Although it is well known that acute hepatobiliary damage results in increased morbidity and mortality in the surgical patient, estimating the operative risk in patients with hepatic dysfunction is difficult based on the history and physical examination. The most accurate method for risk assessment of surgery in patients with hepatic dysfunction is Child’s classification (Table 22.21). Using this system, accurate assessment of morbidity and mortality can be directly related to the degree of liver dysfunction (270). The Child’s classification is useful for patients undergoing a variety of different types of abdominal surgery. Data show operative mortalities of 10%, 30%, and 82% for each of the three Child’s classifications, respectively, while other data called this into question with operative mortality of 2%, 12%, and 12% (271,272). The major cause of perioperative death was often sepsis. This classification correlated significantly with postoperative complications such as bleeding, renal failure, wound dehiscence, and sepsis. Another method for determining operative risk in patients with cirrhosis is the Model for End-Stage Liver Disease (MELD), which takes into account the patient’s prothrombin time, bilirubin, and creatinine with various iterations used to better predict perioperative morbidity and mortality (273,274). Originally designed to predict outcomes in cirrhotic patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure, it was further studied to include patients undergoing other surgical procedures. In patients with a MELD score greater than 15, elective surgery should be deferred (275).
Acute Viral Hepatitis Acute viral hepatitis poses an increased risk of operative complications and perioperative mortality and is a contraindication for elective surgery (276). Elective surgery should be delayed for approximately 1 month after the results of all biochemical tests have returned to normal (277). In patients with ectopic pregnancy, hemorrhage, or bowel obstruction secondary to malignancy, surgical intervention must take place before normalization of serum transaminase levels (276). In these situations, the perioperative morbidity (12%) and mortality (9.5%) rates are much higher than when they are performed under ideal situations (269).