Predicting Intraoperative Difficulty of Open Liver Resections: The DIFF-scOR Study, An Analysis of 1393 Consecutive Hepatectomies From a French Multicenter Cohort.

Abstract

OBJECTIVE\nThe aim of this study was to build a predictive model of operative difficulty in open liver resections (LRs).\n\n\nSUMMARY BACKGROUND DATA\nRecent attempts at classifying open-LR have been focused on postoperative outcomes and were based on predefined anatomical schemes without taking into account other anatomical/technical factors.\n\n\nMETHODS\nFour intraoperative variables were perceived by the authors as to reflect operative difficulty: operation and transection times, blood loss, and number of Pringle maneuvers. A hierarchical ascendant classification (HAC) was used to identify homogeneous groups of operative difficulty, based on these variables. Predefined technical/anatomical factors were then selected to build a multivariable logistic regression model (DIFF-scOR), to predict the probability of pertaining to the highest difficulty group. Its discrimination/calibration was assessed. Missing data were handled using multiple imputation.\n\n\nRESULTS\nHAC identified 2 clusters of operative difficulty. In the Difficult LR group (20.8% of the procedures), operation time (401\u200amin vs 243\u200amin), transection time (150 vs.63\u200aminute), blood loss (900 vs 400\u200amL), and number of Pringle maneuvers (3 vs 1) were higher than in the Standard LR group. Determinants of operative difficulty were body weight, number and size of nodules, biliary drainage, anatomical or combined LR, transection planes between segments 2 and 4, 4, and 8 or 7 and 8, nonanatomical resections in segments 2, 7, or 8, caval resection, bilioentric anastomosis and number of specimens. The c-statistic of the DIFF-scOR was 0.822. By contrast, the discrimination of the DIFF-scOR to predict 90-day mortality and severe morbidity was poor (c-statistic: 0.616 and 0.634, respectively).\n\n\nCONCLUSION\nThe DIFF-scOR accurately predicts open-LR difficulty and may be used for various purposes in clinical practice and research.