定义大型肝外科手术的基准：5202 例活体肝移植供者的多中心分析。

Defining Benchmarks for Major Liver Surgery: A multicenter Analysis of 5202 Living Liver Donors.

机构信息

*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.

出版信息

Ann Surg. 2016 Sep;264(3):492-500. doi: 10.1097/SLA.0000000000001849.

DOI:10.1097/SLA.0000000000001849

PMID:27433909

Abstract

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.

摘要

目的

测量并定义肝切除术的最佳预后。

背景

目前尚无肝切除术的最佳预后参考值。在活体肝供者中进行分析，以安全为最高优先级，为定义预后基准提供了机会，将其定义为可能的最佳结果。

方法

对来自全球 12 个高容量中心的 5202 例活体肝供者半肝切除术的结果进行了 10 年的分析。术后出院时、术后 3 个月和 6 个月的终点包括术后并发症发生率，采用 Clavien-Dindo 分类、综合并发症指数（CCI）和不同定义的肝衰竭来衡量。基准值定义为中位数发病率的第 75 个百分位数，以代表术后 3 个月的最佳可实现结果。

结果

患者年龄较轻（34 ± [9] 岁），主要为男性（65%）且健康。手术持续 7 ± [2] 小时；2%需要输血。平均住院时间为 11.7± [5] 天。12%的患者至少发生了 1 种并发症，其中 3.8%为重大事件（≥3 级，包括 1 例死亡），主要与胆道/出血事件相关，右半肝切除后发生率增加了 2 倍。术后肝衰竭的发生率较低。在 3 个月的随访中，总体并发症的基准值为≤31%，轻度/重度并发症的基准值分别为≤23%和≤9%，伴有并发症的 CCI≤33。实施≥100 例肝切除术的中心的总体（10.2%比 35.9%，P < 0.001）和重大（3%比 12.1%，P < 0.001）并发症发生率和总体 CCI（2.1 比 8.5，P < 0.001）显著降低。