title: Patterns of care among patients undergoing hepatic resection: a query of the National Surgical Quality Improvement Program-targeted hepatectomy database.
abstract: BACKGROUND
  The American College of Surgeons recently added liver-specific variables to the National Surgical Quality Improvement Program (NSQIP). We sought to use these variables to define patterns of care, as well as characterize perioperative outcomes among patients undergoing hepatic resection.
  
  
  METHODS
  The American College of Surgeons-NSQIP database was queried for all patients undergoing hepatic resection between January 1, 2013 and December 31, 2013 (n = 2448). Liver-specific variables were summarized.
  
  
  RESULTS
  Preoperatively, 11.3% of patients had hepatitis B or C or both, whereas 9.2% had cirrhosis. The indication for hepatic resection was benign (20.8%) or malignant (74.2%) disease. Among patients with a malignant indication, metastatic disease (47.3%) was more common than primary liver cancer (26.9%). Preoperative treatment included neoadjuvant chemotherapy (25.5%), portal vein embolization (2.1%), and intra-arterial therapy (0.9%). At surgery, most patients underwent an open hepatic resection (70.7%), whereas 21.4% and 1.1% underwent a laparoscopic or robotic procedure. The Pringle maneuver was used in 27.7% of patients. Although 6.5% of patients had a concomitant hepaticojejunostomy, 10.1% had a concurrent ablation. An operative drain was placed in half of patients (46.5%, minor resection: 42.0% versus major resection: 53.4%; P < 0.001). Among the entire cohort, bile leak (7.3%, minor resection: 4.9% versus major resection: 10.9%; P < 0.001) and liver insufficiency and/or failure (3.8%, minor resection: 1.9% versus major resection: 6.9%; P < 0.001) were relatively uncommon. A subset of patients (9.5%) did experience major liver-specific complications that required intervention (drainage of collection and/or abscess: 38.4%; stenting for biliary obstruction and/or leak: 21.2%; biloma drainage: 18.4%).
  
  
  CONCLUSIONS
  In addition to standard variables, the new inclusion of liver-specific variables provides a unique opportunity to study NSQIP outcomes and practice patterns among patients undergoing hepatic resection.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Aslam
authors.initials: A
authors.lastname: Ejaz
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Department of Surgery, Washington University, St. Louis, Missouri.
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Hall
authors.affiliation: Department of Surgery, Northwestern University, Chicago, Illinois.
authors.forename: Karl
authors.initials: K
authors.lastname: Bilimoria
authors.affiliation: American College of Surgeons, Chicago, Illinois.
authors.forename: Mark
authors.initials: M
authors.lastname: Cohen
authors.affiliation: Department of Surgery, University of California Los Angeles, Los Angeles, California.
authors.forename: Clifford
authors.initials: C
authors.lastname: Ko
authors.affiliation: Department of Surgery, Temple University Health Systems, Philadelphia, Pennsylvania.
authors.forename: Henry
authors.initials: H
authors.lastname: Pitt
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D006498:Hepatectomy / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D058996:Quality Improvement; D016896:Treatment Outcome
keywords: HPB; Hepatic resection; NSQIP; Outcomes; Surgery