Abbas Nadir, Fallowfield Jonathan, Patch David, Stanley Adrian J, Mookerjee Raj, Tsochatzis Emmanouil, Leithead Joanna A, Hayes Peter, Chauhan Abhishek, Sharma Vikram, Rajoriya Neil, Bach Simon, Faulkner Thomas, Tripathi Dhiraj
The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
Frontline Gastroenterol. 2023 Mar 8;14(5):359-370. doi: 10.1136/flgastro-2023-102381. eCollection 2023.
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
由于英国肝硬化发病率不断上升，越来越多的慢性肝病患者正在考虑接受择期非肝脏手术。过去不愿为这类患者提供手术，是因为普遍认为术后预后不佳。虽然失代偿期肝硬化患者确实如此，但经过仔细的风险评估，部分代偿期早期肝硬化患者术后可以获得良好的预后。公认的风险包括全身麻醉、出血、感染、伤口愈合受损、急性肾损伤和心血管功能不全。腹腔内或心胸外科手术是特别高风险的干预措施。通过血液检查、影像学检查、肝脏硬度测量、内镜检查和门静脉压力评估（源自肝静脉压力梯度）进行临床评估，有助于风险分层。包括Child-Turcotte-Pugh评分和终末期肝病模型在内的传统预后评分系统有一定帮助，但可能高估手术风险。像梅奥风险评分、VOCAL-Penn评分和ADOPT-LC评分等特定的预后评分可以提高风险评估的准确性。降低风险的措施包括仔细管理静脉曲张、优化营养，并尽可能解决任何持续存在的病因驱动因素，如饮酒。对于部分高风险患者，可以考虑进行门静脉减压，如经颈静脉肝内门体分流术，但需要对这种方法进行进一步的前瞻性研究。至关重要的是，要在多学科论坛上讨论患者的情况，并就潜在的风险和益处对患者进行仔细的咨询。
