Risk Assessment of Cirrhotic Patients Undergoing

Non-Transplant Surgery

Paul J. Thuluvath, MD, FRCP Professor of Surgery & Medicine

Georgetown University Hospital, Washington DC; Director, Institute of Digestive Health & Liver Diseases &

Chief, Gastroenterology Mercy Medical Center, Baltimore, MD

Disclosures

• I have no disclosures pertinent to this talk • Industry relationship

– Grants: BMS, Gilead, Novartis, Boehringer, Vertex, Bayer

– Consultation: BMS, Bayer, Gilead – Speaking: Bayer, Onyx, Gilead, Vertex

Case 1

• 50 yr old man with epigastric discomfort seen in ER – Liver biochemistry: Total Bilirubin 3.2 AST 30, ALT

42, alk phos 150, INR 1.3, creatinine 1.4 – CBC: Hb 12.0, WBC 7.0, platelets 140,000 – CT scan: thickened GB wall, no GB stones, minimal

fluid around the GB

Emergency cholecystectomy?

Case 2

• 64 yr old woman with diabetes and cryptogenic cirrhosis is found to have severe osteoarthritis of hips. LV function is good. Patient’s mobility is impaired by osteoarthritis and orthopedics surgeon recommends hip replacement. – MELD 16, Child-Pugh score 7, creatinine 1.4 mg/dl – Strong family support

Anesthesia requests GI opinion. What should GI

physician recommend?

Outline

– Portal hypertension and consequences – Risk assessment and prognostic models – Morbidity & mortality – General management guidelines

Reasons for Higher Morbidity and Mortality in Patients with Cirrhosis • Compromised liver function

– Serum bilirubin, INR, albumin – Child-Pugh score or MELD score

• Portal hypertension – Presence of ascites, collaterals, HE – Serum creatinine – Child-Pugh or MELD score

Complications of PHTN

• Gastro-esophageal variceal bleeding

• Ascites • Hepatorenal

Syndrome • Hepatic

encephalopathy

• Hepatopulmonary syndrome & porto-pulmonary HTN

• Bacteremia • Hypersplenism • Impaired drug

metabolism

F1 F2

F3

Esophageal Varices; F0 – none, F1 – small, F2 – medium, F3 - large

Fundal varix

Rectal varices

PHTN gastropathy

Portal Hypertension

• Subtle changes are often overlooked by physicians – Borderline platelets, mild elevation in bilirubin or prothrombin

time, short-term memory loss, sleep pattern changes • Pathophysiology is complex and involves multiple

organs

Cirrhosis

Portal HTN

Splanchnic vasodilation

Increased capillary pressure & permeability

Lymph formation more than return

Ascites Arterial

hypovolemia

Renin-Angiotension, Sympathetic nerves

Na & Water retention

Renal vasoconstriction

Renal Dysfunction

Consequences of Splanchnic Vasodilation

• Increased portal blood flow and hence increased portal HTN [Portal Pressure Gradient = Blood

flow x Resistance (Ohm’s Law)] • Hypovolemia & decrease in systemic blood

pressure – Hypovolemia and decrease in systemic pressure leads

to a cascade of events including upregulation of vasoconstrictors, sodium retention, decrease in renal blood flow and finally renal failure (hepatorenal syndrome)

Cardiac Changes

• Increased cardiac output (sepsis like situation)

• Sometimes cirrhotic cardiomyopathy (probably in late stages) and decreased cardiac output

• Cardiac autonomic neuropathy

Pulmonary Changes

• Hepatopulmonary Syndrome – Decreased pulmonary vascular resistance due to

shunting – Cyanosis, clubbing

• Portopulmonary Hypertension – Increased pulmonary vascular resistance – Mild to severe

Renal Changes

• Renin-Angiotension-Aldosterone system • Sympathetic nervous system • Glomerular filtration rate • Atrial natriuretic peptide

No ascites Ascites

Renin-Angiotension-Aldosteron & Na retention Antidiuretic hormone &

hyponatremia

Type 1 HRS

Type II HRS

Time

Pere Gines Lancet 2003

Mortality Associated with Surgery in Patients with Cirrhosis

• Severity of liver disease • Presence of portal hypertension • Type of surgery • Emergency vs. elective • Age • Other co-morbidities

Mortality Associated with Abdominal Surgery in Patients with Cirrhosis

• Peptic ulcer perforation or bleeding – Overall mortality 54% (n=62)

• Elective 29%, perforation 35%, perforation 64% – Lehnert T & Herfarth C. Ann Surg 1993;217;338-46

• Cholecystectomy: 10.8% – NIS 1998-2005

• Mortality in cirrhosis with PHTN 10.8% – Nguyen GC et al Clin Gastroenterol Hepatol 2008;6;1146

Mortality Associated with Abdominal Surgery in Patients with Cirrhosis

• Colectomy: 41% • Small bowel 67% • Emergncy abdominal surgery 47-57% • Bile duct surgery: 21% • Hysterctomy 7.6%

Mortality Associated with Trauma Surgery in Patients with Cirrhosis

• Blunt abdominal trauma – Mortality 29 .4 - 43.3%

• Seamon MJ et al 2010, Lin BC et al 2012

• Each increase in MELD score was associated with 18% increase on odds for mortality a – Inaba K et al

Mortality Associated with Cardiac Surgery in Patients with Cirrhosis

• 44 patients (16 CABG, 16 valve, 10 combination both, 2 pericardiectomy)

• Child A 31, B/C 13 • Mortality 1/31 in Child A, 6/13 B/C Suman A et al Clin Gastroenterol Hepatol, 2004;2:719-23

Child-Pugh Score vs. MELD Score

• Probably both are equal based on published data

Child-Turcotte-Pugh & MELD score

• CTP scores based on 3 laboratory values and 2 physical findings – Serum albumin (1-3), bilirubin (1-3), INR or

prothrombin time (1-3), ascites (1-3) & hepatic encephalopathy(1-3)

– Child A (< 6); Child B (score 7-9), Child C score >10) • MELD score based on 3 laboratory values

– Mathematical survival model created from data on patients undergoing TIPS & estimates risk of 3-month mortality

– Model based on serum bilirubin, creatinine & INR

Model for End-Stage Liver Disease (MELD): Mortality without Surgery

MELD = (0.957 x log (creatinine)

+ 0.378 x log (bilirubin)

+1.12 x log (INR) + 0.643) x 10

Score Mortality Risk at 3 Months 22 10% 29 30% 33 50% 38 80%

Risk of Non-hepatic Surgery in Patients with Cirrhosis

• 138 patients (Child A 41, B59, C 38); 49% emergent

• Mortality 28% – Elective 9%, emergent 47% – Child A 10%, B 17%, C 63% – <10 Meld 9%, 19% Meld 10-15, 54% Meld>15)

Neeff H et al J Gastrointest Surg, 2011;15:1-11

Risk of Surgery in Patients with Cirrhosis

• 722 patients – Major digestive 586, orthopedic 107,

cardiovascular 79 • Controls

– 303 minor surgical, 562 ambulatory patients • Mortality

– <8 MELD 5.7%, MELD >20 – 50%) Teh SH et al al Gastroenterology 2007; 132:1261

Risk Based on MELD Score

30 day mortality

90 day mortality Teh et al. Gastroenterology 2007;132:1261-69

Patients: 586 abdominal surgery 107 orthopedic 79 cardiac Controls: 303 minor surgery and 562 ambulatory patients

Risk Based on Child-Pugh Class

• Child A – Elective surgery tolerated

• Portal HTN increases the risk of abdominal and cardiac surgery

• Child B – Elective surgery permissible after pre-operative

preparation • Child C

– Elective surgery contraindicated

Risk Based on Type of Surgery

• High risk surgery – Lung resection, heart surgery – AAA repair, shunt surgery – Splenectomy – Laparotomy – Esohagus, stomach, small intestine, colon – Liver & biliary – Renal surgery – Hip surgery, back fusion, long bone fractures

Management Algorithm - I • Determine whether there is underlying cirrhosis

– History (substance abuse, past and family history) – Physical examination (spider nevi, splenomegaly,

ascites, encephalopathy) – Laboratory tests (low platelets or albumin; increased

INR or direct bilirubin) – Imaging (U/S, CT or MRI) – Biopsy when in doubt

Management Algorithm -II

• If cirrhosis is present, assess the cause of cirrhosis and whether treatable

• Assess the presence or severity – Child-Pugh, MELD, ASA – Portal hypertension – Renal function (?HRS) – Portopulmonary HTN; hepatopulmonary

syndrome – Relative adrenal insufficiency

• Other co-morbid conditions

Management Algorithm -III

• Determine if surgery is critical – Indication must be strong – If in doubt, wait – Optimize the conditions

• Coagulopathy & anemia, renal function, infection control, pulmonary status, fluid management

• If not critical, postpone – LT candidates: postpone after LT – Critical cardiac surgery: consider doing it with

LT

Management Algorithm -IV

• Anesthetic agent – isoflurane

• Neuromuscular agent – atracurium

• Anxiolytic seatives – oxazepam, lorazepam

• Narcotics – fentanyl

Management Algorithm -V

• Watch for complications – Worsening ascites, HE, GI bleeding, renal

failure, liver failure • Avoid nephrotoxic drugs, fluid overload

– DIC – Surgical wound complications

• Infection, dehiscence, abscess, fistula – Infections – General complications

• Pneumonia, heart failure, paralytic ileus et..

Take Home Message

• Non-transplant surgery in cirrhotic patients is associated with a very high morbidity and mortality

• Risk assessment and stratification are critical, and consider surgery only if it is essential

• Hepatology consultation is helpful before any major surgery

• Optimize the patient condition, surgery, anesthesia care and post-operative care

• It takes five years to learn when to operate and twenty years to learn when not to. — Anonymous

• I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.

— Harvey Cushing

Mortality Associated with Abdominal Surgery in Patients with Cirrhosis

• Peptic ulcer perforation or bleeding – Overall mortality 54% (n=62)

• Elective 29%, perforation 35%, perforation 64% – Lehnert T & Herfarth C. Ann Surg 1993;217;338-46

• Cholecystectomy: 10.8% – NIS 1998-2005

• Mortality in cirrhosis with PHTN 10.8% – Nguyen GC et al Clin Gastroenterol Hepatol 2008;6;1146

Consequences of Splanchnic Vasodilation

• Increased portal blood flow and hence increased portal HTN [Portal Pressure Gradient = Blood

flow x Resistance (Ohm’s Law)] • Hypovolemia & decrease in systemic blood

pressure – Hypovolemia and decrease in systemic pressure leads

to a cascade of events including upregulation of vasoconstrictors, sodium retention, decrease in renal blood flow and finally renal failure (hepatorenal syndrome)

Mortality Associated with Abdominal Surgery in Patients with Cirrhosis

• Peptic ulcer perforation or bleeding – Overall mortality 54% (n=62)

• Elective 29%, perforation 35%, perforation 64% – Lehnert T & Herfarth C. Ann Surg 1993;217;338-46

• Cholecystectomy: 10.8% – NIS 1998-2005

• Mortality in cirrhosis with PHTN 10.8% – Nguyen GC et al Clin Gastroenterol Hepatol 2008;6;1146

Mortality Associated with Abdominal Surgery in Patients with Cirrhosis

• Peptic ulcer perforation or bleeding – Overall mortality 54% (n=62)

• Elective 29%, perforation 35%, perforation 64% – Lehnert T & Herfarth C. Ann Surg 1993;217;338-46

• Cholecystectomy: 10.8% – NIS 1998-2005

• Mortality in cirrhosis with PHTN 10.8% – Nguyen GC et al Clin Gastroenterol Hepatol 2008;6;1146