics can precipitate hepatic encephalopathy and prolong periods of depressed consciousness.
PSH 2017
What
are the postoperative concerns
PSH 2017
Coagulopathy
Decreased production of clotting factors
Depletion of vitamin K stores
Increased fibrinolytic activity
Thrombocytopenia
PSH 2017
Ascites
Hepatic hydrothorax—respiratory complications
Wound complications
Hernia
PSH 2017
Hepatic encephalopathy
Precipitating factors in post operative period
Volume contraction
Hypokalemia
Infection
Bleeding
Medications
Renal Dysfunction
Potential causes:
Intravascular volume depletion
Nephrotoxicity
ATN
Hepatorenal syndrome (HRS)
PSH 2017
Pulmonary complications
Ascites and hepatic hydrothorax
Increased risk of aspiration
Pneumonia
ARDS
Ventilation dependence
Hepatopulmonary syndrome:
Triad of liver disease, increased AA gradient and intrapulmonary shunting
Platypnea
Orthodeoxia
EFFECTS OF ANESTHESIA AND SURGERY ON THE LIVER
Depends upon:
Type of anesthesia used
specific surgical procedures
severity of liver disease.
Perioperative events
hypotension
sepsis
Administration of hepatotoxic drugs
PSH 2017
ESTIMATING SURGICAL RISK
Appraisal of the severity of liver disease
The urgency of surgery (and alternatives to surgery)
Coexisting medical illness.
Surgical risk assessment is less relevant if immediate surgery is required to prevent death.
Elective procedures
Risk assessment
Optimization of the patient's medical status
Consideration of alternative approaches.
PSH 2017
Study Design Flaws
Mostly small studies
Retrospective
Clinical experience
Arbitrary parameters
PSH 2017
Contraindications for elective surgery
Acute hepatitis
Alcoholic hepatitis
Abstinence from alcohol for at least 12 weeks
improves hepatic inflammation and hyperbilirubinemia
Reassess after 12 weeks
PSH 2017
Acute liver failure
HARVILLE DD, SUMMERSKILL WH. Surgery in acute hepatitis. Causes and effects. JAMA 1963; 184:257. Greenwood SM, Leffler CT, Minkowitz S. The increased mortality rate of open liver biopsy in alcoholic hepatitis. Surg Gynecol Obstet 1972; 134:600. Powell-Jackson P, Greenway B, Williams R. Adverse effects of exploratory laparotomy in patients with unsuspected liver disease. Br J Surg 1982; 69:449.
PATIENTS AT VARIABLE INCREASED RISK
The risk of surgery in patients with cirrhosis depends
the severity of disease,
the clinical setting
type of surgical procedure
PSH 2017
SCORING SYSTEMS TO ASSESS SURGERY RISK 1.
CTP
2.
MELD
3.
ASA
PSH 2017
Child-Turcotte-Pugh score
ASA Classification
PSH 2017
PSH 2017
PSH 2017
PSH 2017
In a retrospective study of 261 patients (45 with cirrhosis and 216 matched controls without cirrhosis) undergoing cardiac surgery between 1992 and 2009,
CP < 8 : 95 % survival rate at 90 days
CP > 8 : 30 % survival rate at 90 days
MELD score
MELD is supplanting the CP classification as the principal method for determining surgical risk
The MELD score, American Society of Anesthesiologists (ASA) class, and age predicted mortality in a study of 772 patients with cirrhosis who underwent major digestive, orthopedic, or cardiovascular surgery.
The MELD score was the best predictor of 30- and 90-day mortality. Mortality at 30 days ranged from 6 percent (MELD score, <8) to more than 50 percent (MELD score, >20) and correlated linearly with the MELD score.
PSH 2017
PSH 2017
Increased risk of mortality up to 90 days postoperatively
Mortality rates
MELD <7: 5.7%
MELD 8-11: 10.3%
MELD 12-15: 25.4%
ASA class IV adds 5.5 MELD points. ASA class V = 100% mortality
PSH 2017
MELD < 10 : elective surgery
MELD 10 to 15 : elective surgery with caution
MELD >15 : should not undergo elective surgery
PSH 2017
Obstructive jaundice —
Increased risk of perioperative complications
Infections
stress ulceration
DIC
wound dehiscence
renal failure
PSH 2017
An overall mortality rate of 9 percent was found in a large retrospective study that included 373 patients undergoing surgery for obstructive jaundice.
Multivariate analysis identified three predictors of postoperative mortality:
An initial hematocrit value <30 percent
An initial serum bilirubin level >11 mg/dL (200 micromoles/L)
A malignant cause of obstruction (eg, pancreatic carcinoma or cholangiocarcinoma)
All three factors +ive Mortality 60 %
All three factors -ive Mortality 5 %
PSH 2017
A number of interventions have been attempted to reduce morbidity and mortality in these patients:
Perioperative administration of broad-spectrum intravenous antibiotics
External biliary drainage via a transhepatic approach
Endoscopic biliary drainage
PSH 2017
Limited evidence suggests that the administration of bile salts or lactulose to patients with obstructive jaundice can prevent both the endotoxemia and the exaggerated renal vasoconstriction
PSH 2017
Cardiac surgery —
Cardiac surgery is associated with increased mortality in patients with cirrhosis compared to other surgical procedures
PSH 2017
9 studies involving 210 patients with cirrhosis
Mortality : 17 %.
CP A: 5%
CP B : 35%
CP C : 70%
MELD score has not been adequately studied as a prognostic tool for patients undergoing cardiac surgery.
PSH 2017
Risk factors for hepatic decompensation
total time of cardiopulmonary bypass
use of nonpulsatile as opposed to pulsatile cardiopulmonary bypass
need for perioperative pressor support
Thus, the least invasive options
Angioplasty,
Valvuloplasty
Minimally invasive revascularization techniques, should be considered in patients with advanced cirrhosis who require invasive intervention for cardiac disease
PSH 2017
Hepatic resection —
RESIDUAL VOLUME NEEDED
Normal Liver
25%
Cirrhotic liver
40%
Risk factors for hepatic decompensation
CTP
MELD
BILIRUBIN
PT
Portal Hypertension
PSH 2017
A database study of 587 patients who underwent hepatic resection concluded that the Child-Turcotte-Pugh score and ASA score were better predictors of morbidity and mortality than the MELD
Schroeder et al Ann Surg 2006; 243:373.
PSH 2017
PSH 2017
Clinically significant portal hypertension
Gastroesophageal varices OR
Platelet < 100,000/mL with splenomegaly
clinical decompensation after surgery
3 & 5 year mortality
PSH 2017
Trauma —
Trauma patients found to have cirrhosis at laparotomy are at increased risk for morbidity and mortality.
In one study, the overall mortality rate was 45 percent, significantly higher than of a matched control population (24 percent)
PSH 2017
Abdominal surgery —
In patients undergoing cholecystectomy, a laparoscopic approach is associated with lower mortality rates than an open approach and can be performed in patients with CP class A and B cirrhosis and MELD scores up to 13
PSH 2017
Colorectal surgery, primarily for diverticular disease and colorectal cancer, is associated with mortality rates as high as 26 percent in patients with cirrhosis
PSH 2017
Less invasive approaches such as stent placement to relieve obstruction should be considered when possible.
Elective umbilical hernia repair can be performed with excellent outcomes, even in patients with CP class C cirrhosis
PSH 2017
PSH 2017
Patients with minimally increased risk —
Mild to moderate chronic liver disease without cirrhosis
Mild chronic hepatitis
PSH 2017
Fatty liver and nonalcoholic steatohepatitis
Increased mortality following hepatic resection has been observed in those with moderate to severe steatosis (>30 percent of hepatocytes containing fat
NASH is associated with increased morbidity following hepatic resection
PSH 2017
Recommending a period of abstinence from alcohol prior to surgery is advisable for all patients with the histologic appearance of steatohepatitis or those who are suspected of excessive alcohol consumption
PSH 2017
Autoimmune hepatitis —
Elective surgery is usually well tolerated in patients with autoimmune hepatitis who have compensated liver disease.
Perioperative "stress" doses of hydrocortisone should be given to patients taking prednisone.
PSH 2017
Hemochromatosis —
Evaluation for complications
Diabetes
Cardiomyopathy
PSH 2017
Wilson disease —
Patients with Wilson disease who have neuropsychiatric involvement may not be able to provide informed consent.
Surgery can precipitate or aggravate neurologic symptoms
D-penicillamine interferes with the crosslinking of collagen and may impair wound healing
the dose should be decreased prior to surgery and during the first one to two postoperative weeks
OPTIMIZING MEDICAL THERAPY
COAGULOPATHY
Management of haemostatic abnormalities in patients with cirrhosis
optimize the platelet count
optimize fibrinogen level
optimize renal function
avoid the INR values to guide therapy
A prolonged bleeding time can be treated with desmopressin (DDAVP).
Optimal surgical technique and maintenance of low central venous pressure may reduce blood loss and may be more important than attempting to correct the prothrombin time
PSH 2017
PSH 2017
PSH 2017
PSH 2017
PSH 2017
Take Home Points
Medical therapy should be optimized in all patients
Operative mortality can be estimated based upon the CTP, MELD, ASA, Age and co-morbidities
Elective surgery not be performed in patients with
Acute or fulminant hepatitis
Alcoholic hepatitis,
Child-Pugh class C or MELD score >15 cirrhosis,
Severe coagulopathy
Severe extrahepatic manifestations of liver disease (such as hypoxia, cardiomyopathy, or acute renal failure)
PSH 2017
PSH 2017
Surgery is generally well tolerated
CTP A and MELD <10
Mild chronic liver disease without cirrhosis
Surgery is generally permissible
CTP B and MELD 10 to 15 except those undergoing extensive hepatic resection or cardiac surgery) who have undergone thorough preoperative preparation
PSH 2017
THANK YOU
Peshawar Meeting November 2017 EVERYDAY CHALLENGES IN CLINICAL PRACTICE
Surgical Risk Assessment in patients with Liver Disease DR ZABIH ULLAH
MBBS, FCPS( GASTROENTEROLOGY)
PSH 2017
Objectives
Review basic principles of pre op assessment of patients with liver disease
Effects of anesthesia and surgery on the liver
Estimation of operative risk
Risk associated with specific types of Surgery
Discuss strategies to optimize pre op management of liver diseases
Choice of sedation for surgery
PSH 2017
SCREENING FOR LIVER DISEASE BEFORE SURGERY
HISTORY
prior blood transfusions
tattoos
illicit drug use
sexual promiscuity
family history of jaundice or liver disease
history of jaundice or fever following anesthesia
alcohol use (current, prior and quantity)
complete review of current medications
PSH 2017
Clinical features
Increased abdominal girth
Jaundice
Palmar erythema
Spider telangiectasias
Splenomegaly
Gynecomastia and testicular atrophy in men
PSH 2017
PSH 2017
PSH 2017
Effects of anesthesia on the liver Hepatic ischemia: elevated transaminases Cirrhosis
Hyperdynamic circulation with decreased blood flow to liver More susceptible to hypoxemia and hypotension
Surgical factors contributing to hepatic ischemia:
Hypotension, hemorrhage, vasoactive medications
Positive pressure ventilation
Pneumoperitoneum during laparoscopic cases
Traction on abdominal viscera
PSH 2017
Metabolism of medications
Volume of distribution of medications is increased in cirrhotic patients.
Inhaled anesthetic choice
Halothane dcrease hepatic blood flow and can cause hepatotoxicity
Isoflurane, sevoflorane and desflorane has less effect on hepatic blood flow and hepatotoxicity
PSH 2017
Metabolism of medications
Atracurium/cisatracurium preferred—not excreted by liver or kidney
Sedatives and narcotics can precipitate hepatic encephalopathy and prolong periods of depressed consciousness.
PSH 2017
What
are the postoperative concerns
PSH 2017
Coagulopathy
Decreased production of clotting factors
Depletion of vitamin K stores
Increased fibrinolytic activity
Thrombocytopenia
PSH 2017
Ascites
Hepatic hydrothorax—respiratory complications
Wound complications
Hernia
PSH 2017
Hepatic encephalopathy
Precipitating factors in post operative period
Volume contraction
Hypokalemia
Infection
Bleeding
Medications
Renal Dysfunction
Potential causes:
Intravascular volume depletion
Nephrotoxicity
ATN
Hepatorenal syndrome (HRS)
PSH 2017
Pulmonary complications
Ascites and hepatic hydrothorax
Increased risk of aspiration
Pneumonia
ARDS
Ventilation dependence
Hepatopulmonary syndrome:
Triad of liver disease, increased AA gradient and intrapulmonary shunting
Platypnea
Orthodeoxia
EFFECTS OF ANESTHESIA AND SURGERY ON THE LIVER
Depends upon:
Type of anesthesia used
specific surgical procedures
severity of liver disease.
Perioperative events
hypotension
sepsis
Administration of hepatotoxic drugs
PSH 2017
ESTIMATING SURGICAL RISK
Appraisal of the severity of liver disease
The urgency of surgery (and alternatives to surgery)
Coexisting medical illness.
Surgical risk assessment is less relevant if immediate surgery is required to prevent death.
Elective procedures
Risk assessment
Optimization of the patient's medical status
Consideration of alternative approaches.
PSH 2017
Study Design Flaws
Mostly small studies
Retrospective
Clinical experience
Arbitrary parameters
PSH 2017
Contraindications for elective surgery
Acute hepatitis
Alcoholic hepatitis
Abstinence from alcohol for at least 12 weeks
improves hepatic inflammation and hyperbilirubinemia
Reassess after 12 weeks
PSH 2017
Acute liver failure
HARVILLE DD, SUMMERSKILL WH. Surgery in acute hepatitis. Causes and effects. JAMA 1963; 184:257. Greenwood SM, Leffler CT, Minkowitz S. The increased mortality rate of open liver biopsy in alcoholic hepatitis. Surg Gynecol Obstet 1972; 134:600. Powell-Jackson P, Greenway B, Williams R. Adverse effects of exploratory laparotomy in patients with unsuspected liver disease. Br J Surg 1982; 69:449.
PATIENTS AT VARIABLE INCREASED RISK
The risk of surgery in patients with cirrhosis depends
the severity of disease,
the clinical setting
type of surgical procedure
PSH 2017
SCORING SYSTEMS TO ASSESS SURGERY RISK 1.
CTP
2.
MELD
3.
ASA
PSH 2017
Child-Turcotte-Pugh score
ASA Classification
PSH 2017
PSH 2017
PSH 2017
PSH 2017
In a retrospective study of 261 patients (45 with cirrhosis and 216 matched controls without cirrhosis) undergoing cardiac surgery between 1992 and 2009,
CP < 8 : 95 % survival rate at 90 days
CP > 8 : 30 % survival rate at 90 days
MELD score
MELD is supplanting the CP classification as the principal method for determining surgical risk
The MELD score, American Society of Anesthesiologists (ASA) class, and age predicted mortality in a study of 772 patients with cirrhosis who underwent major digestive, orthopedic, or cardiovascular surgery.
The MELD score was the best predictor of 30- and 90-day mortality. Mortality at 30 days ranged from 6 percent (MELD score, <8) to more than 50 percent (MELD score, >20) and correlated linearly with the MELD score.
PSH 2017
PSH 2017
Increased risk of mortality up to 90 days postoperatively
Mortality rates
MELD <7: 5.7%
MELD 8-11: 10.3%
MELD 12-15: 25.4%
ASA class IV adds 5.5 MELD points. ASA class V = 100% mortality
PSH 2017
MELD < 10 : elective surgery
MELD 10 to 15 : elective surgery with caution
MELD >15 : should not undergo elective surgery
PSH 2017
Obstructive jaundice —
Increased risk of perioperative complications
Infections
stress ulceration
DIC
wound dehiscence
renal failure
PSH 2017
An overall mortality rate of 9 percent was found in a large retrospective study that included 373 patients undergoing surgery for obstructive jaundice.
Multivariate analysis identified three predictors of postoperative mortality:
An initial hematocrit value <30 percent
An initial serum bilirubin level >11 mg/dL (200 micromoles/L)
A malignant cause of obstruction (eg, pancreatic carcinoma or cholangiocarcinoma)
All three factors +ive Mortality 60 %
All three factors -ive Mortality 5 %
PSH 2017
A number of interventions have been attempted to reduce morbidity and mortality in these patients:
Perioperative administration of broad-spectrum intravenous antibiotics
External biliary drainage via a transhepatic approach
Endoscopic biliary drainage
PSH 2017
Limited evidence suggests that the administration of bile salts or lactulose to patients with obstructive jaundice can prevent both the endotoxemia and the exaggerated renal vasoconstriction
PSH 2017
Cardiac surgery —
Cardiac surgery is associated with increased mortality in patients with cirrhosis compared to other surgical procedures
PSH 2017
9 studies involving 210 patients with cirrhosis
Mortality : 17 %.
CP A: 5%
CP B : 35%
CP C : 70%
MELD score has not been adequately studied as a prognostic tool for patients undergoing cardiac surgery.
PSH 2017
Risk factors for hepatic decompensation
total time of cardiopulmonary bypass
use of nonpulsatile as opposed to pulsatile cardiopulmonary bypass
need for perioperative pressor support
Thus, the least invasive options
Angioplasty,
Valvuloplasty
Minimally invasive revascularization techniques, should be considered in patients with advanced cirrhosis who require invasive intervention for cardiac disease
PSH 2017
Hepatic resection —
RESIDUAL VOLUME NEEDED
Normal Liver
25%
Cirrhotic liver
40%
Risk factors for hepatic decompensation
CTP
MELD
BILIRUBIN
PT
Portal Hypertension
PSH 2017
A database study of 587 patients who underwent hepatic resection concluded that the Child-Turcotte-Pugh score and ASA score were better predictors of morbidity and mortality than the MELD
Schroeder et al Ann Surg 2006; 243:373.
PSH 2017
PSH 2017
Clinically significant portal hypertension
Gastroesophageal varices OR
Platelet < 100,000/mL with splenomegaly
clinical decompensation after surgery
3 & 5 year mortality
PSH 2017
Trauma —
Trauma patients found to have cirrhosis at laparotomy are at increased risk for morbidity and mortality.
In one study, the overall mortality rate was 45 percent, significantly higher than of a matched control population (24 percent)
PSH 2017
Abdominal surgery —
In patients undergoing cholecystectomy, a laparoscopic approach is associated with lower mortality rates than an open approach and can be performed in patients with CP class A and B cirrhosis and MELD scores up to 13
PSH 2017
Colorectal surgery, primarily for diverticular disease and colorectal cancer, is associated with mortality rates as high as 26 percent in patients with cirrhosis
PSH 2017
Less invasive approaches such as stent placement to relieve obstruction should be considered when possible.
Elective umbilical hernia repair can be performed with excellent outcomes, even in patients with CP class C cirrhosis
PSH 2017
PSH 2017
Patients with minimally increased risk —
Mild to moderate chronic liver disease without cirrhosis
Mild chronic hepatitis
PSH 2017
Fatty liver and nonalcoholic steatohepatitis
Increased mortality following hepatic resection has been observed in those with moderate to severe steatosis (>30 percent of hepatocytes containing fat
NASH is associated with increased morbidity following hepatic resection
PSH 2017
Recommending a period of abstinence from alcohol prior to surgery is advisable for all patients with the histologic appearance of steatohepatitis or those who are suspected of excessive alcohol consumption
PSH 2017
Autoimmune hepatitis —
Elective surgery is usually well tolerated in patients with autoimmune hepatitis who have compensated liver disease.
Perioperative "stress" doses of hydrocortisone should be given to patients taking prednisone.
PSH 2017
Hemochromatosis —
Evaluation for complications
Diabetes
Cardiomyopathy
PSH 2017
Wilson disease —
Patients with Wilson disease who have neuropsychiatric involvement may not be able to provide informed consent.
Surgery can precipitate or aggravate neurologic symptoms
D-penicillamine interferes with the crosslinking of collagen and may impair wound healing
the dose should be decreased prior to surgery and during the first one to two postoperative weeks
OPTIMIZING MEDICAL THERAPY
COAGULOPATHY
Management of haemostatic abnormalities in patients with cirrhosis
optimize the platelet count
optimize fibrinogen level
optimize renal function
avoid the INR values to guide therapy
A prolonged bleeding time can be treated with desmopressin (DDAVP).
Optimal surgical technique and maintenance of low central venous pressure may reduce blood loss and may be more important than attempting to correct the prothrombin time
PSH 2017
PSH 2017
PSH 2017
PSH 2017
PSH 2017
Take Home Points
Medical therapy should be optimized in all patients
Operative mortality can be estimated based upon the CTP, MELD, ASA, Age and co-morbidities
Elective surgery not be performed in patients with
Acute or fulminant hepatitis
Alcoholic hepatitis,
Child-Pugh class C or MELD score >15 cirrhosis,
Severe coagulopathy
Severe extrahepatic manifestations of liver disease (such as hypoxia, cardiomyopathy, or acute renal failure)
PSH 2017
PSH 2017
Surgery is generally well tolerated
CTP A and MELD <10
Mild chronic liver disease without cirrhosis
Surgery is generally permissible
CTP B and MELD 10 to 15 except those undergoing extensive hepatic resection or cardiac surgery) who have undergone thorough preoperative preparation
PSH 2017
THANK YOU
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