Surgical Risk

May 2009

The number of patients with cirrhosis who require surgery is on the rise. Despite advances in antiviral therapeutics, the prevalence of cirrhosis secondary to hepatitis C continues to increase, as does the prevalence of cirrhosis due to chronic alcoholic liver disease.

Additionally, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are gaining more attention, especially in association with metabolic syndrome and obesity. At the same time, the amount of medications and treatments aimed at improving survival among patients with cirrhosis has been increasing.

Therefore, it can be expected that a growing number of patients with liver disease, both known and as yet undiagnosed and asymptomatic, will undergo surgery.

An estimated 1 in 700 patients admitted for elective surgery has abnormal liver enzyme levels. Some authors have estimated that as many as 10% of patients with advanced liver disease will undergo surgery in the last 2 years of their lives.1 This article focuses on the challenges of perioperative care of patients with liver disease.

Identification of the surgical risk is imperative in the care of any patient. Patients with liver disease are at particularly high risk for morbidity and mortality in the postoperative period due to both the stress of surgery and the effects of general anesthesia. del Olmo et al compared 135 patients with cirrhosis with 86 patients without cirrhosis, all undergoing nonhepatic general surgery.

At 1 month, mortality rates were 16.3% for patients with cirrhosis compared with 3.5% in the control group. What is further evident in the literature is that decompensated liver disease increases the risk of postoperative complications (eg, acute hepatic failure, sepsis, bleeding, renal dysfunction). Assessing risk in these patients is a challenging but important endeavor.

The liver is vital for protein synthesis, glucose homeostasis, bilirubin excretion, drug metabolism, and toxic removal, among other critical functions. In general, the liver has substantial functional reserve because of its dual blood supply: portal-venous (75%) and hepatic-arterial (25%). Hence, clinical manifestations of liver damage occur only after considerable injury.

Liver disease comprises a large spectrum of hepatic dysfunction. It includes asymptomatic transaminitis, cirrhosis, and end-stage liver disease. The most common causes of advanced liver disease are chronic viral infections (hepatitis C HCV and B HBV), alcohol abuse, NAFLD/NASH , autoimmune disease, drugs or toxins, metabolic disorders (eg, alpha-1 antitrypsin deficiency, hemochromatosis, and Wilson disease), and biliary tract diseases.