title: Hepatic resection for hepatocellular carcinoma: do contemporary morbidity and mortality rates demand a transition to ablation as first-line treatment?
abstract: BACKGROUND
  Despite the rising incidence of hepatocellular carcinoma (HCC), challenges and controversy persist in optimizing treatment. As recent randomized trials suggest that ablation can have oncologic equivalence compared with resection for early HCC, the relative morbidity of the 2 approaches is a central issue in treatment decisions. Although excellent contemporary perioperative outcomes have been reported by a few hepatobiliary units, it is not clear that they can be replicated in broader practice. Our objective was to help inform this treatment dilemma by defining perioperative outcomes in a broader set of patients as represented in NSQIP-participating institutions.
  
  
  METHODS
  Mortality and morbidity data were extracted from the 2005-2010 NSQIP Participant Use Data Files based on Current Procedural Terminology (hepatectomy and ablation) and ICD-9 (HCC). Perioperative outcomes were reviewed, and factors associated with morbidity and mortality were identified with multivariable logistic regression.
  
  
  RESULTS
  Eight hundred and thirty-seven (52%) underwent minor hepatectomy, 444 (28%) underwent major hepatectomy, and 323 (20%) underwent surgical ablation. Mortality rates were 3.4% for minor hepatectomy, 3.7% for ablation, and 8.3% for major hepatectomy (p < 0.01). Major complication rates were 21.3% for minor hepatectomy, 9.3% for ablation, and 35.1% for major hepatectomy (p < 0.01). When controlling for confounders, ablation was associated with decreased mortality (adjusted odds ratio = 0.20; 95% CI, 0.04-0.97; p = 0.046) and major complications (adjusted odds ratio = 0.34; 95% CI, 0.22-0.52; p < 0.001).
  
  
  CONCLUSIONS
  Exceedingly high complication rates after major hepatectomy for HCC exist in the broader NSQIP treatment environment. These data strongly support the use of parenchymal-sparing minor resections or ablation over major hepatectomy for early HCC when feasible.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
authors.forename: George Z
authors.initials: GZ
authors.lastname: Li
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Speicher
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Lidsky
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
authors.forename: Marcus D
authors.initials: MD
authors.lastname: Darrabie
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
authors.forename: John E
authors.initials: JE
authors.lastname: Scarborough
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
authors.forename: Rebekah R
authors.initials: RR
authors.lastname: White
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
authors.forename: Ryan S
authors.initials: RS
authors.lastname: Turley
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC. Electronic address: bryan.clary@dm.duke.edu.
authors.forename: Bryan M
authors.initials: BM
authors.lastname: Clary
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000601:surgery*; D017115:Catheter Ablation / Q000401:mortality*; D016208:Databases, Factual; D005260:Female; D006498:Hepatectomy / Q000401:mortality*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States