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Patel I, Hall LA, Osei-Bordom D, Hodson J, Bartlett D, Chatzizacharias N, Dasari BVM, Marudanayagam R, Raza SS, Roberts KJ, Sutcliffe RP. Risk factors for failure to rescue after hepatectomy in a high-volume UK tertiary referral center. Surgery 2024; 175:1329-1336. [PMID: 38383242 DOI: 10.1016/j.surg.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Mortality after severe complications after hepatectomy (failure to rescue) is strongly linked to center volume. The aim of this study was to evaluate the risk factors for failure to rescue after hepatectomy in a high-volume center. METHODS Retrospective study of 1,826 consecutive patients who underwent hepatectomy from 2011 to 2018. The primary outcome was a 90-day failure to rescue, defined as death within 90 days posthepatectomy after a severe (Clavien-Dindo grade 3+) complication. Risk factors for 90-day failure to rescue were evaluated using a multivariable binary logistic regression model. RESULTS The cohort had a median age of 65.3 years, and 56.6% of patients were male. The commonest indication for hepatectomy was colorectal metastasis (58.9%), and 46.9% of patients underwent major or extra-major hepatectomy. Severe complications developed in 209 patients (11.4%), for whom the 30- and 90-day failure to rescue rates were 17.0% and 35.4%, respectively. On multivariable analysis, increasing age (P = .006) and modified Frailty Index (P = .044), complication type (medical or combined medical/surgical versus surgical; P < .001), and body mass index (P = .018) were found to be significant independent predictors of 90-day failure to rescue. CONCLUSION Older and frail patients who experience medical complications are particularly at risk of failure to rescue after hepatectomy. These results may inform preoperative counseling and may help to identify candidates for prehabilitation. Further study is needed to assess whether failure to rescue rates could be reduced by perioperative interventions.
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Affiliation(s)
- Ishaan Patel
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Lewis A Hall
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK; Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, UK
| | | | - James Hodson
- Research Development and Innovation, University Hospitals Birmingham NHS Foundation Trust, UK
| | | | | | | | | | - Syed S Raza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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Flanagan L, Choi C, Shah V, Shah A, Parray A, Grube J, Fang C, Baredes S, Eloy JA. MELD-Na Score as a Predictor of Postoperative Complications in Ventral Skull Base Surgery. Skull Base Surg 2022. [DOI: 10.1055/a-1842-8668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The Model for End-stage Liver Disease-Sodium (MELD-Na) Score was designed for prognosis of chronic liver disease and has been predictive of outcomes in a variety of procedures. Few studies have investigated its utility in Otolaryngology. This study uses the MELD-Na score to investigate the association between liver health and ventral skull base surgical complications.
Methods: The National Surgical Quality Improvement Program database was used to identify patients who underwent ventral skull base procedures between 2005 and 2015. Univariate and multivariate analyses were performed to investigate the association between elevated MELD-Na score and postoperative complications.
Results: 1077 patients undergoing ventral skull base surgery with lab values required to calculate the MELD-Na score were identified. The mean age was 54.2 years. The mean MELD-Na score was 7.70 (SD=2.04). Univariate analysis showed that elevated MELD-Na score was significantly associated with increased age (58.6 vs. 53.8 years) and male gender (70.8% vs. 46.1%). Elevated MELD-Na score was associated with increased rates of postoperative acute renal failure, transfusion, septic shock, surgical complications, and extended length of hospital stay. On multivariate analysis, associations between elevated MELD-Na and increased risk of perioperative transfusions (OR 1.62, 95%CI 1.20-2.93, p=0.007) and surgical complications (OR 1.58, 95%CI 1.25-2.35, p=0.009) remained significant.
Conclusions: This analysis points to an association between liver health and postoperative complications in ventral skull base surgery. Future research investigating this association is warranted.
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Affiliation(s)
| | | | - Vraj Shah
- Rutgers New Jersey Medical School, Newark, United States
| | - Aakash Shah
- Rutgers New Jersey Medical School, Newark, United States
| | | | - Jordon Grube
- Rutgers New Jersey Medical School, Newark, United States
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Sherer EL, Erickson EC, Holland MH. Enhanced Recovery After Surgery. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Stevens CL, Reid JL, Babidge WJ, Maddern GJ. Peer review of mortality after hepatectomy in Australia. HPB (Oxford) 2020; 22:611-621. [PMID: 31558369 DOI: 10.1016/j.hpb.2019.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after hepatectomy can provide greater insight into how deaths can be prevented. The objective of this study was to determine the reasons for patient deaths post-hepatectomy in Australia. METHODS ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following hepatectomy were selected for analysis. Assessors determinations of whether management could have been improved were reviewed, and then classified into groups of significant clinical events using thematic analysis with a data driven approach. RESULTS The study included 88 deaths reported to ANZASM after hepatectomy. The assessors questioned the decision to operate in 23/88 (25%) patients with a further nine (10%) patients insufficiently investigated prior to resection. ANZASM assessors determined that there was a delay in recognising a significant complication in 16/88 (18%) patients. CONCLUSION Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with hepatic resection. Optimal care post-hepatectomy includes early recognition of complications and enactment of an adequate rescue plan.
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Affiliation(s)
- Claire L Stevens
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia.
| | - Jessica L Reid
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
| | - Wendy J Babidge
- Discipline of Surgery, University of Adelaide, Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Australia
| | - Guy J Maddern
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
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Trends and Outcomes of Synchronous Resection of Colorectal Metastasis in the Modern Era-Analysis of Targeted Hepatic NSQIP Database. J Surg Res 2019; 238:35-40. [PMID: 30735964 DOI: 10.1016/j.jss.2019.01.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 12/01/2018] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previous studies using the NSQIP database to study hepatectomies lacked hepatic specific variables and outcomes. We used the targeted NSQIP hepatectomy database to examine the nationwide trend and the safety profile of synchronous liver and colorectal resection compared with hepatectomy alone for colorectal liver metastasis. METHODS The targeted NSQIP hepatectomy database from 2014 was used to study patients who underwent hepatectomy for diagnosis of adenocarcinoma of the colon and rectum. RESULTS Of the 3064 hepatic resections in the database, 1138 cases were performed for colorectal metastasis. Of these, 1040 were liver-alone surgery and 98 were synchronous liver and colorectal resection. Most (58.7%) patients received neoadjuvant therapy. The rate of neoadjuvant therapy, intraoperative ablation, biliary reconstruction, and the use of minimally invasive technique were similar between the two groups. The overall 30-d mortality in this cohort was low (1.1%). While the mortality rate in the synchronous group was similar to liver-only group (3.1% versus 0.9%, P = 0.077). The rate of liver failure (3.3% versus 4.1%, P = 0.722) and biliary leak (5.3% versus 9.6%, P = 0.084) were similar between the two groups. However, the rate of major complications was higher on multivariable analyses (25.5% versus 12.1%, OR 2.5, 95% CI 1.5-4.1, P < 0.001) for the synchronous group. CONCLUSIONS Hepatic resection for colorectal metastasis in the modern era has low short-term mortality. While synchronous resection was associated with a higher incidence of major complications, liver-specific complications did not increase with synchronous resection.
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Chacon E, Vilchez V, Eman P, Marti F, Morris-Stiff G, Dugan A, Turcios L, Gedaly R. Effect of critical care complications on perioperative mortality and hospital length of stay after hepatectomy: A multicenter analysis of 21,443 patients. Am J Surg 2018; 218:151-156. [PMID: 30528789 DOI: 10.1016/j.amjsurg.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine predictors of critical care complications (CCC) in patients undergoing hepatectomy. METHODS All hepatectomy patients in NSQIP from 2012 to 2016 were analyzed. CCC included prolonged ventilation (>48 h), sepsis/septic shock, renal failure/insufficiency, cardiac arrest/AMI and pulmonary embolism. RESULTS A total of 21,443 patients underwent hepatectomy during the study period. Overall rate of CCC was 11%, with the most common being sepsis/septic shock (6.1%) and respiratory failure (4.9%). On multivariate analysis the preoperative risk factors associated with CCC included ASA Class IV-V (OR:2.04, p < 0.0001), diabetes (OR = 1.28, p = 0.0001), pre-operative ventilator use (OR: 17.75, p = 0.0003); COPD (OR: 1.65, p < 0.0001); pre-operative weight loss >10% (OR: 1.35, p = 0.0026); pre-operative sepsis (OR: 2.14, p < 0.0001). Propensity score matched analysis demonstrated a significant increased risk of mortality in patients with CCC (OR: 26.75, p < 0.0001) and a prolonged LOS of 10.5 days above the mean (β Estimate: 10.51, p < 0.0001). CONCLUSIONS ASA class, diabetes, COPD, pre-operative weight loss >10% and pre-operative sepsis are the strongest predictors of CCC after hepatectomy. The presence of CCC significantly increased the risk of peri-operative mortality 26-fold.
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Affiliation(s)
- Eduardo Chacon
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Valery Vilchez
- Section of Hepato-Pancreato-Biliary Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Pedro Eman
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Francesc Marti
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Gareth Morris-Stiff
- Section of Hepato-Pancreato-Biliary Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Adam Dugan
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Lilia Turcios
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA
| | - Roberto Gedaly
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, 40536, USA.
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Abstract
Enhanced recovery after surgery (ERAS) pathways target specific areas within perioperative patient care in a multidisciplinary and evidence-based manner. Because of the subsequent positive outcomes associated with its use, ERAS has expanded to most surgical subspecialties, including hepatopancreatobiliary surgery. Although certain concepts are universal to all ERAS protocols, there are unique areas of emphasis pertaining to the hepatopancreatobiliary specialties, which will be highlighted throughout this article. In addition, some of the less frequently discussed aspects of enhanced recovery, including patient-reported outcomes, recovery assessment, cost, and auditing, will be addressed.
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Affiliation(s)
- Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Gribben JL, Ilonzo N, Neifert S, Michael Leitman I. Predictors of Reoperation and Failure to Rescue in Bariatric Surgery. JSLS 2018; 22:JSLS.2017.00074. [PMID: 29472758 PMCID: PMC5814103 DOI: 10.4293/jsls.2017.00074] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background and Objectives Morbidity and mortality have been shown to increase several-fold in patients who have undergone bariatric surgery and returned to the operating room after their initial procedures. Failure-to-rescue (FTR) analyses allow for an understanding of patient management and outcomes that is more distinguished than assessments of adverse occurrences and mortality rates alone. The objective of this study was to assess failure to rescue (FTR) and the characteristics and outcomes of patients undergoing reoperation after laparoscopic gastric bypass (LGBP) and laparoscopic sleeve gastrectomy (LSG). Methods The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) participant data files were accessed to identify patients >18 years of age who underwent LGBP and LSG from 2011 through 2015. Patients were further classified into 3-day reoperation and nonreoperation cohorts. Patient demographics, comorbidities, and baseline health characteristics were collected. Pertinent outcomes, complications, and FTR were analyzed. Results A total of 96,538 patients were included. Of those, 1,850 (1.92%) returned to the operating room, and 94,688 (98.08%) did not. Patients who underwent reoperation had a greater likelihood of having any complication (72.20% vs. 51.29%; P < .0001) and had a higher overall mortality rate (1.46% vs. 0.10%, P < .0001). The FTR rates were 2.01% in the reoperation group and 0.14% in the nonreoperation group (P < .0001). Conclusion Patients who undergo LGBP and LSG and have reoperations are at higher risk of developing complications with subsequent mortality.
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Affiliation(s)
- Jeanie L Gribben
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole Ilonzo
- Department of Surgery, Mount Sinai St. Luke's, New York, New York, USA
| | - Sean Neifert
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Rahnemai-Azar AA, Cloyd JM, Weber SM, Dillhoff M, Schmidt C, Winslow ER, Pawlik TM. Update on Liver Failure Following Hepatic Resection: Strategies for Prediction and Avoidance of Post-operative Liver Insufficiency. J Clin Transl Hepatol 2018; 6:97-104. [PMID: 29577036 PMCID: PMC5863005 DOI: 10.14218/jcth.2017.00060] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/22/2017] [Accepted: 10/23/2017] [Indexed: 01/27/2023] Open
Abstract
Liver resection is increasingly used for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique and perioperative management, posthepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection. Given the devastating physiological consequences of PHLF and the lack of effective treatment options, identifying risk factors and preventative strategies for PHLF is paramount. In the past, a major limitation to conducting high quality research on risk factors and prevention strategies for PHLF has been the absence of a standardized definition. In this article, we describe relevant definitions for PHLF, discuss risk factors and prediction models, and review advances in liver assessment tools and PHLF prevention strategies.
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Affiliation(s)
- Amir A. Rahnemai-Azar
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin Hospital, Madison, WI, USA
| | - Jordan M. Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sharon M. Weber
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin Hospital, Madison, WI, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carl Schmidt
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Emily R. Winslow
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin Hospital, Madison, WI, USA
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- *Correspondence to: Timothy M. Pawlik, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Department of Surgery, Wexner Medical Center, Ohio State University, 395 W. 12 Ave., Suite 670, Columbus, OH 43210, USA. Tel: +1-614 293 8701, Fax: +1-614 293 4063, E-mail:
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Kim BJ, Aloia TA. What Is "Enhanced Recovery," and How Can I Do It? J Gastrointest Surg 2018; 22:164-171. [PMID: 29067620 PMCID: PMC5784849 DOI: 10.1007/s11605-017-3605-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/28/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced recovery (ER) and fast-track protocols were initially implemented in the perioperative management of the surgical patient over 20 years ago. These standardized protocols are now broadly implemented across most surgical specialties for its many benefits. ER is well known for its positive effects on decreasing length of stay and complications. However, patient-centric outcomes for adequate pain control, functional recovery, costs, and overall patient experience are less considered. HOW I DO IT A successful ER foundation stands on the pillars of several perioperative care principles: early feeding, early ambulation, goal-directed fluid therapy, and opiate-sparing analgesia. Moreover, it requires a multi-disciplinary team buy-in (including patient and family) that must also be thoughtfully executed. The following is a review of key elements within successful evidence-based ER protocols and relevant concepts to consider when starting a successful enhanced recovery program.
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Affiliation(s)
- Bradford J. Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A. Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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