Surgical clearance in Liver Disease

SURGICAL CLEARANCE IN LIVER DISEASEDr. Sawan BopannaPreceptor :Dr Shalimar

Patients with liver disease presenting for various surgical interventions are increasing

Patients with liver disease form an important subset of surgical candidates

Altered liver function has various implications for those undergoing surgery

Pre-op evaluation of patients with liver disease- common hepatology consult

ASSESSING SURGICAL RISK CHALLENGING TASK

OVERVIEWEffects of surgery and anesthesia on liver disease

Operative risks in various liver diseases

Operative risks in various surgeries

Preoperative risk assessment and clearance for surgery

Surgical risk in patients with obstructive jaundice

EFFECT OF SURGERY & ANESTHESIA ON LIVERHEMODYNAMIC CHANGES IN LIVER DISEASE

Liver Disease especially cirrhosis - state of altered hemodynamics

At baseline hepatic perfusion is reduced in cirrhosis:

Peripheral and splanchic vasodilation reduced effective circulatory volume

Hepatic arterial flow further reduced- altered autoregulation

Portal blood flow is reduced due to increased intrahepatic resistance

Decreased hepatic perfusion at baseline makes the diseased liver more susceptible to :

HYPOTENSION

HYPOXEMIA

PERIOPERATIVE HYPOTENSION

May occur due to excessive blood loss, intra-operative arrhythmias, and secondary to anesthetic agents

Intermittent positive pressure ventilation and pneumoperitoneum due to laparoscopic surgery mechanically decrease blood flow to the liver

Laparotomy with traction on abdominal viscera causes dilation of splanchnic veins and thereby lower hepatic blood flow

Anesthetic agents including epidural and spinal anesthesia reduce hepatic blood flow by 30-50%

RISK FACTORS FOR INTRAOPERATIVE HYPOXEMIA IN PATIENTS WITH LIVER DISEASE

Hepatic hydrothorax

Ascites

Hepatopulmonary syndrome

Portopulmonary hypertension

Ascites and hepatic hydrothorax should be treated before elective surgery

Hepatopulmonary syndrome and portopulmonary hypertension contraindications to surgery

ANESTHETIC RISKSThe risk of surgery cannot be separated from the risk of anesthesia

All volatile anesthetics decrease hepatic blood flow

Advanced liver disease may impair the elimination, prolong half-life and potentiate clinical effects of several drugs

Sedatives, narcotics, and intravenous induction agents must be used with caution in patients with decompensated CLD - may precipitate hepatic encephalopathyOPERATIVE RISKS IN VARIOUS LIVER DISEASES

OverviewSurgical Risk Acute HepatitisChronic HepatitisCirrhosisObstructive Jaundice Precise estimates of operative risk in patients with well characterized liver disease are few

Most available data derived are from small studies

Mostly retrospective studies of cirrhotic patients who underwent surgery

ACUTE HEPATITISOperative mortality 10-13% - Data from older studies in patients who underwent laparotomy Surgery in Acute Hepatitis Causes and Effects Donald D. Harville, MD.JAMA 1963;184(4):257-261High mortality in patients with alcoholic hepatitis mortality rates as high as 55%

Surgery is thus contraindicated in patients with acute hepatitis

Can be undertaken after clinical and biochemical resolution of hepatitis

CHRONIC HEPATITISSurgical risk correlates with clinical, biochemical, and histological severity of disease

Asymptomatic mild chronic hepatitis- not a contraindication for elective surgery

Patients with symptomatic and histologically severe chronic hepatitis have an increased surgical risk

Increased risk if hepatic synthetic function is decreased or portal hypertension is present

SURGICAL RISK IN CIRRHOSIS DEPENDS ON

1. Severity of liver disease

2. Nature of the surgical procedure

3. Associated comorbidities16 ASSESSMENT OF SEVERITY OF LIVER DISEASE FOR SURGICAL CLEARANCE

Child Turcotte Pugh scoring system - most commonly used

Rationale for use of the Child score based on retrospective studies

Predicts postoperative mortality

Child class correlates well with post operative complication including liver failure, worsening encephalopathy, bleeding, infection and ascites

MORTALITY RATEEvidence in the form of retrospective studies

Studies in patients undergoing abdominal surgeries Garrison RN, Cryer HM, Howard DA, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984;199:64855 Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 1997;122:7305 Telem DA, Schiano T, Goldstone R, et al. Factors that predict outcome of abdominal operations in patients with advanced cirrhosis. Clin Gastroenterol Hepatology 2010;8:4517Child ClassGarrison et al 1984(%)Mansour et al1997(%)Telem et al2010(%)A10 %10%2%B31 %30%12%C76%82%12%

Lower mortality attributed to better preoperative management Morbidity rate still remained highIMPACT OF PORTAL HYPERTENSIONChild A cirrhosis with portal hypertension - mortality rates increase

Similar to Child B cirrhosis - 30%

Reduction in portal pressure by preoperative placement of TIPS - may improve surgical outcome in these patients Azoulay D, Buabse F, Damiano I, et al. Neoadjuvant transjugular intrahepatic portosystemic shunt: A solution for extrahepaticabdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001;193:46-51Azoulay D, Buabse F, Damiano I, et al. Neoadjuvant transjugular intrahepatic portosystemic shunt: A solution for extrahepaticabdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001;193:46-51Seven cirrhotic patients with severe portal hypertension

Portal hypertension was the leading cause of surgical contraindication

TIPS to control portal hypertension followed by surgery in 6 of the 7 patients

Surgery was performed with a delay ranging from 1 month to 5 months after TIPS

Operative mortality was seen in only 1 patient

Study evaluated the clinical outcomes of 18 patients with cirrhosis who underwent TIPS

TIPS was performed a mean ( SD) of 7221 days before surgery

Cirrhotic patients who underwent elective abdominal surgery without preoperative TIPS placement were used as the control group

Can J Gastroenterol Vol 20 No 6 June 2006p= 0.58Study suggested preoperative TIPS did not significantly improve postoperative survival to suggest routine use

Emergency surgery increases the perioperative mortality in addition to the Child score

Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 1997;122:7305.

Child scoreEmergencyElectiveA22%10%B38%30%C100%82%MELD SCORE TO ASSESS SURGICAL RISK

Has distinct advantages when compared to Child score

It is objective, weights the variables differently and does not rely on arbitrary cut off

Each 1-point increase in MELD score- incremental contribution to operative risk

MELD increases precision in assessing surgical risk

140 surgical procedures were identified and analyzed. The 30-day mortality rate was 16.4%

Further subgroup analysis of 67 intra-abdominal surgeries showed an in-hospital mortality of 23.9%.

Linear relationship to mortality, with mortality rising by 1% for each MELD point below 20, and 2% for higher MELD scores (P 0.0001 ) Northup PG, Wanamaker RC, Lee VD et al. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann. Surg. 2005; 242: 24451

N=140Died at 30 daysSurvived >30 daysP valueMean admission MELD23.3(19.6 27.0)16.9 (15.6 18.2)0.0003N=67Died at 30 daysSurvived >30 daysP valueMean admission MELD24.8 (20.4 29.3)16.2( 14.218.2)P 0.0001Large retrospective study

772 cirrhotic patients who underwent surgery were included in the study

Digestive(n=586), Orthopedic(n=107), Cardiovascular(n=79)

Control group of patients with cirrhosis included 303 patients undergoing minor surgical procedure and 562 outpatient cirrhotics

GASTROENTEROLOGY Vol. 132, No. 4Patients undergoing major surgery were at increased risk for mortality upto 90 days postoperatively

In the multivariable analysis - significant predictors of mortality1. MELD score2. Age3. ASA class

A single point increase in the MELD score 14% increase in mortality in the first 30 and 90 postoperative days 15% increase in mortality in the first postoperative year 6% increase in mortality for subsequent years

RELATIONSHIP BETWEEN MELD AND MORTALITYMortality risk almost linear for MELD scores greater than 830 day mortality

60 day mortality

MELD scoreMortality7 or less5.7%8-1110.3%12-1525.4%ASA CLASSIFICATION (AMERICAN SOCIETY OF ANESTHESIOLOGISTS)ClassIHealthy patientIIMild systemic disease without functional limitationIIIPatient with severe systemic disease with functional limitationIVPatient with severe systemic disease that is a constant threat to lifeVMoribund patient not expected to survive >24 hours with or without surgery ASA class IV added the equivalent of 5.5 to the prior MELD points

The influence of the ASA class was greatest in the first 7 days after surgeryNo patient under 30 years of age died and an age greater than 70 years added the equivalent of 3 MELD points to the mortality rate

Emergency surgery was not an independent predictive factor for mortality when the MELD score was considered

A website based calculator was developed which could calculate the mortality risk at different time points based on Age, MELD score and ASA class

CTP vs MELD SCORE

World J Gastroenterol 2008 March 21; 14(11): 1774-1780195 patients with cirrhosis who underwent surgery were reviewed

CTP and MELD scores performed equally in predicting mortality and hepatic decompensation

Though MELD score as its advantages, NO CLEAR RECOMMENDATION can be made regarding use of one over the other, based on current literature

MELD + CTPSURGICAL CLEARANCEChild C and MELD >14No surgical interventionChild B and MELD >8-14Increased perioperative risk and indication for surgery should be reassessedChild C and MELD 11 mg/dL) Malignant cause of biliary obstruction

When all 3 present risk of mortality -60%When none present risk of mortality -5%

Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice Br J Surg.2013 Nov;100(12):1589-96. doi: 10.1002/bjs.9260

Meta-analysis of 6 RCTs

520 patients with malignant or benign obstructive jaundice were included

265 patients had undergone Preoperative Biliary Drainage and 255 patients had no Preoperative Biliary Drainage

There was no significant difference in mortality between the 2 groups

More morbidity among patients who underwent preoperative biliary drainage

PBD cannot significantly reduce the postoperative mortality and complications of malignant obstructive jaundice, and therefore should not be used as a preoperative routine procedure for malignant obstructive jaundice Effect of preoperative biliary drainage on malignant obstructive jaundice: a meta-analysis World J Gastroenterol.2011 Jan 21

There is currently not sufficient evidence to support or refute routine pre-operative biliary drainage for patients with obstructive jaundice. Pre-operative biliary drainage may increase the rate of serious adverse events Pre-operative biliary drainage for obstructive jaundice Cochrane Database Syst Rev. 2012

HEPATIC RESECTIONPost-resectional liver failure has been defined as a prothrombin-time index of less than 50% (INR> 1.7) and serum bilirubin greater than 50 mol/L (>2.9 mg/dL)[50-50 criteria]

When these criteria are met postoperative mortality is 59% when compared to patients to 1.2% in patients not meeting the above criteria

Sensitivity of 50% and specificity of 96% for prediction of post resection liver failurevan den Broek MA, Olde Damink SW, Dejong CH, et al. Liver failure after partial hepatic resection: definition, pathophysiology, risk factors and treatment. Liver Int 2008;28:76780Risk Stratification: MELD score

Indication of the extent of hepatectomy for hepatocellular carcinoma on cirrhosis by a simple algorithm based on preoperative variables Arch Surg 2009

Retrospective study

466 patients who underwent hepatectomy for HCC

29 patients had post hepatectomy liver failure

MELDPLF1015% PERIOPERATIVE ASSESSMENT

Every effort should be undertaken to optimize the condition of a patient with liver disease prior to surgery

Ascites should be treated prior to surgery to avoid respiratory compromise, wound dehiscence or abdominal wall hernia

Volume status and renal function should be optimized to reduce risk of HRS

Nutritional assessment and optimization of nutritional support PREOPEREATIVE EVALUATION OFASYMPTOMATIC PATIENT WITH ABNORMAL LIVER TEST Raised ALT/AST2xNL or>1xNL +raised INRNormal ALPBilirubinINRSurgeryH/O of prior liver diseaseImaging and further evaluationRAISED ALKALINE PHOSPHATASE2x NLAbnormal GGT/Bilirubin Further evaluation before surgeryANESTHETIC CONSIDERATIONSThe anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow

Desflurane and Isoflurane are preferred inhalational anesthetics in chronic liver disease

Intravenous anesthetics have only a modest effect on hepatic blood flow

Neuromuscular blocker action is prolonged due to reduced hepatic clearance

Atracurium is the safest NM blocker in chronic liver disease

POSTOPERATIVE ASSESSMENTPatients with cirrhosis need to be monitored for the development of signs of hepatic decompensation

When any of these indicators is found supportive therapy should be initiated immediately

Monitoring of liver function postoperatively- serum bilirubin and prothrombin time

Glucose monitoring to prevent hypoglycemia

Careful attention should be paid to the assessment of intravascular volume

SUMMARYPatients with chronic liver disease face greater risk of perioperative morbidity and mortality

Risk is greater among patients with cirrhosis

Child-Pugh score has consistently performed well in estimating relative risk or mortality

The best outcomes among Child-Pugh class A patients and poor outcomes for patients with Child-Pugh class C cirrhosisMELD score can predict surgical outcomes

The combination of the Child-Pugh score and the MELD score can guide patients and their surgeons regarding operative risks

Various open abdominal and even cardiac surgeries can be performed in patients of Child A status and MELD score < 8 with low perioperative mortality

In patients with Child C status and MELD score > 14, elective surgeries should be avoided

Elective surgery - the procedure should be delayed to allow for a complete evaluation of the severity of liver disease

Optimization of complications such as varices, ascites, and encephalopathy - necessary before surgery

Elective surgery should not be offered to patients with acute liver failure and alcoholic hepatitis

Acute Liver DiseaseAcute HepatitisAcute Liver FailureWait till resolvesConsider TransplantChild C/MELD score >14Child B/MELD score 8-14Child A/MELD