In-hospital mortality and dynamic modified end-stage liver disease score after emergency general surgery in patients with cirrhosis

Abstract

BACKGROUND

Improvement in care has resulted in a greater incidence of patients with cirrhosis requiring emergency general surgery procedures (EGSPs). Understanding perioperative risk factors is essential to guide surgical decision-making and optimize outcomes in this high-risk population.

AIM

To describe perioperative characteristics and outcomes of and identify risk factors for in-hospital mortality among patients with cirrhosis requiring EGSP.

METHODS

This was a retrospective study of patients with cirrhosis who underwent EGSP at a single quaternary care center from 2016 to 2023. Data collected included demographics, disease characteristics, perioperative management, and outcomes. The primary outcome was in-hospital mortality. Multivariable logistic regression models were employed to identify factors independently associated with in-hospital mortality. P < 0.05 was considered statistically significant.

RESULTS

Of the 94 patients included, 69% survived. In-hospital mortality was 31%. Non-survivors presented with higher model for end-stage liver disease (MELD) scores (26 vs 13; P < 0.001), had more complex surgical pathology, and suffered more non-surgical complications (97% vs 57%; P < 0.001). Of the 24 patients with improved MELD scores, 92% survived; conversely, of the 14 patients whose MELD scores worsened, 93% died. All patients with a final MELD ≥ 30 died. Worsening MELD was primarily driven by bilirubin and creatinine rather than international normalized ratio. In the adjusted model, preoperative vasopressors (odds ratio [OR]: 18, 95% confidence interval [CI]: 2.9-116) and MELD score at discharge/death (OR: 1.3, 95%CI: 1.1-1.4) were independently associated with in-hospital mortality.

CONCLUSION

In patients with cirrhosis requiring EGSP, initial MELD alone may be insufficient for assessing risk of in-hospital mortality, as it can change postoperatively and may improve after indicated intervention. Postoperative MELD trajectory aligned with prognosis, and increasing MELD – primarily driven by bilirubin and creatinine – was associated with higher in-hospital mortality, highlighting potential targets for postoperative risk mitigation.

Keywords: Emergency general surgery; Cirrhosis; Outcomes; Mortality; Model for end-stage liver disease

Core Tip: For patients with cirrhosis requiring emergency general surgery, initial model for end-stage liver disease (MELD) score alone may be insufficient for perioperative risk assessment, as MELD can change postoperatively. In this single-center retrospective study of 94 patients, MELD at discharge/death was independently associated with in-hospital mortality, whereas admission and day-of-surgery MELD were not. Among 24 patients whose MELD improved after surgery, 92% survived; among 14 whose MELD worsened, 93% died. All patients with final MELD ≥ 30 died. Increases in MELD were driven by bilirubin and creatinine, highlighting the need for targeted postoperative strategies to limit renal and hepatic dysfunction.