Predictors of complications after liver surgery: a systematic review of the literature

BACKGROUND

Numerous potential predictors of adverse outcomes have been reported but their performance and utilization in practice seem heterogenous. This study aimed to systematically review the literature on the role and value of predictors of complications after hepatectomy.

METHODS

A systematic review following the PRISMA guidelines was performed. Studies on liver transplant were excluded. Only studies assessing overall or major complications were included.

RESULTS

A total of 10'965 abstracts were screened. After application of exclusion criteria, 72 articles including 68'480 patients were included. A total of 72 markers with 48 pre-, 9 intra- and 15 postoperative factors were identified as predictors of complications. Preoperative and intraoperative predictive markers retrieved several times with the highest odds ratios (OR) were ASA score (OR range: 1.3-7.5, significant in 8 studies) and intraoperative need for red blood cell transfusion (OR range: 1.2-17.1, significant in 24 studies), respectively.

CONCLUSION

Numerous markers have been described to predict the complication risk after hepatectomy. Because of their intrinsic characteristics, most markers such as ASA score and need for red blood cell transfusion are of limited clinical interest. There is a clear need to identify new biomarkers and to develop scores that could easily be implemented in clinical practice.

Models predicting the risks of six life-threatening morbidities and bile leakage in 14,970 hepatectomy patients registered in the National Clinical Database of Japan

To construct a robust morbidity risk-prediction model based on a Japanese nationwide web-based database of patients who underwent liver surgery.Although liver resection has become safer, patient mortality and morbidity still occur. This study investigated postoperative morbidity risks in patients who underwent hepatectomy in Japan at institutions registered in the National Clinical Database.This analysis involved 14,970 patients who underwent hepatectomy of more than 1 section, except for left lateral sectionectomy, during 2011 and 2012 at 1192 hospitals in Japan. Patients were randomized into 2 subsets, with 80% of patients analyzed for model development and the remaining 20% for model validation.Rates of 90-day inhospital mortality and overall morbidity were 3.7% and 25.7%, respectively. Rates of surgical site infection and bile leakage were 9.0% and 8.0%, respectively, but these morbidities showed little association with mortality. Rates of nonsurgical complications, including postoperative transfusion over 5 units, unexpected intubation, renal failure, cardiac events, septic shock, and postoperative pneumonia, ranged from 0.2% to 2.6%. These complications were highly associated with mortality, suggesting they were life-threatening. Risk models for morbidity yielded high C-indices for transfusion of over 5 units (0.758), unplanned intubation (0.755), renal failure (0.80), cardiac events (0.779), septic shock (0.783), pneumonia (0.768), and bile leakage (0.676).Preoperative parameters/comorbidities can accurately predict life-threatening complications after hepatectomy. These models allow early identification of patients at risk of mortality and may be useful in deciding on surgical interventions and in improving surgical quality.

Outcome following major hepatic resection in the elderly patients

Recent advances in operative techniques, anaesthesiologic management and intensive care have greatly reduced morbidity and mortality of major hepatectomy allowing a progressive broadening of its indications by including patients with chronic liver disorders as well as elderly subjects. It is apparent that with the aging population, more elderly patients are being referred for surgery. Selecting appropriate candidates for surgical resection is therefore crucial to maximize the benefit derived from surgery. Nevertheless, it is not clear whether advanced age itself increases surgical risk or additional age-independent variables are associated with higher operative morbidity. Regardless of the indications for surgery and the extent of planned liver resections, this population is more likely to suffer from relevant disorders. Previous studies on the safety of major liver resections in the elderly patients cite morbidity and mortality rates of approximately 30-40% and 4-5% respectively. In addition, hepatic resections for hepatocellular carcinoma or colorectal liver metastases have been reported as safe in the elderly as in the younger population. Nevertheless, a small number of investigations studied the outcome of major hepatectomy in the population over 70 years of age. The aim of our study was to evaluate overall experience with liver resections in the elderly population by comparing the early as well as the long-term outcome of the procedure in 70 years and older versus the less than 70 age group and to identify whether the age of patients alone is associated with increased rate and severity of postoperative complications.