[HSF] Operating on Liver Cirrhotics

[Claudia Teles]

Dear all,
 Some clinical considerations.
First: it is useful to classify the degree of liver dysfunction before
surgery. This can be done with Child Pugh modified score or with
scyntillographic methods, which are very accurate in this regard.
Second: Nutritional and metabolic improvement can make a difference if you
can raise a Class C patient´s dysfunction degree to a class A or B.
Third: Don´t rely only in the prothrombin time and INR to evaluate
coagulation: some of these patients have active fibrinolysis and this can be
a complication in the surgical theatre. Fibrinogen levels, factor V and VII
levels, D dimer and Thrombin- Antithrombin complexes serum levels can be
useful in this regard, if you don´t have any functional dynamic coagulation
evaluation device available (Sono Clot, TEG, ROTEM, etc).
Many times, if you improve nutrition, you can ameliorate the coagulation
status and immune function of the patient.

Hope it helps,

Claudia Teles, MD





Liver Transpl. <javascript:AL_get(this, 'jour', 'Liver Transpl.');> 2007 Apr
10;13(7):990-995 [Epub ahead of print][image: Click here to
read]<http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=3058&itool=AbstractPlus-def&uid=17427174&db=pubmed&url=http://dx.doi.org/10.1002/lt.21075>
Links <javascript:PopUpMenu2_Set(Menu17427174);>
 Early and late outcome of cardiac surgery in patients with liver cirrhosis.
*Filsoufi F*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Filsoufi%20F%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
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*Schiano TD*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Schiano%20TD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
*Elsiesy H*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Elsiesy%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
*Squire A*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Squire%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
*Adams DH*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Adams%20DH%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>
.

Department of Cardiothoracic Surgery, Mount Sinai Hospital, New York.

Liver cirrhosis is a major risk factor in general surgery. Few studies have
reported on the outcome of cardiac surgery in these patients. Herein we
report our recent experience in this high-risk patient population according
to the Child-Turcotte-Pugh classification and Model for End-Stage Liver
Disease (MELD) score. Between January 1998 and December 2004, 27 patients
(mean age 58 +/- 10 yr, 20 male) with cirrhosis who underwent cardiac
surgery were identified. Patients were in Child-Turcotte-Pugh class A (n =
10), B (n = 11), and C (n = 6) and mean MELD score was 14.2 +/- 4.2.
Operative mortality was 26% (n = 7). Stratified mortality according to
Child-Turcotte-Pugh class was 11%, 18%, and 67% for class A, B, and C,
respectively. No mortality occurred in patients who had revascularization
without the use of cardiopulmonary bypass (n = 5). The 1-yr survival was
80%, 45%, and 16% for Child-Turcotte-Pugh class A, B, and C, respectively (P
= 0.02). Major postoperative complications occurred in 22%, 56%, and 100%
for Child-Turcotte-Pugh class A, B, and C, respectively. Child-Turcotte-Pugh
classification was a better predictor of hospital mortality (P = 0.02)
compared to MELD score (P = 0.065). In conclusion, our results suggest that
cardiac surgery can be performed safely in patients with Child-Turcotte-Pugh
class A and selected patients with class B. Operative mortality remains high
in class C patients. Careful patient selection is critical in order to
improve surgical outcome in patients with cirrhosis. Liver Transpl, 2007.
(c) 2007 AASLD.
* * * *Curr Treat Options Gastroenterol. <javascript:AL_get(this, 'jour',
'Curr Treat Options Gastroenterol.');> 2005 Dec;8(6):473-80.[image: Click
here to read]<http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=3188&itool=AbstractPlus-def&uid=16313865&db=pubmed&url=http://www.treatment-options.com/1092-8472/8/473>
Links <javascript:PopUpMenu2_Set(Menu16313865);> Management of the cirrhotic
patient that needs surgery. *Bell
CL*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bell%20CL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
*Jeyarajah DR*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Jeyarajah%20DR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>
.

Department of Surgery, Methodist Hospital of Dallas, 221 West Colorado
Blvd., Pavilion I, Suite 100, Dallas, TX 75208, USA.

Conditions that necessitate surgery frequently arise in patients with
chronic liver disease and cirrhosis. Because cirrhosis has the ability to
cause physiologic derangements in every organ system in the body, clinicians
face significant challenges in preoperative preparation of the patient with
cirrhosis in order to decrease postoperative morbidity and mortality.
Emergent operations add an extra dimension of complexity to the clinical
picture, due to limited preoperative time to prepare the patient with
cirrhosis for surgery. In cases of severely decompensated cirrhosis,
clinicians should have in their armamentarium possible alternatives to
surgery that can be used to temporize the emergent nature of the disease and
improve patient outcomes. The classification of cirrhotic liver disease by
Child and Turcotte was initially utilized to predict mortality in patients
undergoing surgically placed shunts for portal hypertensive bleeding.
Subsequent studies have pointed to the fact that other general and thoracic
surgery procedures can be assigned predicted mortality rates according to a
similar classification scheme, the modified Child-Pugh score. Patients with
cirrhosis facing surgery should undergo a careful history and physical
examination and should be accurately placed into a designated Child-Pugh
category. Because the modified Child-Pugh class is the most reliable
determinant of postoperative morbidity and mortality, every attempt should
be made to upgrade a patient's class in a favorable direction prior to
surgery. Patients should be carefully evaluated for the presence of ascites
and dietary alterations. In addition, medical management with diuretics
should be employed to prevent postoperative ascites leak and possible
infectious complications including bacterial peritonitis. Perhaps one of the
most feared complications in the patient with cirrhosis facing surgery is
hemorrhage. Because the liver is vital in maintenance of coagulation
homeostasis, several pharmacologic adjuncts may be administered to correct
any coagulopathy in the peri-operative period. Several diseases such as
cholelithiasis and peptic ulcer disease are known to be more prevalent in
the cirrhotic patient, and clinicians treating these diseases should have a
thorough understanding of the pathophysiology of cirrhosis and portal
hypertension. Patients with cirrhosis and portal hypertensive bleeding that
are considered good surgical candidates (ie, Child-Pugh class A) may benefit
from surgical portasystemic shunt in contrast to angiographically placed
portacaval shunt (ie, transjugular intrahepatic portosystemic shunt ) due to
the lack of durable patency and cost effectiveness in the latter. In
patients with cirrhosis awaiting orthotopic liver transplantation, TIPS may
be a lifesaving temporizing technique that is utilized as a bridge to
transplantation.