Half of Postoperative Deaths After Hepatectomy May Be Preventable

A Root-Cause Analysis of a Prospective Multicenter Cohort Study

Iman Khaoudy, MD; Olivier Farges, MD, PhD; Emmanuel Boleslawski, MD, PhD; Eric Vibert, MD, PhD; Olivier Soubrane, MD, PhD; Mustapha Adham, MD, PhD; Jean Yves Mabrut, MD, PhD; Laurent Christophe, MD, PhD; Philippe Bachellier, MD, PhD; Olivier Scatton, MD, PhD; Yves-Patrice Le Treut, MD, PhD; Jean Marc Regimbeau, MD, PhD


Annals of Surgery. 2018;268(5):792-798. 

In This Article

Abstract and Introduction


Objective: To perform a retrospective root-cause analysis of the causes of postoperative mortality after hepatectomy.

Background: Mortality after liver resection has not decreased over the past decade.

Methods: The 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.

Results: The 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.

Conclusion: Measures to ensure compliance with guidelines and (in the event of unexpected operative findings) better within-team communication should be implemented systematically.


The mortality rate after hepatectomy remains high and ranges from 4.7% in expert centers[1,2] to 5.8% for national centers[1] and has not declined over the last 20 years.[3]

To understand and anticipate postoperative morbidity and mortality, surgeons can refer to prognostic models based on large, prospective studies.[4–7] However, these objective profiles are not sufficiently applied in routine surgical practice.[8] Moreover, the surgeon's intuition has been shown to be insufficiently discriminatory.[9] Recent studies conducted by our research group revealed that sensitizing hepatic, pancreatic, and biliary (HBP)-surgeons to their outcome does not reduce mortality rate.[10] Lastly, in order to better understand adverse events, the French High Authority for Health requires hospitals to perform a morbidity and mortality review (MMR), that is, a retrospective analysis of cases ending in death or a complication.

Root-cause analysis (RCA) is based on the same approach as an MMR and is performed on a selected population. The RCA concept was invented by the US National Aeronautics and Space Administration, in order to identify and correct the root causes of events, rather than simply dealing with the outcomes. A factor is considered to be the root cause if its removal avoids the occurrence of the analyzed event.

There are few literature data on its value in assessing surgical outcomes.[11] However, an RCA of mortality following major pancreatectomy demonstrated how this approach could highlight a relationship between an inadequate surgical technique and the occurrence of a procedure-specific complication; the report revealed that deaths were related to intraoperative events (12%), technical errors (21%), poor patient selection (15%), and deaths remained unknown in 25%.[12]

The objective of the present study was to perform an RCA of a prospective, multicenter cohort of deceased patients having undergone hepatectomy in order to propose new data/arguments to decrease the post-hepatectomy mortality.