Outcomes of abdominal surgery in patients with liver cirrhosis

Table 1 Recommendations for evaluation before non-hepatic abdominal surgery in liver cirrhotic patients

Elements to evaluate		Recommended tests	Recommended action
Homeostasis	Thrombo-cytopenia	Platelet number and function by means of thromboelastography	Preoperative transfusion if:
			Platelet > 50000/μL → moderate risk procedures
			Platelet > 100000/μL → high risk procedures
			Consider desmopressin (300 μg intranasal) if uremia or altered platelet function in thromboelastography
	Coagulopathy	PT-INR; thromboelastography.	IV replenishment of vitamin K (≥ 10 mg OD during 3 d)
		Serum fibrinogen;	Cryoprecipitate if serum fibrinogen ≥ 100 mg/dL
		Thromboelastography
		Consider Tranexamic acid (10 mg/kg TD during 2-7 d)
Liver function	PTH	Abdominal US	Consider the less invasive surgical treatment or avoid surgery if severe PTH
			Consider TIPS
	Ascites	Diagnostic ascitic tap; check diuretics response	Discard SBP
			Antibiotic prophylaxis or treatment.
			Sodium restriction and diuretics (careful monitoring of renal function avoiding hyponatremia)
			Large volume of paracentesis for uncontrolled ascites
	Esophageal varices	Upper endoscopy; Abdominal US	Consider prophylactic treatment (i.e., β-blockers, variceal banding) based of risk of bleeding
Immune function and nutritional status	Malnutrition, hypoalbuminemia	White blood cells count; Nutritional biomarkers: Albumin, Pre-albumin, transferrin; muscle wasting	Optimize protein and caloric intake (higher requirements than normal individuals)
			Vitamin B1 in alcoholics
			Administer antibiotic prophylaxis if suspected concurrent infections (Other than SBP)
	Glucose intolerance	Laboratory testing	Insulin infusion
cardiac function	Cardiomyopathy	Dobutamine stress echocardiography	Consider the less invasive surgical treatment or avoid surgery if severe cardiac dysfunction
			Consider close invasive monitoring and hemodynamic strategy in order to preserve normal cardiac function and avoid organ hypoperfusion (especially liver and kidney)
			Consider β-blockers in perioperative period
Renal function	Renal dysfunction; Hepatorenal syndrome	Serum creatinine; Glomerular filtration rate; Evaluate normal Blood Pressure and cardiac performance	Avoid dehydration if possible before surgery
			Avoid positive fluid balance during perioperative course (if hemodynamics allow that)
Pulmonary function	Hydrothorax; HPS; PPH	Chest-X ray; Electrocardiogram and echocardiography; Spirometry	Optimize pulmonary function:
			Discard high arterial pulmonary pressure
			Discard pleural effusion/thoracentesis if necessary
			If HPS/PPH evaluate appropriate therapy (i.e., IV epoprostenol, sildenafil)
CNS	HE	Clinical assessment;	Use of lactulose despite absence of HE if medical past history or PTH
		Ammonia serum levels	Treat or avoid potential triggers of HE (i.e., diuretics, infections, constipations, CNS depressants, azotemia, uremia, hyponatremia)

PT-INR: Prothrombin time-derived international normalized ratio; IV: Intravenous; PTH: Portal hypertension; US: Ultrasound; TIPS: Transjugular intrahepatic portosystemic shunt; SBP: Spontaneous bacterial peritonitis; HPS: Hepatopulmonary syndrome; PPH: Portopulmonary hypertension; CNS: Central nervous system; HE: Hepatic encephalopathy.

Table 2 Modifications in operative laparoscopic techniques in non-hepatic abdominal surgery in liver cirrhosis who underwent cholecystectomy and hernia repair

Ref.	Modified technique	Objective and advantage
Laparoscopic cholecystectomy
Friel et al[77], 1999	Use of open technique using Hassan’s trocar	Prevent inadvertent puncture of umbilical varix
Shiff et al[78], 2005	Placement of the trocar in the right paramedian position
Clark et al[79], 2001	Use of additional ports	Facilitate laparoscopic technique and prevent complications in cases of severe gallbladder inflammation
	Performance of retrograde cholecystectomy
Clark et al[79], 2001	Modified subtotal cholecystectomy
Palanivelu et al[80], 2006
Friel et al[77], 1999	Mechanical compression from introduced surgical sponges (i.e., oxidized cellulose)	Facilitate haemostasis
	Application of ultrasonic energy via harmonic scalpel
	Use of argon beam coagulator through an operative port
Laparoscopic hernia repair
Belli et al[81], 2006	Minimally invasive and tension-free laparoscopic technique	Prevent inadvertent puncture of collateral veins
		Prevent recurrence rates and wound infections
McAlister et al[82], 2003	Dual mesh prosthesis: fixation of mesh in a preperitoneal space	Prevent recurrence rates and mesh migration
	Sterile fashion of mesh insertion	Prevent wound infections

Table 3 Outcomes of liver cirrhosis who underwent non-hepatic abdominal surgery based on type of surgery

Type of surgery	Morbidities	Mortality in LC population	Mortality in non-LC population
Cholecystectomy[77-79,83-86,91-97]
Laparotomy	30%-35%	1%-7.7%	0.5%-1%
Laparoscopy	13%-33%	< 1%	< 1%
Colorectal surgery[10,98]	43%	14%-29% (20.9%-35.8% if ES)	5%
Radical gastric surgery[99]	56% (53.3% CTP A, 67.7% CTP B)	-	80% (5-yr)
Appendectomy[87,89]
Laparotomy	5%	9%	0.7%
Laparoscopy	< 1%	< 1%	< 1%
Pancreatic surgery[100]	69% (67% CTP A, 100% CTP B)	9% (3% CTP A, 100% CTP B)	-
Abdominal wall surgery[81,82,101-110]
Umbilical hernia	7%-20%	< 1%-5.5%	< 1%
Inguinal hernia	6.3%-10.9%	< 1%-2.7%	< 1%

LC: Liver cirrhosis; ES: Emergency surgery; CTP: Child-Turcotte-Pugh; ICU: Intensive care unit.