Operating on a patient with cirrhosis

Considerations

• Complications of cirrhosis:
  • Ascites – consider paracentesis, fluid/sodium restriction
  • Variceal bleeding risk – beta blocker, gastroscopy/banding, TIPS
  • Encephalopathy – lactulose, rifaximin
  • Nutrition
  • Other comorbidities
• Anaesthetic considerations:
  • Cardiac dysfunction
  • Hypoxia
  • Hypotension, intravascular volume
  • Sepsis
  • Portopulmonary hypertension
  • Drugs – hepatotoxicity
• Operative risks
  • Assessment of severity
    • Subjective and objective (CP - both, Meld just objective = prefrence)
    •  Child-Pugh Score
      • Mortality in major abdominal surgery
        • A - 10%
        • B - 30%
        • C - 80%
    • MELD Score
      • Mortality
        • 1% increase each one-point increase from 5 to 20
        • 2% increase for each one-point increase above 20

Pre-operative preparation

• Is operation needed? Is this time critical? Can liver disease be optimised?
• Is there time to transfer to an HPB unit
• MDT – hepatologist, anaesthetist.
• Optimisation
  • Manage ascites
    • Paracentesis
    • Sodium restriction
    • Diuretics
    • TIPSS
  • Variceal bleeding risk
    • OGD to assess varicies pre op
    • NSBB
    • Banding
    • TIPS
  • Encephalopathy
    • Lactulose
    • Rifaxamin
  • Nutrition
    • B12/Folate/ Vit ADKE
    • Macro
    • Dietican review
    • Low salt and high energy diet
  • Coagulation
    • Coagulopathy in cirrhosis
    • Imbalance between anti/pro clot
    • Normal clotting tests dont always show an issue
    • TEG is the best to monitor
  • Portal pressure
    • Wedge pressure
    • EUS guided portal vein pressure
    • Splenic pulp pressure
    • Subjective
      • PV >13mm
      • Spleen >13cm
  • Renal function
  • Electrolytes
  • Other comorbidities
• Planning
  • Cross section imaging to help operative planning
  • Bail out strategy
  • TIPS/shunt if severe bleeding
• Prior to surgery
  • G&H +/- transfusion
  • HDU/ICU support
  • Hepatology review

Intra-operative

• Prophylactic antibiotics
• Entry
  • Port
    • Recanalised umbilical veins
    • Place your port away from the umbilicus or directly via the umbilicus
    • Or divide/energy device them
  • Avoid transverse incisions
    • More likely to divide varices
• Manage ascites
  • Suction out if present
  • Consider leaving and train vs intermittent ascitic tap (preferred as no route for infection)
• Minimise dehiscence risk
  • Close all layers including peritoneum
• Bail out
  • Leaving the back wall of the gallbaldder on
• Bleeding
  • Use a ligasure

Postop care

• Aware of risk of decompensated liver failure
  • Stress response to pathology, surgery, GA, fluid shifts
• Risk factors for decompensation:
  • Dehydration
  • Constipation
  • Bleeding
  • Infection e.g. SBP
• Monitor bloods: Bili / INR / LFTs
• Monitor clinically for ascites and encephalopathy and treat appropriately
  • Ascites: Na restrict, diuretics, paracentesis if refractory
  • Encephalopathy: exclude other causes (e.g. hypoxia, hypercapnia, hypoglycaemia, uraemia, EtOH Withdrawal, ICH), treat with lactulose to ensure 2-3 BM per day
    • Lactulose acidifies colon and promotes conversion of ammonia to ammonium in bowel and not absorbed
• Monitor for Hepatorenal Syndrome
  • AKI but HD stable, no nephrotoxics and not improving
  • Treatment: Splanchnic vasoconstrictors (Terlipressin, Noradrenaline, Midodrine)
• Ensure VTE Prophylaxis
• Monitor for infection
• Be aware of complications unrelated to surgery:
  • Variceal bleeding
  • Volume overload
  • Portal Vein Thrombosis
• Post-operative complications
  • Bleeding/coagulopathy
  • Wound complications – infection, impaired healing
    • Kupfer cell dysfunction, low proteom
  • Ascites leak
  • Sepsis
  • Decompensation of liver failure
  • Renal dysfunction
    • Hepatorenal syndrome
  • Cardiopulmonary dysfunction
  • Impaired metabolism of drugs

Supportive management

• N-Acetyl cysteine
  • Initially used for paracetamol poisoning only.
  • Now used generally to replenish glutathione.
• Nutritional support
  • Enteral nutrition without excessive protein administration.
• Extracorporeal liver support:
  • Artificial liver support
    • MARS device.
      • Used albumin dialysis circuit to remove water soluble and protein-bound toxins.
  • Bioartificial liver systems
    • HepatAssist device
      • human hepatoblastoma cell lines
    • ELAD (Extracorporeal Liver Assist Device)
      • porcine hepatocytes