Risk-stratified posthepatectomy pathways based upon the Kawaguchi–Gayet complexity classification and impact on length of stay

Background: The Kawaguchi–Gayet classification is a validated system to stratify open liver resections by complexity and postoperative complications. We hypothesized that Kawaguchi–Gayet classification could be used to create and implement risk-stratified posthepatectomy pathways to reduce length of stay and variation in care. Methods: Clinicopathologic data from hepatectomy patients (1/2017–6/2020) were abstracted from a prospective database. All open hepatectomies were assigned to groups based on 2 levels of Kawaguchi–Gayet classification, and corresponding risk-stratified posthepatectomy pathways were created to decrease length of stay by 1 day compared to patients who were historically treated without a pathway: low–intermediate risk (open Kawaguchi–Gayet I/II) and high risk (open Kawaguchi–Gayet III). Outcomes were compared between periods before ("PRE"; 1/1/2017–9/30/2019) and after ("POST"; 10/1/2019–6/30/2020) implementation. Results: Among 487 open hepatectomies (PRE: 374, POST: 113), 55.0% (n = 268) were low–intermediate risk and 45.0% (n = 219) were high risk. Major complications were similar PRE/POST: low–intermediate risk (PRE: 7.8%, POST: 9.4%, P =.681) and high risk (PRE: 18.9%, POST 10.0%, P = 0.139). Risk-stratified posthepatectomy pathway implementation reduced median length of stay for both low–intermediate risk (4 to 3.5 days, P =.009) and high risk (5 to 4 days, P = 0.022) patients. Risk-stratified posthepatectomy pathways decreased length of stay variation, reflected in mean and standard deviation for all patients (PRE 5.5 ± 7.5 vs POST 4.4 ± 2.8 days). There was no difference in 90-day readmission rates between PRE (12.6%) and POST (8.8%) periods (P =.278). Conclusion: The creation and implementation of risk-stratified posthepatectomy pathways reduced length of stay without increasing readmissions after hepatectomy. These generalizable risk-stratified posthepatectomy pathways preoperatively stratify patients a priori into pathways for individualized preoperative discussions on realistic postoperative complications and length of stay expectations.