CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:451– 457
ORIGINAL ARTICLES—LIVER, PANCREAS,
AND BILIARY TRACT
Factors That Predict Outcome of Abdominal Operations in Patients With
Advanced Cirrhosis
DANA A. TELEM,* THOMAS SCHIANO,‡ ROBERT GOLDSTONE,* DANIEL K. HAN,* KERRI E. BUCH,* EDWARD H. CHIN,*
SCOTT Q. NGUYEN,* and CELIA M. DIVINO*
*Division of General Surgery, Department of Surgery, and ‡Recanati Miller Transplant Institute, Division of Liver Disease, The Mount Sinai Hospital, New York, New York
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.
See Editorial on page 399.
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 mor-
tality 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 ⱖ15, with 29% mortality. On the basis of
multivariate analyses, risk factors for adverse outcome were
American Society of Anesthesiologists (ASA) score ⬎3; proce-
dures being emergent; intraoperative blood transfusion; intra-
operative blood loss ⬎150 mL; presence of ascites; total biliru-
bin level ⬎1.5 mg/dL; and albumin level ⬍3 mg/dL. Addition of
serum albumin to MELD score showed that patients with
MELD score ⱖ15 and albumin ⱕ2.5 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 corre-
lates with outcome and could guide operative decisions.
Intraoperative packed red blood cell transfusion correlates
with adverse outcome and should be limited.
Keywords: Cirrhosis; Operative Outcome; CTP; MELD; General
Surgery.
F or patients with cirrhosis, increased operative risk relative
to the severity of liver disease is well-established.1–3 Deter-
mination of appropriate operative candidates is difficult, par-
ticularly for patients with advanced disease. Child–Turcotte–
Pugh (CTP) and Model for End-Stage Liver Disease (MELD)
scoring systems are often used to guide operative decisions.1– 8
Studies demonstrate that patients classified as CTP A, B, and C
have postoperative mortality rates of up to 10%, 30%, and 80%,
respectively.4,5 Assessment by MELD criteria demonstrates
scores of 0 –11 correlate with 5%–10% mortality rates, 12–25
with 25%–54% mortality rates, and scores greater than 26 with
a 90% postoperative mortality rate.8 –10
A limitation of both the CTP and MELD scoring systems is
that neither accurately predicts operative outcome.3– 8 This lim-
itation might be attributable to the exclusion of other influen-
tial outcome factors including acuity of patient presentation
and operative course.4 – 6,8 In addition, cardiac literature recently
identified preoperative platelet count, a surrogate marker for
degree of portal hypertension, as an independent predictor of
patient outcome after coronary artery bypass grafting.11 No
literature specifically addressing the impact of platelet count on
outcome after abdominal procedures currently exists.11
The importance of patient selection based on assessment of
operative risk is reaffirmed by a recent population-based study
of 22,569 cirrhotic patients who underwent elective operative
procedures.7 This study demonstrated significantly worse oper-
ative outcomes for cirrhotic patients, particularly those with
portal hypertension.7 A major study limitation, however, was
the inability to classify patients by CTP or MELD score or
identify variables associated with adverse outcome.7 Thus, we
undertook this hospital-based study to assess the impact of
Abbreviations used in this paper: ASA, American Society of Anes-
thesiologists; CI, confidence interval; CTP, Child–Turcotte–Pugh; ICU,
intensive care unit; LOS, length of stay; MELD, Model for End-Stage
Liver Disease; OR, odds ratio.
© 2010 by the AGA Institute
1542-3565/10/$36.00
doi:10.1016/j.cgh.2009.12.015
452 TELEM ET AL
perioperative factors on patient outcome after abdominal pro-
cedures at an institution specializing in liver disease and trans-
plant medicine. We aimed to identify factors that might facil-
itate selection of appropriate operative candidates and guide
perioperative patient management.
Methods
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 Interna-
tional Classification of Diseases, 9th revision codes for cirrhosis
(571.0, 571.2, 571.5, 571.6) with Current Procedural Terminol-
ogy procedure codes for cholecystectomy (47600, 47605, 47610,
47562, 47564), ventral or incisional hernia repair (49560, 49561,
49565, 49566, 49568), umbilical hernia repair (49585, 49587),
enterectomy (44120, 44121, 44125, 44130, 44202, 44203), colec-
tomy (44140, 44141, 44143, 44144, 44145, 44150, 44151, 44153,
44155, 44156, 44160, 44204, 44205, 44206, 44207, 44208, 44210,
44211, 44212), and appendectomy (44950, 44955, 44960, 44979).
Minors, patients who underwent prior liver transplantation, and
those undergoing hepatic resection or vascular, cardiovascular, or
thoracic procedures were excluded. Etiology and diagnosis of cir-
rhosis were confirmed by patient medical history and liver biopsy.
Data Collection
Patient electronic medical records were reviewed for
demographics and medical, surgical, and social history. Etiol-
ogy of cirrhosis and accompanying disease complications in-
cluding history of spontaneous bacterial peritonitis, presence of
esophageal or gastric varices, portal hypertension, and refrac-
tory ascites requiring shunt placement were recorded. Presence
of esophageal or gastric varices was confirmed by esophagogas-
troduodenoscopy and portal hypertension by radiographic im-
aging. CTP and MELD scores were calculated on the basis of
preoperative laboratory values, grade of encephalopathy, and
ascites. Grade of encephalopathy was determined according to
the West Haven classification system.12 Ascites was graded on a
scale of escalating severity based on the International Ascites
Club proposed guidelines.13
Operative and anesthesia records were reviewed for ASA
score, type of procedure, intraoperative time, intraoperative
blood loss, transfusion requirement, presence of ascites at time
of operation, gross description of the liver, and intraoperative
complications. Acuity of operation was determined from anes-
thesia records. Emergent procedures were defined according to
institutional guidelines. Our institution has 2 categories clas-
sifying emergent operations: category 1, which is defined as a
threat to life or limb without intervention within 1 hour, or
category 2, which is defined as a threat to life or limb without
intervention within 6 hours. All patients within this study
classified as either a category 1 or 2. Hospital course including
intensive care unit (ICU) admission and length of stay (LOS),
hospital LOS, and 30-day postoperative morbidity and mortal-
ity were assessed. Patient outcome at a mean of 36 months
assessing hospital readmission or reoperation, necessity of liver
transplantation, and mortality was recorded. Patient mortality
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 5
was determined by medical record review and by cross-referenc-
ing patient social security number with the online social secu-
rity death index database.14
Approach to the Care of Cirrhotic Patients
The Mount Sinai Medical Center performs the largest
volume of hepatic resections nationwide and has performed
more than 3100 liver transplants. For this reason, our institu-
tion has developed specific pathways pertaining to perioperative
care of cirrhotic patients. Protocols for cirrhotic patients with
advanced disease include strict guidelines regarding fluid man-
agement. Crystalloid administration is restricted both intraop-
eratively and postoperatively. For example, patients with ad-
vanced cirrhosis are often placed on an albumin drip as
maintenance fluid postoperatively until an oral diet is tolerated.
Specific protocols regarding medication administration and
dietary management have also been developed. Ketorolac and
epidural anesthesia are not used, and patients are often started
on lactulose the first postoperative day to prevent encephalop-
athy. Hospital nutritionists have developed low sodium, low fat
diets with adequate protein balance adapted specifically for
cirrhotic patients.
In addition, cirrhotic patients requiring general surgical pro-
cedures who are candidates for liver transplantation are evalu-
ated by our multidisciplinary liver transplant service. At our
institution, patients with MELD score ⱖ15 are considered can-
didates for liver transplant. For these patients, general surgical
operations are performed by liver transplant surgeons, and
patients are subsequently admitted to a multidisciplinary liver
service where postoperative care is undertaken by physicians
specializing in liver transplant medicine and transplant surgery.
Statistical Analysis
Univariate statistical analysis was performed by using
unpaired Student t test with two-tail distribution for quantita-
tive variables and ␹2 test for categorical values. Multivariate
logistic regression models were used to estimate odds ratios
(ORs) and associated 95% confidence interval (CI). Final mul-
tivariate models were created by elimination of nonsignificant
variables from univariate analysis. P values of less than .05 for
associations were considered to indicate statistical significance.
Table 1. Major Postoperative Morbidity
Morbidity (n)
Wound complication (12)
Infection (6)
Hematoma (4)
Leakage of ascites (2)
Liver decompensation (12)
Altered mental status (5)
Worsening ascites (5)
Shock liver (2)
Postoperative ileus or obstruction (4)
Respiratory failure (10)
Tracheostomy (4)
Decannulated (4)
Sepsis (7)
Postoperative variceal bleed (3)
Anastomotic leak (1)
May 2010
Figure 1. Morbidity and mortality by CTP class.
Prism 4.0 statistical software (April 2003, San Diego, CA) was
used for all analyses.
Results
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 um-
bilical and 12 ventral), 26 cholecystectomies, 17 colectomies, 3
appendectomies, 2 pancreaticoduodenectomies, and 5 other
abdominal procedures. Mean ASA score was 3.0. Sixty-eight
procedures were performed electively and 32 on an emergent
basis. The overall 30-day morbidity and mortality rates were
43% and 7%, respectively. Patient morbidity data are shown in
Table 1. Fourteen patients required ICU stay, with mean ICU
stay of 17.4 ⫾ 15.5 days (range, 2–58 days). Mean LOS was 6.3
days, 1.8 days for patients without and 12.1 days for patients
with postoperative complications (P ⬍ .001). Five patients un-
derwent liver transplantation within 1 year of operative proce-
dure. Follow-up at a mean of 36 months demonstrated an
overall 9% mortality rate.
Outcome by Child–Turcotte–Pugh Class and
Model for End-Stage Liver Disease Score
Fifty patients (50%) were classified as CTP A, 33% as
CTP B, and 17% as CTP C. Figure 1 demonstrates operative
morbidity and mortality by CTP class. Of the 17 CTP C pa-
tients, 5 required liver transplantation within 1 year of opera-
tive procedure; 3 ⬍30 days, 1 ⬍45 days, and one 240 days after
operation. The 3 liver transplants that occurred within 30 days
of operative procedure were a result of postoperative liver de-
compensation. Follow-up at a mean of 36 months demon-
strated a 20% 1-year mortality rate. Six CTP C patients are
currently alive and did not require liver transplantation, 5 who
underwent umbilical herniorrhaphy and 1 who had cholecys-
tectomy.
Mean MELD score was 12.4; 33 patients had scores ⱖ15, and
3 patients had a score ⱖ26. Figure 2 demonstrates morbidity
ABDOMINAL OPERATIONS IN ADVANCED CIRRHOSIS 453
and mortality by MELD score. MELD scores ⱖ15 had a calcu-
lated OR of 5.0 with 95% CI of 2.0 –12.5 (P ⬍ .001) for post-
operative morbidity. Scores ⬎17 had a 6.9 OR with 95% CI of
1.4 –34.2 (P ⬍ .01) for postoperative mortality.
Outcome by Operative Procedure and
Advanced Cirrhosis
Table 2 shows intraoperative variables and LOS by
operative procedure.
Cholecystectomy. All procedures were performed by
laparoscopic approach, with 2 open conversions as a result of
technical difficulty. No emergent procedure was performed.
Mean ASA score was 2.8. One death and 6 morbidities occurred.
Five patients were classified as CTP B and 1 as CTP C. Two
morbidities (40%) and 1 (20%) death occurred in CTP B patients
and 1 morbidity (100%) in CTP C patients. Five patients had
MELD ⱖ15, with 3 (60%) postoperative morbidities and 1 (20%)
death.
Umbilical herniorrhaphy. Of the 35 umbilical her-
niorrhaphies, 20 were elective and 15 emergent. Indications for
emergent operation included acute incarceration with inability
to reduce hernia (n ⫽ 13) and umbilical perforation with
leakage of ascites (n ⫽ 2). Seven (35%) were performed by
laparoscopic approach, and there were no open conversions. All
laparoscopic procedures occurred in the elective setting. For
those patients undergoing the laparoscopic approach, 6 (85%)
had an uneventful postoperative course, and 1 (14%) developed
postoperative morbidity (P ⬍ .001).
Mean ASA score was 3.0. One death (3%) and 20 (57%)
morbidities occurred. Twelve patients were CTP B, and 13 were
CTP C. Twenty-one patients had ascites at time of operation.
Morbidity and mortality rates for CTP B were 50% and 0% and
for CTP C 77% and 8%, respectively. Eleven patients had MELD
scores ⱖ15, with postoperative morbidity rate of 64% and 11%
mortality rate. Of the 21 patients who had ascites, 15 patients
presented with incarceration and 6 with spontaneous umbilical
rupture. The overall mortality rate was 5%, and morbidity rate
was 71%. Two patients required perioperative liver transplanta-
tion, and 5 developed ascites-related wound complications.
Colectomy. Nine procedures were elective, and 8 were
emergent. All elective procedures were attempted by laparo-
scopic approach, with 2 (22%) open conversions as a result of
adhesions. Indications for emergent colectomy included colonic
Figure 2. Morbidity and mortality by MELD score.
454 TELEM ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 5

Table 2. Univariate Comparison of Intraoperative Variables and Postoperative LOS by Operative Procedure and Postoperative
Complication
Operative procedure Overall (–) Morbidity (⫹) Morbidity P valuea

Cholecystectomy (n ⫽ 26)
Mean operative time (min) 119.1 112.5 128 NS
Mean EBL (mL) 117.4 53.1 282.9 .007
Transfusion requirement PRBC 8% 0% 8% .003
Mean LOS (days) 3.96 1.5 11.1 .003
Umbilical hernia (n ⫽ 35)
Mean operative time (min) 72.89 75.4 61.1 NS
Mean EBL (mL) 35.27 22.1 52.5 NS
Transfusion requirement PRBC 9% 6% 3% NS
Mean LOS (days) 3.87 1.5 7.1 ⬍.001
Colectomy (n ⫽ 17)b
Mean operative time (min) 142.5 133.6 212.7 .012
Mean EBL (mL) 580.0 536.4 628.0 NS
Transfusion requirement PRBC 35% 0% 35% ⬍.05
Mean LOS (days) 4.9 5.6 14.8 NS

EBL, estimated blood loss; PRBC, packed red blood cells.

aP value represents univariate comparison of patients with uncomplicated versus complicated operative course.
bIndications for colectomy: colorectal cancer (8), inflammatory bowel disease (4), diverticular disease (2), fulminant Clostridium difficile colitis

(1), gastrointestinal bleed due to arteriovenous malformation (1), and colopleural fistula (1).

perforation (n ⫽ 4), gastrointestinal bleed (n ⫽ 3), and fulmi-
nant colitis (n ⫽ 1). Mean ASA score was 3.1. Four deaths (24%)
and 6 morbidities (35%) occurred. Seven patients were classified
as CTP B, with a total of 5 (71%) morbidities and 2 deaths
(29%). One patient who was classified as CTP C died (100%).
Eight patients had MELD ⱖ15, with 3 (38%) morbidities and 4
(50%) deaths.
Risk Factors for Adverse Outcome
Tables 3 and 4 demonstrate the results of univariate
analysis of potential risk factors for adverse operative outcome.
Mean platelet count was not significant; however, only 11 pa-
tients had preoperative platelet count ⬍60 ⫻ 103/␮L. Of these
patients, 1 was CTP A, 7 were CTP B, and 3 were CTP C.
Analysis revealed a mortality rate of 18% (2/11) and morbidity
rate of 54% for these patients. Of the 2 mortalities, 1 patient was
CTP A who underwent right hemicolectomy, and the other was
CTP C who underwent low anterior resection. Table 5 demon-
strates the associated OR with 95% CI for significant predictors
of adverse operative outcome after multivariate analysis of
significant univariate variables.
Albumin and Model for End-Stage Liver
Disease
Serum albumin in combination with MELD score sig-
nificantly correlated with postoperative outcome. Addition of
serum albumin to MELD score demonstrated that patients with
MELD score ⱖ15 and albumin ⱕ2.5 mg/dL versus ⬎2.5 mg/dL
had significantly increased mortality or transplant rate (60% vs
14%, P ⬍ .01) and independently increased probability of ad-
verse outcome, OR of 8.4 and 95% CI of 1.7– 40.9 (P ⫽ .015).
Two patients (3%) with MELD score ⬍15 had albumin ⱕ2.5
mg/dL. Both patients underwent uncomplicated umbilical her-
niorrhaphy.
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 postopera-
tive 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 the association between preoperative serum albumin and
MELD score. Preoperative serum albumin, in addition to
MELD score, strongly correlated with postoperative outcome in
patients with advanced cirrhosis. Patients with MELD scores
ⱖ15 and albumin levels ⱕ2.5 mg/dL had a postoperative mor-
tality or transplantation rate of 60% versus 14% in patients with
albumin ⬎2.5 mg/dL (P ⬍ .01). In addition, albumin ⱕ2.5
mg/dL in association with MELD score ⱖ15 was an indepen-
dent predictor (OR, 8.4; P ⫽ .015) of adverse operative outcome.
On the basis of this result, we recommend preoperative albu-
min be considered a criterion for operative decisions in cirrhotic
patients with MELD ⱖ15. Because serum albumin is not a
component of MELD, it might not fully be taken into account
preoperatively at institutions that use MELD score to guide
operative decisions.
The basis for the low serum albumin remains unclear. Low
albumin is often a result of malnutrition, a known risk factor
for postoperative morbidity and mortality in cirrhotic pa-
tients.15 This study, however, was not able to objectively assess
nutritional status. The lower serum albumin could also be a
marker for muscle wasting and decreased muscle stores or
representative of difficulties with management of hyponatremia
and ascites. Regardless, the subset of patients with MELD ⱖ15
and albumin ⱕ2.5 mg/dL appear to be poor operative candi-
dates, and operative intervention will likely result in adverse
outcome.
Operative blood loss and intraoperative transfusion of
packed red blood cells were also strong predictors of adverse
outcome. Blood loss greater than 150 mL had an OR of 3.9, and
intraoperative transfusion requirement had an associated OR of
16.8 for postoperative morbidity and mortality. Although mul-
May 2010 ABDOMINAL OPERATIONS IN ADVANCED CIRRHOSIS 455

Table 3. Univariate Analysis of Potential Preoperative Variables Influencing Operative Risk

Uncomplicated Morbidity Mortality/transplant
Preoperative parameter (n ⫽ 57) % (n ⫽ 43) % (n ⫽ 12) % P value

Mean age (y) 56.9 n/a 59.6 n/a 61.8 n/a NS

Gender
Male 33 58 25 58 5 42 NS
Female 24 42 18 42 7 58 NS
Mean body mass index 28.1 n/a 26.9 n/a 25.7 n/a NS
Comorbidity NS
Hypertension 22 39 17 39 5 42 NS
Diabetes 17 30 17 39 4 33 NS
Coronary artery disease 4 7 6 14 1 8 NS
Cardiac arrhythmia 2 4 3 7 3 25 NS
Cerebrovascular event 2 4 2 5 1 8 NS
End-stage renal disease 4 7 0 0 0 0 NS
COPD 4 7 3 7 0 0 NS
Hypothyroidism 7 12 5 12 2 17 NS
Etiology of cirrhosisa
Hepatitis C 29 51 22 51 6 50 NS
Alcohol 8 14 8 19 2 17 NS
Hepatitis B 8 14 3 7 0 0 NS
Biliary 4 7 3 7 1 8 NS
Cryptogenic 6 11 7 16 2 17 NS
Autoimmune 2 4 2 5 1 8 NS
Other 2 4 0 0 0 0 NS
Prior SBP 3 5 5 12 1 8 NS
(⫹) Esophageal/gastric varices 13 23 15 35 1 8 NS
(⫹) Portal hypertension 6 11 8 19 0 0 NS
Preoperative TIPS 2 5 6 14 1 8 .06
Encephalopathy
Grade 1 47 82 29 67 6 50 .08
Grade 2 7 12 8 19 4 33 NS
Grade 3 3 6 6 14 2 17 NS
Ascites
Grade 1 44 77 20 47 3 25 .002
Grade 2 9 16 9 21 4 33 NS
Grade 3 4 7 14 32 5 42 .001

Uncomplicated Morbidity Mortality/transplant

Mean laboratory values (n ⫽ 57) 95% CI (n ⫽ 43) 95% CI (n ⫽ 12) 95% CI P value

Total bilirubin (mg/dL) 1.2 0.9–1.5 2.5 1.8–3.1 3.7 2.0–5.3 ⬍.001
Albumin (mg/dL) 3.7 3.6–3.9 3.1 2.9–3.3 2.7 2.3–3.0 ⬍.001
Blood urea nitrogen (U/L) 16.8 14–19.7 19.1 16.6–21.6 24.5 20–29 .038
Prothrombin time (s) 15.3 14.2–16.3 16.9 15.8–17.9 18.9 16.4–21.4 .005
Partial thromboplastin time (s) 31 29.5–32.5 35 33.2–36.7 34.7 31.6–37.8 .002
Leukocyte count (⫻103/␮L) 7.3 6.1–8.6 11.5 7.9–15.1 12.9 6.6–19.3 .024
Hematocrit (%) 38.3 36.3–40.2 34.1 32.1–36 31.2 27.2–35.2 ⬍.001
Aspartate aminotransferase (U/L) 60.3 40.3–80.2 58.58 47.16–70 61.67 34.35–89 NS
Alanine aminotransferase (U/L) 57.3 39–75.6 41.77 32.6–50.9 36.42 25.3–47.5 NS
Alkaline phosphatase (U/L) 137.7 95.8–179 179.0 129.5–228 181.2 84.9–277 NS
Direct bilirubin (mg/dL) 0.75 0.19–1.3 1.2 0.8–1.7 1.3 0.6–1.97 NS
Sodium (mEq/L) 137.8 137–138.8 138.3 136.6–140 135.7 132.2–139 NS
Creatinine (mg/dL) 0.99 0.69–1.3 1.1 0.95–1.2 1.3 0.95–1.7 NS
International normalization ratio 1.5 0.9–2.1 1.4 1.3–1.5 1.7 1.4–1.9 NS
Platelets (⫻103/␮L) 176.7 152.1–201 154.0 124.4–184 166.3 88.5–244 NS

COPD, chronic obstructive pulmonary disease; SBP, spontaneous bacterial peritonitis; TIPS, transjugular intrahepatic portosystemic shunt.
an ⬎ 100, 4 patients with cirrhosis due to hepatitis C and alcohol.

tivariate analysis demonstrated blood loss and transfusion re-
quirement to be independent predictors of poor outcome, dif-
ferentiating the effect of each variable is difficult. Increased
blood loss might represent technical difficulty, whereas adverse
events associated with transfusion might be due to operative
difficulty or effects of transfusion on the immune system im-
peding recovery.16 Future studies designed to distinguish the
effects of transfusion and blood loss on outcome are necessary.
At this time, however, the authors recommend limiting packed
red blood cell transfusion when possible.
456 TELEM ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 5

Table 4. Univariate Analysis of Potential Intraoperative Risk Factors for Adverse Outcome
Uncomplicated Morbidity Mortality/transplant
(n ⫽ 57) 95% CI (n ⫽ 43) 95% CI (n ⫽ 12) 95% CI P value

ASA score 2.7 2.6–2.9 3.3 3.1–3.5 3.6 3.3–3.9 ⬍.001

EBL (mL) 95.0 29–161 348.2 120–576 636.5 99–934 .005

Uncomplicated Morbidity Mortality/transplant

(n ⫽ 57) % (n ⫽ 43) % (n ⫽ 12) % P value

Acuity
Emergent 8 14 24 77 8 67 ⬍.001
Elective 49 86 19 23 4 33 ⬍.001
Approach
Laparoscopic 31 54 19 44 3 25 .002
Conversion 2 6 3 16 1 33 NS
Open 26 46 24 56 9 75 NS
PRBC transfusion 1 2 11 26 6 50 .0003

EBL, estimated blood loss; PRBC, packed red blood cells.

Overall, the laparoscopic approach was associated with sig- cirrhotics of 2%, 12%, and 12%, respectively, and for MELD
nificantly decreased postoperative complications. This result scores 15–25 a mortality rate of 29%. We attribute this success
might be confounded by selection bias, because it is more likely to institutional volume, experience with intraoperative and
used in healthier patients presenting for elective operative pro- postoperative management of cirrhotic patients, and most im-
cedures. To control for bias, the laparoscopic approach was portantly our model of multidisciplinary care. Thus, despite the
assessed by operative procedure and acuity of operation. When same frequency and severity of complications, the experience of
doing so, laparoscopy was associated with a significantly de- the team and preoperative identification of the potential for
creased rate of postoperative complication in patients undergo- morbidity allowed such management to prevent high mortality
ing umbilical herniorrhaphy. A trend toward decreased morbid- rates. Although futures studies are necessary, regionalization of
ity was also demonstrated by other operative procedures; care for patients with advanced cirrhosis to centers specializing
however, sample size precluded significance. Although study in liver medicine with transplant capability might improve
power is limited, the overall reduction in morbidity supports outcome. Regionalization of care has already been demon-
the growing body of literature demonstrating that the laparo- strated to improve outcome for several operative procedures
scopic approach is safe and feasible in cirrhotic patients with- and disease processes.23–25
out ascites.17–20 The major strength of this study is that it represents one of
Consistent with other studies, both emergent surgery and the largest single institution experiences involving patients with
more invasive operative procedures conferred worse postopera- advanced cirrhosis. In contrast to population studies, our study
tive outcomes.21,22 This is not unexpected because emergent was able to account for patient characteristics and assess factors
operative procedures are typically performed in patients with influencing operative outcome. A major limitation of this study
more advanced liver disease. In addition, the increased morbid- was the retrospective study design. Definitive therapeutic rec-
ity and mortality rates associated with colon resection in this ommendations based on retrospective studies are not ideal;
study, as opposed to other operative procedures, are corrobo- however, the infrequent nature of operative intervention in this
rated by other studies within the literature.22 patient subset limits the applicability of prospective or random-
Although the rate and severity of postoperative complication ized control studies. Nonetheless, methodologic limitations of
demonstrated by this study are similar to reported literature, our study limit definitive conclusions. Another limitation was
they did not translate to comparable mortality rates. This study the exclusion of cirrhotic patients requiring operative interven-
demonstrated an overall mortality rate for CTP A, B, and C tion where a decision was made not to intervene. Thus, sicker
patients might have been excluded from analysis. One final
limitation was the ability to assess the influence of preoperative
Table 5. Independent Risk Factors for Adverse Outcome platelet count on postoperative outcome. Although overall
After Multivariate Analysis of Significant Univariate platelet count did not influence patient morbidity and mortal-
Variables ity, only 11 patients presented with preoperative platelet count
Parameter OR 95% CI P value
below 60 ⫻ 103/␮L. Although mortality rate (18%) was compa-
rable, this small sample size precluded significant analysis.
Intraoperative transfusion 16.8 2.1–38.7 ⬍.001 Future studies assessing the impact of platelet count on post-
Albumin ⬍3 mg/dL 15.0 2.2–36.8 ⬍.01 operative outcome after abdominal surgery are necessary.
ASA score ⬎3 10.5 2.8–39.2 ⬍.001
Total bilirubin ⬎1.5 mg/dL 9.8 3.5–27.6 ⬍.001
Emergent procedure 7.0 2.7–18.4 ⬍.001 Conclusions
Presence of ascites 6.1 2.2–17.3 ⬍.001
In summary, preoperative albumin strongly correlated
Blood loss ⬎150 mL 3.9 1.2–10.96 ⬍.01
with outcome in patients with MELD ⱖ15 and should be
May 2010
considered a criterion guiding operative decisions. Patients with
MELD ⱖ15 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 pa-
tients with advanced cirrhosis and preoperative serum albumin
⬎2.5 mg/dL who might be suitable for operative procedures
with better than anticipated outcome. Intraoperative packed
red blood cell transfusion also independently correlated with
adverse operative outcome (OR, 16.8) and should be limited
when feasible. The lower than anticipated mortality rate for
patients with advanced cirrhosis, demonstrated by this study, is
attributed to institutional experience and multidisciplinary ap-
proach to patient care. Although future studies are necessary,
regionalization of care for cirrhotic patients with advanced
disease might improve mortality rates.
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Reprint requests
Address requests for reprints to: Celia M. Divino, MD, Department
of Surgery, The Mount Sinai Medical Center, 5 East 98th Street, Box
1259, 15th Floor, New York, New York 10029. e-mail: celia.
divino@mountsinai.org; fax: (212) 534-2654.
Conflicts of interest
The authors disclose no conflicts.