Gastroenterology

Gastroenterology

Volume 132, Issue 4, April 2007, Pages 1261-1269
Gastroenterology

Clinical–liver, pancreas, and biliary tract
Risk Factors for Mortality After Surgery in Patients With Cirrhosis

Presented in abstract form at the plenary session of the American Association for the Study of Liver Diseases (AASLD) meeting, Digestive Diseases Week (DDW), Chicago, Illinois, May 15, 2005.
https://doi.org/10.1053/j.gastro.2007.01.040Get rights and content

Background & Aims: Current methods of predicting risk of postoperative mortality in patients with cirrhosis are suboptimal. The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. The aim of this study was to determine the risk factors for postoperative mortality in patients with cirrhosis. Methods: Patients with cirrhosis (N = 772) who underwent major digestive (n = 586), orthopedic (n = 107), or cardiovascular (n = 79) surgery were studied. Control groups of patients with cirrhosis included 303 undergoing minor surgical procedures and 562 ambulatory patients. Univariate and multivariable proportional hazards analyses were used to determine the relationship between risk factors and mortality. Results: Patients undergoing major surgery were at increased risk for mortality up to 90 days postoperatively. By multivariable analysis, only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, <8) to more than 50% (MELD score, >20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period. Conclusions: MELD score, age, and American Society of Anesthesiologists class can quantify the risk of mortality postoperatively in patients with cirrhosis, independently of the procedure performed. These factors can be used in determining operative mortality risk and whether elective surgical procedures can be delayed until after liver transplantation.

Section snippets

Study Population

Using the Surgical Procedure Index database at the Mayo Clinic in Rochester, Minnesota, we retrospectively searched for the records of patients with cirrhosis from any cause who underwent major digestive, orthopedic, or cardiac surgical procedures. Patients were stratified into 2 study populations based on decade of treatment (1980–1990 vs 1994–2004). A total of 825 patients were identified. All patients who had laparoscopic cholecystectomy (n = 46) and those in whom all MELD parameters were

Demographics

Patient characteristics are shown in Table 1; follow-up was complete in all groups. The etiology of cirrhosis included alcoholic liver disease; viral hepatitis; cholestatic liver disease (primary biliary cirrhosis and primary sclerosing cholangitis); and other causes such as autoimmune hepatitis, nonalcoholic steatohepatitis, and cryptogenic. Patients in the outpatient and minor surgery control groups did not differ from each other according to the Charlson index (mean ± standard deviation, 5.3

Discussion

In patients with cirrhosis, the risk of mortality is related to the severity of liver disease, the comorbid conditions, the type of surgery, and probably the skill of the medical team. This study concludes that the most important predictors of mortality are (1) severity of liver disease as reflected by the MELD score, (2) age, and (3) comorbid conditions as determined by the ASA physical status classification. Therefore, MELD score, ASA class, and age may be used to characterize patients with

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    Supported in part by grant DK-34238 from the National Institute of Diabetes, Digestive and Kidney Diseases.

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