title: A risk model to predict 90-day mortality among patients undergoing hepatic resection.
abstract: BACKGROUND
  Reliable criteria to predict mortality after hepatectomy remain poorly defined. We sought to identify factors associated with 90-day mortality, as well as validate the "50-50" and peak bilirubin of >7 mg/dL prediction rules for mortality after liver resection. In addition, we propose a novel integer-based score for 90-day mortality using a large cohort of patients.
  
  
  METHODS
  Data from 2,056 patients who underwent liver resection at 2 major hepatobiliary centers between 1990 and 2011 were identified. Perioperative laboratory data, as well as surgical and postoperative details, were analyzed to identify factors associated with liver-related 90-day death.
  
  
  RESULTS
  Indications for liver resection included colorectal metastasis (39%), hepatocellular carcinoma (19%), benign mass (17%), or noncolorectal metastasis (14%). Most patients had normal underlying liver parenchyma (71%) and resection involved ≥3 segments (36%). Overall morbidity and mortality were 19% and 2%, respectively. Only 1 patient fulfilled the 50-50 criteria; this patient survived and was discharged on day 8. Twenty patients had a peak bilirubin concentration >7 mg/dL and 5 died within 90 days; the sensitivity and specificity of the >7-mg/dL rule were 25% and 99.3%, respectively, but overall accuracy was poor (area under the curve 0.574). Factors associated with 90-day mortality included international normalized ratio (odds ratio = 11.87), bilirubin (odds ratio = 1.16), and serum creatinine (odds ratio = 1.87) on postoperative day 3, as well as grade of postoperative complications (odds ratio = 5.08; all p < 0.05). Integer values were assigned to each factor to develop a model that predicted 90-day mortality (area under the curve 0.89). A score of ≥11 points had a sensitivity and specificity of 83.3% and 98.8%, respectively.
  
  
  CONCLUSIONS
  The 50-50 and bilirubin >7-mg/dL rules were not accurate in predicting 90-day mortality. Rather, a composite integer-based risk score based on postoperative day 3 international normalized ratio, bilirubin, creatinine, and complication grade more accurately predicted 90-day mortality after hepatectomy.
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
authors.forename: Omar
authors.initials: O
authors.lastname: Hyder
authors.forename: Carlo
authors.initials: C
authors.lastname: Pulitano
authors.forename: Amin
authors.initials: A
authors.lastname: Firoozmand
authors.forename: Rebecca
authors.initials: R
authors.lastname: Dodson
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wolfgang
authors.forename: Michael A
authors.initials: MA
authors.lastname: Choti
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D017677:Age Distribution; D000368:Aged; D002423:Cause of Death / Q000639:trends; D005260:Female; D006498:Hepatectomy / Q000401:mortality*; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008107:Liver Diseases / Q000401:mortality / Q000601:surgery*; D008297:Male; D008396:Maryland / Q000453:epidemiology; D008875:Middle Aged; D016017:Odds Ratio; D011184:Postoperative Period; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D017678:Sex Distribution; D015996:Survival Rate / Q000639:trends; D013997:Time Factors