National trends in use of open and laparoscopic hepatectomy related to short-term composite outcomes: an IDEAL stage 4, age- and sex-adjusted cohort study

Background National studies on implementation of minimal-invasive liver surgery (MILS) are scarce. The aim of this study was to report how nationwide trends in use of MILS related to short-term outcomes. Methods A nationwide registry-study of all liver surgery in a universal health care system. Time-trends, age- and sex-adjusted resection rates, and factors related to short-term composite outcomes were analysed, reporting odds ratio (OR) and 95% confidence intervals (95%CI). Results A total of 3508 hepatectomies were performed (1444 in females, 41.2%). Over time, MILS-rate increased from 43·5% (765/1759) to 54·1% (947/1749, P<0·001). Median LoS was 5 days (IQR 2-7 days). Increasingly, patients had a significantly shorter LoS (LoS≤2 days; from 22·7% to 30·8%; P<0·001). Mortality was low (n=24; 0·7%). Severe complications occurred in 525 (15·0%) with higher risk in open surgery compared to MILS (22·6% vs. 7·0%, respectively; OR=2.36 95%CI=2.01-2.77; P<0·001). Reoperations occurred in 3·9% (n=137), and more often in open hepatectomy. Readmission occurred in 6·5% (n=224) with highest rate in open surgery. A composite ideal-outcome was achieved in 2576 patients (73·4%) and associated with female sex, pre-surgery risk-score, minor hepatectomy, MILS and recent time-period. Conclusion In a complete nationwide consecutive cohort across all indications of liver resections a predominant preference for MILS occurred over time, with several factors contributing to shorter length of stay and more favourable outcomes even if confounded by indication and patient selection. The decline in major resections and increased use of laparoscopy coincided in time with the observed improvements in short-term outcomes.