VOCAL-Penn score

Predicted mortality after surgery in a patient with cirrhosis, and the risk of decompensation within 90 days. It takes account of the type of surgery, and outperforms MELD, MELD-Na, Child-Pugh and the Mayo risk score for this purpose.

PatientAge yearsAlbumin g/LTotal bilirubin µmol/LPlatelets × 10⁹/L

BMI 30 or more Yes No

MASLD as the cause of cirrhosis Yes No

ASA class 1 or 2: healthy, or mild systemic disease 3: severe systemic disease 4: severe systemic disease that is a constant threat to life

Emergency surgery Yes No

Type of surgeryAbdominal, laparoscopic (Cholecystectomy, diagnostic laparoscopy, appendicectomy)Abdominal, open (Exploratory laparotomy, colectomy, pancreatectomy, open cholecystectomy)Abdominal wall (Inguinal, umbilical, incisional or ventral hernia repair)Vascular (Aortic aneurysm repair (open or endovascular), femoral bypass, endarterectomy)Major orthopaedic (Hip or knee arthroplasty, above or below knee amputation, fixation of a fractured neck of femur)Chest or cardiac (Lobectomy, pleurodesis, wedge resection, CABG, aortic or mitral valve replacement)

Enter all the values above.

Notes

Derived in about 4,700 US veterans with cirrhosis having surgery between 2008 and 2016, mostly men, and externally validated in two US health systems. It has not been validated in Australian cohorts.
Accuracy is reduced outside the range most patients in the derivation cohort fell within: age 40 to 85, albumin 15 to 50 g/L, bilirubin about 3 to 85 µmol/L, and platelets 30 to 450.
It is not validated for liver transplant, liver resection or TIPS, and does not account for portal hypertension directly (for example, the hepatic venous pressure gradient).
Use it to inform a discussion with the patient and the surgical and anaesthetic teams, alongside an assessment of portal hypertension and the option of doing the surgery at a transplant centre.

References

Mahmud N, Fricker Z, Hubbard RA, et al. Risk prediction models for post-operative mortality in patients with cirrhosis. Hepatology. 2021;73(1):204-218.

Mahmud N, Fricker Z, Panchal S, et al. External validation of the VOCAL-Penn cirrhosis surgical risk score in 2 large, independent health systems. Liver Transpl. 2021;27(7):961-970.

Model equations as published in the authors' calculator,vocalpennscore.com.