Published online Feb 27, 2019. doi: 10.4254/wjh.v11.i2.199
Peer-review started: September 10, 2018
First decision: October 5, 2018
Revised: November 5, 2018
Accepted: January 28, 2019
Article in press: January 28, 2019
Published online: February 27, 2019
In the past two decades, there was a trend to concentrate major hepatectomies in specific centers in order to support sub-specialty teams performing these operations at high volumes. This trend was supported by accumulating data to suggest that there were better peri-operative outcomes in high-volume referral hospitals. However, this is not practical in the Caribbean and other resource-poor countries.
Clinicians in the Caribbean do not have the luxury of “case selection” because most patients treated at our facilities have no other options for care. Therefore, these patients must receive treatment at low-volume, resource-poor centers with limited support services and numerous institutional limitations. The motivation for our research was to determine if the clinical outcomes are acceptable despite the numerous limitations.
To determine the clinical outcomes after major hepatectomies in a low-volume, resource-poor center in the Caribbean.
We prospectively studied post-operative morbidity and mortality in all patients undergoing major hepatectomies in a low-volume Caribbean hepatobiliary center over a five-year study period. Statistical analyses were performed using SPSS ver 16.0.
There were 69 major hepatectomies performed over the study period (mean case volume of 13.8 major resections/year). More than half of the major hepatectomies were performed in high-risk patients, with ASA scores ≥ III (58%), ECOG scores ≥ 2 (57%) or at least one co-morbidity (93%). A further 38% of the major hepatectomies performed in this setting were technically difficult operations. Twenty-one patients experienced at least 1 complication, for an overall morbidity rate of 30.4%. There were minor complications in 17 (24.6%) patients, major complications in 11 (15.9%) patients and 4 (5.8%) deaths.
Although Caribbean hospitals do not qualify as high-volume centers, there can be good short-term outcomes after major hepatectomies are performed in established hepatobiliary units. This demonstrates that case volume is not the only determinant of good outcomes after major hepatectomy.
To achieve good outcomes, there is the need for teamwork, appropriately trained staff, due diligence in care administration, continued audit and knowledge of population-based data. Case volume is not the only determinant of good outcomes after major hepatectomy.