AGA Clinical Practice Update on Surgical Risk Assessment and Perioperative Management in Cirrhosis: Expert Review

Despite worldwide increases in the prevalence of chronic liver disease due to viral hepatitis and nonalcoholic steatohepatitis (NASH), patients with cirrhosis are living longer with more advanced disease because of improved medical and surgical management. 1 As a result, they are at risk for other diseases and morbidities that patients with cirrhosis might not have experienced in past decades. Patients with cirrhosis now have a significant lifetime risk of hepatocellular carcinoma (HCC) and obesity-related diseases, and they may require emergent or elective surgical procedures other than liver transplantation. Early reports of outcomes of standard surgical procedures in patients with cirrhosis described intolerable mortality rates as high as 67%.(2) Improved management and better selection of patients with cirrhosis have led to improved surgical survival and the development of new risk prediction algorithms. Nevertheless, the evaluation and treatment of the patient with cirrhosis in whom an invasive surgical procedure is planned is not standardized, and there are no definitive prospective trials to provide clarity to clinicians in assessing patients in the preoperative period and managing them in the postoperative period. The modern literature on surgical risk stratification in cirrhosis patients consists of case reports, small series, and only a few serious attempts to stratify risk. This review summarizes the available data and recommendations based on expert opinion on how best to predict surgical outcomes and optimize the condition of patients with cirrhosis who undergo surgical procedures. Table 1 summarizes our recommendations.