Liver surgery in cirrhosis and portal hypertension

Table 1 Causes of liver cirrhosis

Alcoholic liver disease

Chronic viral hepatitis (hepatitis B and C)

Non-alcoholic fatty liver disease

Primary and secondary biliary cirrhosis

Primary sclerosing cholangitis

Hemochromatosis

Autoimmune hepatitis

Wilson’s disease

α1-Antitrypsin deficiency

Celiac disease

Right-sided heart failure

Granulomatous liver disease

Congenital malformation syndromes

Table 2 Most frequent causes of portal hypertension

Prehepatic etiology of portal hypertension

Portal vein thrombosis

External portal vein compression

Intrahepatic etiology of portal hypertension

Hepatic cirrhosis (of any origin)

Congenital hepatic fibrosis

Schistosomiasis

Idiopathic non-cirrhotic portal hypertension

Posthepatic etiology of portal hypertension

Budd-Chiari’s syndrome

Sinusoidal obstruction syndrome

Cirrhose cardiaque

Table 3 Preoperative risk stratification models for patients with liver cirrhosis[28-30,35-37]

Score	Groups	Initial function	Mortality assessment	Mortality after liver resection
ASA	1-6	Perioperative risk stratification for any patient	Predictor of 7-d mortality	Not specifically defined
CPT	A-C	Overall survival in patients with liver cirrhosis	A: 10%, B: 30%, C: 80%; predictor for 30- and 90-d mortality	A: < 9%, no data for B and C
MELD	0-40	Mortality of TIPS-placement	0-11: 5%-10%, 12%-25: 25%-54%, > 26: 55%-80%; predictor for 30- and 90-d mortality	≤ 8: 0%; > 8: 29%
Mayo		Mortality after abdominal, orthopedic and cardiac surgery	7-, 30-, 90-, 360-, 1800-d mortality	Not specifically defined

ASA: American Society of Anaesthesiologists; CPT: Child-Pugh-Turcotte; MELD: Model of End Stage Liver Disease; TIPS: Transjugular portosystemic stent shunt.

Table 4 Definitions of postoperative liver-failure

	Definition	Time of scoring
“50-50”	bilirubin > 50 μmol/L, prothrombin time < 50% (INR > 1.7) → mortality of 50%	POD 5
ISGLS	Increased INR and hyperbilirubinemia	On or after POD 5
ISGLS A	No intervention necessary
ISGLS B	Non-invasive intervention necessary
ISGLS C	Invasive intervention necessary
peakBili > 7	Maximum hyperbilirubinemia > 7 mg/dL any day after surgery - predictor for 90-d mortality	Any POD

POD: Postoperative day; ISGLS: International Study Group of Liver Surgery.

Table 5 Shunt surgery in portal hypertension and hepatic cirrhosis[93,95,96]

Shunt	Bypass of portal venous flow	Recurrent haemorrhage/complications
Porto-caval; end-to-side	Complete	Low rate of recurrent haemorrhage (< 5%)
		Low degree of shunt occlusion
		40% encephalopathy
		Increase in ascites
Porto-caval, side-to-side +/- interposition graft	Partial	Recurrent haemorrhage 5%
		Low degree of shunt occlusion (5%)
		5% encephalopathy
Distal splenorenal shunt (Warren)	Partial	Recurrent haemorrhage 5%-8%
		Shunt occlusion 10%
		Selective decompression of gastroesophageal varices