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Original Investigation | Pacific Coast Surgical Association

Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients Online Only

Joaquim M. Havens, MD1,2; Alexandra B. Columbus, MD1; Olubode A. Olufajo, MD, MPH1,2; Reza Askari, MD2; Ali Salim, MD1,2; Kenneth B. Christopher, MD, SM3
[+] Author Affiliations
1Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
2Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
3The Nathan E. Hellman Memorial Laboratory, Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Surg. 2016;151(7):e160789. doi:10.1001/jamasurg.2016.0789.
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Importance  Emergency general surgery (EGS) patients have a disproportionate burden of death and complications. Chronic liver disease (CLD) increases the risk of complications following elective surgery. For EGS patients with CLD, long-term outcomes are unknown and risk stratification models do not reflect severity of CLD.

Objective  To determine whether the Model for End-Stage Liver Disease (MELD) score is associated with increased risk of 90-day mortality following intensive care unit (ICU) admission in EGS patients.

Design, Setting, and Participants  We performed a retrospective cohort study of patients with CLD who underwent an EGS procedure based on International Classification of Diseases, Ninth Revision (ICD-9) procedure codes and were admitted to a medical or surgical ICU within 48 hours of surgery between January 1, 1998, and September 20, 2012, at 2 academic medical centers. Chronic liver disease was identified using ICD-9 codes. Multivariable logistic regression was performed. The analysis was conducted from July 1, 2015, to January 1, 2016.

Main Outcomes and Measures  The primary outcome was all-cause 90-day mortality.

Results  A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98).

Conclusions and Relevance  In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.

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Figure.
Time-to-Event Curves for Mortality

Unadjusted mortality rates were calculated with Kaplan-Meier methods and compared with log-rank test. Categorization of risk groups is per the primary analysis. The global comparison log-rank P value is P < .001. MELD indicates Model for End-Stage Liver Disease.

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MELD Scoring in Emergency General Surgery: Rising Subtletly to Epitomize Problems
Posted on July 31, 2016
Kumar Jayant
1 Department of hepato-pancreato-biliary surgery (HPB), Hammersmith Hospital, Imperial College, London, UK. 2 Faculty of Health and Science, Institute of Learning and Teaching, University of Liverp
Conflict of Interest: None Declared
To the Editor:
All of us wish to thank Havens et al., for their efficient handling of the project studying the association of model for end-stage liver disease Score with mortality in Emergency General Surgery Patients (1). Despite advancement in surgical techniques and perioperative care, the complications are quite high in emergency general surgery (EGS). These are reflected regarding increased rates of morbidity and mortality. These could be because of various disturbances in the physiological milieu of a body either due to present disease status or ongoing co-morbid malady. One of such condition is the chronic liver disease (CLD) which impose a higher risk for developing postoperative complications independent of a type of surgery. The enormity of morbidity and mortality squares with the extent of hepatic decompensation (2).
Studies have shown that anaesthetic drugs have an adverse impact on the liver enzymes levels, which could be of little significance in a healthy individual. However, in patients with CLD these insults may precipitate hepatic decompensation (3). In patients with CLD, Model for End-Stage Liver Disease (MELD) score has been evinced to correspond with the preoperative risk. This linear regression model has been designed on serum bilirubin and creatinine levels and international normalised ratio (INR). It is more objective and weights the variables, thereby even a slight increase in the MELD score makes an incremental input into the menace (4). Even though this system was moulded to foresee mortality following TIPS, later it was also enacted to stratify patients ahead of liver transplantation, to predict perioperative mortality post-transplant. Lately, researchers have found a notable link allying MELD score and mortality in trauma patients (5).
The published works of literature on this topic are based on retrospective cohorts though they have described a consistent increase in operative risk with CLD. However, there is a lack of any meta-analysis or systemic review. These cultivating evinces and inefficiency of existent models, e.g. the American College of Surgeons National Surgical Quality Improvement Project Surgical Risk Calculator, connote a complete openness for MELD score; that may be indispensable in envisioning outcomes in a number of patients not going through a liver transplant procedures (6).

The study by Havens et al., have described that MELD score is kindred with mortality following intensive care unit admission in the group of emergency general surgery patients with CLD. In this multicenter trial of approximately 700 patients, they have valued the 90 days predictability of MELD score in such patients. Furthermore, they have adumbrated that decreases in MELD scores after 48 hours following intensive care unit admission has a positive impact on outcomes (1).
There is no doubt that this prospective study by has further added our understanding regarding management of EGS patients with CLD, and thus we are grateful to them for their efforts, however, few points deserve mention (7).
First, is that the inclusion of the Deyo-Charlson index which has been widely used to assess the burden of chronic illness and predict outcomes. A study by Poses et al. have valued its importance in prognostication in ICU patients by adding them to a more physiological system such as Acute Physiology and Chronic Health Evaluation II (APACHE II) (8). However in a very landmark study by Quach et al., have reported the limited role of the Deyo-Charlson index in predicting mortality in ICU patients (9). However, this index may have practical applications when another physiological scoring system has not been prospectively determined. Studies have outlined the importance of Charlson index in the assessment of outcomes beyond hospital discharge in non-ICU settings thus further studies are needed to explore the ability of this scoring system in ICU patients.
The second salient point to mention is the need for analysing predictability of MELD scoring system against other prognostic scores as APACHE II), Sequential organ failure assessment (SOFA), Child-Turcotte-Pugh (CTP). Referencing the study by Dusseja et al., over 100 patients with acute on chronic liver disease, which showed that APACHE II scoring system is superior to other prognostic scores in predicting its short-term mortality (10). Here I like to quote a prospective study by Theocharidou et al., 2014 involving a cohort of 635 patients with cirrhosis admitted to ICU. Where they have developed a Royal Free Hospital (RFH), a score for disease prognostication and mortality prediction and compared it against other prognostic models like APACHE II, MELD, CTP and Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) model. Although they have reported good discriminative ability and calibration like other though this also needs further external validation (11).
The third point in the panel of this commentary is making allowance for the role serum lactate and standard base deficit in the praxis scoring system of CLD patients admitted to the intensive care unit is useful for risk assessment, prognostication and foretelling in-hospital mortality (12). By the same token, need and duration of mechanical ventilation, hypoalbuminemia, anaemia, blood transfusion, the length of hospital stay are few other factors which are laid in various studies as a contributor of poorer long-term survival (13).
The quintessential requirements that ideal prognostication model should fulfil are; it must be established on easily measurable parameters, non-invasive, clinically sound, and its validity should be generalizable to a variegated congregation of population. Albeit, many groups have put forwarded various systems with promising internal outcomes, however, external validation with reference to aetiology, gender, ethnicity, geography is lacking in the real world.
Since the appearance of the MELD modus operandi in 2001, MELD has been legitimated and enacted to a vast majority of clinical situations encountered by CLD patients. The enforcement of MELD scoring to prioritise donor livers for transplant in 2002 had called forth a diminution in waiting list registrations and scaled down the mortality on the waiting list without grieving post-transplant outcomes. The MELD score helps clinicians to risk stratifying various interventions on a daily basis in patients with CLD in addition to influencing treatment options (14). The MELD scoring system does have its foibles, and require further reinforcement by other measures of liver, or global functioning is imperative to boost may its prognostic accuracy in the CLD patient undergoing general surgery.

Bibliography:
1. HavensJM, ColumbusAB, OlufajoOA, AskariR, Salim A CK. Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients. 2016;151(7):1–7.
2. Havens JM, Peetz AB, Do WS, Cooper Z, Kelly E, Askari R, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015;78(2):306–11.
3. Gholson CF, Provenza JM, Bacon BR. Hepatologic considerations in patients with parenchymal liver disease undergoing surgery. Am J Gastroenterol. 1990;85(5):487–96.
4. O’Leary JG, Friedman LS. Predicting surgical risk in patients with cirrhosis: from art to science. Vol. 132, Gastroenterology. United States; 2007. p. 1609–11.
5. Peetz A, Salim A, Askari R, De Moya MA, Olufajo OA, Simon TG, et al. Association of Model for End-Stage Liver Disease Score and Mortality in Trauma Patients With Chronic Liver Disease. JAMA Surg. 2016 Jan;151(1):41–8.
6. Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: A decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5).
7. Fong ZV, McMillan MT, Marchegiani G, Sahora K, Malleo G, De Pastena M, et al. Discordance Between Perioperative Antibiotic Prophylaxis and Wound Infection Cultures in Patients Undergoing Pancreaticoduodenectomy. JAMA Surg [Internet]. 2015; Available from: http://www.ncbi.nlm.nih.gov/pubmed/26720272
8. Poses RM, McClish DK, Smith WR, Bekes C, Scott WE. Prediction of survival of critically ill patients by admission comorbidity. J Clin Epidemiol. 1996;49(7):743–7.
9. Quach S, Hennessy D a, Faris P, Fong A, Quan H, Doig C. A comparison between the APACHE II and Charlson Index Score for predicting hospital mortality in critically ill patients. BMC Health Serv Res. 2009;9:129.
10. Duseja A, Choudhary NS, Gupta S, Dhiman RK, Chawla Y. APACHE II score is superior to SOFA, CTP and MELD in predicting the short-term mortality in patients with acute-on-chronic liver failure (ACLF). J Dig Dis. 2013 Sep;14(9):484–90.
11. Theocharidou E, Pieri G, Mohammad AO, Cheung M. The Royal Free Hospital Score : A Calibrated Prognostic Model for Patients With Cirrhosis Admitted to Intensive Care Unit . Comparison With Current Models and CLIF-SOFA Score. Am J Gastroenterol [Internet]. 2014;109(4):554–62. Available from: http://dx.doi.org/10.1038/ajg.2013.466
12. Tobias AZ, Guyette FX, Seymour CW, Suffoletto BP, Martin-Gill C, Quintero J, et al. Pre-resuscitation Lactate and Hospital Mortality in Prehospital Patients. Prehospital Emerg Care [Internet]. 2014;18(3):321–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24548128
13. Han ML, Chen CC, Kuo SH, Hsu WF, Liou JM, Wu MS, et al. Predictors of in-hospital mortality after acute variceal bleeding in patients with hepatocellular carcinoma and concurrent main portal vein thrombosis. J Gastroenterol Hepatol. 2014;29(2):344–51.
14. Kamath PS, Kim WR. The model for end-stage liver disease (MELD). Hepatology [Internet]. 2007;45(3):797–805. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17326206







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