COMMENTARY

Postoperative Mortality in Patients With Cirrhosis

David A. Johnson, MD, FACG, FACP

Disclosures

July 17, 2007

Risk Factors for Mortality After Surgery in Patients With Cirrhosis

Teh SH, Nagorney DM, Stevens SR, et al
Gastroenterology. 2007;132:1261-1269

It is well accepted that patients with cirrhosis have an increased risk for morbidity and mortality associated with surgery. A number of assessments have been used in an attempt to predict the relative risks associated with surgery in these patients. Factors associated with perioperative complications and mortality include a Child-Turcotte-Pugh score > 7, cardiopulmonary comorbidity, American Society of Anesthesiologists (ASA) physical status class of IV or V, or increased serum creatinine.[1] More recently, the Model for End-stage Liver Disease (MELD) score has been used to assess risk in this setting. Although this chronic liver disease severity scoring system was originally developed to assess the short-term prognosis of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt, MELD has subsequently been validated as a predictor of mortality in patients with many types of liver disease, particularly for the assessment of mortality risk both with and without transplant intervention. Since 2002, MELD has been the primary assessment used to prioritize allocation of organs for liver transplantation in the United States. The MELD scoring system, however, has not been well studied in predicting mortality in cirrhotic patients undergoing surgery other than liver transplantation.

This retrospective database analysis conducted at the Mayo Clinic, Rochester, Minnesota, involved patients with cirrhosis from any cause. A total of 772 patients were identified who underwent major gastrointestinal (n = 586), orthopaedic (n = 107), and cardiovascular (n = 79) surgery. Patients who underwent gastrointestinal surgery were arbitrarily stratified into 2 groups, Group A and Group B. The specifics of the surgical procedures for all patient groups were as follows:

  • Group A: hepatobiliary (n = 209), portosystemic shunts (n = 86), esophagus/gastric (n = 51), and duodenum and pancreas (n = 26);

  • Group B: small and large intestine (n = 170), spleen (n = 44);

  • Group C: knee replacement (n = 52), hip arthroplasty (n = 28), femur (n = 18), and spine (n = 9); and

  • Group D: coronary artery bypass (n = 27), aortic aneurysm repair (n = 18), and valve replacement (n = 34).

The ASA physical status and MELD scores were calculated for each patient and assessed for short- and long-term mortality risks as the target endpoints. The outcomes for patients with cirrhosis undergoing major surgery were compared with those of a cohort of matched cirrhotic patients who were outpatients or undergoing "minor surgery" under general anesthesia (eg, herniorrhaphy, appendectomy). All patients with cirrhosis undergoing major surgery had an increased risk for postoperative mortality both at 30 and 90 days. By univariate analysis, there were significant differences in the mortality for ASA status class III and IV among patients undergoing major surgery. A single-point increase in the MELD score was associated with a 14% increase in the 30- and 90-day postoperative mortality, a 15% increase in mortality in the first postoperative year, and with a 6% increase in mortality for subsequent years. By multivariable analysis, only the MELD score, ASA class, and age predicted mortality at 30 or 90 days, at 1 year, and at subsequent years -- all independent of the type of surgery that was done. The 30-day mortality rate ranged from 5.5% for a MELD score < 8 to 53.8% for MELD score 21-25 and to 90% for a MELD score > 25.

This report will be extremely helpful to gastroenterologists consulting on the operative risks for surgical intervention in their patients with cirrhosis. Prior studies that used MELD scores for predicting mortality in patients with cirrhosis undergoing surgery showed that higher scores were associated with increased morbidity and mortality. However, these studies were restricted to cardiac surgery alone, included a patient cohort with a low mortality rate, or focused only on 30-day mortality. In contrast, the current study evaluated both the short- and long-term mortality risk for cirrhotic patients undergoing surgery, and included patients undergoing a broad spectrum of gastrointestinal surgical interventions as well as orthopaedic and cardiovascular procedures. The advantage of the MELD score is that it can be used to assess postoperative mortality, regardless of the intervention.

Abstract

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