Novel Benchmark Values for Open Major Anatomic Liver Resection in Non-Cirrhotic Patients. A Multicentric Study of 44 International Expert Centers
Authors: Sousa Da Silva Richard X. , Breuer Eva , Shankar Sadhana , Kawakatsu Shoji , Hołówko Wacław , Coelho João Santos , Jeddou Heithem , Sugiura Teiichi , Ghallab Mohammed , Da Silva Doris , Watanabe Genki , Botea Florin , Sakai Nozomu , Addeo Pietro F. , Tzedakis Stylianos , Bartsch Fabian , Balcer Kaja , Lim Chetana , Werey Fabien , López Victor , Montero Luciana Peralta , Claria Rodrigo Sanchez , Leiting Jennifer , Vachharajani Neeta , Hopping Eve , Torres Orlando J. M. , Hirano Satoshi , Andel Daan , Hagendoorn Jeroen , Psica Alicja , Ravaioli Matteo , Ahn Keun S. , Reese Tim , Montes Leonardo Agustin , Gunasekaran Ganesh , Alcázar Cándido , Lim Jin H. , Haroon Muhammad , Lu Qian , Castaldi Antonio , Orimo Tatsuya , Moeckli Beat , Abadía Teresa , Ruffolo Luis , Hasan Josefina Dib , Ratti Francesca , Kaufmann Emmanuele F. , de Wilde Roeland , Polak Wojciech G. , Boggi Ugo , Aldrighetti Luca , McCormack Lucas , Hernandez-Alejandro Roberto , Serrablo Alejandro , Toso Christian , Taketomi Akinobu , Gugenheim Jean , Dong Jiahong , Hanif Faisal , Park Joon S. , Ramia José M. , Schwartz Myron , Ramisch Diego , De Oliveira Michelle , Oldhafer Karl J. , Kang Koo J. , Cescon Matteo , Lodge Peter , Rinkes Inne H. M. Borel , Noji Takehiro , Thomson John-Edwin , Goh Su K. , Chapman William C. , Cleary Sean P. , Pekolj Juan , Regimbeau Jean-Marc , Scatton Olivier , Truant Stéphanie , Lang Hauke , Fuks David , Bachellier Philippe , Otsuka Masayuki , Popescu Irinel , Hasegawa Kiyoshi , Lesurtel Mickaël , Adam René , Cherqui Daniel , Uesaka Katsuhiko , Boudjema Karim , Marques Hugo Pinto , Grąt Micha , Petrowsky Henrik , Ebata Tomoki , Prachalias Andreas , Robles-Campos Ricardo , Clavien Pierre-Alain 
Published: July 2023

Objective:
This study aims at establishing benchmark values for best achievable outcomes following open major anatomic hepatectomy for liver tumors of all dignities.

Background:
Outcomes after open major hepatectomies vary widely lacking reference values for comparisons among centers, indications, types of resections, and minimally invasive procedures.

Methods:
A standard benchmark methodology was used covering consecutive patients, who underwent open major anatomic hepatectomy from 44 high-volume liver centers from 5 continents over a five-year period (2016–2020). Benchmark cases were low-risk non-cirrhotic patients without significant co-morbidities treated in high-volume centers (≥30 major liver resections/year). Benchmark values were set at the 75th percentile of median values of all centers. Minimum follow-up period was 1 year in each patient.

Results:
Of 8044 patients, 2908 (36%) qualified as benchmark (low risk) cases. Benchmark cutoffs for all indications include R0 resection ≥78%; liver failure (grade B/C) ≤10%; bile leak (grade B/C) ≤18%; complications ≥grade 3 and CCI® ≤46% and ≤9 at 3 months, respectively. Benchmark values differed significantly between malignant and benign conditions so that reference values must be adjusted accordingly. Extended right hepatectomy (H1,4-8 or H4-8) disclosed higher cutoff for liver failure, while extended left (H1-5,8 or H2-5,8) were associated with higher cutoffs for bile leaks, but had superior oncologic outcomes, when compared to formal left hepatectomy (H1-4 or H2-4). The minimal follow up for a conclusive outcome evaluation following open anatomic major resection must be 3 months.

Conclusion:
These new benchmark cut-offs for open major hepatectomy provide a powerful tool to convincingly evaluate other approaches including parenchymal-sparing procedures, laparoscopic/robotic approaches, and alternative treatments, such as ablation therapy, irradiation or novel chemotherapy regimens.