Model for End-Stage Liver Disease Underestimates Morbidity and Mortality in Patients with Ascites Undergoing Colectomy
The Model for End-Stage Liver Disease (MELD) score and ascites correlate with surgical morbidity and mortality. However, the MELD score does not account for ascites. We sought to evaluate whether the MELD score accurately risk stratifies patients with ascites.
We analyzed the American College of Surgeons National Surgical Quality Improvement Program (2005–2014) to examine the risk-adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing colectomy for diverticulitis. Patients were stratified by MELD score, and the presence of ascites and outcomes were compared between patients with and without ascites to the reference group of low MELD and no ascites. Multivariable logistic regression was used to control for demographic factors and comorbidities.
A total of 16,877 colectomies were analyzed. For each MELD stratum, patients with ascites have increased risk of complications compared to those without ascites (P < 0.05 unless indicated): low MELD ascites OR 1.13, P = 0.69, moderate MELD no ascites OR 1.37, moderate MELD ascites OR 2.06, high MELD no ascites OR 1.93, and high MELD ascites OR 3.54. These trends hold true for mortality: low MELD ascites OR 2.91, P = 0.063, moderate MELD no ascites OR 1.47, moderate MELD ascites OR 5.62, high MELD no ascites OR 3.04, and high MELD ascites OR 9.91.
Ascites predicts an increased risk for postoperative morbidity and mortality for cirrhotic patients undergoing colectomy for all MELD classifications. These findings suggest that the MELD score significantly underestimates postoperative risk as it does not account for ascites.
Fleming, Zhang, and Pei contributed to study conception and design, and critical revision of manuscript; Liu, Zhang, and Pei involved in acquisition of data; and Fleming, Liu, Zhang, and Pei helped in analysis and interpretation of data, drafting of manuscript, and final approval of the manuscript
Compliance with ethical standards
Conflict of interest
The authors have no established or potential conflict of interest to disclose.
- 1.Lozano R, Naghavi M, Foreman K et al (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet Lond Engl 380:2095–2128. https://doi.org/10.1016/S0140-6736(12)61728-0 CrossRefGoogle Scholar
- 18.Befeler AS, Palmer DE, Hoffman M et al (2005) The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg (Chic Ill 1960) 140:650–654. https://doi.org/10.1001/archsurg.140.7.650 (discussion 655) CrossRefGoogle Scholar
- 20.Cowan RE, Jackson BT, Grainger SL, Thompson RP (1991) Effects of anesthetic agents and abdominal surgery on liver blood flow. Hepatology (Baltim Md) 14:1161–1166Google Scholar
- 24.Causey MW, Nelson D, Johnson EK et al (2014) The impact of Model for End-Stage Liver Disease-Na in predicting morbidity and mortality following elective colon cancer surgery irrespective of underlying liver disease. Am J Surg 207:520–526. https://doi.org/10.1016/j.amjsurg.2013.06.008 CrossRefPubMedGoogle Scholar
- 27.Fleisher LA, Beckman JA, Brown KA et al (2007) ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 50:e159–e241. https://doi.org/10.1016/j.jacc.2007.09.003 CrossRefPubMedGoogle Scholar
- 33.American College of Surgeons (2015) User guide for the 2014 ACS NSQIP participant use data file. ACS, Chicago, ILGoogle Scholar
- 38.Heidelbaugh JJ, Bruderly M (2006) Cirrhosis and chronic liver failure: part I. Diagnosis and evaluation. Am Fam Phys 74:756–762Google Scholar