**4. Assessment of the risk factors**

#### **4.1. Severity and nature of the underlying liver disease**

Operative risks are markedly influenced by the severity and nature of the underlying liver disease.

**Obstructive jaundice:** Obstructive jaundice markedly increases perioperative mortality.

**Acute hepatitis:** Acute hepatitis is associated with increased morbidity and mortality associ‐ ated with surgery.

**Cirrhosis:** The perioperative risk is influenced by the degree of hepatic dysfunction, portal hypertension, and its complications as ascites, intra-abdominal varices, renal impairment, and portopulmonary hypertension.

The amount of perioperative risks is related to the degree of liver decompensation. An accurate assessment of the degree of liver decompensation is important for determination of the perioperative risk.

#### **4.2. Child's classification and its modifications**

This is based on the patient's serum bilirubin and albumin levels, prothrombin time, and severity of encephalopathy and ascites.


In general, elective surgery is well tolerated in patients with Child class A, permitted with careful preoperative preparation in patients with Child class B, and contraindicated in patients with Child class C.


Other factors can also increase the perioperative risk beyond the Child classification. The perioperative risk is increased if there is portal hypertension. Emergency surgery is associated with a higher mortality rates.

Child score for estimating the perioperative risks has been shown to be quite variable. This may be explained by the following:


For this reason, alternative systems have been sought

#### **4.3. Model for end-stage liver disease (MELD) score**

The MELD score is a linear regression model based on a patient's serum bilirubin and creatinine levels and international normalized ratio (INR).

#### *4.3.1. MELD scoring equation*

When surgery is mandatory, meticulous perioperative management is required, including hemodynamic stability, broad-spectrum antibiotics, correction of coagulopathy, improvement of nutritional status, avoidance of nephrotoxins and sedatives that could precipitate hepatic

Operative risks are markedly influenced by the severity and nature of the underlying liver

**Acute hepatitis:** Acute hepatitis is associated with increased morbidity and mortality associ‐

**Cirrhosis:** The perioperative risk is influenced by the degree of hepatic dysfunction, portal hypertension, and its complications as ascites, intra-abdominal varices, renal impairment, and

The amount of perioperative risks is related to the degree of liver decompensation. An accurate assessment of the degree of liver decompensation is important for determination of the

This is based on the patient's serum bilirubin and albumin levels, prothrombin time, and

**Points 1 2 3** Ascites None Small or diuretic controlled Tense Encephalopathy Absent States I–II States III–IV

Albumin (g/L) >3.5 2.8–3.5 <2.8 Bilirubin (mg/dL) <2 2–3 >3

> 4–6 1.7–2.3

In general, elective surgery is well tolerated in patients with Child class A, permitted with careful preoperative preparation in patients with Child class B, and contraindicated in patients

>6 >2.3

<1.7

**Obstructive jaundice:** Obstructive jaundice markedly increases perioperative mortality.

encephalopathy, and intensive care unit admission if needed.

**4.1. Severity and nature of the underlying liver disease**

**4. Assessment of the risk factors**

8 Recent Advances in Liver Diseases and Surgery

disease.

ated with surgery.

perioperative risk.

**Child–Pugh scoring system**

PT(sec above control), or INR <4

with Child class C.

portopulmonary hypertension.

**4.2. Child's classification and its modifications**

severity of encephalopathy and ascites.

MELD score for TIPS = 0.957 × loge (creatinine [mg/dL]) + 0.378 × loge (bilirubin [mg/dL]) + 1.120 × loge (INR) + 0.643 (cause of liver disease)

MELD score for liver transplantation = 0.957 × loge(creatinine [mg/dL]) + 0.378 × loge(bilirubin [mg/dL]) + 1.120 × loge(INR) + 0.643

It was created to predict mortality after TIPS, then to stratify the risks in patients awaiting liver transplant, and recently used to predict perioperative mortality. It has several distinct advantages over the Child classification, being objective, and does not rely on cutoff values.

The general guidelines are as follows:


These guidelines should be modified for specific circumstances.

### **4.4. Type of surgery**

The operative risk is higher with certain types of surgery, such as hepatic resection, biliary surgery, gastric surgery, colectomy, and cardiac surgery.

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

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

**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 percutaneous transhepatic cholangiography are preferred.

**Cardiac Surgery**: Procedures that require cardiopulmonary bypass are associated with greater mortality in patients with cirrhosis.

**Hepatic Resection:** Hepatectomies in cirrhotic patients are associated with increased risks. The extent of hepatectomy is a predictor of mortality.
