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Greater Complexity of Liver Surgery is Not Associated with an Increased Incidence of Liver-Related Complications Except for Bile Leak: An Experience with 2,628 Consecutive Resections

  • 2012 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Advances in technique, technology, and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver-related complications.

Methods

A large prospective single-institution database of patients who underwent hepatic resection was used to identify the incidence of liver-related complications. Liver resections were divided into an early era and a late era with equal number of patients (surgery performed before or after 18 May 2006). Patient characteristics and perioperative factors were compared between the two groups.

Results

Between 1997 and 2011, 2,628 hepatic resections were performed, with a 90-day morbidity and mortality rate of 37 and 2 %, respectively. We identified higher rates of repeat hepatectomy (12.2 vs 6.1 %; p < 0.001), two-stage resection (4.0 vs 1 %; p < 0.001), extended right hepatectomy (17.6 vs 14.6 %; p = 0.04), and preoperative portal vein embolization (9.1 vs 5.9 %; p < 0.001) in the late era. The incidence of perihepatic abscess (3.7 vs 2.1 %; p = 0.02) and hemorrhage (0.9 vs 0.3 %; p = 0.045) decreased in the late era and the incidence of hepatic insufficiency (3.1 vs 2.6 %; p = 0.41) remained stable. In contrast, the rate of bile leak increased (5.9 vs 3.7 %; p = 0.011). Independent predictors of bile leak included bile duct resection, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic resection, and intraoperative transfusion.

Conclusions

The complexity of liver surgery has increased over time, with a concomitant increase in bile leak rate. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leaks is indicated.

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Acknowledgments

This research was supported in part by the National Institutes of Health through MD Anderson’s Cancer Center Support Grant, CA016672.

Conflict of Interest

The authors report no conflicts of interest relevant to this article.

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Authors and Affiliations

  1. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA

    Giuseppe Zimmitti, Robert E. Roses, Andreas Andreou, Junichi Shindoh, Steven A. Curley, Thomas A. Aloia & Jean-Nicolas Vauthey

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  1. Giuseppe Zimmitti
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  2. Robert E. Roses
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Correspondence to Jean-Nicolas Vauthey.

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Discussant

Dr. Frank Makowiec (Freiburg, Germany): In his paper, Dr. Rosen presented new perioperative outcome results from one of the largest liver resection programs. The group from MD Anderson analyzed the evolution of hepatic resections and their postoperative complications during the last 15 years. In the second time period, the patients had a higher rate of medical comorbidity, more preoperative portal vein embolizations, more extended resections, more two stage resections, and more repeat resections. I have three questions and one suggestion:

Question #1: Your group published the influence of liver transection technique on the need for blood transfusion in 2009. Did you examine the influence of surgical technique on complication rates including bile leak rate?

Question #2: The majority of your resections were performed for colorectal liver metastases. Did you evaluate the influence of preoperative chemotherapy on the complication rates?

Question #3: You showed a higher overall complication rate in the second study period. There were, for example, clearly more urinary tract infections and cardiac complications. Such an effect may, in part, be due to a better documentation of complications in databases. Is it possible that you have such a bias by different or changing data documentation during the study period?

Question #4: My suggestion for further data evaluation: The risk factors for bile leakage originating from the liver parenchyma transection surface or for bile leakage from biliary or bilioenteric anastomosis may be different. Thus, it could be helpful to perform separate subanalysis of risk factors for bile leak in the groups with or without biliary anastomosis.

Closing Discussant

Dr. Robert E. Rosen: Thank you very much for your questions and suggestion. As you note, the MD Anderson group previously reported on the influence of liver transection technique on intraoperative blood loss and transfusion requirements. In the present study, we did not look at the influence of transection technique on the rate of bile leak. However, intraoperative transfusion requirement was an independent predictor of bile leak. Transection techniques associated with less blood loss are, therefore, likely to be associated with lower rates of bile leak.

This study included patients with a wide range of tumor types treated with a range of chemotherapeutic regimens of variable duration. It would be difficult to draw any meaningful conclusions about the impact of chemotherapy because of the heterogeneity of the patient cohort. Previous studies from our institution, however, have documented the influence of chemotherapy on perioperative outcomes in patients with colorectal liver metastases undergoing hepatic resection.

With regards to your third question, there is a potential for bias given the retrospective nature of this analysis. Notwithstanding, the mechanism by which we captured complications was the same for the early and late periods. It also bears emphasis that the late group had a greater degree of comorbidity than the early group and some of the differences in minor complication rate may be attributable to this.

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Zimmitti, G., Roses, R.E., Andreou, A. et al. Greater Complexity of Liver Surgery is Not Associated with an Increased Incidence of Liver-Related Complications Except for Bile Leak: An Experience with 2,628 Consecutive Resections. J Gastrointest Surg 17, 57–65 (2013). https://doi.org/10.1007/s11605-012-2000-9

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