Abstract
Background
Patients with cirrhosis have significant postoperative risks following major abdominal surgery. Historic literature and prediction tools do not reflect current practices and outcomes. An assumed 30-day mortality by the model for end-stage liver disease (MELD) score of <12 and 12+ in patients undergoing abdominal surgery is 8% and 33%, respectively. The study objectives were to describe relevant practice patterns and postoperative outcomes in cirrhosis after elective colorectal surgery.
Methods
This retrospective cohort study included 1439 individuals in Ontario with a diagnosis of cirrhosis who underwent colorectal surgery from 2009 to 2017. Demographics, cirrhosis-specific characteristics, and outcomes were identified using linked administrative databases. Univariable and multivariable analyses were performed.
Results
The median MELD-Sodium score was 8 (IQR 7-11). The most common cirrhosis etiologies were metabolic dysfunction-associated steatotic liver disease (58%) and alcohol-associated (24%). Indications for surgery included colorectal cancer (70%), diverticulitis (11%), and inflammatory bowel disease (10%). The 3 most common procedures performed were colon resection with primary anastomosis (66%), rectal resection with primary anastomosis (17%), and abdominal perineal resection (6%). In-hospital and 90-day mortality were 5% and 7%, respectively. Ninety-day complications included readmission (24%), emergency department visit (39%), intensive care admission (27%), and hepatic decompensation (6%). Ninety-day mortality based on MELD-Sodium score included 6% versus 21% in those with a score <12 compared to 12+. Alcohol-related cirrhosis, age, and comorbidities were associated with mortality (P < .01).
Conclusion
This work confirms that the increased surgical risks are lower than once believed in patients with cirrhosis undergoing colorectal surgery in the elective setting. This evidence will guide management of patients in this high-risk group.
Keywords: cirrhosis, colorectal surgery, elective surgery, mortality, morbidity
Graphical abstract
Graphical Abstract.
Note: Image generated using OpenAI ChatGPT, model GPT-4.
Introduction
Individuals with cirrhosis have significant postoperative risks following major abdominal surgery.1 Previous risk prediction models and studies are derived from historical cohorts and likely do not reflect current practices and experiences due to improved medical and perioperative management in this patient group. Furthermore, most of these initial studies did not use validated methods of cirrhosis identification or include measures of liver disease severity which limits accuracy and generalizability.
Colorectal surgeries are among the most commonly performed abdominal procedures. Given the rising incidence of cirrhosis,2 especially in younger adults with nonalcoholic fatty liver disease, it is more common to find oneself deliberating over how to best manage these patients as well as guide patient decision-making regarding treatment. This is especially true in the elective setting since it allows time for risk modification.
The existing literature on colorectal surgery in patients with cirrhosis in the elective setting is limited due to small sample sizes, inconsistent approaches to disease classification, large heterogeneity, and broad discrepancy in outcomes reported.3–15 The only available outcome reported consistently across multiple studies is 30-day mortality ranging from 1.8% to 17.2%.4,8–12 These data are fraught with methodological weakness including bias, confounding, misclassification, heterogeneity, and poor generalizability. High-quality contemporary data are opportune to help guide surgical decision-making in this enlarging high-risk population.
This study’s objectives are to describe practice patterns and short-term outcomes in patients with cirrhosis undergoing elective major colorectal surgery using a large contemporary population-based cohort with robust patient identification and strong analytical methodology.
Methods
Ethics
ICES manages a large repository of population-level health data and operates under a strict legal and ethical framework. As a designated “prescribed entity” under Ontario’s Personal Health Information Protection Act (PHIPA), ICES is authorized to collect personal health information, without consent, for the purpose of analysis or compiling statistical information with respect to the management of, evaluation or monitoring of, the allocation of resources to or planning for all or part of the health system. The use of the data in this project is authorized under Sect. 45 of PHIPA and approved by ICES’ Privacy and Legal Office. The study was approved by the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (DMED-1651- 13) and waived informed consent because deidentified data were used.
Study design, setting, and participants
This is a retrospective population-based cohort study of individuals with cirrhosis undergoing elective colorectal surgery in Ontario, Canada between January 2009 and December 2017. Ontario is Canada’s largest province, with a population of 14.6 million. Single payer, universal health care is provided through the Ontario Health Insurance Plan (OHIP). The study cohort was developed using provincial administrative data from ICES which, as an organization designated a prescribed entity under section 45 of Ontario’s Personal Health Information Privacy Act, houses and enables the use of healthcare data from Ontario residents without acquiring individual consent.
The administrative data used in this study in the elective setting are described in detail in our complementary work examining colorectal surgery in the emergency setting16 and can be found in Tables S1 and S2. The datasets included: the OHIP physician claims database; the Canadian Institute for Health Information’s discharge abstract database (CIHI-DAD: information on inpatient admissions); the Registered Persons Database (RPDB: demographic information and vital status); the Postal Code Conversion Files (PCCF: postal code linkage to geographic areas and census area-based information, including income quintile); the Ontario Lab Information System (OLIS: pathology and laboratory test results from hospital and clinical laboratories); Public Health Ontario (hepatitis data); the National Ambulatory Care Reporting System (NACRS: information on ambulatory care and emergency room visits); the Ontario Cancer Registry (OCR: information on cancer diagnosis); the Same Day Surgery database (SDS: information on day-surgery and outpatient clinic visits); the Ontario Ministry of Health and Long-term Care’s institution information system; and the ICES Physician Database (IPDB: information on physician demographics, specialty, and activity). Datasets used for this study were linked at the individual level using unique encrypted identifiers and analyzed at ICES Queen’s.
Individuals aged 18 or older with cirrhosis were identified using a previously validated algorithm in ICES data.17 Those with a cirrhosis diagnosis before undergoing a major elective colorectal surgical procedure were included in the final study cohort. If the billing code for emergency surgery was omitted, the surgery was considered to be elective. Major colorectal surgeries were identified using billing codes in the OHIP physician claims database and included colon or rectal resections and/or creation colostomy or ileostomy. Surgeries identified in OHIP were linked to their corresponding hospital admission record in CIHI-DAD. Individuals with an emergency admission status indicated on their surgery record were excluded. Individuals were excluded if they did not have a unique identifier, did not have at least 2 years of OHIP eligibility prior to surgical admission date in order to define comorbidity, received a liver transplant any time prior to surgery, or were missing a corresponding CIHI-DAD record for surgery admission.
Variables, outcomes, and data sources
Patient demographics at the time of surgery including age, sex, and income quintile (a measure of relative household income within a census dissemination area, with quintile 1 being the lowest and quintile 5 being the highest) were identified from the RPDB and PCCF. Cirrhosis etiology was defined as either alcohol-associated disease (ALD), hepatitis C, hepatitis B, metabolic dysfunction-associated steatotic liver disease (MASLD), autoimmune (AI) liver disease, or other from a hierarchical algorithm which incorporates both viral serology and diagnostic codes.17 A history of hepatic decompensation was identified using previously validated coding.17 In those with available data in OLIS, the model for end-stage liver disease (MELD)-Na score was calculated using the most recent lab values within 1 year of surgery for bilirubin, INR, creatinine, and sodium. An MELD-Na score of <12 and 12+ was selected for comparison given an a priori literature review supported the correlation of an MELD-Na score of <12 with a Child Pugh A score.18–20 The Charlson comorbidity index was calculated based on hospital admission diagnoses within 2 years prior to surgery.21 Patient comorbidities of asthma, diabetes mellitus, hypertension, congestive heart failure, and chronic obstructive pulmonary disease were identified from ICES-validated cohorts.22–25 Patients with diagnostic codes for obesity within 2 years prior to surgery were also identified.
Acuity and details of the surgical procedures were derived from the corresponding hospital admission record from CIHI-DAD. The indications for surgery (colorectal cancer [CRC], inflammatory bowel disease [IBD], diverticulitis, other) were identified from the most responsible diagnosis during hospital admission, followed by additional diagnoses in CIHI-DAD or OHIP during hospital admission, and pre- and post-surgery diagnoses in CIHI-DAD, OHIP, NACRS, SDS, or OCR (for CRC) within 90 days of procedure. If the patient had no admitting, pre- or post-surgery diagnoses for CRC, IBD, or diverticulitis, then the indication for surgery was classified as other. The hospitals where the surgeries took place were categorized as teaching or non-teaching hospitals according to the Ontario Ministry of Health and Long-term Care’s institution information system. Consultations billed during the hospital admission or within 120 days prior to surgery from physicians with a gastroenterology specialty designation were identified using OHIP physician claims and the IPDB for physician specialty.
In-hospital and 90-day mortality were determined by linkage to the RPBD. Inpatient outcomes included intensive care unit (ICU) admission, length of ICU stay, and total hospital length of stay were identified from CIHI-DAD. Emergency department visits within 90 days post-discharge were identified from NACRS. Hospital re-admission within 90 days was determined from CIHI-DAD. Postoperative hepatic decompensation within 90 days after surgery was described using validated coding.17
Statistical analysis
Patient demographics and surgery treatment details were compared by 90-day mortality status and short-term outcomes were compared by MELD-Na score. Means with standard deviations were calculated for numeric variables, while count and proportions were tabulated for categorical variables. Statistical comparisons of means between groups were performed with 1-way analysis of variance. Comparisons of proportions were made using the chi-square test and the Cochran-Armitage test for trend. Overall survival by MELD-Na score was evaluated with Kaplan-Meier estimates. A priori identified risk factors associated with 90-day mortality were evaluated by multivariable Cox proportional hazards regression models. Patients were followed from time of surgery until the event of interest, death, occurred. Censoring was at 90 days post-surgery. Factors associated with mortality (age, sex, cirrhosis etiology, comorbidities, and indication for surgery) were included a priori and we calculated hazard ratios (HR) and 95% confidence intervals (CI) to quantify associations. We assessed the proportional hazards assumption for each model using Schoenfeld residuals and accounted for factors that violated the assumption by including an interaction term with time in the model.
As per ICES policy, data with small cells (<6) were not reported due to the risk of re-identification. Results were considered statistically significant at P-value <.05. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). In addition, this study was designed, analyzed, and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement.26
Results
Over the study period, 173 126 individuals with cirrhosis were identified and of those, 1439 were admitted for an elective colorectal surgery (Figure 1).
Figure 1.
Flowsheet of included study individuals.
Patient demographics, characteristics, and cirrhosis details
Baseline patient characteristics are described in Table 1. Most individuals were male (59%), with a mean average age of 65 (SD 12.9). Income quintiles were evenly distributed. MASLD was the most common etiology of cirrhosis (58%), followed by ALD (24%). A history of previous hepatic decompensation was infrequent (3.1%), and 609 (42%) individuals had MELD-Na scores available, with a median score of 8 (IQR 7-11).
Table 1.
Baseline demographics and characteristics.
| Variable | Total |
|---|---|
| N = 1439 | |
| Mean age, years ± SD | 65.01 ± 12.94 |
| Median age (IQR) | 66 (57-74) |
| Sex | |
| Female (%) | 592 (41.14) |
| Male (%) | 847 (58.86) |
| Income quintile (%) a | |
| 1—lowest | 313 (21.75) |
| 2 | 289 (20.08) |
| 3 | 287 (19.94) |
| 4 | 282 (19.60) |
| 5—highest | 268 (18.62) |
| Cirrhosis etiology (%) | |
| Hepatitis B or C | 149 (10.35) |
| Autoimmune/Other | 104 (7.23) |
| Alcohol-related | 351 (24.39) |
| MASLD | 835 (58.03) |
| History of decompensation (%) | 45 (3.13) |
| Mean MELD-NA ± SD | 9.58 ± 4.16 |
| Median MELD-Na (IQR) | 8 (7-11) |
| Charlson comorbidity index (%) | |
| 0 | 1021 (70.95) |
| 1-2 | 220 (15.29 |
| 3+ | 198 (13.76) |
| Reason for surgery (%) | |
| Colorectal cancer | 1006 (69.91) |
| IBD | 145-150 (10.08-10.56) |
| Diverticulitis | 150-155 (10.56-10.77) |
| Other | 132 (9.17) |
| Type of surgery (%) | |
| Resection and anastomosis | 1092 (75.89) |
| Resection without anastomosis | 166 (11.54) |
| Resection, anastomosis, and proximal diversion | 111 (7.71) |
| Colostomy/ileostomy only | 70 (4.86) |
| Hospital type (%) | |
| Non-teaching | 820 (56.98) |
| Teaching | 619 (43.02) |
| GI consultation < 120 days Prior (%) | |
| No | 707 (49.13) |
| Yes | 732 (50.87) |
| ICU admission timing (%) | |
| Preoperatively | 28 (1.95) |
| Same day | 267 (18.55) |
| >1 day postoperatively | 93 (6.46) |
| No ICU admission | 1051 (73.04) |
Abbreviations: MASLD, metabolic dysfunction-associated steatotic liver disease; MELD-Na, model of end-stage liver disease; IBD, inflammatory bowel disease; GI, gastroenterology; ICU, intensive care unit.
<2% of patients missing information on income quintile. Patients with missing income quintile were grouped with quintile 1.
Treatment and practice patterns
Colorectal cancer was the most common indication for surgery (70%), followed by diverticulitis (11%) and IBD (10%) (Table 1). Resection with anastomosis was performed in 76% of cases. Forty-three percent of patients had surgery performed at teaching hospitals. Of the 1439 patients, 388 (27%) required ICU admission, 28 (2%) were admitted to ICU prior to surgery, 267 (19%) on the day of surgery, and 93 (6%) after the surgical date. Fifty-one percent of patients were seen by gastroenterology or hepatology in consultation within 120 days before surgery.
Postoperative outcomes
The outcomes are presented in Table 2. The median length of hospital stay was 7 days (IQR 5-11). In-hospital mortality was 4.9%, and 90-day mortality was 7.4%. Six percent of individuals experienced hepatic decompensation within 90 days. Among the individuals discharged from the hospital, 41% had an emergency department visit and 24% had a readmission to the hospital within 90 days.
Table 2.
Short term outcomes.
| Outcome | MELD-Na <12 | MELD-Na 12+ | Total with MELD-Na score | MELD-Na missing | All patients | P-value a |
|---|---|---|---|---|---|---|
| N = 483 | N = 126 | N = 609 | N = 830 | N = 1439 | ||
| 90-Day mortality (%) | 27 (5.59) | 27 (21.43) | 54 (8.87) | 52 (6.27) | 106 (7.37) | <.001 |
| In-hospital mortality (%) | 14 (2.90) | 20 (15.87) | 34 (5.58) | 37 (4.46) | 71 (4.93) | <.001 |
| ICU admission (%) | 121 (25.05) | 70 (55.56) | 191 (31.36) | 197 (23.73) | 388 (26.96) | <.001 |
| Mean hospital length of stay, days ± SD | 10.37 ± 13.22 | 16.97 ± 20.70 | 11.74 ± 15.29 | 10.40 ± 14.87 | 10.97 ± 15.06 | <.001 |
| Median hospital length of stay, days (IQR) | 7 (4-11) | 8 (6-19) | 7 (4-12) | 7 (5-11) | 7 (5-11) | <.001 |
| 90-Day hepatic decompensation (%) | 27 (5.59) | 24 (19.05) | 51 (8.37) | 38 (4.58) | 89 (6.18) | <.001 |
| 90-Day readmission (%) b | 120 (25.59) | 34 (32.08) | 154 (26.78) | 173 (21.82) | 327 (23.90) | .173 |
| 90-Day emergency department visit (%) b | 190 (40.51) | 47 (44.34) | 237 (41.22) | 300 (37.83) | 537 (39.25) | .470 |
Abbreviations: MELD-Na, model of end-stage liver disease score; ICU, intensive care unit; SD, standard deviation; IQR, interquartile range.
Statistical testing compared those with an available MELD-Na only (excluded those missing an MELD-Na).
Only those discharged from hospital included.
Outcomes by MELD scores
Outcomes stratified by MELD-Na scores are presented in Table 2. A comparison of those with and without an MELD-Na score available is presented in Table S3. Although some difference between the groups existed, the groups were similar in terms of their baseline characteristics. Those patients with an MELD-Na <12 had a 6% risk of death at 90 days, but the risk increased to 21% for those with MELD-Na of 12+ (P < .001). Those with an MELD-Na score of 12+ also had a significantly higher rate of ICU admission (56% vs 25%, P < .001).
Outcomes by 90-day mortality
Ninety-day mortality was associated with older age (mean age 70.3 [SD 10.2] vs 64.6 [SD 13.0], P = .001) and increasing Charlson comorbidity score (P < .001). Cirrhosis etiology was also associated with 90-day mortality, with ALD being the highest risk compared to others (43/351, 12.2% vs MASLD 45/835, 5.4% vs. viral 8/149, 5.3% vs AI/other 10/104, 9.6%, P < .001) (Table 3). Patients who died within 90 days after surgery were more likely to have seen gastroenterology in consultation within the 120 days before surgery (67.0% vs 49.6%, P < .001) and to have been admitted to ICU (73.6% vs 23.3%, P < .001).
Table 3.
Characteristics by 90-day mortality status.
| Variable | Alive at 90 days | Dead at 90 days | Total | P-value |
|---|---|---|---|---|
| N = 1333 | N = 106 | N = 1439 | ||
| Mean age, years ± SD | 64.58 ± 13.04 | 70.34 ± 10.22 | 65.01 ± 12.94 | <.001 |
| Median age (IQR) | 66 (57-74) | 72 (64-77) | 66 (57-74) | <.001 |
| Sex | .459 | |||
| Female (%) | 552 (41.41) | 40 (37.74) | 592 (41.14) | |
| Male (%) | 781 (58.59) | 66 (62.26) | 847 (58.86) | |
| Income quintile (%) a | .510 | |||
| 1—lowest | 284 (21.31) | 29 (27.36) | 313 (21.75) | |
| 2 | 271 (20.33) | 18 (16.98) | 289 (20.08) | |
| 3 | 267 (20.03) | 20 (18.87) | 287 (19.94) | |
| 4 | 259 (19.43) | 23 (21.70) | 282 (19.60) | |
| 5—highest | 252 (18.90) | 16 (15.09) | 268 (18.62) | |
| Cirrhosis etiology (%) | <.001 | |||
| Hepatitis B or C | 141 (10.58) | 8 (7.54) | 149 (10.35) | |
| Autoimmune/Other | 94 (7.05) | 10 (9.43) | 104 (7.23) | |
| Alcohol-related | 308 (23.11) | 43 (40.57) | 351 (24.39) | |
| MASLD | 790 (59.26) | 45 (42.45) | 835 (58.03) | |
| History of decompensation (%) | 38 (2.85) | 7 (6.60) | 45 (3.13) | .033 |
| Mean MELD-Na ± SD | 9.22 ± 3.77 | 13.21 ± 5.95 | 9.58 ± 4.16 | <.001 |
| Median MELD-Na (IQR) | 8 (6-11) | 12 (9-16) | 8 (7-11) | <.001 |
| Charlson comorbidity index (%) | <.001 | |||
| 0 | 971 (72.84) | 50 (47.17) | 1,021 (70.95) | |
| 1-2 | 194 (14.55) | 26 (24.53) | 220 (15.29 | |
| 3+ | 168 (12.60) | 30 (28.30) | 198 (13.76) | |
| Reason for surgery (%) | <.001 | |||
| Colorectal cancer | 922 (69.17) | 84 (79.25) | 1006 (69.91) | |
| IBD | 145-150 (10.88-11.25) | <6 (<5.66) | 145-150 (10.08-10.56) | |
| Diverticulitis | 146-151 (10.95-11.33) | <6 (<5.66) | 150-155 (10.56-10.77) | |
| Other | 114 (8.55) | 18 (16.98) | 132 (9.17) | |
| Type of surgery (%) | .067 | |||
| Resection and anastomosis | 1020 (76.52) | 72 (67.92) | 1092 (75.89) | |
| Resection without anastomosis | 148 (11.10) | 18 (16.98) | 166 (11.54) | |
| Resection, anastomosis, and proximal diversion | 104 (7.80) | 7 (6.60) | 111 (7.71) | |
| Colostomy/ileostomy only | 61 (4.58) | 9 (8.49) | 70 (4.86) | |
| Hospital type (%) | .463 | |||
| Non-teaching | 756 (56.71) | 64 (60.38) | 820 (56.98) | |
| Teaching | 577 (43.29) | 42 (39.62) | 619 (43.02) | |
| GI consultation < 120 days prior (%) | <.001 | |||
| No | 672 (50.41) | 35 (33.02) | 707 (49.13) | |
| Yes | 661 (49.59) | 71 (66.98) | 732 (50.87) | |
| ICU admission plan (%) | <.001 | |||
| Preoperatively | 14 (1.05) | 14 (13.21) | 28 (1.95) | |
| Same day | 228 (17.10) | 39 (36.79) | 267 (18.55) | |
| >1 day postoperatively | 68 (5.10) | 25 (23.58) | 93 (6.46) | |
| No ICU admission | 1023 (76.74) | 28 (26.42) | 1051 (73.04) |
Abbreviations: MASLD, metabolic dysfunction-associated steatotic liver disease; MELD-Na, model of end-stage liver disease; IBD, inflammatory bowel disease; GI, gastroenterology; ICU, intensive care unit.
<2% of patients missing information on income quintile. Patients with missing income quintile were grouped with quintile 1.
Survival analyses
Table 4 reports the Cox Proportional Hazards analyses. Increasing age was associated with mortality (HR 1.04; 95% CI, 1.02-1.06 [per year]; P < .001), as well as increasing Charlson comorbidity score (Score 3+ HR 2.88; 95% CI, 1.82-4.54 vs Score 0 [ref], P < .001). ALD was similarly associated with 90-day mortality (HR 2.25; 95% CI, 1.45-3.45 vs MASLD [ref], P = .001).
Table 4.
Cox-proportional hazards analysis of 90-day mortality and risk factors.
| Variable | Univariable |
Multivariable |
|||
|---|---|---|---|---|---|
| HR (95% CI) | P-value | HR (95% CI) | P-value | ||
| Age at time of surgery, per year | 1.04 (1.02-1.06) | <.001 | 1.04 (1.02-1.06) | <.001 | |
| Sex | Female | 1.00 (ref) | .463 | 1.00 (ref) | .865 |
| Male | 1.16 (0.78-1.72) | 0.97 (0.64-1.45) | |||
| Cirrhosis etiology | MASLD | 1.00 (ref) | <.001 | 1.00 (ref) | .001 |
| Alcohol-related | 2.35 (1.55-3.57) | 2.25 (1.45-3.48) | |||
| Other | 0.52 (0.20-1.40) | 0.59 (0.22-1.57) | |||
| Charlson comorbidity index | 0 | 1.00 (ref) | <.001 | 1.00 (ref) | <.001 |
| 1-2 | 2.52 (1.57-4.05) | 2.25 (1.40-3.62) | |||
| 3+ | 3.28 (2.09-5.16) | 2.88 (1.82-4.54) | |||
| Reason for surgery | IBD, diverticulitis or other | 1.00 (ref) | .035 | 1.00 (ref) | .875 |
| Colorectal cancer | 1.66 (1.04-2.65) | 1.04 (0.64-1.70) | |||
Abbreviations: HR, hazards ratio; CI, Confidence interval; ref, Referent; MASLD, metabolic dysfunction-associated steatotic liver disease; IBD, inflammatory bowel disease.
Survival analyses by MELD scores
Kaplan-Meier survival curves stratified by MELD score are presented in Figure 2. The estimate for patients with an MELD score of 12+ was significantly worse than <12 (P < .001). Multivariable Cox proportional hazards model analysis in patients with an available MELD-Na score is demonstrated in Table 5. An MELD-Na score of 12 or higher was significantly associated with increased 90-day mortality (HR 3.52; 95% CI, 2.00-6.19; P < .001).
Figure 2.
Kaplan-Meier survival estimates by model for end-stage liver disease (MELD)-Na category in cirrhosis patients who received elective colorectal surgery and had available MELD-Na score.
Table 5.
Cox-proportional hazards ratio of 90-day mortality, in those with an available MELD-Na score (n = 609).
|
Variable |
Univariable |
Multivariable |
|||
|---|---|---|---|---|---|
| HR (95% CI) | P-value | HR (95% CI) | P-value | ||
| Age at time of surgery, per year | 1.04 (1.01-1.06) | .003 | 1.04 (1.01-1.07) | .006 | |
| Sex | Female | 1.00 (ref) | .504 | 1.00 (ref) | .937 |
| Male | 1.21 (0.70-2.10) | 1.02 (0.58-1.79) | |||
| Cirrhosis etiology | MASLD | 1.00 (ref) | .016 | 1.00 (ref) | .080 |
| Alcohol-related | 2.38 (1.29-4.39) | 2.10 (1.10-4.01) | |||
| Other | 1.23 (0.61-2.49) | 1.45 (0.71-2.96) | |||
| Charlson comorbidity index | 0 | 1.00 (ref) | .002 | 1.00 (ref) | .030 |
| 1-3 | |||||
| 4+ | |||||
| Reason for surgery | IBD, diverticulitis or other | 1.00 (ref) | .289 | 1.00 (ref) | .953 |
| Colorectal cancer | 1.42 (0.75-2.69) | 0.98 (0.49-1.96) | |||
| MELD-Na score | <12 | 1.00 (ref) | <.001 | 1.00 (ref) | <.001 |
| 12+ | 4.31 (2.53-7.36) | 3.52 (2.00-6.19) | |||
Abbreviations: HR, hazards ratio; CI, confidence interval; ref, referent; MASLD, metabolic dysfunction-associated steatotic liver disease; IBD, inflammatory bowel disease; MELD-Na, model of end-stage liver disease.
Discussion
Herein, we report on a contemporary cohort of patients with cirrhosis undergoing elective colorectal surgery. The in-hospital mortality was 5% and the 90-day mortality rate was 7%. Twenty-seven percent of patients were admitted to ICU during a median hospital stay length of 7 days. Six percent experienced hepatic decompensation. Within 90 days after surgery, a quarter of patients were readmitted to hospital and almost half visited the emergency department. Increasing MELD-Na score was associated with 90-day mortality while confounding variables were controlled for. When MELD score was 12+, outcomes worsened significantly. The 90-day mortality increased to 21%, ICU admission rate was 56%, 90-day hepatic decompensation risk rose to 19% and the 90-day readmission rate was 32%.
It is well established that cirrhosis is associated with worse outcomes in patients undergoing abdominopelvic surgery.1 In our recent work, we demonstrated that the risk of 90-day mortality in patients with cirrhosis undergoing emergency colorectal surgery was significantly higher (32%).16 Elective surgery, however, benefits from preoperative optimization, patient selection, and the generally better baseline status of patients undergoing planned procedures. Indeed, in this elective setting, we found a much lower 90-day mortality risk (7%), clearly stratified by MELD-Na score.
Compared with earlier and smaller studies,8,11,13,15 where relevant outcomes are available, our findings show notably lower mortality and complication rates, likely multifactorial and reflecting advancements in surgical and perioperative care. Previous literature often exhibited methodological limitations, including smaller sample sizes and inconsistent disease identification and severity stratification methods.3–15 Our standardized and detailed approach addresses many of these gaps, providing clearer, and more accurate evidence. It is noteworthy that several of our informative outcomes have not been previously reported (eg, preoperative visits with a gastroenterologist or hepatologist), and therefore literature comparisons are not possible, however offer valuable insight into real-world practice patterns.
Severity of liver disease was also associated with postoperative outcomes. The median MELD-NA score was 8 in our study and a mean of 9.6. More than half of the published studies do not control for liver disease severity,3,4,6,9,11–13 while the remaining had average MELD scores clustering at 8-910,14,15 or 12-14.5,7,8
It is worth examining 3 comparable studies with similar MELD scores. The study by Hedrick et al.15 utilized the American College of Surgeons National Surgical Quality Improvment Program data from 2005 to 2006 for 10 033 patients with cirrhosis undergoing elective or emergent colorectal surgery. Unfortunately, cirrhosis was identified by the diagnostic codes for “ascites” or “esophageal varices” and there was no specific mention of mortality rates in patients undergoing elective surgery. The overall 30-day mortality for the cohort was 6.6%, fairing in between the in-hospital (5%) and 90-day mortality (7%) rates we observed. Interestingly, they demonstrated that patients undergoing elective surgery, with an MELD score of 10 had a 5% probability of death at 30 days, which increased by 1% per 1 MELD point until a score of 20 before rising exponentially thereafter. Lee et al.10 studied 161 patients with cirrhosis who underwent elective surgery for CRC from 2001 to 2010. They report perhaps lower estimates with a 30-day mortality rate of 3% and a 30-day morbidity rate of 37.3%. Zhou et al.14 examined 62 patients with liver cirrhosis undergoing surgery for CRC and were specifically interested in the safety of a laparoscopic surgical approach. All patients in this study had an MELD score of less than 15. The 90-day mortality was 0% and the overall morbidity was reported as 59.7% without any timeframe. Unique to this small study is the most common primary cirrhosis etiology of schistosomiasis, likely jeopardizing its relevance to this work.
Furthermore, MASLD and surgery for CRC appeared to be protective in our previous work.16 In this study, we similarly found that MASLD was associated with relatively better outcomes compared to ALD, possibly reflecting differences in patient baseline health, comorbid conditions, or underlying hepatic reserve. The changing epidemiology of cirrhosis, in particular the increasing burden of obesity-related liver disease, may partially account for improved outcomes over time, as these patients are often younger and have fewer competing comorbidities. In contrast, CRC was found to be associated with higher 90-day mortality, which may reflect more complex surgical procedures, advanced disease burden, or delayed presentation in this subgroup. This is supported by the majority of elective colorectal surgery in our cohort being performed for malignancy. When compared to the general population, reasons for elective colorectal surgery included 48% for CRC, 23% for diverticulitis and 8% for IBD,27 whereas herein our proportions were 70%, 11%, and 10%, respectively.
Preoperative gastroenterology or hepatology consultation and ICU admission were also more common among patients who died within 90 days. These associations are likely a reflection of greater underlying disease severity and perioperative risk rather than causal effects, and highlights the role of multidisciplinary assessment in identifying high-risk patients.
Strengths and limitations
Strengths of this study include the large, population-based dataset enhancing generalizability, and the use of validated administrative databases ensuring reliable identification of cirrhosis and accurate classification of surgical procedures. Our standardized stratification by MELD-Na scores also provided robust and clinically relevant risk assessments. Utilizing linked administrative data within a universal healthcare system minimized loss to follow-up, further improving outcome assessment completeness. Our work significantly strengthens the body of literature in that it is more recent and delivers on outcomes that are practical and clinically relevant.
Limitations of our study include the retrospective design inherent to population-based research, limiting access to detailed clinical data such as nutritional status, frailty, specific perioperative management practices, and precise surgical indications. Thus, residual confounding remains a possibility despite multivariable adjustment due to missing information (eg, extent of disease in CRC, or invasiveness of surgery, or continued alcohol intake).
Selection bias is inherent to the study of elective surgery as there is a strong possibility that fitter or healthier patients were offered surgery. Capturing severity of liver disease and comorbidities helps to demonstrate and control for the fitness or baseline health of the patients but does not affect the selection bias that may be present related to who and who is not included in the study. Noting that fewer surgeries were performed for benign indications in comparison to the general population supports the presence of this limitation.
Though it is impressive at the population level and an improvement to existing evidence to have access to the data necessary to calculate MELD-Na scores, accompanying limitations require attention. MELD-Na scores often fluctuate, so while having the score calculated close to the date of surgery is ideal, it still only represents a single point in time making misclassification possible. MELD-Na scores were available for only 42% of the patients, introducing potential selection bias, despite similarities in baseline characteristics between groups. Interestingly, those without an MELD-Na score had slightly improved outcomes, suggesting less severe disease than those with an MELD-Na score.
Clinical implications
Until relatively recently, it was assumed that patients with cirrhosis were at too high of risk to embark on elective colorectal surgery. The data presented in this manuscript suggest otherwise, especially in patients with MELD-Na <12. Elective surgery for colorectal disease in patients with cirrhosis can be undertaken at acceptable risk in the right patient. This work provides a more precise estimate of the risk to inform shared, patient-centered decision-making on surgical management of colorectal disease in the presence of cirrhosis.
Supplementary Material
Acknowledgments
This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from Canada Post Corporation and Statistics Canada. Parts of this material are based on data and/or information compiled and provided by: MOH, Ontario Health, and the Canadian Institutes for Health Information. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. This work was presented as a Poster Presentation at the American Society of Colon and Rectal Surgeons Annual Scientific Meeting and the Canadian Surgical Forum in 2022.
Contributor Information
Kelly Brennan, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada.
Lisa Zhang, Department of Surgery, University of Ottawa, Ottawa, Ontario K1H 8L6, Canada.
Hayton Chui, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada.
Jennifer A Flemming, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada.
Sulaiman Nanji, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada.
Maya Djerboua, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada.
Shaila Merchant, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada.
Antonio Caycedo-Marulanda, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada; Orlando Health Colon & Rectal Institute, Orlando, FL 32806, United States; Department of Surgery, Florida State University, Gainesville, FL 32610, United States.
Sunil V Patel, Department of Surgery, Queen’s University, Kingston, Ontario K7L 3N6, Canada.
Supplementary material
Supplementary material is available at Journal of the Canadian Association of Gastroenterology online.
Funding
This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of long-term Care (MLTC). This study also received funding from the Ontario Association of General Surgeons, the Southeastern Ontario Academic Medical Association, and Queen’s University.
Conflicts of interest
Conflict of interest disclosure forms (ICMJE) have been collected for all co-authors and can be accessed as supplementary material.
Data availability
The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification. Any additional questions can be directed to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification. Any additional questions can be directed to the corresponding author.