Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay

Indications for and limitations of laparoscopic anatomical liver resection: assessment of postoperative complications stratified by complexity of liver resection

BACKGROUND

Although complex anatomical liver resections are more often being performed laparoscopically, the short-term outcomes following laparoscopic anatomical liver resection (LALR), its optimal indications, and limitations remain unclear. This study aimed to clarify the indications for and limitations of LALR by assessing the short-term outcomes.

METHODS

This retrospective study included 233 patients who underwent LALR. The complexity of LALR was categorized into three levels: Grade I (low), grade II (moderate), and grade III (high). Short-term outcomes were compared among these groups, and the risk factors for severe morbidity were identified.

RESULTS

The patients' backgrounds were similar across the three groups. Intraoperative blood loss, Pringle maneuver time, and postoperative hospital stay were comparable between grade I (n = 59) and grade II (n = 65) LALR but were greater for grade III (n = 109). The transfusion and conversion rates were similar among the three groups. The operative time increased with the rise in difficulty grade. The rate of severe morbidity was 3.4% in grade I, 6.2% in grade II, and 16.5% in grade III LALR (P = 0.012). Multivariable analysis identified three perioperative risk factors for severe morbidity: Operative time of ≥ 540 min (odds ratio [OR] = 4.762, P = 0.009), intraoperative blood loss of ≥ 350 mL (OR = 3.982, P = 0.024), and preoperative serum albumin of ≤ 3.8 g/dL (OR = 3.518, P = 0.035).

CONCLUSIONS

Grade II LALR can be performed with the same level of safety as grade I LALR. However, grade III LALR has a higher complication rate than grades I and II LALR, and the risk increases further due to longer operative time and greater blood loss.

COMPLICATIONS AFTER HEPATECTOMY

Complete removal of metastatic disease and maintenance of an adequate liver remnant remains the only treatment option with curative intent concerning colorectal liver metastases. Surgery impacts on the long-term prognosis and complications adversely affect oncological results. The actual morbidity involving this scenario is debatable and estimated to be ranging from 15% to 50%. Postoperative complications eventually lead to an increase in both mortality rates and tumor recurrence. Biliary fistula and liver failure are the leading complications following liver resection to metastatic colorectal cancer. Prophylactic drainage does not prevent fistulas or hemorrhage. Drainage along with endoscopic intervention and/or surgery may be necessary for grade B and C fistulas. Liver failure is a potentially lethal complication with few therapeutic options. Patient selection and preoperative care are crucial for its prevention.

Gradual expansion of the indications for minimally invasive liver resection to include highly complex procedures may improve postoperative outcomes

Aim: Liver resection is performed in patients with benign and malignant liver tumors. Advancements in surgical instruments and improved perioperative management have enabled safe laparoscopic and robotic liver resections. Herein, we aimed to evaluate the patients who underwent minimally invasive liver resection (MISLR) and compare their short-term outcomes with those of patients who underwent open liver resection (OLR), according to surgical complexity.

Methods: Data of patients who underwent liver resection at our institution from January 2011 to August 2023 were obtained from a prospectively maintained database. We gradually expanded the indications for MISLR from technically less demanding procedures to intermediate- and high-complexity MISLRs. The procedures were categorized into three grades (low, intermediate, and high) according to the liver resection complexity classification.

Results: Of the 1,866 patients who underwent liver resection, 953 were included in the analysis. Of the 953 patients, 781 underwent OLR and 172 underwent MISLR. The operative time and estimated blood loss increased with the increase in surgical complexity in the MISLR group, which was similar to finding in the OLR group. The complication rate also increased with the increase in surgical complexity in the OLR group (low complexity vs. high complexity, 34.8% vs. 50.1%). However, the complication rate was steadily low and approximately 10% across all complexity grades in the MISLR group.

Conclusion: Careful selection and gradual expansion of the indications of MISLR may facilitate improved postoperative outcomes in patients undergoing highly complex MISLRs.

A data-informed timeline for hospital discharge with a reasonably low risk of unplanned readmission after open and minimally invasive liver resections

BACKGROUND

Postoperative complications following liver resection remain high, ranging from 20% to 50%. Patients are hospitalized for a certain period of time following liver resection because of the risk of postoperative complications. We hypothesized that the risk of complications decreases with each complication-free postoperative day after open and minimally invasive liver resections and can be stratified using a recently reported three-level complexity classification.

METHODS

Patients undergoing first liver resection without concomitant other organ resections between 2006 and 2019 were included. The three-level complexity classification was used to categorize liver resection procedures into grades I-III. We assessed the rate of cumulative postoperative complications from the time of liver resection to the time of post-hepatectomy complications (≥ Clavien-Dindo grade II).

RESULTS

Of the 911 patients included, 200 underwent resection of grade I procedures, 185 underwent resection of grade II procedures, and 526 underwent resection of grade III procedures. The risks of post-hepatectomy complications changed over time and were stratified by surgical complexity. For patients at the time of liver resection, the estimated 30-day complication rate was 21.8% for open grade I resection, 26.7% for open grade II resection, 38.4% for open grade III resection, 8.6% for laparoscopic grade I resection, and 12.5% for laparoscopic grade II resection. For patients without complications at 7 days, the estimated 30-day complication rate decreased to 2.1% for open grade I, 9.2% for open grade II, 17.6% for open grade III, 1.3% for laparoscopic grade I, and 4.5% for laparascopic grade II.

CONCLUSIONS

The post-hepatectomy complication risks were stratified by surgical complexity, liver resection approach, and the period without complication after liver resection.