S. Dolejs1, E. P. Ceppa1, J. Kays1, B. L. Zarzaur1 1Indiana University School Of Medicine,Indianapolis, IN, USA
Introduction: Surgeons are commonly asked to perform elective operations on patients with cirrhosis. Cirrhosis has consistently been shown to be a predictor of worse perioperative outcomes, but the magnitude of that risk is poorly understood as the current literature on these patients is predominantly small retrospective series. The Model for End-Stage Liver Disease (MELD) has been validated as a predictor of perioperative outcomes. The American College of Surgeons National Surgical Improvement Program (ACS-NSQIP) provides a unique opportunity to study a large population of patients with high MELD scores for many commonly performed operations to better quantify the perioperative risks of these patients.
Methods: The ACS-NSQIP database from 2005-2013 was used to study patients undergoing cholecystectomy. All patients with CPT codes identifying cholecystectomy were included, and the cohort was divided into laparoscopic or open cholecystectomy. Patients without all laboratory values needed to calculate the MELD were excluded. ICD-9 diagnoses related to choledocholithiasis and preoperative dialysis patients were excluded given the potential for confounding elevation of the MELD score. Bivariate data analysis was performed and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. Logistic regression modeling was performed with 26 preoperative validated variables included in ACS-NSQIP.
Results: A total of 63,464 patients were included in the study. Unadjusted mortality steadily increased as the MELD score increased in the laparoscopic (MELD=6-10, 0.2%; 11-15, 1.1%; 16-20, 3.2%; >20, 5.8%) and open groups (MELD=6-10, 1.5%; 11-15, 3.7%; 16-20, 8.6%; >20, 17.9%; P<0.0001). Unadjusted morbidity similarly increased with MELD score increases in the laparoscopic (MELD=6-10, 3.8%; 11-15, 9.9%; 16-20, 16.3%; >20, 22.8%) and open groups (MELD=6-10, 18.7%; 11-15, 28.2%; 16-20, 40.7%; >20, 57.8%; P<0.0001). MELD score acts as a progressive and independent predictor of morbidity and mortality after logistic regression modeling as shown in the attached table.
Conclusion: The MELD score is an objective and easy to calculate scoring system that independently predicts postoperative morbidity and mortality in patients undergoing cholecystectomy. Open cholecystectomy is associated with significantly more morbidity and mortality than laparoscopic cholecystectomy across all MELD groups.
