Transcript surgical risk in patients with liver disease

RISK OF SURGERY IN THE
PATIENT WITH LIVER
DISEASE
Ajay Jain
Gastroenterology Fellow
January 16, 2002
CASE
ID/CC: 57 F admitted Aug. 28 with L femur #
PMHx:
HCV Cirrhosis
» OGD (1998) Gr II varices
» No GI bleed, encephalopathy, SBP
MEDS:
nadolol
spironolactone
furosemide
Other Hx:
» no alcohol abuse
40 mg OD
100mg OD
40 mg OD
CASE
O/E: 110/72,70, 18, afebrile
H&N:scleral icterus, jaundice, spider angiomata
CVS: JVP 3cm ASA, normal S1 S2, no S3 S4, no
murmurs, + SOA
PULM: clear
ABDO:distended, bulging flanks, + fluid wave,
spleen tip palpable, liver span 8cm, non-tender
NEURO: no asterixis
CASE
LAB:
 Hb
97 (MCV 94)
Na+
 WBC
8.6
Cr
 Plts
84
Urea
 ALB
18
AST
 INR
2.1
ALT
 T.BILI
180
ALP
ABDO U/S:
 nodular liver 9cm c/w cirrhosis
 spleen 14cm
 moderate ascites
132
36
5.1
85
60
253
 What
recommendations would you
provide to the orthopedic surgeon and
the patient?
Introduction

multiple functions of the liver
» synthesis of most serum proteins
» metabolism of nutrients and drugs
» excretion and detoxification of endogenous toxins
and exogenous agents
» filtering of portal venous blood
Introduction

any or all of the functions of the liver may be impaired in
patients with liver disease

pharmacokinetic parameters of:
» anaesthetics
» muscle relaxants
» analgesics, and sedatives
can be affected by changes in their
» binding to plasma proteins
» detoxification
» excretion
Introduction

bleeding risk may be increased due to coagulopathy

susceptibility to infection may be increased due to:
» altered functioning of hepatic reticuloendothelial cells
» changes in the immune system
» portal hypertension
Introduction

in the vast majority of patients with liver disease
in whom liver function is preserved, the operative
risk is not likely to be increased

mild elevations of serum transaminases, alkaline
phosphatase, or bilirubin levels are frequent postoperatively
» in pts without liver disease, these elevations are
usually transient and of no clinical significance
Introduction
A diseased liver is particularly susceptible to
the hemodynamic changes that accompany
surgery
» altered hepatic flow may result in hepatic dysfunction
in predisposed individuals
Med Clin North Am, 1987
Hepatology, 1991
Effects of Anesthesia on the
Diseased Liver

anesthesia results in moderate reduction in hepatic
arterial blood flow and hepatic oxygen uptake
» no clinical significance of these changes seen in
healthy volunteers

liver blood flow returns to baseline during surgery
» initial hypoperfusion and/or reperfusion injury may
contribute to postoperative liver dysfunction
Effects of Anesthesia on the
Diseased Liver

Volatile Anesthetics (Halothane & Enflurane)
» reduce hepatic arterial (HA) blood flow (systemic
vasodilatation)
» small negative inotropic effect
» significant hepatic metabolism (halothane - 20%,
enflurane - 3%)

Isoflurane
» may actually increase HA blood flow
» preferred agent in patients with liver disease
» undergo less hepatic metabolism (0.2%)
(corresponds with lower risk of drug-induced hepatitis)
(risk of halothane hepatitis quite low: 1 in 35 000)
Effects of Anesthesia on the
Diseased Liver

Hypercarbia
» sympathetic stimulation of splanchnic vasculature,
thereby decreasing portal blood flow
» pCO2 should be maintained between 35-40 mmHg
during surgery
Effects of Anesthesia on the
Diseased Liver

Neuromuscular Blocking Agents
» prolonged in patients with liver disease due to:




reduced plasma pseudocholinesterase activity
decreased biliary excretion
increased volume of distribution
Atracurium
» preferred agent in patients with liver disease
» metabolism independent of the liver

Doxacurium
» long-acting muscle relaxant
» recommended for prolonged procedures including
hepatic transplantation
Effects of Anesthesia on the
Diseased Liver
Narcotics
 morphine and meperidine
» reduces hepatic blood flow

fentanyl
» preferred narcotic agent
Sedatives
 diazepam
» prolonged metabolism in patients with liver disease

lorazepam
» eliminated by glucoronidation without hepatic metabolism
» preferred agent
Effect of Type of Surgical Procedure
on the Diseased Liver


important determinant of post-operative hepatic
dysfunction
risk: laparotomy > extra-abdominal surgery
» greater reduction in HA blood flow


cholecystectomy, gastric surgery and colectomy
associated with high mortality rates in patients
with decompensated cirrhosis
morbidity/mortality higher for emergent than
elective surgery
Effect of Type of Surgical Procedure
on the Diseased Liver

Cardiac Surgery (limited experience)
» 13 pts with alcoholic cirrhosis underwent emergent
CABG/valve replacement
» post-operative mortality rate


Child’s A:
Child’s B:
Ann Thorac Surg, 1998
0%
80 %
Modified Child-Pugh Score
Parameter
albumin
INR
bilirubin (mg/dL)
ascites
encephalopathy
Class A:
Class B:
Class C:
1
>35
<1.7
<2.0
absent
none
5-6 points
7-9 points
10-15 points
Points
2
3
28-35
<28
1.7-2.3
>2.3
2-3
>3.0
slight-mod tense
Gr. I-II
Gr. III-IV
Estimating Operative Risk in Patients
with Liver Disease

minimal data on precise estimates of operative risk

most data from small retrospective studies of
cirrhotic patients undergoing abdominal surgery

pre-operative risk likely dependent on type of
underlying liver disease
Contraindications to Elective Surgery
in Patients with Liver Disease







Acute viral hepatitis
Acute alcoholic hepatitis
Fulminant hepatic failure
Severe chronic hepatitis
Child’s class C cirrhosis
Severe coagulopathy (PT > 3 sec vs control, Plt<50)
Severe extrahepatic complications
» hypoxemia
» cardiomyopathy, heart failure
» acute renal failure
Acute Hepatitis

acute hepatitis contraindication to elective surgery

peri-operative mortality rates: 9.5 to 13%
(in icteric patients)

surgery also contraindicated in patients with a
histological diagnosis of alcoholic hepatitis
» mortality rates as high as 55% reported in patients
undergoing open liver biopsy or portosystemic shunt
surgery
JAMA, 1963
Br J Surg, 1982
Chronic Hepatitis

surgical risk correlate with clinical, biochemical,
and histological severity of disease

elective surgery reported to be safe in patients
with asymptomatic mild chronic hepatitis
Fatty Liver and Non-Alcoholic
Steatohepatitis

alcoholic or non-alcoholic fatty liver is not a
contraindication to elective surgery

trend toward increased mortality following hepatic
resection in patients with moderate to severe steatosis
(ie. >30% of hepatocytes containing fat)
J Gastrointest Surg, 1998

period of abstinence from alcohol before surgery
advisable
Fatty Liver and Non-Alcoholic
Steatohepatitis





EFFECT OF PREOPERATIVE ABSTINENCE ON POOR
POSTOPERATIVE OUTCOME IN ALCOHOL MISUSERS:
RANDOMIZED CONTROLLED TRIAL
(BMJ, 1999)
41 alcoholic (>60g ethanol/d) patients without liver disease
undergoing elective colorectal surgery
abstinence from alcohol (n=20) vs continuous drinking (n=21)
Abstinence
Continuous
post-op complications
31%
74%
post-op myocardial ischemia 23%
85%
post-op arrhythmias
33%
86%
Other Causes of Liver Disease

Autoimmune Hepatitis
» if in remission, elective surgery well tolerated in
patients with compensated liver disease
» perioperative administration of “stress” doses of
hydrocortisone indicated in patients taking prednisone

Hemochromatosis
» monitoring of diabetes in perioperative period
» assess for possibility of cardiomyopathy

Wilson’s Disease
» neuropsychiatric involvement - interferes with consent
» D-pencillamine can impair wound healing - decrease
dose in first 1-2 postoperative weeks
Cirrhosis


retrospective studies have shown that perioperative
mortality and morbidity rates correlate well with the ChildTurcotte-Pugh class of cirrhosis
Alcoholic Cirrhosis (abdominal surgery): Mortality Rates
1984
1997
» Child’s A
» Child’s B
» Child’s C


10%
31
76
10%
30
82
some studies have not confirmed predictive value of
Child’s classification, mainly due to few Child’s C patients
APACHE III can predict survival in cirrhotic patients
admitted to an ICU; yet to be studied in cirrhotics
undergoing surgery
Resection for Hepatocellular
Carcinoma (HCC)





annual incidence of HCC 3 to 5%
perioperative mortality rate for hepatic resection
3 to 16%
postoperative morbidity rates as high as 60%
5 year recurrence rates are as high as 100%
5 year survival rates are no higher than 50%
Preoperative Evaluation


1 in 700 otherwise healthy individuals will have abnormal
liver function tests
any patient undergoing surgery:
» careful history to identify risk factors for liver disease
» a history of jaundice or fever after anesthesia
» alcohol history and complete review of medications
» sx or findings on physical examination suggestive of liver dz

patients with known liver disease:
» identify presence of jaundice, ascites, or encephalopathy
» complete biochemical assessment of liver function
» correct coagulopathy, ascites and encephalopathy
Postoperative Period




monitor for signs of liver decompensation
including worsening jaundice, encephalopathy and
ascites
bilirubin and prothrombin time best measures of
hepatic function
renal function important to monitor because of the
risk of hepatorenal syndrome
monitoring of serum glucose levels as
hypoglycemia often accompanies postoperative
hepatic failure
CASE - Hospital Course
Hospital Day 4
 doubling of Cr and urea, small drop in Hb
 diagnostic paracentesis c/w SBP ==> ceftriaxone
Hospital Day 6
 asterixis
 bili 398, INR 1.90, increasing Cr
Hospital Day 9
 OGD - Gr III varix - no active bleed
CASE - Hospital Course
Hospital Day 12
 Na+ 122, Cr 170, T.Bili 493, INR 2.2
 drowsy
 DNR status obtained
Hospital Day 13
 hypotensive - Rx with IV fluids
 comfort measures
Hospital Day 14
 progressive obtundation
 glucometer 1.5
 expired
DISCUSSION