BACKGROUND:
Hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis is generally recommended for those who are Child-Pugh Class A. The Model for End-Stage Liver Disease (MELD) has been shown to accurately predict survival in patients with cirrhosis. Whether MELD can be used to select patients with cirrhosis for hepatic resection is unknown.

AIMS:
To determine the risk factors for mortality in cirrhotic patients undergoing hepatic resection.

METHODS:
A retrospective chart review of all patients with HCC and cirrhosis who underwent surgical resection between January 1993 and December 2003 was undertaken to determine risk for mortality. RESULTS: There were 82 patients, 62 male, 20 female (mean age 62.1 years); 45 patients had a MELD score ³ 9 (range 9-15). Child-Pugh score ranged between 5-9 points. The mean size of the tumor was 5.2 cm. Fifty-nine patients had minor (£ 3 segments) hepatic resection (MELD £ 8, n= 29; MELD ³ 9, n= 30 ), and 23 patients had major (³ 4 segments) hepatic resections (MELD £ 8, n= 8 ; MELD ³ 9, n= 15 ). Hospital mortality and 30-day mortality were 12% and 16% respectively, predominantly due to liver failure. Multivariate analysis demonstrated that factors significantly associated with increasing mortality were: MELD score ³ 9 (p< 0.0001); presence of symptoms (p=0.0001); tumor larger than 5 cm (p=0.01), and high grade (p=0.03), but not Child-Pugh class (p=0.6), vascular invasion or multilobar disease. Overall, MELD score £ 8 was associated with 0% 30-day mortality as compared with 29% for those with MELD score of ³ 9 (p=0.002) (Table). For MELD ³ 9, 30-day mortality (p=0.6) and long-term survival was similar between minor and major hepatic resection.

CONCLUSION:
MELD is a strong predictor of both perioperative mortality and long-term survival in cirrhotic patients undergoing hepatic resection. In patients with cirrhosis, hepatic resection (minor or major) for HCC is recommended if the MELD score is £ 8. In patients with MELD score ³ 9, other treatment modalities should be considered.

Table 1: Overall Survival by MELD Score