A simple and clinically applicable model to predict liver-related morbidity after hepatic resection for hepatocellular carcinoma

Objective assessment of physician work in infrainguinal arterial bypass surgery

OBJECTIVE

The purpose of this study is obtain robust objective data from the Vascular Quality Initiative on physician work in infrainguinal artery bypass surgery. Operative time, patient comorbidities, anatomical complexity, consequences of adverse outcomes, and postoperative length of stay all factor into procedure relative value unit assignment and physician reimbursement.

METHODS

Baseline demographics and comorbidities were identified among 74,920 infrainguinal bypass surgeries in Vascular Quality Initiative between 2003 and 2022. Investigation into areas of progressive complexity over time was conducted. Bypasses were divided into 10 cohorts based on inflow and target arteries and conduit type. Mean operative times, lengths of stay, major morbidity rates, and 90-day mortality rates were identified across the various bypasses. Comparison of relative value unit per minute service time during the acute inpatient hospital admission was performed between the most 4 common bypasses and 14 commonly performed highly invasive major surgeries across several subdisciplines.

RESULTS

Patients undergoing infrainguinal arterial bypass have an advanced combination of medical complexities highlighted by diabetes mellitus in 40%, hypertension in 88%, body mass index >30 in 30%, coronary artery disease that has clinically manifested in 31%, renal insufficiency in 19%, chronic obstructive pulmonary disease in 27%, and prior lower extremity arterial intervention (endovascular and open combined) in >50%. The need for concomitant endarterectomy at the proximal anastomosis site of infrainguinal bypasses has increased over time (P < .001). The indication for bypass being limb-threatening ischemia as defined by ischemic rest pain, pedal tissue loss, or acute ischemia has also increased over time (P < .001), indicating more advanced extent of arterial occlusion in patients undergoing infrainguinal bypass. Finally, there has been a significant (P < .001) progression in the percentage of patients who have undergone a prior ipsilateral lower extremity endovascular intervention at the time of their bypass (increasing from 9.9% in 2003-2010 to 31.9% in the 2018-2022 eras). Among the 18 procedures investigated, the 4 most commonly performed infrainguinal bypasses were included in the analysis. These ranked 14th, 16th, 17th and 18th as the most poorly compensated per minute service time during the acute operative inpatient stay.

CONCLUSIONS

Infrainguinal arterial bypass surgery has an objectively undervalued physician work relative value unit compared with other highly invasive major surgeries across several subdisciplines. There are elements of progressive complexity in infrainguinal bypass patients over the past 20 years among a patient cohort with a very high comorbidity rate, indicating escalating intensity for infrainguinal bypass.

Hepatocellular carcinoma as predominant cancer subgroup accounting for sex differences in post-hepatectomy liver failure, morbidity and mortality

BACKGROUND

Experimental evidence suggests sex dependent differences in liver regeneration. Limited evidence is available examining sex differences in post-hepatectomy liver failure (PHLF) and postoperative outcomes. Our aim was to assess the influence of sex on the outcomes after liver resection.

METHODS

The hepatectomy targeted National Surgical Quality Improvement Program (NSQIP) database was assessed for associations between sex and outcomes.

RESULTS

A total of 13,401 patients underwent elective hepatic resection between 2014-2017. PHLF was highest among male patients with hepatocellular carcinoma (HCC) (OR = 2.81,95%CI:1.40-5.62). Male sex was independently associated with increased PHLF (OR = 1.47,95%CI:1.15-1.88), major complications (OR = 1.25,95%CI:1.08-1.45), mortality (OR = 1.61,95%CI:1.03-2.50), and if only major resections were assessed (OR = 1.38,95%CI:1.03-1.84). Diagnosis specific subgroup analyses revealed that effects of sex were predominantly HCC associated.

CONCLUSIONS

This is the largest series investigating the effects of gender on outcomes after hepatic resection. We documented that women undergoing liver resection have significantly lower risk of PHLF. This difference seemed influenced by the striking increase of PHLF in male HCC patients. These hypothesis suggest that sex might play a role in preoperative risk stratification.