CAMBRIDGE, MD. — The increased risk of mortality in patients who undergo surgery for serious liver disease is reason to postpone an operation until the disorder responds to treatment or resolves, Adrian Reuben, M.B., said at a hepatobiliary update sponsored by Johns Hopkins University.
“Surgery is contraindicated in those with acute hepatitis—especially alcoholic hepatitis—and severe chronic hepatitis and advanced cirrhosis,” said Dr. Reuben of the Medical University of South Carolina, Charleston.
“In cardiac surgery, patients with Child-Turcotte-Pugh [CTP] Class A scores do well, but for anyone with CTP Class B or C, surgery may be prohibitively dangerous,” he said.
Patients with severe liver disease are more susceptible to infection, which aggravates vasodilation and exacerbates the hyperdynamic circulation.
“This can precipitate hepatorenal syndrome or convert existing hepatorenal syndrome from stage II to stage I,” he explained.
Other reasons for adverse outcomes include concomitant renal dysfunction; reduced hepatic drug metabolism; poor nutrition, which is common in those with advanced liver disease; and ascites. Ascites carries the risks of infection, poor wound closure, and dehiscence, and it impairs respiration.
Mortality risk is much greater in patients with cirrhosis and increases steadily with higher CTP score.
Dr. Reuben reviewed five studies of abdominal surgery in patients with cirrhosis conducted from 1984 to 2004. Among a total of 391 patients, overall mortality ranged from 16% to 28%, with a range of 8%–19% for elective surgery and 32%–50% for emergency surgery. Rates were much lower among those with CTP Class A (3%–10%) than those with CTP Class C (55%–100%).
Other variables predictive of mortality in these studies were encephalopathy, ascites, infection, coagulopathy (high international normalized ratio [INR]), high creatinine, and gastrointestinal and pulmonary operations.
The risk of postsurgical mortality is increased in both viral and alcoholic hepatitis. “With acute viral hepatitis, the increased risk is about 10%–15%. With alcoholic hepatitis, it's vastly increased: 55%–100%,” Dr. Reuben said.
“You must also be very aware of alcoholic hepatitis; sometimes it mimics acute cholangitis,” he added.
An increased mortality risk has also been associated with nonalcoholic fatty liver disease (NAFLD). A 1998 study that looked at hepatic resection for cancer showed a 3% mortality rate for those with nonfatty livers. Mortality increased to 7% for those with mild NAFLD and to 14% for those with moderate to severe disease (J. Gastrointest. Surg. 1998;2:292–8).
Biliary tract surgery is also risky for the cirrhotic patient. Only those with very low scores (less than 8) on the Model for End-Stage Liver Disease (MELD) scale are at minimal or no risk. Laparoscopic surgery is recommended for cirrhotic patients, because it reduces blood loss, postoperative complications, anesthetic and surgical times, and length of hospital stay.
Arthroplasties are also dangerous for the patient with cirrhosis, he said, with combined mortality and complication rates increasing with liver disease severity. The rates are about 11% in those with CTP Class A disease, almost 50% among those with CTP Class B, and 100% in those with CTP Class C.
If surgery is necessary in patients with cirrhosis, all nephrotoxic drugs should be avoided, and opiates should be limited. Opiates can cause sedation and lead to constipation, a contributing factor to hepatic encephalopathy.
Cirrhotic patients undergoing transurethral prostatectomy had a 7% mortality rate, compared with 2% in controls, he said.