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Minimally Invasive vs. Open Hepatectomy: A Comparative Analysis of the National Surgical Quality Improvement Program
Fabio Bagante*1, Steven M. Strasberg2, Faiz Gani1, Vanessa Thompson4, Bruce L. Hall2, Henry Pitt3, Timothy M. Pawlik1
1Surgery, Johns Hopkins Hospital, Baltimore, MD; 2Surgery, Washington University in St. Louis, St. Louis, MO; 3Surgery, Temple University Health System, Philadelphia, PA; 4American College of Surgeon-National Surgical Quality Improvement Program, Chicago, IL
Background: While use of the minimally invasive surgery (MIS) approach to treat tumors of the liver has increased, national data on perioperative outcomes of MIS relative to open hepatic resection are lacking. As such, the objective of the current study was to compare short-term outcomes among patients undergoing MIS versus open liver surgery in a nationally representative database.
Methods: The National Surgical Quality Improvement Program database was used to identify patients undergoing a liver resection between January 01, 2014 and December 31, 2014. A propensity-score matching algorithm was used to control for differences in sociodemographic and clinicopathologic characteristics in the MIS vs. open groups. Chi-Squared and Fisher exact tests were used to compare short-term clinical outcomes among the matched cohort of patients.
Results: 3,064 patients were identified who underwent a liver resection. Median age of the cohort was 60 years (IQR:50-68) and 52.4% (n=1,604) of patients were female. Among the cohort, 2,452 (80.0%) patients underwent an open liver resection, while 612 (20.0%) had an MIS approach (n=612). Using propensity analysis, 606 patients who underwent an MIS liver resection were matched to a comparable cohort of 606 patients who had an open liver resection. Among the matched cohort, morbidity was lower among patients who had an MIS approach compared with patients undergoing an open procedure (11.6% vs. 20.8%%;p<0.001). Specifically, the incidence of surgical site infections (1.2% vs. 4.6%;p<0.001), blood transfusions (7.3% vs. 14.9%;p<0.001), pulmonary embolism (0.2% vs. 2.0%;p=0.002) and myocardial infarction (0% vs. 1.2%;p=0.008) was lower among patients undergoing MIS vs. open liver resection. Postoperative bile leak (3.0% vs. 7.0%;p=0.002) and liver failure (1.2% vs. 3.6%;p=0.005) were also less frequently noted among patients undergoing MIS hepatic resection. Similarly, an MIS approach was associated with a shorter in-hospital length-of-stay (LOS) compared with patients undergoing open liver surgery (median LOS: 3 days [IQR:2-5] vs. 5 days [IQR:4-7];p<0.001)(Figure). Of note, 30-day postoperative mortality and readmission were comparable among the MIS and open approach cohorts (both p>0.05).
Conclusions: Patients undergoing MIS liver resection had a lower postoperative morbidity and shorter LOS compared with patients undergoing open liver surgery. 30-day mortality and rehospitalization were, however, comparable. MIS liver resection is safe and may be associated with improved patient and quality metrics following hepatic surgery.
 Figure. Short-term postoperative outcomes between minimally-invasive (MI) and open liver surgery using a cohort of matched patients.
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