Cirrhosis, a condition marked by advanced scarring of the liver, impairs its function over time. This damage can lead to complications, making surgical interventions a consideration. While surgery does not reverse scarring, it addresses specific complications or, in severe cases, replaces the diseased liver.
Types of Surgical Interventions
Liver transplantation is the definitive treatment for end-stage liver disease caused by cirrhosis, offering restored liver function and improved life expectancy. It replaces the diseased liver with a healthy one from a donor. Donated livers can come from either deceased donors, often individuals who have suffered brain death, or living donors, who donate a portion of their liver. Living donation can significantly reduce wait times, as the donated liver segment regenerates in both the donor and recipient within a few months.
Beyond transplantation, other surgical procedures address complications from cirrhosis. Portal hypertension, a common complication where blood pressure in the portal vein increases, can lead to variceal bleeding. A Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure can manage this by creating a new connection between the portal vein and a hepatic vein, reducing pressure and diverting blood flow away from the liver. This minimally invasive procedure involves inserting a stent through a vein in the neck, guided by X-ray, to connect these vessels within the liver. TIPS is also utilized for refractory ascites, which is fluid accumulation in the abdomen that does not respond to conventional treatments.
Hernias, particularly umbilical and inguinal types, are frequently observed in individuals with cirrhosis, often due to increased abdominal pressure from ascites. Surgical repair of these hernias is considered, with careful attention to controlling ascites both before and after the procedure to minimize complications like wound infection or fluid leakage. Elective hernia repair is preferred over emergency surgery, which carries higher risks.
Gallbladder surgery, or cholecystectomy, may also be considered for cirrhotic patients with symptomatic gallstones, which are more common in this population. While laparoscopic approaches are favored due to their less invasive nature, the presence of cirrhosis increases the complexity and risks associated with these procedures. Patients with more advanced cirrhosis, such as Child-Pugh class C, may face higher complication rates and may be advised against cholecystectomy, with conservative treatment being a more suitable option.
Surgical Risk Assessment
Surgery for individuals with cirrhosis presents unique challenges due to impaired liver function affecting various bodily systems. The liver’s reduced ability to metabolize drugs, produce clotting factors, and heal tissues increases the likelihood of complications such as slow wound healing, fluid accumulation, infections, and even kidney or liver failure. A thorough evaluation is conducted to determine the safety and feasibility of any surgical intervention.
Medical professionals rely on established scoring systems to quantify liver disease severity and predict surgical outcomes. The Child-Pugh score assesses five factors: total bilirubin, serum albumin, prothrombin time or INR (which measures blood clotting time), the presence and severity of ascites (fluid in the abdomen), and hepatic encephalopathy (a brain disorder caused by liver dysfunction). Each factor is assigned a score from one to three, with higher scores indicating more severe impairment. The total score classifies liver disease into three categories: Class A well-compensated disease, Class B signifies moderate damage, and Class C represents severe or advanced liver damage. Historically, postoperative mortality rates increase significantly with higher Child-Pugh classes, with Class C patients facing substantially elevated risks.
The MELD (Model for End-Stage Liver Disease) score is another objective system used to assess liver disease severity and prioritize candidates for liver transplantation. This numerical scale, ranging from six to 40, incorporates blood test results for bilirubin, creatinine (reflecting kidney function), INR, and serum sodium. A higher MELD score indicates more severe illness and a greater urgency for transplant. For non-transplant surgeries, a higher MELD score also correlates with increased postoperative mortality. A multidisciplinary team of specialists, including hepatologists, anesthesiologists, and surgeons, collaborates to assess overall health and determine the most appropriate course of action.
Preparing for and Recovering from Surgery
Undergoing surgery with cirrhosis necessitates careful preparation to optimize the patient’s condition and minimize risks. Preoperative evaluations include cardiac and pulmonary assessments, and a thorough nutritional assessment, since malnutrition is common in cirrhosis. Efforts focus on optimizing liver function and managing existing complications like ascites or varices. This may involve medication adjustments, fluid and electrolyte balance correction, and sometimes procedures like paracentesis to remove excess abdominal fluid. Nutritional support is also a key component, aiming to improve overall health before the procedure.
Following surgery, patients with cirrhosis often require intensive postoperative monitoring, frequently in an intensive care unit, due to the increased risk of complications. Pain management is carefully administered, considering the liver’s role in drug metabolism. Close attention is paid to fluid balance to prevent overload, which can worsen portal hypertension and ascites. Monitoring for complications such as bleeding, infection, and worsening liver function is continuous. Long-term recovery involves ongoing medical management to support liver health, including adherence to prescribed medications and sustained lifestyle adjustments.