Digestive Surgery at the Cirrhotic Patient

In chronic liver disease, the incidence of cirrhosis is increasing. About 1 million deaths from cirrhosis are reported annually by WHO, occupying the 11th position in the hierarchy of pathologies that cause death (1). The prevalence of cirrhosis is often underestimated based on the fact that one third of the patients are asymptomatic (2). Regardless of whether it is elective or urgent extra-hepatic surgery, operative interventions in this range of patients are burdened by an increased risk of perioperative morbidity and mortality (3,4). This reality requires the evaluation of the benefit-risk balance for each patient with the surgical firm indication. A journal of the medical literature, presented over the period 1995-2018 (PubMed), noted that the most frequent extrahepatic interventions in the cirrhotic patient were addressed to the cholecyst and CBD (23%), parietal defects (hernias, events) in 17 %, gastric pathology (19%) and rectum-colon (19%).v Liver cirrhosis is frequently associated with abnormalities of coagulation mechanisms: thrombopenia and platelet dysfunctions, decreased coagulation factors but also proteins involved in fibrinolysis. Cardio-circulatory changes are all the more important as the cirrhotic pathology is more evolved, being expressed by hyperkinetic syndrome and systemic vasodilation with hyper-flow, tachycardia and low peripheral resistance (5). The "trigger" element of these anomalies is the portal hypertension and the porto-systemic shunts that involve vasodilating mediators but also the compensatory activation of the renin-angiotensin system (6). The perioperative anaesthetic strategy in the patients is integrated in a multidisciplinary effort of specific management.