Patients with cirrhosis have a greater risk of morbidity and mortality following colorectal surgery. Therefore, preoperative medical optimization and risk assessment using criteria such as the MELD score are vital in preventing complications. Some risk factors include age, urgency of surgery, and ASA score. Postoperative morbidity and mortality are related to portal hypertension, ascites, infection, and anastomotic and stomal complications. This review highlights the assessment of risk and perioperative management of cirrhotic patients undergoing colorectal surgery.
Gad EH, et al. Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study. Ann Med Surg (Lond). 2020 Jan 15;51:1-10. Free full-text.
Results: The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.
Conclusion: LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.Continue reading
One discussion this week involved the impact of the Child-Pugh scoring system. A special thank you to Dr. Sellers for providing the wealth of original documents for this post. We love hearing you talk about liver disease and portal hypertension!
Cheung A., Cheung A. The Child-Pugh score: prognosis in chronic liver disease and cirrhosis [Classics Series]. 2 Minute Medicine, The Classics in Medicine: Summaries of the Landmark Trials. 2013 Jul 16. Retrieved May 17, 2019 from https://www.2minutemedicine.com
Garrison RN, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Annals of Surgery. 1984 Jun;199(6):648-655.
Malinchoc M, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000 Apr;31(4):864-871.
Mansour A, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997 Oct;122(4):730-735. discussion 735-736.
Pugh RN, et al. Transection of the oesophagus for bleeding oesophageal varices. The British Journal of Surgery. 1973 Aug;60(8):646-649.
Teh SH, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007 Apr;132(4):1261-1269.
Summary: The Child-Pugh score consists of five clinical features and is used to assess the prognosis of chronic liver disease and cirrhosis. It was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices. It has since been modified, refined, and become a widely used tool to assess prognosis in patients with chronic liver disease and cirrhosis.
The score considers five factors, three of which assess the synthetic function of the liver (i.e., total bilirubin level, serum albumin, and international normalized ratio, or INR) and two of which are based on clinical assessment (i.e., degree of ascites and degree of hepatic encephalopathy). Critics of the Child-Pugh score have noted its reliance on clinical assessment, which may result in inconsistency in scoring. Others have suggested that its broad classifications of disease are impractical when determining priority for liver transplantation; nevertheless, it remains widely used.
In their 1997 study, Mansour et al found the mortality in Child’s class A was 10%, compared to 30% in Class B and 82% in Class C patients.
The Model for End-Stage Liver Disease (MELD) is a newer scoring system that has been developed to address some of the concerns with the Child-Pugh score, and the two systems are often used in conjunction to determine liver transplantation priority.
The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. In determining the risk factors for postoperative mortality in patients with cirrhosis, Teh et al (2007) found that only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, <8) to more than 50% (MELD score, >20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period.