The Frontline Gastroenterology Twitter-debate (#FGDebate) in April 2023 focused on risks of non-hepatic surgery in patients with cirrhosis and was based on the BSG and BASL guidelines.1 The event generated 186 tweets and >292 000 impressions.
Prognostic scores
The debate kicked-off with a case presentation, followed by discussion on prognostic scores for estimating surgical risks. Among online participants, 53.2% chose the Child-Turcotte-Pugh (CTP) or Model for End-stage Liver Disease (MELD) scores for risk prediction. Other scores chosen included the VOCAL-Penn Score2 (26.2%), Mayo Surgical Score3 (16.3%) and Hepatic Venous Pressure Gradient (HVPG) (4.3%). Most respondents chose CTP or MELD as these were familiar and tried-and-tested. However, neither CTP or MELD truly assesses the presence or severity of portal hypertension—the sequelae of liver disease most relevant in determining operative risks.4 The American Society of Anesthesiologists (ASA) classification was also proposed,5 given its long history in surgical risk stratification.
The VOCAL-Penn and Mayo Surgical scores are designed for surgical risk assessment in cirrhosis.4 VOCAL-Penn is the only score to account for surgical factors, whereas the Mayo Surgical score incorporated the ASA classification. These scores were developed using retrospective data, and portal hypertension assessment may be more direct in predicting postoperative decompensation. Preoperative HVPG accurately assesses portal hypertension and has been studied for adverse outcome prediction.6 However, given the invasive and impractical nature of HVPG, alternatives such as liver/spleen stiffness and endoscopic ultrasound-guided portal pressure assessment were discussed. Participants agreed that these modalities have not been tested in preoperative settings and require validation.
Service provision
Discussions progressed to service provision and which clinicians should manage patients with cirrhosis undergoing non-hepatic surgery. Considering the potential role of HVPG, tertiary centres with interventional radiology expertise are required. The importance of multidisciplinary care was highlighted, as good communication between hepatologists, anaesthesiologists and surgeons would be critical. The role of allied health colleagues (ie, physiotherapists and dietitians) to provide personalised preoperative, perioperative and postoperative care was also raised.
Preoperative transjugular intrahepatic portosystemic shunt
The final part of the debate focused on preoperative transjugular intrahepatic portosystemic shunting (TIPSS) for risk reduction. A systematic review highlighted that preoperative TIPSS enabled most patients to undergo elective surgeries with minimal delay.7 Nonetheless, it was emphasised that data on preoperative TIPSS, particularly on patient selection and surgical outcomes, remain limited. Ongoing multi-centre studies will provide essential data, yet preoperative TIPSS remains experimental at present. Decisions for preoperative TIPSS should be decided on a case-by-case basis in multidisciplinary meetings, and patients should be carefully counselled on the risks and benefits.8 Given that preoperative TIPSS aims to reduce portal hypertension, the utility of carvedilol/statins in this setting also remains unanswered.
Conclusion
Surgical risk prediction and optimisation in cirrhosis are important topics. Key areas requiring research include long-term postoperative outcomes, risk stratification in specific populations (ie, patients with compensated/decompensated cirrhosis), non-invasive testing for outcome prediction and the role of preoperative TIPSS. This #FGDebate highlighted the research and service gaps for patients with cirrhosis undergoing non-hepatic surgery. We anticipate this field to rapidly grow, and we look forward to discussing the advancements in future #FGDebates.
Footnotes
Twitter: @RexWHHui, @Nadirabbas_x
Contributors: RW-HH drafted the initial manuscript. NA, PD and DT provided critical appraisal and revised the manuscript. All authors have reviewed and approved the final version of this manuscript.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication
Not applicable.
Ethics approval
Not applicable.
References
- 1. Abbas N, Fallowfield J, Patch D, et al. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023;14:359–70. 10.1136/flgastro-2023-102381 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Mahmud N, Fricker Z, Hubbard RA, et al. Risk prediction models for post-operative mortality in patients with cirrhosis. Hepatology 2021;73:204–18. 10.1002/hep.31558 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007;132:1261–9. 10.1053/j.gastro.2007.01.040 [DOI] [PubMed] [Google Scholar]
- 4. Morris SM, Abbas N, Osei-Bordom DC, et al. Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach. Expert Review of Gastroenterology & Hepatology 2023;17:155–73. 10.1080/17474124.2023.2163627 [DOI] [PubMed] [Google Scholar]
- 5. Saklad M. Grading of patients for surgical procedures. Anesthesiology 1941;2:281–4. 10.1097/00000542-194105000-00004 [DOI] [Google Scholar]
- 6. Reverter E, Cirera I, Albillos A, et al. The Prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery. J Hepatol 2019;71:942–50. 10.1016/j.jhep.2019.07.007 [DOI] [PubMed] [Google Scholar]
- 7. Lahat E, Lim C, Bhangui P, et al. Transjugular intrahepatic portosystemic shunt as a bridge to non-hepatic surgery in cirrhotic patients with severe portal hypertension: a systematic review. HPB (Oxford) 2018;20:101–9. 10.1016/j.hpb.2017.09.006 [DOI] [PubMed] [Google Scholar]
- 8. Manzano-Nunez R, Jimenez-Masip A, Chica-Yanten J, et al. Unlocking the potential of TIPS placement as a bridge to elective and emergency surgery in cirrhotic patients: a meta-analysis and future directions for endovascular resuscitation in acute care surgery. World J Emerg Surg 2023;18:30. 10.1186/s13017-023-00498-4 [DOI] [PMC free article] [PubMed] [Google Scholar]