Skip to main content
SpringerLink
Log in

Perioperative Management of the Patient with End-Stage Liver Disease

  • Patient Safety in Anesthesia (SJ Brull and JR Renew, Section Editors)
  • Published:
Current Anesthesiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

End-stage liver disease is associated with increased perioperative morbidity and mortality. This narrative review provides a summary of perioperative concerns and management of patients with end-stage liver disease.

Recent Findings

Model for end-stage liver disease (MELD) 3.0 is the most updated version of the MELD score which is used as both a prognostic score to prioritize organ allocation and to assess the severity of liver disease. The American Association for the Study of Liver Disease and The American Gastroenterological Association have provided updated guidelines on procedural bleeding and transfusion management in patients with liver disease. There is controversy on the issue of prophylactic transfusion for target thresholds prior to surgery.

Summary

Preoperative risk assessment is dependent on the severity of liver disease, type of surgery, urgency of surgery, age, and comorbidities. Patients with end-stage liver disease may need higher acuity of care in the postoperative period.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data Availability

No datasets were generated or analysed during the current study.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Devarbhavi H, Asrani SK, Arab JP, Nartey YA, Pose E, Kamath PS. Global burden of liver disease: 2023 update. J Hepatol. 2023;79(2):516–37. https://doi.org/10.1016/j.jhep.2023.03.017.

    Article  PubMed  Google Scholar 

  2. Moon AM, Singal AG, Tapper EB. Contemporary epidemiology of chronic liver disease and cirrhosis. Clin Gastroenterol Hepatol. 2020;18(12):2650–66. https://doi.org/10.1016/j.cgh.2019.07.060.

    Article  PubMed  Google Scholar 

  3. National Vital Statistics Reports. Underlying cause of death, 2018-2021. National Center for Health Statistics 2021. https://www.cdc.gov/nchs/fastats/liver-disease.htm

  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):2398–414. https://doi.org/10.1016/j.cgh.2019.07.051.

    Article  PubMed  Google Scholar 

  5. Gilbert-Kawai N, Hogan B, Milan Z. Perioperative management of patients with liver disease. BJA Educ. 2022;22(3):111–7. https://doi.org/10.1016/j.bjae.2021.11.006.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Cheemerla S, Balakrishnan M. Global epidemiology of chronic liver disease. Clin Liver Dis. 2021;17(5):365–70. https://doi.org/10.1002/cld.1061.

    Article  Google Scholar 

  7. . 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):1394–9. https://doi.org/10.1111/liv.14156. Retrospective study reviewing in-hospital mortality and procedure type in patients with cirrhosis.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 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. https://doi.org/10.1016/j.cgh.2018.09.043.

    Article  PubMed  Google Scholar 

  9. 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):204–18. https://doi.org/10.1002/hep.31558.

    Article  PubMed  Google Scholar 

  10. Pei KY, Asuzu DT, Davis KA. Laparoscopic colectomy reduces complications and hospital length of stay in colon cancer patients with liver disease and ascites. Surg Endosc. 2018;32(3):1286–92. https://doi.org/10.1007/s00464-017-5806-4.

    Article  PubMed  Google Scholar 

  11. Eslam M, Newsome PN, Sarin SK, Anstee QM, Targher G, Romero-Gomez M, et al. A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus Statement. J Hepatol. 2020;73:202–9. https://doi.org/10.1016/j.jhep.2020.03.039.

    Article  PubMed  Google Scholar 

  12. Ayoub CH, Dakroub A, El-Asmar JM, Ali AH, Beaini H, Abdulfattah S, et al. Preoperative MELD score predicts mortality and adverse outcomes following radical cystectomy: analysis of American College of Surgeons National Surgical Quality Improvement Program. Ther Adv Urol. 2022;15(14):17562872221135944. https://doi.org/10.1177/17562872221135944.

    Article  Google Scholar 

  13. Havens JM, Columbus AB, Olufajo OA, Askari R, Salim A, Christopher KB. Association of model for end-stage liver disease score with mortality in emergency general surgery patients. JAMA Surg. 2016;151(7):e160789. https://doi.org/10.1001/jamasurg.2016.0789.

    Article  PubMed  Google Scholar 

  14. •• 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. https://doi.org/10.1053/j.gastro.2021.08.050. Update on the latest MELD.

    Article  PubMed  Google Scholar 

  15. 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):542–5. https://doi.org/10.1007/s12072-023-10494-0.

    Article  PubMed  Google Scholar 

  16. •• O'Leary JG, Greenberg CS, Patton HM, Caldwell SH. AGA clinical practice update: coagulation in cirrhosis. Gastroenterology. 2019;157(1):34–43.e1. https://doi.org/10.1053/j.gastro.2019.03.070. Most recent American Gastroenterological Association Guidelines on cirrhosis.

    Article  PubMed  Google Scholar 

  17. •• Northup PG, Garcia-Pagan JC, Garcia-Tsao G, Intagliata NM, Superina RA, Roberts LN, et al. Vascular liver disorders, portal vein thrombosis, and procedural bleeding in patients with liver disease: 2020 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;73(1):366–413. https://doi.org/10.1002/hep.31646. Updated guidelines from the American Association of Liver Disease (AASLD) on procedural bleeding in liver disease.

    Article  PubMed  Google Scholar 

  18. Manzano-Nunez R, Jimenez-Masip A, Chica-Yanten J, Ibn-Abdelouahab SM, 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. https://doi.org/10.1186/s13017-023-00498-4.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Wu Y, Zhu Y, Feng Y, Wang R, Yao N, Zhang M, et al. Royal free hospital-nutritional prioritizing tool improves the prediction of malnutrition risk outcomes in liver cirrhosis patients compared with nutritional risk screening 2002. Br J Nutr. 2020;124(12):1293–302. https://doi.org/10.1017/S0007114520002366.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Lai JC, Tandon P, Bernal W, Tapper EB, Ekong U, Dasarathy S, et al. Frailty, and sarcopenia in patients with cirrhosis: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(3):1611–44. https://doi.org/10.1002/hep.32049.

    Article  PubMed  Google Scholar 

  21. Markin N, Sharma A, Grant W, Shillcutt S. The safety of transesophageal echocardiography in patients undergoing orthotopic liver transplantation. J Cardiothorac Vasc Anesth. 2015;29(3):588–93. https://doi.org/10.1053/j.jvca.2014.10.012.

    Article  PubMed  Google Scholar 

  22. Canillas L, Pelegrina A, Álvarez J, Colominas-González E, Salar A, Aguilera L, Burdio F, Montes A, Grau S, Grande L, Carrión JA. Clinical guideline on perioperative management of patients with advanced chronic liver disease. Life (Basel). 2023;13(1):132. https://doi.org/10.3390/life13010132.

    Article  CAS  PubMed  PubMed Central  ADS  Google Scholar 

  23. Simegn AE, Melesse DY, Bizuneh YB, Alemu WM. Perioperative management of patients with liver disease for non-hepatic surgery: a systematic review. Ann Med Surg (Lond). 2022;24(75):103397. https://doi.org/10.1016/j.amsu.2022.103397.

    Article  Google Scholar 

  24. Deana C, Barbariol F, D’Incà S, et al. Sugammadex versus neostigmine after rocuronium continuous infusion in patients undergoing liver transplantation. BMC Anesthesiol. 2020;20(1):70. https://doi.org/10.1186/s12871-020-00986-z.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Fujita A, Ishibe N, Yoshihara T, Ohashi J, Makino H, Ikeda M, et al. Rapid reversal of neuromuscular blockade by sugammadex after continuous infusion of rocuronium in patients with liver dysfunction undergoing hepatic surgery. Acta Anaesthesiol Taiwan. 2014;52(2):54–8. https://doi.org/10.1016/j.aat.2014.04.007.

    Article  PubMed  Google Scholar 

  26. Rai R, Nagral S, Nagral A. Surgery in a patient with liver disease. J Clin Exp Hepatol. 2012;2(3):238–46. https://doi.org/10.1016/j.jceh.2012.05.003.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Van Limmen J, Wyffels P, Berrevoet F, Vanlander A, Coeman L, Wouters P, et al. Effects of propofol and sevoflurane on hepatic blood flow: a randomized controlled trial. BMC Anesthesiol. 2020;20(1):241. https://doi.org/10.1186/s12871-020-01150-3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Brezeanu LN, Brezeanu RC, Diculescu M, Droc G. Anaesthesia for liver transplantation: an update. J Crit Care Med (Targu Mures). 2020;6(2):91–100. https://doi.org/10.2478/jccm-2020-0011.

    Article  PubMed  Google Scholar 

  29. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378:819–28. https://doi.org/10.1056/NEJMoa1711586.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57:1651–3.

    Article  PubMed  Google Scholar 

  31. European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; 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):406–60. https://doi.org/10.1016/j.jhep.2018.03.024.

  32. Seshadri A, Appelbaum R, Carmichael SP 2nd, Cuschieri J, Hoth J, Kaups KL, et al. Management of decompensated cirrhosis in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022;7(1):e000936. https://doi.org/10.1136/tsaco-2022-000936.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2017;65(1):310–35. https://doi.org/10.1002/hep.28906.

    Article  PubMed  Google Scholar 

  34. Liu P, Hum J, Jou J, Scanlan RM, Shatzel J. Transfusion strategies in patients with cirrhosis. Eur J Haematol. 2020;104(1):15–25. https://doi.org/10.1111/ejh.13342.

    Article  CAS  PubMed  Google Scholar 

  35. Rakoski M, Goyal P, Spencer-Safier M, Weissman J, Mohr G, Volk M. Pain management in patients with cirrhosis. Clin Liver Dis (Hoboken). 2018;11(6):135–40. https://doi.org/10.1002/cld.711.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Richter B, Schmandra TC, Golling M, Bechstein WO. Nutritional support after open liver resection: a systematic review. Dig Surg. 2006;23:139–45. https://doi.org/10.1159/000094345.

    Article  CAS  PubMed  Google Scholar 

  37. Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: an updated review. Clin Res Hepatol Gastroenterol. 2023;47(8):102205. https://doi.org/10.1016/j.clinre.2023.102205.

    Article  CAS  PubMed  Google Scholar 

  38. Joliat GR, Kobayashi K, Hasegawa K, Thomson JE, Padbury R, Scott M, et al. Guidelines for perioperative care for liver surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg. 2023;47(1):11–34. https://doi.org/10.1007/s00268-022-06732-5.

    Article  PubMed  Google Scholar 

  39. Taylor N, Pierce ET. The patient with hepatic disease. In: Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM, editors. Anesthesiology, 3e. McGraw Hill; 2017. https://accessanesthesiology-mhmedical-com.foyer.swmed.edu/content.aspx?bookid=2152&sectionid=164218164.

    Google Scholar 

  40. Lopez-Delgado JC, Ballus J, Esteve F, et al. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol. 2016;22(9):2657–67. https://doi.org/10.3748/wjg.v22.i9.2657.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Liver Transplant Team, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA

    Flora Simmons & Tailour Roberson

  2. The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA

    Adebukola Owolabi

Authors
  1. Flora Simmons
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tailour Roberson
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Adebukola Owolabi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

F.S. - created the outline and guidelines for the paper- wrote the abstract, preoperative management section, and conclusion- designed the tables- critically revised all sections of the paper. A.O. - wrote the initial drafts of the intraoperative management section. T.R. - wrote the initial drafts of the introduction and postoperative management sections.

Corresponding author

Correspondence to Flora Simmons.

Ethics declarations

Conflict of Interest

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Simmons, F., Roberson, T. & Owolabi, A. Perioperative Management of the Patient with End-Stage Liver Disease. Curr Anesthesiol Rep (2024). https://doi.org/10.1007/s40140-024-00618-z

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s40140-024-00618-z

Keywords

Search

Navigation