Early identification of patients at increased risk for hepatic insufficiency, complications and mortality after major hepatectomy

Objective: Total bilirubin (TB) of >7 mg/dl is an accepted definition of postoperative hepatic insufficiency (PHI) given its association with the occurrence of complications and mortality after hepatectomy. The aim of this study was to identify a surrogate marker for PHI early in the postoperative course. Methods: A single-institution database of patients undergoing major hepatectomy (three or more segments) during 2000.2012 was retrospectively reviewed. Demographic, clinicopathologic and perioperative factors were assessed for their association with PHI, defined as postoperative TB of >7 mg/dl or new ascites. Secondary outcomes included complications, major complications (Clavien. Dindo Grades III.V) and 90-day mortality. Results: A total of 607 patients undergoing major hepatectomy without bile duct reconstruction were identified. Postoperative hepatic insufficiency occurred in 60 (9.9%) patients. A postoperative day 3 (PoD 3) TB level of.3 mg/dl was the only early perioperative factor associated with the development of PHI on multivariate analysis [hazard ratio (HR) = 7.81, 95% confidence interval (CI) 3.74.16.31; P < 0.001]. A PoD3 TB of.3 mg/dl was associated with increased risk for postoperative complications (75.7% versus 53.9%), major complications (45.6% versus 17.6%), and 90-day mortality (15.5% versus 2.3%). This association persisted on multivariate analysis for any complications (HR = 1.98, 95% CI 1.10.3.54; P = 0.022), major complications (HR = 3.18, 95% CI 1.90.5.32; P < 0.001), and 90-day mortality (HR = 8.11, 95% CI 3.00.21.92; P < 0.001). Conclusions: Total bilirubin of.3 mg/dl on PoD 3 after major hepatectomy is associated with PHI, increased complications, major complications and 90-day mortality. This marker may serve as an early postoperative predictor of hepatic insufficiency.