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PSH 2017

Peshawar Meeting November 2017

EVERYDAY CHALLENGES IN
CLINICAL PRACTICE
PSH 2017
Objectives

• Review basic principles of pre op assessment of patients


with liver disease
• Effects of anesthesia and surgery on the liver
• Estimation of operative risk
• Risk associated with specific types of Surgery
• Discuss strategies to optimize pre op management of liver
diseases
• Choice of sedation for surgery
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SCREENING FOR LIVER DISEASE
BEFORE SURGERY
• HISTORY
– prior blood transfusions
– tattoos
– illicit drug use
– sexual promiscuity
– family history of jaundice or liver disease
– history of jaundice or fever following anesthesia
– alcohol use (current, prior and quantity)
– complete review of current medications
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Clinical features

• Increased abdominal girth


• Jaundice
• Palmar erythema
• Spider telangiectasias
• Splenomegaly
• Gynecomastia and testicular atrophy in men
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Effects of anesthesia on the liver


Hepatic ischemia: elevated transaminases
Cirrhosis
Hyperdynamic circulation with decreased blood flow to
liver
More susceptible to hypoxemia and hypotension
• Surgical factors contributing to hepatic ischemia:
• Hypotension, hemorrhage, vasoactive medications
• Positive pressure ventilation
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Metabolism of medications

• Volume of distribution of medications is increased in


cirrhotic patients.
• Inhaled anesthetic choice
• Halothane dcrease hepatic blood flow and can cause
hepatotoxicity
• Isoflurane, sevoflorane and desflorane has less effect on
hepatic blood flow and hepatotoxicity
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Metabolism of medications

• Atracurium/cisatracurium preferred—not excreted by liver


or kidney

• Sedatives and narcotics can precipitate hepatic


encephalopathy and prolong periods of depressed
consciousness.
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• What are the postoperative


concerns
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Coagulopathy

• Decreased production of clotting factors


• Depletion of vitamin K stores
• Increased fibrinolytic activity
• Thrombocytopenia
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Ascites

• Hepatic hydrothorax—respiratory complications


• Wound complications
• Hernia
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Hepatic encephalopathy

• Precipitating factors in post operative period


• Volume contraction
• Hypokalemia
• Infection
• Bleeding
• Medications
Renal Dysfunction

• Potential causes:
• Intravascular volume depletion
• Nephrotoxicity
• ATN
• Hepatorenal syndrome (HRS)
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Pulmonary complications
• Ascites and hepatic hydrothorax
• Increased risk of aspiration
• Pneumonia
• ARDS
• Ventilation dependence
• Hepatopulmonary syndrome:
Triad of liver disease, increased AA gradient and
intrapulmonary shunting
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EFFECTS OF ANESTHESIA AND
SURGERY ON THE LIVER
• Depends upon:
– Type of anesthesia used
– specific surgical procedures
– severity of liver disease.
– Perioperative events
 hypotension
 sepsis
 Administration of hepatotoxic drugs
PSH 2017
ESTIMATING SURGICAL RISK

• Appraisal of the severity of liver disease


• The urgency of surgery (and alternatives to surgery)
• Coexisting medical illness.
• Surgical risk assessment is less relevant if immediate
surgery is required to prevent death.
• Elective procedures
• Risk assessment
• Optimization of the patient's medical status
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Study Design Flaws

• Mostly small studies


• Retrospective
• Clinical experience
• Arbitrary parameters
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Contraindications for elective surgery

 Acute hepatitis
 Alcoholic hepatitis
 Abstinence from alcohol for at least 12 weeks
 improves hepatic inflammation and hyperbilirubinemia
 Reassess after 12 weeks
 Acute liver failure
HARVILLE DD, SUMMERSKILL WH. Surgery in acute hepatitis. Causes and effects. JAMA 1963; 184:257.

Greenwood SM, Leffler CT, Minkowitz S. The increased mortality rate of open liver biopsy in alcoholic
hepatitis. Surg Gynecol Obstet 1972; 134:600.

Powell-Jackson P, Greenway B, Williams R. Adverse effects of exploratory laparotomy in patients with


unsuspected liver disease. Br J Surg 1982; 69:449.
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PATIENTS AT VARIABLE INCREASED
RISK
• The risk of surgery in patients with cirrhosis depends
– the severity of disease,
– the clinical setting
– type of surgical procedure
SCORING SYSTEMS TO ASSESS
SURGERY RISK
1.CTP
2.MELD
3.ASA
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Child-Turcotte-Pugh score
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ASA Classification
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• In a retrospective study of 261 patients (45 with cirrhosis


and 216 matched controls without cirrhosis) undergoing
cardiac surgery between 1992 and 2009,
• CP < 8 : 95 % survival rate at 90 days
• CP > 8 : 30 % survival rate at 90 days
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MELD score

• MELD is supplanting the CP classification as the principal


method for determining surgical risk
• The MELD score, American Society of Anesthesiologists
(ASA) class, and age predicted mortality in a study of 772
patients with cirrhosis who underwent major digestive,
orthopedic, or cardiovascular surgery.
• The MELD score was the best predictor of 30- and 90-day
mortality. Mortality at 30 days ranged from 6 percent
(MELD score, <8) to more than 50 percent (MELD score,
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• Increased risk of mortality up to 90 days postoperatively


• Mortality rates
• MELD <7: 5.7%
• MELD 8-11: 10.3%
• MELD 12-15: 25.4%
• ASA class IV adds 5.5 MELD points. ASA class V = 100%
mortality
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• MELD < 10 : elective surgery


• MELD 10 to 15 : elective surgery with caution
• MELD >15 : should not undergo elective surgery
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• Obstructive jaundice —
• Increased risk of perioperative complications
Infections
stress ulceration
DIC
wound dehiscence
renal failure
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• An overall mortality rate of 9 percent was found in a large


retrospective study that included 373 patients undergoing
surgery for obstructive jaundice.
• Multivariate analysis identified three predictors of
postoperative mortality:
– An initial hematocrit value <30 percent
– An initial serum bilirubin level >11 mg/dL (200 micromoles/L)
– A malignant cause of obstruction (eg, pancreatic carcinoma or
cholangiocarcinoma)
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• A number of interventions have been attempted to reduce


morbidity and mortality in these patients:
– Perioperative administration of broad-spectrum intravenous
antibiotics
– External biliary drainage via a transhepatic approach
– Endoscopic biliary drainage
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• Limited evidence suggests that the administration of bile


salts or lactulose to patients with obstructive jaundice can
prevent both the endotoxemia and the exaggerated renal
vasoconstriction
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• Cardiac surgery —
 Cardiac surgery is associated with increased mortality in
patients with cirrhosis compared to other surgical
procedures
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• 9 studies involving 210 patients with cirrhosis


• Mortality : 17 %.
• CP A: 5%
• CP B : 35%
• CP C : 70%
• MELD score has not been adequately studied as a
prognostic tool for patients undergoing cardiac surgery.
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• Risk factors for hepatic decompensation


• total time of cardiopulmonary bypass
• use of nonpulsatile as opposed to pulsatile
cardiopulmonary bypass
• need for perioperative pressor support
• Thus, the least invasive options
• Angioplasty,
• Valvuloplasty
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• Hepatic resection —
• RESIDUAL VOLUME NEEDED
• Normal Liver 25%
• Cirrhotic liver 40%
• Risk factors for hepatic decompensation
CTP
MELD
BILIRUBIN
PT
Portal Hypertension
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• A database study of 587 patients who underwent hepatic


resection concluded that the Child-Turcotte-Pugh score and
ASA score were better predictors of morbidity and mortality
than the MELD

Schroeder et al Ann Surg 2006; 243:373.


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• Clinically significant portal hypertension


• Gastroesophageal varices OR
• Platelet < 100,000/mL with splenomegaly
clinical decompensation after surgery
 3 & 5 year mortality
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• Trauma —
• Trauma patients found to have cirrhosis at laparotomy are at
increased risk for morbidity and mortality.
• In one study, the overall mortality rate was 45 percent,
significantly higher than of a matched control population
(24 percent)
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• Abdominal surgery —
In patients undergoing cholecystectomy, a laparoscopic
approach is associated with lower mortality rates than an
open approach and can be performed in patients with CP
class A and B cirrhosis and MELD scores up to 13
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• Colorectal surgery, primarily for diverticular disease and


colorectal cancer, is associated with mortality rates as high
as 26 percent in patients with cirrhosis
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• Less invasive approaches such as stent placement


to relieve obstruction should be considered when
possible.
• Elective umbilical hernia repair can be performed with
excellent outcomes, even in patients with CP class C
cirrhosis
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• Patients with minimally increased risk —


• Mild to moderate chronic liver disease without cirrhosis
• Mild chronic hepatitis
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• Fatty liver and nonalcoholic steatohepatitis

• Increased mortality following hepatic resection has been


observed in those with moderate to severe steatosis (>30
percent of hepatocytes containing fat

• NASH is associated with increased morbidity following


hepatic resection
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• Recommending a period of abstinence from alcohol prior to


surgery is advisable for all patients with the histologic
appearance of steatohepatitis or those who are suspected of
excessive alcohol consumption
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• Autoimmune hepatitis —
– Elective surgery is usually well tolerated in patients with
autoimmune hepatitis who have compensated liver disease.
– Perioperative "stress" doses of hydrocortisone should be given to
patients taking prednisone.
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• Hemochromatosis —
– Evaluation for complications
Diabetes
Cardiomyopathy
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• Wilson disease —
Patients with Wilson disease who have neuropsychiatric
involvement may not be able to provide informed consent.
Surgery can precipitate or aggravate neurologic symptoms
D-penicillamine interferes with the crosslinking of collagen
and may impair wound healing
the dose should be decreased prior to surgery and during the
first one to two postoperative weeks
OPTIMIZING MEDICAL THERAPY
PSH 2017
COAGULOPATHY

• Management of haemostatic abnormalities in patients with


cirrhosis
 optimize the platelet count
 optimize fibrinogen level
 optimize renal function
 avoid the INR values to guide therapy
• A prolonged bleeding time can be treated
with desmopressin (DDAVP).
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