Related Experiment Video
Updated: Sep 5, 2025
Author Spotlight: Advancing Liver Regeneration Research through ALPPS Mouse Model
Published on: January 19, 2024
Surgical Risk Assessment in Patients with Chronic Liver Diseases
Shekhar S Jadaun1, Sanjiv Saigal1
1Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India.
Insights
Patients with chronic liver disease (CLD) face increased surgical risks due to cirrhosis and portal hypertension. Preoperative assessment using tools like MELD and CTP scores is crucial for safe surgical management.
Area of Science:
- Hepatology
- Surgical Risk Assessment
- Anesthesiology
Background:
- Chronic liver diseases (CLD) are a leading cause of mortality, with increasing lifespans leading to more surgeries in affected patients.
- Cirrhosis and associated hemodynamic changes increase surgical risks, including hypotension, hypoxia, liver injury, and renal dysfunction.
- Preoperative evaluation for clinically significant portal hypertension and cirrhosis is essential for risk stratification.
Purpose of the Study:
- To outline the preoperative risk assessment and management strategies for patients with CLD undergoing surgery.
- To review available risk assessment tools and their applicability in surgical decision-making.
- To highlight perioperative considerations and optimization for high-risk surgical candidates with CLD.
Main Methods:
- Review of existing literature and risk assessment tools for CLD patients undergoing surgery.
- Evaluation of surgical risk stratification based on disease severity (cirrhosis, portal hypertension) and specific procedures.
- Discussion of perioperative management and optimization strategies.
Main Results:
- Patients without cirrhosis or significant portal hypertension have minimal surgical risk.
- Advanced CLD with Child class C or Mayo risk score >15 indicates high risk, often warranting deferral of elective surgery.
- Risk stratification tools like CTP, MELD, and Mayo scores guide surgical permissibility, with newer tools like VOCAL-Penn showing promise.
Conclusions:
- Detailed preoperative assessment is vital for CLD patients undergoing surgery.
- Risk stratification using validated scores helps determine surgical candidacy and optimize outcomes.
- Multidisciplinary perioperative management is crucial for preventing complications like liver decompensation and failure.
Abstract:
Chronic liver diseases (CLD) is one of the leading causes of morbidity and mortality. The overall life span of patients with CLD has increased and so is the number of surgical procedures these patients undergo. Pathophysiological and hemodynamic changes in cirrhosis make these patients more susceptible to hypotension and hypoxia during surgery. They also have a high risk of drug induced liver injury, renal dysfunction and post-operative liver decompensation. Patients with CLD planned for elective or semi-elective surgery should undergo detailed preoperative risk assessment. Patients should be evaluated for the presence of clinically significant portal hypertension and cirrhosis. In the absence of both cirrhosis and clinically significant portal hypertension, patients with CLD can undergo surgery with minimal or low risk. Various risk assessment tools available for patients with advanced CLD are-CTP score, MELD Score, Mayo risk score, VOCAL-Penn score. A Child class C and/or Mayo risk score >15 in general is associated with high risk of post-operative mortality and elective surgery should be deferred in these patients. In patients with Child class, A and MELD 10-15 surgery is permissible with caution (except liver resection and cardiac surgery) while in Child A and MELD <10 surgery is well tolerated. VOCAL-Penn score is a new promising tool and can be the better alternative of CTP, MELD, and Mayo risk score models but more prospective studies with large patients' population are warranted. Certain surgeries like Hepatic resection, intraabdominal, and cardiothoracic have higher risk than abdominal wall hernia repair and orthopedic surgery. Laparoscopic approaches have better outcomes and less risk of liver failure than open surgery. Minimally invasive alternatives like colonic stent placement in case of obstruction can be considered in high-risk cases. Perioperative optimization and management of ascites, HE, bleeding, liver decompensation, and nutrition should be done with multidisciplinary approach. Patients with cirrhosis undergoing high risk elective surgery can develop liver failure in post-operative period and should be evaluated and counseled for liver transplantation if not contraindicated.
