Defining Benchmarks for Major Liver Surgery: A multicenter Analysis of 5202 Living Liver Donors

Objective: To measure and define the best achievable outcome after major hepatectomy. Background: No reference values are available on outcomes after major hepatectomies. Analysis in living liver donors, with safety as the highest priority, offers the opportunity to define outcome benchmarks as the best possible results. Methods: Outcome analyses of 5202 hemi-hepatectomies from living donors (LDs) from 12 high-volume centers worldwide were performed for a 10-year period. Endpoints, calculated at discharge, 3 and 6 months postoperatively, included postoperative morbidity measured by the Clavien-Dindo classification, the Comprehensive Complication Index (CCI), and liver failure according to different definitions. Benchmark values were defined as the 75th percentile of median morbidity values to represent the best achievable results at 3 month postoperatively. Results: Patients were young (34 ± [9] years), predominantly male (65%) and healthy. Surgery lasted 7 ± [2] hours; 2% needed blood transfusions. Mean hospital stay was 11.7± [5] days. 12% of patients developed at least 1 complication, of which 3.8% were major events (≥grade III, including 1 death), mostly related to biliary/bleeding events, and were twice higher after right hepatectomy. The incidence of postoperative liver failure was low. Within 3-month follow-up, benchmark values for overall complication were ⩽31 %, for minor/major complications ⩽23% and ⩽9%, respectively, and a CCI ⩽33 in LDs with complications. Centers having performed ≥100 hepatectomies had significantly lower rates for overall (10.2% vs 35.9%, P < 0.001) and major (3% vs 12.1%, P < 0.001) complications and overall CCI (2.1 vs 8.5, P < 0.001). Conclusions: The thorough outcome analysis of healthy LDs may serve as a reference for evaluating surgical performance in patients undergoing major liver resection across centers and different patient populations. Further benchmark studies are needed to develop risk-adjusted comparisons of surgical outcomes.

[1]  J. Birkmeyer,et al.  Surgeon volume and operative mortality in the United States. , 2003, The New England journal of medicine.

[2]  P. Farrell.  The Meaning of “Early” Diagnosis in a New Era of Cystic Fibrosis Care , 2007, Pediatrics.

[3]  E. Abdalla,et al.  Prediction of Mortality After ALPPS Stage-1: An Analysis of 320 Patients From the International ALPPS Registry. , 2015, Annals of surgery.

[4]  G. Spolverato,et al.  Defining Post Hepatectomy Liver Insufficiency: Where do We stand? , 2015, Journal of Gastrointestinal Surgery.

[5]  A. Zaslavsky,et al.  Variation In Accountable Care Organization Spending And Sensitivity To Risk Adjustment: Implications For Benchmarking. , 2016, Health affairs.

[6]  H. Petrowsky,et al.  Strategies for safer liver surgery and partial liver transplantation. , 2007, The New England journal of medicine.

[7]  T. Starzl,et al.  Complications of right lobe living donor liver transplantation. , 2009, Journal of hepatology.

[8]  D. Segev,et al.  Estimates of early death, acute liver failure, and long-term mortality among live liver donors. , 2012, Gastroenterology.

[9]  Robert C. G. Martin,et al.  Assessment of the reporting of quality and outcome measures in hepatic resections: a call for 90-day reporting in all hepatectomy series. , 2015, HPB : the official journal of the International Hepato Pancreato Biliary Association.

[10]  M. Puhan,et al.  Biased reporting in surgery , 2014, The British journal of surgery.

[11]  D. Raptis,et al.  What is critical for liver surgery and partial liver transplantation: Size or quality? , 2010, Hepatology.

[12]  C. Lo,et al.  Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers , 2003, Transplantation.

[13]  D. Winchester,et al.  The 90-Day Mortality After Pancreatectomy for Cancer Is Double the 30-Day Mortality: More than 20,000 Resections From the National Cancer Data Base , 2014, Annals of Surgical Oncology.

[14]  Jeffrey D. Horbar,et al.  Revalidation of the Score for Neonatal Acute Physiology in the Vermont Oxford Network , 2007, Pediatrics.

[15]  N. Selzner,et al.  Fostering liver living donor liver transplantation , 2016, Current opinion in organ transplantation.

[16]  M. Abecassis,et al.  Improvement in survival associated with adult-to-adult living donor liver transplantation. , 2007, Gastroenterology.

[17]  Jeffrey E. Lee,et al.  Ninety-day Postoperative Mortality Is a Legitimate Measure of Hepatopancreatobiliary Surgical Quality , 2015, Annals of surgery.

[18]  M. Puhan,et al.  Defining Benchmarks for Major Liver Surgery , 2016 .

[19]  M. Makuuchi,et al.  Scenario 1 : Complication After a Surgical Procedure Not Caused by a Surgeon , 2022 .

[20]  M. Brennan.  Postoperative complication reporting: more than mortality and morbidity. , 2013, Annals of surgery.

[21]  Y. Maehara,et al.  Donor Risk in Adult-to-Adult Living Donor Liver Transplantation: Impact of Left Lobe Graft , 2009, Transplantation.

[22]  S. Curley,et al.  Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy. , 2007, Journal of the American College of Surgeons.

[23]  H. Ohdan,et al.  The Incidence of Posthepatectomy Liver Failure Defined by the International Study Group of Liver Surgery among Living Donors , 2016, Journal of Gastrointestinal Surgery.

[24]  Jürgen Weitz,et al.  Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). , 2011, Surgery.

[25]  S. Kawasaki,et al.  Donor Complications Associated With Living Donor Liver Transplantation in Japan , 2009, Transplantation.

[26]  M. Bailey,et al.  The ANZROD model: better benchmarking of ICU outcomes and detection of outliers. , 2016, Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine.

[27]  M. Puhan,et al.  The Comprehensive Complication Index: A Novel and More Sensitive Endpoint for Assessing Outcome and Reducing Sample Size in Randomized Controlled Trials , 2014, Annals of surgery.

[28]  M. Sandier.  CMF-CRED: Analyzing 1950-1985 health expenditures in France: by Jean-Marc Buhler, Jacques Harrouin and Simone Sandier, CREDES, 1 rue Paul Cezanne, 75008 Paris, France. Tel. 33 (1) 42 25 00 38 , 1987 .

[29]  J. Birkmeyer,et al.  Hospital Volume and Surgical Mortality in the United States , 2002 .

[30]  S. Truant,et al.  Relevance of the ISGLS Definition of Posthepatectomy Liver Failure in Early Prediction of Poor Outcome After Liver Resection: Study on 680 Hepatectomies , 2014, Annals of surgery.

[31]  G. Song,et al.  More than 300 consecutive living donor liver transplants a year at a single center. , 2013, Transplantation proceedings.

[32]  W. Bechstein,et al.  Inzidenz von Leberversagen und Galleleckagen nach Leberteilresektion , 2014, Der Chirurg.

[33]  Chao-Long Chen,et al.  Intraoperative blood loss is a risk factor for complications in donors after living donor hepatectomy , 2006, Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society.

[34]  N. Demartines,et al.  Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey , 2004, Annals of Surgery.

[35]  O. Farges,et al.  The “50-50 Criteria” on Postoperative Day 5: An Accurate Predictor of Liver Failure and Death After Hepatectomy , 2005, Annals of surgery.

[36]  Brice Gayet,et al.  Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. , 2015, Annals of surgery.

[37]  K. Sung,et al.  Lessons learned from 1,000 living donor liver transplantations in a single center: How to make living donations safe , 2006, Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society.

[38]  Y. Cheah,et al.  Incidence of death and potentially life‐threatening near‐miss events in living donor hepatic lobectomy: A world‐wide survey , 2013, Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society.

[39]  Hester F. Lingsma,et al.  The 30-Day Versus In-Hospital and 90-Day Mortality After Esophagectomy as Indicators for Quality of Care , 2014, Annals of surgery.

[40]  J. Putnam,et al.  Ninety-day mortality after resection for lung cancer is nearly double 30-day mortality. , 2014, The Journal of thoracic and cardiovascular surgery.

[41]  S. Fan,et al.  Lessons Learned From One Hundred Right Lobe Living Donor Liver Transplants , 2004, Annals of surgery.

[42]  J. Barkun,et al.  The Comprehensive Complication Index: A Novel Continuous Scale to Measure Surgical Morbidity , 2013, Annals of surgery.

[43]  H. Baba,et al.  Long-Term Follow-Up After Right Hepatectomy for Adult Living Donation and Attitudes Toward the Procedure , 2011, Annals of surgery.

[44]  J. Emond,et al.  Donor morbidity after living donation for liver transplantation. , 2008, Gastroenterology.

[45]  G. Maddern,et al.  Living donor liver transplantation—Adult donor outcomes: A systematic review , 2006, Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society.

[46]  P. Clavien,et al.  Small‐for‐Size Syndrome After Partial Liver Transplantation: Definition, Mechanisms of Disease and Clinical Implications , 2005, American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons.

[47]  G. Stukenborg,et al.  Understanding mortality as a quality indicator after esophagectomy. , 2014, The Annals of thoracic surgery.

[48]  F. Lehner,et al.  Living donor liver transplantation: effect of the type of liver graft donation on donor mortality and morbidity , 2011, Transplant international : official journal of the European Society for Organ Transplantation.

[49]  D. Manas,et al.  Summary of the British Transplantation Society UK Guidelines for Living Donor Liver Transplantation. , 2016, Transplantation.

[50]  S. Lee.  A Complete Treatment of Adult Living Donor Liver Transplantation: A Review of Surgical Technique and Current Challenges to Expand Indication of Patients , 2015, American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons.

[51]  H. Küchenhoff,et al.  Thirty-day mortality leads to underestimation of postoperative death after liver resection: A novel method to define the acute postoperative period. , 2015, Surgery.