**5. Preoperative care of patients with liver disease [28-48]**

#### **5.1. Aims**


#### **5.2. Complications of liver diseases**


**8.** Malnutrition

**4.4. Type of surgery**

10 Recent Advances in Liver Diseases and Surgery

hepatic function.

cirrhosis.

**5.1. Aims**

The operative risk is higher with certain types of surgery, such as hepatic resection, biliary

**Emergency surgery** carries higher mortality in hepatic patients than patients with normal

**Abdominal surgery** as cholecystectomy, gastric bypass, biliary procedures, peptic ulcers, and colon resection is associated with increased morbidity and mortality risks in patients with

**Biliary tract surgery:** Patients with obstructive jaundice have increased risk of infections, disseminated intravascular coagulation, gastrointestinal bleeding, delayed wound healing, wound dehiscence, incisional hernias, and renal failure. Patients with cirrhosis are at increased risk of gallstones and their complications. For Child class C patients, cholecystostomy, rather than cholecystectomy, is considered. For patients with obstructive jaundice, nonsurgical approaches to decompression via endoscopic retrograde cholangiopancreatography or

**Cardiac Surgery**: Procedures that require cardiopulmonary bypass are associated with greater

**Hepatic Resection:** Hepatectomies in cirrhotic patients are associated with increased risks. The

surgery, gastric surgery, colectomy, and cardiac surgery.

percutaneous transhepatic cholangiography are preferred.

**5. Preoperative care of patients with liver disease [28-48]**

extent of hepatectomy is a predictor of mortality.

**1.** Prophylactic measures to prevent complications

**2.** Early recognition and treatment of complications

mortality in patients with cirrhosis.

**5.2. Complications of liver diseases**

**2.** Spontaneous bacterial peritonitis (SBP)

**3.** Fluid and electrolyte disturbances

**7.** Hepatocellular carcinoma (HCC)

**4.** Hepatorenal syndrome (HRS) **5.** Portal hypertensive bleedings **6.** Hepatic encephalopathy (HE)

**1.** Refractory ascites

**9.** Progress of other medical diseases

#### **5.3. Tests to assess the complications of liver disease**


Particular attention needs to be paid to the management of common complications of advanced liver disease, as coagulopathy, thrombocytopenia, ascites, renal insufficiency, encephalopathy, and malnutrition, as well as to disease-specific factors.

#### **5.4. Coagulopathy**

The cause of coagulopathy is multifactorial. It may result from poor absorption of vitamin K due to cholestasis or impaired synthesis of coagulation factors.


#### **5.5. Ascites**

Grades of ascites:

Grade 1: ascites only detected by ultrasound

Grade 2: moderate with symmetrical distention of the abdomen

Grade 3: large or tense with marked abdominal distension


*Refractory ascites* is that which is unresponsive to high-dose diuretics and a Na-restricted diet and tends to rapidly recur following paracentesis. Prior to labeling a patient as having refractory ascites, an in-hospital trial of dietary management and diuretic therapy should be attempted.

Treatment options include the following:

	- **•** For large volume paracentesis, an albumin infusion of 8-10 g/L of fluid removed should be considered.
	- **•** Paracentesis increases the risk of peritonitis.
	- **•** Cases where the frequency of paracentesis is >3 times/month
	- **•** Patients not tolerating large-volume paracentesis
	- **•** Large-volume paracentesis is ineffective due to multiple adhesions or loculated ascites
	- **•** Refractory hepatic hydrothorax

The major disadvantages are shunt stenosis and HE.


#### **5.6. Spontaneous bacterial peritonitis**

*Definition:* infection of the ascitic fluid in the absence of any known intra-abdominal source.

*Diagnosis:* positive ascites culture and/or polymorphonuclear cell count ≥25 0 cells/mm<sup>3</sup> .

Its prevalence justifies diagnostic paracentesis in cirrhotics with ascites admitted to the hospital. Norfloxacin (400 mg/day) significantly reduces the probability of SBP.

Secondary long-term prophylaxis is recommended for all patients with a history of SBP. Antibiotic prophylaxis is recommended in patients with an upper GI bleed irrespective of the presence or absence of ascites.

#### **5.7. Renal impairment**

**•** The usual regimen is a single morning dose of 100 mg spironolactone and 40 mg furosemide. The dose can be increased every 3-5 days, if weight loss is not satisfactory. Maximum doses

**•** Side effects include volume depletion, which may precipitate encephalopathy, or renal

**•** Weekly monitoring of electrolytes and weight must be undertaken when initiating or

**•** Encephalopathy, serum Na <125 mmol/L, creatinine >1.7mg/dL, should lead to cessation of

*Refractory ascites* is that which is unresponsive to high-dose diuretics and a Na-restricted diet and tends to rapidly recur following paracentesis. Prior to labeling a patient as having refractory ascites, an in-hospital trial of dietary management and diuretic therapy should be

**1.** Paracentesis with albumin replacement remains the first treatment option for patients on

**•** For large volume paracentesis, an albumin infusion of 8-10 g/L of fluid removed should

**•** Large-volume paracentesis is ineffective due to multiple adhesions or loculated ascites

*Definition:* infection of the ascitic fluid in the absence of any known intra-abdominal source.

Its prevalence justifies diagnostic paracentesis in cirrhotics with ascites admitted to the

.

*Diagnosis:* positive ascites culture and/or polymorphonuclear cell count ≥25 0 cells/mm<sup>3</sup>

hospital. Norfloxacin (400 mg/day) significantly reduces the probability of SBP.

the waiting list and are likely to undergo LT within a few months.

**•** Cases where the frequency of paracentesis is >3 times/month

are 600 mg/day spironolactone and 200 mg/day furosemide.

failure.

changing therapy.

12 Recent Advances in Liver Diseases and Surgery

Treatment options include the following:

**2.** TIPS is considered for the following:

**•** Refractory hepatic hydrothorax

**4.** Surgical shunts are rarely indicated

**5.6. Spontaneous bacterial peritonitis**

The major disadvantages are shunt stenosis and HE. **3.** Peritoneovenous shunt: for historical interest only

**•** Paracentesis increases the risk of peritonitis.

**•** Patients not tolerating large-volume paracentesis

be considered.

diuretic use.

attempted.

Patients with ESLD are at increased risk to develop renal failure (RF), either spontaneously (hepatorenal syndrome [HRS]) or iatrogenically (diuretics, nephrotoxic drugs). Preoperative renal function significantly affects postoperative survival.

HRS can only be diagnosed after other causes of renal failure are excluded: obstruction, volume depletion, ATN, and drug-induced nephrotoxicity. All diuretics should be stopped. Fluid challenge with 1.5 L of isotonic saline should be administered to exclude volume depletion.

#### *5.7.1. Types of HRS*

**Type I HRS**: rapidly progressive renal failure with an increase in the serum creatinine to more than 2.5 mg/dL within 14 days and marked oliguria.

**Type II HRS:** stable or slowly progressive impairment in renal function in patients with refractory ascites.

#### *Management:*

	- **•** vasoconstrictor drugs, such as vasopressin analogues, noradrenalin, and the combina‐ tion of midodrine and octreotide together,
	- **•** plasma volume expansion with albumin (1 g/kg intravenously on day 1, 20-40 daily thereafter).

*Hemodialysis* as a bridge to liver transplant might be useful in patients who fail to respond to medical treatment.

*Nephrotoxic drugs* should be used with cautious, and overtreatment with diuretics should be avoided. It is recommended to stop diuretics if serum creatinine is >1.7 mg/dL.

#### **5.8. Dilutional hyponatremia**

*Definition:* Serum sodium <130 mmol/L.

*Cause:* impaired free water clearance by the kidneys due to nonosmotic hypersecretion of ADH.


#### *Management*

	- **1.** Diuretics should be stopped.
	- **2.** Infusion of albumin (100 g/24 h) or red blood cells is instituted attempting at expanding the effective circulating blood volume.

Na level will increase as a result of turning off ADH secretion by the increased blood volume. Once the serum sodium starts to rise, the albumin infusion is tapered.


#### **5.9. Hepatic Encephalopathy (HE)**

HE is a diagnosis of exclusion. Other etiologies as space-occupying lesions, vascular events, metabolic disorders, and infectious diseases should be excluded.

#### *Stages of hepatic encephalopathy*


#### *Precipitating factors*


#### *Therapy*


**3.** Nasogastric tube should be placed.

*Management*

**1.** Diuretics should be stopped.

14 Recent Advances in Liver Diseases and Surgery

**3.** Free water restriction.

**5.9. Hepatic Encephalopathy (HE)**

**3.** Confusion, reactive only to vocal stimuli

**1.** Renal and electrolyte abnormalities

**6.** Excessive dietary protein intake

**5.** Benzodiazepines, narcotics, or other sedatives

**7.** Worsening liver function, e.g., portal vein thrombosis **8.** Noncompliance with medications, especially lactulose

**1.** The mainstay is correcting the precipitating event.

**2.** Gastrointestinal bleeding

*Stages of hepatic encephalopathy* **1.** Slowing of consciousness

**2.** Drowsiness

*Precipitating factors*

**4.** Coma

**3.** Infection

*Therapy*

**4.** Constipation

sciousness.

the effective circulating blood volume.

metabolic disorders, and infectious diseases should be excluded.

**•** As long as the serum Na remains >125 mmol/L, no specific measures are required.

**•** Attempts to rapid correction with hypertonic saline can lead to more complications.

HE is a diagnosis of exclusion. Other etiologies as space-occupying lesions, vascular events,

**2.** Intubation has to be considered to prevent aspiration, depending on the level of con‐

**2.** Infusion of albumin (100 g/24 h) or red blood cells is instituted attempting at expanding

Na level will increase as a result of turning off ADH secretion by the increased blood volume. Once the serum sodium starts to rise, the albumin infusion is tapered.

**•** If the serum Na level is <125 mmol/L, the following should be considered:


#### **5.10. Portopulmonary Hypertension (PPHTN)**

*Definition:* portal hypertension (clinical diagnosis), mean pulmonary artery pressure (MPAP) >25 mm Hg, pulmonary artery occlusion pressure (PAOP) 15< mm Hg**,** pulmonary vascular resistance (PVR) >240 dyne/s/cm−5.

The detection of PPHTN is crucial as it increases the perioperative and long-term risks.

The most common presenting symptom is progressive dyspnea on excretion; however, patients with even severe PPHTN can be completely asymptomatic. Echocardiography is the screening method of choice. A systolic right ventricular pressure (RVsys) of >50 mm Hg as a cutoff is used. Only these patients need to undergo right heart catheterization to characterize pulmonary hemodynamics.

#### **5.11. Hepatopulmonary syndrome**

This is defined as a triad of the following:


Hypoxemia at rest is the prerequisite for the diagnosis. Medical management is disappointing, and liver transplant is advocated as the treatment of choice.

#### **5.12. Malnutrition**

Malnutrition is common with liver impairment and is a risk factor for mortality following LT. Nutritional supplementation has not been proven to affect outcome. The total amount of calories provided should be at least 30-35 kcal/kg/day. Adults can receive daily 1-2 g protein/ kg of dry body weight. Patients should take daily multivitamin and other supplements as needed. Specific fat-soluble vitamin supplements are provided if a deficiency is present.

#### **5.13. Psychosocial stress**

The preoperative period can be extremely stressful. Declining health, uncertainty about the results, and inability to continue working and participating in daily activities may increase the risk of depression and/or anxiety. Patients with chronic HCV have a greater incidence of depression and anxiety. Patients who experience significant psychological distress have increased complications.
