Combined Hepatopancreaticobiliary Volume and Hepatectomy Outcomes in Hepatocellular Carcinoma Patients at Low-Volume Liver Centers

BACKGROUND: The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs). STUDY DESIGN: The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations. RESULTS: Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p < 0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival. CONCLUSIONS: LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met. ((C) 2021 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Automated summary

The study examined the impact of hospital volume on outcomes of liver resections for hepatocellular carcinoma. It found that patients treated at low-volume hospitals had higher 30-day mortality compared to high-volume hospitals, but those treated at mixed-volume hospitals had comparable outcomes to high-volume hospitals. The study suggests that liver operations at low-volume centers with experience in HPB cancer operations can be safe, indicating a need for a more holistic assessment of the volume-outcomes curve.