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Defining Benchmarks for Major Liver Surgery

A multicenter Analysis of 5202 Living Liver Donors

Rössler, Fabian MD; Sapisochin, Gonzalo MD; Song, GiWon MD; Lin, Yu-Hung MD; Simpson, Mary Ann MD, PhD; Hasegawa, Kiyoshi MD, PhD; Laurenzi, Andrea MD; Sánchez Cabús, Santiago MD, PhD; Nunez, Milton Inostroza MD; Gatti, Andrea MD; Beltrame, Magali Chahdi MD; Slankamenac, Ksenija MD, PhD; Greig, Paul D. MD; Lee, Sung-Gyu MD, PhD; Chen, Chao-Long MD, PhD; Grant, David R. MD; Pomfret, Elizabeth A. MD, PhD; Kokudo, Norihiro MD, PhD; Cherqui, Daniel MD; Olthoff, Kim M. MD; Shaked, Abraham MD; García-Valdecasas, Juan Carlos MD, PhD; Lerut, Jan MD, PhD; Troisi, Roberto I. MD, PhD; De Santibanes, Martin MD; Petrowsky, Henrik MD; Puhan, Milo A. MD, PhD; Clavien, Pierre-Alain MD, PhD

doi: 10.1097/SLA.0000000000001849

Objective: To measure and define the best achievable outcome after major hepatectomy.

Background: No reference values are available on outcomes after major hepatectomies. Analysis in living liver donors, with safety as the highest priority, offers the opportunity to define outcome benchmarks as the best possible results.

Methods: Outcome analyses of 5202 hemi-hepatectomies from living donors (LDs) from 12 high-volume centers worldwide were performed for a 10-year period. Endpoints, calculated at discharge, 3 and 6 months postoperatively, included postoperative morbidity measured by the Clavien-Dindo classification, the Comprehensive Complication Index (CCI), and liver failure according to different definitions. Benchmark values were defined as the 75th percentile of median morbidity values to represent the best achievable results at 3 month postoperatively.

Results: Patients were young (34 ± [9] years), predominantly male (65%) and healthy. Surgery lasted 7 ± [2] hours; 2% needed blood transfusions. Mean hospital stay was 11.7± [5] days. 12% of patients developed at least 1 complication, of which 3.8% were major events (≥grade III, including 1 death), mostly related to biliary/bleeding events, and were twice higher after right hepatectomy. The incidence of postoperative liver failure was low. Within 3-month follow-up, benchmark values for overall complication were ≤31 %, for minor/major complications ≤23% and ≤9%, respectively, and a CCI ≤33 in LDs with complications. Centers having performed ≥100 hepatectomies had significantly lower rates for overall (10.2% vs 35.9%, P < 0.001) and major (3% vs 12.1%, P < 0.001) complications and overall CCI (2.1 vs 8.5, P < 0.001).

Conclusions: The thorough outcome analysis of healthy LDs may serve as a reference for evaluating surgical performance in patients undergoing major liver resection across centers and different patient populations. Further benchmark studies are needed to develop risk-adjusted comparisons of surgical outcomes.

*Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital and University of Zurich, Zurich, Switzerland

Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada

Department of Surgery, University of Ulsan College of Medicine, Seoul, Republic of Korea

§Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

Department of Transplantation, Lahey Hospital and Medical Center, Burlington, MA

||Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan

**The Hepatobiliary Center, Department of Surgery, Paul Brousse Hospital, University Paris Sud, Villejuif, France

††Department of Surgery, Hospital Clínic de Barcelona, Barcelona, Spain

‡‡Department of Abdominal and Transplantation Surgery, University Hospitals Saint Luc, Brussels, Belgium

§§Department of General Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital and Medical School, Ghent, Belgium

¶¶Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

||||Department of Surgery, Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA

***Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.

Reprints: Pierre-Alain Clavien, MD, PhD, Departement of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland. E-mail:

All the authors of this manuscript declare no conflicts of interest and no funding was received for this study.

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