S. W. De Geus1, G. G. Kasumova1, T. E. Sachs1, O. Akintorin1, S. Ng1, D. McAneny1, J. F. Tseng1 1Boston University,Surgery,Boston, MA, USA
Introduction: Previous investigators have suggested that laparoscopic liver resection may be superior to an open operation based on studies at high-volume centers; however, the applicability of these findings remains unclear. This study investigates whether hospital volume is a factor in determining the short- and long-term outcomes of laparoscopic versus open hepatectomy for liver cancer.
Methods: The National Cancer Database (NCDB) was queried for patients who underwent open or laparoscopic hepatectomy, without transplantation, for liver cancer 2010-2013. Institutions were defined as being either low-volume hospitals (LVH, ≤ 11 operations/year) or high-volume hospitals (HVH, >11 operations/year). For entire cohort and within each category, positive margin rate, 30-day mortality, readmissions, prolonged hospital stay (hospital stay ≥ 14 days), and overall survival were compared between patients who had laparoscopic and open resections, using multivariate logistic regression and Kaplan-Meier methods.
Results: 2,867 patients underwent hepatectomy for liver cancer. Overall, 612 (21.4%) of resections were performed laparoscopically. After adjustment for covariates, resections for liver cancers at a HVH were significantly associated with lower positive-margin rates (HVH vs. LVH: 8.3% vs. 11.0%; adjusted odd ratio [AOR], 0.744; p=0.0413) and 30-day mortality (HVH vs. LVH: 3.5% vs. 6.2%; AOR, 0.646; p=0.0375). However, no significant differences were observed among the HVHs and LVHs regarding readmissions (HVH vs. LVH: 4.6% vs. 4.8%; AOR, 1.039; p=0.8482), prolonged hospital stay (HVH vs. LVH: 9.2% vs. 8.8%; AOR, 1.065; p=0.6648), or overall survival (HVH: log-rank p=0.1405; LVH: log-rank p=0.2322). Multivariate regressions showed in both HVH and LVH, laparoscopic resections were not significantly associated with positive margins (HVH: AOR, 1.246; p=0.4176; LVH: AOR, 0.991; p=0.9627), 30-day mortality (HVH: AOR, 0.755; p=0.5456; LVC: AOR, 1.037; p=0.8808), readmission (HVH: AOR, 0.834; p=0.6297; LVH: AOR, 0.698; p=0.2302) prolonged hospital stay (HVH: AOR, 0.626; p=0.1172; LVH: AOR, 0.886; p=0.5766), or overall survival (HVH: log-rank p=0.1405; LVH: log-rank p=0.2322) when compared to open.
Conclusion: Although outcomes after major operations are influenced by various factors beyond hospital volume alone, the results of this study suggest that patients with liver cancer are at higher risk of having positive resection margins and 30-day mortality if they are treated at LVH instead of HVH. However, for both high- and low-volume hospitals, laparoscopic resections of liver cancer were associated with surgical and oncologic outcomes that were similar to those for open operations. Although residual selection bias regarding MIS vs open approach must be acknowledged, our data suggest that laparoscopic liver resection when feasible is a reasonable approach across hospital volume strata.