• Clara Pothet, Élodie Drumez, Alexandre Joosten, Michaël Genin, Christian Hobeika, Jean-Yves Mabrut, Émilie Grégoire, Jean Marc Régimbeau, Mathieu Bonal, Olivier Farges, Éric Vibert, François-René Pruvot, and Emmanuel Boleslawski.
• University Lille, CHU Lille, Service de Chirurgie Digestive et Transplantations, Lille, France.
• Ann. Surg. 2021 Nov 1; 274 (5): 805813805-813.

ObjectiveThe aim of this study was to build a predictive model of operative difficulty in open liver resections (LRs).Summary Background DataRecent attempts at classifying open-LR have been focused on postoperative outcomes and were based on predefined anatomical schemes without taking into account other anatomical/technical factors.MethodsFour intraoperative variables were perceived by the authors as to reflect operative difficulty: operation and transection times, blood loss, and number of Pringle maneuvers. A hierarchical ascendant classification (HAC) was used to identify homogeneous groups of operative difficulty, based on these variables. Predefined technical/anatomical factors were then selected to build a multivariable logistic regression model (DIFF-scOR), to predict the probability of pertaining to the highest difficulty group. Its discrimination/calibration was assessed. Missing data were handled using multiple imputation.ResultsHAC identified 2 clusters of operative difficulty. In the "Difficult LR" group (20.8% of the procedures), operation time (401 min vs 243 min), transection time (150 vs.63 minute), blood loss (900 vs 400 mL), and number of Pringle maneuvers (3 vs 1) were higher than in the "Standard LR" group. Determinants of operative difficulty were body weight, number and size of nodules, biliary drainage, anatomical or combined LR, transection planes between segments 2 and 4, 4, and 8 or 7 and 8, nonanatomical resections in segments 2, 7, or 8, caval resection, bilioentric anastomosis and number of specimens. The c-statistic of the DIFF-scOR was 0.822. By contrast, the discrimination of the DIFF-scOR to predict 90-day mortality and severe morbidity was poor (c-statistic: 0.616 and 0.634, respectively).ConclusionThe DIFF-scOR accurately predicts open-LR difficulty and may be used for various purposes in clinical practice and research.Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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