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1 Korean J Gastroenterol Vol. 57 No. 6, DOI: 0.466/kjg ORIGINAL ARTICLE 단일기관에서관찰한간경변증환자에서복부수술후사망률예측에대한 Model for End-stage Liver Disease 점수의유용성 송창석, 윤민용, 김홍주, 박정호, 박동일, 조용균, 손정일, 전우규, 김병익 성균관대학교의과대학강북삼성병원내과학교실 Usefulness of Model for End-stage Liver Disease Score for Predicting Mortality after Intra-abdominal Surgery in Patients with Liver Cirrhosis in a Single Hospital Chang-Seok Song, Min-Yong Yoon, Hong-Joo Kim, Jung-Ho Park, Dong-Il Park, Yong-Kyun Cho, Chong-Il Sohn, Woo-Kyu Jeon and Byung-Ik Kim Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, Korea Background/Aims: Recent studies have suggested that the model for end-stage liver disease (MELD) score is superior to the Child-Turcotte-Pugh (CTP) score as a predictor of postoperative mortality, especially up to 90 days. This study aimed to determine whether MELD score can predict the postoperative outcome of patients with liver cirrhosis in Korea. Methods: We reviewed the medical records of 98 patients with liver cirrhosis who underwent intra-abdominal surgery under generalized anesthesia between March 2003 and December 2008 at Kangbuk Samsung Hospital. Univariate and multivariate cox proportional hazards analyses were performed to determine the correlation between risk factors and mortality. Results: Eighty-two percent of patients (n=80) were male. Mean MELD score was 0.82±3.84. Common causes of liver cirrhosis were hepatitis B (57.2%) and alcohol (22.4%). Ninety-day mortality ranged from 2.% (MELD score, 9) to 25% (MELD score, 7). By multivariate analysis, MELD score>9 (HR 2.490; [95% CI ; p=.026]) and American Society of Anesthesiologists Class IV (HR 2.433; [95% CI ; p=.04]) predicted mortality at 30 days after surgery. Only MELD score was a predictor of prognosis at 90 days (HR 2.446; [95% CI ; p=.025]). Etiology of cirrhosis and CTP score were not predictors of mortality. Conclusions: MELD score was a useful predictive parameter of postoperative mortality at 30 days and 90 days, independent of the etiology of cirrhosis. (Korean J Gastroenterol 20;57: ) Key Words: Model for end-stage liver disease; Child-Turcotte-Pugh; Liver cirrhosis; Surgery; Mortality 서론 간경변증은동일연령대의일반인과비교하여기대수명이 40% 이하인중증질환이지만합병증에대한규칙적인경과관찰과조기치료로인해생존율이점차높아지고있다. 또한간경변증환자의기대수명이연장되면서수술적치료를필요로하는질병에대한노출위험도증가하고있다. 즉, 간경변증 환자들에서빈도가증가한다고알려진소화기궤양, 탈장등의합병증뿐아니라연령의증가와함께위장관악성종양등에이르기까지수술이필요한질병의빈도가늘어나는추세이다. 간경변증환자는전신마취하수술시수술자체에대한위험과마취와관련된위험이모두증가한다. 2 즉, 간기능저하가응고장애를유발하여출혈성경향을유발하며면역저하를야기하여감염의위험을증가시킨다. 수술시발생하는간혈 Received September 24, 200. Revised November 8, 200. Accepted December 3, 200. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 교신저자 : 김홍주, 0-746, 서울시종로구평동 08, 성균관대학교의과대학강북삼성병원내과학교실 Correspondence to: Hong-Joo Kim, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 08, Pyung-dong, Jongro-gu, Seoul 0-746, Korea. Tel: , Fax: , hongjoo3.kim@samsung.com Financial support: None. Conflict of interest: None. Korean J Gastroenterol, Vol. 57 No. 6, June 20

2 Song CS, et al. Usefulness of MELD Score for Predicting Mortality after Surgery 34 류감소, 스트레스호르몬증가등으로인해간의허혈성손상을유발할수있으며여러종류의마취제들이직접적혹은간접적으로간손상을유발할수도있다. 3-6 또한수술시실혈및간질로의수분이동으로인한저혈압과감염, 패혈증등을치료하기위해사용하는약제들역시간손상을일으킬수있다. 따라서간경변증환자의수술시에는수술전환자의상태가예후를결정하는중요한요인이된다. 간경변증환자의잔여간기능평가와예후판정에가장많이이용되는것은 Child-Turcotte-Pugh (CTP) 점수이다. 이는문맥-전신단락술의위험도를평가하기위해고안된방법으로 964년에처음발표된이후현재까지간경변증환자의장기적인예후를평가하는데널리이용되고있다. CTP 점수는혈청빌리루빈, 알부민, 프로트롬빈시간, 복수및간성혼수의정도로계산하며점수에따라서간경변환자를 Class A, B, C로분류한다. 7 하지만 CTP 점수를산출할때사용되는각요인들의절단값 (cut-off value) 이경험적인수치로이루어져있고복수의정도, 간성뇌증의정도를평가할때주관적요소가반영될수있다는한계점을가지고있다. Model for end-stage liver disease (MELD) 점수는혈청빌리루빈, 프로트롬빈시간, 혈청크레아티닌등의객관적인변수들로계산되는데이는경정맥간내문맥-전신단락술 (transjugular intrahepatic portosystemic shunt, TIPS) 을시행받는간경변증환자에서예후평가를위해처음고안된이후간이식환자에서사망률예측에유용하게사용되고있다. 8,9 최근에는간이식이외의수술에서도수술후 3개월동안의사망률을예측하는데유의한결과를보여주는연구결과들이발표되고있다. 0, 하지만간경변증의원인질환분포가다른국내환자를대상으로같은결과를적용하는데어려움이있다. 따라서이번연구를통해저자는국내간경변증환자들을대상으로 MELD 점수와복부수술후사망률간의관계에대하여알아보고자하였다. 대상및방법. 대상및방법 2003년 3월부터 2008년 2월까지성균관대학교의과대학강북삼성병원에서전신마취하복부수술을받은환자들중에서퇴원요약지의 ICD-0 code를근거로간경변증환자를선별하여후향분석하였다. 복부수술을받은환자들중에서단순탈장수술은제외하였고 CTP 분류와 MELD 점수는수술전 일이내의검사결과로계산하였다. 각환자들에게성별, 연령, 간경변증의원인, 응급수술여부, 미국마취과학회 (American Society of Anesthesiologists, ASA) 분류등을포함하 여조사하였다. 간경변증의원인은알코올성, 만성 B형간염연관성, 만성 C형간염연관성및기타원인 ( 자가면역성, 담즙울체성, 원인불명 ) 등으로나누어서기술하였다. ASA 분류는수술을준비하는모든환자를대상으로수술에대한적합성을보기위해제안된방법으로 ASA I은수술적문제를제외하고는건강한환자, ASA II는경증의전신질환이있는환자, ASA III는중증의전신질환이있는환자, ASA IV는생명을위협하는전신질환이있는환자, ASA V는빈사상태로수술없이생존이어려우나수술후에도사망할가능성이높은환자, ASA VI는뇌사상태의환자로정의하였다. 2 간경변증은임상증상, 신체검사, 혈액학적검사, 내시경검사, 영상검사등을통해진단하였다. 즉, () 내시경검사에서위-식도정맥류가관찰되거나 (2) 혈청알부민수치가 3.4 g/dl 이하, 프로트롬빈시간 (INR) 이.3 이상이며혈청총빌리루빈이 2 mg/dl 이상인경우 (3) 영상검사 ( 초음파혹은컴퓨터단층촬영 ) 에서간경변증과문맥압항진증이의심되는경우등의기준에서 2가지이상을만족할때간경변증으로진단하였다. 또한조직병리학검사와수술시육안소견에서간경변증에합당한경우도진단기준에포함하였다. 대상환자들의추적검사기간은환자가사망하거나추적관찰중단의시점을기준으로하였다. 수술후 30일이내, 90 일이내, 년이내및 년이후의기간별로각변수와사망률과의관계를분석하였다. 2. MELD 점수의계산간경변증환자의 MELD 점수는 2003년 7월이후수정된공식에따라수술전 일이내에시행한검사결과로프로트롬빈시간 (INR), 혈청총빌리루빈 (mg/dl), 혈청크레아티닌 (mg/dl) 을이용하여계산하였다. MELD=9.57 ln (Cr)+3.78 ln (Bilirubin) +.20 ln (INR) (2세환자를대상으로하고혈청크레아티닌최대치는 4.0 mg/dl이며, 만약혈청크레아티닌수치가 4 mg/dl 이상이거나혈액검사전 주이내에 2회이상의혈액투석을받았다면그수치는 4 mg/dl로계산하였다.) 3. 통계분석통계분석은 PASW Statistics 7.0 (SPSS Inc., Chicago, IL, USA) 을사용하였다. CTP 점수와 MELD 점수의생존율예측의유용성검증으로 ROC curve를사용하였다. 95% 신뢰구간 (confidence interval, CI) 을가지는사망률과관련된예후인자의 hazard ratio (HR) 를구하기위해 Cox proportional Vol. 57 No. 6, June 20

3 342 송창석등. 수술후사망률예측에서 MELD 점수의유용성 hazards regression 분석을시행하였다. p값이 0.05 미만인경우를통계적으로유의한차이가있는것으로하였다. 결. 대상환자의임상적특성 Table. Basic Characteristics of the Cirrhotic Patients with Intraabdominal Surgery Age, mean (SD) Male gender (%) MELD score, mean (SD) ASA class IV Etiology of cirrhosis, n Alcohol (%) Hepatitis B (%) Hepatitis C (%) Others Emergency, n (%) 과 총 36명의환자중수술전 일이내의검사결과가없는환자, 복부수술외다른수술을받은환자, 복부수술중탈장수술을받은환자를포함하여총 38명의환자를제외한 98명을선별하였다. 연구기간동안사망자는 39명 (39.7%) 이었다. 간경변증의원인으로알코올성, 만성 B형간염연관성, 만성 C형간염연관성및기타원인 ( 자가면역성, 담즙울체성, 원인불명 ) 등이각각 24명 (24.4%), 58명 (59.2%), 0명 (0.2%), 2 명 (2.2%) 으로조사되었다 (Table ). 조사기간중에서가장 Total surgical population (n=98) 57.8 (0.5) 80 (8.6%) 0.82 (3.84) 9 (9.4%) 22 (22.4%) 56 (57.2%) 0 (0.2%) 0 (0.2%) 8 (7.7%) SD, standard deviation; MELD, model for end stage liver disease; ASA, American Society of Anesthesiologists. 많이시행한복부수술은간엽절제술이었다 (Table 2). 2. 수술후사망률의예측인자 ) 단변량분석수술후사망률에대한단변량분석으로각변수에대해 30일이내, 90일이내, 년이내, 년이후의기간에따라사망률을구하였다 (Table 3). ROC 곡선을이용하여 MELD 점수의절단값은 9점으로정하였다. CTP 점수는 7점을절단값으로하였다 (Fig. ). Table 2. Types of Intra-abdominal Surgery in 98 Patients with Liver Cirrhosis Surgical procedure No. of patients (%) Stomach Resection with Billroth I or II Total gastrectomy Small bowel Resection and anastomosis Takedown ileojejunal bypass Appendectomy Colon Partial colectomy Subtotal colectomy Pancreas Roux-en-Y pancreatojejunostomy Pancreatoduodenectomy Liver/Biliary/Spleen Resectioin of lobe Open cholecystectomy Splenectomy Exploratory laparotomy Abscess Lysis of adhesions 5 (5.3) 4 (4.2) 6 (6.) 2 (2.0) 6 (6.) (.2) 4 (4.2) 8 (8.2) 7 (7.) 7 (7.3) (.2) 2 (2.0) 3 (3.2) 2 (2.0) Fig.. The ROC curves for MELD and CTP scores for predicting mortality after intra-abdominal surgery in patients with cirrhosis. (A) AUC for CTP score was 0.7 (95% CI, ) and (B) AUC for MELD score was 0.82 (95% CI, ), respectively. ROC, receiver operating characteristic; MELD, model for end stage liver disease; CTP, Child-Turcotte-Pugh; AUC, area under curve. The Korean Journal of Gastroenterology

4 Song CS, et al. Usefulness of MELD Score for Predicting Mortality after Surgery 343 ASA 분류, MELD 점수, CTP 점수는추적관찰의전체기간동안사망률과의유의한결과를보여주었다. 그외의요인들에대한사망률의변화는관찰되지않았다 (Table 3). 2) 다변량분석수술후사망률에대한다변량분석역시 30일이내, 90일이내, 년이내, 년이후의기간에따라사망률을구하였다 (Table 4). 단변량분석에서유의한결과를보여주었던 ASA 분류 (HR 2.433; [95% CI ; p=.04]), MELD 점수 (HR 2.490; [95% CI ; p=.026]) 는 30일이내의사망률예측시다변량분석에서도유의한결과를보여주었다. 90일이내의사망률예측에유의한결과를보여준것은 MELD 점수뿐이었다 (HR 2.446; [95% CI ; p=.025]). 단변량분석에서사망률과연관성을보여주었던 CTP 점수는다변량분석에서유의한결과를보여주지않았다. 간경변증의원인질환에따른사망률의변화도관찰되지않았다. 3. CTP 점수와 MELD 점수의기간별사망률비교수술후 30일이내, 90일이내, 년이내기간별누적사망률을 CTP 점수와 MELD 점수의구간별로나누어제시하였다 (Table 5). MELD 점수는 0-9점, 0-2점, 3-6점, 7점이상의네군으로분류하였고각각의 90일이내누적사망률은 2.% (n=),.% (n=3), 6.7% (n=2), 25% (n=3) 이었다. 고찰 간경변증환자의수술위험도평가시에는간질환의정도, 동반질병의이환여부, 수술의종류, 응급상황여부, 수술의질등이포함되어야한다. 이번연구의결과간질환의척도로사용되는 MELD 점수와수술당시동반질병의이환여부를보여주는 ASA 분류가수술후단기사망률의예측인자임을 Table 3. Univariate Analysis of the Predictive Capability of Clinical Parameters for Postoperative Mortality Factors 30 days 90 days year After year HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value MELD >9 CTP >7 ASA IV Etiology Alcohol HBV HCV Others Male Age Emergency ( ).947 ( ) 2.69 ( ) ( ) ( ) ( ).357 ( ).02 ( ) ( ) ( ) ( ) 2.76 ( ) ( ) ( ) ( ).34 ( ).022 ( ) 0.42 ( ) ( ) ( ) ( ) ( ) ( ) ( ).524 ( ).023 ( ) ( ) ( ) ( ) ( ) ( ) 0.77 ( ) ( ).903 ( ).05 ( ) ( ) HR, hazard ratio; CI, confidence interval; MELD, model for end-stage liver disease; CTP, Child-Turcotte-Pugh; ASA, American Society of Anesthesiologists. Table 4. Multivariate Analysis of the Predictive Capability of Clinical Parameters for Postoperative Mortality Factors 30 days 90 days year After year HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value MELD >9 CTP >7 ASA IV Etiology Alcohol HBV HCV Others Male Age Emergency ( ).54 ( ) ( ) ( ) ( ) ( ).499 ( ).307 ( ) ( ) ( ).23 ( ) ( ) ( ) ( ) 0.99 ( ).097 ( ).022 ( ).046 ( ) ( ).445 ( ).954 ( ) ( ) 0.72 ( ) ( ).357 ( ).022 ( ) ( ) ( ).570 ( ).796 ( ) ( ) ( ) 0.80 ( ).65 ( ).020 ( ).27 ( ) HR, hazard ratio; CI, confidence interval; MELD, model for end-stage liver disease; CTP, Child-Turcotte-Pugh; ASA, American Society of Anesthesiologists. Vol. 57 No. 6, June 20

5 344 송창석등. 수술후사망률예측에서 MELD 점수의유용성 Table 5. Correlation between MELD Score, CTP score and Postoperative Mortality MELD score 9 (n=47, 48.0%) 0-2 (n=27, 27.6%) 3-6 (n=2, 2.2%) 7 (n=2, 2.2%) CTP class A (n=48, 49.0%) B (n=46, 46.9%) C (n=4, 4.%) Mortality (%) 30 days 90 days year 2. (n=) 7.4 (n=2) 8.3 (n=) 6.7 (n=2) 6.3 (n=3) 4.3 (n=2) 25 (n=) 2. (n=). (n=3) 6.7 (n=2) 25 (n=3) 0.4 (n=5) 6.5 (n=3) 25 (n=) 4.9 (n=7) 40.7 (n=) 6.7 (n=2) 33.3 (n=4) 8.8 (n=9) 26. (n=2) 75 (n=3) MELD, model for end stage liver disease; CTP, Child-Turcotte-Pugh. 알수있었다. 간경변증환자는대사기능장애, 응고기능장애등으로인해일반인과달리수술전후위험성평가시어려움이있다. 2000년이전발표된논문들에의하면수술후 30일이내사망률을 Child A, B, C 각각 0%, 30%, 76-82% 라보고하고있다. 3,4 하지만 CTP 분류는주관적인척도가포함되어있다. MELD 점수는측정가능한수치로정량화된요인들과각요인별로가중치를주어객관적인척도로알려져있다. 또한 CTP 점수와달리넓은범위의점수로구성되어있어 (CTP 점수 5-5점 vs. MELD 점수 6-40점 ) 간경변증환자의평가에좀더정확한지표로사용할수있다. 이번연구에서저자는 CTP 점수와 MELD 점수를사용하여간경변증환자의전신마취하복부수술후사망률의예측에대하여알아보고자하였다. 연구에서는전신마취하복부수술을시행한간경변증환자를후향분석하였다. 이중신경외과수술, 정형외과수술, 흉부외과수술등은증례가많지않고수술당시간경변증이외의사망에이를수있는응급상황이포함되어있어제외하였으며복부수술에대해서만연구를진행하였다. 수술후 30일이내사망자는 7명이었으며그원인으로패혈증 (2명), 간기능부전 (2명), 급성폐부종 (2명), 위장관출혈 (명) 등이보고되었다. 같은기간내사망환자에서시행한수술은전위절제술 (명), 부분대장절제술 (2명), 간엽절제술 (2명), 췌장절제술 (명), 소장절제술 (명) 등이었다. 단변량분석에서 CTP 점수는복부수술후사망률과통계적으로유의한연관성을보여주었으나다변량분석에서는유의한결과가관찰되지않았다. 반면 ASA 분류와 MELD 점수는단변량분석과다변량분석에서모두수술후 30일이내사망률과통계적으로유의한결과를보여주었다. MELD 점수는이전발표들과같이 30일이내, 90일이내의사망률과유의한연관성을보여주었다. 5-8 이번연구를통하여간경변증환자의복부수술후예측인 자로 MELD 점수의유용함을알수있었지만몇가지제한점이있다. 우선분석에사용된자료는후향분석을실시하여얻어진자료로써수술이가능한상태의환자만이포함되어있다. 즉, 수술이필요한간경변증환자중에서예후가나쁠것으로예상되는환자들은포함되지않았을가능성이있어전체간경변증환자를대변하기힘들다. 또한이번연구는단일병원에서복부수술을시행한환자의자료로써의의있는결과를보여주었던 90일이내의사망자에대한분석시표본수가적어좀더다양한분석을시행하지못하였다. 이런제한점에도불구하고이번연구는국내간경변증환자를대상으로전신마취하복부수술후사망률예측시 MELD 점수와 CTP 점수를비교한첫연구로서의의가있다. 수술후사망률에대한다변량분석결과 CTP 점수는사망률과연관성을보이지않았지만 MELD 점수는수술후 30일이내, 90일이내의사망률예측에유의한상관관계를보여주었다. 뿐만아니라이번연구에서는 MELD 점수의범위에따라 30일, 90일, 년이내의사망률을보여주고있어간경변증환자의복부수술시환자에게필요한정보를제공할수있다. 하지만환자들의표본수가적어추후전향적인대규모의연구가필요할것이다. 요약 목적 : 최근연구들에따르면간경변증환자들의수술후사망률의예측인자로 Child-Turcotte-Pugh (CTP) 점수보다 model for end-stage liver disease (MELD) 점수가더나은연관성이있다고보고되고있다. 저자들은간경변증의원인질환의빈도가다른국내간경변증환자들을대상으로 MELD 점수와수술후사망률과의상관관계를알아보고자하였다. 대상및방법 : 2003년 3월부터 2008년 2월까지성균관대학교강북삼성병원을내원한간경변증환자들중탈장수술을제외하고전신마취하복부수술을시행한 98명의환자를대상으로연령, 성별, 간경변증의원인, 응급수술여부, ASA 분류등을포함하여조사하였다. 수술전시행한신체검사와혈액검사결과로 CTP 점수를계산하였고 MELD 점수는수술전 일이내의검사결과로계산하였다. MELD 점수와 CTP 점수는각각 9점초과, 7점초과를기준으로분류하였고복부수술후 30일이내, 90일이내, 년이내, 년이상의기간으로나누어사망률을조사하였다. 단변량및다변량 Cox proportional hazards 분석을이용하여위험인자와사망률간의통계적인유의성을알아보았다. 결과 : 환자의 8.6% (n=80) 는남성이었고평균연령은 57.8 세 (SD=0.5) 였다. 간경변증의원인으로알코올, B형간염, C 형간염이각각 22.4% (n=22), 57.2% (n=56), 0.2% (n=0) The Korean Journal of Gastroenterology

6 Song CS, et al. Usefulness of MELD Score for Predicting Mortality after Surgery 345 였다. MELD 점수가 9점을초과하는환자들의 30일, 90일, 년사망률은 9.8% (n=5), 5.7% (n=8), 33.3% (n=7) 였고 CTP 점수가 7점을초과하는환자들에서는각각 6.0% (n=3), 8.0% (n=4), 30.0% (n=5) 였다. 다변량분석상 MELD 점수 9점초과 (HR 2.490; [95% CI ; p=.026]) 와 ASA class III 초과 (HR 2.433; [95% CI ; p=.04]) 가수술후 30일이내의사망률과유의한상관관계를보였다. 9 점초과의 MELD 점수만이수술후 90일이내의사망률과유의한상관관계가있었다 (HR 2.446; [95% CI ; p=.025]). 간경변증의원인과 CTP 분류는사망률과연관성을보이지않았다. 결론 : 국내간경변증환자들에서복부수술후사망률예측에 MELD 점수가유용한예측인자로사용될수있겠다. 색인단어 : Model for end-stage liver disease, Child- Turcotte-Pugh, 간경화, 복부수술, 사망률 REFERENCES. Tanaka R, Itoshima T, Nagashima H. Follow-up study of 582 liver cirrhosis patients for 26 years in Japan. Liver 987;7: Cowan RE, Jackson BT, Grainger SL, Thompson RP. Effects of anesthetic agents and abdominal surgery on liver blood flow. Hepatology 99;4: Amitrano L, Guardascione MA, Brancaccio V, Balzano A. Coagulation disorders in liver disease. Semin Liver Dis 2002;22: Borzio M, Salerno F, Piantoni L, et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis 200;33: Thalheimer U, Triantos CK, Samonakis DN, Patch D, Burroughs AK. Infection, coagulation, and variceal bleeding in cirrhosis. Gut 2005;54: Vilstrup H. Cirrhosis and bacterial infections. Rom J Gastroenterol 2003;2: Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg 964;: Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 200;33: Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 3: Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007;32: Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 2003;24: Keats AS. The ASA classification of physical status--a recapitulation. Anesthesiology 978;49: Garrison RN, Cryer HM, Howard DA, Polk HC Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 984;99: Mansour A, Watson W, Shayani V, Pickleman J. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 997;22: Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg 2005;40: Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005;242: Perkins L, Jeffries M, Patel T. Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis. Clin Gastroenterol Hepatol 2004;2: Suman A, Barnes DS, Zein NN, Levinthal GN, Connor JT, Carey WD. Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of Child-Pugh and MELD scores. Clin Gastroenterol Hepatol 2004;2: Vol. 57 No. 6, June 20

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding