VOCAL-Penn Cirrhosis Surgical Risk Score

1. Why a Surgery-Specific Model

MELD was derived to predict survival after a transjugular intrahepatic portosystemic shunt and then adopted for transplant allocation. Child-Turcotte-Pugh was a bedside classification from 1964 with two subjective items in it. Both describe the liver, and neither knows what operation is planned.

• The operation matters. An open abdominal procedure carries an odds ratio of about 4.8 for 30-day mortality against a laparoscopic one, before anything about the patient is considered.
• External validation, two health systems. C-statistic 0.82 for 90-day mortality, against 0.79 for the Mayo score, 0.79 for MELD and 0.78 for MELD-sodium. The differences were not significant. Calibration separated them: the Mayo score overestimated risk throughout, and VOCAL-Penn held its discrimination at higher MELD scores where MELD and MELD-sodium lost theirs.
• The guideline position. The 2025 American College of Gastroenterology guideline names it the preferred model and states that MELD and Child-Turcotte-Pugh alone are inadequate for this decision.

2. The Four Models and Their Sources

Four logistic models. Three predict mortality, from the 2021 Hepatology paper, derived on 4,712 procedures in 3,785 patients in the Veterans Health Administration. The fourth predicts decompensation, from the 2022 Clinical Gastroenterology and Hepatology paper, fitted on the same cohort.

• The timepoints are conditional, not independent. Death among those who survived 30 days is what the 90-day model predicts, and the 180-day model works the same way against 90. Combining them by the law of total probability is what the paper does, and it is why the 90-day figure is never below the 30-day one. Printing each model's raw output would understate the later two.
• Decompensation is a separate question. The endpoint is new clinically significant ascites, hepatic encephalopathy, hepatorenal syndrome or variceal bleeding within 90 days. C-statistic 0.766 in derivation and 0.762 in validation, against 0.663 for the Mayo score, 0.603 for MELD-sodium and 0.560 for Child-Turcotte-Pugh. Low mortality with high decompensation risk is the combination that decides ward against high dependency unit.
• The surgery coefficients run the other way here. Every other category carries a lower decompensation risk than laparoscopic abdominal surgery, vascular by the widest margin and abdominal wall repair by the narrowest. Open abdominal surgery alone carries a higher one.
• Where the coefficients come from. The Hepatology supplement prints the three mortality models in full, and this tool reproduces all forty coefficients exactly. The decompensation model is printed nowhere: its paper gives odds ratios to two decimal places, which cannot rebuild a model or recover an intercept. It follows the authors' reference calculator at vocalpennscore.com, which fourteen of those odds ratios corroborate.
• The calculator and the papers disagree twice. On the platelet spline knots, and on two bilirubin coefficients of the decompensation model. This tool follows the calculator, so that it agrees with what a reader who cross-checks will see. The papers would move the mortality figures by at most 1.0 percentage point and the decompensation figure by at most 2.2, and only at the edges of the accepted input range.
• The predictors differ between the four. Bilirubin is in the 30-day and the decompensation models only, age in three of the four but not the 30-day, obesity in the 30-day, the 180-day and the decompensation models. Each model kept whatever survived selection, so no single predictor list describes the tool.

3. Surgery Categories, Exclusions and Gaps

• Excluded by design. Liver-specific surgery including partial hepatectomy, central nervous system surgery, endovascular valve replacement such as transcatheter aortic valve replacement, and minor superficial skin procedures. Central nervous system surgery was dropped for fewer than 50 procedures in the cohort. Do not use the tool for these.
• Never derived, so unanswerable here. Urological, ear nose and throat, gynaecological, obstetric, ophthalmic and transplant surgery. The nearest-looking category produces a number with nothing behind it. The categories that do exist are broad: a cholecystectomy and a pancreatectomy share one coefficient.

4. Reading and Reporting the Figures

A percentage can be said to a family. It is also the figure that decides whether a high dependency bed is booked in advance.

• The one published threshold. The 2025 American College of Gastroenterology guideline says to consider pre-operative liver transplant evaluation where the projected 90-day mortality reaches 15 per cent. It is the only cut-off this tool uses.
• The labels are not a grading. Low and intermediate on the result cards are a display convention of this page and nothing more. Read the percentage.
• The comparison table re-runs the model with one input changed, elective against emergency and open against laparoscopic. Those are the two inputs a clinical decision can move. The gap is often the most useful figure on the page, but it is the model at a different input and not a prediction of what converting an operation would achieve.

5. Variables the Model Omits

Two patients with the same albumin, bilirubin and platelet count get the same number from this page, whether one of them has tense ascites and the other has none.

• Absent from all four models. Ascites, hepatic encephalopathy, varices, sarcopenia, frailty, sodium, creatinine, the international normalised ratio and hepatocellular carcinoma. Uncontrolled ascites or encephalopathy is a reason to postpone an elective operation whatever this page reports, and ascites under an abdominal wall repair impairs wound healing directly.
• The obesity coefficient is protective. A Body Mass Index of 30 or above carries an odds ratio of 0.47 for 30-day mortality. That is an association in the derivation data, not a demonstrated benefit, and it sits beside sarcopenic obesity, which carries the opposite prognosis and which the model does not measure.
• Two obesity cut-offs collide here. The model was fitted on the World Health Organization figure of 30, not the Asian cut-off of 25 this site uses everywhere else, so a Body Mass Index of 27 is obese for every other purpose and not obese to this model. The tool reads it as the model requires and flags the collision rather than resolving it silently.
• What the data are. Both papers are retrospective cohort studies built on administrative coding. Laboratory values come from within 30 days before surgery, which is what the models were fitted on. A value three months old is not the same input.

6. Derivation Cohort and Indian Applicability

The derivation cohort was the United States Veterans Health Administration: predominantly older, male and White. External validation in two further American health systems held up. There is no published Indian validation; one study is registered from a Hyderabad centre. Until it reports, these figures are an extrapolation and should be quoted as one.

• The aetiology mix differs sharply. A systematic review of 158 Indian studies puts alcohol at 43.2 per cent of adult cirrhosis, metabolic and cryptogenic disease at 14.4, hepatitis B at 11.5 and hepatitis C at 6.2, with alcohol commonest in every zone. The model carries one aetiology term, MASLD against everything else, so a large alcohol-related population sits in the reference group by default.
• One Indian series, as context and not validation. The Institute of Liver and Biliary Sciences, New Delhi, followed 133 patients with cirrhosis through non-transplant surgery between 2009 and 2017. Observed mortality was 12 per cent at 30 days, 20.3 at 90 days and 26.3 at one year. A tertiary liver-institute case mix, analysed against the Mayo model rather than this one.
• The pre-operative round. Tap unexplained ascites before an elective abdominal operation and send the fluid: subclinical spontaneous bacterial peritonitis changes the plan. Do not restrict protein. Continue a non-selective beta blocker peri-operatively unless contraindicated. Where the projected 90-day mortality is high and the operation is elective, ask where as well as whether, because a transplant-capable centre changes what is possible if the liver decompensates.