Volumes of liver transplant and partial hepatectomy procedures are independently associated with lower postoperative mortality following resection for hepatocellular carcinoma

Abstract

Partial hepatectomy for hepatocellular carcinoma (HCC) is a high-risk procedure, especially in the presence of portal hypertension. We assessed whether the volume of hospital liver transplant procedures was associated with lower in-hospital mortality independently of the volume of partial hepatectomy procedures. We queried the Nationwide Inpatient Sample (1998-2005) to identify patients who had undergone partial hepatectomy for HCC and used logistic regression to assess the independent effect of volumes of hospital liver transplant and partial hepatectomy procedures on mortality while adjusting for demographic, clinical, and hospital factors. Overall in-hospital mortality was 7.7%. Patients with portal hypertension experienced higher mortality than those who did not (24.5% versus 5.8%, P < 0.0001). Postoperative mortality benefited from a higher volume of hospital liver transplants (>12 per year) and partial hepatectomy procedures (>5 resections per year). Undergoing partial hepatectomy at a center that performed an effective liver transplant volume (eLTV; >12 transplants per year) was associated with lower mortality in both the portal hypertensive group (16.4% versus 33.7%, P = 0.004) and non-portal hypertensive group (4% versus 8%, P = 0.0002). After multivariate adjustment, the odds ratio (OR) of in-hospital death for those with portal hypertension was 4.5 [95% confidence interval (CI), 2.98-6.81]. The lower mortality observed with eLTV (OR, 0.59; 95% CI, 0.37-0.93) was independent of the mortality benefit from an effective partial hepatectomy volume (>5 hepatectomies per year; OR, 0.54; 95% CI, 0.31-0.94). Postoperative complications were also fewer at centers with eLTV compared to those without eLTV (39.2% versus 29.3%, P < 0.0001). In conclusion, given the postoperative mortality benefit independent of the volume of partial hepatectomy procedures, referral to a center with eLTV should be considered for HCC resection, especially in the presence of portal hypertension.