Original article—liver, pancreas, and biliary tract
Factors That Predict Outcome of Abdominal Operations in Patients With Advanced Cirrhosis

https://doi.org/10.1016/j.cgh.2009.12.015Get rights and content

Background & Aims

Patients with cirrhosis have an increased risk of complications during surgery that is relative to the severity of liver disease; it is a challenge to determine which patients are the best candidates for surgery. We performed a hospital-based study to identify factors that might facilitate selection of operative candidates and guide their management.

Methods

A retrospective review was performed of 100 cirrhotic patients (50 classified as Child–Turcotte–Pugh [CTP] A, 33 as CTP B, and 17 as CTP C) who underwent abdominal surgery at an institution specializing in liver medicine and transplant from 2002–2008. Significant univariate variables were evaluated by multivariate logistic regression models to identify factors that correlate with outcome.

Results

The overall, 30-day postoperative mortality rate was 7%. The mortality for patients who were CTP A was 2%, CTP B was 12%, and CTP C was 12%; 33 patients had a Model for End-Stage Liver Disease (MELD) score ≥15, with 29% mortality. On the basis of multivariate analyses, risk factors for adverse outcome were American Society of Anesthesiologists (ASA) score >3; procedures being emergent; intraoperative blood transfusion; intraoperative blood loss >150 mL; presence of ascites; total bilirubin level >1.5 mg/dL; and albumin level <3 mg/dL. Addition of serum albumin to MELD score showed that patients with MELD score ≥15 and albumin ≤2.5 mg/dL (vs >2.5 mg/dL) had significantly increased mortality (60% vs 14%, P < .01) and independently increased probability of adverse outcome (odds ratio, 8.4; P = .015).

Conclusions

For patients with MELD scores ≥15, the preoperative albumin level correlates with outcome and could guide operative decisions. Intraoperative packed red blood cell transfusion correlates with adverse outcome and should be limited.

Section snippets

Patient Acquisition

After approval by the Mount Sinai School of Medicine Institutional Review Board, a retrospective chart review was performed of 100 cirrhotic patients who underwent general surgical procedures at The Mount Sinai Medical Center from January 1, 2002 to December 31, 2008. Patients were identified from an administrative database by cross-matching International Classification of Diseases, 9th revision codes for cirrhosis (571.0, 571.2, 571.5, 571.6) with Current Procedural Terminology procedure codes

Population Characteristics and Outcome

One hundred cirrhotic patients qualified for the study. Mean patient age was 58.1 years, and 58% of patients were male. Twenty-eight patients had documented history of esophageal varices, 8 of spontaneous bacterial peritonitis, and 8 patients had a portosytemic shunt placed before operative procedure. Operative procedures consisted of 47 herniorrhaphies (35 umbilical and 12 ventral), 26 cholecystectomies, 17 colectomies, 3 appendectomies, 2 pancreaticoduodenectomies, and 5 other abdominal

Discussion

Operative decisions concerning cirrhotic patients are challenging. Identifying preoperative factors that might help determine appropriate operative candidates, the optimal timing of operative intervention, is that potentially reduce postoperative complications are of great importance. Our study has identified multiple factors, in addition to those already reported by current literature, that strongly influence postoperative course.

Perhaps the most significant finding our data demonstrated was

Conclusions

In summary, preoperative albumin strongly correlated with outcome in patients with MELD ≥15 and should be considered a criterion guiding operative decisions. Patients with MELD ≥15 and serum albumin levels <2.5 mg/dL appear to be poor operative candidates, and adverse outcomes should be anticipated. Conversely, this study identified a subset of patients with advanced cirrhosis and preoperative serum albumin >2.5 mg/dL who might be suitable for operative procedures with better than anticipated

References (25)

  • A. Mansour et al.

    Abdominal operations in patients with cirrhosis: still a major surgical challenge

    Surgery

    (1997)
  • R. Wong et al.

    Risk of nonshunt abdominal operation in the patient with cirrhosis

    J Am Coll Surg

    (1994)
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      Citation Excerpt :

      Circulatory failure: not surprisingly, preoperative need for circulatory support was a strong independent risk factor for worsening of liver function or death after surgery (OR 12.4; p = 0.029). In contrast to other studies in cirrhotic patients, the urgency of the procedure was not an independent risk factor for worsening of liver function.1,3,28 The reason for this difference is not immediately clear, but it may suggest that cirrhotic patients awaiting liver transplantations may differ in important aspects from other cirrhotic populations.

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    This article has an accompanying continuing medical education activity on page e58. Learning Objectives—At the end of this activity, the learner should be able to define the expected frequency of morbidity and mortality of abdominal operations in patients with advanced cirrhosis, and how best to predict such outcomes.

    Conflicts of interest The authors disclose no conflicts.

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