COMMENTARY

Cirrhosis and Surgery: How Do We Prevent Unnecessary Risk in These Vulnerable Patients?

David A. Johnson, MD

Disclosures

February 27, 2019

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Taking care of cirrhotic patients in the preoperative setting has become an increasingly important consideration. As these patients live longer owing to improved medical management, it means they're also potentially facing additional surgeries compared with in years past. As a result, we're now tasked with better informing our surgical colleagues regarding the relative risk that these patients face, given their liver disease.

Northup and colleagues[1] at the University of Virginia in Charlottesville have provided a tremendous contribution to this issue in a recent literature review that appeared in the journal Clinical Gastroenterology and Hepatology. Their work aims to give us the tools for performing a quick and effective preoperative evaluation of these patients, which is something we all now deal with on a regular basis. In this discussion, I'll summarize some of the key concepts I took away from their work.

What Are the Best Tools for Predicting Surgical Risk?

The scale of these patients' relative risk has traditionally been assessed using the Child-Turcotte-Pugh score, a great tool that has stood the test of time. The Model for End-Stage Liver Disease (MELD) score has been used to guide decisions regarding liver donor transplantation, and has also held up well. In addition to these tools, the authors add the Mayo Postoperative Mortality Risk Score, which can be assessed using a calculator available on the Mayo Clinic's website. This incorporates both the American Society of Anesthesiologists Physical Status Classification score and the patient age, which provide better granularity than MELD alone. Interestingly, the MELD-Na (sodium) score, which has been heralded as an improvement, has not been subject to the scrutiny of testing as a preoperative assessment tool. Therefore, I think this Mayo score is quite helpful.

The authors also directly address the concept of futility in this patient group. This is something that I think we all need to be a little sanguine about, because these are sick patients, and the futility of performing surgery in some of them really needs to be discussed. This is not only an ethical issue, but a very practical one as well.

With this in mind, let's see how we can apply this review's lessons to specific surgical procedures.

Primary Hepatic Resection

Traditionally, hepatic resection occurs only in patients with very early hepatocellular carcinoma (Barcelona Clinic Liver Cancer staging classification stage 0). This indicates that the tumor is < 2 cm, and that the patients have high performance status and normal liver function.

One of the key messages in this review is to use a surrogate marker for the lack of portal hypertension, which is having a peripheral blood platelet count > 100,000 cells/µL. Other studies have identified lack of relevant portal hypertension using hepatic venous pressure gradients < 10 mm Hg or the absence of venous collaterals on hepatic transabdominal imaging with no esophageal or gastric varices on endoscopy, but this surrogate marker of a platelet count > 100,000 cells/µL is a relatively good prognosticator that they don't have portal hypertension.

Cholecystectomy

We often see patients in whom the gallbladder wall is thickened. The authors adroitly point out that this is probably the norm, whereby fibrotic thickening is associated with cirrhosis rather than the edema that you see with acute cholecystitis. We therefore need to be careful, as many patients with cirrhosis present with abdominal pain. If they're mislabeled as having acute cholecystitis, the results of urgent surgery can be disastrous. If the patients do have clearly diagnosed acute cholecystitis, they should be referred to a center that is capable of dealing with cholecystectomy in those with cirrhosis.

The authors advise against ever recommending cholecystectomy in patients with Child-Pugh class C cirrhosis or refractory ascites, who are simply waiting to have an accident. These patients are obviously not candidates for percutaneous drainage, given the presence of ascites. However, in certain circumstances, the authors recommend considering some of the new, advanced endoscopic treatments, in particular transpapillary gallbladder drainage, if it's available.

Abdominal Wall Hernia Surgery

Symptomatic hernias are common in patients with cirrhosis, especially in those with ascites. The ability to control an operative intervention is critically dependent on the presence of ascites, given their tendency to leak, exhibit dehiscence, and potentially become infected. Medical management and large-volume paracentesis are options prior to surgery, but patients should be followed with regular assessments postoperatively. There is a recommendation for a transjugular intrahepatic portosystemic shunt (TIPS) procedure before surgery, although it is not without complications. Regardless, ascites must be managed in a very proactive way.

Cardiovascular Surgery

It is increasingly common for patients to undergo cardiovascular surgery; many of these patients also have nonalcoholic steatohepatitis and the components of metabolic syndrome, which are covariant risks for coronary disease. In this review, the authors note that overall, elective coronary bypass surgery is associated with mortality rates anywhere from 4% to 70%. They drive home the very resonant message that a MELD score ≥ 13.5 or a Child-Turcotte-Pugh score > 7 is considered a contraindication to cardiac surgery. We also need to educate our surgeons that there is no need to prophylactically try and correct the international normalized ratio (INR) with plasma, because this will never happen.

Bariatric Surgery

Rates of obesity—the most common risk factor for cirrhosis in developed countries—continue to rise. In the hands of experts, the complication rates of bariatric surgery can be minimal if the patients are not decompensated. However, if they are decompensated, the risk profile changes considerably. For patients going on to liver transplantation, performing a sleeve gastrectomy (ie, resection of the greater curvature of the stomach) at the time of transplantation is effective and does lower the risk for metabolic syndrome. Sleeve gastrectomy does not add significant mortality for the liver transplant procedure, and it does not change the alteration of absorption, which may be critically important when you talk about postoperative immunosuppressant function.

Ascites

Large-volume paracentesis is clearly an important management strategy in these patients. The authors recommend performing this preoperatively with an albumin dose of 6-8 g per liter of fluid removed. I recommend you look at a commentary I recently gave for Medscape on the value of intravenous (IV) albumin as it relates to regular infusions for risk reduction in decompensation, improvement in renal blood flow, and transcompartmental white cell function. Again, look for IV albumin in a very aggressive way, in particular as you start to manage these patients with ascites.

Hemostasis and Coagulation

We all see patients who come into the emergency department with an elevated INR, in particular those with variceal bleeding. The first thing you see them being given is IV fresh frozen plasma. This is something that the authors really do not concur with, and they're the experts in this area. What needs to be emphasized here is that, contrary to popular belief, these patients may actually have a thrombophilic-type situation. They clearly have coagulopathy, but they also develop protein C deficiency, resulting in a thrombophilic state. That's why we see more portal vein thrombosis in these patients with cirrhosis. Therefore, the INR is not predictive of bleeding complications in cirrhosis, so preoperative prophylactic fresh frozen plasma is not recommended.

We have also seen a number of new thrombopoietin analogues emerge on the market in recent years. These were initially developed for idiopathic thrombocytopenic purpura but are also available to patients with cirrhosis. The authors recommend that these be considered an elective procedure if the platelet count is < 50,000/µL. They take some time to become effective, generally a week, so the authors recommend paying special attention for thrombotic events, in particular portal vein and deep vein thrombosis.

The next part of the discussion around coagulation relates to the predictive value of fibrinogen levels. The authors note that fibrinogen levels < 100 mg/dL are associated with an increased bleeding risk. These levels can be easily measured during preoperative assessment, once the patients walk through your door. Fibrinogen can be replaced by a low-volume cryoprecipitate transfusion, which do not significantly increase the plasma volume, portal pressures, or relative risk for bleeding.

Pain Control

The final topic the authors touch on is pain control. Owing to altered drug metabolism and elimination, the risk for medication-related toxicity is especially high in patients with cirrhosis. Opiates in particular, they recommend, should be used at a lower dose and a longer dosing interval than in the general population. Patients seem to do the best with hydromorphone and transdermal fentanyl, although randomized trials have not yet been done with these.

We also know that these patients have a bit of a problem with benzodiazepine excretion. So if you're going to use these agents, it's recommended that a short-acting benzodiazepine, such as midazolam, is used. Tramadol is another agent that has a favorable hepatic metabolism.

Something that may shake you of your current beliefs, based on what you may have read in the past, is the changing perception of acetaminophen in this indication, which is now recommended in dosages no greater than 2 g daily. Traditionalists have always counseled to avoid acetaminophen in these patients. Data now suggest that we should instead avoid the routine use of nonsteroidal anti-inflammatory drugs, given the impairment in renal blood flow in patients with cirrhosis. So low-dose acetaminophen or tramadol are very much the standard and the recommendation from these authors.

Solid Recommendations

I recommend that you read this paper; keep it on your desktop, so you can go back to it repeatedly for each relevant circumstance it addresses. I also recommend looking at the Mayo Clinic evaluation, which I think is a very handy assessment tool. Northup and colleagues have given us solid recommendations in a very succinct and evidence-based way. I have changed my practice, and you may as well. I will leave it to your best judgment on how to implement their advice.

I'm Dr David Johnson. Thanks again, as always, for listening.

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