Outcomes of abdominal surgery in patients with liver cirrhosis

Abstract

Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and s p e c i a l i z e d a p p r o a c h c a n i m p r o v e o u t c o m e s ; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.Key words: Liver cirrhosis; Outcomes; Coagulopathy; Nutritional status; Abdominal surgery; Adaptive levels of expertise of the surgeons, anesthetists, and intensive care unit (ICU) staff. Liver function is usually assessed by the Child-Turcott-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores [11] . Early studies found 30 d mortality rates after surgery were 10% in CTP-A, 30% in CTP-B, and 76%-82% in CTP-C, figures that have not significantly changed in more recent assessments [12,13] . Despite the poor results, advances in the medical management of LC and life expectancy have increased the eligibility of these patients for abdominal surgery [14] . To be able to give definitive recommendations and indications for non-hepatic abdominal surgery in the cirrhotic population, it is important to identify the patients most likely to benefit from it. There is also a need to assess contemporary surgical techniques and the various scoring systems currently in use.This review summarizes the outcomes of patients with LC undergoing non-hepatic abdominal surgery. Indexed articles in Medline of series of patients with LC who underwent non-hepatic abdominal surgery between 1950 and March 2014 were reviewed using the OVID interface. We aimed to select manuscripts addressing outcome based on the degree of LC assessed with MELD and/or CTP scores. Articles addressing the pathophysiology of cirrhotic patients and the clinical implications in non-hepatic abdominal surgery were selected based on their importance, their date of publication, and the citations of the manuscripts. As for articles describing the different types of surgery in LC patients, the most recent publications were selected in order to preser...

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