Preparing for Surgery in Liver Disease

Liver is an important organ in many aspects and when it comes to surgery the importance is even higher. The main reason for such importance is the potential for patient with liver disease to develop complications in several aspects. This article would be looking into some of these aspects and finds out how these risk factors can be modified in order to undergo a safe recovery.

There are several factors which needs to be looked at,

The associated complications Defective production of clotting factors Impaired metabolism of certain drugs Derangement of blood sugar levels Nutritional state

Before such patients undergo surgery, an anaesthetist will assess the patient as with any other patient undergoing surgery. The doctor will order several investigations if already hasn’t been done in order to detect the seriousness of the liver disease as well as to identify any associated complications. Thus, these patients will generally have to undergo,

Full blood count Liver profile Blood urea levels Serum creatinine levels Serum Electrolytes ECG Blood sugar levels Clotting profile (PT/INR and Bleeding time / clotting time)

Most often the derangement that could be noticed is in the liver functions with high liver enzyme levels, high bilirubin levels, low protein levels, low haemoglobin…etc. If the kidneys are also affected, the serum creatinine levels and blood urea will also be high along with altered levels of electrolytes. In certain instances, the blood sugar levels can go down but if the patient is a diabetic the levels could remain high.

As the production of proteins are impaired, the clotting profile would be deranges and if the condition is worse the patient may be suffering from spontaneous bleeding with low platelet counts as well.

The most important of the above findings would be the bleeding tendencies as well as the impaired kidney function.

Thus, if these abnormalities are found, it would be dangerous to continue for surgery immediately. Thus, the surgery will be delayed till the abnormalities are corrected unless it’s an emergency surgery which has a higher risk towards the life if not performed than the risk from the liver disease itself.

In such patients with higher bleeding tendency, fresh frozen plasma may need to be given to top-up the protein levels in the circulation and to reduce the excessive fluid accumulation in the interstitial tissues. The supplementary plasma will also contain the clotting factors which will be adequate for the time being. If the haemoglobin levels are found to be low, an infusion of blood may be indicated till adequate levels are reached.

At the same time, the depleted vitamin levels may also need to be supplemented through necessary means and this will provide essential factors for the production of red blood cells in the bone marrows.

In certain instances, giving such patients N-Acetyl Cystine (NAC) would also be useful as it can replenish the depleted glutathione levels in the liver which is vital in preventing further damage which can be done by free radicals.

The patients may also be seen by nephrologists in order to assess the renal function and necessary fluid maintenance will be decided. Such patients would be started on low sodium diets as well.

Once the acute risks are managed, the patient can undergo surgery with close observation as the reactions to drugs might also vary and could only be assessed at the time of the surgery.