Risk of Surgery in Patients with Liver Cirrhosis

• Chronic liver disease patients often undergo surgery for indications other than liver transplantation and may face increased perioperative risk due to both surgical and anesthesia-related complications.
• In cirrhotic patients, hepatic causes are considerably the cause of not having surgery, additionally, the majority of patients underwent surgery had a Child Pugh score of A or B, whereas only few had Child Pugh C.
• Hepatic and non-hepatic complications are common in cirrhotic patients including decompensation.
• Postoperative mortality significantly associated with higher WBCs, serum creatinine, and MELD score in addition to lower serum albumin.
• Cirrhotic patients need distinctive perioperative care. Optimal perioperative care could decease such complications.

Table (1): Demographic data and clinical characteristics (history and examination) of the studied groups.

HTN: Hypertension, DM: diabetes mellitus, DCL: Disturbed conscious level, PHG: Portal hypertensive gastropathy, GIT: gastrointestinal tract, Cutaneous manifestations: including palmar erythema, spider navai, white nails, ecchymosis patches and skin pigmentations. Bleeding from other sites: epistaxis, bleeding gums, X² chi-squared, test *significant

Table (2): Pre-operative laboratory investigations of the studied groups.

Hb: hemoglobin, AST: aspartate aminotransferase, INR: international normalized ratio, PLT: platelet count,

ALT: Alanine transaminase t: independent t test U: Mann-Whitney U test *significant

S. Table (1): Indications for surgery (elective or emergency) of the studied groups.

PU: peptic Ulcer, RIF: Reduction and internal fixation Maxillo Facial surgery: includes repair of fracture maxilla, fracture mandible and fracture zygomatic arch. Piles operations: lateral sphinocterotomy /Hemorrhoidectomy Urgent ORIF: Fracture Acetabulum (1), Fracturs neck femur (1), Multiple fracture with vascular injury (2) X²: chi squared test *significant

S. Table (2): Number of patients who underwent surgery (operated) or not (non-operated) in spite of the need for surgery of studied groups.

S. Table (3): Causes of not performing operations in studied patients and the outcome.

CBG: calcular gall bladder, OV: Oesophageal varices, HE: Hepatic Encephalopathy RTA: Road traffic accident PHG: Portal hypertensive gastropathy Hb: hemoglobin HFL: hepatic focal lesion SBP: Spontaneous bacterial peritonitis.  NSAIDS: non-steroidal anti-inflammatory drugs.

Table (3): Type of preoperative preparation and urgent intraoperative measures and postoperative ICU admission in patients who undergo surgery groups.

ICU: Intensive Care Units UGI: upper gastrointestinal series

Table (4): Post-operative laboratory changes in comparison to pre- operative basic findings of studies groups.

Hb: hemoglobin, TLC: total leucocyte count, AST: aspartate aminotransferase, INR: international normalized ratio, PLT: platelets, ALT: Alanine transaminase, Paired t test used to compare laboratory investigations pre and post operation among patients and control group t: independent t test *significant 

S. Table (4): Intraoperative measures and postoperative ICU admission in patients undergoing surgery regarding operation urgency type.

ICU: Intensive Care Unit X² chi -squared test *significant

Table (5): Comparison between survived and died patients regarding preoperative data in cirrhotic group.

*: Chi-square test; •: Independent t-test; ‡: Mann Whitney test

Table (6): Validity (AUC, sensitivity, specificity) of some parameters (TLC, serum creatinine, serum albumin and MELD score) to discriminate between different groups.

TLC: total leucocyte count

DISCUSSION

Cirrhosis is caused by various liver injury mechanisms that result in necro-inflammation and fibrogenesis. Histologically, it is identified by diffuse nodular regeneration surrounded by dense fibrotic septa which significantly distorts the hepatic vascular architecture. This results in portal hypertension and in hepatic synthetic dysfunction. Clinically, cirrhosis has been considered an end-stage disease that results in death, unless liver transplantation is done, the only prophylactic measures have been esophageal varices screenings and hepatocellular carcinoma screenings [11].

As the incidence of CLD and cirrhosis increases, more cirrhosis patients are undergoing surgery of various kinds. It is generally known that after surgery, individuals with underlying CLD experience higher rates of morbidity and mortality than those without. Surgery-related and anesthesia-related problems are more likely to occur in patients with liver disease than in those with a healthy liver [12]. There are a number of factors that contribute to poor outcomes in patients with advanced liver disease after surgery, including the fact that cirrhosis is linked to an increased output and hyperdynamic circulation, as well as a decreased hepatic perfusion that may be vulnerable to hypoxemia and hypotension related to the anesthesia [13].

Cirrhosis has 2 distinct phases: compensated and decompensated. The decompensated state of cirrhosis is characterized by the presence of its consequences, including variceal bleeding, HE, ascites, SBP, HCC, hepatopulmonary syndrome (HPS), and hepatorenal syndrome (HRS), characterizes the decompensated state of the cirrhosis [11]. Patients with impaired liver function are known to experience decompensatory effects from anesthesia and surgery.

In spite of being known that general anesthesia reduces the arterial blood flow to liver and increases the risk of ischemic injury, spinal or epidural anesthesia may also lower mean arterial pressure, which is problematic in cirrhotic patients who already have hyperdynamic circulation as a result of peripheral vasodilatation. As coagulopathy or thrombocytopenia is present, these approaches are not preferred because of the increased risk of bleeding. Consequently, for these patients, general anesthesia may represent the preferred option [14].

In our study, we aimed to assess the surgical risk for patients with liver cirrhosis and to identify numerous variables that would influence how successfully these patients would respond to surgery.  231 participants underwent non hepatic surgery under general anesthesia. 231 individuals in this study underwent non-hepatic surgery while under general anesthesia. Their preoperative assessment of their readiness for surgery, as well as the intra operative outcome after surgery were all part of their workup.

In this work we noticed that only 12.8% of the cirrhotic patients who had surgery had a Child Pugh score of C, making the majority of them either Child Pugh score A or B, representing 42.7% and 44.5% respectively. These results were in line with those of del Olmo and his colleagues, in their study on non-hepatic surgery on 135 cirrhotic patients, reported that the degree of liver dysfunction before operation was evaluated as Child-Pugh grade A in 83 patients, B in 41 patients, and C in 11 patients [15].

Although there were statistically non-significant differences between the cirrhotic and non-cirrhotic groups in the current study for patients who had or had not undergone surgery (p>0.05), there was nevertheless a trend for cirrhotic patients to be non-operated. We found that hepatic causes predominate in Child B and C, whereas non-hepatic causes predominate in patients with Child A cirrhosis.

Comparing the preoperative preparation of cirrhotic and non-cirrhotic patients, the current study found that 40.20% of the cirrhotic group required plasma transfusion and 7.84% required platelet transfusion, while, none of the non-cirrhotic group did. According to Keegan and Plevak, coagulopathy and thrombocytopenia should be treated with vitamin K replenishment, fresh-frozen plasma (FFP) administration, and possibly cryoprecipitate transfusions in order to reduce prothrombin times to within 3 seconds of normal values platelet counts should be greater than 50,000/mm³ [16].

Additionally, this study also revealed that only cirrhotic patients required intra-operative plasma and platelet transfusion, and that there was a statistically significant difference between the cirrhotic and non-cirrhotic groups in terms of the need for post-operative ICU admission and intra-operative blood transfusions.

Cirrhotic patients' hemostasis changes are complex. Cirrhosis impacts procoagulant and anticoagulant levels [17]. Further complicating the matter is the lack of routine diagnostics to determine how cirrhosis affects anticoagulant levels. Because of this, assessing the impact on procoagulants only and showing a higher INR in a patient with cirrhosis do not indicate an increased risk of bleeding in these patients. However, use of INR is still a frequent practice in the absence of a suitable test to assess changes in hemostasis in patients with cirrhosis [14].

A cutting- novel technique called thromboelastography evaluates all the stages of clot lysis and formation. When accessible, it should be used since it assesses the blood clotting process' viscoelastic characteristics. It can accurately determine which blood product should be used based on the lack of various components involved in the formation of blood clots [18]. It has been demonstrated to lower the procedure's need for unnecessary transfusions and the complications that go along with it without raising bleeding complications. Fresh frozen plasma (FFP) is frequently utilized to reduce increased INR when thromboelastography is not available [19].

Furthermore, thrombocytopenia is typical in cirrhotic patients. The suggested mechanisms include enhanced destruction by hypersplenism and decreased thrombopoietin synthesis, which stimulates the production of platelets in the bone marrow. If the platelet count is less than 50000/mm³, a prophylactic platelet transfusion is recommended before surgery [20].

Additionally, cirrhotic patients received pre-operative care that included nutritional supplementation, hepatic encephalopathy management, and ascites correction. We noticed that optimal management of ascites reduced certain postoperative complications such as recurrence of an umbilical hernia. Similarly, Abbas et al. have cautioned that surgical procedures that were previously prohibited due to ascites may become achievable in some cirrhotic patients and that pharmacological management of ascites may improve the CTP class [14].

We paid close attention to any preexisting infections during the preoperative assessment and appropriately treated them. According to a previous study, Douard et al. found that cirrhotic patients with undetected and untreated infections had higher rates of morbidity and mortality following the same surgery than non-cirrhotic patients [21].

In this study, post-operative mean values of TLC, blood urea, and serum creatinine were significantly higher than pre-operative mean values, whereas post-operative mean values of serum albumin and serum Na were significantly lower, however, no significant changes were noted regarding liver functions in non-cirrhotic group. In accordance with the findings of Ziser et al. According to their findings, 20% of cirrhotic patients had worsening hepatic functions, and some of them experienced decompensation of liver cirrhosis that was not evident prior to surgery [22].

In the current study, we noticed a substantial difference between patients who received elective and emergency surgeries in the cirrhotic group, with elective surgeries showing more frequent complications and only emergency surgeries revealing post-operative death. Only emergency procedures were linked to post-operative mortality in non-cirrhotic patients, however, where there was a statistically non-significant difference between elective and emergency operations regarding post-operative morbidity. Prior research has shown that patients with cirrhosis who require emergency surgery have a higher risk of morbidity and mortality unless they receive the appropriate preoperative management and care [23].

Regarding the Child-Turcotte-Pugh grading, we observed a non-significant difference between survived dead and dead patients, However, dead patients only belonged to Child Pugh Grades B or C. Earlier analyses have shown less of an association between the Child-Pugh class and surgical outcomes [24]. Perhaps this is attributed to the small number of patients with Child-Pugh class C cirrhosis who were included in trials to avoid surgery in patients with decompensated cirrhosis and prefer conservative therapy whenever possible.

In the current study, patients who survived and those who died were compared based on preoperative data from the cirrhotic group. We noticed that the dead patient had a significantly higher serum creatinine, total leucocyte count, and MELD score together with a considerable lower serum albumin. This is closely similar to previous studies that have reported that the MELD score has largely replaced the use of the CTP score for surgical risk stratification due to the somewhat subjective nature of estimating the severity of ascites and encephalopathy. The MELD score incorporates the objective liver function-dependent components of the CTP score which have been found to be predictive of outcomes [25, 26].

CONCLUSION

Hepatic and non-hepatic complications are common in cirrhotic patients including decompensation. Cirrhotic patients had considerable higher morbidity and mortality rates than controls, in both groups emergent operations are associated with undesirable outcomes. Cirrhotic patients need distinctive perioperative care. Optimal perioperative care could decease such complications. Correction of coagulopathy, care for preexisting encephalopathy, management of ascites, avoidance of sepsis, and optimizing kidney function should all be part of preoperative preparation‎‎.

Abbreviations

ALT: Alanine transaminase, AST: Aspartate aminotransferase, CTP; Child-Turcotte-Pugh, HBV: Hepatitis B virus, HCV: Hepatitis C virus, INR: International normalized ratio, MELD: Model for End-Stage Liver Disease, SBP: Spontaneous bacterial peritonitis,      

Disclosure

Ethics approval and consent to participate

Before being enrolled in this study, all participants were given a description of the study and given the opportunity to give their informed consent. The study was carried out after approval from the ethical committee, Faculty of Medicine, Menoufia University and per the Declaration of Helsinki.

Consent for publication

Not applicable.

Availability of data and material

All data generated or analyzed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding       

The study was fully non-funded from any organization.

Authors' contributions

All authors contributed significantly to the work reported, whether it be in the ideation, study design, implementation, data collection, analysis, and interpretation, or in all of these areas. They also participated in writing, revising, or critically evaluating the article, gave their final approval for the version to be published, decided on the journal to which the article has been submitted, and agreed to be responsible for all aspects of the work.

Acknowledgements

Not applicable.