Pre-Operative Assessment for Biliary Tract Surgery

Abstract

The pre-operative approach to the patient with prolonged jaundice due to a long-standing obstruction of the bile duct is, we find, very similar to that of the patient with hepatic parenchymal disease who requires surgery for the treatment of portal hypertension. Complex and sophisticated tests of liver function are not required and a reasonable assessment of the patient's ability to withstand operation may be made by estimating the serum ammonia and bilirubin and the plasma glucose and albumin.

Particularly useful in this assessment is the Child's classification (Child, 1964). This is based on 3 clinical and 2 laboratory tests. On this basis the patient may be assigned to 1 of 3 groups. Patients who belong to Child's group A have good hepatic reserve and are similar to individuals who have been deprived of no more than 30 per cent of their liver function. Patients of Child's group C, on the other hand, are similar to patients who have lost 90 to 95 per cent of liver function and operation in them carries a considerable risk. Moreover, because of their basic disease, the liver may have no regenerative powers and further improvement in liver function cannot be expected. These patients are hardly ever operable, although certain supportive measures may improve their general status and they may eventually be operated upon but considerable risks must be recognised. In an intermediate position are the patients who belong to group B of the Child's classification. These patients have evidence of hepatic dysfunction and require the energetic and detailed preparation described below.