title: Clinical assessment before hepatectomy identifies high-risk patients.
abstract: BACKGROUND
  Liver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). Subjective assessment is also made in clinic, and patients perceived to be high-risk are referred for CPX at our institution. This article addresses clinicians' ability to identify patients with a higher risk of surgical complications after hepatectomy, using selection for CPX as a surrogate marker for increased operative risk.
  
  
  METHODS
  Prospectively collected data on patients undergoing hepatectomy between February 2008 and November 2013 were retrieved and the cohort divided according to CPX referral. Complications were classified using the Clavien-Dindo system.
  
  
  RESULTS
  CPX testing was carried out before 101 of 405 liver resections during the study period. The median age was 72 and 64 in CPX and non-CPX groups, respectively (P < 0.001). The resection size was similar between the groups. No difference was noted for grade III complications between CPX and non-CPX tested-groups; however, 19 (18.8%) and 28 (9.2%) patients suffered grade IV-V complications, respectively (P = 0.009). There was no difference in long-term survival between groups (P = 0.63).
  
  
  CONCLUSIONS
  This study attempts to assess clinicians' ability to identify patients at greater risk of complications after hepatectomy. The confirmation that patients identified in this way are at greater risk of grade IV-V complications demonstrates the value of preoperative counseling. High-risk patients do not have worse long-term outcomes suggesting survival is determined by other factors, particularly disease recurrence.
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom; Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom. Electronic address: simon.ulyett@nhs.net.
authors.forename: Simon
authors.initials: S
authors.lastname: Ulyett
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom.
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Wiggans
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bowles
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom.
authors.forename: Somaiah
authors.initials: S
authors.lastname: Aroori
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Briggs
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom.
authors.forename: Paul
authors.initials: P
authors.lastname: Erasmus
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom.
authors.forename: Gary
authors.initials: G
authors.lastname: Minto
authors.affiliation: South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom; Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom.
authors.forename: David A
authors.initials: DA
authors.lastname: Stell
mesh_terms: D000368:Aged; D005080:Exercise Test; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care; D011446:Prospective Studies; D018570:Risk Assessment
keywords: Cardiopulmonary exercise test; Clinical intuition; Liver resection; Preoperative assessment; Surgical complications