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SURGICAL CLEARANCE IN LIVER DISEASE

SURGICAL CLEARANCE IN LIVER DISEASE. Dr. Sawan Bopanna Preceptor :Dr Shalimar. Patients with liver disease presenting for various surgical interventions are increasing Patients with liver disease form an important subset of surgical candidates

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SURGICAL CLEARANCE IN LIVER DISEASE

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  1. SURGICAL CLEARANCE IN LIVER DISEASE Dr. SawanBopanna Preceptor :Dr Shalimar

  2. 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

  3. ASSESSING SURGICAL RISK CHALLENGING TASK

  4. OVERVIEW • Effects 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

  5. EFFECT OF SURGERY & ANESTHESIA ON LIVER

  6. HEMODYNAMIC 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

  7. Decreased hepatic perfusion at baseline makes the diseased liver more susceptible to : HYPOTENSION HYPOXEMIA

  8. 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%

  9. 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

  10. ANESTHETIC RISKS • The 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 encephalopathy

  11. OPERATIVE RISKS IN VARIOUS LIVER DISEASES

  12. Surgical Risk Overview Cirrhosis Obstructive Jaundice Acute Hepatitis Chronic Hepatitis

  13. 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

  14. ACUTE HEPATITIS • Operative 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):257-261 • High 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

  15. CHRONIC HEPATITIS • Surgical 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

  16. SURGICAL RISK IN CIRRHOSIS DEPENDS ON 1. Severity of liver disease 2. Nature of the surgical procedure 3. Associated comorbidities

  17. 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

  18. MORTALITY RATE • Evidence 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 Surg1984;199:648–55 Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 1997;122:730–5 TelemDA, Schiano T, Goldstone R, et al. Factors that predict outcome of abdominal operations in patients with advanced cirrhosis. Clin Gastroenterol Hepatology 2010;8:451–7

  19. Lower mortality –attributed to better preoperative management • Morbidity rate still remained high

  20. IMPACT OF PORTAL HYPERTENSION • Child 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. Neoadjuvanttransjugularintrahepaticportosystemic shunt: A solution for extrahepaticabdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001;193:46-51

  21. Azoulay D, Buabse F, Damiano I, et al. Neoadjuvanttransjugularintrahepaticportosystemic shunt: A solution for extrahepaticabdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001;193:46-51 • Seven 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

  22. Can J GastroenterolVol 20 No 6 June 2006 • Study evaluated the clinical outcomes of 18 patients with cirrhosis who underwent TIPS • TIPS was performed a mean (± SD) of 72±21 days before surgery • Cirrhotic patients who underwent elective abdominal surgery without preoperative TIPS placement were used as the control group

  23. p= 0.58 • Study suggested preoperative TIPS did not significantly improve postoperative survival to suggest routine use

  24. 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;122:730–5.

  25. 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

  26. 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: 244–51

  27. GASTROENTEROLOGY Vol. 132, No. 4 • Large 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

  28. Patients undergoing major surgery were at increased risk for mortality upto 90 days postoperatively • In the multivariable analysis - significant predictors of mortality 1. MELD score 2. Age 3. 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

  29. RELATIONSHIP BETWEEN MELD AND MORTALITY • Mortality risk almost linear for MELD scores greater than 8 30 day mortality 60 day mortality

  30. ASA CLASSIFICATION (AMERICAN SOCIETY OF ANESTHESIOLOGISTS) • 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 surgery

  31. No 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 • Awebsite based calculator was developed which could calculate the mortality risk at different time points based on Age, MELD score and ASA class

  32. CTP vs MELD SCORE World J Gastroenterol 2008 March 21; 14(11): 1774-1780 • 195 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 RECOMMENDATIONcan be made regarding use of one over the other, based on current literature

  33. PERIOPERATIVE CONSIDERATIONS IN VARIOUS LIVER DISEASES

  34. CONTRAINDICATIONS TO ELECTIVE SURGERY 1. AcuteLiver Failure 2. Acute Kidney Injury 3. Acute Viral Hepatitis 4. Alcoholic hepatitis 5. Cardiomyopathy 6. Hypoxemia 7. Severe coagulopathy (despite treatment)

  35. OPERATIVE RISKS IN VARIOUS SURGERIES

  36. CARDIAC SURGERY • Cardiac surgery and other procedures that require use of cardiopulmonary bypass are associated with greater mortality in patients with cirrhosis

  37. ABDOMINAL WALL SURGERY: UMBULICAL HERNIA REPAIR • Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites Surgery 2011 Sep;150(3):542-6 • 30 patients underwent operation at a mean age of 58 years • 6 were classified as CPT grade A (20%), 19 (63%) as grade B, and 5 (17%) as grade C • No mortality or complications were noted post surgery

  38. CHOLECYSTECTOMY IN CIRRHOTICS: OPEN VS LAPAROSCOPIC • Prevalence of gallstones in patients with cirrhosis is estimated at 29–46% and thus is three times as high as those in patients without cirrhosis • Symptomatic gallstones in cirrhotics need to be treated • In the era prior to Lap Cholecystectomy, reported postoperative mortality in patients with cirrhosis undergoing Open Cholecystectomy was 7.5–25.5%

  39. HPB (Oxford). 2012 Mar;14(3):153-61 • Forty-four studies were analyzed • These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n = 1756) or open (n = 249) cholecystectomy • Mortality rates of 0.74% in laparoscopic cholecystectomy and 2.00% in open cholecystectomy • Meta-analysis of 3randomized controlled trials were performed(total 220 patients) • Studies weresmall, heterogeneous in design and include almost exclusively patients with Child–Pugh class A and B disease

  40. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC • However, frequencies of postoperative hepatic insufficiency did not differ significantly • In patients with cirrhosis when cholecystectomy is indicated, laparoscopic approach should be considered

  41. A meta-analysis of three RCTs involving a total of 220 patients was conducted Forrest Plots of outcomes: 1.Total postoperative complications (P = 0.03) 2.Infectious complications (P = 0.001) 3.Postoperative hepatic insufficiency (P = 0.40)

  42. OBSTRUCTIVE JAUNDICE Factors affecting morbidity and mortality after obstructive jaundice: review of 373 patients Gut 1983 • Retrospective analysis of 373 patients • Of the 373 patients 281 had a benign and 92 had a malignant cause of obstruction Three risk factors identified for perioperative death: • Low hematocrit (< 30%) • Elevated serum bilirubin (> 11 mg/dL) • Malignant cause of biliary obstruction When all 3 present risk of mortality -60% When none present risk of mortality -5%

  43. 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

  44. 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

  45. HEPATIC RESECTION • Post-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 failure van den Broek MA, OldeDamink SW, Dejong CH, et al. Liver failure after partial hepatic resection: definition, pathophysiology, risk factors and treatment. Liver Int 2008;28:767–80

  46. Risk 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

  47. 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

  48. PREOPEREATIVE EVALUATION OFASYMPTOMATIC PATIENT WITH ABNORMAL LIVER TEST Raised ALT/AST <2x NL >2xNL or >1xNL +raised INR Normal ALP Bilirubin INR H/O of prior liver disease Imaging and further evaluation Surgery

  49. RAISED ALKALINE PHOSPHATASE <2x NL >2x NL Abnormal GGT/Bilirubin Normal GGT / Bilirubin Further evaluation before surgery Surgery

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