Towards zero mortality in elective liver surgery

Abstract

Introduction: Elective liver surgery can be undertaken with low mortality. This study reports outcome of a protocolised approach to patient selection, surgery and peri-operative care. Methods: The study population is a consecutive series of patients undergoing liver resection under the care of an individual hepatobiliary surgeon (AKS) in the regionally accredited liver surgery service in Manchester, UK. 323 consecutive liver resections undertaken during the period January 2009 to October 2017 provide the study population. All patients >65 yrs of age (and younger pts undergoing complex liver surgery) underwent cardiopulmonary exercise testing (CPET) with those having poor performance being excluded from surgery. Patients had arterial and central venous pressure monitoring and most had epidural analgesia. No pharmacological reduction of CVP was employed. Liver transection was undertaken with CUSA (Valleylab, UK) with intermittent inflow occlusion. All-cause, episode-related, in-hospital mortality is reported. Data were recorded prospectively. Results: There were 123 (38%) major resections classified as hemi-hepatectomy (or more extensive). 35 patients (11%) required blood transfusion; median 0 (range 0 - 32 units; 4 patients required more than 2 units). There was 1 death [3000g extended right hepatectomy on veno-venous bypass with death due to post-operative liver failure]. The post-operative mortality rate was 0.3%. Conclusions: This type of case series is typically skewed by case selection bias, ascertainment and reporting bias but accepting these limitations, good results can be achieved in liver surgery with low peri-operative mortality over a sustained period of time using a protocolised approach to patient selection and peri-operative care.