Liver Disease

Liver Disease is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

Patients with liver disease face increased operative morbidity and mortality in comparison to those with normal hepatic function. Not only does the stress of surgery place them at risk for acute hepatic decompensation, the myriad systemic effects of liver disease result in an increased frequency of complications to multiple other organs as well. The preoperative consultant’s role is to minimize these risks.

Classification

  • Both the older Child-Turcotte-Pugh (CTP) and more recent Model for End-stage Liver Disease (MELD) classification schemes (see Chapter 19, “Liver Diseases”) are well-validated statistical models for predicting surgical risk in patients with cirrhosis.
    • Two different studies separated by 13 years revealed strikingly similar results: a mortality rate of 10% for patients with CTP class A, 30% for class B, and 76%–82% for class C cirrhosis.1,2 Accordingly, it has been suggested that patients with CTP class A cirrhosis can safely undergo elective surgery in general, and those with class C cirrhosis should not under any circumstances.3 However, the distinction is less clear for class B cirrhosis, and the inherent subjectivity of the CTP system limits its discriminatory ability.4
    • MELD offers several advantages for calculation of 30-day mortality:
      • Variables are both objective and weighted.
      • It includes serum creatinine, which has been shown to correlate with postoperative mortality.5
      • Predictive performance is equal to if not better than that of CTP.6,7,8
    • Because CTP includes ascites, which is also correlated with poor prognosis in general surgical patients, the two scoring systems could be considered complementary rather than mutually exclusive.9,10
  • American Society of Anesthesiologists (ASA) class appears to be the strongest predictor of 7-day mortality in cirrhotic patients undergoing surgery.11 All 10 patients with ASA class V disease died, indicating that ASA class V should be a contraindication to surgery other than liver transplantation.12

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