Utilization of the Kawaguchi-Gayet Complexity Classification to Stratify Hepatectomy Patients for Distinct Enhanced Recovery Pathways Based on Anticipated Length of Stay

Abstract

The Kawaguchi-Gayet (K-G) Classification of laparoscopic hepatectomy complexity was recently validated for open liver resection. The objective of this study was to use the K-G classification to stratify patients based on anticipated length of stay for the creation of distinct enhanced recovery pathways. A single-institution prospective database was queried to identify a continuous set of patients from 1/1/2017-12/31/2018. The 3-level K-G classification was utilized for open operations: Grades I (“low”: non-anatomic resection for anterolateral or posterosuperior segment and left lateral sectionectomy), II (“intermediate”: anterolateral segmentectomy and left hepatectomy), and III (“high”: posterosuperior segmentectomy, right posterior sectionectomy, right hepatectomy, central hepatectomy, and extended hepatectomy). All hepatectomies were classified into one of four categories: MIS, Low-Intermediate (Open K-G I-II), High (Open K-G III), and Combo. Of 466 patients, the distribution of hepatectomies included: 86(18.5%) MIS, 168(36%) Low-Intermediate, 140(30%) High, and 72(15.5%) Combo. Modified Accordion Complications Grade ≥3 occurred more frequently with more complex hepatectomies (MIS: 3[4%], Low/Intermediate: 17[10%], High: 25[18%], and Combo: 9[13%], p< 0.001). Median LOS was associated with approach and difficulty (MIS:2d, Low:4d, High:5d and Combo:5d, p< 0.001, Figure 1). Multivariate analysis confirmed that K-G classification (Low/Intermediate: OR 5.5, High: OR 11.6, Combo: OR 11.8, p< 0.001) was the greatest predictor of LOS (LOS>median 4 days). Kawaguchi-Gayet Classification grouped a contemporary cohort of patients undergoing hepatectomy into four strata with LOS between 2-5 days. Using surgical approach and K-G Classification, future patients can be grouped a priori into pathways at the time of surgical consent in clinic.