Guideline refines surgical decision-making for patients with cirrhosis

Editor's Note

Elective surgical procedures such as cholecystectomy and hernia repair can be performed safely in carefully selected patients with cirrhosis, but high-risk individuals still need alternatives, according to an updated American College of Gastroenterology guideline, Medscape October 3 reports. The guideline emphasizes individualized risk stratification that integrates liver disease severity, comorbidities, and procedure-specific considerations rather than relying solely on traditional liver scores.

Lead author Nadim Mahmud, MD, of the University of Pennsylvania, explained that as more patients with cirrhosis live longer and require surgery, clinicians need practical guidance to balance operative benefits against preventable complications. The document outlines four preoperative recommendations: one strong and three conditional. The strong recommendation advises thrombopoietin receptor agonists for patients with severe thrombocytopenia undergoing invasive procedures, with the goal of reducing transfusion requirements and bleeding risk.

Conditional recommendations include:

• noninvasive liver stiffness measurement and platelet count to detect portal hypertension in compensated cirrhosis
• preoperative transjugular intrahepatic portosystemic shunt (TIPS) in select patients with portal hypertension and additional indications such as varices or refractory ascites
• referral to high-volume liver surgery or transplant centers for major hepatic operations.

The guideline introduces several notable changes. It endorses cirrhosis-specific risk calculators, particularly the VOCAL-Penn Score, which incorporates surgery type and provides more accurate estimates than older models. It also supports standardized assessment of portal hypertension with imaging and noninvasive tests, structured nutritional and prehabilitation interventions, viscoelastic testing to guide transfusions, and early consideration of transplant evaluation in high-risk patients.

Procedure-specific advice helps translate risk into practice. Examples include elective hernia repair once ascites is controlled, laparoscopic cholecystectomy in well-compensated cirrhosis, and sleeve gastrectomy as the preferred bariatric option. For some patients with significant portal hypertension, preoperative TIPS may be reasonable, though not broadly recommended.

Commenting on the guideline, Peter D. Block, MD, of Yale School of Medicine, noted cirrhosis complicates clotting, fluid balance, immunity, kidney function, and drug metabolism, making perioperative planning especially complex. He stressed the guideline’s strength lies in combining liver-specific scores with surgery-specific factors and clinical judgment. High-risk operations include major open abdominal, cardiothoracic, and vascular procedures, along with emergency procedures where optimization is limited.