Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Clin Gastroenterol Hepatol. 2022 May;20(5):e1121-e1134. doi: 10.1016/j.cgh.2021.06.050. Epub 2021 Jul 8.
Patients with cirrhosis have an increased risk of postoperative mortality for a range of surgeries; however, they are also at risk of postoperative complications such as infection and cirrhosis decompensation. To date, there are no prediction scores that specifically risk stratify patients for these morbidities.
This was a retrospective study using data of patients with cirrhosis who underwent diverse surgeries in the Veterans Health Administration. Validated algorithms and/or manual adjudication were used to ascertain postoperative decompensation and postoperative infection through 90 days. Multivariable logistic regression was used to evaluate prediction models in derivation and validation sets using variables from the recently-published Veterans Outcomes and Costs Associated with Liver Disease (VOCAL)-Penn cirrhosis surgical risk scores for postoperative mortality. Models were compared with the Mayo risk score, Model for End-stage Liver Disease (MELD)-sodium, and Child-Turcotte-Pugh (CTP) scores.
A total 4712 surgeries were included; patients were predominantly male (97.2 %), white (63.3 %), and with alcohol-related liver disease (35.3 %). Through 90 postoperative days, 8.7 % of patients experienced interval decompensation, and 4.5 % infection. Novel VOCAL-Penn prediction models for decompensation demonstrated good discrimination for interval decompensation (C-statistic 0.762 vs 0.663 Mayo vs 0.603 MELD-sodium vs 0.560 CTP; P < .001); however, discrimination was only fair for postoperative infection (C-statistic 0.666 vs 0.592 Mayo [P = .13] vs 0.502 MELD-sodium [P < .001] vs 0.503 CTP [P < .001]). The model for interval decompensation had excellent calibration in both derivation and validation sets.
We report the derivation and internal validation of a novel, parsimonious prediction model for postoperative decompensation in patients with cirrhosis. This score demonstrated superior discrimination and calibration as compared with existing clinical standards, and will be available at www.vocalpennscore.com.
患有肝硬化的患者在接受多种手术时，术后死亡率风险增加；但他们也面临术后并发症的风险，如感染和肝硬化失代偿。迄今为止，尚无专门用于对这些并发症进行风险分层的预测评分。
这是一项使用退伍军人健康管理局中接受各种手术的肝硬化患者数据的回顾性研究。通过 90 天的时间，使用经过验证的算法和/或手动裁决来确定术后失代偿和术后感染。多变量逻辑回归用于在推导和验证集中评估基于最近发表的退伍军人肝病结局和成本与肝脏疾病（VOCAL）-宾夕法尼亚肝硬化手术风险评分的术后死亡率的预测模型。将模型与 Mayo 风险评分、终末期肝病模型（MELD）-钠和 Child-Turcotte-Pugh（CTP）评分进行比较。
共纳入 4712 例手术；患者主要为男性（97.2%）、白人（63.3%）和酒精性肝病（35.3%）。术后 90 天内，8.7%的患者发生间隔性失代偿，4.5%的患者发生感染。用于失代偿的新型 VOCAL-Penn 预测模型具有良好的间隔性失代偿鉴别能力（C 统计量 0.762 vs 0.663 Mayo vs 0.603 MELD-sodium vs 0.560 CTP；P<0.001）；但对术后感染的鉴别能力仅为中等（C 统计量 0.666 vs 0.592 Mayo [P=0.13] vs 0.502 MELD-sodium [P<0.001] vs 0.503 CTP [P<0.001]）。在推导和验证组中，间隔性失代偿模型均具有出色的校准度。
我们报告了一种用于肝硬化患者术后失代偿的新的、简约预测模型的推导和内部验证。与现有临床标准相比，该评分具有更高的鉴别能力和校准度，可在 www.vocalpennscore.com 上获得。
