Timing of Complication and Failure to Rescue after Hepatectomy: Single-Institution Analysis of 28 Years of Hepatic Surgery

A critical analysis of surgical outcomes indicators in hepato-pancreato-biliary surgery: From crude mortality to composite outcomes

BACKGROUND

Indicators of surgical outcomes are designed to objectively evaluate surgical performance, enabling comparisons among surgeons and institutions. In recent years, there has been a surge in complex indicators of perioperative short-term and long-term outcomes. The aim of this narrative review is to provide an overview and a critical analysis of surgical outcomes indicators, with a special emphasis on hepato-pancreato-biliary (HPB) surgery.

METHODS

A narrative review of outcome measures was conducted using a combined text and MeSH search strategy to identify relevant articles focused on perioperative outcomes, specifically within HPB surgery.

RESULTS

The literature search yielded 624 records, and 94 studies were included in the analysis. Included papers were classified depending on whether they assessed intraoperative or postoperative specific or composite outcomes, and whether they assessed purely clinical or combined clinical and socio-economic indicators. Specific indicators included in composite outcomes were categorized into three main domains: intraoperative metrics, postoperative outcomes, and oncological outcomes. While postoperative mortality, complications, hospital stay and readmission were the indicators most frequently included in composite outcomes, oncological outcomes were rarely considered.

CONCLUSIONS

The evolution of surgical outcomes has shifted from the simplistic assessment of crude mortality rates to complex composite outcomes. Whether the recent explosion of publications on these topics has a clinical impact in real life is questionable. Outcomes from the patient perspective, integrating social and financial indicators, are not yet integrated into most of these composite analytical tools but should not be underestimated.

Risk factors for failure to rescue after hepatectomy in a high-volume UK tertiary referral center

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.

Association of risk analysis index with 90-day failure to rescue following major abdominal surgery in geriatric patients

BACKGROUND

Failure to rescue (FTR) is a quality metric defined as mortality after potentially preventable complications after surgery. Predicting patients who are at the highest risk of mortality after a complication may aid in preventing deaths. Thirty-day follow-up period inadequately captures postoperative deaths; alternatively, a 90-day follow-up period has been advocated. This study aimed to examine the association of a validated frailty metric, the risk analysis index (RAI), with 90-day FTR (FTR-90).

METHODS

Patients aged ≥65 years who underwent a major abdominal operation between 2014 and 2020 at a quaternary care center were abstracted. Institutional data were merged with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Geriatric Surgery Research File variables. The association between RAI and FTR-90 was evaluated using multivariable logistic regression.

RESULTS

A total of 398 patients with postoperative complications were included. Fifty-two patients (13.1%) died during the 90-day follow-up. The FTR-90 group was older (median age: 76 vs 73 years, respectively; P = .002), had a greater preoperative American Society of Anesthesiologists classification score (P < .001), and had a higher ACS NSQIP estimated risk of morbidity (0.33% vs 0.20%, P < .001) and mortality (0.067% vs 0.012%, P < .001). The FTR-90 group had a greater median RAI score (23 vs 19; P = .002). The RAI score was independently associated with FTR-90 (odds ratio, 1.04; 95% CI, 1.0042-1.0770; P = .028) but not with FTR-30 (P = .13).

CONCLUSION

Preoperative frailty, as defined by RAI, is independently associated with FTR at 90-day follow-up. FTR-90 captured nearly 60% more deaths than did FTR-30. Frailty has major implications beyond the typical 30-day follow-up period, and a longer follow-up period must be considered.

Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis

INTRODUCTION

There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy.

METHODS

We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed.

RESULTS

Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044).

CONCLUSIONS

On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

Postoperative infectious complications following laparoscopic versus open hepatectomy for hepatocellular carcinoma: a multicenter propensity score analysis of 3876 patients

OBJECTIVES

Hepatocellular carcinoma (HCC) is a common indication for hepatectomy that is often complicated by postoperative complication. The authors sought to investigate the relationship between the open with laparoscopic approach of hepatectomy and incidences of postoperative infectious complications.

PATIENTS AND METHODS

Using a multicenter database, HCC patients who underwent laparoscopic hepatectomy (LH) or open hepatectomy (OH) were reviewed and analyzed. Propensity score matching (PSM), inverse probability of treatment weight (IPTW), and multivariate logistic regression analyses were utilized to assess the association of the operative approach with postoperative infectious complications, including incisional surgical site infection (SSI), organ/space SSI, and remote infection (RI).

RESULTS

Among 3876 patients, 845 (21.8%) and 3031 (78.2%) patients underwent LH and OH, respectively. The overall incidence of infection was 6.9 versus 14.6% among patients who underwent LH versus OH, respectively ( P <0.001). Of note, the incidences of incisional SSI (1.8 vs. 6.3%, P <0.001), organ/space SSI (1.8 vs. 4.6%, P <0.001), and RI (3.8 vs. 9.8%, P <0.001) were all significantly lower among patients who underwent LH versus OH. After PSM (6.9, 1.8, 1.8, and 3.8% vs. 18.5, 8.4, 5.2, and 12.8%, respectively) and IPTW (9.5, 2.3, 2.1, and 5.5% vs. 14.3, 6.3, 4.5, and 9.8%, respectively), LH remained associated with statistically lower incidences of all types of infectious complications. After adjustment for other confounding factors on multivariate analyses, LH remained independently associated with lower incidences of overall infection, incisional SSI, organ/space SSI, and RI in the overall, PSM, and IPTW cohorts, respectively.

CONCLUSION

Compared with open approach, laparoscopic approach was independently associated with lower incidences of postoperative infectious complications following hepatectomy for HCC.

Influencing factors and predictive model of postoperative infection in patients with primary hepatic carcinoma

BACKGROUND

The purpose of this study was to explore the risk factors for postoperative infection in patients with primary hepatic carcinoma (PHC), build a nomogram prediction model, and verify the model to provide a better reference for disease prevention, diagnosis and treatment.

METHODS

This single-center study included 555 patients who underwent hepatobiliary surgery in the Department of Hepatobiliary Surgery of Tianjin Third Central Hospital from January 2014 to December 2021, and 32 clinical indicators were selected for statistical analysis. In this study, Lasso logistic regression was used to determine the risk factors for infection after liver cancer resection, establish a predictive model, and construct a visual nomogram. The consistency index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were used for internal validation, and decision curve analysis (DCA) was used to analyze the clinical applicability of the predictive model. The bootstrap method was used for intramodel validation, and the C-index was calculated to assess the model discrimination.

RESULTS

Among the 555 patients, 279 patients met the inclusion criteria, of whom 48 had a postoperative infection, with an incidence rate of 17.2%. Body mass index (BMI) (P = 0.022), alpha-fetoprotein (P = 0.023), total bilirubin (P = 0.016), intraoperative blood loss (P < 0.001), and bile leakage (P < 0.001) were independent risk factors for infection after liver cancer surgery. The nomogram was constructed and verified to have good discriminative and predictive ability. DCA showed that the model had good clinical applicability. The C-index value verified internally by the bootstrap method results was 0.818.

CONCLUSION

Postoperative infection in patients undergoing hepatectomy may be related to risk factors such as BMI, preoperative AFP level, TBIL level, intraoperative blood loss and bile leakage. The prediction model of the postoperative infection nomogram established in this study can better predict and estimate the risk of postoperative infection in patients undergoing hepatectomy.

Laparoscopic versus open hepatectomy for intrahepatic cholangiocarcinoma: Systematic review and meta-analysis of propensity score-matched studies

OBJECTIVE

To compare the effects of laparoscopic hepatectomy (LH) versus open hepatectomy (OH) on the short-term and long-term outcomes of patients with intrahepatic cholangiocarcinoma (ICC) through a meta-analysis of studies using propensity score-matched cohorts.

METHODS

The literature search was conducted in PubMed, Embase, and Cochrane Library databases until August 31, 2022. Meta-analysis of surgical (major morbidity, the length of hospital stay, 90-day postoperative mortality), oncological (R0 resection rate, lymph node dissection rate) and survival outcomes (1-, 3-, and 5-year overall survival and disease-free survival) was performed using a random effects model. Data were summarized as relative risks (RR), mean difference (MD) and hazard ratio (HR) with 95% confidence intervals (95% CI).

RESULTS

Six case-matched studies with 1054 patients were included (LH 518; OH 536). Major morbidity was significantly lower (RR = 0.57, 95% CI = 0.37-0.88, P = 0.01) and the length of hospital stay was significantly shorter (MD = -2.44, 95% CI = -4.19 to -0.69, P = 0.006) in the LH group than in the OH group, but there was no significant difference in 90-day postoperative mortality between the 2 groups. There were no significant differences in R0 resection rate, lymph node dissection rate, 1-, 3-, and 5-year overall survival or disease-free survival between the LH and OH groups.

CONCLUSIONS

LH has better surgical outcomes and comparable oncological outcomes and survival outcomes than does OH on ICC. Therefore, laparoscopy is at least not inferior to open surgery for intrahepatic cholangiocarcinoma.

The essential requirements for an HPB centre to deliver high-quality outcomes

The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in 'virtual' HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre's beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of "centre of reference" limited to actual, as opposed to virtual, centres.

Associations Between Preoperative Risk, Postoperative Complications, and 30-Day Mortality

BACKGROUND

Comorbidities and postoperative complications increase mortality, making early recognition and management critical. It is useful to understand how they are associated with one another. This study assesses associations between comorbidities, complications, and mortality.

METHODS

We calculated associations between comorbidities, complications, and 30-day mortality using the 2012-2018 ACS-NSQIP database. We examined the association between mortality and number of complications which complications were most associated with mortality.

RESULTS

5,777,108 patients were included. 30-day mortality was 0.95%. For most comorbidities or postoperative complications, patients with these had higher mortality than patients without. Having ≥ 1 complication increased mortality risk by 32.5-fold (6.5% vs. 0.2%). Mortality rate significantly increased with increasing number of complications, particularly after two or more complications. Bleeding and sepsis were associated with the most deaths.

CONCLUSION

The 30-day mortality rate was < 1% but was 32-fold higher in patients with complications and increased rapidly for patients with ≥ 2 complications. Bleeding and sepsis were the most prominent complications associated with mortality.