Department of Surgery, The James Cancer Center, Ohio State University, Columbus, OH.
Department of Surgery, The James Cancer Center, Ohio State University, Columbus, OH.
Surgery. 2021 Dec;170(6):1741-1748. doi: 10.1016/j.surg.2021.06.028. Epub 2021 Jul 27.
The aim of this analysis was to determine whether optimal outcomes have increased in recent years. Hepatic surgery is high risk, but regionalization and minimally invasive approaches have evolved. Best practices also have been defined with the goal of improving outcomes.
The American College of Surgeons National Surgical Quality Improvement Program database was queried. Analyses were performed separately for partial (≤2 segments), major (≥3 segments), and all hepatectomies. Optimal hepatic surgery was defined as the absence of mortality, serious morbidity, need for a postoperative invasive procedure or reoperation, prolonged length of stay (<75th percentile) or readmission. Tests of trend, χ, and multivariable analyses were performed.
From 2014 to 2018, 17,082 hepatectomies, including 11,862 partial hepatectomies and 5,220 major hepatectomies, were analyzed. Minimally invasive approaches increased from 25.6% in 2014 to 29.6% in 2018 (P < .01) and were performed more frequently for partial hepatectomies (34.2%) than major hepatectomies (14.4%) (P < .01). Operative time decreased from 220 minutes in 2014 to 208 minutes in 2018 (P < .05) and was lower in partial hepatectomies (189 vs 258 minutes for major hepatectomies) (P < .01). Mortality (0.7%) and length of stay (4 days) were lower for partial hepatectomies compared with major hepatectomies (1.9%; 6 days), and length of stay decreased for both partial hepatectomies (5 days in 2014 to 4 days in 2018) and major hepatectomies (6 days in 2014 to 6 days in 2018) (all P < .01). Postoperative sepsis (2.9% in 2014 and 2.4% in 2018), bile leaks (6% in 2014 and 4.8% in 2018), and liver failure (3.7% in 2014 and 3.3% in 2018) decreased for all patients (<.05). On multivariable analyses, overall morbidity decreased for major hepatectomies (OR 0.95, 95% CI 0.91-0.99) and all hepatectomies (OR 0.97, 95% CI 0.94-0.99, both P < .01), and optimal hepatic surgery increased over time for partial hepatectomies (OR 1.05, 95% CI 1.02-1.09) and all hepatectomies (OR 1.04, 95% CI 1.02-1.07, both P < .01).
Over a 5-year period in North America, minimally invasive hepatectomies have increased, while operative time, postoperative sepsis, bile leaks, liver failure, and prolonged length of stay have decreased. Optimal hepatic surgery has increased for partial and all hepatectomies and is achieved more often in partial than in major resections.
本分析旨在确定近年来是否提高了最佳结果。肝切除术风险较高，但区域化和微创方法已经发展。随着目标是改善结果，最佳实践也已经确定。
查询美国外科医师学院国家手术质量改进计划数据库。分别对部分（≤2 段）、主要（≥3 段）和所有肝切除术进行分析。最佳肝切除术定义为无死亡、严重发病率、需要术后侵入性操作或再次手术、延长住院时间（<75 百分位数）或再入院。进行趋势检验、χ 和多变量分析。
2014 年至 2018 年期间，分析了 17082 例肝切除术，包括 11862 例部分肝切除术和 5220 例主要肝切除术。微创方法的比例从 2014 年的 25.6%增加到 2018 年的 29.6%（P<0.01），并且更多地用于部分肝切除术（34.2%）而不是主要肝切除术（14.4%）（P<0.01）。手术时间从 2014 年的 220 分钟减少到 2018 年的 208 分钟（P<0.05），部分肝切除术的手术时间更低（189 分钟比主要肝切除术的 258 分钟）（P<0.01）。与主要肝切除术相比，部分肝切除术的死亡率（0.7%）和住院时间（4 天）较低（1.9%；6 天），并且部分肝切除术和主要肝切除术的住院时间均减少（2014 年为 5 天，2018 年为 4 天）（均 P<0.01）。术后脓毒症（2014 年为 2.9%，2018 年为 2.4%）、胆漏（2014 年为 6%，2018 年为 4.8%）和肝功能衰竭（2014 年为 3.7%，2018 年为 3.3%）在所有患者中均有所下降（均 P<0.05）。多变量分析显示，主要肝切除术（OR 0.95，95%CI 0.91-0.99）和所有肝切除术（OR 0.97，95%CI 0.94-0.99，均 P<0.01）的总体发病率降低，并且部分肝切除术（OR 1.05，95%CI 1.02-1.09）和所有肝切除术（OR 1.04，95%CI 1.02-1.07，均 P<0.01）的最佳肝切除术随着时间的推移而增加。
在北美 5 年期间，微创肝切除术增加，而手术时间、术后脓毒症、胆漏、肝功能衰竭和延长住院时间减少。部分和所有肝切除术的最佳肝切除术都有所增加，而且在部分肝切除术中比主要切除术中更常见。
