Original Communication| Volume 155, ISSUE 4, P623-632, April 2014

Early mortality and long-term survival after abdominal surgery in patients with liver cirrhosis

Published:November 25, 2013DOI:


      Patients with liver cirrhosis have an increased risk of postoperative mortality. In addition, cirrhotic patients per se have a reduced life expectancy. Little is known about the combined effect of these factors on long-term outcomes after surgery. We thus evaluated early -and long-term survival in patients with cirrhosis who underwent abdominal surgery.


      We evaluated 30- and 90-day mortality as well as long-term survival after 212 general surgical procedures performed in 194 patients with liver cirrhosis. Risk factors for early and late mortality were assessed by uni- and multivariate methods. To avoid multicollinearity of data, different models (Child Turcotte Pugh [CTP], model for end-stage liver disease [MELD], or American Society of Anesthesiologists [ASA] score) were used in multivariate analysis.


      The 30- and 90-day mortality rates were 20% and 30%, respectively. CTP, MELD, and ASA were all independently associated with 30- and 90-day mortality. Although emergency operations and intraoperative transfusions independently influenced 30-day mortality, 90-day mortality also was influenced by the extent of the procedure and thrombocytopenia. Survival after surgery (n = 180) was 54% after one and 25% after 5 years (median survival 1.24 years). Long-term survival was independently influenced by CTP, MELD, ASA, hyponatremia, emergency operations, thrombocytopenia, and underlying malignancies. Survival in patients discharged after surgery (n = 140) was 69% after 1 and 33% after 5 years (median survival 2.8 years). Survival after discharge was independently influenced by MELD, CTP, hyponatremia, underlying malignant disease, and (partially) by serum creatinine. The inclusion of serum sodium into MELD scores did not further facilitate prediction of early and late mortality.


      A high postoperative mortality as well as a strongly reduced survival even after hospital discharge contribute to the very poor life expectancy in patients with liver cirrhosis requiring general surgery. Postoperative outcome is influenced by liver function, comorbidity and “surgical” factors such as the need for blood transfusion and emergent or major operations. However, after hospital discharge, “surgical” factors did not influence survival.
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        • D'Amico G.
        • Garcia-Tsao G.
        • Pagliaro L.
        Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.
        J Hepatol. 2006; 44: 217-231
        • Child C.G.
        • Turcotte J.G.
        Surgery and portal hypertension.
        in: Child C.G. The liver and portal hypertension. Saunders, Philadelphia1964: 50-52
        • Pugh R.N.
        • Murray-Lyon I.M.
        • Dawson J.L.
        • Pietroni M.C.
        • Williams R.
        Transection of the oesophagus for bleeding oesophageal varices.
        Br J Surg. 1973; 60: 646-649
        • Malinchoc M.
        • Kamath P.S.
        • Gordon F.D.
        • Peine C.J.
        • Rank J.
        • ter Borg P.C.
        A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.
        Hepatology. 2000; 31: 864-871
        • Kamath P.S.
        • Wiesner R.H.
        • Malinchoc M.
        • Kremers W.
        • Therneau T.M.
        • Kosberg C.L.
        • et al.
        A model to predict survival in patients with end-stage liver disease.
        Hepatology. 2001; 33: 464-470
        • Garrison R.N.
        • Cryer H.M.
        • Howard D.A.
        • Polk H.C.
        Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis.
        Ann Surg. 1984; 199: 648-655
        • Jakab F.
        • Ráth Z.
        • Sugár I.
        • Ledniczky G.
        • Faller J.
        Complications following major abdominal surgery in cirrhotic patients.
        Hepatogastroenterology. 1993; 40: 176-179
        • Mansour A.
        • Watson W.
        • Shayani V.
        • Pickleman J.
        Abdominal operations in patients with cirrhosis: still a major surgical challenge.
        Surgery. 1997; 122 (discussion 735–6): 730-735
        • Franzetta M.
        • Raimondo D.
        • Giammanco M.
        • Di Trapani B.
        • Passariello P.
        • Sammartano A.
        • et al.
        Prognostic factors of cirrhotic patients in extra-hepatic surgery.
        Minerva Chir. 2003; 58: 541-544
        • del Olmo J.A.
        • Flor-Lorente B.
        • Flor-Civera B.
        • Rodriguez F.
        • Serra M.A.
        • Escudero A.
        • et al.
        Risk factors for nonhepatic surgery in patients with cirrhosis.
        World J Surg. 2003; 27: 647-652
        • Farnsworth N.
        • Fagan S.P.
        • Berger D.H.
        • Awad S.S.
        Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients.
        Am J Surg. 2004; 188: 580-583
        • Befeler A.S.
        • Palmer D.E.
        • Hoffman M.
        • Longo W.
        • Solomon H.
        • Di Bisceglie A.M.
        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. 2005; 140 (discussion 655): 650-654
        • Csikesz N.G.
        • Nguyen L.N.
        • Tseng J.F.
        • Shah S.A.
        Nationwide volume and mortality after elective surgery in cirrhotic patients.
        J Am Coll Surg. 2009; 208: 96-103
        • Modi A.
        • Vohra H.A.
        • Barlow C.W.
        Do patients with liver cirrhosis undergoing cardiac surgery have acceptable outcomes?.
        Interact Cardiovasc Thorac Surg. 2010; 11: 630-634
        • Neeff H.
        • Mariaskin D.
        • Spangenberg H.C.
        • Hopt U.T.
        • Makowiec F.
        Perioperative mortality after non-hepatic general surgery in patients with liver cirrhosis: an analysis of 138 operations in the 2000s using Child and MELD scores.
        J Gastrointest Surg. 2011; 15: 1-11
        • Arif R.
        • Seppelt P.
        • Schwill S.
        • Kojic D.
        • Ghodsizad A.
        • Ruhparwar A.
        • et al.
        Predictive risk factors for patients with cirrhosis undergoing heart surgery.
        Ann Thorac Surg. 2012; 94: 1947-1952
        • Chen C.C.
        • Hsu P.W.
        • Lee S.T.
        • Chang C.N.
        • Wei K.C.
        • Wu C.T.
        • et al.
        Brain surgery in patients with liver cirrhosis.
        J Neurosurg. 2012; 117: 348-353
        • Northup P.G.
        • Wanamaker R.C.
        • Lee V.D.
        • Adams R.B.
        • Berg C.L.
        Model for end-stage liver disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis.
        Ann Surg. 2005; 242: 244-251
        • Teh S.H.
        • Nagorney D.M.
        • Stevens S.R.
        • Offord K.P.
        • Therneau T.M.
        • Plevak D.J.
        • et al.
        Risk factors for mortality after surgery in patients with cirrhosis.
        Gastroenterology. 2007; 132: 1261-1269
        • Vacanti C.J.
        • VanHouten R.J.
        • Hill R.C.
        A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases.
        Anesth Analg. 1970; 49: 564-566
        • Mehta R.L.
        • Kellum J.A.
        • Shah S.V.
        • Molitoris B.A.
        • Ronco C.
        • Warnock D.G.
        • et al.
        Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury.
        Crit Care. 2007; 11: R31
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Cohen S.M.
        • Te H.S.
        • Levitsky J.
        Operative risk of total hip and knee arthroplasty in cirrhotic patients.
        J Arthroplasty. 2005; 20: 460-466
        • Said A.
        • Williams J.
        • Holden J.
        • Remington P.
        • Gangnon R.
        • Musat A.
        • et al.
        Model for end stage liver disease score predicts mortality across a broad spectrum of liver disease.
        J Hepatol. 2004; 40: 897-903
        • Mayo S.C.
        • Shore A.D.
        • Nathan H.
        • Edil B.H.
        • Hirose K.
        • Anders R.A.
        • et al.
        Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion.
        HPB (Oxford). 2011; 13: 473-482
        • Wang S.B.
        • Wang J.H.
        • Chen J.
        • Giri R.K.
        • Chen M.H.
        Natural history of liver cirrhosis in south China based on a large cohort study in one center: a follow-up study for up to 5 years in 920 patients.
        Chin Med J (Engl). 2012; 125: 2157-2162
        • Bhangui P.
        • Laurent A.
        • Amathieu R.
        • Azoulay D.
        Assessment of risk for non-hepatic surgery in cirrhotic patients.
        J Hepatol. 2012; 57: 874-884
        • Nicoll A.
        Surgical risk in patients with cirrhosis.
        J Gastroenterol Hepatol. 2012; 27: 1569-1575
        • de Goede B.
        • Klitsie P.J.
        • Lange J.F.
        • Metselaar H.J.
        • Kazemier G.
        Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review.
        Best Pract Res Clin Gastroenterol. 2012; 26: 47-59
        • de Goede B.
        • Klitsie P.J.
        • Hagen S.M.
        • van Kempen B.J.
        • Spronk S.
        • Metselaar H.J.
        • et al.
        Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis.
        Br J Surg. 2013; 100: 209-216
        • Fong Y.
        • Sun R.L.
        • Jarnagin W.
        • Blumgart L.H.
        An analysis of 412 cases of hepatocellular carcinoma at a Western center.
        Ann Surg. 1999; 229 (discussion 799–800): 790-799
        • Neeff H.
        • Makowiec F.
        • Harder J.
        • Gumpp V.
        • Klock A.
        • Thimme R.
        • et al.
        Hepatic resection for hepatocellular carcinoma—results and analysis of the current literature.
        Zentralbl Chir. 2009; 134: 127-135
        • Oh H.K.
        • Kim H.
        • Ryoo S.
        • Choe E.K.
        • Park K.J.
        Inguinal hernia repair in patients with cirrhosis is not associated with increased risk of complications and recurrence.
        World J Surg. 2011; 35 (discussion 1234): 1229-1233
        • Laurence J.M.
        • Tran P.D.
        • Richardson A.J.
        • Pleass H.C.
        • Lam V.W.
        Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials.
        HPB (Oxford). 2012; 14: 153-161
        • Artinyan A.
        • Marshall C.L.
        • Balentine C.J.
        • Albo D.
        • Orcutt S.T.
        • Awad S.S.
        • et al.
        Clinical outcomes of oncologic gastrointestinal resections in patients with cirrhosis.
        Cancer. 2012; 118: 3494-3500