Perioperative management of patients with liver cirrhosis

In elective or emergency surgery, the presence of liver cirrhosis or end-stage liver disease significantly increases the morbidity and mortality risk. Due to current medical possibilities, a shift from absolute to relative surgical contraindications becomes evident. While patients with Child–Turcotte–Pugh (CTP) score A cirrhosis have no elevated surgical risk and this is only moderately elevated in CTP score B patients, elective surgery is generally contraindicated in patients with CTP C liver cirrhosis or a Model for End-Stage Liver Disease (MELD) score >14 due to considerable mortality. However, liver transplantation has a particular position with respect to liver failure. In at-risk patients, improvement of clinical condition in the period before surgery can prevent complications or even enable the surgery itself. Key points of this management focus on perioperative therapy of the complications associated with liver cirrhosis (coagulopathy, encephalopathy, ascites, renal impairment, and malnutrition). In addition to preoperative identification of at-risk patients using scoring systems or liver function tests, the perioperative risk can also be reduced by means of anesthesiologic management (drug selection, avoiding hypotension, and volume control). Furthermore, improved surgical procedures, such as minimally invasive laparoscopic surgery and techniques for reducing intraoperative blood loss, as well as postoperatively prolonged intensive care monitoring and comprehensive care by all involved disciplines reduce perioperative morbidity and mortality. © 2017, Springer Medizin Verlag GmbH.