Special Considerations for People with Liver Disease Undergoing Oral Surgery

The special characteristics of dental treatment for cirrhotic patients should be understood to minimize possible complications in the treatment of people with liver disease. A recent study found that intranasal desmopressin at a dose of 300 mcg is as effective as blood product transfusion in achieving hemostasis in cirrhotic patients with moderate coagulopathy who undergo tooth extraction. Vitamin K injection is preferably administered intravenously at doses of 10 mg for 3 days in patients with decompensated cirrhosis undergoing surgery. Dental treatment in cirrhotic patients, in particular interventions involving bleeding, should not be performed before considering the stage of the disease and the need for antibiotic prophylaxis to reduce complications resulting from the spread of infection, especially in patients with advanced cirrhosis.

It is important to assess the severity of liver dysfunction before surgery and the risk and benefit of the procedure should be carefully evaluated. The severity of the disease can range from a slight increase in transaminases to decompensated cirrhosis. If possible, surgery should be avoided in the emergency setting, in the case of acute and alcoholic hepatitis, in a patient with childhood class C cirrhosis or with a MELD score greater than 15, or in any patient with significant extrahepatic organ dysfunction. In this subgroup of patients, every possible means should be tried to treat these patients conservatively. Modified Child-Pugh scores and the End-Stage Liver Disease (MELD) scoring model can predict mortality after surgery quite reliably, including non-hepatic abdominal surgery.

Preoperative optimization would include ascites control, correction of electrolyte imbalance, improvement of renal dysfunction, cardiorespiratory evaluation, and coagulation correction. Global hemostasis tests, such as thromboelastography and thrombin generation time, can better predict the risk of bleeding compared to conventional coagulation tests in patients with cirrhosis. Correcting the international standard ratio with fresh frozen plasma does not necessarily mean a reduction in the risk of bleeding and may increase the risk of volume overload and lung injury. The international normalized ratio (liver) may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis who need surgery needs further studies.

During the operation, safe anesthetics such as isoflurane and propofol are recommended to prevent hypotension. In general, nonsteroidal anti-inflammatory drugs (NSAIDs) or benzodiazepines should not be used. Intraabdominal surgery in a patient with cirrhosis becomes more difficult in the presence of ascites, portal hypertension and hepatomegaly. Uncontrolled bleeding due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening liver failure contribute to morbidity and mortality in these patients. Measures should be taken to reduce ascitic leakage and infections.

Any patient with cirrhosis who undergoes major surgery should be referred to a specialized center with experience in treating liver diseases. Abstinence before elective surgery should be recommended for people with a history of excessive alcohol consumption to avoid alcohol withdrawal in the perioperative period, even in the absence of significant liver disease. Although it corrects in vitro coagulation tests, its benefit has not been documented in patients with cirrhosis undergoing non-hepatic surgery. Patients with cirrhosis should undergo regular dental checkups to maintain good oral hygiene, thus avoiding oral infections and invasive treatments. In any patient with cirrhosis B or C in children who undergoes surgery under general anesthesia, it is important that the patient be monitored after the operation in an ICU. The risk of surgery in a patient with liver disease depends on several factors, such as the etiology and severity of the liver disease and the type of surgery.

About three-quarters of bariatric surgery patients have hepatic steatosis, a quarter have fibrosis, and between 1 and 2% of patients will have cirrhosis as an unexpected result. Gender, the underlying systemic disease, the state of oral hygiene, the dental treatment considered necessary, the dental treatment actually performed and the duration of follow-up were tabulated. Independent predictors of complications and mortality in patients with cirrhosis undergoing surgery.

Mónica Dahlheimer
Mónica Dahlheimer

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