title: Greater complexity of liver surgery is not associated with an increased incidence of liver-related complications except for bile leak: an experience with 2,628 consecutive resections.
abstract: BACKGROUND
  Advances in technique, technology, and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver-related complications.
  
  
  METHODS
  A large prospective single-institution database of patients who underwent hepatic resection was used to identify the incidence of liver-related complications. Liver resections were divided into an early era and a late era with equal number of patients (surgery performed before or after 18 May 2006). Patient characteristics and perioperative factors were compared between the two groups.
  
  
  RESULTS
  Between 1997 and 2011, 2,628 hepatic resections were performed, with a 90-day morbidity and mortality rate of 37 and 2 %, respectively. We identified higher rates of repeat hepatectomy (12.2 vs 6.1 %; p < 0.001), two-stage resection (4.0 vs 1 %; p < 0.001), extended right hepatectomy (17.6 vs 14.6 %; p = 0.04), and preoperative portal vein embolization (9.1 vs 5.9 %; p < 0.001) in the late era. The incidence of perihepatic abscess (3.7 vs 2.1 %; p = 0.02) and hemorrhage (0.9 vs 0.3 %; p = 0.045) decreased in the late era and the incidence of hepatic insufficiency (3.1 vs 2.6 %; p = 0.41) remained stable. In contrast, the rate of bile leak increased (5.9 vs 3.7 %; p = 0.011). Independent predictors of bile leak included bile duct resection, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic resection, and intraoperative transfusion.
  
  
  CONCLUSIONS
  The complexity of liver surgery has increased over time, with a concomitant increase in bile leak rate. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leaks is indicated.
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX 77030, USA.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Zimmitti
authors.forename: Robert E
authors.initials: RE
authors.lastname: Roses
authors.forename: Andreas
authors.initials: A
authors.lastname: Andreou
authors.forename: Junichi
authors.initials: J
authors.lastname: Shindoh
authors.forename: Steven A
authors.initials: SA
authors.lastname: Curley
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
mesh_terms: D000328:Adult; D000368:Aged; D001646:Bile; D001649:Bile Duct Diseases / Q000453:epidemiology / Q000209:etiology*; D015331:Cohort Studies; D005260:Female; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D008107:Liver Diseases / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome