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Portal Hypertension: An Underestimated Entity?
Zakiyah Kadry1, Eric W Schaefer, Riaz Ali Shah
1*Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA †Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA ‡Division of Gastroenterology, College of Medicine, The Pennsylvania State University, Hershey, PA §Department of Medicine, The Pennsylvania State University, Hershey, PA ¶Department of Anesthesiology, College of Medicine, The Pennsylvania State University, Hershey, PA.
Insights
Portal hypertension significantly increases mortality and morbidity in general surgery. This risk is present even in patients with a Model for End Stage Liver Disease score of 15 or less, highlighting the need for careful assessment.
Area of Science:
- General Surgery
- Hepatology
- Clinical Risk Assessment
Background:
- Limited data exists on portal hypertension's impact on general surgical outcomes.
- Existing risk scores (Child-Pugh, MELD) do not fully capture portal hypertension severity.
- Research has primarily focused on portal hypertension in liver surgery.
Purpose of the Study:
- To evaluate portal hypertension as an independent risk factor in general surgical procedures.
- To assess the association between portal hypertension and 30-day mortality and morbidity.
- To determine if the Model for End Stage Liver Disease (MELD) score accurately reflects risk in portal hypertension patients undergoing general surgery.
Main Methods:
- Case-matched cohort study using the National Surgical Quality Improvement Program (NSQIP) database (2005-2012).
- Patients with esophageal varices (portal hypertension cohort) were matched 1:2 with patients without esophageal varices (NEV) by demographics, surgery type, and year.
- Generalized estimating equations were used to analyze 30-day mortality and morbidity. MELD scores were used for subgroup analysis.
Main Results:
- A cohort of 1,574 esophageal varices (EV) patients was matched with 3,148 NEV patients.
- EV patients demonstrated a 3.01-fold increased odds of 30-day mortality (P < 0.001) and 1.28-fold increased odds of complications (P < 0.001) versus NEV patients.
- EV patients with MELD >15 had significantly higher mortality (4.64-fold) and morbidity (1.75-fold) risks, while those with MELD ≤15 still showed increased mortality (1.95-fold) and morbidity risks.
Conclusions:
- Portal hypertension is a significant independent risk factor for mortality and morbidity in general surgery.
- The risk associated with portal hypertension should not be underestimated, even in patients with MELD scores of 15 or less.
- Current risk assessment tools may not adequately account for the impact of portal hypertension in non-liver specific general surgical contexts.
Objective:
The aim of this study is to evaluate portal hypertension as an independent risk factor in general surgical procedures.
Background:
Data on the impact of portal hypertension in general surgical outcomes has been limited. Published literature has focused mainly on its effect in liver surgery. The Child Pugh score and Model for End Stage Liver Disease are utilized for surgical risk assessment in liver disease but they do not accurately reflect degree of portal hypertension.
Methods:
From 2005 to 2012, patients with esophageal varices (EV) in the National Surgical Quality Improvement Program (NSQIP) formed the portal hypertension cohort, and were case matched to patients without esophageal varices (NEV) based on sex, age, surgery type, and year of operation. Thirty day mortality and morbidity were analyzed using generalized estimating equations for binary outcomes. EV patients were also dichotomized by Model for End Stage Liver Disease (MELD) score (≤15 vs >15) and compared with NEV patients.
Results:
One thousand five hundred and seventy-four EV patients were matched to 3148 NEV patients. In multivariable analysis, EV patients had a 3.01 higher odds of 30 day mortality (P < 0.001) and 1.28 higher odds of complications (P < 0.001) compared with NEV patients. EV patients with MELD >15 had 4.64 higher odds of death within 30 days (P < 0.001) and had 1.75 higher odds of complications within 30 days (P < 0.001) compared with NEV patients; EV patients with MELD 15 or less had 1.95 higher odds of 30 day mortality (P < 0.001) compared with NEV patients.
Conclusions:
Portal hypertension is associated with a significant mortality and morbidity risk in general surgery, and should not be underestimated even in patients with MELD 15 or less where the early mortality risk remained significant.
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