Outcomes of Colectomy in United States Veterans With Cirrhosis: Predicting Outcomes Using Nomogram

Abstract

IntroductionWith growing incidence of liver cirrhosis worldwide, there is more need for a risk assessment tool to aid in perioperative management of cirrhotic patients undergoing colorectal procedures. We aim to assess the association of open (OC) versus laparoscopic (LC) approach with colorectal procedures’ outcomes and develop an easy-to-use nomogram to predict outcomes. MethodsWe analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent colorectal procedures from 2008 to 2015. Model for End-stage Liver Disease score was calculated as well as five-items modified frailty index. The chi-square test was utilized to analyze categorical variables. Two-sided unpaired Student's t-test or Mann–Whitney U-test were used for numerical variables as appropriate. Multivariate logistic regression adjusting for demographics, comorbidities, and other preoperative factors was used to analyze postoperative outcomes. A predictive nomogram was constructed and internally validated. ResultsA total of 731 patients were identified. Overall, complications occurred in 48.2% of patients, and 30-d mortality was 24.8%, with 57.5% were performed emergently. Malignant neoplasm was the most common indication (25.4%). LC was performed in 22.4%, with shorter operative time, less blood transfusions, shorter length of stay, and lower morbidity compared to OC. Overall, Model for End-stage Liver Disease score was an independent factor of mortality, while laparoscopic approach had a protective effect on morbidity. An easy-to-use nomogram was generated for morbidity and 30-d mortality with calculated area under cure of 74.5% and 77.9%, respectively, indicating reliability. ConclusionsAlthough colectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing colectomy is proposed.