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Clin Gastroenterol Hepatol. 2019 Jul 31. pii: S1542-3565(19)30840-7. doi: 10.1016/j.cgh.2019.07.051. [Epub ahead of print]

Perioperative Evaluation and Management of Patients with Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions.

Author information

1
Internal Medicine Residency Program, University of Washington School of Medicine, Seattle WA. Electronic address: kiranewm@uw.edu.
2
Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle WA and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA.
3
Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle WA.
4
Chief of Surgery, Boston VA Health Care System, and Professor of Surgery, Boston University, Boston MA.
5
Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle WA; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle WA.

Abstract

BACKGROUND AND AIMS:

Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures.

METHODS:

We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review.

RESULTS:

Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP Class A, or MELD <10) have minimal increase in operative mortality. CTP Class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate.

CONCLUSIONS:

Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management, which warrant further investigation.

KEYWORDS:

Surgery outcomes; liver cirrhosis; perioperative management; perioperative risk assessment

PMID:
31376494
DOI:
10.1016/j.cgh.2019.07.051

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