Risk-stratified posthepatectomy pathways based upon the Kawaguchi–Gayet complexity classification and impact on length of stay
Bradford J. Kim, Elsa M. Arvide, Cameron E. Gaskill, Allison N. Martin, Yoshikuni Kawaguchi, Yi‐Ju Chiang, Whitney L. Dewhurst, Teresa L. Phan, Hop S. Tran Cao, Yun Shin Chun, Matthew H. G. Katz, Jean‐Nicolas Vauthey, Ching‐Wei D. Tzeng, Timothy E. Newhook
Abstract
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.