Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean

Abstract

BACKGROUND Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease. There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes. These high volume referral centers are usually located in developed countries, but many patients in developing nations are not able to access these centers because of financial limitations, lack of social support and/or travel restrictions. Therefore, local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease. This is the situation in many Caribbean countries. AIM To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the Caribbean. METHODS We prospectively studied all patients who underwent major liver resections over five years. The following data were extracted: patient demographics, diagnoses, ECOG status, operation performed, post-operative morbidity and mortality. Statistical analyses were performed using SPSS ver 16.0 RESULTS There were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/year. Sixty-nine major hepatic resections were performed for: colorectal liver metastases 40 (58%), non-colorectal metastases 9 (13%), hepatocellular carcinoma 8 (11.6%), ruptured adenomas 4 (5.8%), hilar cholangiocarcinomas 4 (5.8%), hemangiomata 2 (2.9%), trauma 1 (1.5%) and hepatoblastoma 1 (1.5%). Twenty-one patients had at least one complication, for an overall morbidity rate of 30.4%. There were minor complications in 17 (24.6%) patients, major complications in 11 (15.9%) patients and 4 (5.8%) deaths. CONCLUSION There are unique geographic, political and financial limitations to healthcare delivery in the Caribbean. Nevertheless, clinical outcomes are acceptable in the established, low-volume hepatobiliary centers in the Eastern Caribbean.

Laparoscopic Hepatectomy via Remote Mentoring From Jamaica to Trinidad

“…We propose that distance mentoring may be a solution when there are competent surgeons who possess the necessary advanced skill sets to complete laparoscopic hepatectomies. Mentoring is the well-accepted concept where an experienced surgeon coaches a less experienced colleague [4][5][6]. We extended the traditional mentoring concept to one where the mentor only present virtually [4].…”

“…The scenario described in this case report is common in developing countries, where sub-specialty expertise may not be immediately available for laparoscopic hepatectomies. Some patients may opt to travel to developed countries, but many do not have this opportunity due to financial barriers [ 5 ]. We propose that distance mentoring may be a solution when there are competent surgeons who possess the necessary advanced skill sets to complete laparoscopic hepatectomies.…”

Totally Laparoscopic Whipple’s Operation: Initial Report from the Caribbean

“…The operation was completed with morbidity and mortality profiles matching those from high-volume centers performing these operations in developed countries [14][15][16]. It was also accompanied by oncologic outcomes comparable to those from open operations in Caribbean centers of excellence and from high-volume centers in developed countries [17][18][19][20].…”

Laparoscopic Liver Resection by Distance Mentoring – Trinidad to Barbados: A Report

“…This situation extends to laparoscopic liver resections as well. In this environment, laparoscopic liver resections are only performed in Trinidad and Tobago, Jamaica, and the Bahamas [1, 3, 5-6], where there are active hepatobiliary teams (Figure 1). Some of the other Caribbean countries have competent surgeons who may not have formal training in liver resections but possess the necessary advanced laparoscopic skill sets to complete laparoscopic liver resections.…”

“…However, these operations are technically demanding and require advanced laparoscopic skill sets. A unique situation exists in the Anglophone Caribbean where regional centers of excellence for liver resections were established in 2010 [1], but there are few surgeons with advanced laparoscopic training across the region [2]. In addition, Caribbean Island nations are separated by miles of ocean that limit the movement of patients, surgeons, and equipment.…”