Early identification of patients at increased risk for hepatic insufficiency, complications and mortality after major hepatectomy.
OBJECTIVE
Total bilirubin (TB) of >7 mg/dl is an accepted definition of postoperative hepatic insufficiency (PHI) given its association with the occurrence of complications and mortality after hepatectomy. The aim of this study was to identify a surrogate marker for PHI early in the postoperative course.


METHODS
A single-institution database of patients undergoing major hepatectomy (three or more segments) during 2000-2012 was retrospectively reviewed. Demographic, clinicopathologic and perioperative factors were assessed for their association with PHI, defined as postoperative TB of >7 mg/dl or new ascites. Secondary outcomes included complications, major complications (Clavien-Dindo Grades III-V) and 90-day mortality.


RESULTS
A total of 607 patients undergoing major hepatectomy without bile duct reconstruction were identified. Postoperative hepatic insufficiency occurred in 60 (9.9%) patients. A postoperative day 3 (PoD 3) TB level of ≥3 mg/dl was the only early perioperative factor associated with the development of PHI on multivariate analysis [hazard ratio (HR) = 7.81, 95% confidence interval (CI) 3.74-16.31; P < 0.001]. A PoD 3 TB of ≥3 mg/dl was associated with increased risk for postoperative complications (75.7% versus 53.9%), major complications (45.6% versus 17.6%), and 90-day mortality (15.5% versus 2.3%). This association persisted on multivariate analysis for any complications (HR = 1.98, 95% CI 1.10-3.54; P = 0.022), major complications (HR = 3.18, 95% CI 1.90-5.32; P < 0.001), and 90-day mortality (HR = 8.11, 95% CI 3.00-21.92; P < 0.001).


CONCLUSIONS
Total bilirubin of ≥3 mg/dl on PoD 3 after major hepatectomy is associated with PHI, increased complications, major complications and 90-day mortality. This marker may serve as an early postoperative predictor of hepatic insufficiency.
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
Joanna W
JW
Etra
Malcolm H
MH
Squires
Sarah B
SB
Fisher
Daniel R
DR
Rutz
Benjamin M
BM
Martin
David A
DA
Kooby
Kenneth
K
Cardona
Juan M
JM
Sarmiento
Charles A
CA
Staley
Shishir K
SK
Maithel
Maria C
MC
Russell
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001663:Bilirubin / Q000097:blood*; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D016208:Databases, Factual; D042241:Early Diagnosis; D005260:Female; D005845:Georgia; D006498:Hepatectomy / Q000009:adverse effects* / Q000401:mortality; D048550:Hepatic Insufficiency / Q000097:blood / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality; D006801:Humans; D008115:Liver Regeneration; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D015854:Up-Regulation; D055815:Young Adult
D015415:Biomarkers; D001663:Bilirubin