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10.1245/ASO.2005.06.007
Annals of Surgical Oncology 12:133-137 (2005)
© 2005 Society of Surgical Oncology
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Original Article

Hepatic Resection at a Major Community-Based Teaching Hospital Can Result in Good Outcome

Ramaz E. Metreveli, MD, Katherine Sahm, MD, Frederick Denstman, MD, Raafat Abdel-Misih, MD and Nicholas J. Petrelli, MD, FACS

Department of Surgery, Christiana Care Health Services, Helen F. Graham Cancer Center, 4701 Ogletown-Stanton Road, Suite 1213, Newark, Delaware 19713

Correspondence: Address correspondence and reprint requests to: Nicholas J. Petrelli, MD, FACS; E-mail: npetrelli{at}christianacare.org.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The relationship between volume and outcome has been established in the literature for several complex surgical procedures. Improved outcome has been suggested at high-volume hospitals or with high-volume surgeons.

Methods: The objective of this study was to evaluate the experience of a low-volume hospital with major liver resections. The setting of the study was a community-based teaching hospital with a surgical residency training program.

Results: A total of 46 major liver resections were performed between January 1992 and December 2002. Procedures performed were hepatic lobectomies (n = 15; right, n = 11; left, n = 4), trisegmentectomies (n = 5; right, n = 3; left, n = 2), segmentectomies (n = 16; left lateral, n = 12; right posterior, n = 4), and wedge resections (n = 10). Operations were performed by 14 different surgeons; however, 23 operations were performed by 1 surgeon. Sixteen patients (34%) developed 23 complications. The average length of hospital stay was 9.7 days. There were no 30-day postoperative mortalities. Out of 46 patients who underwent major liver resection over the last 10 years, 13 patients are still alive. Overall survival ranged from 3 to 84 months, with a median survival of 30.6 months. The actual 5-year survival was 36% (8 of 22) for all patients operated on >5 years ago, and the actual 2-year survival was 61% (20 of 33).

Conclusions: Major liver resection can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at a low-volume community-based teaching hospital.

Key Words: Hepatic • Colorectal • Metastases • Resection


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In recent years, multiple reports in the literature have stated that the clinical outcome of major surgical procedures is directly dependent on the volume of the institution and the experience of the individual surgeon.1–4 The importance of the influence of the hospital volume on the clinical outcome varies markedly depending on the procedure. For example, a study by Finlayson et al.1 demonstrated a 10%difference in mortality with pancreatic resection between high-volume and low-volume hospitals (13.1% vs. 2.5%, respectively). A significant difference in mortality was also observed for esophagectomy in low-volume versus high-volume hospitals (15% vs. 6.5%, respectively). However, the difference between high-volume and low-volume hospitals was minimal for such major surgical procedures as nephrectomy, cystectomy, and pneumonectomy. A study performed by Begg et al.5 demonstrated that higher volume was associated with lower mortality for pancreatectomy, esophagectomy, liver resection, and pelvic exenteration, but not for pneumonectomy. The most striking results were for esophagectomy, for which the operative mortality increased to 17.3% in low-volume hospitals, compared with 3.4% in high-volume hospitals, and for pancreatectomy, for which the corresponding rates were 12.9% and 5.8%, respectively. In these studies, there is evidence of a relationship between volume and outcome for some surgical procedures in some settings. The volume/outcome relation for major liver resection is less clear. Some studies4,6 demonstrated a significant reduction in risk-adjusted operative mortality rates between high-volume hospitals and low-volume hospitals: 22.7% vs. 9.4%, respectively, in one study4 and 10.2% vs. 2.8% in another.6 Other studies demonstrated that good outcomes could be achieved in select low-volume centers as well. For example, a recent series by Ston et al.7 of 18 liver resections (4 trisegmentectomies, 4 hepatic lobectomies, 4 segmentectomies, and 6 wedge resections) in a community hospital in Maryland reported a 0% mortality rate. Although this experience may be anecdotal, it suggests that hospital volume may not be the best predictor of clinical outcome. Further studies are needed to determine factors that explain the volume/outcome relationship.8 We propose that it is not just volume or even the surgeon’s experience, but also additional variables, such as anesthesia, intensive care unit resources, and patient selection, that account for clinical outcome. The goal of our study was to demonstrate that with careful selection of patients, major liver resections can be performed safely, with low morbidity and mortality, at a low-volume community-based teaching hospital.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Our study examined the clinical outcome of all patients who underwent a major liver resection at one hospital between January 1992 and December 2002. The study setting was a large community-based 750- bed hospital with a general surgery residency training program, approved by the accreditation counsel for graduate medical education, acting through the residency review committee for surgery. The hospital has a separate surgical intensive care unit for 22 beds and has no solid organ transplant service. The hospital is a level 1 trauma center, with 25,000 surgical procedures performed annually. It is responsible for 66% of all health care in the state and 80% of the health care in the county in which it resides.

This was a retrospective review of the patients’ medical records. Outcomes were limited to those in the perioperative period, which was defined as within 30 days of hepatic resection. A total of 46 patients underwent hepatic resections over the 10-year period. Surgery residents from postgraduate year 4 or 5 assisted on all resections. There were 22 males (48%) and 24 females (52%). The mean age of the patients was 62 years (range, 17–83 years). Surgery was performed for several different disease processes, but liver metastases from colorectal cancer were the most common pathology (Table 1Go).


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  		TABLE 1. Indications for hepatic resection
 

   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Thirty-seven patients (80.4%) presented with a wide variety of comorbidities; most were coronary artery disease and hypertension (Table 2Go). Some patients (27 of 37) had more than one comorbid condition. A major goal of preoperative evaluation was to identify patients at high operative risk and comorbidities that could have been ameliorated before surgery. Coronary artery disease was defined by the clinical signs of angina pectoris, a history of myocardial infarction, angiographic evidence of coronary artery disease, evidence of ischemia on prior noninvasive studies, or peripheral vascular disease. Patients with any of these characteristics or signs of congestive heart failure underwent preoperative noninvasive testing with dipyridamole-thallium scintigraphy or dobutamine stress echocardiography. This was followed by coronary angiography if myocardial ischemia was identified during a noninvasive stress test. Patients with diabetes mellitus (insulin dependent or non–insulin dependent) required close control of the blood glucose level, with an insulin sliding-scale protocol if necessary. None of the patients had a diagnosis of Child’s B or C liver cirrhosis.


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  		TABLE 2. Comorbidities of patients undergoing hepatic resections
 
Preoperative diagnostic work-up included a spiral contrast computed tomographic (CT) scan with arterial and venous phase in all patients. In addition, five patients underwent magnetic resonance imaging, and four patients were evaluated with a CT portography.

Hepatic resections were performed by 14 different surgeons, and half of the procedures were performed by one surgeon (F.D.). This surgeon received additional specialty training and is a board-certified colorectal surgeon. The rest of the surgeons did not have any additional specialty training and are board certified general surgeons.

All patients underwent a full abdominal exploration with bimanual palpation of the liver and intraoperative ultrasound. Unresectability was determined by the presence of extrahepatic metastases or more than four metastases in the case of colorectal cancer. These criteria did not change over the 10 years the study was conducted.

Procedures performed were hepatic lobectomies (n = 15), trisegmentectomies (n = 5), segmentectomies (n = 16), and wedge resections (n = 10; Table 3Go). In five patients with colorectal metastasis, major liver resection was combined with radiofrequency ablation of hepatic metastases in the contralateral lobe (one right hepatic lobectomy, two right posterior segmentectomies, and two left lateral segmentectomies). In all cases of radiofrequency ablation, it was performed for a single lesion in a lobe contralateral to the hepatic resection. None of the patients in this group underwent repeat hepatic resections. In all cases of gallbladder carcinoma, a wide nonanatomical wedge resection of the gallbladder bed was performed with a 2-cm margin within segments IV and V.


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  		TABLE 3. Types of hepatic resections
 
Procedures were performed as anatomical resections and as nonanatomical wedge resections. Blood inflow control with an intermittent Pringle maneuver (porta hepatis clamp) was used in all cases. The Pringle maneuver was used intermittently for 10 minutes at a time with a 5-minute break, usually anywhere three to five times during the parenchymal transsection, with a median duration of 40 minutes. In cases of major anatomical resections—hepatic lobectomies, trisegmentectomies, or right posterior segmentectomies —blood inflow was controlled by a transparenchymal intrahepatic approach to the portal pedicle, as first described by Galperin and Karagulian. 8 Blood outflow was controlled at the level of hepatic veins before parenchymal dissection. In most patients, resections were performed with a low central venous pressure to minimize blood loss. Low central venous pressure was maintained in all patients with pharmacological manipulation by using morphine sulfate or nitroprusside drip with the goal of 0 to 5 mm Hg. Parenchymal dissection was performed with a wide variety of techniques: Cavitron (Valleylab, Boulder, CO) ultrasonic surgical aspirator, Harmonic (Ethicon Endo-Surgery, Inc., Cincinnati, OH) scalpel, and finger-fracture/clamp-crushing technique, according to the operating surgeon’s personal preference.

There were no perioperative mortalities. Mortality in our study was defined as patient death within 30 days of surgery. Estimated blood loss ranged from 300 to 7000 mL, with a mean of 700 mL. Twenty patients (43%) required blood transfusions, and 26 patients (57%) did not have blood transfusions. In two cases, patients had massive blood loss. In one patient (left hepatic lobectomy), there was an injury of the confluence of the left hepatic vein and inferior vena cava that resulted in blood loss of 7000 mL. In the postoperative period, the patient required prolonged mechanical ventilation and was discharged home on postoperative day 12. In the second patient (right hepatic lobectomy), there was an injury of the inferior vena cava during the dissection of the tumor, which was close to the wall of the vena cava. Blood loss was 6000 mL. The postoperative period was complicated by pulmonary failure that required prolonged mechanical ventilation. This patient was discharged on postoperative day 19 and was then readmitted because of the development of a perihepatic bile collection, which required percutaneous CT scan–guided drainage on postoperative day 24 after the hepatic resection. The first case was performed by a surgeon who had only two hepatic resections in this series. The second case was performed by a surgeon who performed half of all hepatic resections in this series (F.D.).

Of the 46 patients, 16 (34%) developed 23 complications, including bile leak/biloma in 6 patients (13%), wound infections in 4 patients (8.4%), and respiratory failure with prolonged mechanical ventilation (>3 days) in 5 patients (11%). Two of the five patients who required prolonged mechanical ventilation had underlying chronic obstructive pulmonary disease, including one of the two patients with massive intraoperative bleeding. Two of the patients with postoperative wound infection had underlying diabetes. None of these patients had undergone any concurrent gastrointestinal procedures during the hepatic resection. There was one documented pulmonary embolism (2.3%), and two patients (4.6%) developed atrial fibrillation. Four patients (8.7%) had a pleural effusion that required thoracentesis. One additional patient developed an acute pancreatitis, which resolved with no clinical sequelae. The mean length of hospital stay was 9.7 days, including two patients who required hospitalization for 29 and 35 days. One patient, as described previously, was readmitted to the hospital for drainage of a perihepatic bile collection under CT scan guidance and had no further sequelae after discharge to home 3 days after the drainage. Individual raw data of 14 different surgeons are listed in Table 4Go.


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  		TABLE 4. Individual results of hepatic resection
 
Of 46 patients who underwent major liver resection over the last 10 years, 13 patients are still alive. Overall survival ranged from 3 to 84 months, with a median survival of 30.6 months. The actual 5-year survival was 36% (8 of 22) for all patients operated on >5 years ago, and the actual 2-year survival was 61% (20 of 33).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Several studies have suggested that high-volume hospitals achieve lower operative mortality with selected high-risk procedures. On the basis of this information, there are currently strategies to concentrate selected procedures at high-volume hospitals. 1,2,9,10 The Leapfrog Group, a large coalition of private and public purchasers, is encouraging patients undergoing 5 high-risk procedures—coronary artery bypass surgery (500 procedures a year), coronary angioplasty (400 per year), carotidendarterectomy (100 per year), abdominal aortic aneurysm repair (30 per year), and esophagectomy (6 per year)—to seek care at high-volume hospitals.3 Although these volume- based referral initiatives have very respectable goals (to save patients’ lives), these policies could have negative effects on patients and hospitals. For patients in isolated rural areas, regionalizing surgery could imply unreasonable travel burdens, delays in initial evaluation, and problems with continuity of care after surgery. Loss of surgical caseload at small hospitals could threaten their financial stability or their ability to recruit and retain surgeons. In addition, loss of procedure volume would also have a negative effect on a hospital or on a surgeon’s ability to manage emergent cases.

Although several studies1–4 in recent years support the opinion that operative mortality is higher in lowvolume hospitals, many questions still remain unanswered. What factors are responsible for the higher mortality? Is it simply because of poor patient selection, more comorbidities, or worse perioperative management of patients at low-volume hospitals? Are the surgical skills of surgeons performing these operations at high-volume hospitals significantly better than those at low-volume hospitals? Are those skills transferable, or should patients with certain malignancies receive treatment only at certain highvolume centers? Finally, how should we define the volume? Does a low-volume surgeon at a high-volume institution have better outcome than the same surgeon would have at a low-volume hospital?11

A recent study12 has demonstrated that low-volume surgeons at high-volume centers have outcomes similar to those of high-volume surgeons at the same centers. Our study supports the same conclusion. Hepatic resections in our study period were performed by 14 different surgeons, and half of all cases were performed by one surgeon in an otherwise highvolume hospital. Davie11 states,"The law of diminishing returns applies to surgery the same way it does to politico-economic endeavors. Therefore, the application of effort or skill towards a particular goal (low operative mortality) declines in effectiveness after a certain level of results has been achieved."

Begg et al.5 concluded that their data contradict the expanding literature supporting the hypothesis that specialist cancer care significantly improves patient outcome. However, the authors used the caveat that a high patient volume suggests specialization. Pancreatic resection was one procedure for which there was strong evidence that it could be performed more safely in high-volume referral centers. The data for hepatic resection supported a similar conclusion but with less statistical conviction (P = .05).

Most of the reduction in mortality is likely to occur after a certain minimal number of cases.13,14 What is that number? In the 11 studies on pancreatic resection evaluated by the Institute of Medicine in 2000, the definition of low volume varied between <1 to <22 cases per year, with most in the range of 1 to 5 cases per year.15 For instance, in a study by Finlayson et al.,1 low-, medium -, and high-volume hospitals for pancreatic resection were defined as <3,3 to 13, and >13 per year, respectively, suggesting that significant mortality improvements could be achieved for a very modest increase in hospital volumes. Only 2 of the 11 studies reviewed by the Institute of Medicine on pancreatic resection could examine the interaction between hospital and individual practitioner volumes on mortality and demonstrated that only hospital volumes influenced mortality. Why hospital rather than individual physician volume should be a key determinant of outcome remains unclear. The information on hepatic resections is even less clear. More studies with access to clinical data are necessary before changes in health-care policy occur.

In conclusion, our data indicate that at our community- based teaching hospital, which has a high volume for surgical procedures in general but a low volume for hepatic resections, with careful selection of patients, major hepatic resections can be performed safely with low rates of morbidity and operative mortality.

Received for publication May 25, 2004. Accepted for publication October 28, 2004.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Finlayson EV, Goodney PP, Birkmeyer JD. Hospital volume and operative mortality in cancer surgery. Arch Surg 2003;138: 721–6.[Abstract/Free Full Text]
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  3. Birkmeyer JD, Finlayson EV, Birkmeyer CM. Volume standards for high-risk surgery: potential benefits of the Leapfrog initiative. Surgery 2001;130:415–22.[CrossRef][Medline]
  4. Glasgow RE, Showstack JA, Katz PP, et al. The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma. Arch Surg 1999;134:30–5.[Abstract/Free Full Text]
  5. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747–51.[Abstract/Free Full Text]
  6. Dimick JB, Pronovost PJ, Cowan JA, Lipset PA. Postoperative complication rates after hepatic resections in Maryland hospitals. Arch Surg 2003;138:41–6.[Abstract/Free Full Text]
  7. Ston ME, Rehman SU, Conaway G, et al. Hepatic resection at a community hospital. J Gastrointest Surg 2000;4:349–53.[Medline]
  8. Galperin EL, Karagulian SR. A new simplified method of selective exposure of hepatic pedicles for controlled hepatectomies. HPB Surg 1989;1:110–7.
  9. Birkmeyer MD, Stukel TA, Siewers AE, Goodney PP, Wenberg DE, Lucas FL. Surgeon volume and operating mortality in the United States. N Engl J Med 2003;349:2117–27.[Abstract/Free Full Text]
  10. Hannan EL. The relation between volume and outcome in health care. N Engl J Med 1999;340:1677–9.[Free Full Text]
  11. Davie RJ. Invited critique. Arch Surg 2003;138:726.[Free Full Text]
  12. Harmon JW, Tang DG, Gordon TA, et al. Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. Ann Surg 1999;230:404–13.[CrossRef][Medline]
  13. Petrelli NJ, Gupta B, Piedmonte M, Herrera L. Morbidity and survival of liver resection for colorectal adenocarcinoma. Dis Colon Rectum 1991;34:899–904.[CrossRef][Medline]
  14. Jarnagin WR, Gohen M, Fong Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1800 consecutive cases over the past decade. Ann Surg 2002;236:397–407.[CrossRef][Medline]
  15. Halm EA, Lee C, Chassin MR (2001) Appendix C: how is volume related to quality in health care: a systemic review of the research literature. In: Interpreting the Volume–Outcome Relationship in the Context of Health Care Quality: Workshop Summary. Washington, DC, National Academic Press, pp 46–51.



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J. Spiliotis, A. Rogdakis, A. C. Datsis, A. Christopoulou, and S. Kekelos
Hepatic Resection at a Major Community-Based Teaching Hospital Can Result in Good Outcome
Ann. Surg. Oncol., November 1, 2005; 12(11): 951 - 951.
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