Author: John C. Martin
Author Date: 3/10/2003

Hepatitis patients who undergo medical procedures for various
reasons face a range of complications that must be considered long
before they are wheeled into the operating room.

The decision to move forward with surgery can be challenging for the
surgical team when hepatitis is involved, primarily because of the
multiple functions of the liver that can potentially create problems.

The Multiplicity of Liver Function
The liver might be considered one of the most complex organs in your
body. It is responsible not only for the metabolism of nutrients and
drugs, but the detoxification and excretion of agents that can
otherwise be poisonous to your body, as well as blood filtering.(1)

In fact, all the blood that leaves your stomach and intestines
passes through your liver. It breaks down the nutrients and drugs in
your bloodstream into forms that are easier to use for the rest of
the body. All told, there are more than 500 vital functions
associated with the liver.(2)

That is why when hepatitis affects liver function, there are many
considerations that surgeons must take into account before surgery
can begin. The effectiveness of anesthetics, muscle relaxants, pain-
relieving analgesics, and sedatives can be compromised in patients
with diminished liver function.

"Precise estimates of operative risk in patients with well
characterized liver disease are hard to come by," wrote Lawrence S.
Friedman M.D., a professor of medicine at Harvard Medical School, in
a 1999 review paper.(3) "Most available data derive from relatively
small retrospective studies of cirrhotic patients undergoing
abdominal surgery."

But enough is known to help surgeons make informed decisions.

Interferon Therapy
If you are taking interferon/ribavirin therapy for your hepatitis,
be sure to inform your doctor before surgery. While there may or may
not be drug interactions related to this therapy, it is important to
ensure that you doctor knows that you are on this treatment.

Still, interferon is not cause for much concern in surgical
procedures. "Whereas in experimental studies, interferon does
accelerate the clearance of certain drugs such as theophylline, for
all intents and purposes, there are no significant drug
interactions," said Robert Perrillo, M.D., head of the
Gastroenterology and Hepatology Section at the Ochsner Clinic
Foundation in New Orleans. "However, any drug which is associated
with a condition called agranulocytosis, like certain antibiotics,
should be given cautiously in patients on interferon since the
latter can suppress bone marrow function."

Also known as Schultzs disease, agranulocytosis is characterized by
a significant decrease in granulocytes (certain white blood cells)
in the body, and shows up as lesions in the throat and other mucous
membranes, in the gastrointestinal tract, and on the skin. It is
caused by chronic bacterial infections.

Interferon can drive down platelet levels, the factors in the blood
responsible for clotting. "This would require dose reduction of
interferon to prevent the possibility of bleeding prior to surgery;
after bleeding is noted, this would require platelet transfusions
and supportive care," Perrillo said, in an interview with Priority
Healthcare.

Additionally, increased bleeding may result from a condition known
as coagulopathy because a healthy liver normally regulates blood
clotting. There may also be an increased risk of infection prior to
surgery.

The various medications used in surgery must be taken into account
prior to the procedure, as well. For example, reduced blood flow
that occurs in diseased livers can also degrade the metabolism of
certain surgical narcotics, such as morphine and meperidine.
Surgeons typically use other agents that are not affected by this
decreased bloodflow, according to Friedman.

Surgical Complications
Abdominal surgery itself can lead to reduced bloodflow through the
liver because of the abnormally low blood pressure that can result
from possible hemorrhaging. "Patients with liver cirrhosis with or
without liver cancer may be more susceptible to fluctuations in
blood pressure, since the liver normally consumes at least 20
percent of the cardiac output," Perillo explained.

If blood pressure significantly drops during surgery, or abnormal
vascular changes occur, ischemic liver injury may result, which can
have grave consequences, such as "sudden worsening of liver
function, jaundice, and a higher rate of postoperative mortality,"
Perrillo said.

"In patients with cirrhosis and previous abdominal surgery,
adhesions around the liver can be highly vascular, leading to an
increased risk of intraoperative bleeding," wrote Friedman.

In other cases, patients with biliary tract disease can sometimes
develop liver abscesses which are collections of pus related to
infection, either during or after surgery as well as abscess
cavities that can form between the liver and diaphragm.

However, Friedman noted that in patients with chronic hepatitis,
surgical risk depends mainly on the severity of the disease. Those
with mild chronic hepatitis appear to face a lower risk than those
with more severe forms.(4)

Cardiac Surgery Risks
There have also been limited studies that found a high risk of death
in patients with liver cirrhosis who undergo cardiac surgery.(5)
Researchers at Cornell University Medical Center, assessing the
charts of 13 patients with liver cirrhosis who underwent heart
surgery, found that each patient faced an average 31 percent risk of
death following surgery, as well as higher postoperative chest tube
output and transfusion requirements. The higher death rate was
attributed to the higher risk of infections and bleeding following
surgery, rather than heart failure.

Those with more severe liver disease had postoperative
complications. "These findings suggest that patients with minimal
clinical evidence of cirrhosis can tolerate cardiopulmonary bypass
and cardiac surgical procedures, whereas those with more advanced
liver disease should not be offered operation," the doctors
concluded.

Heart bypass surgery is also ill advised for those with advanced
liver disease because the operation may exacerbate the livers
diminished ability to coagulate blood, as mentioned earlier;
specifically, it can inhibit production of blood-clotting particles
known as platelets, and a clotting factor in the blood known as
fibrin. Such surgery can also induce a condition known as
hypocalcaemia, an abnormally low production of calcium in the blood.
(6)

Instead, patients with advanced cirrhosis and heart disease usually
must undergo less invasive procedures such as angioplasty,
valvuloplasty, or newer revascularization techniques.(7)

Hepatocellular Carcinoma
In the past, surgery to remove liver tumors was generally not an
option for patients whose cirrhosis had progressed to hepatocellular
carcinoma (liver cancer) because of an associated 50 percent risk of
death.

However, with earlier detection of tumors, "meticulous" preoperative
preparation, intensive monitoring of surgical patients, and improved
surgical techniques, the mortality rate for these patients has
plummeted to between 3 percent and 16 percent, Fried noted. Yet he
adds that rates of disease after surgery are still as high as 60
percent, recurrence rates are as high as 100 percent, and 5-year
survival rates are no more than about 50 percent.

There are other related complications, as well, Perrillo added. When
surgeons remove cancerous liver tissue, they also may remove healthy
liver tissue in the process. "Thus, if this type of patient already
has cirrhosis of the liver, and a reduced number of healthy liver
cells, then the patient can develop liver failure after surgery,"
Perrillo explained.

Ascites Risks
Finally, patients with a condition known as ascites, in which large
volumes of fluid build up in the abdominal area as one result of
liver dysfunction, must undergo a preoperative procedure in which
fluid is completely drained to avoid complications later.

The take home message is that patients and surgeons must fully
communicate prior to any surgical procedure to ensure all potential
risks are minimized.

Taking a complete patient history prior to any type of surgical
procedure is imperative, Friedman stresses. "Evaluation of any
patient undergoing surgery should include careful history-taking to
identify risk factors for liver disease, including previous blood
transfusions, tattoos, illicit drug use, sexual promiscuity, a
family history of jaundice or liver disease, a history of jaundice
or fever after anesthesia, alcohol use, and a complete review of
current medications."