Comprehensive Complication Index Validates Improved Outcomes Over Time Despite Increased Complexity in 3707 Consecutive Hepatectomies

Objective: The aim of this study was to evaluate trends over time in perioperative outcomes for patients undergoing hepatectomy. Background: As perioperative care and surgical technique for hepatectomy have improved, the indications for and complexity of liver resections have evolved. However, the resulting effect on the short-term outcomes over time has not been well described. Methods: Consecutive patients undergoing hepatectomy during 1998 to 2015 at 1 institution were analyzed. Perioperative outcomes, including the comprehensive complication index (CCI), were compared between patients who underwent hepatectomy in the eras 1998 to 2003, 2004 to 2009, and 2010 to 2015. Results: The study included 3707 hepatic resections. The number of hepatectomies increased in each era (794 in 1998 to 2003, 1402 in 2004 to 2009, and 1511 in 2010 to 2015). Technical complexity increased over time as evidenced by increases in the rates of major hepatectomy (20%, 23%, 30%,P< 0.0001), 2-stage hepatectomy (0%, 3%, 4%,P< 0.001), need for portal vein embolization (5%, 9%, 9%,P= 0.001), preoperative chemotherapy for colorectal liver metastases (70%, 82%, 89%,P< 0.001) and median operative time (180, 175, 225 minutes,P< 0.001). Significant decreases over time were observed in median blood loss (300, 250, 200 mL,P< 0.001), transfusion rate (19%, 15%, 5%,P< 0.001), median length of hospitalization (7, 7, 6 days,P< 0.001), rates of CCI >= 26.2 (20%, 22%, 16%,P< 0.001) and 90-day mortality (3.1%, 2.6%, 1.3%,P< 0.01). On multivariable analysis, hepatectomy in the most recent era 2010 to 2015 was associated with a lower incidence of CCI >= 26.2 (odds ratio 0.7, 95% confidence interval 0.6-0.8,P< 0.0001). Conclusion: Despite increases in complexity over an 18-year period, continued improvements in surgical technique and perioperative outcomes yielded a resultant decrease in CCI in the most current era.