Perioperative Risk Assessment & Management in Cirrhosis

Risk stratification, preoperative optimization, intraoperative management, and postoperative monitoring — ACG 2025.

Risk Assessment

VOCAL-Penn, MELD & Child-Pugh

Perioperative Risk: Cirrhosis Changes Everything

Cirrhotic patients face dramatically elevated surgical mortality. Accurate risk stratification guides the decision to operate — and how to optimize before surgery.

Child-Pugh A

~2%

Acceptable surgical risk

Child-Pugh B

~12%

Intermediate risk; optimize aggressively

Child-Pugh C

>50%

Avoid elective surgery; consider transplant

VOCAL-Penn Score (ACG 2025 Guideline — Preferred Tool)

Validated in >1,400 cirrhotic patients. Predicts 30-day and 90-day postoperative mortality. Includes: MELD-Na, surgery type, ASA class, age, albumin, operative urgency.

MELD-Na (strongest predictor)

Surgery type (highest risk: cardiac, hepatic resection)

ASA physical status class

Age

Serum albumin

Elective vs. emergency surgery

Available online: www.vocalpenn.org — use before any elective surgery in cirrhotic patients

Contraindications to Elective Surgery

Child-Pugh C, acute liver failure, severe acute alcoholic hepatitis, acute decompensation (active variceal bleed, SBP, HRS), MELD >25 for most procedures, MELD >15 for major abdominal surgery.

Mahmud N et al. ACG Clinical Guideline: Perioperative Risk Assessment in Cirrhosis. Am J Gastroenterol. 2025.