MEDICINE
REVIEW ARTICLE
Operative Risk in Patients with
Liver and Gastrointestinal Diseases
Part 3 in a Series on Preoperative Risk Assessment
Jochen Rädle, Bettina Rau, Stefan Kleinschmidt, Stefan Zeuzem
SUMMARY
Introduction: Surgical procedures are common in patients with liver and gastrointestinal
diseases, but perioperative risk and surgical contraindications in these patients, especially
those with liver cirrhosis, are poorly understood. Methods: Selective literature review. Results:
Perioperative risk assessment is based on the Child-Pugh or MELD score in patients with liver
cirrhosis. Elective surgery is usually well tolerated in patients with chronic liver disease without
cirrhosis or in those with Child A cirrhosis. Patients with Child B cirrhosis are at moderate
perioperative risk while elective surgery is contraindicated in patients with Child C cirrhosis or a
MELD score 14, due to high perioperative mortality. Patients with gastrointestinal disease
appear to have a highly variable operative risk, which depends on the organs affected, disease
severity and extent of the proposed surgical intervention. Inflammatory or acute onset
gastrointestinal diseases are particularly prone to result in emergency surgery due to the
severity of the clinical picture. Discussion: Patients with advanced liver disease have a high
perioperative risk due to hepatic and other organ dysfunction. In contrast, gastrointestinal
diseases rarely constitute a contraindication to surgery in other organ systems.
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Key words: operative risk, mortality, chronic liver diseases, liver cirrhosis, gastrointestinal
diseases
H
epatological and gastroenterological diseases rarely constitute particular risk factors in
operative procedures. Cardiopulmonary disorders and progressive hepatic disorders
are primarily regarded as relative or absolute contraindications or result in modification of the
operative method. Few prospective studies that deal with this topic have been performed to date.
In this article, we attempt to define the operative mortality risk for surgery on central
organ systems, which usually requires full anesthesia, on the basis of a selective review of
the currently available literature. Procedures that bear a lower risk and are performed under
local or regional anesthesia are not taken into account.
In addition to the underlying illness and the operation itself, we determined the operative
risk especially from comorbidity due to internal causes and the patient's age. The operative risk
rises notably with the age of the patient (e1–e5). A simple risk assessment can be done
independently of the patient's age, by using the ASA (American Society of Anesthesiologists)
score (e6–e8). In addition to the risk associated with anesthesia, this score correlates well with
the duration of general morbidity and mortality (e9, e10) (table 1). By contrast, the rather
scientifically used POSSUM (Physiological and Operative Severity Score for the enumeration
of Mortality and morbidity) score and improved Portsmouth-POSSUM score capture several
physiological and operative variables that help in assessing individual mortality and prognosis
(1, 2).
Liver
Operations in patients with existing liver disease are not uncommon. Some 10% of such
patients are being operated on during the last two years of life (e11, e12). The extent of the
Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes, Homburg/Saar: PD Dr. med. Rädle, Prof. Dr. med. Zeuzem; Klinik
für Allgemeine Chirurgie, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg/Saar: PD Dr. med.
Rau; Abteilung für Anästhesie, Intensivmedizin und Schmerztherapie, BG-Unfallklinik Ludwigshafen: Prof. Dr. med. Kleinschmidt;
Medizinische Klinik I, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt a. M.: Prof. Dr. med. Zeuzem
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TABLE 1
Risk assessment according to the classification of the American Society of Anesthesiologists
(ASA) for elective surgery (ASA I–V) and emergency operations (ASA Ie–Ve; e: emergency) (e6–e8)
Group
Criteria
Systemic diseases (examples)
ASA I
Healthy patient
–
ASA II
Patient with mild systemic disease
without impaired functioning
Moderate hypertonus; moderate diabetes
not requiring insulin
ASA III
Patient with severe systemic disease
with impaired functioning
Compensated and decompensated heart failure;
chronic respiratory insufficiency;
severe diabetes with complications;
cirrhosis of the liver;
chronic renal insufficiency
ASA IV
Patient with severe systemic disease
that is life threatening with or
without surgery
Striking decompensated heart failure;
severe malignant hypertonus; shock and coma
of different genesis; progressive hepatic
and renal insufficiency
ASA V
Moribund patient who is not expected to
survive the following 24 hours with or
without surgery
Severe systemic disease with immediate risk
of death (e.g., fulminant pulmonary
embolus; extensive myocardial infarction with
cardiogenic shock)
liver damage and the actual operation are the main influential factors. Further risk factors
are a delayed metabolism of anesthetics/pharmaceuticals, altered perioperative hemodynamics
(volume load, hypotonus, reduced perfusion of the liver) and a higher postoperative risk
because of existing liver disease (3, 4). In liver surgery, improvements in preoperative
diagnostics, selection of patients, operative technique, administration of anesthesia, and
intensive care, as well as by concentrating these interventions in high volume centers have
reduced mortality to less than 5% (5–7).
Parameters for risk assessment
Liver function tests – Liver function tests are not suitable for risk assessment, with the
exception of synthesis and excretion parameters. In combination with clinical symptoms
they are useful in identifying hepatopathies (box 1) (e13).
Scoring systems – Since the liver has several functions, systems have been developed that
assess partial functions separately and relate the overall score to the mortality risk. The best
known of these prognostic scores is the Child-Turcotte-Pugh classification, first developed
by Child and Turcotte in 1964 and modified by Pugh in 1973 (table 2) (e14–e16). Although
encephalopathy and amount of ascites are undergoing subjective assessment and a deterioration
of the clinical condition is not always reflected in a change in classification, in patients with
liver cirrhosis it correlates well with perioperative mortality in very different operations (8–13).
The MELD (model for end stage liver disease) score is based on 4 objective clinical
parameters (box 2). This score was developed in 2000 as a mathematical model in patients with
liver disease to estimate the 3 month survival rate before TIPS implantation (14). The score
correlates well with overall mortality, captures individual changes in the course of the disease,
and is therefore used for organ allocation for liver transplantations. It is suitable as the predictive
parameters for perioperative morbidity and mortality in different procedures (e17–e22, 15, 16).
Quantitative liver function tests – Different testing systems have been developed to quantify
liver function (box 1). Prospectively, good correlations with the existing liver function were
found particularly for the indocyanine green plasma disappearance rate and 99mTc GSA
scintigraphy (17). These liver function tests are used for the preoperative assessment in
some centers (5, 7), but they are not suitable for generally used routine diagnostics.
Assessing the operative risk
The operative risk in patients with liver disease is shown on the basis of 3 clinical situations:
A patient has raised liver function tests without known liver disease: This occurs at a
rate of 1:300 to 1:700 in otherwise "healthy" candidates for surgery (e23, e24). If a
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single value is raised – for example, GPT, gamma GT, or AP – the operative risk is not
increased (e13, 18). Asymptomatic patients with several raised liver function test
results usually have relevant liver disease but rarely liver cirrhosis beyond Child-Pugh
stage A. Such patients thus have no increased operative risk.
Patients with known, functionally stable liver disease: These patients have no increased
operative risk in routine surgery (3, 4). Even in liver resections, patients with Child-A
cirrhosis of the liver have no increased mortality compared with controls (3.5% versus
3.0%) (9). In hepatic steatosis, mortality increases as a rule only in liver resection,
according to the extent of the steatosis (>10% if the liver fat content exceeds 30%)
(e 25, e26).
Patients with symptomatic liver disease: In progressive liver disease or decompensated
cirrhosis, the perioperative risk of complications, morbidity, and mortality is notably
increased. However, many studies documenting this date back several years now (3, 4,
8–13, e27). These days in perioperative management, pathophysiological changes in
other organ systems – such as the cardiovascular, lung, kidney, brain, and metabolic
systems – are being taken into consideration (table 3). The extent of such secondary
organ damage is as decisive for the operative risk as the primary liver function
impairment. In non-hepatic operations, the mortality risk for severe encephalopathy
increases by a factor of 35 (e28). Perioperative improvement of the patient's clinical
condition – such as therapy of coagulatory disorders, ascites, encephalopathy,
hyponatremia, and impaired renal function – may prevent complications especially in
Child-B and Child-C patients and reduce the operative risk. In cachectic patients,
preoperative parenteral feeding may be useful (e29– e33). In addition to the extent of
protein binding, pharmacological aspects of medical drugs relevant for anesthesia
and analgesia have to be taken into consideration. Newer volatile anesthetics, such as
BOX 1
Laboratory parameters and quantitative function
tests for the characterization of liver function
(e13, e78–e80, 17)
Laboratory parameters
Testing hepatocellular integrity:
GOT (AST)
GPT (ALT)
GLDH
Testing excretion function and cholestasis:
Bilirubin in serum (direct, indirect)
Alkaline phosphatase (AP)
Gamma glutamyl transferase (gamma GT)
Testing synthesis function:
Albumin
Cholinesterase (CHE)
Quick (INR), PTT
Individual coagulation factors (e.g., ATIII, Factor II, V)
Quantitative function tests
Testing excretory and metabolic capacity:
Indocyanine green (ICG) plasma disappearance rate*1
Aminopyrine breath test*2
Monoethylglycinexylidide lidocaine test (MEGX test)*2
99mTc galactosyl serum albumin (GSA) scintigraphy*2
*1 Evaluates excretory transport capacity for anorganic ions in analogy to serum bilirubin values
*2 Evaluates metabolic capacity in analogy to uric acid synthesis
GOT, glutamate oxalacetate transaminase; AST, aspartate aminotransferase;
GPT, Glutamate pyruvate transaminase; ALT, alanine aminotransferase; GLDH, Glutamate dehydrogenase;
INR, international normalized ratio; PTT, partial thromboplastin time
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desfluran and sevofluran, affect arterial liver circulation only slightly; but decreased
portal vein flow can be expected (18). Most induction anesthetics – for example,
barbiturates and propofol – result in generally reduced liver circulation. Intraoperatively
and perioperatively, stable hemodynamics should therefore be guaranteed. In addition to
further reduced liver function after the operation, surgical, infectious, or bleeding-related
complications have to be considered.
Operative risk and choice of method – In asymptomatic patients with liver disease, no
limitations apply for operative procedures; but particular attention might go to the liver
disease perioperatively and in managing anesthesia. In symptomatic patients, the liver
disease has to be considered in the context of the operative risk assessment. This is the case
for the indication and urgency of the procedure, as well as the choice of surgical method.
The risk is higher in abdominal surgery, especially in portal hypertension, than in extraabdominal operations. Surgery of the liver itself has to be differentiated from surgery of
other abdominal organs. Liver transplantation in the context of fulminant hepatitis or
end-stage chronic liver disease are special cases.
Emergency surgery – Interventions performed to save lives by definition are unequivocal
with regard to the necessity for and urgency of surgery. Independent of the risk of injury, in
patients with cirrhosis of the liver, emergency laparotomy increases the risk of complications
and the duration of postoperative intensive care (19). Altogether, mortality may be expected
to be up to 50% (10% in Child-A, 30% in Child-B, 82% in Child-C) (18% for elective
surgery) (8), which rises further postoperatively over 3 months (mortality after 1 month/
3 months; emergency surgery: 19%/44%; elective surgery. 17%/21%) (12).
Elective procedures – In elective procedures, liver function impairment has to be factored
into the risk assessment. This may determine the decision in favor of surgery or selection of
surgical method. In abdominal non-hepatic surgery, 30 day mortality in patients with cirrhosis of the liver is raised 4-fold (16.3% versus 3.5% in patients without liver disease). This
is determined by the Child-Pugh classification (Child-A 4%, Child-B 32%, Child-C 55%),
the time taken by the surgery, and the general postoperative complications (10). Child-C
cirrhosis as well as severe coagulopathy or extrahepatic complications are regarded as
contraindications. Surgical interventions to the hepatobiliary system are an exception in
liver disease. The operative treatment – for example, resection, liver transplantation – of
TABLE 2
Child-Pugh classification (e15) of cirrhosis of the liver and surgical risk on the basis of the
literature reviewed (e11, 3, 4, 8, 10)
Parameter
Points
1
2
3
Albumin (g/dl)
> 3.5
2.8–3.5
< 2.8
Bilirubin (mg/dl)
<2
2–3
>3
(in primarily biliary cirrhosis)
Quick value (%)
(alternatively INR)
<4
4–10
> 10
> 70
40–70
< 40
< 1.7
2.3–1.7
> 2.3
Ascites
None
Mild; responds
to treatment
Severe; resistant
to treatment
Encephalopathy
None
Stages I–II
Stages III–IV
Child-Pugh classification
A
B
C
Points
5–6
7–9
10–15
Operative risk
<1%
ca. 10 %
> 50 %
1 year mortality (%)
3–10 %
10–30 %
50–80 %
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hepatocellular carcinoma is determined by liver function, extent of the tumor, and location
of the carcinoma.
Mortality for resection of hepatocellular carcinoma in a cirrhotic liver has been reduced
to less than 5%, thanks to an improvement in patient selection (that is, a preference for
Child-A and Child-B patients, considering the liver function reserve, and comorbidity) and
to modern techniques (for example, preoperative ligation or embolization of the portal vein,
3-D simulation, calculation of residual liver volume, improved surgical resection techniques).
In liver transplantation, the rate is about 10% (5, 7, 20, 21, e34, e35). The indication for
cholecystectomy is made in people with healthy livers, because recent studies have reported
mortality figures of <1% for laparoscopic cholecystectomy in Child-A and Child-B patients
(22, e36, e37). Surgery on organs far removed from the liver present the main proportion of
all elective surgery in patients with liver disease. Surgery to the extremities or peripheral
vasculature is usually tolerated well, but cardiac surgery or operations on larger abdominal
or thoracic vessels are associated with a higher rate of complications and mortality (e27,
e38, e39).
Decisions in favor of operative or less invasive treatment methods should be taken with
patients and/or relatives, depending on the liver function and the existing finding while
considering the quality of life and life expectancy.
Esophagus and stomach
Patients with gastro-esophageal reflux disease often have bronchopulmonary complications,
for example, aspiration with subsequent pneumonia. These should be taken into
consideration when introducing anesthesia (rapid sequence induction technique). Stomach
ulcers and duodenal ulcers can easily be treated with drugs and present a lesser perioperative
risk factor. In many bigger surgical procedures or in risk patients (for example, with a
history of ulcers, Helicobacter-associated gastritis, medication with non-steroidal antiinflammatory drugs), the perioperative ulcer prophylaxis with a proton pump inhibitor is
standard treatment. If in a scenario of an upper gastrointestinal bleed that cannot be stopped
endoscopically or interventionally surgery to stop the bleed is required, mortality is 5–17%
depending on the resection method (e40).
In spite of numerous technical improvements, elective esophageal surgery ranges among
the complication prone intestinal surgical procedures even in experienced centers – the
Box 2
Calculation of MELD score
The calculation of the MELD score is done on the basis of 4 objective clinical
parameters (bilirubin, coagulation [INR], creatinine, and etiology of liver disease) (14, e17). The etiology of the liver disease is scored with 1 point in case of
lacking prognostic relevance.
When liver resection, cholecystectomy, or cardiac surgery is performed,
a score 8 (while taking into consideration the etiology of the liver disease) is
associated with notable perioperative morbidity.
On the basis of the current calculation without considering etiology, a MELD
score 14 is associated with a notably higher perioperative risk (15, 16,
e18–e22).
MELD-Score
= 3.8
11.2
9.6
6.4
x
x
x
x
ln(Bilirubin in mg/dL)
ln(INR)
ln(creatinin in mg/dL)
Etiology
Evaluation of etiology:
+
+
+
cholestatic or alcoholic = 0
Other = 1
Internet-based calculation possible under
http://www.mayoclinic.org/gi-rst/mayomodel5.html (initial model) or
http://www.mayoclinic.org/gi-rst/mayomodel6.html
(current United Network for Organ Sharing Modification)
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TABLE 3
Possible pathophysiological changes in other organ systems subsequent
to existing liver disease (3, 4, 18)
System
Pathophysiological change
Cardiovascular
Cardiac time volume raised
Blood volume raised
Peripheral vascular resistance lowered
Tendency to hypotonus
Pulmonary
Hypoxemia (hepatopulmonary syndrome)
Pulmonary arterial pressure raised
(portopulmonary hypertonus)
Emphysematous restructuring (e.g.,
in alpha-1 antitrypsin deficiency)
Renal
Renal blood flow lowered
Glomerular filtration rate lowered (hepatorenal syndrome)
Aldosterone raised
Cerebral
Glial edema owing to toxic effects
(hepatic encephalopathy)
Sensitivity to opioids raised
Metabolic-systemic
Thrombopenia, thrombasthenia
Hypocoagulability and hypercoagulability
Hypalbuminemia
Hyponatremia
Lowered serum cholinesterase
Hypoglycemia, hyperglycemia
Lowered uric acid synthesis
Reduced proliferation of osteoblasts (osteopathy)
Drug metabolism restricted
Endotoxin clearance restricted
minimum morbidity and mortality are 30% and 5%, respectively (e41, e42). In addition to a
concentration in high volume centers, a treatment algorithm that is adapted to the risk profile
of the patient (composite risk score) has mainly contributed to lowering morbidity and mortality.
If this algorithm, which has been prospectively evaluated by Siewert et al., is included in the
indication and selection of resection method (one or two stage procedure), hospital mortality
for esophageal resection can be lowered from 16% to 5% owing to better selection of patients
(23). The main risk factors include age, Karnofsky index, ASA score, proximal location of
tumor, and intraoperative blood loss (e43). Similar risk factors exist for gastrectomies (e10).
The preoperative risk profile should therefore be included into any treatment decision. For the
treatment of esophageal malignancies, equivalent, non-surgical, therapeutic options exist,
with regard to survival and quality of life (e44, e45).
Colon
In patients with chronic inflammatory colon disorders, elective resection or colectomy are
not associated with relevant perioperative mortality (e46, e47). Long term pretreatment
with steroids (prednisolone >20 mg/day), other immunosuppressive drugs, or infliximab do
not increase perioperative mortality (e48–e50). Severe pancolitis, colonic bleeds that
cannot be managed endoscopically or interventionally, abscesses, toxic megacolon or
perforation require immediate surgical treatment.
Perioperative mortality in toxic megacolon is 16% (e51). Severe pseudomembranous or
ischemic colitis – itself associated with mortality of up to 15% – can result in emergency
colectomy with a raised mortality risk, if conservative treatment fails (e52, e53). For surgical
treatment of colorectal cancer, age (>70 or 80 years), a high ASA or APACHE-II score,
anemia, and emergency surgery were found to be risk factors for an increase in perioperative
mortality by 10–20% (e2, e3, e5). In elective surgery to the colon, however, in the context
of "fast track" surgery, a standardized sequence of useful perioperative measures – for example,
atraumatic surgical technique, avoidance of hypovolemia and hypoxia, sufficient analgesia,
and early mobilization and nutrition – markedly improved the complication rate and particularly
the postoperative reconvalescence (e54).
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TABLE 4
Gastroenterological disorders with severe and relative contraindications for elective surgery
to other organ systems
Contraindications for elective surgical
procedures
Disorders that may result in an indication
for urgent surgery
Severe
Acute pancreatitis
Gastrointestinal hemorrhage
Acute mesenteric ischemia
Peritonitis
Acute cholangitis
Paralytic ileus
Acute infectious enteritis
Infected necroses
Therapy refractory hemorrhage
Intestinal gangrene
Perforation of intestinal organ
Acute cholecystitis
Appendicitis
Mechanical ileus
Relative
Florid stomach or duodenal ulcer
Diverticulitis
Severe colitis
– Ulcerative colitis, Crohn's disease
– Ischemic colitis
– Pseudomembranous colitis
Severe reflux esophagitis
Intestinal pseudo-obstruction
Malnutrition
Bleeding ulcer refractory to therapy, perforation of ulcer
Perforated diverticulum
Toxic megacolon, perforation of colon
Because of their severity or in disease specific complications, () these disorders may themselves result in an urgent surgical indication.
Pancreas
In contrast to the clinically mild edematous form, severe acute pancreatitis is still associated
with a total mortality of 10–20% (e55). The main risk factors include organ failure that is
refractory to treatment in the early phase (e56, e57) and later infection of the pancreatic
necroses (e58). The severity of the organ failure becomes increasingly important
compared to a necrosis infection (e57, e59). In infected necroses that are refractory to
therapy, necrosectomy is required after 3 to 4 weeks, which is associated with a mortality
of 20–30% (e60). Further relevant risk factors are obesity, the patient's age, comorbidities,
and the need for surgery soon after onset of illness (e59, e61–e63).
Chronic pancreatitis does not present an operative risk factor, provided that substitution
therapy is sufficient. In large patient series, even in pancreatic malignancies no relevant
surgical risk factor was assessed that was associated with increased mortality. When
patients were older than 70, only the complication rate due to comorbidities was 25%
higher (e64–e67). The influence of surgical and location-related factors on postoperative
mortality and morbidity after pancreatic resection has been amply documented (e64, e65).
Acute porphyria
The 4 forms of acute porphyria present as acute, life threatening illness that manifest with
gastrointestinal, neurological, and cardiovascular symptoms and are often difficult to
diagnose. Smoking, fasting, infections, operations, or pharmaceuticals – for example,
barbiturates – may result in an acute episode. Elective surgery can mostly be undertaken
without any problem, as long as disease triggering drugs and long periods of no food intake
are avoided, glucose is administered continually during the operation, and postoperative
monitoring is extended (e68–e70). However, the operative risk for a patient with previously
undiagnosed porphyria is almost impossible to assess.
Nutritional status
The importance of a reduced nutritional status for the perioperative rate of complications,
morbidity, and mortality has been well documented (24, 25). A reduced physical and mental
state, lowered immunity, and delayed wound healing are sequelae of malnutrition. For the
evaluation of the nutritional status, the methods listed in the additional table (see additional
material at the end of this article) are recommended.
To prepare for abdominothoracic operations, in patients with a nutritional deficiency,
parenteral hyperalimentation for 7 to 14 days, and an adequate substitution of vitamins and
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DIAGRAM
How to proceed in patients with liver disease and planned surgical procedure (adapted from 4)
*1Current calculation without taking into consideration the etiology of the liver disease (box 2)
*2Because of high mortality, individual decision possible especially in emergency procedures
minerals are effective. Recent studies show a reduced complication rate after
abdominothoracic surgery after administration of preoperative oral supplementation
(liquid food for 5 to 7 days) even in patients of normal weight (e71-e74). Early parenteral
or oral feeds are associated with a reduction in infectious complications and a shorter stay
in hospital (e75). However, this effect is often smaller than that associated with preoperative
supplementation.
Clearly overweight patients (BMI >30) also have more operative and perioperative
problems, for example, poor wound healing, cardiac comorbidities, thrombo-embolic
complications. Postoperatively, adequate thromboprophylaxis and regular control of the
surgical wound and cardiac function are required (e76, e77).
Gastroenterological disorders: risk during surgery to other organ systems
Gastroenterological disorders include a wide range of different disorders that require different
therapies. The risk is determined particularly by the severity of the illness and the kind of
operation that is planned. This is also the case for procedures without a direct association to
the underlying illness. Chronic, clinically stable and easy to treat diseases are included with
the general comorbidities during the perioperative risk assessment and usually do not pose
a particular risk factor. The disease status should, however, be evaluated preoperatively by
using suitable laboratory chemistry, imaging techniques, or endoscopic procedures; and the
same is true for the existing drug treatment.
In individual gastroenterological disorders that are characterized by acute onset or high
inflammatory activity (table 4), surgery should not be undertaken during the acute phase.
An improvement in the disorder should be worked towards by using specific treatment and
then one should wait until this improvement has occurred. But these disorders may
themselves lead to urgent surgical indications-as a result of life threatening complications
and failure of the drug or interventional therapy-which may even be associated with clearly
increased perioperative mortality. The disorders listed in table 4 may be regarded as
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contraindications for other surgical procedures. However, especially in emergencies, the
individual case should be assessed independently.
Conclusion
Severe or progressive illness can markedly increase the risk of operative procedures. In
view of current medical options, absolute contraindications have become less important in
favor of relative contraindications. Whereas patients with Child-A cirrhosis have no
increased operative risk and patients with Child-B cirrhosis a moderately increased risk,
elective operations are usually contraindicated in patients with Child-C cirrhosis or a
MELD score 14 because of considerable mortality (diagram). Liver transplantation in
acute or chronic liver failure is a special case, however. In high risk patients, a targeted
improvement in their clinical condition before an operation may prevent complications or
enable operability. The cornerstones of this management are based on perioperative therapy
of complications of the liver disease (coagulopathy with bleeds, ascites, encephalopathy,
impaired renal function, and malnutrition).
In addition to an improved preoperative identification of risk patients with scoring
systems or liver function tests, perioperative morbidity and mortality can be lowered further
through anesthesiological management, i.e., selection of drugs, volume management, and
avoidance of hypotonus. Improved surgical techniques – such as procedures to transect the
hepatic parenchyma and reduce intraoperative blood loss, as well as comprehensive
interdisciplinary care delivered from all involved specialties – improve perioperative
morbidity and mortality.
Gastroenterological disorders include a wide range of different diseases that entail a very
variable perioperative risk. While clinically stable disorders have a secondary role in
perioperative risk assessment, elective surgery should be avoided in a scenario of severe
inflammation or acute onset of illness. In the context of current medical treatment options,
however, only few gastroenterological disorders present serious contraindications.
Conflict of Interest Statement
The authors declare that no conflict of interest exists according to the Guidelines of the International Committee of Medical
Journal Editors.
Manuscript received on 3 August 2006, final version accepted on 17 April 2007.
Translated from the original German by Dr Birte Twisselmann.
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Corresponding author
PD Dr. med. Jochen Rädle
Klinik für Innere Medizin II, Gastroenterologie, Hepatologie,
Endokrinologie, Diabetologie und Ernährungsmedizin
Universitätsklinikum des Saarlandes
Kirrberger Str., 66424 Homburg/Saar, Germany
jochen.raedle@uniklinikum-saarland.de
ADDITIONAL TABLE - SEE NEXT PAGE
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ADDITIONAL TABLE
Screening methods for assessing the nutritional status of outpatients and inpatients,
as well as elderly patients (e81, e82)
Screening method
Target group/setting
MUST
Adults
Influential variables and assessment
Body mass index
Malnutrition universal
screening Tool
General practice
Unplanned weight loss in preceding
3–6 months
Acute illness with no food intake for
more than 5 days
Maximum of 6 points:
Malnutrition 2 points
NRS-2002
Adults
Nutritional risk screening
Hospital
Prescreening with 4 questions
Body mass index
Weight loss in preceding 3 months
Lowered food intake
Severity of illness
Main screening if one of the prescreening
questions answered in the affirmative
Impaired nutritional status
Severity of illness
Age
Maximum of 7 points:
Nutritional risk 3 points
MNA
Mini nutritional assessment
Old patients
Institution for old people
Pre-history with 6 questions;
Maximum 14 points;
Nutritional risk 11 points
Appetite
Weight loss
Mobility
Acute illness
Psychological situation
Body mass index
Main history with 12 questions
Living situation
Drugs
Nutritional habits (number of meals, choice
of foods, amount of fluids taken in)
Self assessment
Anthropometric measures
(circumference of upper arm, calf)
Maximum 30 points;
Malnutrition 17 points
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