Pre-Operative Assessment of Patients with Cirrhosis for Extrahepatic Surgery

Patients with cirrhosis are at increased risk of peri-operative morbidity and mortality compared to those without cirrhosis, requiring careful pre-operative assessment of their liver disease, extra-hepatic comorbidities, and surgery-specific risk factors.

Adverse surgical outcomes in this population are often related to complications of advanced liver disease, including portal hypertension, impaired hemostasis, malnutrition/sarcopenia, and infection. Risk prediction tools, including the Child-Turcotte-Pugh score, Model for End-Stage Liver Disease score, Mayo Risk Score, and VOCAL-Penn Score, can be used to estimate post-operative mortality and support clinical decision-making when assessing surgical candidacy. Several common procedures, including hernia repair, laparoscopic cholecystectomy, and sleeve gastrectomy, are well-tolerated in appropriate candidates. Pre-procedural transplant evaluation and referral to a high-volume cirrhosis surgery center should be considered when feasible.

This review discusses the pathophysiological mechanisms underlying increased peri-operative risk in cirrhosis, the application of surgical risk scores, liver-related contraindications to surgery, and specific considerations for several common procedures.