Prognostic Features in Patients With Chronic Liver Failure
Undergoing Nonhepatic Surgery
Henry E. Rice, MD; Grant E. O'Keefe, MD; W. Scott Helton,
MD; Kaj Johansen, MD, PhD
Background: Although the risk of portal decompression
surgery is accurately predicted by objective scoring systems
(Child classification and Pugh score), few useful prognostic
criteria exist regarding nonhepatic surgery in patients with
chronic liver failure.
Objective: To evaluate the clinical findings associated
with perioperative mortality in patients with chronic liver
failure undergoing nonhepatic surgery.
Design: A retrospective cohort study.
Setting: University teaching hospitals.
Patients: Forty consecutive patients with an International
Classification of Diseases, Ninth Revision (ICD-9), diagnosis
of chronic liver failure and one or more of the following:
jaundice, cirrhosis, chronic hepatitis, or alcoholism.
Interventions: Forty operations, including 28 abdominal
procedures, 2 coronary artery bypass grafts, 5 orthopedic
procedures, and 5 miscellaneous procedures.
Main Outcome Measures: Thirty-day mortality as related to
19 preoperative clinical and laboratory variables.
Results: Eleven (28%) of the patients died within 30 days
of surgery. By univariate analysis, the following variables
were significantly (P<.05, Pearson chi2 test for
categorical data or Mann-Whitney U test for continuous data)
associated with nonsurvival: encephalopathy, congestive heart
failure, the need for emergent surgery, infection,
hyperbilirubinemia, international normalized ratio greater
than 1.6, hypoalbuminemia, and an elevated creatinine level.
By multiple logistic regression analysis, an international
normalized ratio greater than 1.6 and encephalopathy were
associated with a greater than 10- and 35-fold increased
mortality risk, respectively. Child classification and Pugh
score failed to predict 30-day mortality.
Conclusions: We identified 8 clinical and laboratory
variables associated with death within 30 days in patients
with chronic liver failure undergoing nonhepatic surgery. Two
factors-international normalized ratio greater than 1.6 and
encephalopathy-independently predicted mortality by
multivariate analysis. Neither Child classification nor Pugh
score was prognostically helpful. Nonhepatic surgery confers a
substantial mortality risk in patients with chronic liver
Arch Surg. 1997;132:880-885