Is prolonged operative time associated with postoperative complications in liver surgery? An international multicentre cohort study of 5424 patients

Christoph Kuemmerli^#^{1

2}, Jasper P Sijberden^#^{3

4

5}, Federica Cipriani⁶, Daniel Osei-Bordom⁷, Davit Aghayan⁸, Jacopo Lanari⁹, Celine de Meyere¹⁰, Andrea Benedetti Cacciaguerra¹¹, Fernando Rotellar¹², David Fuks¹³, Rong Liu¹⁴, Marc G Besselink^{4

5}, Giuseppe Zimmitti³, Andrea Ruzzenente¹⁵, Fabrizio di Benedetto¹⁶, Iswanto Succandy¹⁷, Mikhail Efanov¹⁸, Riccardo Memeo¹⁹, Elio Jovine²⁰, Dionisios Vrochides²¹, Ibrahim Dagher²², Roland Croner²³, Santi Lopez-Ben²⁴, David Geller²⁵, Jawad Ahmad²⁶, Tom Gallagher²⁷, Steven White^{28

29}, Adnan Alseidi³⁰, Brian K P Goh³¹, Ernesto Sparrelid³², Francesca Ratti⁶, Ravi Marudanayagam⁷, Åsmund Avdem Fretland⁸, Marco Vivarelli¹¹, Mathieu D'Hondt¹⁰, Umberto Cillo⁹, Bjørn Edwin⁸, Robert P Sutcliffe⁷, Luca A Aldrighetti⁶, Mohammed Abu Hilal^{33

34}; International Consortium on Minimally Invasive Liver Surgery (I-MILS)

Affiliations

¹ Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Via Leonida Bissolati, 57, 25124, Brescia, Italy. chuemmerli@hotmail.com.
² Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK. chuemmerli@hotmail.com.
³ Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Via Leonida Bissolati, 57, 25124, Brescia, Italy.
⁴ Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
⁵ Cancer Center Amsterdam, Amsterdam, The Netherlands.
⁶ Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.
⁷ Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
⁸ The Intervention Center, Department of HPB Surgery, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norway.
⁹ Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy.
¹⁰ Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
¹¹ Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy.
¹² HPB and Liver Transplantation Unit, Department of Surgery, Institute of Health Research of Navarra (IdisNA), University Clinic, Universidad de Navarra, Pamplona, Spain.
¹³ Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France.
¹⁴ Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
¹⁵ Department of Surgery, University of Verona, Verona, Italy.
¹⁶ Hepato-Pancreatic-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
¹⁷ Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA.
¹⁸ Department of Hepato-Pancreatic-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia.
¹⁹ Hepato-Pancreato-Biliary Surgery Unit, Miulli Hospital, Acquaviva Delle Fonti, Bari, Italy.
²⁰ Department of Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
²¹ Division of Abdominal Transplantation, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
²² Department of Digestive Minimally Invasive Surgery, Antoine Béclère Hospital, Paris, France.
²³ Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany.
²⁴ Department of Surgery, Hospital Universitari de Girona Dr Josep Trueta, Girona, Spain.
²⁵ Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²⁶ University Hospitals Coventry and Warwickshire, Clifford Bridges Road, Coventry, UK.
²⁷ Vincent's University Hospital, Elm Park, Dublin, Ireland.
²⁸ Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
²⁹ Department of Surgery, Virginia Mason Medical Center, Seattle, USA.
³⁰ Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
³¹ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore.
³² Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
³³ Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Via Leonida Bissolati, 57, 25124, Brescia, Italy. abuhilal9@gmail.com.
³⁴ Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK. abuhilal9@gmail.com.

^# Contributed equally.

PMID: 39347957
DOI: 10.1007/s00464-024-11276-x

Multicenter Study

Is prolonged operative time associated with postoperative complications in liver surgery? An international multicentre cohort study of 5424 patients

Christoph Kuemmerli et al. Surg Endosc. 2024 Dec.

. 2024 Dec;38(12):7118-7130.

doi: 10.1007/s00464-024-11276-x. Epub 2024 Sep 30.

Authors

Affiliations

¹ Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Via Leonida Bissolati, 57, 25124, Brescia, Italy. chuemmerli@hotmail.com.
² Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK. chuemmerli@hotmail.com.
³ Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Via Leonida Bissolati, 57, 25124, Brescia, Italy.
⁴ Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
⁵ Cancer Center Amsterdam, Amsterdam, The Netherlands.
⁶ Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.
⁷ Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
⁸ The Intervention Center, Department of HPB Surgery, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norway.
⁹ Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy.
¹⁰ Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
¹¹ Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy.
¹² HPB and Liver Transplantation Unit, Department of Surgery, Institute of Health Research of Navarra (IdisNA), University Clinic, Universidad de Navarra, Pamplona, Spain.
¹³ Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France.
¹⁴ Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
¹⁵ Department of Surgery, University of Verona, Verona, Italy.
¹⁶ Hepato-Pancreatic-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
¹⁷ Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA.
¹⁸ Department of Hepato-Pancreatic-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia.
¹⁹ Hepato-Pancreato-Biliary Surgery Unit, Miulli Hospital, Acquaviva Delle Fonti, Bari, Italy.
²⁰ Department of Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
²¹ Division of Abdominal Transplantation, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
²² Department of Digestive Minimally Invasive Surgery, Antoine Béclère Hospital, Paris, France.
²³ Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany.
²⁴ Department of Surgery, Hospital Universitari de Girona Dr Josep Trueta, Girona, Spain.
²⁵ Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²⁶ University Hospitals Coventry and Warwickshire, Clifford Bridges Road, Coventry, UK.
²⁷ Vincent's University Hospital, Elm Park, Dublin, Ireland.
²⁸ Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
²⁹ Department of Surgery, Virginia Mason Medical Center, Seattle, USA.
³⁰ Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
³¹ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore.
³² Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
³³ Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Via Leonida Bissolati, 57, 25124, Brescia, Italy. abuhilal9@gmail.com.
³⁴ Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK. abuhilal9@gmail.com.

^# Contributed equally.

PMID: 39347957
DOI: 10.1007/s00464-024-11276-x

Abstract

Background: The relation between operative time and postoperative complications in liver surgery is unclear. The aim of this study is to assess the impact of operative time on the development of postoperative complications in patients who underwent minimally invasive or open liver resections of various anatomical extent and technical difficulty levels.

Methods: In this retrospective cohort study, patients that underwent a right hemihepatectomy (RH), technically major resection (anatomically minor resection in segment 1, 4a, 7 or 8; TMR) or left lateral sectionectomy (LLS) between 2000 and 2022 were extracted from a multicenter database comprising the prospectively maintained databases of 31 centers in 13 countries. Minimally invasive procedures performed during the learning curve were omitted. Logistic regression models, performed separately for 9 different groups based on stratification by procedure type and allocated surgical approach, were used to assess the association between the fourth quartile of operative time (25% of patients with the longest operative time) and postoperative complications.

Results: Overall, 5424 patients were included: 1351 underwent RH (865 open, 373 laparoscopic and 113 robotic), 2821 TMR (1398 open, 1225 laparoscopic and 198 robotic), and 1252 LLS (241 open, 822 laparoscopic and 189 robotic). After adjusting for potential confounders (age, BMI, gender, ASA grade, previous abdominal surgery, disease type and extent, blood loss, Pringle, intraoperative transfusions and incidents), the fourth quartile of operative time, compared to the first three quartiles, was associated with an increased risk of postoperative complications after open, laparoscopic and robotic TMR (aOR 1.35, p = 0.031; aOR 1.74, p = 0.001 and aOR 3.11, p = 0.014, respectively), laparoscopic and robotic RH (aOR 1.98, p = 0.018 and aOR 3.28, p = 0.055, respectively) and solely laparoscopic LLS (aOR 1.69, p = 0.019).

Conclusions: A prolonged operative time is associated with an increased risk of postoperative complications, although it remains to be defined if this is a causal relationship.

Keywords: Hepatectomy; Minimally invasive surgery; Operative time; Postoperative complications.

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Conflict of interest statement

Declarations. Disclosures: The authors Christoph Kuemmerli, Jasper P. Sijberden, Federica Cipriani Daniel Osei-Bordom, Davit Aghayan, Jacopo Lanari, Celine de Meyere, Andrea Benedetti Cacciaguerra, Fernando Rotellar, David Fuks, Rong Liu, Marc G. Besselink, Giuseppe Zimmitti, Andrea Ruzzenente, Fabrizio di Benedetto, Iswanto Succandy, Mikhail Efanov, Riccardo Memeo, Elio Jovine, Dionisios Vrochides, Ibrahim Dagher, Roland Croner, Santi Lopez-Ben, David Geller, Jawad Ahmad, Tom Gallagher, Steven White, Adnan Alseidi, Brian K.P. Goh, Ernesto Sparrelid, Francesca Ratti, Ravi Marudanayagam, Åsmund Avdem Fretland, Marco Vivarelli, Mathieu D’Hondt, Umberto Cillo, Bjørn Edwin, Robert P. Sutcliffe, Luca A. Aldrighetti, Mohammed Abu Hilal have no conflicts of interest or financial ties to disclose.

References

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Is prolonged operative time associated with postoperative complications in liver surgery? An international multicentre cohort study of 5424 patients

Affiliations

Is prolonged operative time associated with postoperative complications in liver surgery? An international multicentre cohort study of 5424 patients

Authors

Affiliations

Abstract

Conflict of interest statement

References

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Medical