Individual Components of Post-Hepatectomy Care Pathways Have Differential Impacts on Length of Stay

Abstract

Introduction: Optimization of perioperative factors contributing to post-hepatectomy length of stay (LOS) is an aim of current care pathways. However, individual variable contributions to LOS are difficult to separate. Method: Using a prospectively-maintained quality improvement database, hepatectomy patients (1/1/2017-7/1/2020) were included in Poisson regression and marginal effects analysis for LOS. Kawaguchi-Gayet (K-G) complexity classifications were used for comparing expected LOS among pathways (minimally-invasive=MIS; low-intermediate=K-G I/II; high=K-G III; combination operations). Prolonged LOS was >25% median LOS by pathways. “Diet tolerance” was defined as 24 hours of eating. Results: Among 978 consecutive patients, median LOS was 2, 4, 5, and 5 days for MIS, K-G I/II, K-G III and combination operations, respectively. Multivariable Poisson regression identified age, intraoperative fluids, delayed diet tolerance, and combination cases associated with increased LOS (all p<0.01). MIS pathway was associated with shorter LOS (p<0.001, Table 1). Marginal effects analysis demonstrated on average, each additional year of age contributed 0.03x increased LOS; each 250mL of intraoperative IV fluids contributed 0.06x; each additional operative hour contributed 0.2x; each additional day to diet tolerance contributed 0.4x, while MIS approach had 1.2x increased probability of shorter LOS. Combination operations contributed 0.7x increased probably of longer LOS (Figure 1). Conclusions: Modifiable components of post-hepatectomy care pathways to potentially impact LOS include restricting intraoperative fluids, optimizing operative time, introducing a diet on postoperative day 1, and favoring MIS approaches when feasible. Intentionally highlighting these individual pathway components may maximize the overall effects of the comprehensive care bundle.Tabled 1Table 1: Multivariable Model for Length of Stay after Hepatectomy According to Level of Operative ComplexityVariableIRRp-value*95% CIAge (in years)1.006<0.0011.003-1.009Male sex1.0060.8710.94-1.08Intraoperative IV fluids (per 250 mL)1.0140.0111.003-1.02Total operative time (per 60 min)1.037<0.0011.17-1.06Estimated blood loss (in mL)1.000.6470.99-1.00Tolerated regular diet for 24 hours (in days)1.09<0.0011.07-1.10PathwayK-G I/IIK-G IIIMISCombination casesRef1.080.731.15Ref0.129<0.0010.004Ref0.98-1.190.64-0.821.04-1.26IRR: Incidence Rate Ratio; IV: intravenous; CI: confidence interval; MIS: minimally invasive surgery; K-G: Kawaguchi-Gayet*p-value set at alpha of 0.05 Open table in a new tab IRR: Incidence Rate Ratio; IV: intravenous; CI: confidence interval; MIS: minimally invasive surgery; K-G: Kawaguchi-Gayet *p-value set at alpha of 0.05