Hepatectomy carries a risk of complications that can lead to hospital readmission and even death. Even as modern surgical techniques make liver surgery safer and less invasive, a series of initiatives at The University of Texas MD Anderson Cancer Center has resulted in reduced rates of complications and hospital readmission for patients who undergo hepatectomy.
For any surgical procedure, readmission to the hospital after discharge has been recognized in recent years as an indicator of the quality of care. Even before the Affordable Care Act reduced Medicare payments for hospitals with high readmission rates, many institutions sought ways to improve various areas of patient care to reduce the occurrence of complications that lead to readmission.
At MD Anderson, ongoing efforts led by Jean-Nicolas Vauthey, M.D., a professor and chief of the Liver and Pancreas Section in the Department of Surgical Oncology, aim to reduce complications stemming from hepatectomy. Among the most important of these efforts has been the development of surgical techniques that reduce the occurrence of bile leaks and intraoperative blood transfusions, both of which are associated with hospital readmission.
Efforts to reduce complications
Preventing bile leaks
Bile leak has long been recognized as a serious complication that can lead to life-threatening sepsis after liver surgery. Several years ago, Dr. Vauthey and Thomas Aloia, M.D., an associate professor in the Department of Surgical Oncology, began working on a novel technique to detect and repair bile leaks during hepatectomy.
The intraoperative air leak test is a two-step process. In the first step, a cholangiography catheter is inserted into the cystic duct to inject air into the biliary tree while the distal common bile duct is closed by finger compression. Ultrasonography is used to visualize pneumobilia, which indicates a patent biliary system. If pneumobilia is not seen on ultrasonography, a bile leak may be present. In the second step, the right upper quadrant of the abdomen is filled with sterile saline solution or water. A second injection of air into the cystic duct causes bubbles to emerge from any leaking bile ducts. The water is slowly drained so that each leak can be located and repaired with a polypropylene suture.
Drs. Aloia and Vauthey got the idea for the test from colorectal surgery, in which air is injected into the anus and the pelvic cavity is filled with water to check for colon leaks.
“You have to cut a lot of bile ducts when you do a liver resection,” Dr. Vauthey said. “But any bile duct that is leaking can be found with this technique. It’s an advance in liver surgery.”
The effectiveness of the technique was confirmed by a retrospective study in which postoperative bile leaks occurred in 10.8% of hepatectomy patients who did not undergo the air leak test but in only 1.9% of those who did undergo the test.
Avoiding blood transfusion
Another advance in liver surgery developed by Drs. Aloia and Vauthey, along with other MD Anderson colleagues, is a two-surgeon technique to reduce blood loss during hepatectomy. In this technique, the primary surgeon dissects the liver parenchyma while a second surgeon controls bleeding using a saline-linked cautery device. An added benefit of the technique is reduced operative time.
This technique, which has been in use for more than a decade, has reduced the need for blood transfusions during liver surgery at MD Anderson, as has the use of minimally invasive laparoscopic procedures. Dr. Vauthey said, “Less than 5% of our patients currently undergoing liver resections receive blood transfusions.”
The benefit of reducing bile leaks and blood loss during hepatectomies was underscored by a recent study of factors leading to hospital readmission. In the study, Dr. Vauthey and his colleagues reviewed the records of 3,041 patients who underwent hepatectomies at MD Anderson between 1998 and 2013.
An important aspect of the study was its distinction between planned and unplanned readmissions. “In cancer patients, it is important to differentiate between planned and unplanned readmissions because many patients return to the hospital for chemotherapy or other procedures that were planned before discharge,” Dr. Vauthey said. The researchers found that most unplanned readmissions that can be attributed to liver surgery occur within 45 days of discharge from the hospital.
The initiatives to minimize bile leaks and blood loss, along with other efforts to ensure quality of care, appear to have helped prevent unplanned readmissions. Only 10.3% of the liver surgery patients in the study had unplanned remissions within 45 days of hospital discharge.
In addition, a separate review of postoperative mortality rates among patients who underwent hepatectomy between October 2014 and September 2015 at National Cancer Institute–designated cancer centers found that, despite having the highest case volume, MD Anderson had no deaths within 30 days of the surgery or during the same hospitalization. Dr. Vauthey is pleased with both the low mortality and readmission rates, especially considering the complex liver surgeries that often are involved.
“Readmission is a reflection of the quality and the extent of the surgery,” Dr. Vauthey said. “At our institution, we do major liver resections. In more than half of our liver cancer patients, we remove a lobe or more of the liver, which is considered a major resection. But despite our doing these extensive resections, we are able to maintain high standards and quality of care.”
For more information, contact Dr. Jean-Nicolas Vauthey at 713-792-2022.
Brudvik KW, Mise Y, Conrad C, et al. Definition of readmission in 3,041 patients undergoing hepatectomy. J Am Coll Surg. 2015;221:38–46.
Day RW, Brudvik KW, Vauthey JN, et al. Advances in hepatectomy technique: Toward zero transfusions in the modern era of liver surgery. Surgery. 2015. doi: 10.1016/j.surg.2015.10.006. [Epub ahead of print]
Zimmitti G, Vauthey JN, Shindoh J, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. J Am Coll Surg. 2013;217:1028–1037.
In the second step of a bile leak test performed during a hepatectomy, the right upper quadrant of the abdomen is filled with saline, and then air is injected into the cystic duct. Air bubbles (arrows) indicate a leaking bile duct. Image courtesy of Dr. Jean-Nicolas Vauthey.
Patient characteristics associated with unplanned readmission within 45 days of hepatectomy. Adapted from Brudvik KW, et al., J Am Coll Surg. 2015;221:38–46.
OncoLog, January 2016, Volume 61, Issue 1