The risk of surgery in patients with liver disease

Friedman, Lawrence S.

doi:10.1002/hep.510290639

Cited by 248 publications

(152 citation statements)

References 110 publications

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“…Recently, a study using erythrocyte creatine (EC), the life-span sensitive marker of erythrocytes, revealed that the EC level was significantly increased in patients with splenomegaly due to post-necrotic cirrhosis compared with patients with hepatic cirrhosis with normal spleens (P<0.05). In addition, the same was observed compared with the normal control group but without a significant difference [17] . This suggested that splenomegaly accelerated the destruction of erythrocytes and the determination of the EC value could be used to evaluate the severity of cirrhotic splenomegaly [18] .…”

Section: Splenomegaly and Hypersplenismsupporting

confidence: 73%

Changes of Peripheral Blood Cells in Patients with Cirrhotic Portal Hypertension

Lv¹

2012

Portal Hypertension - Causes and Complications

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Section: Splenomegaly and Hypersplenismsupporting

confidence: 73%

Changes of Peripheral Blood Cells in Patients with Cirrhotic Portal Hypertension

Lv¹

2012

Portal Hypertension - Causes and Complications

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“…We considered the 3-month mortality of partial hepatectomy to be 5%, ranging between 3% and 8%, considering that all patients had compensated cirrhosis. 3,17,[22][23][24] HCC Recurrence Rate After Partial Hepatectomy. The rate of recurrence of HCC after partial hepatectomy varies according to the different series and to the characteristics of the patients in each series.…”

Section: Proportion Of Patients With Hcc Developing Contraindicationsmentioning

confidence: 99%

Primary liver resection and salvage transplantation or primary liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: An outcome-oriented decision analysis

et al. 2000

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Two treatments are accepted for patients with solitary hepatocellular carcinoma Յ5 cm in size and with preserved hepatic function: (1) liver resection, which can be performed without delay but has a high recurrence rate, and (2) liver transplantation, which has a better long-term survival, but is not easily available because grafts are scarce. A third possibility is to offer liver resection first and liver transplantation for tumor recurrence or deteriorating liver function (''salvage'' transplantation). We investigated the implications of such a strategy with a Markov-based decision analytic model. Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide, and its incidence is increasing in the western world because of the epidemics of the hepatitis C virus. 1 In patients aged less than 65 years, 2 therapies are currently accepted for early HCC (Յ5 cm): partial hepatectomy (PH) and orthotopic liver transplantation (OLT). 2,3 Although studies comparing the 2 treatments are retrospective and concern patients with disparate tumor characteristics and liver function, 4-6 it is agreed that OLT is preferable to partial hepatectomy in patients with hepatic insufficiency and in patients with more than 1 tumor, in whom the results of liver resection are poor.Patients with single tumors and preserved liver function present a therapeutic dilemma. Partial hepatectomy can cure the tumor immediately, with low mortality. The underlying cirrhosis, however, is responsible for a high recurrence rate, and the patient is exposed to the long-term complications of portal hypertension and hepatocellular failure. 7 OLT, by treating both the tumor and the cirrhosis, offers a better long-term survival. The tumor, however, can outgrow the criteria accepted for transplantation while waiting for donor organs, affecting the ultimate outcome as shown in a previous analysis. 2 For patients with a single resectable HCC, an alternative strategy to either partial hepatectomy or OLT would be to offer resection first and transplantation if the tumor recurs or if the liver function deteriorates (salvage OLT). Before such a strategy can be tested in a prospective controlled trial, the present study examines its implications in terms of patient outcome, graft use, and costs, using a decisional analysis model based on the data available in the literature. PATIENTS AND METHODS Decision Analytic ModelWe investigated the impact of 2 options: (1) primary liver transplantation and (2) partial hepatectomy followed by salvage liver transplantation (Fig. 1A) in patients with compensated cirrhosis and solitary HCC Յ5 cm in diameter, with a Markov simulation (Decision Maker 7

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“…Friedman in an analysis of risk factors affecting surgical outcome in patients with liver disease identified acute hepatitis as an independent risk factor and suggested that it should be considered a contraindication for elective surgery. 3 Major elective surgery for a patient with suspected acute hepatitis E, for example, should be deferred until the patient has recovered, barring some compelling reason for urgency such as a perforated viscus.…”

Section: Acute Liver Diseasementioning

confidence: 99%

“…3 The decreased hepatic perfusion at baseline makes the cirrhotic liver more susceptible to hypoxemia and hypotension in the operating room. At baseline, hepatic arterial and venous perfusion of the cirrhotic liver may be decreased: portal blood flow is reduced as a result of portal hypertension, and arterial blood flow may be decreased because of impaired autoregulation.…”

Section: Anesthetic Managementmentioning

confidence: 99%

Surgery in a Patient with Liver Disease

Rai

Nagral

2012

Journal of Clinical and Experimental Hepatology

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Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease. ( J CLIN EXP HEPATOL 2012;2:238-246)

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The risk of surgery in patients with liver disease

Cited by 248 publications

References 110 publications

Changes of Peripheral Blood Cells in Patients with Cirrhotic Portal Hypertension

Changes of Peripheral Blood Cells in Patients with Cirrhotic Portal Hypertension

Primary liver resection and salvage transplantation or primary liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: An outcome-oriented decision analysis

Surgery in a Patient with Liver Disease

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