Faculty mentor/PI email address
crhoffm1@virtua.org
Keywords
End-stage liver disease (ESLD), perioperative risk stratification, MELD and Child-Turcotte-Pugh scores, non-hepatic surgery complications, multidisciplinary perioperative protocols, cirrhosis surgical outcomes
Date of Presentation
5-6-2026 12:00 AM
Poster Abstract
Introduction: End-stage liver disease (ESLD) significantly increases perioperative morbidity and mortality during non-hepatic surgery. Although validated risk stratification tools, including the Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores, are available, their use frequently remains limited to quantifying risk without prompting standardized perioperative protocols. This case demonstrates that elevated cirrhosis-specific risk scores should function as triggers for enhanced preparation and multidisciplinary planning, following models established in other high-risk clinical contexts.
Case Report: A 43-year-old female with decompensated alcohol-related cirrhosis was scheduled for total thyroidectomy for papillary thyroid cancer, a procedure required for liver transplant eligibility. Preoperative evaluation revealed coagulopathy (INR 1.85), thrombocytopenia (platelets 107 k/µL), anemia (hemoglobin 8.3 g/dL), ascites, and baseline hypotension. Retrospective assessment identified CTP Class C (score 11) and MELD 3.0 of 27. The patient was classified as ASA 4 with documented anesthetic concerns. However, no cirrhosis-specific surgical risk scores were recorded in the preoperative assessment. Intraoperatively, dissection of the right superior thyroid pole resulted in injury to a friable right internal jugular vein, causing approximately 3 liters of blood loss and necessitating activation of the massive transfusion protocol (≥6 units pRBC, ≥6 units FFP). Hemodynamic instability required emergent arterial line placement and vasopressor support. Only a right hemithyroidectomy was completed. The patient was transferred intubated to the ICU, where a 10-day course included progression from hemorrhagic to septic shock, ARDS, hepatic encephalopathy, upper gastrointestinal bleeding, and multi-organ failure. The patient expired on postoperative day 10 after the family elected comfort care.
Discussion: This case shows a critical gap between risk identification and protocol activation in surgical patients with cirrhosis. CTP Class C designation and MELD scores above 15 are associated with elevated perioperative mortality, and current guidelines recommend that these patients receive a thorough multidisciplinary review before elective surgery. 1, 2Despite the documented ASA 4 classification and known coagulopathy, no cirrhosis-specific risk scoring was applied preoperatively, and no enhanced protocol was initiated. Precedent for score-triggered escalation exists in other high-risk clinical settings. For example, postpartum hemorrhage risk scores are automatically calculated in the electronic medical record for every laboring patient, and a threshold score triggers interdisciplinary discussion and activates an expanded care plan that includes second intravenous (IV) access, blood bank preparation, and NICU notification. An analogous protocol is proposed for surgical patients with ESLD: CTP Class C or MELD >15 should automatically prompt (1) placement of a second large-bore IV line, (2) immediate availability of blood products, (3) planned postoperative admission, (4) arterial line placement prior to incision, and (5) formal multidisciplinary review to determine whether surgery is the safest approach to the clinical objective. For patients whose surgical indication is transplant candidacy, the multidisciplinary discussion should explicitly address whether alternative treatment pathways could achieve the same goal with lower perioperative risk.
Conclusion: In patients with ESLD undergoing non-hepatic surgery, elevated CTP and MELD scores should serve not only as risk quantifiers but as triggers for a standardized perioperative protocol. The infrastructure for this model already exists. Risk-score-driven escalation is used in obstetrics and other arenas. Applying it systematically to cirrhotic surgical patients may help prevent cases where complications eliminate the very outcome the surgery was intended to achieve.
References:
1. Mahmud N, Fricker ZP, McElroy LM, et al. ACG Clinical Guideline: Perioperative Risk Assessment and Management in Patients With Cirrhosis. Am J Gastroenterol. 2025;120(9):1968-1984. doi:10.14309/ajg.0000000000003616
2. Mahmud N, Fricker Z, Hubbard RA, et al. Risk Prediction Models for Post-Operative Mortality in Patients With Cirrhosis. Hepatology. 2021;73(1):204-218. doi:10.1002/hep.31558
Disciplines
Digestive System Diseases | Hepatology | Medicine and Health Sciences
Included in
Anesthetic and Perioperative Challenges of End-Stage Liver Disease in Non-Hepatic Surgery: A Case for Score-Triggered Perioperative Protocols
Introduction: End-stage liver disease (ESLD) significantly increases perioperative morbidity and mortality during non-hepatic surgery. Although validated risk stratification tools, including the Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores, are available, their use frequently remains limited to quantifying risk without prompting standardized perioperative protocols. This case demonstrates that elevated cirrhosis-specific risk scores should function as triggers for enhanced preparation and multidisciplinary planning, following models established in other high-risk clinical contexts.
Case Report: A 43-year-old female with decompensated alcohol-related cirrhosis was scheduled for total thyroidectomy for papillary thyroid cancer, a procedure required for liver transplant eligibility. Preoperative evaluation revealed coagulopathy (INR 1.85), thrombocytopenia (platelets 107 k/µL), anemia (hemoglobin 8.3 g/dL), ascites, and baseline hypotension. Retrospective assessment identified CTP Class C (score 11) and MELD 3.0 of 27. The patient was classified as ASA 4 with documented anesthetic concerns. However, no cirrhosis-specific surgical risk scores were recorded in the preoperative assessment. Intraoperatively, dissection of the right superior thyroid pole resulted in injury to a friable right internal jugular vein, causing approximately 3 liters of blood loss and necessitating activation of the massive transfusion protocol (≥6 units pRBC, ≥6 units FFP). Hemodynamic instability required emergent arterial line placement and vasopressor support. Only a right hemithyroidectomy was completed. The patient was transferred intubated to the ICU, where a 10-day course included progression from hemorrhagic to septic shock, ARDS, hepatic encephalopathy, upper gastrointestinal bleeding, and multi-organ failure. The patient expired on postoperative day 10 after the family elected comfort care.
Discussion: This case shows a critical gap between risk identification and protocol activation in surgical patients with cirrhosis. CTP Class C designation and MELD scores above 15 are associated with elevated perioperative mortality, and current guidelines recommend that these patients receive a thorough multidisciplinary review before elective surgery. 1, 2Despite the documented ASA 4 classification and known coagulopathy, no cirrhosis-specific risk scoring was applied preoperatively, and no enhanced protocol was initiated. Precedent for score-triggered escalation exists in other high-risk clinical settings. For example, postpartum hemorrhage risk scores are automatically calculated in the electronic medical record for every laboring patient, and a threshold score triggers interdisciplinary discussion and activates an expanded care plan that includes second intravenous (IV) access, blood bank preparation, and NICU notification. An analogous protocol is proposed for surgical patients with ESLD: CTP Class C or MELD >15 should automatically prompt (1) placement of a second large-bore IV line, (2) immediate availability of blood products, (3) planned postoperative admission, (4) arterial line placement prior to incision, and (5) formal multidisciplinary review to determine whether surgery is the safest approach to the clinical objective. For patients whose surgical indication is transplant candidacy, the multidisciplinary discussion should explicitly address whether alternative treatment pathways could achieve the same goal with lower perioperative risk.
Conclusion: In patients with ESLD undergoing non-hepatic surgery, elevated CTP and MELD scores should serve not only as risk quantifiers but as triggers for a standardized perioperative protocol. The infrastructure for this model already exists. Risk-score-driven escalation is used in obstetrics and other arenas. Applying it systematically to cirrhotic surgical patients may help prevent cases where complications eliminate the very outcome the surgery was intended to achieve.
References:
1. Mahmud N, Fricker ZP, McElroy LM, et al. ACG Clinical Guideline: Perioperative Risk Assessment and Management in Patients With Cirrhosis. Am J Gastroenterol. 2025;120(9):1968-1984. doi:10.14309/ajg.0000000000003616
2. Mahmud N, Fricker Z, Hubbard RA, et al. Risk Prediction Models for Post-Operative Mortality in Patients With Cirrhosis. Hepatology. 2021;73(1):204-218. doi:10.1002/hep.31558