The Impact of Hospital Volume on Failure to Rescue after Liver Resection for Hepatocellular Carcinoma

Abstract

Objective: The aim of this study was to evaluate correlation between centers' volume and incidence of failure to rescue (FTR) following liver resection for hepatocellular carcinoma (HCC). Summary Background Data: FTR, defined as the probability of postoperative death among patients with major complication, has been proposed to assess quality of care during hospitalization. Perioperative management is challenging in cirrhotic patients and the ability to recognize and treat a complication may be fundamental to rescue patients from the risk of death. Methods: Patients undergoing liver resection for HCC between 2008 and 2018 in 18 Centers enrolled in the He.Rc.O.Le.S. Italian register. Early results included major complications (Clavien !3), 90-day mortality, and FTR and were analyzed according to center's volume. Results: Among 1935 included patients, major complication rate was 9.4% (8.6%, 12.3%, and 7.0% for low-, intermediate-and high-volume centers, respectively, P ¼ 0.001). Ninety-day mortality rate was 2.6% (3.7%, 4.2% and 0.9% for low-, intermediate-and high-volume centers, respectively, P < 0.001). FTR was significantly higher at low-and intermediate-volume centers (28.6% and 26.5%, respectively) than at high-volume centers (6.1%, P ¼ 0.002). Independent predictors for major complications were American Society of Anesthesiologists (ASA) >2, portal hypertension, intraoperative blood transfusions, and center's volume. Independent predictors for 90-day mortality were ASA >2, Child-Pugh score B, BCLC stage B-C, and center's volume. Center's volume and BCLC stage were strongly associated with FTR. Conclusions: Risk of major complications and mortality was related with comorbidities, cirrhosis severity, and complexity of surgery. These factors were not correlated with FTR. Center's volume was the only independent predictor related with severe complications, mortality, and FTR.

Factors associated with failure to rescue after liver resection and impact on hospital variation: a nationwide population-based study

“…In the Italian study on FTR after HCC resection only low centre volume was associated with FTR. 25 The current study confirms that patient factors such as higher age, ASA classification 3, histopathological cirrhosis and disease demographics such as liver resection for biliary cancer and major liver resection are risk factors for occurrence of FTR.…”

“…24 A recent study from Italy focussing on FTR within 90 days after resection of HCC observed an overall FTR rate of 19.2% which ranged between 28.6% in low volume centres and 5.1% in high volume centres. 25 In a German study using invoice data including 18,849 patients from 2009 to 2015 the in-hospital FTR rate was 28.9%. 26 Overall FTR rates of 19.1% in the Netherlands are therefore concordant with the literature.…”

Postoperative mortality after liver resection for hepatocellular carcinoma—A systematic review. Metanalysis and metaregression of studies published in the last 5 years

“…A total of 8474 patients' data who underwent liver resections for hepatocellular carcinoma were pooled from 15 studies included 15–29 . 301 patients died within 90 days postoperatively.…”

“…A total of 8474 patients' data who underwent liver resections for hepatocellular carcinoma were pooled from 15 studies included. [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] 301 patients died within 90 days postoperatively. Weighted 90 days mortality was 4.2% with a 95% confidence interval between 3.0% to 5.4% (Figure 3 Forest plot).…”

Extended liver resection in mice: state of the art and pitfalls—a systematic review

“…Unfortunately, the studies' reasons for this enormous variance cannot be explained and reflect a general problem in experimental surgery: The robustness and reproducibility of results when applying the same experimental method. In fact, complication management, failure to rescue, is well described in human medicine, but is often not mentioned in any laboratory experiments [33]. One of the reasons for survival difference could be the learning curve, which shows a sharp rise, especially at the beginning of learning.…”