Rai Rakesh, Nagral Sanjay, Nagral Aabha
Department of HPB Surgery and Liver Transplantation, Fortis Hospital, Mulund, Mumbai, India.
Department of Surgical Gastroenterology, Jaslok Hospital, Mumbai, India.
J Clin Exp Hepatol. 2012 Sep;2(3):238-46. doi: 10.1016/j.jceh.2012.05.003. Epub 2012 Sep 21.
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.
合并肝病的患者通常需要进行手术。肝脏的多种生理功能使这些患者的发病和死亡风险增加。诸如胆结石和疝气等需要手术治疗的疾病在肝硬化患者中更为常见。术前评估肝功能障碍的严重程度很重要，并且需要仔细评估手术的风险效益。疾病严重程度可能从轻度转氨酶升高到失代偿性肝硬化不等。在紧急情况下、急性和酒精性肝炎患者、Child C级或终末期肝病模型（MELD）评分超过15分的肝硬化患者或任何有严重肝外器官功能障碍的患者，应尽可能避免手术。对于这部分患者，应尝试所有可能的保守治疗方法。改良Child-Pugh评分和终末期肝病模型（MELD）评分可以相当可靠地预测手术后的死亡率，包括非肝脏腹部手术。术前优化措施包括控制腹水、纠正电解质失衡、改善肾功能、心肺评估以及纠正凝血功能。与肝硬化患者的传统凝血检测相比，血栓弹力图和凝血酶生成时间等整体止血检测可能更能预测出血风险。用新鲜冰冻血浆纠正国际标准化比值并不一定意味着降低出血风险，反而可能增加容量超负荷和肺损伤的风险。国际标准化比值肝脏可能更好地反映凝血状态。对于需要手术的肝硬化患者，重组因子VIIa需要进一步研究。术中，建议使用异氟烷和丙泊酚等安全的麻醉剂，并避免低血压。一般来说，不应使用非甾体抗炎药（NSAIDs）和苯二氮䓬类药物。对于有腹水、门静脉高压和肝肿大的肝硬化患者，腹部手术更具挑战性。凝血功能障碍和门静脉高压导致的失控性出血、败血症、肾功能障碍以及肝功能衰竭的恶化，都会导致这些患者的发病和死亡。需要采取措施减少腹水渗漏和感染。任何接受大手术的肝硬化患者都应转诊至有肝病管理经验的专科中心。
