The risk of surgery in patients with liver disease.

The burden of chronic liver disease continues to grow dramatically in the United States, driven primarily by chronic viral hepatitis, alcoholic liver disease, and non-alcoholic fatty liver disease. These conditions are associated with substantial morbidity and mortality, as confirmed by recent data from 2013 State of U.S. Health Report demonstrating that liver cirrhosis now represents the eighth leading cause of death in the U.S. with a 43% increase between 1990 and 2010, and corresponding increase in liver cancer-related mortality of 118% during this same period of observation.1 Liver cirrhosis additionally contributes to substantial cost and economic burden, an estimated $1.64 billion USD as of 2002,2 and an additional $2.8 billion USD from chronic hepatitis C infection as of 2004.3 Patients with chronic liver disease often undergo surgery for indications other than liver transplantation, and may face increased perioperative risk due both to surgical and anesthesia-related complications.4 An estimated 10% of patients with advanced liver disease require a surgical procedure other than liver transplantation in their final two years of life,5 and, furthermore, individuals with unrecognized chronic liver disease may also undergo surgery with cirrhosis diagnosed only intra-operatively based on macroscopic assessment.6 Preoperative screening for liver disease and assessment of surgical risk in patients with liver disease is essential to guiding patients in reaching treatment decisions with consideration of benefit and risk, and for optimizing pre-operative and post-operative management. In this lecture, we will review basic principles of pre-operative assessment of patients with chronic liver disease undergoing surgery, estimation of surgical mortality using the Child-Pugh-Turcotte (CPT) and Model for End-Stage Liver Disease (MELD) scores, and strategies to optimize pre-operative management.