ACG Clinical Guideline: Perioperative Risk Assessment and Management in Patients With Cirrhosis

This guideline presents a comprehensive approach to perioperative risk assessment and management in patients with cirrhosis. Recognizing the unique surgical risks in this population, the guideline emphasizes a multidisciplinary approach to preoperative evaluation, perioperative care, and postoperative follow-up. Key considerations include the severity of liver disease, nonhepatic comorbidities, and surgery-specific factors, with an emphasis on the use of validated cirrhosis-specific risk calculators, such as the VOCAL-Penn Score, for individualized risk stratification. Recommendations highlight preoperative optimization strategies, including nutritional support, management of portal hypertension, correction of hemostatic abnormalities, and addressing frailty and sarcopenia. For patients with decompensated cirrhosis, interventions such as transjugular intrahepatic portosystemic shunt may reduce portal pressure and surgical risks when indicated. Elective surgeries, including cholecystectomy and hernia repair, are advised for select patients with compensated cirrhosis, whereas alternatives to surgery are explored for high-risk patients. The guideline underscores the importance of performing surgeries at high-volume centers with expertise in managing patients with cirrhosis and emphasizes shared decision-making informed by objective risk assessments. Furthermore, it addresses procedure-specific considerations, including the role of bariatric and cardiac surgeries in cirrhotic patients. Through evidence-based recommendations and expert insights, this guideline aims to enhance surgical outcomes and inform clinical decision-making in a growing population of patients with cirrhosis undergoing surgery.