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The imperative for an updated cirrhosis surgical risk score
Natalie Zhen Wong1, Nadim Mahmud2
1Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
Insights
Surgical risk prediction for patients with cirrhosis is crucial due to increasing surgery needs. Current tools are limited, necessitating an updated calculator that considers surgery type for better patient outcomes.
Area of Science:
- Hepatology
- Surgical Oncology
- Medical Informatics
Background:
- The incidence of cirrhosis is rising globally, leading to an increased demand for surgical interventions in this patient population.
- Patients with cirrhosis face significantly higher surgical risks compared to non-cirrhotic individuals.
- Existing tools for predicting surgical risk in cirrhosis patients are inadequate due to limitations in specificity, calibration, scope, and timeliness.
Purpose of the Study:
- To highlight the limitations of current cirrhosis surgical risk prediction tools, including the Mayo score.
- To emphasize the need for a more accurate, generalizable, and updated cirrhosis surgical risk calculator.
- To advocate for a risk assessment tool that incorporates the specific type of surgery being considered.
Main Methods:
- Review of existing literature and clinical practice guidelines regarding surgical risk in cirrhosis.
- Analysis of the limitations of the Mayo score, including its single-center origin, outdatedness, and failure to account for surgical type.
- Conceptual framework for an improved risk prediction tool.
Main Results:
- Current prediction tools are non-specific, poorly calibrated, limited in scope, and/or outdated.
- The Mayo score, while dedicated, overestimates risk in external validation and does not differentiate risk by surgery type.
- Inaccurate risk prediction can lead to denial of necessary elective surgeries and increased need for higher-risk emergent procedures.
Conclusions:
- An updated, generalizable, and accurate cirrhosis surgical risk calculator is essential for confident surgical decision-making.
- Incorporating surgery type into risk assessment is critical for improving patient selection and outcomes.
- Addressing the limitations of current tools can prevent adverse clinical consequences and optimize patient care.
Abstract:
The burden of cirrhosis is increasing, as is the need for surgeries in patients with cirrhosis. These patients have increased surgical risk relative to non-cirrhotic patients. Unfortunately, currently available cirrhosis surgical risk prediction tools are non-specific, poorly calibrated, limited in scope, and/or outdated. The Mayo score is the only dedicated tool to provide discrete post-operative mortality predictions for patients with cirrhosis, however it has several limitations. First, its single-center nature does not reflect institution-specific practices that may impact surgical risk. Second, it pre-dates major surgical changes that have changed the landscape of patient selection and surgical risk. Third, it has been shown to overestimate risk in external validation. Finally, and perhaps most importantly, the score does not account for differences in risk based on surgery type. The clinical consequences of inaccurate prediction and risk overestimation are significant, as patients with otherwise acceptable risk may be denied elective surgical procedures, thereby increasing their future need for higher-risk emergent procedures. Confident evaluation of the risks and benefits of surgery in this growing population requires an updated, generalizable, and accurate cirrhosis surgical risk calculator that incorporates the type of surgery under consideration.
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