The prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery

Abstract Background surgery in cirrhosis associates a high morbidity and mortality. Retrospectively reported prognostic factors include emergency procedures, liver function (MELD/Child-Pugh) and portal hypertension (assessed by indirect markers). This study assessed the prognostic role of hepatic venous pressure gradient (HVPG) and other variables in elective extra-hepatic surgery in patients with cirrhosis. Methods 140 patients with cirrhosis (Child A/B/C: 59/37/4%) planned for elective extra-hepatic surgery (abdominal, n=121; cardiovascular/thoracic, n=9; orthopedic and others, n=10) were prospectively included in 4 centres (2002-2011). Hepatic and systemic hemodynamics (HVPG, indocyanine green clearance, pulmonary artery catheterization) were assessed prior to surgery and clinical and laboratory data were collected. Patients were followed-up for 1 year and mortality, transplantation, morbidity and post-surgical decompensation were studied. Results 90 days and 1-year mortalities were 8% and 17%, respectively. Variables independently associated with 1-year mortality were ASA class (American Society of Anesthesiologists), high-risk surgery (defined as open abdominal and cardiovascular/thoracic) and HVPG. These variables closely predicted 90, 180 and 365 days mortality (C-statistic>0.8). HVPG values >16 mmHg were independently associated with mortality and values ≥20 mmHg identified a subgroup at very high risk of death (44%). Twenty-four patients presented persistent or de novo decompensation at 3 months. A low body mass index, Child-Pugh class and high-risk surgery were associated with death or decompensation. No patient with HVPG 0.63 developed decompensation. Conclusions ASA class, HVPG and high-risk surgery were prognostic factors of 1-year mortality in cirrhotic patients undergoing elective extra-hepatic surgery. HVPG values >16 mmHg and specially ≥20 mmHg, associated a high risk of post-surgical mortality. LAY SUMMARY The hepatic venous pressure gradient is associated with outcomes in patients with cirrhosis undergoing elective extra-hepatic surgery. It allows a better stratification of risk in these patients and sets the frame for potential interventions to improve post-surgical outcomes.