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.
ABSTRACT 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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ABSTRACT: Aim: Cirrhosis represents a common histological pathway for a wide variety of chronic liver diseases. Hepatitis C virus (HCV) is the most important cause of liver cirrhosis in Egypt. Although cirrhosis has been regarded as a relative contraindication for laparoscopic cholecystectomy (LC) as a result of bleeding complications and subsequent liver failure, several reports support the safety of LC in selected patients. This was a prospective study to evaluate the efficacy and safety of LC in cirrhotic patients.Methods: A total of 177 hepatitis C positive patients with chronic calculus cholecystitis who here scheduled for LC between January 2010 and March 2011 were included in the present study. LC was carried out on patients who fulfilled the inclusion criteria. Two risk stratification‐schemes were used to estimate the perioperative risk of patients with cirrhosis; the Child–Turcotte–Pugh (CTP) score and the Model for End‐stage Liver Disease (MELD) score.Results: All patients were HCV‐positive patients with Child class A cirrhosis and MELD score ≤ 9. Mean surgical time was 55 min. Surgical difficulty varied between average in 64%, moderate in 28% and extensive in 8%, where 3.4% required conversion to open cholecystectomy. Postoperative follow up of all patients was a multidisciplinary approach by both surgeons and hepatologists. All patients showed sound recovery confirmed by abdominal sonar to exclude intra‐abdominal collections, and application of both CTP and MELD scores, where all patients kept a Child class A score and MELD score ≤ 9.Conclusion: LC is a safe procedure for hepatitis C‐positive cirrhotic patients when established risk stratifications systems, such as CTP and MELD scores, are used for evaluation.Surgical Practice 02/2012; 16(1). DOI:10.1111/j.1744-1633.2011.00574.x · 0.17 Impact Factor
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ABSTRACT: Emergent surgery in the setting of decompensated cirrhosis is highly morbid. We sought to determine the clinical factors associated with negative intraoperative findings at emergent laparotomy. We performed a retrospective cohort study of consecutive inpatients with a diagnosis of cirrhosis (ICD-9 571) admitted to the Beth Israel Deaconess Medical Center (Boston, MA) who underwent emergent, nonhepatic, abdominal surgery between May 6, 2005 and September 3, 2012. Eighty-six patients with cirrhosis were included with a mean model for end-stage liver disease score of 21.3 +/- 7.95 and a 90-day mortality rate of 39.5 %. Twelve (16.2 %) patients had negative laparotomies. Negative intraoperative findings were independently associated with (1) paracentesis prior to a preoperative diagnosis of perforated viscus (P = 0.006), (2) development of an indication for emergent surgery after 24 h into hospital admission for another reason (P = 0.020), and (3) a preoperative diagnosis of bowel ischemia (P = 0.005), with odds ratios of 10.1 (CI 1.92-66.83), 5.80 (CI 1.32-33.39), and 11.1 (CI 2.08-77.4), respectively. Free air on computed tomography (CT) imaging was found in 64.3 % (9/14) of patients who had a paracentesis within the preceding 48 h compared to 10.1 % (7/72) among patients who did not undergo a paracentesis (P < 0.001). Only 45 % of patients with free air following a paracentesis had positive findings at laparotomy compared to 100 % in those without a preceding paracentesis (P = 0.038). Negative laparotomy was independently predictive of in-hospital mortality (OR 4.7; P = 0.034). The possibility of a negative laparotomy is suggested by preoperative clinical factors. In particular, free air following a paracentesis does not necessarily indicate that operative intervention is required. Consideration of close observation before laparotomy in these patients is reasonable.Journal of Gastrointestinal Surgery 08/2014; 18(10). DOI:10.1007/s11605-014-2599-9 · 2.39 Impact Factor
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ABSTRACT: The MELD score was described in 2000 and was employed as part of the US liver allocation policy in 2002. There were many reasons behind the decision to use the MELD score and there have been many benefits to the liver allocation system by doing so. Measuring any system used for allocation of scarce resources can be difficult, but evaluation of the justice and utility of such a system provides some framework for assessing its effectiveness. In this review, the benefits realized from the MELD-based allocation system will be assessed ac-cording to justice and utility parameters. In organ allocation, individual justice is served when patient-specific variables are used to assign waiting list priority rather than using physician-based observations or behaviors. Utility should be measured, not just in terms of patient survival after transplant, but also in terms of the overall utility of the system for as-signing organs to those most in need and giving little priority to those who will be harmed or have little benefit. The impact of adoption of this system can be measured by the number of the publications that include MELD or liver allocation in their data. The world has recognized the relative objectivity of the MELD score and the ability to communicate among widely diverse groups using this common language. Perhaps this is the most important impact of the MELD "era".