Optimizing perioperative for Liver

Function In liver chronic desease

Benny Philipi
 Risk of Surgery in Liver Diseases

Increased risk of perioperative morbidity
and mortality in liver surgery or non-liver
surgery

etcSepsism
 Investigations

Cbc (pancytopenia, thrombocytopenia)

Liver enzymes ast>alt

INR, Bilirubin, Albumin (child class)

Liver imaging

Kidney function and electrolytes

Liver biopsy and fibroscan

Interpretation

Child Class A: 5 to 6 points

Life expectancy: 15 to 20 years

Abdominal surgery peri-operative mortality: 10%

Child Class B: 7 to 9 points

Indicated for liver transplantation evaluation

Abdominal surgery peri-operative mortality: 30%

Child Class C: 10 to 15 points

Life expectancy: 1 to 3 years

Abdominal surgery peri-operative mortality: 82%
SUMMARY OF THE PATHOGENESIS OF PORTAL HYPERTENSION

Cirrhosis
Resistance to
portal flow

Splanchnic
arteriolar
resistance
Portal
pressure

Portal blood
inflow

Varices
 VARICES INCREASE IN DIAMETER PROGRESSIVELY

Varices Increase in Diameter

Progressively

No varices Small varices Large varices

year/7-8% year/7-8%

Merli et al. J Hepatol 2003;38:266

 PREVALENCE AND SIZE OF ESOPHAGEAL VARICES IN PATIENTS WITH NEWLY DIAGNOSED CIRRHOSIS

Prevalence and Size of Esophageal Varices

in Patients with Newly-Diagnosed Cirrhosis

100

80

Large
% 60
Patients
with varices 40 Medium

20
Small

0
Overall Child A Child B Child C
n=494 n=346 n=114 n=34

Pagliaro et al., In: Portal Hypertension: Pathophysiology and Management, 1994: 72

 PROGNOSTIC INDICATORS OF FIRST VARICEAL HEMORRHAGE

Variceal hemorrhage Varix with red signs

:Predictors of hemorrhage
Variceal size 
Red signs 
Child B/C 
NIEC. N Engl J Med 1988; 319:983
 NON-SELECTIVE BETA-BLOCKERS PREVENT FIRST VARICEAL HEMORRHAGE

Non-Selective Beta-Blockers Prevent

First Variceal Hemorrhage

Bleeding rate Control Beta-blocker Absolute

rate
(~2 year)
difference

All varices 25% 15% -10%

(11 trials) (n=600) (n=590) (-16 to

-5)

Large varices 30% 14%

-16%
(8 trials) (n=411) (n=400) (-24 to
-8)
D’Amico et al., Sem Liv Dis 1999; 19:475
 Other treatment options

Band ligation

Sclerotherapy

TIPPS insertion

Shunt surgery

Transplantation
 Acute Variceal Bleed


ABC!!!

Octreotide

PPI

*** Antibiotics ***

Cefotaxime or Norfloxacin

Keep Hb 80-100 g/L
 PROPHYLACTIC ANTIBIOTICS IMPROVE OUTCOMES IN CIRRHOTIC PATIENTS WITH GI HEMORRHAGE

Prophylactic Antibiotics Improve Outcomes in

Cirrhotic Patients with GI Hemorrhage

Control Antibiotic
Absolute rate
(n=270) (n=264)
difference

(95% CI)

Infection 45% 14%

-32%

(-42 to –23)

SBP1999;
Bernard et al., Hepatology / Bacteremia
29:1655 27% 8%
 Encephalopathy

Grade 0 – Asymptomatic
 Can Dx with neuropsychiatry testing/trail test


Grade 1 – Sleep/wake reversal


Grade 2 – Fairly confused


Grade 3 – Awfully confused/obtunded


Grade 4 - Comatose
 Encephalopathy
Precipitants :

GIB

Constipation

Medications

Infections

Fever

High protein intake

Dehydration

Hypotention

Electrolyte disturbance

Others
 Encephalopathy Management

Diet

NO PROTEIN RESTRICTION!!
 1.6 g/kg/day protein


If refractory encephalopathy:
 Restrict aromatic amino acids (animal protein)

 Liberal branched-chain amino acids (plant)


Leucine, isoleucine, valine
 Encephalopathy Management


Lactulose

Titrate to 2-4 BM/day


Antibiotics

Flagyl, Neomycin
 Hepatocellular Carcinoma

recommendations
U/S abdomen, alpha-fetoprotein q6months

All cirrhotic patients

Early detection is associated with better outcome

......Questions