Short-Term Outcomes of Liver Resection

Abstract

Liver surgery has always been challenging, with high mortality and morbidity rates that are due to the complicated anatomy and the risks of massive hemorrhage and liver failure. The first liver resection was reported by Langenbuch in 1888 [1]. Even in the 1970s, only slight improvements were made, and perioperative mortality rate remained as high as 20–28 % [2, 3]. A retrospective study conducted by Foster and Berman [3] in 1977 included 621 liver resections and found that the postoperative mortality rate was 20 % and was as high as 58 % for cirrhosis patients. In the past three decades, refinements in liver surgery have included improvements in surgical techniques, anesthetic techniques, patient selection, and perioperative management, allowing liver resection to become a safe procedure with markedly decreased postoperative morbidity and mortality rates. Recent large studies have suggested that the mortality rates of liver resection have decreased from 20–30 % to 1–4 % [4–8]. It is also encouraging that several large studies have even reported no deaths after liver resections [2, 9]. Fan reported a reduction in the hospital mortality rate from 28 % in 1989 to 0 % in 1996 and 1997 at Queen Mary Hospital, Hong Kong [2], with a corresponding reduction in the postoperative complication rate from 48 to 35 %. Advances in perioperative outcomes are related to the following aspects of care [10]. (1) Accurate patient selection using tests such the Child-Pugh (CTP) score, the Model for End-Stage Liver Disease (MELD) score, and indocyanine green (ICG)-15 has helped to reduce the rates of liver failure, comorbidity, and mortality. (2) Improved understanding of the anatomy of the liver reduces the risk of bile duct and vessel injury and reduces operative times. (3) Hepatic blood flow occlusion during hepatectomy, using approaches such as the Pringer technique, reduces intraoperative hemorrhage. (4) Liver parenchymal transection techniques, such as ultrasonic dissection and LigaSure (Valleylab, Boulder, Colorado, USA), make liver resection more precise and can help to reduce injuries. (5) Operative skills and perioperative management techniques are constantly improving. (6) Many other procedures, including percutaneous radiofrequency ablation, microwave ablation, percutaneous alcohol injection, and laparoscopic hepatectomy, have been introduced to hepatic surgery. These new procedures have ushered the era of minimally invasive surgery into liver resections and have reduced mortality and morbidity. Safety improvements also have allowed surgeons to develop increasingly complicated liver resection procedures. At the same time, surgical indications have expanded constantly; portal hypertension, comorbidities, advanced age, and major liver resection are no longer considered contraindications. In addition, some other therapeutic methods, including portal vein embolization, down-staging treatments for hepatocellular carcinoma (HCC), and radiofrequency ablation, have allowed some advanced-stage patients to undergo radical resection. These patients also have satisfactory postoperative results and long-term survival.