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

Table 1 Demographics, preoperative cirrhosis characteristics, preoperative laboratory values, and operative indications among survivors vs non-survivors (n = 94), n (%)/mean ± SD

	Survivors (n = 65)	Non-survivors (n = 29)	P value
Age	56 ± 10	60 ± 13	0.21
Female	11 (17)	8 (28)	0.23
Race			0.48
White/Caucasian	40 (62)	16 (55)
Black/African American	19 (29)	10 (35)
Hispanic	4 (6)	2 (7)
Asian	2 (3)	0 (0)
CCI, median (IQR)	4 (3-7)	5 (3-8)	0.05
Etiology of cirrhosis			0.07
Alcoholic liver cirrhosis	40 (62)	14 (48)
Hepatitis B	0 (0)	2 (7)
Hepatitis C	16 (25)	3 (10)
NAFLD	1 (2)	2 (7)
Cirrhosis characteristics
Ascites	46 (71)	23 (79)	0.39
Encephalopathy	10 (15)	12 (41)	0.006
History of TIPS	4 (6)	0 (0)	0.17
Childs-Pugh class
Class A	17 (26)	2 (7)	0.02
Class B	37 (57)	9 (31)	0.04
Class C	11 (17)	18 (62)	< 0.001
MELD on admission, median (IQR)	13 (10-22)	26 (18-30)	< 0.001
INR	1.4 ± 0.3	2.3 ± 1.7	< 0.001
Preoperative critical illness indicators
ICU admission	19 (30)	24 (83)	< 0.001
Vasopressors	9 (14)	22 (76)	< 0.001
HD/CRRT	1 (2)	3 (10)	0.05
Laboratory values
White blood cells (× 1000 cells per uL)	10 ± 6	14 ± 8	0.02
Platelets (× 1000 per uL)	168 ± 134	165 ± 125	0.92
Ammonia (ug/dL)	44 ± 78	71 ± 107	0.32
Lactate (mmol/L)	3 ± 3	8 ± 6	< 0.001
Indication for operative intervention			0.002
Acute appendicitis	4 ± 6	0 ± 0
Acute cholecystitis	13 ± 20	3 ± 10
Acute diverticulitis	0 ± 0	1 ± 3
Hernia	16 ± 25	1 ± 3
Infectious colitis	0 ± 0	3 ± 10
Small bowel obstruction	3 ± 5	0 ± 0
Bowel ischemia	8 ± 12	3 ± 10
Acute pancreatitis	3 ± 5	1 ± 3
Perforated peptic ulcer disease	3 ± 5	3 ± 10
Abdominal compartment syndrome	0 ± 0	3 ± 10
Hemorrhage	4 ± 6	4 ± 14
Pneumoperitoneum/pneumatosis	3 ± 5	4 ± 14

CCI: Charlson comorbidity index; HD/CRRT: Hemodialysis/continuous renal replacement therapy; ICU: Intensive care unit; INR: International normalized ratio; IQR: Interquartile range; MELD: Model for end-stage liver disease; NAFLD: Non-alcoholic fatty liver disease; TIPS: Transjugular intrahepatic portosystemic shunt.

Table 2 Intraoperative and postoperative management of survivors vs non-survivors (n = 94), n (%)/mean ± SD

	Survivors (n = 65)	Non-survivors (n = 29)	P value
MELD on day of surgery, median (IQR)	13 (10-25)	23 (17-29)	< 0.001
Approach
Laparoscopic	12 (19)	0 (0)	0.04
Exploratory laparotomy	45 (69)	29 (100)	0.002
Laparoscopic converted to open	8 (12)	0 (0)	0.14
Operation(s) performed
Bowel resection	19 (29)	6 (21)	0.46
Hernia repair	13 (20)	1 (3)	0.06
Laparoscopic cholecystectomy	9 (14)	0 (0)	0.05
Open cholecystectomy	7 (11)	2 (7)	0.72
Laparoscopic appendectomy	3 (5)	0 (0)	0.55
Open appendectomy	2 (3)	0 (0)	0.48
Repair of gastric or duodenal ulcer	4 (6)	3 (10)	0.37
Intraoperative resuscitation at index case
pRBCs (units)	1 ± 2	6 ± 7	< 0.001
FFP (units)	1 ± 2	5 ± 6	< 0.001
Platelets (pack)	0.4 ± 1	0.9 ± 1	0.045
Cryoprecipitate (units)	0.1 ± 0.3	0.4 ± 0.7	0.002
Hemostatic agents used	14 ± 22	15 ± 52	0.003
Closure at index procedure
Open abdomen	19 ± 29	19 ± 66	0.01
Fascia only	5 ± 8	1 ± 3	0.99
Fascia and skin	41 ± 63	8 ± 28	0.01
Skin only	0 ± 0	1 ± 3	0.39
Postoperative management
Antibiotics	50 (77)	27 (93)	0.06
Antifungals	16 (25)	17 (59)	0.001
Diuretics	40 (62)	8 (28)	0.002
Paracentesis	9 (14)	5 (17)	0.67
Total number of operations	2 ± 2	3 ± 2	0.07
Days to final closure	3 ± 7	8 ± 14	0.03
Closure at final procedure
Open abdomen	0 (0)	12 (41)	< 0.001
Fascia only	11 (17)	4 (14)	0.99
Fascia and skin	48 (74)	11 (38)	0.01
Skin only	3 (5)	1 (3)	0.99
Fascial bridge closure	3 (5)	1 (3)	0.99

FFP: Fresh frozen plasma; IQR: Interquartile range; MELD: Model for end-stage liver disease; pRBCs: Packed red blood cells.

Table 3 Postoperative management, complications, and outcomes of survivors vs non-survivors (n = 94), n (%)/mean ± SD

	Survivors (n = 65)	Non-survivors (n = 29)	P value
Postoperative management
ICU admission	36 (55)	29 (100)	< 0.001
Vasopressors	28 (43)	27 (93)	< 0.001
Treatment for SBP	8 (12)	9 (31)	0.03
HD/CRRT	3 (5)	9 (31)	< 0.001
Unplanned operative intervention	17 (26)	13 (45)	0.07
Surgical complications	23 (35)	5 (17)	0.08
Skin dehiscence	3 (56)	1 (8)	0.75
Fascial dehiscence	4 (7)	1 (6)	0.98
Surgical site infection	7 (11)	2 (7)	0.56
Superficial or deep/incisional hematoma	0 (0)	2 (7)	0.03
Intra-abdominal hematoma	7 (11)	6 (21)	0.20
Need for IR intervention	14 (22)	5 (17)	0.63
Non-surgical complications	37 (57)	28 (97)	< 0.001
Bacteremia	13 (20)	10 (35)	0.12
Sepsis	20 (31)	23 (79)	< 0.001
Urinary tract infection	4 (6)	3 (10)	0.48
VTE/PE	3 (5)	1 (3)	0.80
Myocardial infarction	0 (0)	1 (3)	0.13
Arrhythmia	4 (6)	6 (21)	0.04
AKI	26 (40)	24 (83)	< 0.001
Pulmonary effusions	9 (14)	11 (38)	0.01
Pneumonia	8 (12)	10 (35)	0.01
Heart failure	6 (9)	7 (24)	0.05
Postoperative outcomes
Hospital LOS	24 ± 27	32 ± 24	0.93
ICU LOS	10 ± 15	21 ± 29	0.02
Ventilator days	6 ± 12	23 ± 9	0.008
MELD at day of discharge/death, median (IQR)	11 (8-16)	33 (21-37)	< 0.001
Change in MELD score, median (IQR)	-2 (-4 to 0)	3 (0-9)	< 0.001
Discharge disposition			< 0.001
Home	36 (55)	0 (0)
Rehabilitation/skilled nursing facility	27 (42)	0 (0)
Hospice	2 (3)	0 (0)

AKI: Acute kidney injury; HD/CRRT: Hemodialysis/continuous renal replacement therapy; ICU: Intensive care unit; IQR: Interquartile range; IR: Interventional radiology; LOS: Length of stay; MELD: Model for end-stage liver disease; SBP: Secondary bacterial peritonitis; VTE/PE: Venous thromboembolism/pulmonary embolism.

Table 4 Independent predictors of in-hospital mortality and surgical complications across the entire cohort

Outcome	OR	95%CI	P value
Mortality1
MELD at discharge/death	1.25	1.09-1.44	0.002
Vasopressors at index operation	18.3	2.88-116	0.002
Surgical complications2
Final closure: Open abdomen	8.36	1.11-62	0.039
Total number of operations	8.21	3.10-22	< 0.001
Postoperative diuretic use	8.53	2.00-39	0.006

¹Area under the curve = 0.97.

²Area under the curve = 0.89.

CI: Confidence interval; MELD: Model for end-stage liver disease; OR: Odds ratio.