Operative Site Drainage after Hepatectomy: A Propensity Score Matched Analysis Using the American College of Surgeons NSQIP Targeted Hepatectomy Database

Risk factors and outcomes for cholangitis after hepatic resection

INTRODUCTION

There is a paucity in the literature in regard to the incidence, risk factors, and outcomes for post-operative cholangitis following hepatic resection.

METHODS

Retrospective review of the ACS NSQIP main and targeted hepatectomy registries for 2012-2016.

RESULTS

A total of 11,243 cases met the selection criteria. The incidence of post-operative cholangitis was 0.64% (151 cases). Multivariate analysis identified several risk factors associated with the development of post-operative cholangitis, stratified out by pre-operative and operative factors. The most significant risk factors were biliary anastomosis and pre-operative biliary stenting with odds ratios (OR) of 32.39 (95% CI 22.91-45.79, P value < 0.0001) and 18.32 (95% CI 10.51-31.94, P value < 0.0001) respectively. Cholangitis was significantly associated with post-operative bile leaks, liver failure, renal failure, organ space infections, sepsis/septic shock, need for reoperation, longer length of stay, increased readmission rates, and death.

CONCLUSION

Largest analysis of post-operative cholangitis following hepatic resection. While a rare occurrence, it is associated with significantly increased risk for severe morbidity and mortality. The most significant risk factors were biliary anastomosis and stenting.

Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND AND AIM

For those with a centrally located HCC, the two types of liver sectionectomy that can be performed are extended hepatectomy (EH) and central hepatectomy (CH). This meta-analysis aimed to compare the short- and long-term outcomes between patients treated with CH and patients treated with EH for those with centrally located HCC.

METHOD

We searched PubMed, Scopus, Web of Science, and Cochrane library for eligible studies from inception to 1 April 2022 and a systematic review and meta-analysis were done to compare the outcomes between the two groups.

RESULTS

we included 9 studies with a total of 1674 patients in this study. The pooled results in this meta-analysis showed equal long-term overall survival, Disease-free survival, recurrence and mortality between the two groups (5-year OS, RR = 1.14, 95% CI = 0.96-1.35, P = 0.12; I2 = 56%), (5-year DFS, RR = 0.81, 95% CI = 0.61-1.08, P = 0.15; I2 = 60%), (Recurrence, RR = 1.04, 95% CI = 0.94-1.15, P = 0.45; I2 = 27%), and (Mortality, RR = 0.55, 95% CI = 0.26-1.15, P = 0.11; I2 = 0%). In addition to that, no significant difference could be detected in the overall incidence of complications between the two groups (Complications, RR = 0.94, 95% CI = 0.76-1.16, P = 0.57; I2 = 0%). However, CH is associated with a remarkable increase in the rate of biliary fistula (Biliary fistula, RR = 1.90, 95% CI = 1.07-3.40, P = 0.03; I2 = 0%). And Liver cell failure was higher in the case of EH (LCF, RR = 0.47, 95% CI = 0.30-0.76, P = 0.002; I2 = 0%). Regarding the operative details, CH is associated with longer operative time (Time of the operation, Mean difference = 0.82, 95% CI = 0.36, 1.27, P = 0.0004; I2 = 57%).

CONCLUSION

No significant difference in the short and long-term survival and recurrence between CH and MH for CL-HCC. However, CH is associated with greater future remnant liver volume that decreases the incidence of LCF and provides more opportunities for a repeat hepatectomy after tumour recurrence.

Laparoscopic liver resection can be performed safely without intraoperative drain placement

BACKGROUND

Laparoscopic liver resection (LLR) has become a standardized procedure with advances in surgical techniques and perioperative management in the last decade; however, the necessity of routine drain placement in LLR has not been fully investigated. This study aimed to evaluate the need for intraoperative drain placement (IDP) in LLR.

METHODS

A total of 607 patients who underwent LLR for liver tumor at our institution between January 2015 and August 2021 were studied. Clinicopathological data, including intraoperative factors and postoperative outcomes, were compared between patients with and without IDP before and after propensity score matching. Variables shown to be different between the two groups were used for matching. Then, risk analysis for additional drainage procedure after surgery was performed in the original and matched cohorts.

RESULTS

Of the 607 patients, 4 (0.7%) and 14 (2.3%) developed incisional and organ/space surgical site infections, respectively, and 9 (1.5%) required additional drainage procedure after surgery. Ninety-three patients (15.3%) underwent IDP. The incidence and severity of postoperative complications were similar between patients with and without IDP in both the original and matched cohorts. In the matched cohort, simultaneous colectomy (odds ratio, 14.051, 95% confidence interval, 1.103-178.987; P = 0.042), rather than IDP (odds ratio, 1.836, 95% confidence interval, 0.157-21.509; P = 0.629), was independently associated with the risk of additional drainage procedure after surgery.

CONCLUSIONS

This study demonstrated that LLR could be performed safely without IDP.

Is left lateral sectionectomy of the liver without operative site drainage safe and effective?

Backgrounds/Aims

Despite its limited benefits, operative site drainage after elective hepatectomy is routinely used. This study aimed to investigate the safety and effectiveness of left lateral sectionectomy without operative site drainage.

Methods

This study retrospectively collected data from 31 patients who underwent elective left lateral sectionectomy between January 2017 and June 2020. Based on whether operative site drainage was used, the patients were divided into two groups: drainage and non-drainage of the operative site and a comparative analysis was conducted.

Results

A total of 31 patients underwent left lateral sectionectomy during the study period. Of these, 22 patients were diagnosed with hepatocellular carcinoma; three, with intrahepatic cholangiocarcinoma; three, with liver metastasis; and three, with benign liver disease. Ten patients underwent laparoscopy. No significant differences were observed between the open and laparoscopic surgery groups. In the univariate analysis, there were no significant differences in the pre-, intra-, and postoperative clinicopathological factors between the non-drainage and drainage groups. The hospitalization period in the non-drainage group was significantly shorter than in the drainage group (8.44 days vs. 5.87 days, p < 0.05). In the operative site drainage non-use group, there were no cases of intraperitoneal fluid collection requiring additional procedures.

Conclusions

Routine use of surgical drainage for left lateral sectionectomy of the liver to prevent intraperitoneal fluid collection is unnecessary.

Increased Morbidity and Mortality After Hepatectomy for Colorectal Liver Metastases in Frail Patients is Largely Driven by Worse Outcomes After Minor Hepatectomy: It's Not "Just a Wedge"

BACKGROUND

Frailty is associated with postoperative mortality, but its significance after hepatectomy for colorectal liver metastases (CRLM) is poorly defined. This study evaluated the impact of frailty after hepatectomy for CRLM.

METHODS

The study identified 8477 patients in National Surgical Quality Improvement Program databases from 2014 to 2019 and stratified them by frailty score using the risk analysis index as very frail (>90th percentile), frail (75th-90th percentile), or non-frail (< 75th percentile). Multivariate regression models determined the impact of frailty on perioperative outcomes, including by the extent of hepatectomy.

RESULTS

The procedures performed were 2752 major hepatectomies (left hepatectomy, right hepatectomy, trisectionectomy) and 5725 minor hepatectomies (≤2 segments) for 870 (10.3%) very frail, 1680 (19.8%) frail, and 5927 (69.9%) non-frail patients. Postoperatively, the very frail and frail patients experienced more complications (very frail [41.8%], frail [35.1%], non-frail [31.0%]), which resulted in a longer hospital stay (very-frail [5.7 days], frail [5.8 days], non-frail [5.1 days]), a higher 30-day mortality (very-frail [2.2%], frail [1.3%], non-frail [0.5%]), and more discharges to a facility (very frail [6.8%], frail [3.7%], non-frail [2.6%]) (p < 0.05) although they underwent similarly extensive (major vs. minor) hepatectomies. In the multivariate analysis, frailty was independently associated with complications (very-frail [odds ratio {OR}, 1.70], frail [OR, 1.25]) and 30-day mortality (very-frail [OR, 4.24], frail [OR, 2.41]) (p < 0.05). After minor hepatectomy, the very frail and frail patients had significantly higher rates of complications and 30-day mortality than the non-frail patients, and in the multivariate analysis, frailty was independently associated with complications (very frail [OR, 1.97], frail [OR, 1.27]) and 30-day mortality (very frail [OR, 6.76], frail [OR, 3.47]) (p < 0.05) after minor hepatectomy.

CONCLUSIONS

Frailty predicted significantly poorer outcomes after hepatectomy for CRLM, even after only a minor hepatectomy.

Incidence and Clinical Impact of Bile Leakage after Laparoscopic and Open Liver Resection: An International Multicenter Propensity Score-Matched Study of 13,379 Patients

BACKGROUND

Despite many developments, postoperative bile leakage (POBL) remains a relatively common postoperative complication after laparoscopic liver resection (LLR) and open liver resection (OLR). This study aimed to assess the incidence and clinical impact of POBL in patients undergoing LLR and OLR in a large international multicenter cohort using a propensity score-matched analysis.

STUDY DESIGN

Patients undergoing LLR or OLR for all indications between January 2000 and October 2019 were retrospectively analyzed using a large, international, multicenter liver database including data from 15 tertiary referral centers. Primary outcome was clinically relevant POBL (CR-POBL), defined as Grade B/C POBL.

RESULTS

Overall, 13,379 patients met the inclusion criteria and were included in the analysis (6,369 LLR and 7,010 OLR), with 6.0% POBL. After propensity score matching, a total of 3,563 LLR patients were matched to 3,563 OLR patients. In both groups, propensity score matching accounted for similar extent and types of resections. The incidence of CR-POBL was significantly lower in patients after LLR as compared with patients after OLR (2.6% vs 6.0%; p < 0.001). Among the subgroup of patients with CR-POBL, patients after LLR experienced less severe (non-POBL) postoperative complications (10.1% vs 20.9%; p = 0.028), a shorter hospital stay (12.5 vs 17 days; p = 0.001), and a lower 90-day/in-hospital mortality (0% vs 5.4%; p = 0.027) as compared with patients after OLR with CR-POBL.

CONCLUSION

Patients after LLR seem to experience a lower rate of CR-POBL as compared with the open approach. Our findings suggest that in patients after LLR, the clinical impact of CR-POBL is less than after OLR.

Obesity affects outcomes of pancreatoduodenectomy

BACKGROUND

Obesity is a major global health problem, and it has reached epidemic proportions worldwide. Therefore, surgeons will confront an increasingly larger proportion of obese candidates for pancreatoduodenectomy (PD) in the future. Several small retrospective studies have been conducted to evaluate the role of Body Mass Index (BMI) in postoperative surgical complications after PD, with conflicting results. The aim of this study was to use a large multi-institutional database to clarify the impact of different levels of obesity after PD.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent PD from 2014 to 2016. Patients were categorized in the following six BMI groups: <18.5 (Underweight), 18.5-24.9 (Normal Weight), 25-29.9 (Overweight), 30-34.9 (Class I obesity), 35-39.9 (Class II Obesity) and >40 (Class III Obesity). The primary outcomes of interest were 30-day mortality and morbidity after PD among the six BMI groups.

RESULTS

The final population consists of 10,316 patients. Class III is associated with higher risk of 30-day mortality (OR 2.56, 95% CI 1.25-5.25, p = 0.011), major complications (OR 2.23, 95% CI 1.54-3.22, p < 0.001), clinically relevant postoperative pancreatic fistula (OR 2.48, 95% CI 1.89-3.24, p < 0.001), surgical site infections (OR 2.06, 95% CI 1.61-2.65, p < 0.001) and wound dehiscence (OR 3.47, 95% CI 1.7-7.1, p < 0.001) in multivariable analysis.

CONCLUSIONS

In conclusion, our study shows that obesity is significantly associated with higher risk of postoperative complications in patients undergoing PD and patients with BMI≥40 have increased risk of mortality after PD.

Is percutaneous destruction of a solitary liver colorectal metastasis as effective as a resection?

Backgrounds/Aims

Surgical resection remains the gold standard in the treatment of colorectal liver metastasis. However, when a patient presents with a deep solitary colorectal liver metastasis (S-CLM), the balance between the hepatic volume sacrificed and the S-CLM volume is sometimes clearly unappropriated. Thus, alternatives to surgery, such as operative and percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA), have been developed. This study aimed to identify the prognostic factors affecting survival of patients with S-CLM who undergo curative-intent liver resection or local destruction (RFA or MWA).

Methods

We retrospectively identified 211 patients with synchronous or metachronous S-CLM who underwent either surgical resection (n=182) or local destruction (RFA or MWA; n=29) according to the S-CLM size, location, and surrounding Glissonian structures.

Results

Patients who underwent RFA or MWA had S-CLM of a smaller size than those who underwent resection (mean 19.7 vs. 37.3 mm, p<.01). The 1-, 3-, and 5-year overall survival (OS) rates were 97.4%, 84.9%, and 74.9%, respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 77.9%, 47%, and 38.9%, respectively. S-CLM located in the left liver (p=.04), S-CLM KRAS mutation (p<.01), and extra-hepatic recurrence (p<.01) were identified as independent poor risk factors for overall survival (OS); the OS and DFS were comparable in patients with surgical procedure or percutaneous MWA.

Conclusions

In eligible S-CLM cases, percutaneous MWA seems to be as oncologically efficient as surgical resection and should be include in the decision-tree for treatment strategies.

Enhanced recovery after hepatopancreaticobiliary surgery: A single-center case control study

Backgrounds/Aims

The aim of this study was to find the safety and effectiveness of enhanced recovery after surgery (ERAS) in patients who undergo hepatopancreaticobiliary (HPB) surgeries and its association with the postoperative complications and survival rate of the patients.

Methods

This study was conducted on patients who underwent HPB surgeries in Imam Khomeini Hospital Complex, Iran from 2018 to 2020. Patients who underwent surgery after from 2019 to February 2020 considered as the ERAS group (n=47) in which ERAS was implemented postoperatively including removing nasogastric tube and initiating surgical diet at 6 hours post operation, and removing intraabdominal drains and Foley catheter at postoperative day one. Other patients (n=43) were considered as the control group in which conventional postoperative care was implemented.

Results

Ninety patients with the mean age of 47.3±13.3 yrs/old (range= 17-76) including 39 females were enrolled into the study. There were no significant differences between the demographic and preoperative comorbidities between the two groups. Pain severity of the patients in the ERAS group was significantly lower than the control group (visual analogue scales of 3.4±0.77 vs. 4.47±0.88, p<0.001). However, there were no significant differences between the other postoperative data between the two groups. One patient in each group died during hospitalization period due to myocardial infarction.

Conclusions

ERAS may be safe and effective in patients who undergo HPB surgery and may be associated with less severe postoperative pain.

Is routine abdominal drainage necessary for patients undergoing elective hepatectomy? A protocol for systematic review and meta-analysis

OBJECTIVES

To evaluate comparative outcomes of routine abdominal drainage (RAD) and non-routine abdominal drainage (NRAD) during elective hepatic resection for hepatic neoplasms.

MATERIALS AND METHODS

We systematically searched MEDLINE, EMBASE, The Cochrane Library, Web of Science. The searching phrases included "liver resection," "hepatic resection," "hepatectomy," "abdominal drainage," "surgical drainage," "prophylactic drainage," "intraperitoneal drainage," "drainage tube," "hepatectomy," "abdominal drainage" and "drainage tube." Two independent reviewers critically screened literature, extracted data and assessed the risk of bias. Post-operative morbidity and mortality were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effect model.

RESULTS

We have identified 9 RCTs and 3 comparative studies reporting total of 5726 patients undergoing elective hepatectomy under RAD (n = 3084) or NRAD (NRAD group, n = 2642). RAD was associated with significantly higher overall complication rate [odds risk  = 1.79, 95% CI (1.10, 2.93), P = .02] and biliary leakage rate [odds risk  = 2.41, 95% CI (1.48, 3.91), P = .0004] compared with NRAD. Moreover, it significantly increased hospital stays [mean difference  = 0.95, 95% CI (0.02, 1.87), P = .04] compared with NRAD. RAD showed no difference regarding intra-abdominal hemorrhage, wound complications, liver failure, subphrenic complications, pulmonary complications, infectious complications, reoperation and mortality compared with NRAD.

CONCLUSIONS

Although routine abdominal drainage may help surgeons to observe post-operative complication, it seems to be associated with increased post-operative morbidity and longer hospital stays. Non-routine abdominal drainage may be an appropriate option in selected patients undergoing hepatic resection. Higher level of evidence is needed.

Hospital variation in use of prophylactic drains following hepatectomy

BACKGROUND

Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use.

METHODS

Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed.

RESULTS

Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level.

CONCLUSION

Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.

Early drain removal after hepatectomy: an underutilized management strategy

BACKGROUND

Recent data suggest that routine drainage is unnecessary in patients undergoing hepatectomy, but many surgeons continue to utilize drains. We compared the outcomes of patients undergoing early versus routine drain removal after hepatectomy.

METHODS

Patients having drains placed during major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-16 ACS-NSQIP database. Propensity matching between early (POD 0-3) and routine (POD 4-7) drain removal and multivariable regressions were performed.

RESULTS

Early drain removal was performed in 661 (40%) of patients undergoing a partial hepatectomy and 211 (22%) of major hepatectomy patients. After matching, 719 early and 719 routine drain removal patients were compared. Early drain removal patients had lower overall (12 vs 19%, p < 0.001) and serious (9 vs 13%, p < 0.03) morbidity as well as fewer bile leaks (2.1% vs 5.0%, p < 0.003). Length of stay was two days shorter (4 vs 6 days, p < 0.01) and readmissions were less frequent (5.4 vs 8.1%, p = 0.02) for patients undergoing early drain removal.

CONCLUSION

Early drain removal is associated with fewer overall and serious complications, shorter length of stay and fewer readmissions. Early drain removal after hepatectomy is an underutilized management strategy.

On-Site Monitoring of Postoperative Bile Leakage Using Bilirubin-Inducible Fluorescent Protein

Background

Bile leakage is the most common postoperative complication associated with hepatobiliary and pancreatic surgery. Until now, however, a rapid, accurate diagnostic method for monitoring intraoperative and postoperative bile leakage had not been established.

Method

Bilirubin levels in drained abdominal fluids collected from 23 patients who had undergone hepatectomy (n = 22) or liver transplantation (n = 1) were measured using a microplate reader with excitation/emission wavelengths of 497/527 nm after applying 5 µM of UnaG to the samples. UnaG was also sprayed directly on hepatic raw surfaces in swine hepatectomy models to identify bile leaks by fluorescence imaging.

Results

The bilirubin levels measured by UnaG fluorescence imaging showed favorable correlations with the results of the conventional light-absorptiometric methods (indirect bilirubin: rs = 0.939, p < 0.001; direct bilirubin: rs = 0.929, p < 0.001). Approximate time required for bilirubin measurements with UnaG was 15 min, whereas it took about 40 min with the conventional method at a hospital laboratory. Following administration of UnaG on hepatic surfaces, the fluorescence imaging identified bile leaks not only on the resected specimens but also in the abdominal cavity of the swine hepatectomy models.

Conclusion

Fluorescence imaging techniques using UnaG may enable real-time identification of bile leaks during hepatectomy and on-site rapid diagnosis of bile leaks after surgery.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05774-x) contains supplementary material, which is available to authorized users.

Use of primary surgical drains in synchronous resection for colorectal liver metastases: a NSQIP analysis of current practice paradigm

BACKGROUND

There are no studies examining the use of subhepatic drains after simultaneous resection of synchronous colorectal liver metastases (sCRLM). This study aimed to (1) describe the current practices regarding primary drain placement, (2) evaluate drain efficacy in mitigating postoperative complications, and (3) determine impact of drain maintenance duration on patient outcomes.

METHODS

The ACS-NSQIP targeted data from 2014 to 2017 were analyzed. Propensity score of surgical drain versus no drain cohorts was performed. Main study outcomes were mortality, major morbidity, organ/space surgical site infection (SSI), secondary drain/aspiration procedure, and any septic events. Additional univariate/multivariate logistic analyses were performed to identify associations with drain placement and duration. Major hepatectomy was defined as formal right hepatectomy and any trisectionectomy.

RESULTS

584 combined liver and colorectal resection (CRR) cases were identified. Open partial hepatectomy with colectomy was the most common procedure (70%, n = 407). Nearly 40% of patients received surgical drains (n = 226). Major hepatectomy, lower serum albumin, and no intraoperative portal vein occlusion (Pringle maneuver) were significantly associated with drain placement (p < 0.05). In the matched cohort (n = 190 in each arm), patients with surgical drains experienced higher rates of major morbidity (30% vs 12%), organ/space SSI (16% vs 6%), postoperative drain/aspiration procedures (9% vs 3%), and sepsis/septic shock (12% vs 4%) (all p < 0.05). Patients with severely prolonged drain removal, defined as after postoperative day 13 (POD13), had higher risk of postoperative morbidity compared to those with earlier drain removal (p < 0.01). 30-day mortality rate was not significantly different between the two groups.

CONCLUSION

Primary surgical drains were placed in a substantial percentage of patients undergoing combined resection for sCRLM. This case-matched analysis suggested that surgical drains are associated with an increase in postoperative morbidity. Postoperative drain maintenance past 13 days is associated with worse outcomes compared to earlier removal.

Robotic hepatic parenchymal transection: a two-surgeon technique using ultrasonic dissection and irrigated bipolar coagulation

Liver transection is the most challenging part of hepatectomy due to the risk of hemorrhage which is associated with postoperative morbidity and mortality and reduced long-term survival. Parenchymal ultrasonic dissection (UD) with bipolar coagulation (BPC) has been widely recognized as a safe, effective, and standard technique during open and laparoscopic hepatectomy. We here introduce our technique of robotic liver transection using UD with BPC and report on short-term perioperative outcomes. From a single-institution prospective liver surgery database, we identified patients who underwent robotic liver resection. Demographic, anesthetic, perioperative, and oncologic data were analyzed. Fifty patients underwent robotic liver resection using UD and BPC for liver malignancies (n = 42) and benign lesions (n = 8). The median age of the patients was 67 years and 28 were male. According to the difficulty scoring system, 60% (n = 30) of liver resection were considered difficult. Three cases (6%) were converted to open surgery. The median operative time was 240 min, and the median estimated blood loss was 200 ml; 2 patients required operative transfusions. The overall complication rate was 38% (grade I, 29; grade II, 15; grade III, 3; grade IV, 1). Seven patients (14%) experienced biliary leakage. The median length of hospital stay post-surgery was 7 (range 3-20) days. The R0 resection rate was 92%. Robotic parenchymal transection using UD and irrigated BPC appears a simple, safe, and effective technique. However, our results must be confirmed in larger series or in randomized controlled trials.

Sustained positive impact of ACS-NSQIP program on outcomes after colorectal surgery over the last decade

BACKGROUND

We evaluate trends in outcomes after colorectal resection over the decade of the introduction of ACS-NSQIP as well as of targeted-colectomy information.

STUDY DESIGN

From 2007 to 2016, patients undergoing non-emergent colorectal procedures were included. Demographics, operative complexity (American Society of Anesthesiologists and wound classes); complications, early (<5 days) discharge and mortality were plotted over years. Outcomes after introduction of colectomy-targeted datasets (2013-2016) were compared to those prior (2007-2012). Multivariable analyses were performed to evaluate the impact of colectomy-targeted data on outcomes.

RESULTS

Of 310,632 included procedures, 131,122(42.2%) and 179,510(57.8%) were performed before and after the introduction of colectomy-targeted variables respectively. Most complications including surgical site and urinary tract infections, sepsis, septic shock, venous thromboembolism, respiratory complications, reoperation and mortality reduced over time with increased early discharge. On multivariable analysis, introduction of colectomy-targeted data was associated with lower surgical site (OR = 0.78,95%CI = [0.77-0.80]); systemic (OR = 0.94,95%CI = [0.91-0.98]) and urinary tract (OR = 0.70,95%CI = [0.67-0.74]) infections; reoperation (OR = 0.88,95%CI = [0.85-0.91]) and early discharge (OR = 1.60,95%CI = [1.57-1.63]).

CONCLUSION

Over its first decade of introduction, ACS-NSQIP has been associated with improved outcomes after colorectal surgery. The introduction of colectomy-targeted data has further improved outcomes.

ENHANCED RECOVERY (ERAS) AFTER LIVER SURGERY:COMPARATIVE STUDY IN A BRAZILIAN TERCIARY CENTER

BACKGROUND

After the publication of the first recommendations of ERAS Society regarding colonic surgery, the proposal of surgical stress reduction, maintenance of physiological functions and optimized recovery was expanded to other surgical specialties, with minimal variations.

AIM

To analyze the implementation of ERAS protocols for liver surgery in a tertiary center.

METHODS

Fifty patients that underwent elective hepatic surgery were retrospectively evaluated, using medical records data, from June 2014 to August 2016. After September 2016, 35 patients were prospectively evaluated and managed in accordance with ERAS protocol.

RESULTS

There was no difference in age, type of hepatectomy, laparoscopic surgery and postoperative complications between the groups. In ERAS group, it was observed a reduction in preoperative fasting and in the length of hospital stay by two days (p< 0.001). Carbohydrate loading, j-shaped incision, early oral feeding, postoperative prevention of nausea and vomiting and early mobilization were also significantly related to ERAS group. Oral bowel preparation, pre-anesthetic medication, sub-costal incision, prophylactic nasogastric intubation and abdominal drainage were more common in control group.

CONCLUSION

Implementation of ERAS protocol is feasible and beneficial for health institutions and patients, without increasing morbidity and mortality.

Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection

BACKGROUND

Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality.

METHODS

Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak.

RESULTS

Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262).

CONCLUSION

Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.

Readmission, Reoperation, and Complications: Total Hip vs Total Knee Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are currently grouped under the same Diagnosis-Related Group (DRG). With the introduction of bundled payments, providers are accountable for all the costs incurred during the episode of care, including the costs of readmissions and management of complications. However, it is unclear whether readmission rates and short-term complications are similar in primary THA and TKA.

METHODS

The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 248,150 primary THA/TKA procedures using Current Procedural Terminology codes. After excluding 1602 hip fractures and 5062 bilateral procedures, 94,326 THAs and 147,160 TKAs were included in the study. Length of stay, discharge disposition, and 30-day readmission, reoperation and complication rates were compared between THA and TKA using multivariate regression models.

RESULTS

After adjusting for baseline characteristics, length of stay (P = .055) and discharge disposition (P = .304) were similar between THA and TKA. But the 30-day rates of readmission (P < .001) and reoperation (P < .001) were higher in THA. Of the 18 complications evaluated in the study, 7 were higher in THA, 3 were higher in TKA, and 8 were similar between THA and TKA.

CONCLUSION

THA patients had higher 30-day rates of readmission and reoperation. As both readmissions and reoperations can result in higher episode costs, a common target price for both THA and TKA may be inappropriate. Further studies are required to fully understand the extent of differences in the episode costs of THA and TKA.

Does intraoperative closed-suction drainage influence the rate of pancreatic fistula after pancreaticoduodenectomy?

BACKGROUND

Although drainage of pancreatic anastomoses after pancreaticoduodenectomy (PD) is still debated, it remains recommended, especially in patients with a high risk of post-operative pancreatic fistula (POPF). Modalities of drainage of pancreatic anastomoses, especially the use of passive (PAD) or closed-suction (CSD) drains, and their impact on surgical outcomes, have been poorly studied. The aim was to compare CSD versus PAD on surgical outcomes after PD.

METHODS

Retrospective analysis of 197 consecutive patients who underwent a standardized PD at two tertiary centers between March 2012 and April 2015. Patients with PAD (n = 132) or CSD (n = 65) were compared.

RESULTS

There was no significant difference in terms of 30-day overall and severe post-operative morbidity, post-operative hemorrhage, post-operative intra-abdominal fluid collections, 90-day post-operative mortality and mean length of hospital stay. The rate of POPF was significantly increased in the CSD group (47.7% vs. 32.6%; p = 0.04). CSD was associated with an increase of grade A POPF (21.5% vs. 8.3%; p = 0.03), while clinically relevant POPF were not impacted. In patients with grade A POPF, the rate of undrained intra-abdominal fluid collections was increased in the PAD group (46.1% vs. 21.4%; p = 0.18). After multivariate analysis, CSD was an independent factor associated with an increased rate of POPF (OR = 2.43; p = 0.012).

CONCLUSIONS

There was no strongly relevant difference in terms of surgical outcomes between PAD or CSD of pancreatic anastomoses after PD, but CSD may help to decrease the rate of undrained post-operative intra-abdominal collections in some patients. Further randomized, multi-institutional studies are needed.