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Facility Volume Thresholds for Optimization of Short- and Long-Term Outcomes in Patients Undergoing Hepatectomy for Primary Liver Tumors

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Volume-outcome relationships have been described for a variety of surgical procedures. We aimed to define the facility volume threshold at which postoperative mortality after hepatectomy was optimal.

Methods

We determined volume percentiles for institutions performing hepatectomy for any primary liver tumor within the National Cancer Database (2004–2017). Marginal structural logistic regression defined the volume percentile (Vmin) at which the odds of 90-day mortality were optimally reduced in patients with hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC). Short-term postoperative and survival outcomes were compared between patients treated at facilities above and below Vmin.

Results

Thresholds for the 10th/25th/50th/75th/90th percentiles were 2/7/26/46/59 hepatectomies/year. A total of 17,833 patients underwent resection of HCC or ICC. The 90-day postoperative mortality was optimized at the 75th percentile for all hepatectomies (IP-weighted OR = 0.67, 95% CI = 0.52–0.87) and major hepatectomy (IP-weighted OR = 0.62, 95% CI = 0.49–0.80). Seven of 446 facilities met the Vmin threshold. The odds of 30-day mortality were also reduced for all hepatectomies (IP-weighted OR = 0.55, 95% CI = 0.42–0.73) and major hepatectomy (IP-weighted OR = 0.58, 95% CI = 0.41–0.75). There were no differences in length of stay or 30-day readmission rate. Patients with HCC or ICC treated at facilities ≥ 10th percentile had an associated improvement in overall survival.

Conclusions

Resection of HCC and ICC is performed at a large number of facilities. Postoperative mortality is optimally reduced at facilities performing at least 46 liver operations annually. Regionalization of surgical care among patients with primary liver malignancies to high-volume centers may result in improved outcomes.

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Author notes

  1. Kelly Hoerger and Jonathan J. Hue contributed equally to this work.

Authors and Affiliations

  1. Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, 44106, USA

    Kelly Hoerger, Jonathan J. Hue, Mohamedraed Elshami, John B. Ammori, Jeffrey M. Hardacre, Jordan M. Winter & Lee M. Ocuin

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Contributions

- Kelly Hoerger—project development, manuscript writing/editing, approval of the final version.

- Jonathan J. Hue—project development, data analysis, manuscript writing/editing, approval of the final version.

- Mohamedraed Elshami—data analysis, manuscript writing/editing, approval of the final version.

- John B. Ammori—manuscript writing/editing, approval of the final version.

- Jeffrey M. Hardacre—manuscript writing/editing, approval of the final version.

- Jordan M. Winter—manuscript writing/editing, approval of the final version.

- Lee M. Ocuin—project development, data analysis, manuscript writing/editing, approval of the final version.

Corresponding author

Correspondence to Lee M. Ocuin.

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Supplementary Information

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Supplemental Figure 1.

Directed acyclic graph depicting the relationship between facility volume and 90-day postoperative mortality of patients with HCC or ICC after conditioning on the shown confounders. (PNG 600 kb)

High resolution image (EPS 2688 kb)

Supplemental Figure 2.

Summary of the number of facilities above and below each percentile threshold for total liver surgery volume within the NCDB (2004-2017). (PNG 168 kb)

High resolution image (EPS 2756 kb)

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Hoerger, K., Hue, J.J., Elshami, M. et al. Facility Volume Thresholds for Optimization of Short- and Long-Term Outcomes in Patients Undergoing Hepatectomy for Primary Liver Tumors. J Gastrointest Surg 27, 273–282 (2023). https://doi.org/10.1007/s11605-022-05541-4

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