Clinical Challenges in Emergency General Surgery: Cirrhotic Patients

Please join Drs. Graham Skelhorne-Gross, Jordan Nantais and Ashlie Nadler from our Emergency General Surgery Team for a discussion on cirrhotic patients.  

Child-Pugh Score (https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality)
·      Bilirubin, albumin, INR, ascites, encephalopathy
·      Used to predict operative mortality based on cirrhosis severity
·      Mortality in EGS:
- Child-Pugh A: 10% electively and 22% emergently
- Child-Pugh B: 30% electively and 38% emergently
- Child-Pugh C: 80% electively and up to 100% emergently

Model for End Stage Liver Disease (MELD) (https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld?utm_source=site&utm_medium=link&utm_campaign=meld_12_and_older)
·      creatinine, bilirubin, INR, and sodium
·      MELD < 20 – 1% increase in mortality with each point increase
·      MELD > 20 – 2% increase in mortality with each point increase

Pre-operative Planning
·      Identification of cirrhosis with physical examination, bloodwork and imaging
·      Involvement of other medical services (internal medicine, hepatology, ICU) as needed
·      Cirrhosis optimization, if possible
·      Abdominal wall mapping

Unexpected Intraoperative Finding

• Communicate unexpected findings to the operative team and think of additional adjuncts you may need such as additional ports, topical hemostatic agents or energy devices.
• Think about why you are in the OR. If its an elective situation and can wait, consider bailing. If its emergent, you may have to do something more definitive.
• Exposure may be a challenge, you may have to alter your typical approach including where the assistant grabs and retracts. Extra hands are helpful.
• Bleeding can be a big deal. If possible, map out the abdominal wall ahead of time with cross-sectional imaging. Stay away from varices around the umbilicus or porta

Ventral Hernia + Cirrhosis
·      Ideally, control ascites pre-operatively, if you can’t consider leaving drains
·      Small (< 2cm) hernias close primarily
·      Larger (>2cm) hernias repair with mesh unless infected filed (controversial)
·      Minimally invasive repairs can be performed

Benign Biliary Disease + Cirrhosis
·      Incidence of gallstones is 4-5 times higher in cirrhotic patients
·      Prophylactic laparoscopic cholecystectomy (LC) generally not done
·      LC generally considered acceptable in CP A or B but not C (exceptions: HD instability, gangrenous cholecystitis, hemorrhagic cholecystitis)
·      Cholecystostomy and ERCP are safe

References: 

Bleszynski, M. et. Al. Acute care and emergency general surgery in patients with chronic liver disease: how can be optimize perioperative care? A review of the literature. 2018. World Journal of Emergency Surgery; 13:32

Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122:730–5.

Yeom SK, Lee CH, Cha SH, Park CM. Prediction of liver cirrhosis, using diagnostic imaging tools. World J Hepatol. 2015 Aug 18;7(17):2069-79. doi: 10.4254/wjh.v7.i17.2069. PMID: 26301049; PMCID: PMC4539400.

Jain D, Mahmood E, V-Bandres M, Feyssa E. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Ann Gastroenterol. 2018 May-Jun;31(3):330-337. doi: 10.20524/aog.2018.0249. Epub 2018 Mar 15. PMID: 29720858; PMCID: PMC5924855.

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