Improvement in Perioperative Outcome After Hepatic Resection
Objective: To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome.
Methods: Demographics, extent of resection, concomitant major procedures, operative and transfusion data, complications, and hospital stay were analyzed for 1,803 consecutive patients undergoing hepatic resection from December 1991 to September 2001 at Memorial Sloan-Kettering Cancer Center. Factors associated with morbidity and mortality and trends in operative and perioperative variables over the period of study were analyzed.
Results: Malignant disease was the most common diagnosis (1,642 patients, 91%); of these cases, metastatic colorectal cancer accounted for 62% (n = 1,021). Three hundred seventy-five resections (21%) were performed for primary hepatic or biliary cancers and 161 (9%) for benign disease. Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies, and 526 segmental resections. Sixty-two percent of patients had three or more segments resected, 42% had bilobar resections, and 37% had concomitant additional major procedures. The median blood loss was 600 mL and 49% of patients were transfused at any time during the index admission. Median hospital stay was 8 days, morbidity was 45%, and operative mortality was 3.1%. Over the study period, there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this, there was a significant decline in blood loss, the use of blood products, and hospital stay. Despite an increase in concomitant major procedures, operative mortality decreased from approximately 4% in the first 5 years of the study to 1.3% in the last 2 years, with 0 operative deaths in the last 184 consecutive cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both perioperative morbidity and mortality.
Conclusions: Over the past decade, the use of parenchymal-sparing segmental resections has increased significantly. The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality, and reductions in both are largely responsible for the decrease in perioperative mortality, which has occurred despite an increase in concomitant major procedures.

Lortat-Jacob's report of a true anatomical right hepatectomy for cancer in 1952 ushered in the modern era of hepatic resectional surgery. However, the subsequent experience with hepatic resection was far from encouraging. In 1977, Foster and Berman reported a multicenter analysis of 621 hepatic resections for a variety of indications. In this study, operative mortality was 13% and over 20% for major resections (hepatectomy, extended hepatectomy), with 20% of the deaths resulting from hemorrhage.

Over the past decade, many large series have documented better perioperative results, with operative mortality rates typically less than 5% in high-volume centers. As a result, hepatic resection has evolved into the treatment of choice for selected patients with benign and malignant hepatobiliary disease. Also, with improvement in the safety of hepatic resection, indications for its use have broadened, and partial hepatectomy in combination with other major procedures is now performed with greater frequency.

No single factor is responsible for the marked improvement in perioperative outcome. General improvement in operative and anesthetic technique, better patient selection, and the emergence of hepatobiliary surgery as a distinct area of specialization have all been cited, and probably all play a role. A better understanding of hepatic anatomy and increasing application of anatomically based resections are perhaps the most important factors in this regard.

With this refined appreciation of hepatic segmental anatomy has come an awareness of the feasibility of segment-oriented resections. It has been established that, in the appropriate setting, parenchymal-sparing segmental resections offer the same benefit as classic lobar resections with less risk than is associated with removal of a large volume of functional liver tissue. In addition, segmental resections are clearly superior to wedge resections with respect to blood loss and tumor clearance.

The practice of hepatic resectional surgery thus continues to evolve, but few large, contemporary studies have specifically evaluated the impact of these changes. The present study analyzes consecutive, unselected patients undergoing hepatic resection over the past decade to further define factors associated with morbidity and mortality and to evaluate trends in operative and perioperative variables over the period of study.