Biliary tract surgery and cirrhosis: a critical combination.

Gallbladder and extrahepatic bile duct operations merit special consideration in cirrhotic patients. During the past 15 years at Strong Memorial Hospital, 33 cirrhotic patients have undergone cholecystectomy or an operation for bile duct obstruction. Of the 21 patients with cirrhosis subjected to cholecystectomy for cholecystitis and cholelithiasis, nine had uncomplicated courses. Included in this group was one patient in whom the intrahepatic portion of the gallbladder was deliberately not resected. The other 12 patients (57%) had excessive intraoperative bleeding and required transfusion of three or more units of blood. One patient required additional exploratory surgery and antifibrinolytic therapy to control bleeding. In an additional group, only one of seven patients whose gallbladder was removed during a portal decompressive procedure bled excessively from the liver bed. A third group of five patients, including four with secondary biliary cirrhosis who underwent operations on the bile duct for obstruction, had massive intraoperative bleeding (greater than 5 U). Four of the five exsanguinated, and the remaining patient died of sepsis. A more conservative approach toward elective cholecystectomy in the cirrhotic patient is indicated. If an operation is performed, increased bleeding should be anticipated; extensive intrahepatic dissection should be avoided. Intraoperative infusion of vasopressin and an antifibrinolytic agent should be considered.