Preoperative and Postoperative Care of the Liver Patient


1 Point

2 Points

3 Points

Bilirubin (mg/dL)




Albumin (g/dL)




PT prolong (sec)






Easily controlled

Poorly controlled



Grade 1–2

Grade 3–4

A total Child–Turcotte–Pugh score of 5–6 is considered class A (well-compensated disease); 7–9 is class B (significant functional compromise); and 10–15 is class C (decompensated disease). Adapted from Pugh et al. [90]

Prior to surgery, the condition of patients with decompensated cirrhosis should be optimized as much as possible in order to minimize complications. A tool such as the Preoperative Liver Assessment (POLA) checklist (see Table 8.2) provides a simple to use, yet comprehensive approach, in optimizing patients with decompensated cirrhosis. In the following chapter, we will review and discuss the assessment of surgical risk and the management of perioperative complications in patients with cirrhosis who are undergoing surgery.

Table 8.2
Preoperative liver assessment (POLA) checklist

Emergent or elective

If surgery is potentially life-saving, proceed with surgery with adequate informed consent, but also consider nonsurgical alternatives like such as ongoing medical therapy or interventional radiologic procedures or palliative care as appropriate

Characterize liver disease

Determine cause and chronicity of liver disease

⚬ If acute viral or alcoholic hepatitis or severe drug-induced injury, postpone surgery for at least 3 months

⚬ If chronic but mild liver disease, proceed with surgery

⚬ If there is evidence of cirrhosis or non-cirrhotic portal hypertension, continue with liver assessment

Identify significant comorbid conditions

Focus on presence of diabetes, chronic kidney disease, and cardiovascular disease

If moderate or severe nutritional deficiency is present, optimize nutrition by oral, enteral, or even parenteral means before surgery

Perform liver imaging

MRI or CT are preferred to evaluate for liver appearance, vessel patency, hepatocellular carcinoma, and evidence of portal hypertension (e.g., Intra-abdominal varices, spleen size)

Ultrasound with Doppler is sufficient if there are contraindications to CT or MRI such as acute liver injury

Obtain history of prior hepatic decompensation

Ascites: if yes, consider future impact on wound healing with postoperative recurrence

Encephalopathy: if yes, adjust planned sedation and analgesia, and monitor for regular bowel movements

⚬ Do not restrict dietary protein (give 1.2–1.5 g/kg protein daily)

Variceal bleeding: if yes, perform upper endoscopy and initiate variceal hemorrhage prophylaxis

Evaluate for current hepatic decompensation

Ascites: if yes, perform diagnostic paracentesis to evaluate for SBP

⚬ If moderate or severe, perform LVP before surgery

⚬ Consider preoperative TIPS if diuretic resistant and MELD < 15, but not typically for emergent cases

▫ Give 2 g sodium diet, 35–45 kcal/g daily

Encephalopathy: if yes, optimize lactulose to achieve 2–4 bowel movements/day (even by NGT) and give rifaximin

⚬ Do not restrict dietary protein (give 1.2–1.5 g/kg protein daily)

⚬ Order aspiration precautions

Variceal bleeding: if yes, perform upper endoscopy and initiate variceal hemorrhage prophylaxis

Hypoxemia or CHF: if yes, consider hepatopulmonary syndrome or portopulmonary hypertension

⚬ Perform ABG, contrast-enhanced echocardiography

Estimate liver function and likelihood of portal hypertension

Check serum total bilirubin, albumin, INR, creatinine, platelets, hepatic venous pressure gradient, if available

Calculate CTP, MELD, and modified MELD for surgery at several time points

Calculator for postoperative mortality risk in patients with cirrhosis found at http://​www.​mayoclinic.​org/​meld/​mayomodel9.​html

⚬ Compensated cirrhosis is ASA stage III

⚬ Decompensated cirrhosis is ASA stage IV

If Child C or MELD >12 or high risk, consider alternatives to surgery or transfer to liver transplant center

If Child C or MELD >12 or high risk, consider completing liver transplant evaluation before surgery

Evaluate coagulopathy and anemia

Give subcutaneous vitamin K supplementation leading up to surgery

Give DDAVP/desmopressin if renal insufficiency present

Consider use of recombinant factor VIIa for refractory hemorrhage

In the absence of hemorrhage, do not transfuse platelets if count >50 × 103/μL or cryoprecipitate if fibrinogen > 50 mg/dL

Avoid overtransfusion to correct anemia (use hemoglobin goal of 7 g/dL) to avoid increasing portal pressures

Review medications

Avoid hepatotoxic medications like herbal supplementations and acetaminophen >2 g per day

Avoid nephrotoxic medications like NSAIDs (i.e., ketorolac, ibuprofen) or aminoglycosides (i.e., gentamicin)

Avoid all benzodiazepines for anxiety/insomnia and narcotics or administer those with short half-lives

Monitor and correct for electrolyte and acid–base disturbances that may precipitate encephalopathy

Avoid prophylactic antibiotics with greater risks of drug-induced liver injury like amoxicillin-clavulanate (Augmentin), nitrofurantoin, TMP/SMX (Bactrim), ciprofloxacin, and levofloxacin

Ref. [10]

Assessing Surgical Risk

Doctor, The Out-Pouching in My Belly Button Is Bothering Me. I Have Also Been Told I Am Suffering from Alcoholic Hepatitis. Given My Liver Condition, Can I Have This Umbilical Hernia Fixed?

There are a number of settings in which elective surgery is contraindicated, as the perioperative mortality is unacceptably high. Patients with acute hepatitis (whether secondary to viral infection, toxic insults, alcohol, ischemia, or drugs) have increased perioperative mortality and morbidity . Studies have shown that patients with acute viral hepatitis have a 10 % perioperative mortality and an additional 11 % morbidity [2, 3]. Patients with acute alcoholic hepatitis who underwent open surgical liver biopsy had a fivefold increase in mortality compared with closed biopsy [4], Mortality rates as high as 100 % in patients with acute alcoholic hepatitis undergoing open liver biopsy [4, 5], portosystemic shunt surgery [58], or exploratory laparotomy [5, 9] have been reported. Patients with acute alcoholic hepatitis should not undergo surgery for at least 12 weeks or until their condition has improved and the hepatitis and clinical symptoms have resolved. Acute liver failure (ALF) , characterized by acute liver injury, hepatic encephalopathy, and coagulopathy, is treated with supportive care and liver transplantation. Elective surgery is contraindicated in patients with ALF.

Doctor, Does It Make a Difference What Type of Anesthesia I Receive, and What Are the Effects of Anesthesia on My Liver?

General anesthesia with neuromuscular blocking agents and volatile anesthetics reduce hepatic blood flow which can lead to liver decompensation. Aside from halothane which is rarely used anymore, commonly used anesthetics do not have associated direct hepatotoxicity [10]. Thus, the type of general anesthesia administered does not really matter. Monitored sedation with propofol, which is typically used during endoscopic procedures, does not alter hepatic blood flow appreciably and does not require any dose modifications in the setting of liver dysfunction. Spinal or epidural anesthetics may reduce mean arterial pressure and impose significant bleeding risks in cirrhotic patients having coagulopathy [10].

When I Went for My Preoperative Testing the Anesthesiologist Wrote That I Was ASA Class 3: What Does That Mean?

The American Society of Anesthesiologists (ASA) physical status classification system (see Table 8.3) is a general predictor of postoperative mortality [11, 12]. It was initially created in 1941 to assess the degree of a patient’s “sickness” or “physical state” prior to selecting the anesthetic or prior to performing surgery [11]. A large prospective study validating the ASA Physical Status classification system found that intraoperative blood loss, postoperative morbidity and postoperative mortality increased with increasing ASA class [13]. Thirty-day mortality was 0.1, 0.7, 3.5, and 18.3 % for Class I, II, III, and IV, respectively [13]. ASA class III and IV had risk odds ratios for 30-day mortality of 2.2 and 4.2, respectively [13]. Most patients having cirrhosis are ASA Class 3 (see Table 8.3).

Table 8.3
American Society of Anaesthesiologists’ (ASA) classification of physical health


Patient is a completely healthy fit patient


Patient has mild systemic disease


Patient has severe systemic disease that is not incapacitating


Patient has incapacitating disease that is a constant threat to life


A moribund patient who is not expected to live 24 h with or without surgery

Adapted from Ref. [91]

During My Workup for the Liver Transplant, The Heart Doctor Did an Echocardiogram and Told Me That I Have High Lung Pressures That will Make Any Future Surgery Dangerous. Is This Related to My Liver Condition?

Portopulmonary hypertension (PPHTN) occurs in upwards of 0.61–0.73 % of cirrhotic patients [14]. All cirrhotic patients should be screened for PPHTN with echocardiography prior to undergoing any type of surgical procedure. Perioperative mortality rates are prohibitively high in the presence of severe pulmonary hypertension, whether it is related to underlying liver disease or not. Thus, timely diagnosis and treatment are necessary before any elective surgical procedure [1518]. Prior to undergoing surgery, patients with chronic liver disease should receive clearance from a hepatologist, as well as receive clearance from an internist in order to optimize any preexisting medical comorbidities, such as diabetes and other cardiac risk factors [1518].

I Have Early Cirrhosis That Doesn’t Require a Liver Transplant and I Need Colon Surgery. Does the Severity of My Liver Disease Impact the Risks Surrounding This Surgery?

In patients without an absolute contraindication to surgery, a preoperative evaluation is performed. This includes assessment of the severity of the patient’s liver disease, the nature of the operation, the presence of other comorbidities, as well as the urgency of the surgery.

In the setting of chronic hepatitis, there is limited data on patients with milder forms of liver disease undergoing surgery. The CPT classification (see Table 8.1) and MELD score have been studied regarding the estimation of perioperative mortality. CTP classes A, B, and C have been associated with 30-day mortality rates of 10 %, 17–31 % and 63–82 %, respectively [1921]. Patients with a MELD score of less than 10, 10–15, and greater than 15 are estimated to have a 30-day postoperative mortality of 9, 19 and 54 %, respectively [19]. In another study, 30-day mortality ranged from 5.7 % (MELD score<8) to more than 50 % (MELD score >20) [22]. In the same study, the median survival among all patients with digestive, orthopedic or cardiovascular surgery was 4.8 years for MELD scores of 0–7 (n = 351), 3.4 years for scores of 8–11 (n = 257), 1.6 years for scores of 12–15 (n = 106), 64 days for scores of 16–20 (n = 35), 23 days for scores of 21–25 (n = 13), and 14 days for a MELD score of 26 or greater (n = 10) [22].

In a retrospective study of 140 cirrhotic patients undergoing surgery, the MELD score was the only statistically significant predictor of 30-day mortality, with an approximate 1 % increase in mortality risk for each 1-point increase in the MELD score from 5 to 20, and a 2 % increase in mortality risk for each 1-point increase in the MELD score when >20 [23]. Thus, patients who are CTP Class C or have a MELD score greater than 15 should if at all possible not undergo elective surgery. Patients who have CTP Class B cirrhosis or a MELD of 10–15 still have significant risk of perioperative mortality and elective surgery is a relative contraindication.

I Was Recently Admitted to the Hospital with a Gallbladder Attack. Is It Better If I Have My Gall Bladder Removed Laparoscopically or Through the Traditional Way?

Although data are limited, the manner in which the surgery is performed impacts upon outcome. In one study, the outcomes of patients with cirrhosis undergoing emergent or elective cholecystectomy, umbilical herniorrhaphy, or colectomy [24] were evaluated. Most surgeries were completed laparoscopically, with some requiring conversion to an open procedure. The authors reported a 30-day postoperative mortality of 2 % for patients who were CTP A, and 12 % for both CTP B and CTP C groups (see Fig. 8.1) [24]. A similar trend was observed when patients were compared using their MELD scores. Thirty-day postoperative mortality was 3, 8, 29, and 0 % in patients with a MELD score of less than 10, 10–14, 15–25, and greater than 25, respectively (see Fig. 8.2) [24]. Morbidity remained high in cirrhotic patients undergoing laparoscopic surgeries, with rates comparable to studies in which open surgeries were performed. Cirrhotic patients had increasing rates of morbidity with increasing CTP class or MELD score. Thirty-day postoperative morbidity was 20 % for patients who were CTP A, 58 % for CTP B and 80 % for CTP C [24]. Thirty-day postoperative morbidity rates were 35, 50, 60, and 100 % in patients with a MELD score of less than 10, 10–14, 15–25, and greater than 25, respectively [24]. Major morbidities included wound complications (infections, hematomas, leakage of ascites), liver decompensation, ileus or obstruction, respiratory failure, sepsis, variceal bleeding, and anastomotic leakage [24]. Thirty-day mortality was markedly lower in this study [24] compared to other studies in which open surgeries were performed [1921]. Albeit studies are very limited with no direct comparison between laparoscopic and open techniques, it would appear laparoscopic as opposed to open, may be a safer surgical approach in cirrhotic patients.


Fig. 8.1
Thirty-day morbidity and mortality in cirrhotic patients undergoing surgery by CTP score [24]


Fig. 8.2
Thirty-day morbidity and mortality in cirrhotic patients undergoing surgery by MELD [24]

Timing of Surgery: Emergency Surgery, Elective Surgery, and Deferring Surgery

My Mother Requires Emergency Surgery for a Bowel Obstruction. Does Having Emergency Surgery Increase the Risk, Given Her Cirrhosis?

The acuity of surgery impacts on the morbidity, mortality and need for liver transplantation in patients having cirrhosis. In seven studies comparing elective vs. emergent surgery in cirrhotic patients, mortality ranged from 6 to 18 % for elective surgery and 19–86 % for emergent surgery , a 1.1- to 8.6-fold increase in mortality [1921, 2427]. This is not an unexpected result as emergent surgery is precipitated by life-threatening presentations. Increased morbidity and mortality is also seen with emergent vs. elective surgery in non-cirrhotic patients [2830].

If My Heart Surgery will Be Risky, Can the Surgery Be Done at the Same Time as My Liver Transplant?

There is limited experience of elective surgery performed concurrently with liver transplantation . There are a handful of case reports and a case series of successful simultaneous combined liver transplantation and coronary artery bypass grafting procedures (CABG) [3136]. Although successful cases have been reported, simultaneous cardiac surgery and OLT remains technically difficult and should be limited to very specialized centers.

Optimizing Patients Medically

My Father Has Cirrhosis and May Need Lung Surgery. Can Anything Be Done to Make His Liver Better Before Surgery?

Preoperative checklists can be used to reduce morbidity and mortality in cirrhotic patients [37, 38]. Similarly, the Preoperative Liver Assessment (POLA) checklist (Table 8.2) has been proposed to simplify the process of assessing and optimizing surgical risk in patients having chronic liver disease [10].

My Wife Has End Stage Liver Disease and She Is Often Foggy Mentally. Can Anything Be Done Prior to Surgery to Reduce the Risk Postoperatively?

Hepatic encephalopathy is a debilitating complication of decompensated cirrhosis , leading to significant morbidity and mortality. In patients with cirrhosis, HE contributes to functional decline and consumption of appreciable health care resources [39]. In evaluating patients prior to surgery, potential signs and symptoms of HE should be explored. HE manifests in a broad array of neurologic and psychiatric symptoms ranging from minimal hepatic encephalopathy (MHE) to overt hepatic encephalopathy (OHE) . Patients with MHE have minimal or subclinical symptoms and the diagnosis is made via psychometric testing [4043]. Patients with OHE have a wide range of presentations including day-night wake reversal, agitation, somnolence, stupor, and finally coma [44, 45].

There is some evidence for the benefit of prophylaxis of OHE in certain settings. Acute variceal bleeding occurs in 25–30 % of patients with cirrhosis and is an important precipitant of OHE, leading to increased morbidity and mortality [46, 47]. In the setting of acute variceal bleeding, lactulose vs. placebo prophylaxis in one study resulted in significantly less OHE (14 % vs. 40 %) and trended towards less mortality (8.5 % vs. 17 %) [48]. In a second study, rifaximin and lactulose appear to be equally effective for primary prophylaxis in the setting of an acute variceal bleeding, with no significant difference in development of HE (10/60 vs. 9/60; p = 1.0) and mortality (8/60 vs. 9/60; p = 1.0) [49]. There is also evidence for the benefit of secondary prophylaxis of OHE in cirrhotic patients. Lactulose, rifaximin and probiotics are effective at preventing subsequent episodes of OHE in patients with cirrhosis who had a previous episode of OHE [5052].

Identification and treatment of precipitating factors are the primary therapeutic option for patients with OHE [53]. Gastrointestinal bleeding, infection (including spontaneous bacterial peritonitis), hypokalemia and/or metabolic alkalosis, renal failure, hypovolemia, hypoxia, sedative or tranquilizer use, hypoglycemia, constipation, and hepatocellular carcinoma and/or vascular occlusion (hepatic vein or portal vein thrombosis) can all precipitate OHE [53]. In addition to the optimization and treatment of these precipitating factors, medical management is the cornerstone of treatment. Two meta-analyses demonstrated that both oral non-absorbable disaccharides (lactulose or lactitol) and rifaximin are equally effective in the management of OHE with rifaximin being better tolerated [54, 55].

Lactulose or lactitol are effective in patients with MHE , with trials demonstrating improvement in psychometric testing [56, 57], reduced progression to OHE [56], reduced ammonia levels [56, 57] and improved health-related quality of life [56]. Adverse events were not serious and all were related to the gastrointestinal tract (diarrhea, flatulence, abdominal pain, and nausea) [57].

Limiting opiate analgesics for pain may help prevent the development of hepatic encephalopathy postoperatively, especially in patients also taking iron and calcium supplements, all of which contribute to constipation [58]. Concurrent lactulose use may contribute to the development of ileus or small bowel obstruction, as well as dehydration leading to hypovolemia. For analgesia, acetaminophen up to 2 g total daily is safe to use and is preferred over NSAIDs (i.e., ketorolac), which may predispose to renal dysfunction

My Husband Has Liver Disease. He Bruises Easily and Often Has Persistent Nosebleeds. Can Anything Be Done to Decrease His Risk of Bleeding During Surgery?

Patients with cirrhosis commonly have accompanying coagulopathy. It is recommended to supplement with vitamin K 10 mg subcutaneously daily for 3 days in order to correct any nutritional deficiency that may raise a patient’s International Normalized Ratio (INR) and calculated MELD score. Overtransfusion of blood products is to be avoided so as to not increase portal pressures and precipitate variceal bleeding. A restrictive Packed Red Blood Cell (PRBC) transfusion strategy is advised, with a threshold serum hemoglobin of 7–8 g/dL. Fresh frozen plasma (FFP) is given if a patient’s INR is greater than 1.5 preoperatively despite administration of vitamin K. Platelets are transfused for serum platelet levels below 50 × 103/μL preoperatively. Cryoprecipitate is transfused to increase fibrinogen concentration to above 50–100 mg/dL in nonsurgical settings and to approximately 100–200 mg/dL for surgical prophylaxis [59, 60]. DDAVP can be used in patients having renal dysfunction to correct qualitative platelet dysfunction. DDAVP nasal spray may be used instead of blood products in cirrhotic patients undergoing dental extractions who have a modest degree of coagulopathy [61].

I Have Abdominal Distension with Ascites Fluid. How Can This Be Controlled Prior to Surgery and will It Be a Problem Afterwards?

For patients with cirrhosis , a low-sodium diet (<2 g daily) is advised. Patients with ascites should undergo a diagnostic paracentesis preoperatively to exclude spontaneous bacterial peritonitis (SBP) . If there is no SBP, patients with moderate to severe ascites can undergo a large volume paracentesis (LVP) . A Transjugular Intrahepatic Portosystemic Shunt (TIPS) can be considered preoperatively if the surgery is not emergent, if the ascites is diuretic-resistant or if the patient’s MELD if not greater than 15. TIPS reduces portal hypertension by creating a communication between intrahepatic branches of the hepatic vein and portal vein [62]. It is effective for treatment of acute variceal hemorrhage and refractory ascites [62, 63]. The beneficial effects of TIPS in variceal bleeding rapidly occur but the humoral and hemodynamic changes that lead to the improvement and resolution of ascites may take upwards of 6–8 weeks or longer. Older patients and those with preexisting renal dysfunction have less of a chance to resolve their ascites after TIPS, with the associated risks of developing or worsening OHE being much greater. Contraindications to TIPS include: severe heart failure or pulmonary hypertension, portal vein thrombosis with cavernous transformation, and polycystic liver disease [62]. The MELD score was originally developed to predict the 3-month mortality of patients undergoing elective TIPS [64]. Patients with higher MELD scores, particularly MELD scores greater than 18, have a poorer prognosis, with higher 3-month mortality [6568].

Aggressive management of ascites prior to abdominal surgery is essential to afford optimized wound closure and healing of any tissue anastomoses. Liver dysfunction precipitated by surgery can often manifest as an increase in ascites. Leakage of ascites through an abdominal incision may lead to fascial breakdown, poor wound healing, infection and the precipitation of renal failure. Diuretic use and paracentesis postoperatively may need to be utilized to prevent ascites development. A worsening of ascites may also result in the development of a hepatic hydrothorax, and its attendant morbidity [6971].

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Nov 20, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Preoperative and Postoperative Care of the Liver Patient

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