Outcomes of patients with cirrhosis undergoing non-hepatic surgery: Risk assessment and management

Table 1 Reported surgical mortality risk in patients with cirrhosis

Surgery in patients with cirrhosis	n	Died (n)	%	Ref No.
Gastrointestinal
Peptic ulcer surgery-elective	20	2	10	34
Peptic ulcer surgery-bleeding	94	46	49	34
Peptic ulcer surgery-perforation	167	70	42	34
Gastric bypass	125	5	4	38
Biliary tract surgery	212	45	21	34, 39
Small bowel surgeries	9	6	67	34
Colon surgeries	87	36	41	34
Open cholecystectomy	110	8	7.7	40
Laparoscopic cholecystectomy	265	0	0	41
Abdominal
Abdominal surgery for trauma	17	8	47	42
Emergency abdominal surgery			57	12
Splenectomy	7	0	0	43
Umbilical herniorrhaphy	24	2	8.3	6
Inguinal herniorrhaphy	1197	30	2.5	44
Bone/Joint
Hip surgery-elective	14	0	0	45
Hip surgery-emergent	5	3	60	45
Knee surgery	42	0	0	46
Cardiac
Cardiac surgery-elective	18	3	17	47
Cardiac surgery-emergent	5	4	80	48
Genito-urinary
TURP	30	2	6.7	49
Hysterectomy	105	8	7.6	50
Abdominal surgeries in various liver conditions
Acute hepatitis	11	11	100	51
Hepatitis C	34	0	0	52
Chronic hepatitis	20	0	0	36
Obstructive jaundice			5-60	53

TURP: Transurethral resection of the prostrate.

Table 2 Surgical severity risk stratification[14]

Low risk	Moderate risk	High risk
Eye	Intracranial surgery	Lung resection
ENT	Laminectomy/Disc surgery	Heart surgery
Dental	Thyroidectomy	AAA repair
Sinuses/Tonsils	Other endocrine surgery	Porto-systemic shunt
Chest tube/ Thoracentesis	Head and neck surgery	Splenectomy
Bronchoscopy	Major blood vessels surgery	Laparotomy
Laryngoscopy	Peripheral artery surgery	Esophagus/Stomach surgery
Tracheostomy	Embolectomy	Liver/Biliary surgery
Venous procedures	Carotid artery surgery	Small bowel/Large bowel/Pancreas surgery
Vein stripping	Rectal/Anal surgery	Renal surgery
Pacemaker insertion	Herniorrhaphy	Hip surgery
Lymph node biopsy/ resection	Bladder procedures	Back fusion
GI endoscopy	Prostate procedures	Long bone fractures
Laparoscopy	Hysterectomy ± oophorectomy
GU endoscopy	Amputations
Male GU procedures	Hand, foot, knee surgery
Female GU procedures	Breast biopsy/ mastectomy
D & C
Skin lesion excision
Superficial tumor excision
Other diagnostic/ therapeutic procedures

ENT: Ear, nose and throat; GI: Gastrointestinal; GU: Genitourinary; D & C: Dilatation and curettage; AAA: Abdominal aortic aneurysm.

Table 3 Modified Child Turcotte Pugh (CTP) score

Feature	Points
	1	2	3
Albumin (g/dL)	> 3.5	2.8-3.5	< 2.8
Prothrombin time
-Seconds prolonged	< 4	4-6	> 6
-INR	< 1.7	1.7-2.3	> 2.3
Bilirubin (mg/dL)	< 2	2-3	> 3
(PBC/PSC)1	< 4	4-10	> 10
Ascites	Absent	Slight-moderate	Tense
Encephalopathy	None	Grade I-II	Grade III-IV
CTP Class	Points	2 yr patient survival (%)
Class A	5-6	85
Class B	7-9	60
Class C	10-15	35

¹In primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC), the bilirubin references are changed to reflect the fact that these diseases feature high conjugated bilirubin levels.

Table 4 Contraindications to elective surgery in patients with liver disease[11]

Acute hepatitis	Chronic hepatitis
Alcoholic	Chronic severe hepatitis
Autoimmune	Class C cirrhosis
Uncontrolled Wilson’s disease	Uncontrolled portal hypertension with sequelae
	Severe coagulopathy1
	Systemic liver-related co-morbidities
	Hypoxia (POPH or HPS)2
	Cardiac volume overload
	Hepatorenal syndrome

¹Severe coagulopathy defined as platelets < 50 000/mm³ and prothrombin time prolonged beyond 3 s with no response to Vitamin K;

²POPH: Porto-pulmonary hypertension; HPS: Hepatopulmonary syndrome.

Table 5 American Society of Anesthesiologists (ASA) Classification of preoperative risk

ASA Class	Systemic disturbance	Mortality (%)
1	Healthy patient with no disease outside of the surgical process	< 0.03
2	Mild to moderate systemic disease caused by the surgical condition or by other pathological processes, medically well-controlled	0.2
3	Severe disease process which limits activity but is not incapacitating	1.2
4	Severe incapacitating disease process that is a constant threat to life	8
5	Moribund patient not expected to survive 24 h with or without an operation	34
E	Suffix to indicate emergency surgery for any class	Increased

^bP < 0.01 vs group B and control group; ^aP < 0.05 vs control group; ^dP < 0.01 vs group B and control.