Chirurgie bei Patienten mit Leberzirrhose

Transkript

1 Chirurgie bei Patienten mit Leberzirrhose Sicht des Chirurgen Interdisziplinäre Viszeralmedizin 14. Dezember 2016 Kantonsspital St. Gallen Dr. med. Thomas Steffen, MAS Stv. Chefarzt Facharzt Chirurgie FMH Schwerpunkt Viszeralchirurgie FMH Facharzt EBSQ surgical oncology Klinik für Allgemein-, Viszeral-, Endokrinund Transplantationschirurgie Kantonsspital St. Gallen 9007 St. Gallen

2 Surgery and liver disease Patients with liver disease who require surgery are at greater risk for surgical complications The magnitude of the risk depends upon the - type of liver disease - its severity - the surgical procedure Friedmann LS; Hepatology. 1999;29(6):1617 Friedmann LS; Clin Liver Dis. 2009;13(2):211 Patel T; Mayo Clin Proc. 1999;74(6):593 Montomoli J; BMC Gastroenterol. 2013;13:66. Epub 2013 Apr 15

3 High mortality rates Mortality in high Child/MELD-score up to 70% Child-/MELD-score and blood transfusion (both p<0,001) lead to higher mortality rates Child-/MELD-score equal

4 Mortality abdominal surgery in patients with cirrhosis 138 patients CHILD (41 A; 59 B; 38 C); MELD median 13; 50% emergency Mortality: 28% - Elective 10%; emergency 45% - Blood transfusion: 47% vs. 6% without blood transfusion - MELD >17: 69% F Makowiec et al; Klinikum der Albert-Ludwigs-Universität, Freiburg

5 Obstuctive jaundice and surgery Risk factors Serum bilirubin level > 11 mg/dl (200 µmol/liter) Azotemia Cholangitis Hematocrit < 30 percent Hypoalbulminemia Malignant cause of biliary obstruction

6 Contraindications to elective surgery in patients with liver disease I Acute alcoholic hepatitis Acute viral hepatitis Child-Pugh class C Fulminant hepatic failure Severe chronic hepatitis

7 Contraindications to elective surgery in patients with liver disease II Severe coagulopathy (prolongation of the prothrombin time >3 seconds despite vitamin K administration; platelet count <50,000/mm 3 ) Severe extrahepatic complications Acute renal failure Cardiomyopathy, heart failure Hypoxemia

8 Riks evaluation

9 Measures of hepatic function proposed as predictors of perioperative morbidity and mortality in patients with cirrhosis. Galactose elimination capacity Aminopyrine breath testing Indocyanine green clearance Rate of metabolism of lidocaine to monoethylglycinexylidide Albumin Coagulation factors Prothrombin time None has been shown convincingly to provide additional prognostic information compared with the Child-classification. They are not used widely.

10 Obstructive jaundice Multivariate analysis identified three predictors of postoperative mortality: An initial hematocrit <30 percent An initial serum bilirubin level >11 mg/dl (200 micromoles/l) A malignant cause of obstruction When all three factors were present, mortality approached 60 %; when none was present, mortality was only 5 %.

11 Liver transection Time is relevant > Stapler resection Blood loss is relevant > Habib Stapler Habib 4X Bipolar Resection Device

12 Hepatic surgery Needed liver remnant volume: 40% (20%) Prediction of function of the future liver remnant!

13 LiMAx in combination with volumetric CT scan 13 C methacetin breath test (LiMAx) Volumetric CT scan KSSG: No postoperative liver failure since implementation of LiMAx 2010

14 Planned residual LiMAx (LiMAx and volumetric CT scan) Volume 100% LiMAx 300 >150 regular feasible critical <80 non-surgical Volume 35% LiMAx 105 Volume 24% LiMAx 72

15 Planned residual LiMAx (LiMAx and volumetric CT scan) Volume 100% LiMAx 160 >150 regular feasible critical <80 non-surgical Volume 35% LiMAx 56 Volume 24% LiMAx 38 Min. 94%

16 Faktor VII, ICG, LiMAx adsfasdf

17 LiMAx am 1. postop Tag

18 Riskofaktoren für postop. Leberversagen

19 Risikofaktoren postop. Leberinsuffizienz

20 Risikofaktoren für postop. schwere Kompl. adsfasdf

21 LiMAx bester Prädiktor

22 Präop. Assessment Seit Ende 2010 Kein Leberversagen

23 Folientitel Friedman LS. The risk of surgery in patients with liver disease. Hepatology 1999; 29:1617

24 Postoperatively Patients should be observed closely for hepatic decompensation: worsening jaundice Encephalopathy Ascites The best biochemical measures of liver function are probably the prothrombin time (INR) and serum bilirubin concentration.

25 Type of surgery The type of surgery is probably the most important determinant of postoperative hepatic dysfunction in patients with liver disease Abdominal wall surgery vs intraperitoneal surgery

26 Risk assessment Type of surgery I Laparotomy is associated with a greater reduction in hepatic arterial blood flow than extra-abdominal surgery (reflex systemic hypotension due to dilatation of capacitance vessels) Procedures associated with a large amount of blood loss increase the risk of ischemic hepatic injury Patients with cirrhosis who have had prior abdominal surgery can have highly vascular adhesions surrounding the liver, which can bleed excessively during surgery

27 Risk assessment Type of surgery II Emergency surgery is associated with higher morbidity and mortality than elective surgery Cholecystectomy, gastric surgery, and colectomy have been associated with particularly high mortality rates in patients with decompensated cirrhosis Cardiac surgery in patients with cirrhosis is also associated with a high mortality

28 Summary Medical therapy should be optimized in all patients Operative mortality can be estimated based upon the Child-Pugh classification and the MELD score taking into consideration other factors such as the patient's age, ASA score, and additional comorbidities LiMAx test is of value to reduce perioperative mortality

29 Summary Child-Pugh / MELD score Child-Pugh class C or MELD score >15, or other contraindication >>> no elective surgery Child-Pugh class A or MELD score <10 and those with mild chronic liver disease without cirrhosis >>> surgery generally well tolerated Child-Pugh class B or MELD score 10 to 15 who have undergone thorough preoperative preparation >>> surgery permissible

30 Vielen Dank!