Retrospective Cohort Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Feb 27, 2019; 11(2): 199-207
Published online Feb 27, 2019. doi: 10.4254/wjh.v11.i2.199
Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean
Shamir O Cawich, Ravi Maharaj, Vijay Naraynsingh, Neil Pearce, Wesley Francis, Kimon O Bonadie, Dexter A Thomas
Shamir O Cawich, Ravi Maharaj, Vijay Naraynsingh, Dexter A Thomas, Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago 999183, West Indies
Neil Pearce, Department of Surgery, University Hospital Southampton NHS Trust, Southampton, SO16DP, United Kingdom
Wesley Francis, Department Surgery, University of the West Indies, Nassau 999154, Bahamas
Kimon O Bonadie, Department Surgery, Cayman Islands Health Service Authority, Grand Cayman, KY11100, West Indies
Author contributions: Cawich SO designed the study; Cawich SO, Maharaj R, Naraynsingh V, Pearce NW, Francis W, Bonadie KO and Thomas DA performed the research; Pearce NW, Francis W, Bonadie KO and Thomas DA analyzed the data; Cawich SO, Maharaj R, Naraynsingh V and Pearce NW wrote the paper; and Cawich SO, Maharaj R, Naraynsingh V, Pearce NW, Francis W, Bonadie KO and Thomas DA revised the manuscript for final submission.
Institutional review board statement: This research was approved by the Institutional Review Board at the University of the West Indies (IRB CEC/689/08/18).
Informed consent statement: All involved persons (subjects or legally authorized representative) gave their written informed consent prior to study inclusion. Identifying data has been anonymized but is available to the editor in chief upon request.
Conflict-of-interest statement: The authors declare that there are no financial relationships, personal relationships or other scenarios that may represent potential conflicts of interest.
STROBE statement: The authors have read the CONSORT 2010 Statement. The manuscript adheres to the CONSORT 2010 policies, with the exceptions that this is not a randomized trial.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Shamir O Cawich, MBBS, Professor, Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, St Augustine, Trinidad and Tobago 999183, West Indies.
Telephone: +1-868-6229909
Received: September 8, 2018
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
Research background

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.

Research motivation

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.

Research objectives

To determine the clinical outcomes after major hepatectomies in a low-volume, resource-poor center in the Caribbean.

Research methods

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.

Research results

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.

Research conclusions

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.

Research perspectives

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.