SSAT - Quantitative Fractional Analysis of NSQIP Complications After Open Hemihepatectomy in Patients Suitable for Laparoscopic Hemihepatectomy: Burden of Incisional Complications

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Quantitative Fractional Analysis of NSQIP Complications After Open Hemihepatectomy in Patients Suitable for Laparoscopic Hemihepatectomy: Burden of Incisional Complications
Roheena Panni^*, Bruce L. Hall, Steven M. Strasberg
Surgery, Washington University in St. Louis, St louis, MO

Introduction: Open hemihepatectomy (OH) is a standard major liver procedure. Laparoscopic hemihepatectomy (LH) has been introduced but its advantages over (OH) are unclear. When centers begin doing LH there is selection of cases which are suitable for LH. While appropriate this makes it difficult to obtain a cohort of OH cases to compare to LH cases within such centers. The purpose of this study was to provide such a cohort for comparison from a center which still almost exclusively performs OH and do so using quantitative methods for evaluating complications.
Methods: An audit of OHs from 2002 to 2013 was performed. Inclusion/exclusion criteria were established to eliminate patients who would not have been suitable for LH or who had additional procedures which themselves might be associated with complications (Table 1). Complications were recorded by National Surgical Quality Improvement Program (NSQIP), severity was graded by the Modified Accordion Grading System, and burden calculated using previously derived weighting factors.
Results: 96 patients, 59.2 yr +/- 13.2 (SD), 54% female, BMI 28.24 +/- 5.8 (SD) had 75 right OH and 21 left OH. 84% were performed for cancer, and of these 57% were for metastatic colon cancer, 33% for primary liver cancers, and 9% for other metastatic tumors. The R1 rate for metastatic colon cancer and primary liver tumors were 2/46 (4.3%), and 4/27 (14.8%) and respectively. Median LOS was 7 days. 32 complications occurred in 96 patients (33%). Complication results weighted by severity are shown in Table 2. Grade 2 complications were the most common (53.1%) and also accounted for the most weighted burden (42.9%). Organ space surgical site infections (SSI) were the most common complication accounting for 15.6% of all complications and 20.2% of burden. Incisional complications (superficial and deep SSI) accounted for 21.9% of complications and 13.0% of weighted burden. The average burden of highest grade complications in all 96 patients, postoperative morbidity index (PMI) was 0.071. There were no postoperative deaths.
Conclusions: OH performed on patients suitable for LH has a low PMI. Most complications are low grade (1 and 2), but organ space SSI is the most common and severe complication. Incisional complications account for 13% of burden and it is here that LH has the best chance of reducing burden. R1 rate is low for metastatic colon cancer and LH must be able to match such results for it to be effective especially as there was no selection in this cohort for tumor size, number, or location.

Table 1: Inclusion/ Exclusion Criteria

INCLUSION CRITERIA		EXCLUSION CRITERIA
Hemi hepatectomy		Significant evidence of chronic liver disease i.e. cirrhosis, varices or portal hypertension
± Laparoscopic staging ± mobilization		Emergency hemi-hepatectomy
± Caudate lobe resection		Formal tri-sectionectomy
± Minor extension into segment 4 <2 cm		Two stage hepatectomies / multiple procedures on the liver
± Wedge excisions of lesions not >2 cm in any dimension		Any formal resection of other segments or wedge resections >2 cm maximum diameter
± Radiofrequency ablation (RFA) of margins or surface lesions		Hepaticojejunostomy
± Node biopsies		Interstitial ablations
± Diaphragm excision with primary repair		Any laparoscopic procedure beyond mobilization i.e. taking of caudate veins, portal dissection, parenchymal transection
± Adhesiolysis		Formal portal node dissection
± Portal vein embolism		Previous biliary-enteric anastomosis
± Intra op cholangiography ± intra op choledoscopy		Diaphragm repair requiring mesh or graft
		Any secondary procedure bowel resection, hernia repair, gynecologic or urologic procedure
		Resection of adjacent organ or part of adrenal, duodenum, colon or stomach

Table 2. Complications Classified by Severity Grades, Weighted Results

POST OP COMPLICATION	SEVERITY GRADE							WEIGHTED COMPLICATION BURDEN
POST OP COMPLICATION		1	2	3	4	5	6	WEIGHTED COMPLICATION BURDEN
SEVERITY WEIGHT		0.11	0.26	0.37	0.6	0.79	1	n	%
Postop Superficial Incisional SSI		0.44	0.52					0.96	9.3
Superficial Incisional SSI PATOS
Postop Deep Incisional SSI				0.37				0.37	3.6
Deep Incisional SSI PATOS
Postop Organ Space SSI				1.48	0.6			2.08	20.2
Organ Space SSI PATOS
Postop Wound Disruption
Postop Pneumonia			0.26					0.26	2.5
Pneumonia PATOS
Postop Unplanned Intubation					1.2			1.2	11.6
Postop Pulmonary Embolism
Postop On Ventilator > 48 hrs					1.2			1.2	11.6
Postop Progressive Renal Insufficiency
Postop Acute Renal Failure					0.6			0.6	5.8
Postop Urinary Tract Infection			1.04					1.04	10.1
Postop Myocardial Infarction			0.26					0.26	2.5
Postop Bleeding/Transfusions			0.78					0.78	7.6
Postop DVT			0.78					0.78	7.6
Postop Sepsis
Postop Septic Shock			0.78					0.78	7.6
Postop Cardiac Arrest Requiring CPR
Postop Other Occ
Sort by grade,n		0.44	4.42	1.85	3.6			10.31	100
Sort by grade,%		4.3	42.9	17.9	34.9			100

Abbreviations: SSI (surgical site infection), PATOS (present at time of surgery), DVT (deep venous thrombosis)

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