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J Am Coll Surg. 2021 Feb 25:S1072-7515(21)00158-7. doi: 10.1016/j.jamcollsurg.2021.01.017. Online ahead of print.
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 hepato-pancreatico-biliary (HPB) cancer operations impacts outcomes of liver resections (LR).
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 LR. Centers were dichotomized as low- and high-volume centers based on the median number of operations. Three study cohorts were created: low-volume hospitals (LVH) for both LR and HPB, mixed-volume hospital (MVH) with low-volume LR but high-volume HPB, and high-volume LR hospitals (HVH) for both LR and HPB.
RESULTS: Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% patients were treated at LVH, MVH, and HVH, respectively. On multivariable analysis, patients treated at LVH had higher 30-day mortality compared to patients treated at HVH (Odds Ratio [OR], 1.736; p<0.001). However, patients treated at MVH experienced comparable 30-day mortality to HVH (OR, 0.789; p=0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival.
CONCLUSIONS: Liver resection 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-outcome curve for HPB surgery ought to be assessed more holistically and that patients may safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.