Preoperative evaluation of patients with liver disease

The authors of this Review discuss the increased risk of morbidity and mortality associated with surgery in patients with underlying liver disease, and describe the essential role that preoperative assessment has in these patients. The nature and severity of the underlying liver disease and the type of surgery being undertaken are all considered and guidelines for preoperative assessment provided. Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child–Turcotte–Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease. Key Points Elective surgery should be avoided in patients with acute liver diseases such as acute viral hepatitis or alcoholic hepatitis, if there is evidence of ongoing hepatic injury For patients with chronic liver diseases, determine the severity of underlying disease and assess whether or not cirrhosis might be present before deciding whether to proceed with surgery The Model for End-Stage Liver Disease and Child–Turcotte–Pugh scores can be used to stratify the risks of surgery for patients with chronic liver disease Optimal preoperative management of the manifestations of advanced liver disease can reduce the risk of postoperative morbidity and mortality