The Risk Of Surgery In Patients With Liver Disease 1: Epidemiology, Pathophysiology, And Pre-Operative Evaluation

Abstract

The results of retrospective large scale registry and cohort studies, and small case series, substantiate the common perception that operating on a liver disease patient is risky. The preexisting physiological derangements of liver disease may be exacerbated by the trauma of surgery and its complications, which contributes strongly to the aforementioned surgical risks, especially (but not exclusively) in cirrhotics. Perturbations in liver blood flow and oxygenation may be exaggerated by anesthesia, surgery itself, blood loss, and other operative complications. Cirrhotics are especially susceptible to acute and chronic kidney injury. Malnutrition is common in cirrhosis, which compromises wound healing and recovery from surgery. In cirrhosis, elimination of infection is impaired and its systemic effects are deleterious. The metabolic and immunological stresses of surgery may lead to liver function deterioration, even in stable cirrhotics. Presented here is the pre-operative evaluation of liver disease patients, including the use of predictive indices, new dynamic tests of liver function, and modestly invasive assessment of portal hypertension. This review contains 9 figures, 6 tables and 52 references Keywords: acute-on-chronic liver failure, Child-Turcotte-Pugh, cirrhosis, coagulopathy, infection, hepatic venous pressure gradient, liver blood flow, model for end-stage liver disease, systemic inflammatory response syndrome, thrombocytopenia