DAY 3 - Peri-Procedural Risk Stratification and Management in Cirrhosis

Major surgeries in patients with cirrhosis are on the rise. A 2020 analysis of 804 major surgeries in U.S. Veterans with cirrhosis has revealed that high-risk frailty is associated with a 74% increased hazard of postoperative mortality compared to low-risk frailty. 

At the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting in Philadelphia, Pennsylvania, Nadim Mahmud, MD, Assistant Professor at the Hospital of the University of Pennsylvania, focused on the reciprocal nature of surgical risk in patients with cirrhosis: cirrhosis impacts surgical risk, and surgery impacts the stability of cirrhosis. He then discussed various approaches and tools for pre-operative risk stratification and explained how to assess risks associated with non-transplant surgery in patients with cirrhosis.

Dr. Mahmud presented a conceptual framework for risk stratification, encompassing various domains under four key factors: cirrhosis-specific factors, patient factors, surgery-specific factors, and surgery-center-specific factors. He said, "All of these domains matter, and together, they contribute to the risk of postoperative death and complications. I like this framework because when you think about different ways of risk stratifying patients, you can think about how many of these different domains are actually being assessed." He added, "An ideal risk stratification tool should incorporate elements from each domain."

The presentation also addressed the limitations of existing risk assessment tools, such as the Mayo Cirrhosis Surgical Risk Score. Dr. Mahmud demonstrated that this score's calibration has degraded over time, leading to a significant overestimation of risk in modern surgical settings. This inaccuracy can have profound implications for surgical decision-making. Dr. Mahmud discussed a hypothetical scenario: "If you have a patient with cirrhosis that you use a Mayo score for and find that the patient had a 40% chance of dying at 90 days, you would be less inclined to recommend surgery for that patient. Neither patients nor surgeons are excited about pursuing elective surgery. But if that score is wrong, it can really have a dramatic impact on the decision to pursue surgery."

In response to these limitations, Dr. Mahmud and his team developed a new risk assessment tool: The VOCAL-Penn Score. This innovative scale was created using data from the Veterans Affairs Dataset, which included 129,000 cirrhosis patients across 128 centers nationwide and analyzed 4,712 major surgeries. The VOCAL-Penn Score has shown superior predictive performance in external validation compared to existing tools.

Admitting his bias towards the VOCAL-Penn Score, Dr. Mahmud recommended utilizing multiple risk prediction scores when assessing pre-op surgical risk. He added, "I use these tools for shared decision-making with my patients. I use them to have a great conversation explaining the data about what we think is the operative risk out of 100 patients who are just like this patient."

Dr. Mahmud concluded his speech by cautioning, "None of these scores really should substitute for your clinical judgment. Scores are limited by the fact that they're derived from cohorts of only patients who underwent surgery. We don't know what would have happened to patients who did not get surgery, had they gotten surgery."