The Safety of Intra-abdominal Surgery in Patients With Cirrhosis: Model for End-Stage Liver Disease Score Is Superior to Child-Turcotte-Pugh Classification in Predicting Outcome

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University, St Louis, MO 63110, USA.
Archives of Surgery (Impact Factor: 4.93). 08/2005; 140(7):650-4; discussion 655. DOI: 10.1001/archsurg.140.7.650
Source: PubMed


We hypothesized that the model for end-stage liver disease (MELD) score may be a better and less subjective method than the Child-Turcotte-Pugh score for stratifying patients with cirrhosis before abdominal surgery.
Retrospective medical record review.
Tertiary care institution.
Fifty-three adult patients with histologically proven cirrhosis undergoing abdominal surgery at Saint Louis University Hospital, St Louis, Mo, between 1991 and 2001. Those undergoing hepatic surgery (such as resection or transplantation) or closed abdominal surgery (such as hernia repair) were excluded.
A poor outcome after surgery was defined as death or liver transplantation within 90 days of the operative procedure or a hospital stay of longer than 21 days. Demographic, clinical, and laboratory features predictive of poor outcome were assessed by multivariate analysis.
A total of 13 patients (25%) had poor outcomes including 9 deaths (17%). Model for end-stage liver disease score and plasma hemoglobin levels lower than 10 g/dL were found to be independent predictors of poor outcomes. A MELD score of 14 or greater was a better clinical predictor of poor outcome than Child-Turcotte-Pugh class C.
A MELD score of 14 or greater should be considered as a replacement for Child-Turcotte-Pugh class C as a predictor of being very high risk for abdominal surgery. Patients with cirrhosis with hemoglobin levels lower than 10 g/dL should receive corrective blood transfusions before abdominal surgery.

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    • "Thus, the MELD score has been applied to predict the postoperative mortality risk of patients undergoing hepatic resection in Western countries [15,16]. Patients with a MELD score ≥14 have a significantly increased risk of morbidity and poor outcome postabdominal surgery [15]. This recent data has led some authors to suggest that the MELD score be used in place of the Child-Pugh score in assessing the feasibility of surgery for patients with chronic liver disease. "
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    ABSTRACT: To identify the correlation of the model for end-stage liver disease (MELD) scores with the assessment of the risk of hepatic function after hemihepatectomy in patients with hepatocellular carcinoma (HCC) related to hepatitis B virus (HBV). A case-control study was performed based on data for 141 consecutive patients who underwent curative right hepatic resection between January 2006 and June 2010. All patients were Child-Pugh class A. The mean age of the patients was 50 years (range, 29-73 years). The group included 114 men (80.9%) and 27 women (19.1%). The distribution of MELD scores (median, 7; range, 6-14) and indocyanine green retention rate at 15 minutes (ICG-R15) (median, 9.2%; range, 1.1%-19.5%) showed no significant correlation (P = 0.615). Only one perioperative death (0.7%) occurred within 30 days, which was the result of liver failure by hepatic artery dissection during the Pringle maneuver. Hepatic dysfunction occurred in 25 patients (17.7%) after liver resection. In multivariate analysis, male gender, increased HBV DNA level, and elevated serum aspartate transaminase level were significantly related with hepatic dysfunction. Tumor size and satellite nodule were closely associated with tumor recurrence in HBV-related HCC after right hemihepatectomy and satellite nodule was a predisposing factor for mortality in those patients. MELD score does not accurately predict hepatic function after right hemihepatectomy in patients with resectable HBV-related HCC. MELD scores were not correlated with the ICG-R15 values in patients with Child-Pugh class A.
    Annals of Surgical Treatment and Research 03/2014; 86(3):122-9. DOI:10.4174/astr.2014.86.3.122
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    • "Postresection acid–base parameters were affected by the preoperative MELD and MELD-Na scores. That could be due to the already affected preresection acid–base parameters, or it could be explained as the more severe underlying liver disease resulted in more affection by liver surgery, as many previous studies reported that the MELD score is an excellent predictor of both short and medium term survival, and an increase in MELD score is associated with a decrease in the residual liver function [13] [21] [22]. "
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    ABSTRACT: Objective To study acid base changes during hepatectomy in cirrhotic patients and their relations to intraoperative variables and different preoperative scoring systems used to asses hepatic patients. Methods After obtaining approval of the Ethics and Research Committee of the National Liver Institute – Menoufia University and written informed patient consent, 80 patients scheduled for hepatectomy for hepatocellular carcinoma were included in the study. Anesthesia was induced with propofol, fentanyl, and rocuronium then maintained with desflurane and 50% O2 in air. Samples for arterial blood gases and serum lactate were withdrawn from a left radial artery catheter just before the start of resection of liver parenchyma and immediately after its completion. Intraoperative events were recorded including use of Pringle maneuver and fluids and blood products infusions. Results No differences were found in study parameters between Child class A and B patients except for the preresection lactate (p = 0.02). Patients with MELD score <11 had higher preresection HCO3 (p = 0.004), higher BE (p = 0.002), and lower lactate (p = 0.001) than patients with MELD score ⩾11. These findings were true also for patients with MELD-Na score <11 as they had higher preresection HCO3 (p = 0.001), higher BE (p = 0.001), and lower lactate (p < 0.001) than patients with MELD-Na score ⩾11. All patients had significant decrease in pH (p < 0.001), HCO3 (p < 0.001), and BE (p < 0.001) and significant increase in lactate (p < 0.001). These changes were augmented by intraoperative RBCs and FFP transfusion, using Pringle maneuver, but type of hepatectomy had significant effect only on HCO3 and BE. Again these changes in pH, HCO3, BE, and lactate were more obvious in patients with preoperative MELD score ⩾11, and this was also true in patients with preoperative MELD-Na score ⩾11 only with HCO3, BE, and lactate, but not with pH. Conclusion Changes occurred in acid base status during hepatectomy in cirrhotic patients are affected by the preoperative condition of the patient (MELD and MELD-Na scores) as well as by intraoperative transfusion of blood products, use of Pringle maneuver and to a lesser extent by major versus minor hepatectomy.
    Egyptian Journal of Anaesthesia 10/2013; 29(4):305–310. DOI:10.1016/j.egja.2013.05.003
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    • "While large populations of patients seem to be correctly prognosticated using one or both of the grading systems (CTP and MELD), it is evident that not all pathophysiologic conditions can be taken into account by any single score. In addition, not considering acuity of patient presentation and operative course may limit the ability of CTP and MELD scores to predict perioperative outcome [56] "

    Journal of Hepatology 05/2012; 57(4):874-84. DOI:10.1016/j.jhep.2012.03.037 · 11.34 Impact Factor
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