M. Fleming1, F. Liu2,4, Y. Zhang2,3, K. Pei1 1Yale School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School Of Public Health,Department Of Environmental Health Sciences,New Haven, CT, USA 4Beijing 302 Hospital,Beijing, BEIJING SHI, China
Introduction:
Ascites and the Model for End-Stage Liver Disease (MELD) score independently predict surgical morbidity and mortality. However, MELD, unlike other scoring systems for chronic liver disease such as the Child’s-Turcotte-Pugh, does not include the presence of ascites. Recently, MELD score has been shown to underestimate morbidity and mortality for cirrhotic patients undergoing colectomy for diverticulitis. We sought to ascertain whether this previously reported underprediction was generalizable to cirrhotic patients with ascites across a multitude of general surgery procedures.
Methods:
We performed an analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 through 2014 to calculate risk adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing the following common surgical procedures including both open and laparoscopic approaches: inguinal hernia repair, adhesiolysis for small bowel obstruction, cholecystectomy for acute cholecystitis, and ventral hernia repair. Stratification was performed by MELD score and presence of ascites. Patients with and without ascites were compared within each MELD stratum (low, moderate, and high) utilizing low MELD and no ascites as a reference group.
Results:
Overall there were 30,391 procedures included of which 19,311 (63.54%) were open and 11,080 (36.46%) were laparoscopic. Compared to the low MELD strata with no ascites, each group had increased risk for complications (all p < 0.0001) and within each MELD stratum the presence of ascites portends increased risk for complications (low MELD with ascites adjusted OR 3.22 CI 2.00-5.18, moderate MELD no ascites adjusted OR 1.72 CI 1.55-1.90, moderate MELD with ascites adjusted OR 3.70 CI 2.64-5.19, high MELD without ascites adjusted OR 2.93 CI 2.53-3.39, high MELD with ascites adjusted OR 6.38 CI 4.39-9.26). The same findings hold true when evaluating mortality (all p < 0.0001, low MELD with ascites adjusted OR 9.40 CI 3.53-25.01, moderate MELD without ascites adjusted OR 3.22 CI 2.36-4.40, moderate MELD with ascites adjusted OR 15.24 CI 8.17-28.45, high MELD without ascites adjusted OR 7.01 CI 4.90-10.05, high MELD with ascites adjusted OR 28.56 CI 15.43-52.88). These trends hold true for all 4 general surgical procedures when adjusted morbidity and mortality were analyzed by procedure.
Conclusion:
Ascites increases the risk of perioperative morbidity and mortality across a myriad general surgery procedures in chronic liver disease patients when stratified by MELD score. These findings suggest that ascites plays a critical physiologic and predictive role for surgical patients that is not incorporated into MELD. Further studies should attempt to prospectively validate a novel clinical score inclusive of ascites that may predict outcomes with better accuracy.