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Surgical risk stratification in patients with cirrhosis

  • Review Article
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Abstract

Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.

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Abbreviations

PH:

Portal hypertension

ACLD:

Advanced chronic liver disease

LSM:

Liver stiffness measurement

TE:

Transient elastography

CSPH:

Clinically significant portal hypertension

HVPG:

Hepatic venous pressure gradient

AASLD:

American Association for the Study of Liver Diseases

ASA:

American Society of Anesthesiologists

CTP:

Child–Turcotte–Pugh

MELD:

Model for end-stage liver disease

TIPS:

Transjugular intrahepatic portosystemic shunt

AUC:

Area under the curve

MRS:

Mayo Risk Score

CABG:

Coronary artery bypass graft

PCI:

Percutaneous coronary intervention

HCC:

Hepatocellular carcinoma

ALBI:

Albumin–bilirubin

TEG:

Thromboelastography

ROTEM:

Rotational thromboelastometry

NSBB:

Non-selective beta blockers

ACLF:

Acute-on-chronic liver failure

References

  1. Huang DQ, Terrault NA, Tacke F, Gluud LL, Arrese M, Bugianesi E, et al. Global epidemiology of cirrhosis—aetiology, trends and predictions. Nat Rev Gastroenterol Hepatol. 2023;20(6):388–398

    Article  PubMed  PubMed Central  Google Scholar 

  2. Liu YB, Chen MK. Epidemiology of liver cirrhosis and associated complications: current knowledge and future directions. World J Gastroenterol. 2022;28(41):5910–5930

    Article  PubMed  PubMed Central  Google Scholar 

  3. Tessiatore KM, Mahmud N. Trends in surgical volume and in-hospital mortality among United States cirrhosis hospitalizations. Ann Gastroenterol. 2021;34(1):85–92

    PubMed  Google Scholar 

  4. Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative evaluation and management of patients with cirrhosis: risk assessment, Surgical Outcomes, and Future Directions. Clin Gastroenterol Hepatol. 2020;18(11):2398–2414

    Article  PubMed  Google Scholar 

  5. Neeff H, Mariaskin D, Spangenberg HC, Hopt UT, Makowiec F. Perioperative mortality after non-hepatic general surgery in patients with liver cirrhosis: an analysis of 138 operations in the 2000s using Child and MELD scores. J Gastrointest Surg. 2011;15(1):1–11

    Article  PubMed  Google Scholar 

  6. Reverter E, Cirera I, Albillos A, Debernardi-Venon W, Abraldes JG, Llop E, et al. The prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery. J Hepatol. 2019;71(5):942–950

    Article  PubMed  Google Scholar 

  7. de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C. Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959–974

    Article  PubMed  Google Scholar 

  8. Podrug K, Trkulja V, Zelenika M, Bokun T, Madir A, Kanizaj TF, et al. Validation of the new diagnostic criteria for clinically significant portal hypertension by platelets and elastography. Dig Dis Sci. 2022;67(7):3327–3332

    Article  PubMed  Google Scholar 

  9. Kaplan DE, Bosch J, Ripoll C, Thiele M, Fortune BE, Simonetto DA, et al. AASLD practice guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology. 2023. https://doi.org/10.1097/HEP.0000000000000647

    Article  PubMed  Google Scholar 

  10. Nguyen GC, Correia AJ, Thuluvath PJ. The impact of cirrhosis and portal hypertension on mortality following colorectal surgery: a nationwide, population-based study. Dis Colon Rectum. 2009;52(8):1367–1374

    Article  PubMed  Google Scholar 

  11. Merli M, Riggio O, Dally L. Does malnutrition affect survival in cirrhosis? PINC (Policentrica Italiana Nutrizione Cirrosi). Hepatology. 1996;23(5):1041–1046

    Article  CAS  PubMed  Google Scholar 

  12. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, et al. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl. 2012;18(10):1209–1216

    Article  PubMed  Google Scholar 

  13. Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther. 2020;51(1):64–77

    Article  PubMed  Google Scholar 

  14. Montano-Loza AJ, Meza-Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, et al. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2012;10(2):166–173

    Article  PubMed  Google Scholar 

  15. Mahmud N, Kaplan DE, Taddei TH, Goldberg DS. Frailty is a risk factor for postoperative mortality in patients with cirrhosis undergoing diverse major surgeries. Liver Transpl. 2021;27(5):699–710

    Article  PubMed  PubMed Central  Google Scholar 

  16. De Pietri L, Bianchini M, Montalti R, De Maria N, Di Maira T, Begliomini B, et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: a randomized, controlled trial. Hepatology. 2016;63(2):566–573

    Article  PubMed  Google Scholar 

  17. Tripodi A, Primignani M, Mannucci PM, Caldwell SH. Changing concepts of cirrhotic coagulopathy. Am J Gastroenterol. 2017;112(2):274–281

    Article  PubMed  Google Scholar 

  18. Garrison RN, Cryer HM, Howard DA, Polk HC Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg. 1984;199(6):648–655

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. del Olmo JA, Flor-Lorente B, Flor-Civera B, Rodriguez F, Serra MA, Escudero A, et al. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg. 2003;27(6):647–652

    Article  PubMed  Google Scholar 

  20. Alvaro D, Caporaso N, Giannini EG, Iacobellis A, Morelli M, Toniutto P, et al. Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia. Eur J Clin Investig. 2021;51(6):e13508

    Article  Google Scholar 

  21. O’Leary JG, Greenberg CS, Patton HM, Caldwell SH. AGA clinical practice update: coagulation in cirrhosis. Gastroenterology. 2019;157(1):34-43.e1

    Article  PubMed  Google Scholar 

  22. Tripodi A, Primignani M, Chantarangkul V, Clerici M, Dell’Era A, Fabris F, et al. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology. 2006;44(2):440–445

    Article  CAS  PubMed  Google Scholar 

  23. Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status—historical perspectives and modern developments. Anaesthesia. 2019;74(3):373–379

    Article  CAS  PubMed  Google Scholar 

  24. Teh SH, Nagorney DM, Stevens SR, Offord KP, Therneau TM, Plevak DJ, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132(4):1261-1269F

    Article  PubMed  Google Scholar 

  25. Canillas L, Pelegrina A, Colominas-González E, Salis A, Enríquez-Rodríguez CJ, Duran X, et al. Comparison of surgical risk scores in a European cohort of patients with advanced chronic liver disease. J Clin Med. 2023;12(18):6100

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sato M, Tateishi R, Yasunaga H, Horiguchi H, Matsui H, Yoshida H, et al. The ADOPT-LC score: a novel predictive index of in-hospital mortality of cirrhotic patients following surgical procedures, based on a national survey. Hepatol Res. 2017;47(3):E35–E43

    Article  PubMed  Google Scholar 

  27. Northup PG, Friedman LS, Kamath PS. AGA clinical practice update on surgical risk assessment and perioperative management in cirrhosis: expert review. Clin Gastroenterol Hepatol. 2019;17(4):595–606

    Article  PubMed  Google Scholar 

  28. Kalo E, George J, Read S, Majumdar A, Ahlenstiel G. Evolution of risk prediction models for post-operative mortality in patients with cirrhosis. Hepatol Int. 2023;17(3):542–545

    Article  PubMed  Google Scholar 

  29. Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child–Turcotte–Pugh classification in predicting outcome. Arch Surg. 2005;140(7):650–654

    Article  PubMed  Google Scholar 

  30. Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for end-stage liver disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg. 2005;242(2):244–251

    Article  PubMed  PubMed Central  Google Scholar 

  31. Farnsworth N, Fagan SP, Berger DH, Awad SS. Child–Turcotte–Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. Am J Surg. 2004;188(5):580–583

    Article  PubMed  Google Scholar 

  32. Fleming MM, Liu F, Zhang Y, Pei KY. Model for end-stage liver disease underestimates morbidity and mortality in patients with ascites undergoing colectomy. World J Surg. 2018;42(10):3390–3397

    Article  PubMed  Google Scholar 

  33. Kim WR, Mannalithara A, Heimbach JK, Kamath PS, Asrani SK, Biggins SW, et al. MELD 3.0: the model for end-stage liver disease updated for the modern era. Gastroenterology. 2021;161(6):1887-1895.e4

    Article  PubMed  Google Scholar 

  34. Kim WR, Biggins SW, Kremers WK, Wiesner RH, Kamath PS, Benson JT, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med. 2008;359(10):1018–1026

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Kim SY, Yim HJ, Park SM, Kim JH, Jung SW, Kim JH, et al. Validation of a Mayo post-operative mortality risk prediction model in Korean cirrhotic patients. Liver Int. 2011;31(2):222–228

    Article  PubMed  Google Scholar 

  36. Mahmud N, Fricker Z, Serper M, Kaplan DE, Rothstein KD, Goldberg DS. In-Hospital mortality varies by procedure type among cirrhosis surgery admissions. Liver Int. 2019;39(8):1394–1399

    Article  PubMed  PubMed Central  Google Scholar 

  37. Mahmud N, Fricker Z, Hubbard RA, Ioannou GN, Lewis JD, Taddei TH, et al. Risk prediction models for post-operative mortality in patients with cirrhosis. Hepatology. 2021;73(1):204–218

    Article  PubMed  Google Scholar 

  38. Mahmud N, Fricker Z, Panchal S, Lewis JD, Goldberg DS, Kaplan DE. External validation of the VOCAL-Penn cirrhosis surgical risk score in 2 large. Independent Health Syst Liver Transpl. 2021;27(7):961–970

    Article  Google Scholar 

  39. Chang J, Hoffstall S, Gödiker J, Lehmann J, Schwind L, Lingohr P, et al. Surgical site infections are independently associated with the development of postoperative acute-on-chronic liver failure in liver cirrhosis. Liver Transpl. 2023;29(9):928–939

    Article  PubMed  Google Scholar 

  40. Mahmud N, Fricker Z, Lewis JD, Taddei TH, Goldberg DS, Kaplan DE. Risk prediction models for postoperative decompensation and infection in patients with cirrhosis: a veterans affairs cohort study. Clin Gastroenterol Hepatol. 2022;20(5):e1121–e1134

    Article  PubMed  Google Scholar 

  41. Andraus W, Pinheiro RS, Lai Q, Haddad LBP, Nacif LS, D’Albuquerque LAC, et al. Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality. BMC Surg. 2015;15:65

    Article  PubMed  PubMed Central  Google Scholar 

  42. Petro CC, Haskins IN, Perez AJ, Tastaldi L, Strong AT, Ilie RN, et al. Hernia repair in patients with chronic liver disease—a 15-year single-center experience. Am J Surg. 2019;217(1):59–65

    Article  PubMed  Google Scholar 

  43. Adiamah A, Crooks CJ, Hammond JS, Jepsen P, West J, Humes DJ. Mortality following elective and emergency colectomy in patients with cirrhosis: a population-based cohort study from England. Int J Colorectal Dis. 2022;37(3):607–616

    Article  PubMed  Google Scholar 

  44. Carbonell AM, Wolfe LG, DeMaria EJ. Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. Hernia. 2005;9(4):353–357

    Article  PubMed  Google Scholar 

  45. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT. Umbilical herniorrhapy in cirrhosis: improved outcomes with elective repair. J Gastrointest Surg. 2008;12(4):675–681

    Article  PubMed  Google Scholar 

  46. Cho SW, Bhayani N, Newell P, Cassera MA, Hammill CW, Wolf RF, et al. Umbilical hernia repair in patients with signs of portal hypertension: surgical outcome and predictors of mortality. Arch Surg. 2012;147(9):864–869

    Article  CAS  PubMed  Google Scholar 

  47. Oh HK, Kim H, Ryoo S, Choe EK, Park KJ. Inguinal hernia repair in patients with cirrhosis is not associated with increased risk of complications and recurrence. World J Surg. 2011;35(6):1229–1233

    Article  PubMed  Google Scholar 

  48. Mahmud N, Goldberg DS, Abu-Gazala S, Lewis JD, Kaplan DE. Modeling optimal clinical thresholds for elective abdominal hernia repair in patients with cirrhosis. JAMA Netw Open. 2022;5(9): e2231601

    Article  PubMed  PubMed Central  Google Scholar 

  49. Cucinotta E, Lazzara S, Melita G. Laparoscopic cholecystectomy in cirrhotic patients. Surg Endosc. 2003;17(12):1958–1960

    Article  CAS  PubMed  Google Scholar 

  50. Delis S, Bakoyiannis A, Madariaga J, Bramis J, Tassopoulos N, Dervenis C. Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child–Pugh classification in predicting outcome. Surg Endosc. 2010;24(2):407–412

    Article  PubMed  Google Scholar 

  51. Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003;197(6):921–926

    Article  PubMed  Google Scholar 

  52. Laurence JM, Tran PD, Richardson AJ, Pleass HC, Lam VW. Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials. HPB (Oxford). 2012;14(3):153–161

    Article  PubMed  Google Scholar 

  53. de Goede B, Klitsie PJ, Hagen SM, van Kempen BJ, Spronk S, Metselaar HJ, et al. Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis. Br J Surg. 2013;100(2):209–216

    Article  PubMed  Google Scholar 

  54. James TW, Krafft M, Croglio M, Nasr J, Baron T. EUS-guided gallbladder drainage in patients with cirrhosis: results of a multicenter retrospective study. Endosc Int Open. 2019;7(9):E1099–E1104

    Article  PubMed  PubMed Central  Google Scholar 

  55. Irani SS, Sharzehi K, Siddiqui UD. AGA clinical practice update on role of EUS-guided gallbladder drainage in acute cholecystitis: commentary. Clin Gastroenterol Hepatol. 2023;21(5):1141–1147

    Article  PubMed  Google Scholar 

  56. Ng ZQ, Tan P, Theophilus M. Colorectal surgery in patients with liver cirrhosis: a systematic review. World J Surg. 2023;47(10):2519–2531

    Article  PubMed  Google Scholar 

  57. Cheng YX, Tao W, Zhang H, Peng D, Wei ZQ. Does liver cirrhosis affect the surgical outcome of primary colorectal cancer surgery? a meta-analysis. World J Surg Oncol. 2021;19(1):167

    Article  PubMed  PubMed Central  Google Scholar 

  58. Zhou S, Zhu H, Li Z, Ying X, Xu M. Safety of laparoscopic resection for colorectal cancer in patients with liver cirrhosis: a retrospective cohort study. Int J Surg. 2018;55:110–116

    Article  PubMed  Google Scholar 

  59. Berzigotti A, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Portal Hypertension Collaborative Group, et al. Obesity is an independent risk factor for clinical decompensation in patients with cirrhosis. Hepatology. 2011;54(2):555–561

    Article  PubMed  Google Scholar 

  60. Patton H, Heimbach J, McCullough A. AGA clinical practice update on bariatric surgery in cirrhosis: expert review. Clin Gastroenterol Hepatol. 2021;19(3):436–445

    Article  PubMed  Google Scholar 

  61. Singh T, Kochhar GS, Goh GB, Schauer P, Brethauer S, Kroh M, et al. Safety and efficacy of bariatric surgery in patients with advanced fibrosis. Int J Obes (Lond). 2017;41(3):443–449

    Article  CAS  PubMed  Google Scholar 

  62. Wolter S, Duprée A, Coelius C, El Gammal A, Kluwe J, Sauer N, et al. Influence of liver disease on perioperative outcome after bariatric surgery in a Northern German Cohort. Obes Surg. 2017;27(1):90–95

    Article  PubMed  Google Scholar 

  63. Addeo P, Cesaretti M, Anty R, Iannelli A. Liver transplantation for bariatric surgery-related liver failure: a systematic review of a rare condition. Surg Obes Relat Dis. 2019;15:1394–1401

    Article  PubMed  Google Scholar 

  64. Mahmud N, Panchal S, Abu-Gazala S, Serper M, Lewis JD, Kaplan DE. Association between bariatric surgery and alcohol use–related hospitalization and all-cause mortality in a Veterans Affairs cohort. JAMA Surg. 2023;158(2):162–171

    Article  PubMed  Google Scholar 

  65. Ndunda P, Srinivasan S, Vindhyal M, Muutu T, Vukas R, Fanari Z. Clinical outcomes of transcatheter vs surgical aortic valve replacement in patients with chronic liver disease: a systematic review and metaanalysis. Ochsner J. 2019;19(3):241–247

    Article  PubMed  PubMed Central  Google Scholar 

  66. Garatti A, Daprati A, Cottini M, Russo CF, Dalla Tomba M, Troise G, et al. Cardiac surgery in patients with liver cirrhosis (CASTER) study: early and long-term outcomes. Ann Thorac Surg. 2021;111(4):1242–1251

    Article  PubMed  Google Scholar 

  67. Duong N, Nguyen V, De Marchi L, Thomas A. Approach to the patient with decompensated cirrhosis and aortic stenosis during liver transplantation evaluation. Hepatol Commun. 2022;6(12):3291–3298

    Article  PubMed  PubMed Central  Google Scholar 

  68. Lee DU, Han J, Fan GH, Hastie DJ, Kwon J, Lee KJ, et al. The clinical impact of chronic liver disease in patients undergoing transcatheter and surgical aortic valve replacement: systematic analysis of the 2011–2017 US hospital database. Catheter Cardiovasc Interv. 2021;98(7):E1044–E1057

    Article  PubMed  Google Scholar 

  69. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e35–e71

    PubMed  Google Scholar 

  70. Marui A, Kimura T, Tanaka S, Miwa S, Yamazaki K, Minakata K, et al. Coronary revascularization in patients with liver cirrhosis. Ann Thorac Surg. 2011;91(5):1393–1399

    Article  PubMed  Google Scholar 

  71. Ostojic Z, Ostojic A, Bulum J, Mrzljak A. Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease. World J Cardiol. 2021;13(11):599–607

    Article  PubMed  PubMed Central  Google Scholar 

  72. Parikh ND, Chang YH, Tapper EB, Mathur AK. Outcomes of patients with cirrhosis undergoing orthopedic procedures: an analysis of the nationwide inpatient sample. J Clin Gastroenterol. 2019;53(9):e356–e361

    Article  PubMed  PubMed Central  Google Scholar 

  73. Sequeira SB, Labaran LA, Bell JE, Amin RM, Rao SS, Werner BC. Compensated cirrhosis is associated with increased risk of complications following total hip arthroplasty in a Large Medicare Database. J Arthroplasty. 2021;36(4):1361–1366

    Article  PubMed  Google Scholar 

  74. Nyberg EM, Batech M, Cheetham TC, Pio JR, Caparosa SL, Chocas MA, et al. Postoperative risk of hepatic decompensation after orthopedic surgery in patients with cirrhosis. J Clin Transl Hepatol. 2016;4(2):83–89

    PubMed  PubMed Central  Google Scholar 

  75. Serper M, Taddei TH, Mehta R, D’Addeo K, Dai F, Aytaman A, et al. Association of provider specialty and multidisciplinary care with hepatocellular carcinoma treatment and mortality. Gastroenterology. 2017;152(8):1954–1964

    Article  PubMed  Google Scholar 

  76. Vauthey JN, Chaoui A, Do KA, Bilimoria MM, Fenstermacher MJ, Charnsangavej C, et al. Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations. Surgery. 2000;127(5):512–519

    Article  CAS  PubMed  Google Scholar 

  77. European Association for the Study of the Liver. EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2018;69(1):182–236

    Article  Google Scholar 

  78. Toyoda H, Johnson PJ. The ALBI score: From liver function in patients with HCC to a general measure of liver function. JHEP Rep. 2022;4(10): 100557

    Article  PubMed  PubMed Central  Google Scholar 

  79. Ma XL, Zhou JY, Gao XH, Tian L, Wu J, Zhang CY, et al. Application of the albumin-bilirubin grade for predicting prognosis after curative resection of patients with early-stage hepatocellular carcinoma. Clin Chim Acta. 2016;462:15–22

    Article  CAS  PubMed  Google Scholar 

  80. Li MX, Zhao H, Bi XY, Li ZY, Huang Z, Han Y, et al. Prognostic value of the albumin-bilirubin grade in patients with hepatocellular carcinoma: validation in a Chinese cohort. Hepatol Res. 2017;47(8):731–741

    Article  CAS  PubMed  Google Scholar 

  81. Wang YY, Zhong JH, Su ZY, Huang JF, Lu SD, Xiang BD, et al. Albumin-bilirubin versus Child–Pugh score as a predictor of outcome after liver resection for hepatocellular carcinoma. Br J Surg. 2016;103(6):725–734

    Article  CAS  PubMed  Google Scholar 

  82. Mahmud N, Panchal S, Turrentine FE, Kaplan DE, Zaydfudim VM. Performance of risk prediction models for post-operative mortality in patients undergoing liver resection. Am J Surg. 2023;225(1):198–205

    Article  PubMed  Google Scholar 

  83. Llovet JM, Brú C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis. 1999;19(3):329–338

    Article  CAS  PubMed  Google Scholar 

  84. Azoulay D, Ramos E, Casellas-Robert M, Salloum C, Lladó L, Nadler R, et al. Liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension. JHEP Rep. 2020;3(1): 100190

    Article  PubMed  PubMed Central  Google Scholar 

  85. Vauthey JN, Chaoui A, Do KA, Bilimoria MM, Fenstermacher MJ, Charnsangavej C, et al. Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations. Surgery. 2000;127:512–519

    Article  CAS  PubMed  Google Scholar 

  86. Han DH, Choi SH, Park EJ, Kang DR, Choi GH, Choi JS. Surgical outcomes after laparoscopic or robotic liver resection in hepatocellular carcinoma: a propensity-score matched analysis with conventional open liver resection. Int J Med Robot. 2016;12(4):735–742

    Article  PubMed  Google Scholar 

  87. Han HS, Shehta A, Ahn S, Yoon YS, Cho JY, Choi Y. Laparoscopic versus open liver resection for hepatocellular carcinoma: case-matched study with propensity score matching. J Hepatol. 2015;63(3):643–650

    Article  PubMed  Google Scholar 

  88. Sposito C, Battiston C, Facciorusso A, Mazzola M, Muscarà C, Scotti M, et al. Propensity score analysis of outcomes following laparoscopic or open liver resection for hepatocellular carcinoma. Br J Surg. 2016;103(7):871–880

    Article  CAS  PubMed  Google Scholar 

  89. DeAngelis GA, Khot R, Haskal ZJ, Maitland HS, Northup PG, Shah NL, et al. Bleeding risk and management in interventional procedures in chronic liver disease. J Vasc Interv Radiol. 2016;27(11):1665–1674

    Article  PubMed  Google Scholar 

  90. Whiting D, DiNardo JA. TEG and ROTEM: technology and clinical applications. Am J Hematol. 2014;89(2):228–232

    Article  CAS  PubMed  Google Scholar 

  91. Buliarca A, Horhat A, Mocan T, Craciun R, Procopet B, Sparchez Z. Viscoelastic tests in liver disease: where do we stand now? World J Gastroenterol. 2021;27(23):3290–3302

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  92. Kumar M, Ahmad J, Maiwall R, Choudhury A, Bajpai M, Mitra LG, et al. Thromboelastography-guided blood component use in patients with cirrhosis with nonvariceal bleeding: a randomized controlled trial. Hepatology. 2020;71(1):235–246

    Article  PubMed  Google Scholar 

  93. Vuyyuru SK, Singh AD, Gamanagatti SR, Rout G, Gunjan D, Shalimar. A randomized control trial of thromboelastography-guided transfusion in cirrhosis for high-risk invasive liver-related procedures. Dig Dis Sci. 2020;65(7):2104–2111

    Article  CAS  PubMed  Google Scholar 

  94. Rout G, Gunjan D, Mahapatra SJ, Kedia S, Garg PK, Nayak B. Thromboelastography-guided blood product transfusion in cirrhosis patients with variceal bleeding: a randomized controlled trial. J Clin Gastroenterol. 2020;54(3):255–262

    Article  PubMed  Google Scholar 

  95. European Association for the Study of the Liver. EASL clinical practice guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol. 2022;76(5):1151–1184

    Article  Google Scholar 

  96. Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN practical guideline: clinical nutrition in liver disease. Clin Nutr. 2020;39(12):3533–3562

    Article  PubMed  Google Scholar 

  97. European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69(2):406–460

    Article  Google Scholar 

  98. Wiedermann CJ. Human albumin infusion in critically ill and perioperative patients: narrative rapid review of meta-analyses from the last five years. J Clin Med. 2023;12(18):5919

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  99. Sersté T, Francoz C, Durand F, Rautou PE, Melot C, Valla D, et al. Beta-blockers cause paracentesis-induced circulatory dysfunction in patients with cirrhosis and refractory ascites: a cross-over study. J Hepatol. 2011;55(4):794–799

    Article  PubMed  Google Scholar 

  100. Chang J, Höfer P, Böhling N, Lingohr P, Manekeller S, Kalff JC, et al. Preoperative TIPS prevents the development of postoperative acute-on-chronic liver failure in patients with high CLIF-C AD score. JHEP Rep. 2022;4(3): 100442

    Article  PubMed  PubMed Central  Google Scholar 

  101. Piecha F, Vonderlin J, Frühhaber F, Graß JK, Ozga AK, Harberts A, et al. Preoperative TIPS and in-hospital mortality in patients with cirrhosis undergoing surgery. JHEP Rep. 2023;6:100914

    Article  PubMed  PubMed Central  Google Scholar 

  102. Manzano-Nunez R, Jimenez-Masip A, Chica-Yanten J, Ibn-Abdelouahab A, Sartelli M, de'Angelis N, et al. Unlocking the potential of TIPS placement as a bridge to elective and emergency surgery in cirrhotic patients: a meta-analysis and future directions for endovascular resuscitation in acute care surgery. World J Emerg Surg. 2023;18(1):30

    Article  PubMed  PubMed Central  Google Scholar 

  103. Canillas L, Pelegrina A, Álvarez J, Colominas-González E, Salar A, Aguilera L, et al. Clinical guideline on perioperative management of patients with advanced chronic liver disease. Life (Basel). 2023;13(1):132

    ADS  CAS  PubMed  Google Scholar 

  104. Meierhenrich R, Wagner F, Schütz W, Rockemann M, Steffen P, Senftleben U, et al. The effects of thoracic epidural anesthesia on hepatic blood flow in patients under general anesthesia. Anesth Analg. 2009;108(4):1331–1337

    Article  CAS  PubMed  Google Scholar 

  105. Muilenburg DJ, Singh A, Torzilli G, Khatri VP. Surgery in the patient with liver disease. Med Clin North Am. 2009;93(5):1065–1081

    Article  CAS  PubMed  Google Scholar 

  106. Guacho JAL, de Moura DTH, Ribeiro IB, da Ponte Neto AM, Singh S, Tucci MGB, et al. Propofol vs midazolam sedation for elective endoscopy in patients with cirrhosis: a systematic review and meta-analysis of randomized controlled trials. World J Gastrointest Endosc. 2020;12(8):241–255

    Article  PubMed  PubMed Central  Google Scholar 

  107. Starczewska MH, Mon W, Shirley P. Anaesthesia in patients with liver disease. Curr Opin Anaesthesiol. 2017;30(3):392–398

    Article  PubMed  Google Scholar 

  108. Isbell C, Cohn SM, Inaba K, O’Keeffe T, De Moya M, Demissie S, et al. Cirrhosis, operative trauma, transfusion, and mortality: a multicenter retrospective observational study. Cureus. 2018;10(8): e3087

    PubMed  PubMed Central  Google Scholar 

  109. Diaz KE, Schiano TD. Evaluation and management of cirrhotic patients undergoing elective surgery. Curr Gastroenterol Rep. 2019;21(7):32

    Article  PubMed  Google Scholar 

  110. Dwyer JP, Jayasekera C, Nicoll A. Analgesia for the cirrhotic patient: a literature review and recommendations. J Gastroenterol Hepatol. 2014;29(7):1356–1360

    Article  CAS  PubMed  Google Scholar 

  111. Roberts LN, Hernandez-Gea V, Magnusson M, Stanworth S, Thachil J, Tripodi A, et al. Thromboprophylaxis for venous thromboembolism prevention in hospitalized patients with cirrhosis: guidance from the SSC of the ISTH. J Thromb Haemost. 2022;20(10):2237–2245

    Article  CAS  PubMed  Google Scholar 

  112. Klein LM, Chang J, Gu W, Manekeller S, Jansen C, Lingohr P, et al. The development and outcome of acute-on-chronic liver failure after surgical interventions. Liver Transpl. 2020;26(2):227–237

    Article  PubMed  Google Scholar 

  113. Chang J, Bamarni A, Böhling N, Zhou X, Klein LM, Meinke J, et al. Elective surgery but not transjugular intrahepatic portosystemic shunt precipitates acute-on-chronic liver failure. Hepatol Commun. 2021;5(7):1265–1277

    Article  PubMed  PubMed Central  Google Scholar 

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  1. Co-Senior Authors: Nadim Mahmud and K. Rajender Reddy.

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  1. Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia

    Ana Ostojic

  2. Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA

    Nadim Mahmud & K. Rajender Reddy

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Ana Ostojic declares that he has no conflict of interest. Nadim Mahmud declares support from Grifols (investigator-initiated research) K. Rajender Reddy Advisory Board: Mallinckrodt, Spark Therapeutics, Novo Nordisk, Bio Vie. Grant Support ( Paid to the University of Pennsylvania): Mallinckrodt, BMS, Intercept, Bio Vie, Sequana, Grifols, HCC-TARGET, NASH-TARGET, Exact Sciences, Camurus, B and D Device, DSMB: Novartis, Genkyotex, Astra Zeneca.

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Ostojic, A., Mahmud, N. & Reddy, K.R. Surgical risk stratification in patients with cirrhosis. Hepatol Int (2024). https://doi.org/10.1007/s12072-024-10644-y

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