CHICAGO — Perioperative mortality and long-term survival of patients with cirrhosis and hepatocellular carcinoma can be predicted using the Model for End-Stage Liver Disease, said Swee Teh, M.D., at the annual meeting of the Society for Surgery of the Alimentary Tract.
Typically, the Child-Turcotte-Pugh score is used most often to predict survival in patients being considered for resection, said Dr. Teh. He and his colleagues at the Mayo Clinic, Rochester, Minn., wanted to determine if the Model for End-Stage Liver Disease (MELD) score could predict perioperative mortality.
The MELD was developed by the United Network for Organ Sharing as a means of ranking patients waiting for a liver transplant and was used regularly starting in early 2002. Scores range from 6 (less ill) to 40 (gravely ill) and rely on three lab tests: bilirubin, international normalized ratio of prothrombin time, and creatinine.
Dr. Teh and his colleagues reviewed the charts of all patients who had a resection for hepatocellular carcinoma between January 1993 and December 2003, and analyzed perioperative mortality and long-term survival, applying both the Child-Turcotte-Pugh and MELD scores. Child-Turcotte-Pugh scores are categorized by three groups: the least sick patients are in class A and have 5–6 points; the moderately ill are in class B, with 7–9 points; and the more severely ill are in class C, with 10–15 points.
There were 82 patients with both cirrhosis and hepatocellular carcinoma (62 male and 20 female). The mean age was 62.1 years for all patients. Overall, 32% of the patients were stage I; 26%, stage II; and 42%, stage III.
The Child-Turcotte-Pugh score for the patients ranged from 5 to 9. Thirty-seven patients had a MELD score of less than 8, and 45 had a MELD of greater than 9 (with a range of 9–15).
The higher MELD scores tended to be associated with greater resection and lower survival. Fifty-nine of the patients had a minor resection, defined as less than three segments (29 had a MELD of less than 8, and 30 had a MELD of greater than 9); and 23 patients had a resection of more than four segments (with 8 having a MELD of 8 or less and 15 with a MELD of 9 or more).
There were 13 perioperative deaths. There appeared to be no correlation between the Child-Turcotte-Pugh score and death during surgery, said Dr. Teh. But all 13 patients who died had a MELD score greater than 9, he said.
At 30 days post resection, none of the patients with a MELD of less than 8 had died, compared with 29% of those with a MELD of greater than 9. The differences between the scores continued to be significant at 1, 3, and 5 years, at which point there was 51% survival among patients with a MELD of less than 8, and 24% among those with a MELD of greater than 9.
Dr. Teh said that because the study appeared to show that MELD is a strong predictor of perioperative mortality and long-term survival, his group recommends resection in patients with scores of less than 8 and organ transplants in those with a 9 or higher score.
Kevin Behrns, M.D., of the University of North Carolina at Chapel Hill, who discussed the paper at the meeting, said Dr. Teh's work showed that “MELD is predictive not only of perioperative mortality but also of survival” and that it is “more predictive than the Child-Turcotte-Pugh” score.