Liver Diseases pp 769-783 | Cite as

Surgery in Liver Disease

  • Saied Froghi
  • Farid Froghi
  • Brian R. DavidsonEmail author


Chronic liver disease is on the rise. According to WHO cirrhosis now accounts for almost 1.8% of all deaths in Europe causing around 170,000 death per year. Liver disease poses a significant challenge to surgery, particularly with advanced stages of illness. The physiological changes with the development of cirrhosis have a significant impact on both morbidity and mortality of surgery. Careful preoperative evaluation and risk assessment will identify high-risk patients allowing pre-operative optimisation and targeted post-operative care. The decision to proceed with surgery depends on the severity of liver disease, the necessity of the proposed procedure and the magnitude of intervention. Risk assessment and pre-operative optimisation aim to reduce risk in those in whom surgery is likely to be beneficial and to advise against surgical intervention in those in whom the severity of liver disease and the extent of surgery makes intervention futile. Here we provide a summary of risk assessment in chronic liver disease and the preoperative steps required to optimise patient care. An overview of risk assessment in hepatic and non-hepatic surgery is followed by an outline of risk evaluation for individual procedures.


Liver surgery Hepatic resection Non-hepatic procedure 


  1. 1.
    Martin Blachier HL, Peck-Radosavljevic M, Valla D-C, Roudot-Thoraval F. The burden of liver disease in Europe: a review of available epidemiological data. Geneva: EASL; 2013.Google Scholar
  2. 2.
    Zatonski WA, et al. Liver cirrhosis mortality in Europe, with special attention to Central and Eastern Europe. Eur Addict Res. 2010;16(4):193–201.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Peck-Radosavljevic M, et al. Managing complications in cirrhotic patients. U Eur Gastroenterol J. 2015;3(1):80–94.CrossRefGoogle Scholar
  4. 4.
    Chouillard EK, Gumbs AA, Cherqui D. Vascular clamping in liver surgery: physiology, indications and techniques. Ann Surg Innov Res. 2010;4:2.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Smyrniotis V, et al. Vascular control during hepatectomy: review of methods and results. World J Surg. 2005;29(11):1384–96.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Dixon E, et al. Vascular occlusion to decrease blood loss during hepatic resection. Am J Surg. 2005;190(1):75–86.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Lau WY, Lai E, SHY L. Methods of vascular control technique during liver resection: a comprehensive review. Hepatobiliary Pancreat Dis Int. 2010;9(5):473–81.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Friedman LS. Surgery in the patient with liver disease. Trans Am Clin Climatol Assoc. 2010;121:192–204; discussion 205.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Bhangui P, et al. Assessment of risk for non-hepatic surgery in cirrhotic patients. J Hepatol. 2012;57(4):874–84.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Abbas N, et al. Perioperative care of patients with liver cirrhosis: a review. Health Serv Insights. 2017;10:1178632917691270.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Befeler AS, et al. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg. 2005;140(7):650–4.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Merli M, et al. Nutritional status: its influence on the outcome of patients undergoing liver transplantation. Liver Int. 2010;30(2):208–14.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Harimoto N, et al. Prognostic significance of preoperative controlling nutritional status (CONUT) score in patients undergoing hepatic resection for hepatocellular carcinoma: a multi-institutional study. Ann Surg Oncol. 2018;25(11):3316–23.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Schiavo L, et al. Nutritional issues in patients with obesity and cirrhosis. World J Gastroenterol. 2018;24(30):3330–46.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Tsiaousi ET, et al. Malnutrition in end stage liver disease: recommendations and nutritional support. J Gastroenterol Hepatol. 2008;23(4):527–33.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Guerrero-Dominguez R, et al. Perioperative renal protection strategies in liver transplantation. Nefrologia. 2014;34(3):276–84.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Biancofiore G, Davis CL. Renal dysfunction in the perioperative liver transplant period. Curr Opin Organ Transplant. 2008;13(3):291–7.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Gustot T, et al. Severe sepsis in cirrhosis. Hepatology. 2009;50(6):2022–33.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Jalan R, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol. 2014;60(6):1310–24.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Jain D, et al. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Ann Gastroenterol. 2018;31(3):330–7.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Patel T. Surgery in the patient with liver disease. Mayo Clin Proc. 1999;74(6):593–9.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Nicoll A. Surgical risk in patients with cirrhosis. J Gastroenterol Hepatol. 2012;27(10):1569–75.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Mansour A, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122(4):730–5; discussion 735–6.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Kamath PS, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–70.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Northup PG, et al. Model for end-stage liver disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg. 2005;242(2):244–51.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Rahbari NN, et al. The predictive value of postoperative clinical risk scores for outcome after hepatic resection: a validation analysis in 807 patients. Ann Surg Oncol. 2011;18(13):3640–9.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Carbonell AM, Wolfe LG, DeMaria EJ. Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. Hernia. 2005;9(4):353–7.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Friedman LS. The risk of surgery in patients with liver disease. Hepatology. 1999;29(6):1617–23.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Pinter M, et al. Cancer and liver cirrhosis: implications on prognosis and management. ESMO Open. 2016;1(2):e000042.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Zhu Z. Milan criteria and its expansions in liver transplantation for hepatocellular carcinoma. Hepatobiliary Surg Nutr. 2016;5(6):498–502.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Cabibbo G, et al. A meta-analysis of survival rates of untreated patients in randomized clinical trials of hepatocellular carcinoma. Hepatology. 2010;51(4):1274–83.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Teh SH, et al. Hepatic resection of hepatocellular carcinoma in patients with cirrhosis: model of end-stage liver disease (MELD) score predicts perioperative mortality. J Gastrointest Surg. 2005;9(9):1207–15; discussion 1215.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Ercolani G, et al. Liver resection for hepatocellular carcinoma on cirrhosis: univariate and multivariate analysis of risk factors for intrahepatic recurrence. Ann Surg. 2003;237(4):536–43.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Schroeder RA, et al. Predictive indices of morbidity and mortality after liver resection. Ann Surg. 2006;243(3):373–9.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Llovet JM, Schwartz M, Mazzaferro V. Resection and liver transplantation for hepatocellular carcinoma. Semin Liver Dis. 2005;25(2):181–200.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Poon RT, Fan ST. Hepatectomy for hepatocellular carcinoma: patient selection and postoperative outcome. Liver Transpl. 2004;10(2 Suppl 1):S39–45.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Bruix J, et al. Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure. Gastroenterology. 1996;111(4):1018–22.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–2.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Baig JA, et al. Hepatocellular carcinoma (HCC) and diagnostic significance of A-fetoprotein (AFP). J Ayub Med Coll. 2009;21(1):72–5.Google Scholar
  40. 40.
    Ma W-j, Wang H-y, Teng L-s. Correlation analysis of preoperative serum alpha-fetoprotein (AFP) level and prognosis of hepatocellular carcinoma (HCC) after hepatectomy. World J Surg Oncol. 2013;11(1):212.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Cucchetti A, et al. Current concepts in hepatic resection for hepatocellular carcinoma in cirrhotic patients. World J Gastroenterol. 2012;18(44):6398–408.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Coelho JC, et al. Umbilical hernia in patients with liver cirrhosis: a surgical challenge. World J Gastrointest Surg. 2016;8(7):476–82.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Hew S, et al. Safety and effectiveness of umbilical hernia repair in patients with cirrhosis. Hernia. 2018;22(5):759–65.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Odom SR, et al. Emergency hernia repair in cirrhotic patients with ascites. J Trauma Acute Care Surg. 2013;75(3):404–9.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Eker HH, et al. A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery. 2011;150(3):542–6.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Marsman HA, et al. Management in patients with liver cirrhosis and an umbilical hernia. Surgery. 2007;142(3):372–5.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Cho SW, et al. Umbilical hernia repair in patients with signs of portal hypertension: surgical outcome and predictors of mortality. Arch Surg. 2012;147(9):864–9.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Youssef YF, El Ghannam M. Mesh repair of non-complicated umbilical hernia in ascitic patients with liver cirrhosis. J Egypt Soc Parasitol. 2007;37(3 Suppl):1189–97.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Ammar SA. Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial. Hernia. 2010;14(1):35–8.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Delis S, et al. Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child–Pugh classification in predicting outcome. Surg Endosc. 2010;24(2):407–12.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Perini MV, Fink MA. Cholecystectomy in cirrhosis. In: Cox MR, Eslick GD, Padbury R, editors. The management of gallstone disease: a practical and evidence-based approach. Cham: Springer International Publishing; 2018. p. 279–89.CrossRefGoogle Scholar
  52. 52.
    Pinheiro RS, et al. Laparoscopic cholecystectomy and cirrhosis: patient selection and technical considerations. Ann Laparosc Endosc Surg. 2017;2(3):35.CrossRefGoogle Scholar
  53. 53.
    Toro A, Di Carlo I. Caution in the indication for cholecystectomy in patients with modified Child C cirrhosis. HPB. 2011;13(8):592.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Nguyen KT, et al. Cirrhosis is not a contraindication to laparoscopic cholecystectomy: results and practical recommendations. HPB (Oxford). 2011;13(3):192–7.CrossRefGoogle Scholar
  55. 55.
    Puggioni A, Wong LL. A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis. J Am Coll Surg. 2003;197(6):921–6.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Laurence JM, et al. Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials. HPB. 2012;14(3):153–61.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Machado NO. Laparoscopic cholecystectomy in cirrhotics. JSLS. 2012;16(3):392–400.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Zhao R, et al. Hepatic pedicle occlusion with the pringle maneuver during difficult laparoscopic cholecystectomy reduces the conversion rate. World J Surg. 2019;43:207.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Griniatsos J. Factors predisposing to conversion from laparoscopic to open cholecystectomy. Ann Laparosc Endosc Surg. 2018;3(2):12.CrossRefGoogle Scholar
  60. 60.
    Paolino J, Steinhagen RM. Colorectal surgery in cirrhotic patients. ScientificWorldJournal. 2014;2014:239293.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Masoomi H, et al. Predictive factors of in-hospital mortality in colon and rectal surgery. J Am Coll Surg. 2012;215(2):255–61.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Ghaferi AA, et al. Adverse outcomes in patients with chronic liver disease undergoing colorectal surgery. Ann Surg. 2010;252(2):345–50.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Hedrick TL, Swenson BR, Friel CM. Model for end-stage liver disease (MELD) in predicting postoperative mortality of patients undergoing colorectal surgery. Am Surg. 2013;79(4):347–52.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Lange EO, et al. Relationship between model for end-stage liver disease score and 30-day outcomes for patients undergoing elective colorectal resections: an American college of surgeons-national surgical quality improvement program study. Dis Colon Rectum. 2015;58(5):494–501.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Meunier K, et al. Colorectal surgery in cirrhotic patients: assessment of operative morbidity and mortality. Dis Colon Rectum. 2008;51(8):1225–31.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Montomoli J, et al. Liver disease and 30-day mortality after colorectal cancer surgery: a Danish population-based cohort study. BMC Gastroenterol. 2013;13:66.PubMedPubMedCentralCrossRefGoogle Scholar
  67. 67.
    Gervaz P, et al. Colorectal adenocarcinoma in cirrhotic patients. J Am Coll Surg. 2003;196(6):874–9.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Martínez JL, et al. Laparoscopic-assisted colectomy in patients with liver cirrhosis. Surg Endosc Other Interv Tech. 2004;18(7):1071–4.Google Scholar
  69. 69.
    Adani GL. Colorectal surgery in cirrhotic patients: the role of laparoscopy. Ann Surg. 2014;259(4):e57.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Hessheimer AJ, et al. Metabolic risk factors are a major comorbidity in patients with cirrhosis independent of the presence of hepatocellular carcinoma. Eur J Gastroenterol Hepatol. 2010;22(10):1239–44.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Thielmann M, et al. Risk prediction and outcomes in patients with liver cirrhosis undergoing open-heart surgery. Eur J Cardiothorac Surg. 2010;38(5):592–9.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Vanhuyse F, et al. Cardiac surgery in cirrhotic patients: results and evaluation of risk factors. Eur J Cardiothorac Surg. 2012;42(2):293–9.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Lin C-H, Hsu R-B. Cardiac surgery in patients with liver cirrhosis: risk factors for predicting mortality. World J Gastroenterol. 2014;20(35):12608–14.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Filsoufi F, et al. Early and late outcome of cardiac surgery in patients with liver cirrhosis. Liver Transpl. 2007;13(7):990–5.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Jacob KA, et al. Mortality after cardiac surgery in patients with liver cirrhosis classified by the Child-Pugh score. Interact Cardiovasc Thorac Surg. 2015;20(4):520–30.PubMedCrossRefPubMedCentralGoogle Scholar
  76. 76.
    An Y, Xiao YB, Zhong QJ. Open-heart surgery in patients with liver cirrhosis: indications, risk factors, and clinical outcomes. Eur Surg Res. 2007;39(2):67–74.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Morisaki A, et al. Risk factor analysis in patients with liver cirrhosis undergoing cardiovascular operations. Ann Thorac Surg. 2010;89(3):811–7.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    Murashita T, et al. Preoperative evaluation of patients with liver cirrhosis undergoing open heart surgery. Gen Thorac Cardiovasc Surg. 2009;57(6):293–7.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Carr C, Desai J. OPCAB surgery in a cirrhotic hepatocellular carcinoma patient awaiting liver transplant. Ann Thorac Surg. 2004;78(4):1460–2.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    Gopaldas RR, et al. Cirrhosis as a moderator of outcomes in coronary artery bypass grafting and off-pump coronary artery bypass operations: a 12-year population-based study. Ann Thorac Surg. 2013;96(4):1310–5.PubMedCrossRefPubMedCentralGoogle Scholar
  81. 81.
    Alsina AE, et al. Outcomes of abdominal surgeries in cirrhotic patients performed by liver transplant surgeons: are these safe? Am J Surg. 2018;216(3):518–23.PubMedCrossRefPubMedCentralGoogle Scholar
  82. 82.
    Montrief T, Koyfman A, Long B. Acute liver failure: a review for emergency physicians. Am J Emerg Med. 2019;37:329.PubMedCrossRefPubMedCentralGoogle Scholar
  83. 83.
    Armstrong T, et al. The impact of pre-operative serum creatinine on short-term outcomes after liver resection. HPB. 2009;11(8):622–8.PubMedPubMedCentralCrossRefGoogle Scholar
  84. 84.
    Truant S, et al. Factors associated with fatal liver failure after extended hepatectomy. HPB. 2017;19(8):682–7.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Saied Froghi
    • 1
  • Farid Froghi
    • 1
  • Brian R. Davidson
    • 1
    Email author
  1. 1.University College London (UCL)LondonUK

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