Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

Peri-operative identification and management of patients with unhealthy alcohol intake

INTRODUCTION

This consensus statement gives practical advice for the safe management of patients with harmful alcohol intake undergoing elective and emergency surgery. The wide spectrum of alcohol-related organ dysfunction observed in this cohort of patients may have a profound impact on care, and the additional effects of alcohol withdrawal may further exacerbate postoperative morbidity and mortality.

METHODS

A working party was assembled based on clinical and/or academic expertise in the area. Recommendations were formulated using a modified Delphi process. An initial list of recommendations was produced following targeted literature reviews for all relevant phases of patient care throughout the peri-operative pathway. These recommendations were distributed among the authors who rated each as 'include', 'exclude'; or 'revise'. Recommendations with ≥ 75% inclusion decision were included.

RESULTS

The working party produced a list of 10 key peri-operative management recommendations. These include recommendations on how to screen effectively for excessive alcohol usage in the surgical population. To achieve this, a validated point-of-care tool is used with additional weighting provided by considering surgical urgency. This is combined with the use of scoring systems to facilitate decisions regarding peri-operative care including postoperative location. This document also provides clear explanation of the physiological and pharmacological issues relating to alcohol excess, highlighting the direct effects of alcohol and its secondary effects on organ systems.

DISCUSSION

This consensus statement offers strategies and solutions to minimise the impact of harmful alcohol intake on the safe conduct of anaesthesia.

Preoperative risk evaluation and optimization for patients with liver disease

The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.

Position paper on perioperative management and surgical risk in the patient with cirrhosis

INTRODUCTION

Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context.

AIMS

The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients.

RESULTS

Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care.

CONCLUSIONS

The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.

Resuscitation and Preparation of the Emergency General Surgery Patient

Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.

Assessing the risk of surgery in patients with cirrhosis

Patients with cirrhosis have an increased perioperative risk relative to patients without cirrhosis. This is related to numerous cirrhosis-specific factors, including severity of liver disease, impaired synthetic function, sarcopenia and malnutrition, and portal hypertension, among others. Nonhepatic comorbidities and surgery-related factors further modify the surgical risk, adding to the complexity of the preoperative assessment. In this review, we discuss the pathophysiological contributors to surgical risk in cirrhosis, key elements of the preoperative risk assessment, and application of risk prediction tools including the Child-Turcotte-Pugh score, Model for End-Stage Liver Disease-Sodium, Mayo Risk Score, and the VOCAL-Penn Score. We also detail the limitations of current approaches to risk assessment and highlight areas for future research.

Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach

INTRODUCTION

Patients with liver disease and portal hypertension frequently require surgery carrying high morbidity and mortality. Accurately estimating surgical risk remains challenging despite improved medical and surgical management.

AREAS COVERED

This review aims to outline a comprehensive approach to preoperative assessment, appraise methods used to predict surgical risk, and provide an up-to-date overview of outcomes for patients with cirrhosis undergoing non-hepatic surgery.

EXPERT OPINION

Robust preoperative, individually tailored, and precise risk assessment can reduce peri- and postoperative complications in patients with cirrhosis. Established prognostic scores aid stratification, providing an estimation of postoperative mortality, albeit with limitations. VOCAL-Penn Risk Score may provide greater precision than established liver severity scores. Amelioration of portal hypertension in advance of surgery may be considered, with prospective data demonstrating hepatic venous pressure gradient as a promising surrogate marker of postoperative outcomes. Morbidity and mortality vary between types of surgery with further studies required in patients with more advanced liver disease. Patient-specific considerations and practicing precision medicine may allow for improved postoperative outcomes.

Risk Prediction Models for Postoperative Decompensation and Infection in Patients With Cirrhosis: A Veterans Affairs Cohort Study

BACKGROUND AND AIMS

Patients with cirrhosis have an increased risk of postoperative mortality for a range of surgeries; however, they are also at risk of postoperative complications such as infection and cirrhosis decompensation. To date, there are no prediction scores that specifically risk stratify patients for these morbidities.

METHODS

This was a retrospective study using data of patients with cirrhosis who underwent diverse surgeries in the Veterans Health Administration. Validated algorithms and/or manual adjudication were used to ascertain postoperative decompensation and postoperative infection through 90 days. Multivariable logistic regression was used to evaluate prediction models in derivation and validation sets using variables from the recently-published Veterans Outcomes and Costs Associated with Liver Disease (VOCAL)-Penn cirrhosis surgical risk scores for postoperative mortality. Models were compared with the Mayo risk score, Model for End-stage Liver Disease (MELD)-sodium, and Child-Turcotte-Pugh (CTP) scores.

RESULTS

A total 4712 surgeries were included; patients were predominantly male (97.2 %), white (63.3 %), and with alcohol-related liver disease (35.3 %). Through 90 postoperative days, 8.7 % of patients experienced interval decompensation, and 4.5 % infection. Novel VOCAL-Penn prediction models for decompensation demonstrated good discrimination for interval decompensation (C-statistic 0.762 vs 0.663 Mayo vs 0.603 MELD-sodium vs 0.560 CTP; P < .001); however, discrimination was only fair for postoperative infection (C-statistic 0.666 vs 0.592 Mayo [P = .13] vs 0.502 MELD-sodium [P < .001] vs 0.503 CTP [P < .001]). The model for interval decompensation had excellent calibration in both derivation and validation sets.

CONCLUSION

We report the derivation and internal validation of a novel, parsimonious prediction model for postoperative decompensation in patients with cirrhosis. This score demonstrated superior discrimination and calibration as compared with existing clinical standards, and will be available at www.vocalpennscore.com.

The imperative for an updated cirrhosis surgical risk score

The burden of cirrhosis is increasing, as is the need for surgeries in patients with cirrhosis. These patients have increased surgical risk relative to non-cirrhotic patients. Unfortunately, currently available cirrhosis surgical risk prediction tools are non-specific, poorly calibrated, limited in scope, and/or outdated. The Mayo score is the only dedicated tool to provide discrete post-operative mortality predictions for patients with cirrhosis, however it has several limitations. First, its single-center nature does not reflect institution-specific practices that may impact surgical risk. Second, it pre-dates major surgical changes that have changed the landscape of patient selection and surgical risk. Third, it has been shown to overestimate risk in external validation. Finally, and perhaps most importantly, the score does not account for differences in risk based on surgery type. The clinical consequences of inaccurate prediction and risk overestimation are significant, as patients with otherwise acceptable risk may be denied elective surgical procedures, thereby increasing their future need for higher-risk emergent procedures. Confident evaluation of the risks and benefits of surgery in this growing population requires an updated, generalizable, and accurate cirrhosis surgical risk calculator that incorporates the type of surgery under consideration.

Mortality After Extrahepatic Gastrointestinal and Abdominal Wall Surgery in Patients With Alcoholic Liver Disease: A Systematic Review and Meta-Analysis

AIMS

This meta-analysis aimed to define the perioperative risk of mortality in patients with alcoholic liver disease (ALD) undergoing extrahepatic gastrointestinal surgery.

METHODS

Systematic searches of Embase, Medline and CENTRAL were undertaken to identify studies reporting about patients with ALD undergoing extrahepatic gastrointestinal surgery published since database inception to January 2019. Studies were only considered if they reported on mortality as an outcome. Pooled analysis of mortality was stratified as benign and malignant surgery and specific operative procedures where feasible.

RESULTS

Of the 2899 studies identified, only five studies met inclusion criteria, representing cholecystectomy (one study), umbilical hernia repair surgery (one study) and oesophagectomy (three studies). The total number of patients with ALD in these studies was 172. Therefore, any study on liver disease patients undergoing extrahepatic surgery that crucially included a subset with alcohol aetiology was included as a secondary analysis even though they failed to stratify mortality by underlying aetiology. The total number of studies that met this expanded inclusion criteria was 62, reporting on 37,703 patients with liver disease of which 1735 (4.5%) had a definite diagnosis of ALD. Meta-analysis of proportions of in-hospital mortality in patients with ALD undergoing upper gastrointestinal cancer surgery (oesophagectomy) was 23% [95% confidence interval (CI) 14-35%, I2 = 0%]. In-hospital mortality following oesophagectomy in liver disease patients of all aetiologies was lower, 14% (95% CI 9-21%, I2 = 41.1%).

CONCLUSION

Postoperative in-hospital mortality is high in patients with liver disease and ALD in particular. However, the currently available evidence on ALD is limited and precludes definitive conclusions on postoperative mortality risk.

The Impact of Cirrhosis on Pancreatic Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Cirrhosis has been considered a contraindication to major abdominal surgeries, due to increased risk for postoperative morbidity and mortality. The aim of this study was to assess the safety of pancreatectomy in cirrhotic versus non-cirrhotic patients.

METHODS

The present systematic review and meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All meta-analyses were performed using the random effects model.

RESULTS

Eight studies were eventually included, enrolling 1229 patients (cirrhotics: 722; and Child-Pugh A: 593; Child-Pugh B/C: 129) who underwent surgery for pancreatic cancer. The overall postoperative morbidity rate was 66% (51%-80%). Infections (26%) and ascites formation/worsening (23%) were the most common postoperative complications, followed by anastomotic leak/fistula (17%). Non-cirrhotic patients were less likely to suffer from anastomotic leak/fistula (OR: 0.39; 95% CI: 0.23-0.65) and infections (OR: 0.41; 95% CI: 0.25-0.67). Postoperative mortality rate was statistically significantly lower in non-cirrhotic versus cirrhotic patients (OR: 0.18; 95% CI:0.18-0.39). The odds ratios of 1 year (OR: 0.62; 95% CI: 0.30-1.30), 2 year (OR: 0.67; 95% CI: 0.25-1.83) and 3 year all-cause mortality (OR: 0.32; 95% CI: 20.03-2.99) were not significantly different between cirrhotic versus non-cirrhotic patients.

CONCLUSION

This study demonstrated that non-cirrhotic patients were less likely to undergo any type of re-intervention and had statistically significant lower postoperative mortality rates compared to patients with cirrhosis.

Risk Prediction Models for Post-Operative Mortality in Patients With Cirrhosis

BACKGROUND AND AIMS

Patients with cirrhosis are at increased risk of postoperative mortality. Currently available tools to predict postoperative risk are suboptimally calibrated and do not account for surgery type. Our objective was to use population-level data to derive and internally validate cirrhosis surgical risk models.

APPROACH AND RESULTS

We conducted a retrospective cohort study using data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) cohort, which contains granular data on patients with cirrhosis from 128 U.S. medical centers, merged with the Veterans Affairs Surgical Quality Improvement Program (VASQIP) to identify surgical procedures. We categorized surgeries as abdominal wall, vascular, abdominal, cardiac, chest, or orthopedic and used multivariable logistic regression to model 30-, 90-, and 180-day postoperative mortality (VOCAL-Penn models). We compared model discrimination and calibration of VOCAL-Penn to the Mayo Risk Score (MRS), Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease-Sodium MELD-Na, and Child-Turcotte-Pugh (CTP) scores. We identified 4,712 surgical procedures in 3,785 patients with cirrhosis. The VOCAL-Penn models were derived and internally validated with excellent discrimination (30-day postoperative mortality C-statistic = 0.859; 95% confidence interval [CI], 0.809-0.909). Predictors included age, preoperative albumin, platelet count, bilirubin, surgery category, emergency indication, fatty liver disease, American Society of Anesthesiologists classification, and obesity. Model performance was superior to MELD, MELD-Na, CTP, and MRS at all time points (e.g., 30-day postoperative mortality C-statistic for MRS = 0.766; 95% CI, 0.676-0.855) in terms of discrimination and calibration.

CONCLUSIONS

The VOCAL-Penn models substantially improve postoperative mortality predictions in patients with cirrhosis. These models may be applied in practice to improve preoperative risk stratification and optimize patient selection for surgical procedures (www.vocalpennscore.com).

Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions

BACKGROUND AND AIMS

Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures.

METHODS

We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review.

RESULTS

Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate.

CONCLUSIONS

Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.

Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulant and Warfarin in Cirrhotic Patients With Nonvalvular Atrial Fibrillation

Background

Liver cirrhotic patients with nonvalvular atrial fibrillation have been excluded from randomized clinical studies regarding oral anticoagulants for stroke prevention. Whether non–vitamin K antagonist oral anticoagulants (NOACs) are superior to warfarin for these patients remains unclear.

Methods and Results

This nationwide retrospective cohort study, with data collected from the Taiwan National Health Insurance Research Database, enrolled 2428 liver cirrhotic patients with nonvalvular atrial fibrillation taking apixaban (n=171), dabigatran (n=535), rivaroxaban (n=732), or warfarin (n=990) from June 1, 2012, to December 31, 2016. We used propensity score–based stabilized weights to balance covariates across study groups. Patients were followed until the occurrence of an event or the end date of study. The NOAC group (n=1438) showed risk of ischemic stroke/systemic embolism and intracranial hemorrhage comparable to that of the warfarin group (n=990) after adjustment. The NOAC group showed significantly lower risk of gastrointestinal bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.79]; P=0.0030) and all major bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.74]; P=0.0003) compared with warfarin group. Overall, 90% (n=1290) of patients were taking a low‐dose NOAC (apixaban 2.5 mg twice daily, rivaroxaban 10–15 mg daily, or dabigatran 110 mg twice daily). The subgroup analysis indicated that both dabigatran and rivaroxaban showed lower risk of all major bleeding than warfarin. The advantage of lower gastrointestinal and all major bleeding with NOACs over warfarin is contributed by those subgroups with either nonalcoholic or nonadvanced liver cirrhosis.

Conclusions

NOACs have a risk of thromboembolism comparable to that of warfarin and a lower risk of major bleeding among liver cirrhotic Asian patients with nonvalvular atrial fibrillation. Consequently, thromboprophylaxis with low‐dose NOACs may be considered for such patients.

See Editorial by Gallagher et al

The prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery

BACKGROUND & AIMS

Surgery in cirrhosis is associated with a high morbidity and mortality. Retrospectively reported prognostic factors include emergency procedures, liver function (MELD/Child-Pugh scores) and portal hypertension (assessed by indirect markers). This study assessed the prognostic role of hepatic venous pressure gradient (HVPG) and other variables in elective extrahepatic surgery in patients with cirrhosis.

METHODS

A total of 140 patients with cirrhosis (Child-Pugh A/B/C: 59/37/4%), who were due to have elective extrahepatic surgery (121 abdominal; 9 cardiovascular/thoracic; 10 orthopedic and others), were prospectively included in 4 centers (2002-2011). Hepatic and systemic hemodynamics (HVPG, indocyanine green clearance, pulmonary artery catheterization) were assessed prior to surgery, and clinical and laboratory data were collected. Patients were followed-up for 1 year and mortality, transplantation, morbidity and post-surgical decompensation were studied.

RESULTS

Ninety-day and 1-year mortality rates were 8% and 17%, respectively. Variables independently associated with 1-year mortality were ASA class (American Society of Anesthesiologists), high-risk surgery (defined as open abdominal and cardiovascular/thoracic) and HVPG. These variables closely predicted 90-, 180- and 365-day mortality (C-statistic >0.8). HVPG values >16 mmHg were independently associated with mortality and values ≥20 mmHg identified a subgroup at very high risk of death (44%). Twenty-four patients presented persistent or de novo decompensation at 3 months. Low body mass index, Child-Pugh class and high-risk surgery were associated with death or decompensation. No patient with HVPG <10 mmHg or indocyanine green clearance >0.63 developed decompensation.

CONCLUSIONS

ASA class, HVPG and high-risk surgery were prognostic factors of 1-year mortality in cirrhotic patients undergoing elective extrahepatic surgery. HVPG values >16 mmHg, especially ≥20 mmHg, were associated with a high risk of post-surgical mortality.

LAY SUMMARY

The hepatic venous pressure gradient is associated with outcomes in patients with cirrhosis undergoing elective extrahepatic surgery. It enables a better stratification of risk in these patients and provides the foundations for potential interventions to improve post-surgical outcomes.

In-Hospital mortality varies by procedure type among cirrhosis surgery admissions

BACKGROUND

Patients with cirrhosis have increased peri-operative mortality risk relative to non-cirrhotic patients, however, the impact of surgical procedure category on this risk is poorly understood.

METHODS

We performed a retrospective cohort study of cirrhosis surgery admissions using the National Inpatient Sample between 2012 and 2014 to estimate the adjusted odds of in-hospital mortality by surgical procedure category.

RESULTS

In-hospital mortality differed by surgical procedure category. Relative to major orthopedic surgeries, major abdominal surgeries had the highest odds of in-hospital mortality (odds ratio [OR] 8.27, 95% confidence interval [CI] 5.96-11.49), followed by major cardiovascular surgeries (OR 3.45, 95% CI 2.33-5.09). There was also a significant interaction term, whereby elective/non-elective admission status impacted in-hospital mortality risk differently for each surgical procedure category (P < 0.001).

CONCLUSION

In-hospital mortality varies substantially by surgical procedure type. Accounting for procedure type in models may improve risk prediction for peri-operative mortality in patients with cirrhosis.

Development of a novel clinical staging model for cirrhosis using the Nationwide Inpatient Sample

Scoring systems such as Model for End-stage Liver Disease (MELD) and Child-Pugh are often used by clinicians to determine prognosis in patients with cirrhosis. Since clinical complications are important in determining cirrhosis outcomes, our goal was to use these to develop a novel prognostic staging model. Data from the Nationwide Inpatient Sample (NIS), years 2003-2011, were queried for records of patients over the age of 18 with cirrhosis excluding patients with prior or inpatient liver transplantation. The primary outcome was inpatient mortality with focus on cirrhosis-related complications: non-bleeding esophageal varices, variceal hemorrhage, ascites, hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS). Of 59 862 903 hospitalizations, 824 783 (1.4%) with cirrhosis were identified. Overall mortality was 7% with two-thirds (66%) of deaths occurring in patients with a decompensating event, defined as variceal hemorrhage, ascites, HE, SBP, and/or HRS. Overall mortality rates decreased from 2003 to 2011 (9.0-6.0%), in both compensated and decompensated groups. Mortality was higher in patients with variceal haemorrhage (OR 1.56; p<0.05), HE (OR 1.75; p<0.05), SBP (OR 2.64; p<0.05) and HRS (OR 9.10; p<0.05) compared with patients with no complications. HRS had the highest mortality, whether alone or in combination with another event such as HE (OR 12.40; p<0.05) or SBP (OR 12.64; p<0.05). Cirrhosis inpatient outcomes are related to the severity of liver disease, with more severe complications such as HE, SBP, and HRS having the most significant effect on inpatient mortality, and are utilised in this novel four-stage clinical model.

Atrial fibrillation, liver disease, antithrombotics and risk of cerebrovascular events: A population-based cohort study

BACKGROUND

Whether patients with atrial fibrillation (AF) and liver disease are also prone to cerebrovascular events and respond similarly favorably to antithrombotic therapy remains under-investigated.

METHODS

Patients ≥18years with newly-diagnosed AF in the period 2005 to 2009 were scrutinized from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Insurance Institute. Patients were categorized into the Liver (N=433) or the Non-liver (N=3490) cohort according to whether they had a diagnosis of advanced liver disease. Patients were then followed to determine cumulative incidence of hospitalization-requiring cerebrovascular events, preventive effects of antithrombotics, and predictors of cerebrovascular events by Cox regression analysis.

RESULTS

Within a mean follow-up of 3.3±1.4years, ischemic stroke (89.2 vs. 50.3 per 1000 person-years, adjusted HR 1.502, 95% CI 1.207-1.868, p<0.001) and overall cerebrovascular events (102.3 vs. 56.4 per 1000 person-years, adjusted HR 1.535, 95% CI 1.251-1.883, p<0.001) occurred significantly more often in the Liver than in the Non-liver cohort. Cox models identified aging (≥65years), DM, and CHA2DS-VASc score≥2 points as risk factors for overall cerebrovascular events in the Liver cohort, whereas antiplatelet agents (HR 0.932, 95% CI 0.128-6.803, p=NS) and vit-K antagonistic anticoagulants (HR 1.087, 95% CI 0.150-7.862, p=NS) showed no correlation.

CONCLUSION

AF patients comorbid with advanced liver disease are more vulnerable to ischemic and therein overall cerebrovascular events, especially in those with old age, DM, or high CHA2DS-VASc scores. This propensity to cerebrovascular events, however, can't be altered by antithrombotic therapy.

Liver surgery in cirrhosis and portal hypertension

The prevalence of hepatic cirrhosis in Europe and the United States, currently 250 patients per 100000 inhabitants, is steadily increasing. Thus, we observe a significant increase in patients with cirrhosis and portal hypertension needing liver resections for primary or metastatic lesions. However, extended liver resections in patients with underlying hepatic cirrhosis and portal hypertension still represent a medical challenge in regard to perioperative morbidity, surgical management and postoperative outcome. The Barcelona Clinic Liver Cancer classification recommends to restrict curative liver resections for hepatocellular carcinoma in cirrhotic patients to early tumor stages in patients with Child A cirrhosis not showing portal hypertension. However, during the last two decades, relevant improvements in preoperative diagnostic, perioperative hepatologic and intensive care management as well as in surgical techniques during hepatic resections have rendered even extended liver resections in higher-degree cirrhotic patients with portal hypertension possible. However, there are few standard indications for hepatic resections in cirrhotic patients and risk stratifications have to be performed in an interdisciplinary setting for each individual patient. We here review the indications, the preoperative risk-stratifications, the morbidity and the mortality of extended resections for primary and metastatic lesions in cirrhotic livers. Furthermore, we provide a review of literature on perioperative management in cirrhotic patients needing extrahepatic abdominal surgery and an overview of surgical options in the treatment of hepatic cirrhosis.

Child-Pugh Versus MELD Score for the Assessment of Prognosis in Liver Cirrhosis: A Systematic Review and Meta-Analysis of Observational Studies

Child-Pugh and MELD scores have been widely used for the assessment of prognosis in liver cirrhosis. A systematic review and meta-analysis aimed to compare the discriminative ability of Child-Pugh versus MELD score to assess the prognosis of cirrhotic patients.PubMed and EMBASE databases were searched. The statistical results were summarized from every individual study. The summary areas under receiver operating characteristic curves, sensitivities, specificities, positive and negative likelihood ratios, and diagnostic odds ratios were also calculated.Of the 1095 papers initially identified, 119 were eligible for the systematic review. Study population was heterogeneous among studies. They included 269 comparisons, of which 44 favored MELD score, 16 favored Child-Pugh score, 99 did not find any significant difference between them, and 110 did not report the statistical significance. Forty-two papers were further included in the meta-analysis. In patients with acute-on-chronic liver failure, Child-Pugh score had a higher sensitivity and a lower specificity than MELD score. In patients admitted to ICU, MELD score had a smaller negative likelihood ratio and a higher sensitivity than Child-Pugh score. In patients undergoing surgery, Child-Pugh score had a higher specificity than MELD score. In other subgroup analyses, Child-Pugh and MELD scores had statistically similar discriminative abilities or could not be compared due to the presence of significant diagnostic threshold effects.Although Child-Pugh and MELD scores had similar prognostic values in most of cases, their benefits might be heterogeneous in some specific conditions. The indications for Child-Pugh and MELD scores should be further identified.

Recalibrating the Child-Turcotte-Pugh Score to Improve Prediction of Transplant-Free Survival in Patients with Cirrhosis

BACKGROUND

The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. However, the cutpoints for stratifying laboratory variables in CTP have never been validated.

OBJECTIVE

The objective of this study was to identify evidence-based cutpoints for the CTP laboratory subscores to improve its predictive capacity for transplant-free survival.

DESIGN

Retrospective observational study.

DATA SOURCE

Using a cohort of 30,897 cirrhotic US Veteran patients with at least 5 years of follow-up, we performed Cox proportional hazard survival model iterations varying the upper and lower cutpoints for INR, total bilirubin and albumin CTP subscores. Cutpoints yielding the highest Harrell's C-statistics for concordance with transplant-free survival were incorporated into a modified CTP (mCTP) score. Validation of the mCTP was performed at multiple time frames within the follow-up period of the cohort and within subsets defined by disease etiology.

RESULTS

Modification of CTP cutpoints increased the Harrell's C-statistic for age- and gender-adjusted Cox proportional hazard models from 0.701 ± 0.002 to 0.709 ± 0.002 and the risk ratio per unit change from 1.49 (1.48-1.50) to 1.53 (1.52-1.54). The modified cutpoints showed superiority in predicting 5-year transplant-free survival in various disease etiology subgroups. A mCTP substituting serum creatinine for INR performed superiorly for predicting 5-year transplant-free survival.

CONCLUSION

We propose an evidence-based recalibration of CTP score cutpoints that optimizes this model's capacity to predict transplant-free survival in patients with cirrhosis. The CTP score remains the best predictor of 5-year overall and transplant-free survival in patients with cirrhosis.

Development and Performance of an Algorithm to Estimate the Child-Turcotte-Pugh Score From a National Electronic Healthcare Database

BACKGROUND & METHODS

The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. The CTP score is a composite of 5 subscores, 3 based on objective clinical laboratory values and 2 subjective variables quantifying the severity of ascites and hepatic encephalopathy. To date, no system to quantify CTP score from administrative databases has been validated. The Veterans Outcomes and Costs Associated with Liver Disease study is a multicenter collaborative study to evaluate the outcomes and costs of hepatocellular carcinoma in the U.S. Veterans Health Administration. We developed and validated an algorithm to calculate electronic CTP (eCTP) scores by using data from the Veterans Health Administration Corporate Data Warehouse.

METHODS

Multiple algorithms for determining each CTP subscore from International Classification of Diseases version 9, Common Procedural Terminology, pharmacy, and laboratory data were devised and tested in 2 patient cohorts. For each cohort, 6 site investigators (Boston, Bronx, Brooklyn, Philadelphia, Minneapolis, and West Haven VA Medical Centers) were provided cases from which to determine validity of diagnosis, laboratory data, and clinical assessment of ascites and encephalopathy. The optimal algorithm (designated eCTP) was then applied to 30,840 cirrhotic patients alive in the first quarter of 2008 for whom 5-year overall and transplant-free survival data were available. The ability of the eCTP score and other disease severity scores (Charlson-Deyo index, Veterans Aging Cohort Study index, Model for End-Stage Liver Disease score, and Cirrhosis Comorbidity) to predict survival was then assessed by Cox proportional hazards regression.

RESULTS

Spearman correlations for administrative and investigator validated laboratory data in the HCC and cirrhotic cohorts, respectively, were 0.85 and 0.92 for bilirubin, 0.92 and 0.87 for albumin, and 0.84 and 0.86 for international normalized ratio. In the HCC cohort, the overall eCTP score matched 96% of patients to within 1 point of the chart-validated CTP score (Spearman correlation, 0.81). In the cirrhosis cohort, 98% were matched to within 1 point of their actual CTP score (Spearman, 0.85). When applied to a cohort of 30,840 patients with cirrhosis, each unit change in eCTP was associated with 39% increase in the relative risk of death or transplantation. The Harrell C statistic for the eCTP (0.678) was numerically higher than those for other disease severity indices for predicting 5-year transplant-free survival. Adding other predictive models to the eCTP resulted in minimal differences in its predictive performance.

CONCLUSION

We developed and validated an algorithm to extrapolate an eCTP score from data in a large administrative database with excellent correlation to actual CTP score on chart review. When applied to an administrative database, this algorithm is a highly useful predictor of survival when compared with multiple other published liver disease severity indices.

Development and Performance of an Algorithm to Estimate the Child-Turcotte-Pugh Score From a National Electronic Healthcare Database

BACKGROUND & METHODS

The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. The CTP score is a composite of 5 subscores, 3 based on objective clinical laboratory values and 2 subjective variables quantifying the severity of ascites and hepatic encephalopathy. To date, no system to quantify CTP score from administrative databases has been validated. The Veterans Outcomes and Costs Associated with Liver Disease study is a multicenter collaborative study to evaluate the outcomes and costs of hepatocellular carcinoma in the U.S. Veterans Health Administration. We developed and validated an algorithm to calculate electronic CTP (eCTP) scores by using data from the Veterans Health Administration Corporate Data Warehouse.

METHODS

Multiple algorithms for determining each CTP subscore from International Classification of Diseases version 9, Common Procedural Terminology, pharmacy, and laboratory data were devised and tested in 2 patient cohorts. For each cohort, 6 site investigators (Boston, Bronx, Brooklyn, Philadelphia, Minneapolis, and West Haven VA Medical Centers) were provided cases from which to determine validity of diagnosis, laboratory data, and clinical assessment of ascites and encephalopathy. The optimal algorithm (designated eCTP) was then applied to 30,840 cirrhotic patients alive in the first quarter of 2008 for whom 5-year overall and transplant-free survival data were available. The ability of the eCTP score and other disease severity scores (Charlson-Deyo index, Veterans Aging Cohort Study index, Model for End-Stage Liver Disease score, and Cirrhosis Comorbidity) to predict survival was then assessed by Cox proportional hazards regression.

RESULTS

Spearman correlations for administrative and investigator validated laboratory data in the HCC and cirrhotic cohorts, respectively, were 0.85 and 0.92 for bilirubin, 0.92 and 0.87 for albumin, and 0.84 and 0.86 for international normalized ratio. In the HCC cohort, the overall eCTP score matched 96% of patients to within 1 point of the chart-validated CTP score (Spearman correlation, 0.81). In the cirrhosis cohort, 98% were matched to within 1 point of their actual CTP score (Spearman, 0.85). When applied to a cohort of 30,840 patients with cirrhosis, each unit change in eCTP was associated with 39% increase in the relative risk of death or transplantation. The Harrell C statistic for the eCTP (0.678) was numerically higher than those for other disease severity indices for predicting 5-year transplant-free survival. Adding other predictive models to the eCTP resulted in minimal differences in its predictive performance.

CONCLUSION

We developed and validated an algorithm to extrapolate an eCTP score from data in a large administrative database with excellent correlation to actual CTP score on chart review. When applied to an administrative database, this algorithm is a highly useful predictor of survival when compared with multiple other published liver disease severity indices.

Liver dysfunction as an important predicting risk factor in patients undergoing cardiac surgery: a systematic review and meta-analysis

Liver function is not considered as a risk factor by current risk scores, such as EUROSCORE II or STS-Score for cardiac surgery. The aim of this study was to review the role of liver dysfunction, classified by the Child-Turcotte-Pugh classification or model for end-stage liver disease scores, as a risk factor for mortality and morbidity of patients following cardiac surgery. The Pubmed referencing library was searched. The rates of mortality and morbidity were calculated using SPSS software. The mortality rates in patients of Child class A, Child class B, and Child class C were pairwise compared respectively. A total of 22 reports including 939 patients from eight countries were reviewed. The mortality rate of patients increased in accordance with increased CTP classification. The lowest mortality rate was recorded in Child class A patients, followed by Child class B patients and the highest mortality rate was observed in Child class C patients. The mean complication rate ranged from 3.82% to 22.15%. Child class C patients should be considered unacceptable for cardiovascular surgery. As two studies revealed, patients with a higher MELD score had significantly higher mortality rates. Liver function should be viewed as an important risk factor for cardiovascular surgery, based on its strong association with mortality and morbidity.

Pre-operative predictive factors for intra-operative pathological lymph node metastasis in rectal cancers

BACKGROUND

A number of clinicopathologic factors have been found to be associated with pathological lymph node metastasis (pLNM) in rectal cancer; however, most of them can only be identified by expensive high resolution imaging or obtained after surgical treatment. Just like the Child-Turcotte-Pugh (CTP) and the model for end-stage liver disease (MELD) scores which have been widely used in clinical practice, our study was designed to assess the pre-operative factors which could be obtained easily to predict intra-operative pLNM in rectal cancer.

METHODS

A cohort of 469 patients who were treated at our hospital in the period from January 2003 to June 2011, and with a pathologically hospital discharge diagnosis of rectal cancer, were included. Clinical, laboratory and pathologic parameters were analyzed. A multivariate unconditional logistic regression model, areas under the curve (AUC), the Kaplan-Meier method (log-rank test) and the Cox regression model were used.

RESULTS

Of the 469 patients, 231 were diagnosed with pLNM (49.3%). Four variables were associated with pLNM by multivariate logistic analysis, age<60 yr (OR=1.819; 95% CI, 1.231-2.687; P=0.003), presence of abdominal pain or discomfort (OR=1.637; 95% CI, 1.052-2.547; P=0.029), absence of allergic history (OR=1.879; 95% CI, 1.041-3.392; P=0.036), and direct bilirubin ≥ 2.60 μmol/L (OR=1.540; 95% CI, 1.054-2.250; P=0.026). The combination of all 4 variables had the highest sensitivity (98.7%) for diagnostic performance. In addition, age<60 yr and direct bilirubin ≥ 2.60 μmol/L were found to be associated with prognosis.

CONCLUSION

Age, abdominal pain or discomfort, allergic history and direct bilirubin were associated with pLNM, which may be helpful for preoperative selection.

Major abdominal cancer resections in cirrhotic patients: how frequent is postoperative hepatocellular decompensation?

BACKGROUND

The reported incidence of postoperative liver failure in cirrhotic patients is highly varied with diverse risk factors identified to predict risk, mainly drawn from organ or disease-specific studies. We aimed to assess risk factors for the development of postoperative liver failure in a specific cohort of patients with cirrhosis undergoing abdominal cancer resection.

METHODS

From November 2007 to October 2012, 30 cirrhotic patients who underwent curative resection for abdominal cancer were analyzed. The postoperative trends in liver function were followed and the incidence of postoperative liver failure was demonstrated.

RESULTS

Among the 30 patients, the tumors were located in the stomach (n = 5), pancreas (n = 5), colon/rectum (6), liver (n = 11), gallbladder (n = 1), and retroperitoneum (n = 2). Eighteen (60 %) patients experienced postoperative liver failure of which 7 (23 %) patients required deviation from the clinical course or management. There was one mortality due to grade C liver failure and hepatorenal syndrome. On multivariate analysis, only age (>55 years) was found to be statistically significant to predict postoperative liver failure (p = 0.024).

CONCLUSION

Liver dysfunction remains a major problem during the postoperative phase of major gastrointestinal cancer resections. However, less than one fourth of well-selected patients will develop significant postoperative liver failure. This incidence may be further reduced if the selection is restricted to younger patients.

Monitoring and managing hepatic disease in anaesthesia

Patients with liver disease have multisystem organ dysfunction that leads to physiological perturbations ranging from hyperbilirubinaemia of no clinical consequence to severe coagulopathy and metabolic disarray. Patient-specific risk factors, clinical scoring systems, and surgical procedures stratify perioperative risk for these patients. The anaesthetic management of patients with hepatic dysfunction involves consideration of impaired drug metabolism, hyperdynamic circulation, perioperative hypoxaemia, bleeding, thrombosis, and hepatic encephalopathy.

Serum markers for predicting abdominal surgery outcomes in patients with cirrhosis

BACKGROUND

Determinants of adverse events for cirrhotic patients undergoing abdominal surgery have not been adequately assessed. Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) have estimated perioperative outcomes with inconsistent results. Our study sought to combine novel serum markers with CTP and MELD to improve prognostication of 30-day postoperative mortality or liver transplant in cirrhotic patients undergoing abdominal surgery.

METHODS

A review was performed on 120 cirrhotic patients undergoing nonhepatic abdominal surgeries at Mount Sinai Medical Center from 2001-2011. Preoperative serum markers were evaluated by logistic regression and receiver-operator characteristics. Prognostic ability of scoring systems was assessed using Youden's J statistic (J).

RESULTS

Albumin and hematocrit were independently predictive of 30-day mortality or transplant with optimal cutoff values of albumin at <3.05 mg/dl and hematocrit at <35.55 %. Adding these criteria to CTP>A, CTP>B, MELD ≥ 10, MELD ≥ 15, and MELD ≥ 20 improved sensitivity and specificity by an average of 6.1 and 32.1 %, respectively. The highest J values resulted from combining novel criteria with CTP>A (sensitivity, 80 %; specificity, 82 %; p < 0.01; J, 0.63) and MELD ≥ 10 (sensitivity, 63 %; specificity, 90 %; p < 0.01; J, 0.53).

CONCLUSION

Augmenting CTP and MELD with albumin and hematocrit significantly improved the identification of cirrhotic patients at risk of 30-day mortality or transplantation following nonhepatic abdominal surgery.

Model for End-stage Liver Disease

Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15-20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score.

Preliminary results of supra-hepatic intraaortic perfusion with nitroglycerin for patients with significant hepatic dysfunction

BACKGROUND

Preoperative hepatic dysfunction is a risk factor for postoperative fulminant hepatic failure and death. We noted persistent hepatic artery vasospasm in patients dying of postoperative hepatic failure. We hypothesized that an intra-aortic vasodilator such as nitroglycerin could attenuate vasospasm and prevent hepatic failure.

METHODS

Nineteen consecutive patients with significant preoperative hepatic dysfunction underwent cardiac surgery using cardiopulmonary bypass with continuous infusion of intra-aortic nitroglycerin via a catheter placed above the celiac axis. Serial hepatic artery Doppler studies were done perioperatively with and without the nitroglycerin infusion on. Hepatic artery Doppler, hepatic artery size, alterations in liver function and serum creatinine, and outcomes were noted. Survival was compared to the Euroscore and a hepatic risk score that was based on a historical cohort and reported literature.

RESULTS

One patient could not be weaned off cardiopulmonary bypass. In the remaining 18 patients, reversible hepatic arterial vasospasm was noted, and this persisted at 24 hours in 12 patients and 48 hours in 7 patients. All patients had resolution of vasospasm at 72 hours. Serial paired hepatic artery diameter measurements showed a significant difference (P < .001). There was a significant reduction in mortality (5.2 %) compared to historical control and predicted mortality (logistic Euroscore 37.4%, P = .023). None of the survivors had a significant alteration in hepato-renal function.

CONCLUSION

Intra-aortic nitroglycerin can attenuate hepatic arterial vasospasm induced by cardiopulmonary bypass and preserve hepatic function. This may reduce the risk associated with cardiopulmonary bypass and surgery in patients with liver dysfunction.

Safety of cardiac surgery for patients with cirrhosis and Child-Pugh scores less than 8

BACKGROUND & AIMS

Advanced liver disease is a significant risk factor for perioperative complications after cardiac surgery. However, no published studies have adjusted the observed outcomes for other well-known, non-liver-related factors that affect mortality. We evaluated the effects of cirrhosis on operative mortality and morbidity after cardiac surgery, after adjusting for nonrelated risk factors associated with liver disease.

METHODS

We analyzed data from patients with cirrhosis who underwent cardiac surgery with cardiopulmonary bypass from 1992 to 2009 (n = 54). Patients who underwent cardiac surgery at the same institution were identified during the same time period and matched 1:4 by using propensity score matching (controls, n = 216). Child-Pugh (CP) class and score were calculated for the patients with cirrhosis. Mortality and morbidity were determined after 30 and 90 days.

RESULTS

Within 90 days, 4.6% of patients with CP score <8 and 70% of patients with CP score ≥ 8 died (P < .017). Mortality of patients with CP score <8 was comparable to that of matched controls. Patients with CP scores <8 had significantly shorter average length of hospital stay (15.6 vs 26 days; P < .017) and were less likely to develop renal failure (P < .017) and require dialysis (P < .017) than patients with CP scores ≥ 8; these values were similar between patients with CP scores <8 and their matched controls.

CONCLUSIONS

After adjusting for non-liver-related risk factors, patients with compensated cirrhosis (defined by CP score <8) can undergo cardiac surgery with cardiopulmonary bypass with no significant increases in postoperative mortality and morbidity. For this group of patients, comorbidities, rather than liver failure, appear to account for the occasional death.

Hérnias abdominais e inguinais em pacientes cirróticos: qual é a melhor conduta?

INTRODUÇÃO: Tradicionalmente os procedimentos abdominais eletivos em pacientes cirróticos têm sido amplamente desencorajados graças à elevada morbi-mortalidade consequente às complicações da cirrose, descritas por diversos autores. Outros serviços, em contrapartida, obtiveram resultados distintos, advogando a favor de cirurgia eletiva. MÉTODOS: Uma revisão de artigos utilizando-se a palavras "abdominal wall hernia" e "cirrhotic patients" foi realizada na base de dados PubMed. Dos resultados obtidos, 28 artigos foram considerados para elaboração desta revisão. RESULTADOS: Pôde-se observar que a incidência de hérnias em parede abdominal é relativamente elevada em pacientes cirróticos, sendo que muitas delas têm evolução desfavorável e requerem tratamento cirúrgico específico. Com o advento do sistema de alocação de órgãos baseados no escore de MELD, muitos centros estão repensando suas condutas em situações como esta, dado que muitos dos pacientes em questão encontram-se em lista de espera para transplante hepático. Dessa forma a cirurgia eletiva tem conquistado maior papel no manejo desta condição com intuito de diminuir morbi-mortalidade nesses pacientes. Além disso, a qualidade de vida mostrou-se um importante fator a ser considerado, estando muito prejudicada nesta condição. CONCLUSÃO: Poucos estudos com grandes amostragens foram conduzidos até o momento e não há consenso sobre qual conduta é a mais indicada levando em consideração taxas de morbi-mortalidade.

[Anesthesia in the patient with impaired liver function]

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.

Cardiac surgery in cirrhotic patients: results and evaluation of risk factors

OBJECTIVES

Liver cirrhosis increases mortality and morbidity following cardiac surgery. This study evaluated the results of cardiac surgery in cirrhotic patients and the relevance of EuroSCORE, Child-Turcotte-Pugh (CTP) class and model for end-stage liver disease (MELD) score in terms of prediction of surgical mortality and survival.

METHODS

The study involved 34 patients with hepatic cirrhosis who underwent cardiac surgery between January 1996 and January 2010.

RESULTS

The in-hospital mortality was 26%. Postoperative mortality of patients with CTP class A, B or C was 18, 40 and 100%, respectively. In univariate analysis, a history of cerebrovascular disease and hypoalbuminaemia was predictive of operative mortality. Multivariate exact logistic regression revealed that hypoalbuminaemia was an independent factor. Long-term survival was 63 ± 0.08% at 1 year and 40.2 ± 0.12% at 5 years. The 1-year survival for CTP A, B and C was 76.7 ± 0.09, 60 ± 15.4 and 0%, respectively, and the 5-year survival was 60 ± 15.4, 25 ± 0.19 and 0%, respectively. The EuroSCORE was not a discriminant [area under the curve (AUC): 0.57 ± 0.15]. The performance of CTP class and MELD score was better, but neither provided optimal discrimination: AUC was 0.691 ± 0.110 for MELD and 0.658 ± 0.10 for CTP class.

CONCLUSIONS

Cardiac surgery can be performed safely in CTP class A patients. In CTP C patients, surgery is hazardous, and an alternative treatment must be considered. In CTP B, the MELD score could be helpful in deciding whether surgical intervention is a reasonable option.

MELD-based indices as predictors of mortality in chronic liver disease patients who undergo emergency surgery with general anesthesia

BACKGROUND

Underlying chronic liver disease is associated with high morbidity and mortality after emergency surgery, which complicates clinical decisions over performing such surgery. In addition, the Child-Turcotte-Pugh (CTP) score is limited in its ability to predict postoperative residual liver function. This study was designed to determine whether the scores of the Model for End-stage Liver Disease (MELD)-based indices are effective predictors of mortality following emergency surgery in patients with chronic liver disease.

METHOD

Medical records of 53 chronic liver disease patients who underwent emergency surgery under general anesthesia from 2001 to 2008 were analyzed retrospectively.

RESULTS

Median preoperative CTP score was 6 (5-12); MELD, 11 (6-33); MELD-Na, 15 (7-34); integrated MELD (iMELD), 33 (14-64); and MELD to sodium ratio, 8 (4-24). During a median 11-month follow-up period, 19 (35.8%) patients died. Five of them (26.3%) had operative mortality (i.e., mortality within 30 days after surgery). On multivariate analysis, CTP class C was correlated with operative mortality, and estimated blood loss above 300 ml and the iMELD score above 35 were significantly correlated with overall mortality.

CONCLUSIONS

iMELD reflects underlying liver function and predicts overall mortality more accurately than CTP and other MELD-based indices scores do in chronic liver disease patients after emergency surgery with general anesthesia.

Liver dysfunction by model for end-stage liver disease score improves mortality prediction in injured patients with cirrhosis

BACKGROUND

Cirrhosis is associated with poor outcomes in the trauma setting. We aimed to evaluate the utility of Model for End-Stage Liver Disease (MELD) in assessing additional mortality risk in trauma patients with cirrhosis.

METHODS

Injured patients with liver dysfunction were identified by hospital and trauma registry query. Presence of cirrhosis was confirmed by laparotomy, biopsy, or imaging. MELD classification, Child-Turcotte-Pugh (CTP) classification, Injury Severity Score (ISS), and Trauma ISS (TRISS) were recorded, and the primary outcome variable was hospital mortality. We assessed the validity of the four scoring systems in prediction of mortality, individually and in combinations, by comparing the areas under receiver operating characteristic curves (AUC), which is the probability, for scores that increase with the risk of death that a randomly chosen deceased subject will score higher than a randomly chosen living subject.

RESULTS

A total of 163 patients with confirmed cirrhosis were included. ISS (AUC = 0.849, p < 0.001) and TRISS (AUC = 0.826, p < 0.001) were the strongest predictors of mortality. MELD (AUC = 0.725) was not a significantly stronger predictor of mortality than CTP (AUC = 0.639; p = 0.38). ISS + MELD (AUC = 0.891) and ISS + CTP (AUC = 0.897) were stronger predictors than ISS alone (AUC = 0.849; p < 0.001) for both. The MELD score was more available from the records than the CTP score (91.4% vs. 75.5%).

CONCLUSION

In trauma patients with cirrhosis, a score that evaluates the degree of liver dysfunction enhances the ability of ISS alone to predict mortality. The MELD score is more readily available than the CTP score for the prediction of mortality in trauma patients.

Capacidade funcional e força muscular respiratória de candidatos ao transplante hepático

INTRODUÇÃO: A doença hepática crônica resulta em grande impacto funcional, causando perda de massa e função muscular com consequente redução da capacidade funcional. OBJETIVO: Avaliar e comparar a força muscular respiratória e a capacidade funcional dos candidatos ao transplante hepático que possuem classe B ou C segundo o Child-Pugh Score e correlacionar estas variáveis dentro de cada grupo. MÉTODOS: Estudo transversal, com amostra de conveniência composta por 35 pacientes, divididos em dois grupos a partir da pontuação obtida no Child-Pugh Score, sendo B (19 pacientes) e C (16 pacientes). Todos os indivíduos foram avaliados em um único momento, sendo mensuradas as pressões inspiratória máxima (PImáx) e expiratória máxima (PEmáx) e a distância percorrida no teste de caminhada de seis minutos (TC6M). RESULTADOS: Os indivíduos classificados com Child-Pugh Score B apresentaram maiores valores na PImáx (-86,05 ± 23,89 vs. -57,94 ± 14,14), p = 0,001, na PEmáx (84,16 ± 28,26 vs. 72,00 ± 16,94), p = 0,142, e na distância percorrida no TC6M (473,63 ± 55,276 vs. 376,13 ± 39,00), p = 0,001. Encontramos, ainda, correlação positiva entre os valores da PImáx e a distância percorrida no TC6M dentro grupo Child-Pugh Score B, r = 0,64 e p = 0,003. CONCLUSÃO: O progresso da doença hepática contribui para o surgimento de diversas complicações que, em conjunto, parecem contribuir para a redução da capacidade funcional dos indivíduos. Em nosso trabalho, isso ficou evidenciado pelo pior desempenho do grupo Child-Pugh Score C. Isto pode sugerir que a espera para o transplante hepático (TxH) pode agravar a capacidade funcional e a força muscular respiratória desses indivíduos.

The current economic burden of cirrhosis

Cirrhosis is a worldwide problem that is associated with a substantial economic burden. Hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, and alcoholic liver disease are the main causes of cirrhosis, but cost-effective preventive strategies are only available for HBV infection. Treatment algorithms for HBV infection and HCV infection are numerous and may be economically advantageous, depending on the regimen utilized; however, effective treatment for alcoholic liver disease is lacking, with abstinence from alcohol consumption continuing to be the main treatment strategy. In addition, liver transplantation (the only cure for cirrhosis) continues to consume substantial economic resources despite a recent reduction in overall cost. More sensitive predictors of post-liver transplantation disability could reduce this cost by allowing interventions that would promote productivity and increase health-related quality of life after liver transplantation. This paper highlights recent publications that evaluate the cost-effectiveness of strategies that prevent or treat the main causes of cirrhosis as well as publications that assess the impact of quality of life on the overall cost burden of the disease.

Comparison of the Child-Turcotte-Pugh classification and the model for end-stage liver disease score as predictors of the severity of the systemic inflammatory response in patients undergoing living-donor liver transplantation

The aim of this study was to evaluate and compare the Child-Turcotte-Pugh (CTP) classification system and the model for end-stage liver disease (MELD) score in predicting the severity of the systemic inflammatory response in living-donor liver transplantation patients. Recipients of liver graft were allocated to a recipient group (n = 39) and healthy donors to a donor group (n = 42). The association between the CTP classification, the MELD scores and perioperative cytokine concentrations in the recipient group was evaluated. The pro-inflammatory cytokines measured included interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α; the anti-inflammatory cytokines measured included IL-10 and IL-4. Cytokine concentrations were quantified using sandwich enzyme-linked immunoassays. The IL-6, TNF-α, and IL-10 concentrations in the recipient group were significantly higher than those in healthy donor group patients. All preoperative cytokine levels, except IL-6, increased in relation to the severity of liver disease, as measured by the CTP classification. Additionally, all cytokine levels, except IL-6, were significantly correlated preoperatively with MELD scores. However, the correlations diminished during the intraoperative period. The CTP classification and the MELD score are equally reliable in predicting the severity of the systemic inflammatory response, but only during the preoperative period.

Safety of pancreatic surgery in patients with simultaneous liver cirrhosis: a single center experience

BACKGROUND/AIMS

Pancreatic surgery is associated with an increased risk of postoperative complications. We therefore investigated the impact of an additional liver function disorder on the postoperative outcome using a case-control study of patients with or without liver cirrhosis who underwent pancreatic surgery at our department.

METHODS

Between 1998 and 2008, 1,649 pancreatic resections were performed. Of these, 32 operations were performed in patients who also suffered from liver cirrhosis (30× Child A, 2× Child B). For our case-control study, we selected another 32 operated patients without cirrhosis who were matched according to age, sex, diagnosis and tumor classification. The following parameters were compared between both groups: operating time, number of transfusions, duration of ICU and hospital stay, incidence of complications, rate of reoperation, mortality.

RESULTS

Patients with cirrhosis experienced complications significantly more often (69 vs. 44%; p = 0.044), especially major complications (47 vs. 22%; p = 0.035) requiring reoperation (34 vs. 12%; p = 0.039). These patients also had a prolonged hospital stay (27.9 vs. 24.3 days) and a significantly longer ICU stay (8.6 vs. 3.7 days; p = 0.033), and required twice as many transfusions. Overall, 3 patients died following surgery, 1 with Child A (3% of all Child A patients) and 2 with Child B cirrhosis.

CONCLUSION

Pancreatic surgery is associated with an increased risk of postoperative complications in patients with liver cirrhosis, and is therefore not recommended in patients with Child B cirrhosis. In Child A cirrhotic patients the mortality is, however, comparable to noncirrhotic patients. Due to the demanding medical efforts that these patients require, they should be treated exclusively in high-volume centers. and IAP.

Minimally invasive treatment of portal hypertension, abdominal aortic aneurysm, and colon cancer: a case report

Surgical therapy in cirrhotic patients has high morbidity and mortality. Hepatic function and complexity of surgical procedures strongly influence postoperative results. We report the case of a cirrhotic patient with portal hypertension, abdominal aortic aneurysm (AAA), and right colon cancer. After neoadjuvant transjugular intrahepatic portosystemic shunt, we performed 1-stage endovascular aneurysm repair and laparoscopic right colectomy. Minimally invasive surgery allows the effective treatment of high-risk patients with severe comorbidities that some years ago would not have been operated on.

Outcome in cirrhotic patients after elective surgical repair of infrarenal aortic aneurysm

OBJECTIVE

Abdominal surgery in patients with advanced liver disease has been reported to be associated with high morbidity and mortality rates. However, the surgical risk of infrarenal abdominal aortic aneurysm (AAA) repair in cirrhotics remains ill-defined. We reviewed our experience to investigate the predictors of the outcome in cirrhotic patients after elective AAA open repair.

METHODS

Between January 2001 and March 2006, 1189 patients underwent elective open repair of infrarenal AAA and 24 (2%) had a biopsy-proven cirrhosis (23 male, 1 female; mean age, 68 ± 7 years). The latter were retrospectively stratified according to the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score. Operative variables, perioperative complications, and survival were recorded and compared with those of 48 concurrent noncirrhotic controls matched (2:1) by gender, age, aneurysm size, preoperative glomerular filtration rate, and type of reconstruction. The effect of CTP and MELD scores on midterm survival was investigated in cirrhotics with the Kaplan-Meier log-rank method.

RESULTS

No intraoperative or 30-day deaths were recorded. No significant differences in terms of major perioperative complications were observed between cirrhotic patients and controls. Operative time and intraoperative blood transfusion requirement were significantly higher in cirrhotics (162 ± 49 vs 132 ± 39 minutes; P = .007 and 273 ± 364 vs 84 ± 183 mL; P = .040, respectively). Hospital length of stay was nearly doubled in cirrhotic patients (11.0 ± 2.8 vs 5.8 ± 1.5 days; P < .0001). Twenty-two cirrhotic patients were classified as CTP A and two as CTP B. Median MELD score was 8 (range, 6-14). CTP class B was associated with higher intraoperative blood transfusion requirement (941 ± 54 vs 213 ± 314 mL; P = .029). At a mean follow-up of 30.7 ± 22.1 months, five deaths were recorded in cirrhotics, and three in controls. Actuarial survival at 2 years was 77.4% in cirrhotics and 97.8% in controls (log-rank test, P = .026). Both CTP B patients died within 6 months. CTP class B and a MELD score ≥10 were associated with reduced midterm survival rates (log-rank test, P < .0001 and P = .021, respectively).

CONCLUSIONS

In our experience, elective AAA open repair in relatively compensated cirrhotics was safely performed with an acceptable increase of the magnitude of the operation. However, the reduced life expectancy of cirrhotics with a MELD score ≥10 suggests that such a procedure may not be warranted in this subgroup of patients.

Mortality after surgery in patients with liver cirrhosis: comparison of Child-Turcotte-Pugh, MELD and MELDNa score

BACKGROUND/AIMS

This study was aimed at determining the postoperative mortality in patients with cirrhosis by Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease score (MELD), and Model for End-stage Liver Disease and Serum Sodium Concentration score (MELDNa) systems and to compare the predictability of the scoring systems.

METHODS

Analysis was performed on clinical records of 490 patients with cirrhosis who underwent surgery under general anesthesia from January 2003 to December 2008.

RESULTS

(i) Ninety-day mortality in patients with CTP A, B, and C class were 2.1, 22.1 and 54.5%, respectively. (ii) Ninety-day mortality according to MELD score was as follows: 6-9, 3.5%; 10-14, 8.9%; 15-19, 14.3%; 20-24, 12.5%; and ≥25, 63.6%. (iii) Ninety-day mortality according to MELDNa score was as follows: 6-9, 1.9%; 10-14, 6.2%; 15-19, 13.2%; 20-24, 20.6%; and ≥25, 50%. (iv) Multivariable analysis showed that emergency surgery, American Society of Anesthesiologist class ≥IV, CTP score ≥7, MELD score ≥10, and MELDNa score ≥10 were independent risk factors for 90-day mortality. (v) The area under the receiver operating curve of CTP, MELD, and MELDNa in predicting 90-day mortality were 0.859, 0.761, 0.818, and nonparametric approach using the generalized U-statistic showed that the CTP score was equal to the MELDNa score (P=0.855) and the CTP and MELDNa scores were superior to the MELD score (P=0.027 and 0.047) in predicting postoperative 90-day mortality.

CONCLUSION

Mortality according to the CTP, MELD, and MELDNa scoring systems were determined and all scoring systems predicted postoperative mortality in patients with cirrhosis. The CTP score and MELDNa score were superior to the MELD score in predicting postoperative 90-day mortality.

Perioperative mortality after non-hepatic general surgery in patients with liver cirrhosis: an analysis of 138 operations in the 2000s using Child and MELD scores

INTRODUCTION

Despite of advances in modern surgical and intensive care treatment, perioperative mortality remains high in patients with liver cirrhosis undergoing nonhepatic general surgery. In the few existing articles, mortality was reported to be as high as 70% in patients with poor liver function (high Child or model for end-stage liver disease (MELD) score). Since data are limited, we analyzed our recent experience with cirrhotic patients undergoing emergent or elective nonhepatic general surgery at a German university hospital.

METHODS

Since 2000, 138 nonhepatic general surgical procedures (99 intra-abdominal, 39 abdominal wall) were performed in patients with liver cirrhosis. Liver cirrhosis was preoperatively classified according to the Child (41 Child A, 59 B, 38 C) and the MELD score (MELD median 13). Sixty-eight (49%) of the patients underwent emergent operations. Most abdominal wall operations were for hernias. Intra-abdominal operations consisted of GI tract procedures (n=53), cholecystectomies (n=15), and various others (n=31). Perioperative data were gained by retrospective analysis.

RESULTS

Overall perioperative mortality in all 138 cases was 28% (9% in elective surgery, 47% in emergent surgery; p<0.001). Perioperative mortality was higher after intra-abdominal than after abdominal wall operations (35% vs. 8%; p=0.001) or in patients requiring transfusions (43% vs. 5% without transfusions; p<0.001). Perioperative mortality increased with the Child score (10% Child A, 17% Child B, 63% Child C; p<0.01) and the MELD score (9% MELD <10, 19% MELD 10–15, 54% MELD >15; p<0.001). Univariately, further factors like American Society of Anesthesiologists (ASA) score and various preoperative laboratory values were also associated with perioperative mortality. By multivariate analysis of all 138 operations, the Child and ASA classifications, intraoperative transfusions, and a preoperative sodium <130 mmol/l, but not the MELD score, were independent prognostic factors. Analysis of elective operations revealed only a preoperatively increased creatinine as risk factor for perioperative mortality. In emergent operations again, Child class, blood transfusions, and low sodium level, but not the MELD score, predicted postoperative mortality.

CONCLUSIONS

Our results demonstrate that perioperative mortality remains high in patients with liver cirrhosisundergoing general surgery, especially in emergent situations. Patients with poor liver function and/or need for blood transfusions even had a very high mortality. In our experience, the Child score (together with other variables) independently correlates with perioperative mortality in emergent operations whereas the MELD score was inferior in predicting the outcome.