Introduction

The first liver resection was performed by Carl Johann Langenbuch in 1888¹. Liver surgery has significantly evolved worldwide over the past 50 years². In fact, recovery programs have been developed in liver surgery resulting in benefits for patients³. Nowadays, liver surgery is considered a sub-specialty of general surgery¹. There are no publications on the development of liver surgery in the province of Corrientes. José Ramón Vidal Hospital in Corrientes counts with a hepatobiliary and pancreatic (HBP) surgery unit since 2013, which depends on the Department of General Surgery.

Historically, our institution has been the referral center for acute and chronic abdominal diseases in the province. Most of them are of biliary or biliopancreatic etiology. Since 2019, we have staff specialized in HBP surgery, so we could focus more on its development. In 2019, we began performing liver resections of 2 or more segments; previously, we had only performed biopsies or small, atypical resections. The same group of surgeons has been performing these surgeries in the private setting and has constituted the liver and pancreas unit called UHPaCor since 2021. This surgical group works in the private sector in different institutions.

The aim of this study was to describe the initial results of a consecutive series of patients undergoing different types of liver resections, performed by the same surgical team.

Material and methods

We conducted a retrospective, observational, and descriptive study based on data from the medical records and operating room records of patients undergoing liver resection at José Ramón Vidal hospital and private institutions involving the same surgical group, from September 2019 to January 2023. All the patients underwent abdominal ultrasound, triple-phase computed tomography scan with intravenous contrast agent, magnetic resonance imaging with gadolinium- based contrast agent, upper gastrointestinal endoscopy, colonoscopy and tumor markers.

The bilateral subcostal incision with xiphoid extension (Mercedes Benz type) using a Thompson retractor was the incision most commonly used. Intraoperative ultrasound was performed in 25 patients (92.59%) to characterize the lesion.

The following variables were analyzed: preoperative data (demographic data, number of lesions, type of liver resection), intraoperative data (bleeding, hepatic pedicle clamping, need for transfusion) and postoperative data (complications, 90-day mortality). For major resections, liver volumetry was performed using Osirix® software for imaging analysis, associated with the remnant liver volume-to-weight ratio⁴. None of the patients underwent preoperative portal vein embolization.

Statistical analysis was performed using SPSS software package (IBM).

Results

A total of 27 patients were operated on, 16 were women and mean age was 53.19 years (range 25-72). Fifteen procedures (55.5%) were conducted at Hospital Vidal and the remaining cases were operated on in the rest of the institutions. The totally laparoscopic approach was used in 2 cases (7.4%) and the conventional approach was used in 25 patients (92.6%). Four procedures (14.81%) were major liver resections and 23 (85.19%) were minor liver resections (Table 1). The Pringle maneuver was used to control the hepatic pedicle in 25 (92.5%) patients.

Survival at 90 days was 96.2% Operative mortality was 3.7% (n = 1). Other complications included postoperative liver abscesses in 2 patients (7.4%), and re-operation due to bleeding in 2 patients (7.4%), who had a subsequent favorable course and were discharged from the hospital. The complications were categorized using the Clavien-Dindo classification (Table 2).

Cancer accounted for 81.4% of surgeries, with colorectal cancer being the primary cause (n = 11). Other malignancies included metastasis of lung cancer, renal cell carcinoma, and uveal melanoma. Adenoma was the most common finding in the 5 patients with benign conditions (Table 3). The mean operative time was 178 ± 89 minutes. After the operation, 14 patients (51.85%) required admission to the intensive care unit (ICU), and 4 patients (14.84%) required transfusion of blood products. The mean bleeding loss was 247 Ml.

Discussion

The evaluation prior to hepatectomy requires various investigations, such as imaging tests to assess functional liver reserve (liver volumetry) and staging (abdominal ultrasound, computed tomography, magnetic resonance imaging, PET scan), as well as laboratory tests including liver panel, proteinogram, coagulation factors, platelet count, and tumor markers⁵. It is important to have a specialized surgeon with experience in this procedure.

In those patients scheduled for major hepatectomy, computed tomography with volumetry is a useful and practical tool to assess adequate remnant liver volume⁶. We use the Osirix® software to determine liver volumetry. Nevertheless, it is advisable to use volumetry in conjunction with functional testing to safely calculate future remnant liver volume⁷. In our environment we do not have other functional tests available to assess liver volume.

Liver resection remains the gold standard treatment for malignant liver diseases⁸.

Barros Schelotto et al. reported that laparoscopic surgery had a global applicability of 31%⁹. In our population, the laparoscopic approach was used in only 3 patients (11.4%); in one case, the procedure was converted to open surgery due to bleeding that was managed by conventional surgery. The main reasons for not using the laparoscopic approach were the lack of availability of supplies and of laparoscopic ultrasound. In a multicenter study conducted in Argentina over a 10-year period, Dietrich et al. reported that of 114 hepatectomies, 10 (11.4%) were performed using the laparoscopic approach¹⁰. In addition, the conventional approach was more commonly used because most lesions occurred in segments that were unfavorable for laparoscopic surgery¹¹. This approach demands specific skills, and our group is still young and lacks experience, in addition to facing difficulties in accessing laparoscopic supplies.

Diseases with an indication for hepatectomy can be divided into three main groups: benign tumors, malignant primary tumors, and malignant secondary tumors. In this experience, the etiology was variable, as our study population had both benign and malignant conditions. The most common benign conditions include focal nodular hyperplasia (FNH), hepatic adenoma, hepatic hemangioma and cystic tumors (simple cysts, parasitic cysts, and hepatic cystadenoma, which are not the subject of this study). Hepatic adenoma is a benign tumor more common in women associated with oral contraceptive (OCP) use^12,13. Hepatic adenoma was observed in three cases in our sample. One of these cases was found in a male patient who had not used steroid hormones and was being evaluated for cholecystectomy. The bibliography demonstrates that 16-20% of hepatic adenomas affect men¹⁴. The remaining 2 cases were women with a history of OCP use.

Surgery is indicated because of the difficulty in differentiating adenoma from hepatocarcinoma and the risk for malignant transformation and rupture¹⁵. The other benign etiologies in this series were FNH, hemangioma and a case with a regenerative nodule in a patient with a history of prolonged chemotherapy.

The most common malignancies were colorectal liver metastases. Colorectal liver metastases can be categorized into three groups at the time of presentation: those that are clearly resectable; those that are unresectable, but convertible to resection after primary chemotherapy (conversion chemotherapy); and those that are unresectable and are unlikely to become resectable even with effective chemotherapy¹⁶. Surgical resection represents the only chance for improved survival¹⁷.

Uveal melanoma is the most common primary intraocular malignancy in adults¹⁸. In our case, the patient had no abdominal symptoms and liver metastases were found during a routine oncologic surveillance. The liver is the site of metastases in 60-80% of cases^19,20. If liver metastases are not treated, survival decreases to < 6 months²¹. Mariani et al. reported a survival rate of 54% at 2 years after R0 resection²².

Post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, urinary tract infection, subphrenic abscess, pulmonary atelectasis, bleeding, coagulation disorders, gastrointestinal bleeding, biliary tract bleeding, liver failure, and biliary fistula, among others²³.

Coelho et al. reported 44% of complications in a series of 83 hepatectomies over a 10-year period; 40% of these procedures were major liver resections²⁴. Herman et al. reported on their 20-year experience with hepatectomies in 1409 cases, mostly for colorectal cancer, with an open approach rate of 70% and a complication rate of 13.3%²⁵. In Syria, over a 6-year period, 95 patients underwent hepatectomy with a mortality rate of 7.3%²⁶.

In our series, we had the complications described in the literature, which represented 11.1%²³. Two cases presented subphrenic abscess, which were managed with antibiotic treatment in one case and percutaneous drainage in the other. One patient required further intervention in the immediate postoperative period for bleeding, which was successfully treated. Postoperative liver failure can occur after extensive hepatectomy, even in patients without cirrhosis^27,28.

In conclusion, although this is a retrospective analysis of a small series, the initial morbidity and mortality results were comparable to those of other centers with more experience. Laparoscopic hepatectomy is a developing field in our region, and we should continue to work on this technique.