• Iman Khaoudy, Olivier Farges, Emmanuel Boleslawski, Eric Vibert, Olivier Soubrane, Mustapha Adham, Jean Yves Mabrut, Laurent Christophe, Philippe Bachellier, Olivier Scatton, Yves-Patrice Le Treut, and Jean Marc Regimbeau.
• Department of Digestive Surgery, Amiens, France.
• Ann. Surg. 2018 Nov 1; 268 (5): 792-798.

ObjectiveTo perform a retrospective root-cause analysis of the causes of postoperative mortality after hepatectomy.BackgroundMortality after liver resection has not decreased over the past decade.MethodsThe study population was a prospective cohort of hepatectomies performed at hepatic, pancreatic, and biliary (HPB) centers between October 2012 and December 2014. Of the 1906 included patients, 90 (5%) died within 90 days of surgery. Perioperative data were retrieved from the original medical records. The root-cause analysis was performed independently by a senior HBP-surgeon and a surgical HBP-fellow. The objectives were to record the cause of death and then assess whether (1) the attending surgeon had identified the cause of death and what was it?, (2) the intra- and postoperative management had been appropriate, (3) the patient had been managed according to international guidelines, and (4) death was preventable. A typical root cause of death was defined.ResultsThe cause of death was identified by the index surgeon and by the root-cause analysis in 84% and 88% of cases, respectively. Intra- and postoperative management procedures were inadequate in 33% and 23% of the cases, respectively. Guidelines were not followed in 57% of cases. Overall, 47% of the deaths were preventable. The typical root cause of death was insufficient evaluation of the tumor stage or tumor progression in a patient with malignant disease resulting in a more invasive procedure than expected.ConclusionMeasures to ensure compliance with guidelines and (in the event of unexpected operative findings) better within-team communication should be implemented systematically.

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