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Introduction:
Predictors of post-operative outcomes for patients with liver disease who undergo general surgical procedures have not been adequately assessed. Coagulation status consisting of a complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT) and international normalized ratio (INR) is the only routinely measured preoperative screening tool. Child-Pugh and Model for End-Stage Liver Disease (MELD) scores have also been used to estimate perioperative risk but with inconsistent results. The aim of this study is to identify if certain serum assays of the liver function panel and hematological parameters are associated with increased morbidity and mortality in cirrhotic patients who undergo abdominal surgery.

Methods:
After receiving IRB approval, a retrospective chart review was performed which identified 83 cirrhotic patients who underwent 89 abdominal surgical procedures between 2001 and 2008 at Mount Sinai Medical Center. Pre-operative demographic information, comorbidities, etiology of cirrhosis, and serum test results consisting of PT, PTT, INR, CBC, liver function panel, blood urea nitrogen (BUN), and creatinine (Cr) were collected. The primary endpoint was 30-day post-operative mortality. The secondary endpoint was development of post-operative complication prior to discharge, 30-day readmission or 30-day re-operation. Univariate analysis was performed using chi square test and Student’s t test. Associations with p values less than 0.05 were considered significant.

Results:
The primary endpoint occurred in 6.7% (n=6) of operations and was significantly associated with platelet count <80, hemoglobin (Hb) <10, total protein (TP)<6, lactate dehydrogenase>220, albumin<2.8, INR>1.4, and Cr>1.2, and total bilirubin(TB)>2. The secondary endpoint occurred in 42.7% (n=38) of operations and was significantly associated with Hg<10, TP<6, albumin<2.8, INR>1.4, and TB>2. Transaminases (AST and ALT), alkaline phosphatase, white blood count and gamma-glutamyltransferase showed no significant association with the primary or secondary endpoint.

Conclusion:
The current classification systems utilized for risk stratification in cirrhotic patients undergoing general surgery are not optimal. Preliminary analysis shows candidate serum markers for predicting 30 day complication and mortality rate. These additional indicators can be used to supplement the Child-Pugh and MELD scores in assessing surgical outcomes.

Table 1. Mortality and complication rate