title: Predictors of negative intraoperative findings at emergent laparotomy in patients with cirrhosis.
abstract: BACKGROUND
  Emergent surgery in the setting of decompensated cirrhosis is highly morbid. We sought to determine the clinical factors associated with negative intraoperative findings at emergent laparotomy.
  
  
  METHODS
  We performed a retrospective cohort study of consecutive inpatients with a diagnosis of cirrhosis (ICD-9 571) admitted to the Beth Israel Deaconess Medical Center (Boston, MA) who underwent emergent, nonhepatic, abdominal surgery between May 6, 2005 and September 3, 2012.
  
  
  RESULTS
  Eighty-six patients with cirrhosis were included with a mean model for end-stage liver disease score of 21.3 ± 7.95 and a 90-day mortality rate of 39.5%. Twelve (16.2%) patients had negative laparotomies. Negative intraoperative findings were independently associated with (1) paracentesis prior to a preoperative diagnosis of perforated viscus (P = 0.006), (2) development of an indication for emergent surgery after 24 h into hospital admission for another reason (P = 0.020), and (3) a preoperative diagnosis of bowel ischemia (P = 0.005), with odds ratios of 10.1 (CI 1.92-66.83), 5.80 (CI 1.32-33.39), and 11.1 (CI 2.08-77.4), respectively. Free air on computed tomography (CT) imaging was found in 64.3% (9/14) of patients who had a paracentesis within the preceding 48 h compared to 10.1% (7/72) among patients who did not undergo a paracentesis (P < 0.001). Only 45% of patients with free air following a paracentesis had positive findings at laparotomy compared to 100% in those without a preceding paracentesis (P = 0.038). Negative laparotomy was independently predictive of in-hospital mortality (OR 4.7; P = 0.034).
  
  
  CONCLUSIONS
  The possibility of a negative laparotomy is suggested by preoperative clinical factors. In particular, free air following a paracentesis does not necessarily indicate that operative intervention is required. Consideration of close observation before laparotomy in these patients is reasonable.
authors.affiliation: Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA, etapper@bidmc.harvard.edu.
authors.forename: Elliot B
authors.initials: EB
authors.lastname: Tapper
authors.forename: Vilas
authors.initials: V
authors.lastname: Patwardhan
authors.forename: Laura M
authors.initials: LM
authors.lastname: Mazer
authors.forename: Byron
authors.initials: B
authors.lastname: Vaughn
authors.forename: Gail
authors.initials: G
authors.lastname: Piatkowski
authors.forename: Amy R
authors.initials: AR
authors.lastname: Evenson
authors.forename: Raza
authors.initials: R
authors.lastname: Malik
mesh_terms: D002423:Cause of Death / Q000639:trends; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology*; D007432:Intraoperative Period; D007813:Laparotomy / Q000379:methods*; D007902:Length of Stay / Q000639:trends; D008103:Liver Cirrhosis / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends
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