Surgical complications of liver resections

Surgical complications of liver resections

Sherif Abdel Halim, MD, El Sobky A.MD, Mohamed H Hamouda  MD, Youhanna Shohdy Shafik MD, MRCS(Eng),Mohamed E Self, MD,· MohAMarzouk MD

Department of General Surgery, Ain Shams University, Cairo, Egypt.

Background:  Liver resection  has  been increasingly  performed  over  the last  2 decades worldwide because of improved postoperative outcomes and evidence that this approach offers the only chance of cure in many patients.

Technical innovations  have mainly  focused on minimizing  bleeding  during transection of the hepatic parenchyma because excessive hemorrhage and the need  for blood transfusion are associated with increased postoperative morbidity and mortality

Liver resection is still a high risk procedure because of difficulties in preoperative assessment of functional liver  volume and severity  of co-morbidity, complexities  of surgical procedures for preserving enough  functional liver and preventing injury  to mcyor vessels in the remnant liver. Although  zero mortality  can be achieved  during a limited  period in some centers,  the postoperative mortality in most studies is between 1%-5%, even in patients with normal liver background.

Postoperative  death can be attributed  to liver  failure, infection  in surgical  site, bleeding from esophageal varices, bile leakage, and extrahepatic diseases.

Methods: In this study, we classified  postoperative  complications  into  major and  minor ones according to their  fatal potential. We hypothesized  that improved  surgical technique can decrease surgical complications, while patient selection and careful perioperative management are important to prevent mcyor complications.  Randomized  collection of twenty nine patients underwent partial hepatectomy for different indications. Analysis of every case has been done, retrospectively

Results:   In  this  study, the most  common indication  of liver  resection  was liver  tumors accounting  for 82.7% of cases, primary hepatic malignancy accounting  for 75.8%. Extension of liver resection was a predictor  factor of complication. Major complications  were observed with rate  of 29. 4% in  patients  who were subjected  to major  resections.  The most  common complication  was liver  decompensation  accounting   for 24.1%,  was  observed  in  cirrhotic patients.

Conclusion: Our  findings  demonstrate  that liver  resection  can  be  performed  with  low

mortality and acceptable morbidity rates. Surgical complications can be reduced by employing meticulous  surgical technique and,  whenever indicated,  vascular exclusion. In addition,  use of vaccine against HBV eventually decreases the incidence,  especially in endemic areas, and prevents the development of cirrhosis, which predisposes to hepatocellular carcinoma and liver decompensation after rersection.

Introduction:

Liver   resections     were     first   described centuries ago, but until the latter half of the

20th century, the majority of such resections

were  performed  for  management   of  either

injuries or infections.!

Today, these  procedures  are  performed not only for treatment of acute emergencies (e.g., traumatic injuries or abscesses) but also

as potentially  curative therapy  for  a variety

Am-Shams] Surg 2014; 7(19):1-10

of   benign   and   malignant  hepatic   lesions. The most common malignant neoplasms (cancers) of the liver  are metastasis; those arising  from   colorectal  cancer   are  among the  most  common, and  the  most  amenable to surgical  resection. The most common primary  malignant tumor  of  the  liver  is the hepatocellular carcinoma. 2

Although hepatectomies have improved, post  hepatectomy  complications  are  taken in consideration; bleeding  is the most feared technical complication and  may  be grounds for  urgent  reoperation. Biliary  fistula  is also a possible  complication, one more  amenable to non surgical management. Pulmonary complications such as atelectasis and pleural effusion  are also common, and dangerous in patients  with underlying lung disease.3

Patients and methods:

This study was carried m Ain Shams University   Hospitals   during    the    period from  August  2010 to  May 2012  including a randomized collection of twenty nine patients who  underwent partial  hepatectomy for different  indications. Analysis  of every  case has been done, retrospectively.

Patients:  A protocol  was created  in order

to obtain the following data:

Age, sex, relevant past medical history, including cirrhosis,  chronic  hepatitis and previous  neoplasm.

Indication of  hepatectomy, intraoperative data such as tumor location,  extension of resection, employment of vascular  exclusion, blood  transfusion requirements, information related  to the  pathologist report  (tumor  size and histological type).

Data   regarding  postoperative  outcome,

mainly     postoperative    complications, mortality  index and hospital stay.

Methods: A bilateral subcostal incision was

employed in all procedures, with  an upward midline  extension whenever necessary. Mobilization of liver was performed  and cholecystectomy was  indicated  for  cases  of right hepatectomy. Vascular exclusion was done  when necessary.  Follow up was done at one, three, six months  postoperatively.

Data were collected, coded, tabulated, and

then  analyzed  using Microsoft® office Excel

2003 computer software. Numerical variables were  presented  as  mean  and  standard deviation while  frequency and  percent  were used to present  categorical variables.

Results:

A total  of  29  liver  resections   were performed during the study  period. The mean age was 48.2 years, ranging from 2 to 65.

Twenty  patients   were  males  (69%)   and

nine females  (31%).

In  16 patients  (55.2%)  an underlying chronic  liver disease  was detected  in the preoperative evaluation.

The most common indication was hepatic

malignancy, which occurred  in 24 patients (82.7%).  Primary   hepatic   malignancy  was the indication for resection  in 22 patients (75.8%): Hepatocellular carcinoma in  18 (62%), cholangiocarcinoma in 3 (10.3%), and hepatoblastoma in 1 (3.4%).  Of the patients with  hepatocellular carcinoma, 14  had  liver cirrhosis.

Hepatic resection was performed for benign

conditions in 5 patients,  2 with hemangioma,

1 with adenoma,  1 with inflammatory mass, 1 with traumatic rupture.

The type  and  extent  of hepatic  resections was determined according to site, size  and extent of pathology.  We had five patients who underwent right  lobectomy,  five  underwent left extended hepatectomy, two for Left hepatectomy,  seven   had   bisegmentectomy, and ten patients  underwent segmentectomy.

Complications leading  to  life-threatening

conditions were  classified  as MAJOR.  These included major postoperative bleeding, any organic  failure,   intra-abdominal  abscess, sepsis and portal vein thrombosis.

Complications with no fatal potential  were considered MINOR  and included  pleural effusion,  wound  infection, urinary  tract infection and atelectasis. Biliary leakage  was also considered a minor complication since  it was self-limited in the majority  of cases.

Complications  were   observed    in   17

patients  (58.6%). Major  complications occurred in 5 patients  (17.2%).  Hepatic insufficiency  was   the    commonest  major

0Female •Male                                      Cl cirrhotic • Non cirrhotic

45%

55%

Figure {1): Showing preoperative liver condition.

3%     3%      7%

Cl Adenocarcinoma

•Adenoma

oCholangiocarcinoma

7%   oHaemangioma

•HCC ClHepatoblastoma

• Inflammatory

OTraumatic

Figure   {2):  Showing  indication  of  liver resection.

Figure    {4):  Left   lateral   segmentectomy showing tumor.

Figure    {3):  Right   hepatectomy   showing tumor.

Figure {5): Segment VII resection

17%

0Rgi ht lobectomy

•Lefi extended hej)atectomy

3%   3%      7%

aAscites & chest infect on

•Ascites & recurrence OAsoites only DBieeding

• Chestinfection only

0lncisionalhernia

3%   •No oornplication

0Lefi hepatectomy

0Bisegmentectomy

•Segmentectomy

24%

Figure {6): Showing extent of resection.

3%    DRecurrence only

• Renalfailure

aWound infection

Figure {7): Showing range of complications.

Table (1): Showing range of age.

Table (2): Showing sex differentiation.

Table (3): Showing preoperative liver condition.

Table (4): Showing indication of liver resection.

Table (6): Showing extent of resection.

complication, occurring m seven patients (24.1%). Recurrence developed in six cases (20.6%), five of them underwent a major resection.

Intrabdominal bleeding occurred in 1 case

(3.4%).  It was  successfully  managed  with

fluid infusion and blood transfusion.

Major complication rate varied with indication and extension of liver resection. These   complications   occurred   in  2  of  3 patients (66.6%) who underwent hepatectomy for  cholangiocarcinoma,   10  of  18  patients

Table 7: Showing range of complications.

(55.5%) for hepatocellular carcinoma,  2 of 2 patients  (100%)  for metastatic  disease,  and

1 of 5 patients (20%) for benign conditions. Major complications  were observed  in 5 of

17 patients (29.4%) who were subjected to major resections.

Discussion:

Despite improvements m chemoembolization, cryosurgery and other modalities  of  treatment,  liver  resection remains the procedure of choice in the management of most primary liver tumors. Liver transplantation is the best approach in selected cases, mainly in patients with liver cirrhosis  and small tumors.  Hepatectomy  is the  mainstay  treatment  of  selected  patients with metastatic liver tumors, especially those in which the primary site is the large bowel. However, this procedure has been associated with significant morbidity and mortality. 4

In this study the most common indication of liver resection was liver tumors accounting for  82.7%  of  cases,  primary  hepatic malignancy  accounting for 75.8%, followed by benign conditions with 17.2% These results are compared to those of a recently published multicentric study reporting the outcomes of 2,097  patients  subjected to  hepatectomy.  In their series, 52% of the patients underwent resection for metastatic disease and 16% for primary liver malignancy.5

Liver  resection  has been associated  with high morbidity and mortality. The reported morbidity  has  ranged  from  16.2%  to  81%. This enormous range is partially due to the heterogeneity of the published series, with major  differences   in  indication,   extension of hepatic  resection,  percentage  of  patients with cirrhosis and definition of postoperative complication. In this study, our rate of 58.6% is considered high when compared to others. However, we stress that a meticulous data review was employed so that complications such as pleural effusion were considered even when thoracocentesis and chest tube drainage were not required. Major complications occurred in 17.2% of patients and, analyzing specific complications,  our rates  are similar to those of major international centers.6

Risk factors for complications following hepatic resection have been addressed by others. Noguchi et al, detected albumin, glutamic  oxaloacetate  transaminase,   serum total   bilirubin,   plasma   disappearance   rate of indocyanin green and 75 g oral glucose tolerance test as factors associated with increased  morbidity.  Yamanaka  et  al,7 reported age as a risk factor. Miyagawa et al. 6 demonstrated, in a multivariate analysis, that operation   duration,   extension   of  resection and preoperative cardiovascular  disease correlated with postoperative complication period.  Surprisingly,  this  author  observed, in a  univariate  model,  that  a  histologically

normal  liver   (except  for  the  tumor)   was associated with higher morbidity rates. This finding was possibly due to the more extensive liver resections performed in patients without underlying liver disease. In addition to this finding,  we  also  observed  that  the  size  of tumor  and blood transfusion  were predictors of major postoperative complications.

In this study extension ofliver resection was a predictor factor of complication ; Miyagawa et a1.6 found that extension of resection correlated   with   postoperative   complication in a multivariate  model.  in this study, Major complications   were  observed   with  rate  of 29.4% in patients who were subjected to major resections.

Liver resection in patients with cirrhosis presented  a mortality  rate of 58% by 1970.8

In the eighties, Asian and Western countries reported rates of 20%9 Due to advances in perioperative management, refinement of surgical technique, reduced hospital stay and reduced requirement for intensive care unit monitoring, the mortality rates in the nineties reached  a  plateau  near  10%,  Although  our rate  is zero  mortality,  compared  to  8.4% of other  centers, this  difference  may be due to a  smaller  number  of  patients  in  our  study, zero-mortality rate has been reported by a few highly specialized  centers.

Age  was  also  described  as  a  risk  factor

by Dimick et al,5 who found, in a recent multicentric  study, that low-volume hospitals for   hepatectomies,   patients   older   than   65 years of age, major liver resection, primary hepatic malignancy as indication for resection and severity of hepatic dysfunction were all independent predictors of mortality.

In this study,the most common complication was   liver   decompensation   accounting   for24.1%,  were  observed  in  cirrhotic  patients. (Due  to  high  prevelance  of  cirrhosis  in our cases   because   of   prevelance   of   HBV  in Egypt) Also Recurrence rate was 13.8%, are often associated with focal infiltrated surgical margin and needed reintervention in 3.4%.

Biliary complications represent another major topic in liver surgery. In a recent report, Tanaka et al9 published a leakage rate of7.2%, with a significant number of the patients with

this complication  requiring reintervention.  Ina series of5.5% ofbiliary leakage, LAM et al., in agreement with BISMUTH et al, concluded that intraoperative dye tests significantly reduced fistula rates.9

In this study, however, leakage was not significant in most cases; we agree with others that the routine use of dye tests is not justified, since only a small percentage of patients need reintervention. In addition, even with routine assessment of leakage with this test, cases of biliary fistula are still observed.

In  conclusion,   our  findings  demonstrate that  liver  resection  can  be  performed  with low mortality and acceptable morbidity rates. Surgical complications can be reduced by employing meticulous surgical technique and, whenever indicated, vascular exclusion.

In   addition,    Use    of   vaccine    against HBV eventually decreases the incidence, especially  in endemic areas, and prevents the development of cirrhosis, which predispose to hepatocellular  carcinoma.

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