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Dr C K Pandey
Professor amp Head
Department of Anaesthesiology amp Critical Care Medicine
Institute of Liver and Biliary Sciences New Delhi
Anaesthetic considerations and peri-operative risks in patients with liver disease
Objectives
Recognize which coexisting disease processes are associated with increased morbidity
Understand which features of the patientrsquos condition can be improved
Realize that a simple operation does not always mean an equally simple or risk-free anaesthetic
Natural progression of chronic liver disease
Chronic liver disease
Death
Compensated cirrhosis
Decompensated cirrhosis
Risk scoring systems
The risks are assessed in all surgical patients with liver disease
Child-Turcotte-Pugh
Model for End-Stage Liver Disease (MELD) Scoring system
Na+ MELD
The Child-Turcotte-Pugh scoring system
The risk of postoperative mortality and morbidity correlate well with the categorization of the patient as per the Child-Turcotte-Pugh (CTP) class of cirrhosis
Scoring System assigns 1 to 3 points on the basis of five simple factors
Sr bilirubin
Sr albumin
prothrombin time
Ascites
grade of encephalopathy
Risk scoring systems
Variables Points
1 2 3
Encephalopathy
grade
None 1 amp 2 3 amp 4
Ascites Absent Controlled Refractory
Bilirubin mgdl 15 15-20 gt20
Albumin gmdl 35 20-35 lt 20
PT 1-4 4-6 gt6
Points Class One year survival Two year survival
5-6 A 100 85
7-9 B 81 57
10-15 C 45 35
Model for end-stage liver disease (MELD) Scoring system
The MELD scoring system was developed to prioritize eligibility for liver transplantation
The MELD score is considered more objective and reliable because it is based on objective criteria ie serum bilirubin serum creatinine and international normalized ratio (INR)
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Objectives
Recognize which coexisting disease processes are associated with increased morbidity
Understand which features of the patientrsquos condition can be improved
Realize that a simple operation does not always mean an equally simple or risk-free anaesthetic
Natural progression of chronic liver disease
Chronic liver disease
Death
Compensated cirrhosis
Decompensated cirrhosis
Risk scoring systems
The risks are assessed in all surgical patients with liver disease
Child-Turcotte-Pugh
Model for End-Stage Liver Disease (MELD) Scoring system
Na+ MELD
The Child-Turcotte-Pugh scoring system
The risk of postoperative mortality and morbidity correlate well with the categorization of the patient as per the Child-Turcotte-Pugh (CTP) class of cirrhosis
Scoring System assigns 1 to 3 points on the basis of five simple factors
Sr bilirubin
Sr albumin
prothrombin time
Ascites
grade of encephalopathy
Risk scoring systems
Variables Points
1 2 3
Encephalopathy
grade
None 1 amp 2 3 amp 4
Ascites Absent Controlled Refractory
Bilirubin mgdl 15 15-20 gt20
Albumin gmdl 35 20-35 lt 20
PT 1-4 4-6 gt6
Points Class One year survival Two year survival
5-6 A 100 85
7-9 B 81 57
10-15 C 45 35
Model for end-stage liver disease (MELD) Scoring system
The MELD scoring system was developed to prioritize eligibility for liver transplantation
The MELD score is considered more objective and reliable because it is based on objective criteria ie serum bilirubin serum creatinine and international normalized ratio (INR)
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Natural progression of chronic liver disease
Chronic liver disease
Death
Compensated cirrhosis
Decompensated cirrhosis
Risk scoring systems
The risks are assessed in all surgical patients with liver disease
Child-Turcotte-Pugh
Model for End-Stage Liver Disease (MELD) Scoring system
Na+ MELD
The Child-Turcotte-Pugh scoring system
The risk of postoperative mortality and morbidity correlate well with the categorization of the patient as per the Child-Turcotte-Pugh (CTP) class of cirrhosis
Scoring System assigns 1 to 3 points on the basis of five simple factors
Sr bilirubin
Sr albumin
prothrombin time
Ascites
grade of encephalopathy
Risk scoring systems
Variables Points
1 2 3
Encephalopathy
grade
None 1 amp 2 3 amp 4
Ascites Absent Controlled Refractory
Bilirubin mgdl 15 15-20 gt20
Albumin gmdl 35 20-35 lt 20
PT 1-4 4-6 gt6
Points Class One year survival Two year survival
5-6 A 100 85
7-9 B 81 57
10-15 C 45 35
Model for end-stage liver disease (MELD) Scoring system
The MELD scoring system was developed to prioritize eligibility for liver transplantation
The MELD score is considered more objective and reliable because it is based on objective criteria ie serum bilirubin serum creatinine and international normalized ratio (INR)
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Risk scoring systems
The risks are assessed in all surgical patients with liver disease
Child-Turcotte-Pugh
Model for End-Stage Liver Disease (MELD) Scoring system
Na+ MELD
The Child-Turcotte-Pugh scoring system
The risk of postoperative mortality and morbidity correlate well with the categorization of the patient as per the Child-Turcotte-Pugh (CTP) class of cirrhosis
Scoring System assigns 1 to 3 points on the basis of five simple factors
Sr bilirubin
Sr albumin
prothrombin time
Ascites
grade of encephalopathy
Risk scoring systems
Variables Points
1 2 3
Encephalopathy
grade
None 1 amp 2 3 amp 4
Ascites Absent Controlled Refractory
Bilirubin mgdl 15 15-20 gt20
Albumin gmdl 35 20-35 lt 20
PT 1-4 4-6 gt6
Points Class One year survival Two year survival
5-6 A 100 85
7-9 B 81 57
10-15 C 45 35
Model for end-stage liver disease (MELD) Scoring system
The MELD scoring system was developed to prioritize eligibility for liver transplantation
The MELD score is considered more objective and reliable because it is based on objective criteria ie serum bilirubin serum creatinine and international normalized ratio (INR)
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
The Child-Turcotte-Pugh scoring system
The risk of postoperative mortality and morbidity correlate well with the categorization of the patient as per the Child-Turcotte-Pugh (CTP) class of cirrhosis
Scoring System assigns 1 to 3 points on the basis of five simple factors
Sr bilirubin
Sr albumin
prothrombin time
Ascites
grade of encephalopathy
Risk scoring systems
Variables Points
1 2 3
Encephalopathy
grade
None 1 amp 2 3 amp 4
Ascites Absent Controlled Refractory
Bilirubin mgdl 15 15-20 gt20
Albumin gmdl 35 20-35 lt 20
PT 1-4 4-6 gt6
Points Class One year survival Two year survival
5-6 A 100 85
7-9 B 81 57
10-15 C 45 35
Model for end-stage liver disease (MELD) Scoring system
The MELD scoring system was developed to prioritize eligibility for liver transplantation
The MELD score is considered more objective and reliable because it is based on objective criteria ie serum bilirubin serum creatinine and international normalized ratio (INR)
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Risk scoring systems
Variables Points
1 2 3
Encephalopathy
grade
None 1 amp 2 3 amp 4
Ascites Absent Controlled Refractory
Bilirubin mgdl 15 15-20 gt20
Albumin gmdl 35 20-35 lt 20
PT 1-4 4-6 gt6
Points Class One year survival Two year survival
5-6 A 100 85
7-9 B 81 57
10-15 C 45 35
Model for end-stage liver disease (MELD) Scoring system
The MELD scoring system was developed to prioritize eligibility for liver transplantation
The MELD score is considered more objective and reliable because it is based on objective criteria ie serum bilirubin serum creatinine and international normalized ratio (INR)
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Model for end-stage liver disease (MELD) Scoring system
The MELD scoring system was developed to prioritize eligibility for liver transplantation
The MELD score is considered more objective and reliable because it is based on objective criteria ie serum bilirubin serum creatinine and international normalized ratio (INR)
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Model for end-stage liver disease
MELD = 378timesloge (bilirubin in mgdl) + 112 times loge (INR) + 957 times loge (creatinine in mgdl) + 643 (a bilirubin or creatinine value of less than 10 mgdl is rounded to 10 mgdl and the maximum creatinine value allowed is 40 mgdl )
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Strengths of the MELD score
An objective metric using a continuous scale that lends itself to ranking patients based on disease severity
It incorporates laboratory parameters that are easily available and reproducible
Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease
Superior to clinical judgment in identifying patients at risk of mortality
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Evaluation
MELD uses the patients values for serum Bilirubin serum Creatinine and the INR to predict survival
In interpreting the MELD Score in hospitalized patients the 3 month mortality is
40 or gt 40 713 mortality
30ndash39 526 mortality
20ndash29 196 mortality
10ndash19 60 mortality
lt9 19 mortality
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Open abdominal surgery
CTP 5 - 6 10 Mortality
CTP 7-9 30 Mortality
CTPgt9 70 Mortality
MELDlt10 Survival rate 99 at 7 days
96 at 30 days 92 at 90 days
MELDgt 10 Survival rates significantly lower
Suman ACleveJ Med 200673398-404
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components Gish RG Liver Transpl 2007
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Na+ MELD
Serum sodium concentration - an important prognostic factor in patients with cirrhosis
Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone
Serum sodium predicts mortality in patients listed for liver transplantation
Hyponatremia is associated with neurologic dysfunction refractory ascites hepatorenal syndrome and death from liver disease
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Peri-operative risks
Surgery in acute liver disease
Nature of Surgery
Type of surgery
Anaesthetic factors
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Surgery in acute liver disease
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Surgery in acute liver disease
Acute liver diseases have higher operative risk
Acute viral and alcoholic hepatitis has poor outcomes in surgical patients
Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered
Patients with acute hepatitis of any cause are regarded as having increased risk
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Surgery in alcoholic hepatitis
Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality
Laparotomy in patient with alcoholic hepatitis may have serious consequences
The mortality rate was 58 among the 12 patients who underwent open liver biopsy compared with 10 among the 39 patients who underwent percutaneous liver biopsy
Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia
Greenwood SM Leffler CT Minkowitz S The increased mortality rate of open liver biopsy in alcoholic
hepatitis Surg Gynecol Obstet 1972134600-4
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Patients with acute liver are critically ill and all
surgery other than liver transplantation is
contraindicated
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Nature of surgery
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Emergency surgery
49 47
51
870
0
20
40
60
80
100
120
Patients Mortality
Elective
Emergency
138 patients with cirrhosis undergoing non hepatic general surgical procedure
High risk Emergency surgery Neeff H et al J Gastrointest Surg 2011
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
TYPE OF SURGERY
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Only MELD score American Society of Anesthesiologists class and age predicted mortality at 30 and 90 days 1 year and long-term independent of type of surgery
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Type of surgery
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Open abdominal surgery
Fifty-three adult patients with cirrhosis undergoing abdominal surgery
Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded
Total 13 patients (25) had poor outcomes including 9 deaths (17)
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Open abdominal surgery
Model for end-stage liver disease score and
plasma hemoglobin levels lower than10 gdL
found to be independent predictors of poor
outcomes
A MELD score of 14 or greater was a better
clinical predictor of poor outcome than CTP C
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal
surgery in patients with cirrhosis Arch Surg 2005140 650-4
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Open abdominal surgery
The mortality rate was higher in patients with one or more of the followings
elevated bilirubin
prolonged prothrombin time
ascites
decreased albumin
encephalopathy
portal hypertension
emergent surgery
Befeler AS Palmer DE Hoffman M Longo W Solomon H Di Bisceglie AM The safety of intra-abdominal surgery in
patients with cirrhosis Arch Surg 2005140 650-4
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Obstructive jaundice
Retrospective analysis 373 patients - risk factors for peri-operative death were
Hematocritlt 30
Sr Bilirubin gt11 mgdl
Malignant cause of biliary obstruction
If Benign Condition preoperative optimization with
ERCP Stenting
External PTBD with radiology guidance
Madical MM - Ursodeoxycholic acid lactulose
Mortality
60 if all 3 present
5 if none present
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Cardiac surgery
Safe in CTP A and selected CTP B
Best cut of values for predicting mortality and hepatic decompensation
CTP gt7 amp MELD gt13
Clin Gastroenterol Hepatol 20042719-23
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy carries a low mortality
rate
In a retrospective analysis of 226 patients with
cirrhosis (Child-Pugh class A or B) who underwent
laparoscopic cholecystectomy only two died (088)
The reported mortality is low but this figure is still
significantly higher than in non-cirrhotic controls
(001)
Yeh CN Chen MF Jan YY Laparoscopic cholecystectomy in 226 cirrhotic patients Experience
of a single center in Taiwan Surg Endosc 2002161583-7
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Laparoscopic cholecystectomy
This suggest cutoff mark of MELD le 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Laparoscopic cholecystectomy
Patients with cirrhosis undergone laparoscopic cholecystectomy 2 out of the 33 (6) patients with cirrhosis died at 90 days compared with no mortality in 31 matched controls
The rate of morbidity was 33 vs 17 in the study
Perkins L Jeffries M Patel T Utility of preoperative scores for predicting morbidity after
cholecystectomy in patients with cirrhosis Clin Gastroenterol Hepatol 200421123-8
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Asymptomatic gallstone disease
Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic
Because chances of liver function to deteriorate after surgery
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Cholecystectomy open or laparoscopic
Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease
The procedure was open in half of the patients and laparoscopic in the other half
All patients had Child-Pugh class A or B cirrhosis
Poggio JL Rowland CM Gores GJ Nagorney DM Donohue JH A comparison of laparoscopic and open
cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease Surgery
2000127405-11
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Cholecystectomy open or laparoscopic
The study concluded that laparoscopic cholecystectomy is
associated with statistically significant reductions in
operating room time blood loss and length of hospital
stay
There was no deaths in either group
Laparoscopic cholecystectomy should be recommended
for patients with liver disease without decompensation
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Mortality rates in patients undergone cholecystectomy with or without cirrhosis
Variables Mortality
Patients with normal liver
function
1
Patients with cirrhosis (P T
lt 25 second than control)
9
Patient with cirrhosis PT gt
25 seconds than control
83
Aranha GV Sontag SJ Greenlee HB Cholecystectomy in cirrhotic patients a formidable
operation Am J Surg 198214355-60
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery
Preoperative variables of
mortality if
factors
present
of
mortality
if factors
absent
Child Class
A 10
B 31
C 76
Ascites 58 11
Emergency Surgery 57 10
Bilirubin gt 3 mgdl 62 17
Albumin lt 3gmdl 58 12
Prothrombin time gt 15second above control 63 18
WBC count gt 10000 54 19
P lt 001 for all variables
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Preoperative variable associated with mortality
Preoperative variable Mortality if present
Pulmonary failure 100
Cardiac failure 92
Requirement of gt 2 antibiotics 82
Renal failure 73
Hepatic failure 66
Gastrointestinal bleeding 86
Required 2nd operation 81
Positive cultures 61
Blood requirement gt 2 units 69
Blood requirement lt 2 units 22
Garrison RN Cryer HM Howard DA Polk HC Jr Clarification of risk factors for abdominal
operations in patients with hepatic cirrhosis Ann Surg 1984199648-55
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Anesthetic considerations
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Anesthetic considerations
The risk of surgery cannot be separated from the risk of anesthesia
Anesthesia can affect the liver by reducing its blood flow
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Anesthetic considerations
animals studies have shown that under the conditions of stress hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease especially cirrhosis cannot compensate for the reduced portal blood flow which may cause hepatic dysfunction
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Anesthetic considerations
In healthy volunteers hepatic blood flow decreased by 35 to 42 in the first 30 minutes of induction of anesthesia
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Anesthetic considerations
The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow
These effects are minimal with Isoflurane
Inhalational agents Isoflurane Desflurane and Sevoflurane undergo hepatic metabolism extent of which is 02 for isoflurane 2 - 4 for Enflurane and 20 for Halothane
Isoflurane has become the inhalation agent of choice in patients with liver disease
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Anesthetic considerations
Anesthetic agents sedatives and skeletal muscle relaxants can all have adverse effects
The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity decreased biliary excretion and larger volume of distribution
Metabolism of Atracurium is by Hoffman reaction and does not depend on liver
Use of Atracurium is safe and is recommended in liver disease
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Anesthetic considerations
The use of various narcotics like fentanyl sufentanil and sedatives like Oxazepam Lorazepam is recommended
No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane Isoflurane Fentanyl Sufentanil Midazolam or Morphine
The type of anesthetic management either general anesthesia regional anesthesia or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients
Ziser A Plevak DJ Wiesner RH Rakela J Offord KP Brown DL Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery Anesthesiology 19999042-53
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Conclusion
Various type of surgeries can be safely performed in CTP score le 7
CTP amp MELD scores predict morbidity and mortality in cirrhotics
In acute liver diseases surgery should be avoided
Emergency surgery carries high mortality in cirrhotics
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
Conclusion
Abdominal wall surgery may be safely performed in Child-Pugh in A amp B
Laparoscopic surgery should be preferred over open surgeries
Asymptomatic GSD should not be operated
WELCOME TO TRANCRIT
2012 AT ILBS
WELCOME TO TRANCRIT
2012 AT ILBS
