MINITERY OF EDUCATION MINISTRY OF
AND TRANING DEFENCE
MILITARY MEDICAL UNIVERSITY
NGO DAC SANG
RESEARCH ON COMPLICATIONS
AFTER HEPATECTOMY FOR CANCER
ACCORDING TO TON THAT TUNG’S METHOD
Speciality: Surgical gastreoterology
Code: 62 72 01 25
SUMMARY OF PHD THESIS IN MEDICINE
HA NOI – 2017
COMPLETED THESIS AT
MILITARY MEDICAL UNIVERSITY
Full name of supervisor:
1. Prof. Dr. Le Trung Hai
2. Dr. Do Manh Hung
Reviewer 1: Asso. Prof. Dr. Nguyen Tien Quyet
Reviewer 2: Prof. Dr. Pham Nhu Hiep
Reviewer 3: Asso. Prof. Dr. Nguyen Quang Nghia
The thesis will be presented before the Board of appraising
thesis at basic level Military Medical University
Time: hour, day month , 2018
The thesis could be found at:
1. National library.
2. Library of Military Medical University.
1
INTRODUCTION
There are a wide variety of treatment methods such as
hepatotectomy, liver transplant, percutaneous ethanol injection therapy,
radio-frequency ablation, transcatheter arterial chemoembolization and
chemotherapy. Among them, hepatic resection is the most basic and
absolute method to remove tumors from the body. In case of minor liver
resection less than 3 segments, there are fewer complications, however,
morbidity rate tends to be higher for major hepatic resection (over 3
segments). Some other studies indicated that the overall mortality post-
hepatectomy was found in 3.1% and ranged from 7.2 - 15% after major
hepatic resection. The overall morbidity rate accounted for over 30%
and increased up to 75% after major hepatic resection. There are a
number of risk factors which increase the rate of complication after
surgical treatment including: age, gender, ASA score, degree of liver
resection, residue liver volume, operation time; intraoperative blood
loss, intraoperative transfusion, cirrhosis, preoperative chemotherapy...
In the world, there have been many researches on the complications
after hepatectomy for cancer, however, the rate of the complication is
different among the authors. In recent years, some studies on
hepatectomy for cancer have been reported, nevertheless, these
researches only put emphasis on evaluation of liver resection, statistics
without giving details on risk predictors of complications. On a basis,
we conducted this study with a view to:
Identifying complications after hepatic resection according to
Ton That Tung’s procedure.
Evaluating risk factors for complications after hepatic resection
according to Ton That Tung’s procedure.
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3. New contribution to the thesis
In the same study based on Ton That Tung’s approach, we
identified complication rate of 23.34%; of which, the pleural effusion
(11.99%); ascites (8.52%); liver failure (3.47%); post-operative
bleeding (1.26%); bile leakage (1.89%); kidney dysfuction (0.32%);
abscess (0.32%). There were four factors: males, albumin < 35 g/L;
resection of three or four liver segments and operation time ≥ 300
minutes. Nevertheless, that only two risk factors of liver resection of
three or four segments and operation time ≥ 300 minutes were
independent ones of pleural effusion after hepatectomy.
In univariable analysis, six factors including males, cirrhosis,
tumor size > 10 cm; pre-operative platelet < 100 G/L; resection of
three or four liver segments and operation time ≥ 300 minutes are
independent risk factors of complication after operation. Nevertheless,
that only four factors: cirrhosis; perative platelet < 100 G/L; resection
of three or four liver segments and operation time ≥ 300 minutes were
independent risk factors for complication after hepatectomy.
4. Thesis structure
The thesis has 116 pages, of which:
Introduction: 2 pages.
Chapter 1 : Overview: 34 pages.
Chapter 2: Objects and research methods: 18 pages.
Chapter 3: Result: 26 pages.
Chapter 4: Discussion: 33 pages.
Conclusion 2 pages and recommendation 1 page.
The thesis: 33 tables, 11 charts, 22 figures; 141 references
including: 18 ones in Vietnamese and 123 ones in English.
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Chater 1. OVERVIEW
1.1. Sugical methods
Ton ThatTung’s method (vascular control of liver
parenchyma). This method has two steps including total clampling of
hepatic pedicle in order to arrest haemorrhage (Pringle maneuver’s
procedure) and open directly into vascular pedicle in anterior liver
ligation. This technique is simple, fast, effective and easy-to-use,
particularly in emergency surgery, in cases of minor hepatic
resection so as to avoid accidents due to changes in anatomy of liver
pedicle structure. Hepatectomy should be performed according to 3
steps: (1): Liver parenchyma transection; (2): Ligation of hilar
elements into the liver; (3): Ligation of the hepatic vein into the liver.
1.2. Researches on sugical treatment of hepatic resection and
hepatectomy in cancer
1.2.1. Worldwide studies
1.2.2. In Vietnam
1.3. Post-hepatectomy complications
1.3.1. Liver failure
* Clinical symptoms
Post-operative liver failure is manifested clinically with various
symptoms such as jaundice, ascites, coagulation disorder, liver coma.
* Treatment methods: The therapy includes albumin
transfusion, fibrinogen, blood transfusion...
1.3.2. Post- operative bleeding
1.3.3. Bile leakage
1.3.4. Ascites
1.3.5. Pulmonary Complications
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1.3.6. Wound infection
1.3.7. Residual abscess
1.4. Risk factors for complication after hepatic resection
1.4.1. Preoperative factor
* Ages, Gender, Classification Child - Pugh score
* Portal hypertension, levels of cirrhosis
1.4.2. Risk factors for complications intra-and-post surgical
hepatectomy
* ASA score and anesthesia time, Clamping maneuver
* Remaining liver volume, operative time, blood loss and
transfusion after surgery.
Chapter 2. SUBJECTS AND RESEARCH METHODS
2.1. Subjects
All patients diagnosed with liver cancer was performed
hepatectomy according to Ton That Tung’s method from January 2010
to December 2015 at Viet Duc Hospital.
2.1.1. Inclusion criteria
Age ≥ 15 years old, all patients were diagnosed with liver
cancer by post-hepatectomy histopathology; Child class A vs. B);
undergoing liver resection according to Ton That Tung’s method.
2.1.2. Exclusion criteria
Eliminate patients who refuse to cooperate in treatment;
Exclude non-cancerous hepatic resection; liver resection was
combined with some major surgery in the gastrointestinal tract
(gastrectomy, gastro-enterostomie ...); Cases of combined diseases
such as: heart failure, hypertension, cerebrovascular stroke, chronic
pulmonary cardiac, uncontrolled or life-threatening diabetes ...
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2.2. Research methods
2.2.1. Research design
Descriptive cross- sectional studies, propective and
retrospective analysis.
2.2.2. Research steps
a. Retrospective research
- Study data collection including:
+ Clinical symptoms: Functional, symptoms of the existence.
+ Preoperative diagnostic imaging: Ultrasound, computed
tomography, magnetic resonance imaging.
+ Pre- operative examination: Blood group, blood cell count.
Liver function; prothrombin, total bilirubin, renal function,
creatinine. Hepatitis B and C markers (Anti - HBV, Anti - HCV).
Test of αFB, CA19 - 9.
+ Liver resection was performed according to Ton That Tung’s
technique. Diagnosis of liver cancer with posthepatectomy
histopathology. Postoperative examination: bilirubin, PT on days 1, 3, 5
postoperatively. Determine the postoperative complications through
treatment, management of complications, treatment results. Postoperative
ultrasound: abdominal, pleural effusion, abdominal ascites.
b. Perspective research
- Clinical examination, diagnosis and treatment tests including:
+ Basic tests: blood count, blood type, liver function, kidney
function, blood clotting, hepatitis B, C, ultrasound, computed
tomography, magnetic resonance imaging.
- Treatment for the patients, evaluation of the results.
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2.2.3. Research index
Research index were recorded in both groups: retrospective and
prospective group. 2.2.3.1 Criteria for diagnosis of hepatocellular carcinoma
Identification of liver cancer by histopathology through surgical
specimens. Clinical, subclinical: (1) HBsAg (+); (2) tumor size over 2
cm; (3) rich in veins, showing signs of washout on computerized
tomography; (4) αFP 400 ng/mL.
2.2.3.2. Grouping by complications
Group one: have no complications; Group two: have complications.
2.2.3.3. General characteristics of the study group
a. Clinical characteristics
Age: divided into groups ≤ 30; 41 - 50; 51- 60 and > 60 years
old. Gender: risk factors for complications.
- Clinical symtoms: Abdominal pain; fever; jaundice, mucosal:
yes or no. Tiredness, weight loss, exhausion or not. Complications of
liver tumors: rupture tumors, major liver: yes or no. Transcatheter
arterial chemoembolization, portal vein embolization; numbers of
embolization. Other risk factors: alcoholism, beer.
b. Subclinical characteristics
* Peripheral blood cell tests:
Evaluation based on Hb: moderate reduction: 70 to 100 g/L;
dramatic reduction: < 70 g/L.
Plaletes: decreased platelets < 100 G/L.
* Biochemical tests:
Glucose: increased > 7 mmol/L; decreased < 3,9 mmol/L.
Albumin: decreased < 28 g/L; albumin deficiency < 35 g/L.
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Prothombin time (PT): liver failure PT < 50%.
Total bilirubin level: normal < 1,5 mg/dL (25 μmol/L).
* Hepatic function assessment according to the Child - Pugh
Classsification: Child A: 5 - 6 total points. Child B: 7 - 9 total
points. Child C: 10 - 15 total points.
2.2.3.4. Surgical hepatectomy
a. Indications for hepatic resection
* Indications
+ Liver tumors are single or multiple tumors but localized in
the right or left liver, or in lobes, in segments or one or two
subsegments with a compensative liver function (Child A vs. B).
Tumor size: unlimited. Non-invasive blood vessels: portal vein,
inferor cava vena. There was no extrahepatic metastases. Major liver
resection: Child A; remnant liver volume body weight ratio ≥ 1%.
* Contraindications
+ Coagulation disorders was treated ineffectively. There was
cancer- metastases to other organs. Tumors have invaded the portal
vein or the inferior vena cava. It was positive for preoperative portal
vein thrombosis or abdominal veins.
b. Surgical hepatectomy
* Surgical technique
- Abdominal incision: Total clamping manuever (yes, no).
Hepatectomy according to Ton That Tung’s technique. Control liver
resection surface, bile leakage. Abdominal wiping, drainage. Wound
closure.
- Postoperative complications (liver failure, pleural efusion,
intraabdominal abscess, bleeding, biliary fistula, ascites), deaths.
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* Post-operative follow-up
For patients who underwent major liver resection were done total
bilirubin level test, prothrombin time on days 1, 3, 5, 7 postoperatively.
- Abdominal ultrasound after surgical hepatectomy. Chest X-
ray test. Hospital stays, median hospital stays.
* Assessment results: Good: patients stable; deaths.
2.2.3.5. Criteria for defining the complications
a. Liver failure: Defining by bilirubin > 50µmol/L, PT < 50%) on
postoperative day 5.
b. Post- operative bleeding
c. Pleural effusion: X- ray films; ultrasound: pleural effusion.
d. Bile leakage: Bile leakage was defined as the drainage of 50 ml.
e. Ascites: Ultrasound or clinical examination showing daily ascites
fluid drainage exceeding > 500 mL.
g. Intraabdominal abscess:
2.2.3.6. Risk factors for complication
a. Pre-operative factors: Ages (≤ 60 vs. > 60 year old); sex (male vs.
female); liver function (Child A vs. Child B); tumor size (≥ 10 vs. <
10 cm); ASA score (< 3 vs. ≥ 3); pre-platelet count (< 100 G/L vs. ≥
100 G/L); PT time (< 70 vs. ≥ 70%).
b. Intraoperative factors: Operative time, min (< 300 vs. ≥ 300);
Pringle maneuver, min (≤ 10 vs. > 10); liver resection, segments (< 3
vs. ≥ 3 segments); cirrhosis: (yes vs. no); intraoperative transfusion.
2.2.4. Data collection
Statistical analyses were performed with software package
SPSS 15.0. A P value < 0.05 was defined as statistical significance.
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Chapter 3. RESULT
3.1. Clinical and subclinical characteristics
3.1.1. Clinical characteristics
Table 3.3. Symptoms of the existence
Symptoms of the existence patiens percent
Jaundice 15 4.73
Large liver 10 3.15
Ruptured tumors 17 5.36
3.1.2. Subclinical characteristics
Table 3.4. Peripheral blood cell counts, prothrombin preoperative
Parameters Mean ± SD Range
Hemoglobin (g/L) 139.21 ± 18.64 51 - 186
Platelets (G/L) 220.80 ± 81.09 78 - 637
Prothrombin 92.82 ± 16.09 43.10 - 146.00
Table 3.5. Preoperative blood chemistry index
Parameters Mean ± SD Range
Glucose (mmol/L) 5.65 ± 1.48 2.6 - 15.6
GOT (U/L) 54.87 ± 55.82 15 - 662
GPT (U/L) 51.91 ± 51.04 6 - 413
Total bilirubin (µmol/L) 13.92 ± 7.88 1.4 - 78.4
Albumin (g/L) 40.72 ± 5.00 15 - 51
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3.2. Surgical indications
3.2.1. Liver function
Table 3.9. Hepatic function assessment according to the Child-
Pugh Class
Child – Pugh No patiens Percent (%)
290 A 91.48
27 B 8.52
317 Total 100.00
3.2.2. Measurement of preoperative remnant liver volume
Average remnant liver volume was 598.75 ± 135.27 cm3 (the smallest was 414,67cm3; the largest was 916,15cm3). Remnant liver volume body weight ratio was 1.13 ± 0.14%.
3.3. Surgical techniques
Table 3.11. Liver resection types
Liver resection types No patiens percent
Right hemihepatectomy 22 6.94
Right extended hemihepatectomy 1 0.32
Left hemihepatectomy 39 12.30
Left extended hemihepatectomy 7 2.21
Central bisectionectomy (segments 4, 5, 8) 2 0.63
Resection of 3 segments (5, 6, 7 or 6, 7, 8) 6 1.89
Left lateral hepatectomy 59 18.61
Right posterior sectionectomy 44 13.88
Right anterior sectionectomy 4 1.26
Segmentectomy 133 41.96
Total 317 100.00
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3.4. Postoperative outcome
3.4.1. Postoperative complications
Table 3.13. Complications
Complications No patiens percent
Overall complication 74 23.34
Liver failure 11 3.47
Post- operative hemorrhage 4 1.26
Pleural effusion 38 11.99
Ascites 27 8.52
Bile leakage 6 1.89
Kidney dysfuction 1 0.32
Abscess 1 0.32
Table 3.14. Pre- operative risk factors for pleural effusion
No Yes Parameters OR CI p (317 patiens) patients (%) patients (%)
≤ 60 217(87.86) 30(12.14) 0.47 - Ages 1.07 p > 0.05 2.46 > 60 62(88.57) 8(11.43)
Male 219(86.22) 35(13.78) 0.95 – Sex 3.20 p < 0.05 10.75 Female 60(95.24) 3(4.76)
< 35 24(75.00) 8(25.00) 1.17 - Albumin 2.83 p < 0.05 6.87 ≥ 35 255(89.47) 30(11.53)
< 100 9(90.00) 1(10.00) 0.10 - p > 0.05 0.81 Platelets 6.58 ≥ 100 270(87.95) 37(12.05)
no 227(87.64) 32(12.36) 0.33 - p > 0.05 0.82 Cirrhosis 2.56 yes 52(89.66) 6(10.34)
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Table 3.15. Intra- postoperative risk factors for pleural effusion
No Yes Parameters OR CI p (317 patiens) patients(%) patients(%)
< 3 221(92.08) 19(7.92) Extent of 1.90 - 3.81 p < 0.05 resections 7.66 ≥ 3 58(7532) 19(24.68)
< 300 272(89.18) 33(10.82) Operatime 0.05 - 017 p < 0.05 (min) 0.57 ≥ 300 7(58.33) 5(41.67)
Table 3.16. Pre- operative risk factors for ascites
No Yes Parameters OR CI p (317 patiens) patients (%) patients (%)
≤ 10 256(91.43) 24(8.57) Size 0.30 - 1.06 p > 0.05 tumor 3.72 > 10 34(9189) 3(8.11)
< 35 27(84.38) 5(15.62) 0.16 - Albumin 0.45 p > 0.05 1.29 ≥ 35 263(92.28) 22(7.72)
< 100 5(50.00) 5(50.00) 3.48 - Platelets 12.96 p < 0.05 48.17 ≥ 100 285(92.83) 22(7.17)
no 57(98.28) 1(1.72) 0.85 - Cirrhosis 6.36 p < 0.05 47.86 yes 233(89.96) 26(10.04)
Table 3.17. Intraoperative and postoperative risk factors for ascites
No Yes Parameters OR CI p (317 patiens) patients (%) patients (%)
< 3 221(92.08) 19(7.92) Extent of 0.57 - 1.35 p > 0.05 resections 3.22 ≥ 3 69(89.61) 8(10.39)
< 300 280(91.80) 25(8.20) Operative 0.09 - 0.45 p > 0.05 time 2.15 ≥ 300 10(83.33) 2(16.67)
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3.4.2. Postoperative outcome
Table 3.18. Postoperative blood chemistry test
Parameters Day 1 Day 3 Day 5
Creatinin 75.17 ± 23.18 73.18 ± 41.80 74.44 ± 73.26
Total Bilirubin 26.46 ± 22.91 33.65 ± 33.56 36.00 ± 48.77
%PT 69.08 ± 19.62 59.36 ± 19.67 65.01 ± 22.80
11 patients had total serum bilirubin level > 50 µmol/L and
prothrombin time index < 50% posthepatectomy on day 5.
3.5. Risk factors for complications after hepatectomy for cancer
3.5.1. Pre-operative risk factors
Table 3.19. Ages, sex with complication
Group 1 Group 2 Parameters OR CI p patients % patients %
≤ 60 186 75.30 61 24.70 Age 0.74 - p > 1.44 (years) 2.81 0.05 > 60 57 81.43 13 18.57
male 188 74.02 66 25.98 1.09 - p < Sex 2.41 5.33 0.05 female 55 87.30 8 12.70
Table 3.22. Pre-operative plaletes, prothrombin with complication
Group 1 Group 2 Parameters OR CI p patients % patients %
< 100 4 40.00 6 60.00 1.45 - 5.27 p < 0.05 Plaletes 19.22 ≥ 100 239 77.85 68 22.15
< 70 15 71.43 6 28.57 0.50 - 1.33 p > 0.05 %PT 3.56 ≥ 70 226 76.87 68 23.13
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Table 3.23. Liever cirrhosis with complication
Group 1 Group 2 cirrhosis OR CI p patients % patients %
No 51 87.93 7 12.07 0.17 - 0.39 p < 0.05 0.91 Yes 192 74.13 67 25.87
Total 243 76.66 74 23.34
Table 3.25. Tumor size with complication
Group 1 Group 2 Tumor OR CI p size (cm) patients % patients %
≤ 10 221 78.92 21.08 59 0.19 - 0.39 p < 0.05 0.80 > 10 22 59.46 40.54 15
Total 243 76.66 23.34 74
3.5.2. Intraoperative risk factors
Table 3.28. Extent of hepatic resection with complication
Group 1 Group 2 Extent of OR CI p resections patients % patients %
< 3 segments 198 82.50 17.50 42 0.17 - 0.30 p < 0.05 0.52 ≥ 3 segments 45 58.44 41.56 32
Total 243 76.66 23.34 74
Table 3.29. Operative time and its complication
Group 1 Group 2 Operative OR CI p time patients % patients %
< 300 238 78.03 67 21.97 0.06 - 0.20 p < 0.05 0.65 5 41.67 7 58.33 ≥ 300
243 76.66 74 23.34 Total
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3.5.3. Several independent risk factors for postoperative
complications of liver cancer
Table 3.31. Several independent risk factors of pleural effusion
Univariate analysis Multivariate analysis Factors OR (95% CI), p OR (95% CI), p
Gender 3.20 (0.95 - 10.75), p < 0.05 3.52 (0.99 - 12.51), p > 0.05
Albumin < 35 2.83 (1.17 - 6.87), p < 0.05 2.50 (0.98 - 6.39), p > 0.05
Resection of 3.81 (1.90 - 7.66), p < 0.05 0.28 (0.13 - 0.58), p < 0.05 3, 4 segments
Operative time 0.17 (0.05 - 0.57), p < 0.05 0.20 (0.06 - 0.69), p < 0.05 (≥ 300 min)
Multivariable analysis indicated that only two risk factors of
liver resection of three or four segments and operation time ≥ 300
minutes were independent ones of pleural effusion.
Table 3.32. Several independent risk factors for complications
Univariate analysis Multivariate analysis Factors OR(95% CI), p OR(95% CI), p
Gender 2.41(109 - 5.33), p < 0.05 2.26(0.97 - 5.27), p > 0.05
Liver cirrhosis 0.39(0.17 - 0.91), p < 0.05 0.42(0.17 - 1.02), p < 0.05
Tumor size > 10 0.39(0.19 - 0.80), p < 0.05 0.48(0.22 - 1.05), p > 0.05
Plaletes counts 5.27(1.45 - 19.22), p < 0.05 4.90(1.27 - 18.90), p < 0.05
Resection of 3, 4 0.30(0.17 - 0.52), p < 0.05 0.37(0.20 - 0.69), p < 0.05 segments
Operative time 0.20(0.06 - 0.65), p < 0.05 0.24(0.07 - 0.88), p < 0.05 (≥ 300 min)
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Multivariable analysis indicated that only four risk factors:
cirrhosis; operative platelets count < 100 G/L; resection of three or
four liver segments and operation time ≥ 300 minutes were
independent fisk factors for complication after posthepatectomy .
Chapter 4: DISCUSSION
4.1. Complications after hepatectomy for cancer
4.1.1. Liver failure and liver failure prevention
The table 3.13 showed the incidence of postoperative liver
failure is 3.47%. In our study, the patients with posthepatectomy
liver failure have a full signs of clinical including: jaundice, multiple
ascites, coagulopathy disorders and hepatic encephalopathy...
In this study, 77 patients who were performed three or four
segments; 19 patients were estimated to have their hepatic segments resected. Median liver remnant was 598.75 ± 135.27 cm3. Remnant liver volume body weight ratio was 1.13 ± 0.14%.
According to Nguyen Quang Nghia, in order to be safe for
major liver resection, remnant liver volume body weight ratio should
be ≥ 1%. Van Tan et al said that to reduce liver failure after surgical
hepatic resection and the liver function well or relatively well,
parenchyma volume must be preserved at least over 30.
From Fazakas et al’s point of view, so as to be safe for major
liver resection, the remanant liver volume should be at least 30% or
remnant liver volume body weight ratio was ≥ 1%. Similarly, Ferrero
et al indicated that if the remaining liver volume ranged from 25 to
30%, the incidence of postoperative liver dysfunction was 23.1%.
Shirabe et al conducted a study on 80 patients undergoing major hepatectomy and he found that the remnant liver volume > 250 mL/m2
17
will ensure safety for major hepatectomy. Mullin et al also suggests
that remaining liver volume is > 25%, even > 40%, these patients still
develop liver failure. Therefore, the authors show that the remaining
liver volume was not closely correlated with posthepatectomy liver
function. Yigitler et al demonstrated that the mechanism leading to
liver failure after surgical hepatectomy is very complex.
4.1.2. Pleural effusion
Table 3.13, the pleural effusion rate is 11.99%, the main
treatment method is conservative, eight patients had required
paracentesis treament; three patients were performed the drainage in
continuous aspiration of the pleural cavity. Table 3.13 show that four
risk factors for pleural effusion are: male, total albumin level < 35 g/L,
liver resection of 3 or 4 segments and operative time > 300 minutes.
Van Tan et al in a restrospective study of 151 patients of liver
resection found that the rate of pleural effusion was 1.32%. Nguyen
Quang Nghia, the rate of pleural effusion was 18.6%.
Yang et al found that the incidence of pleural effusion was
18.4%, which is common complication. Another study by Jarnagin et
al found that pleural effusion was the most frequent complication and
explained 44.77% of complication in lung. Poon et al conducted a
study of 1,222 patients divided into two groups. The results showed
that the pleural effusion rate needed to be punctured in the first group
of 402 patients, which was 4.0% higher than the second group of 820
patients (2.8%) significant statistically (p < 0.05).
4.1.3. Post- operative bleeding
As indicated from table 3.13, postoperative hemorrhage is 1.26%,
including stitches 1 patient; 3 patients were repeated. Comparing with
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the results of the surgery, two patients with bleeding owing to bleeding
technique; 1 patient bleeding from the liver-side. All 3 patients were
repeated before 12 hours from the time of detection for bleeding.
The time of surgery again to stop bleeding in the first 12 hours
is the best, aimed at avoiding massive postoperative hemorrhage due
to late surgery which may miss the gold chance, coagulation
disorders easily leads to liver failure. From Van Tan et al’s point of
view, the rate of posthepatectomy bleeding requiring surgery was
1.98%; 2 patients died due to delayed surgery, shock of blood loss
with coagulopathy disorders. In the study by Poon et al, he found that
careful selection of the patient, the indication of appropriate hepatic
resection can reduce the rate of postoperative bleeding. Another
analysis by Jarnagin et al (2002) showed a 1% reduction in
postoperative hemorrhage, but research did not show that the rate of
reoperative bleeding and reoperation.
4.1.4. Bile leakage
In our study, the table 3.13 reveals that the posthepatectomy
bile leakage rate was 1.89%. Compared with domestic and foreign
authors, this rate is quite low. A retrospective analysis by Van Tan et
al (2014) on 151 hepatectomy cases shows that the incidence of bile
leakage was 1.32%. In order to check whether postoperative bile
leakage occur, the residual liver can be covered with wet gauze to
avoid postoperative bile leakage, biological glue can applied to the
surface of the residual liver, operative time ≥ 300 minutes was an
independent risk factor for bile leakage after hepatectomy. Yu et al
found that the rate of postoperative bile leakage was about 4.8 -
7.6%. According to Dell et al, the major liver resection over of 3
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segments, operative time ≥ 180 minutes were independently risk
factors for posthepatectomy bile leakage. 4.1.5. Ascites
From table 3.13 and table 3.16; 3.17, we found that the incidence
of ascites was 8.52%; univariate analysis showed that preoperative
platelet count less than 100 G/L and cirrhotic were risk factors for
post-operative ascites after surgical liver resection for cancer.
Underlying mechanisms of a massive amount of ascites after liver
resection is not well-understood. Previous studies revealed that in
patients with cirrhosis, portal hypertension can trigger massive ascites
by stimulating neurohormonal systems to promote renal water and
sodium resorption. Multivariate analysis revealed that blood loss greater
than 1000 mL, preoperative platelet count less than 100 G/L
independently increased the risk of ascites after posthepatectomy.
Additionally, liver resection for patients with liver cirrhosis and portal
hypertension existed before surgery might further damage liver function
and more elevation of portal pressure, thereby leading to the
development of postoperative ascites. Another cause of post-
hepatectomy ascites is lesions in intrahepatic lymphatics and high portal
pressure which may increase in excretion in ascites from the resected
area. Analysis by Chen et al on 651 cases found that five significant
factors: cirrhosis liver, high ICGR15 > 10%, portal hypotension, hypoalbuminemia ≤ 35 g/L and liver resection more 3 segments were
associated with the development of postoperative ascites.
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4.2. Risk factors of complications after liver cancer resection
4.2.1. Pre-operative risk factors
4.2.1.1. Sex
Gender: table 3.19 show that male is a risk factor for
complication after liver cancer resection. Analyzis by Yang et al
showed that the gender was not a risk factor for posthepatectomy
complication. Another research by Reddy et al found that gender was
a risk factor for mortality and morbidity postoperatively, however,
the multivariate analysis found that gender was an independent risk
factor for mortality but gender was not risk factors for morbidity
after surgical liver cancer. Bachellier in a study of 55 cases showed
that male was an independent risk factor for postoperative liver
failure but no fatal surgical liver resection. Multivariate analysis by
Jarnagin showed that gender is a risk factor for morbidity
posthepatectomy but not a risk factor of mortality posthepatectomy.
4.2.1.2. Platelet count
Table 3.22, the low platelet count less than 100 G/L is a risk
factor for morbidity after hepatectomy for cancer; the patients with
preoperative low platelet count less than 100 G/L risk factor for
complication after surgery is 5.27 times higher than other patients.
Our research data is also consistent with some authors.
Analysis by Bruix et al found that preoperative platelet count was
associated with postoperative hepatic dysfunction. Taketomi et al
demonstrated that preoperative platelet count < 100 G/L and the
blood transfusion were independent predictors of postoperative
complications. In patients with lower platelet count < 100 G/L, risk
of morbidity was 4.65 times higher than other patients. Ishizawa et al
21
found that when preopertive platelet count <100 G/L were an
independent risk factor for postoperative ascites.
4.2.1.3. Liver cirrhosis
Univariate analysis from table 3.23 show that cirrhosis is a risk
factor for morbidity after surgical liver resection for cancer.
Analysis by Dokmak et al found that the mortality rate in
patients with F3 - F4 cirrhosis was higher 4.1 times than in other
patients. Research by Chan et al (2012), cirrhosis liver was one of
five independent risk factors for posthepatectomy ascites, of which
was higher 2.63 times than non-cirrhosis liver.
4.2.1.4. Tumor size
Table 3.25 show that the tumors larger than 10 cm in diameter
was a risk factor for postoperative liver resection complication.
Research by Le Loc showed that the main hepatic resection
was performed for tumors less than 10 cm in diameter; patients with
tumors larger than 10 cm in diameter and normal liver function, there
was still the possibility of liver resection. Report by Nguyen Quang
Nghia et al on 6 cases undergoing major hepatic resection (tumors
size diameter > 15 cm) showed that the reduction in the incidence of
morbidity and mortality after hepatectomy was quite difficult.
Analysis by Zhu et al on 739 patients showed that the larger
tumor size than 10 cm was a risk factor for complication after
surgical hepatic resection (p < 0.001). A restrospective analysis on
the results of liver resection by Chen et al found that larger tumor
size ≥ 10 cm was not a risk factor for complications.
22
4.2.2. Risk factors for intra-operative
4.2.2.1. Extent liver resection
Table 3.28 show that major liver resection of 3 or 4 segments
is a risk factor for complication after surgical hepatic resection for
cancer. Our study is also consistent with some authors worldwide.
According to Jarnagin et al, show that major hepatic resection
of more three segments were higher 1.2 times risk factor of overall
morbidity and higher 1.4 times postoperative mortality than other
patients. Another analysis by Poon et al showed that major liver
resection was considered to be independent risk factor for morbidity
posthepatectomy; the risk of morbidity by these patients was higher
1.57 times than other patients. Another study by Chan et al found
that major liver resection of more than three segments saw as one of
the five risk factors for ascites.
4.2.2.2. Operative time
Table 3.29 show that prolonger operative time ≥ 300 minutes was
a risk factor for morbidity (p < 0.05). Analysis by Yang et al showed
that operative time ≥ 180 minutes was not a risk factor for postoperative
morbidity. Study by authors found that the prolonged surgery was
identified at least 300 minutes; and the risk factors of posthepatectomy
morbidity was 2.78 times higher than other patients. As such, our study
is also consistent with the morbidity of the authors.
4.2.3. Several independent risk factors for complications after
hepatectomy for cancer
Multivariale analysis confirmed major hepatectomy of 3 or 4
segments and duration of operation of at least 300 minutes as
independent risk factors for pleural effusion.
23
Multivariable analysis confirmed: liver cirrhosis; preoperative
platelet count < 100 G/L; major hepatectomy of 3 or 4 segments and
prolonged surgery time ≥ 300 minutes as independent risk factors for
complication.
For patients with liver cancer accompanied with cirrhosis,
posthepatectomy poor prognosis decreased prothrombin time. Low
preoperative plalete count in cirrhosis liver has been demonstrated to
be due to blood clots in the spleen that cause hypersplenism; reduce
the supply of blood cells; at the same time inhibits marrow
production of blood cells. Therefore, preoperative low plalete count
is a poor prognosis for posthepatectomy. Some studies have
demonstrated low platelet count as an independent risk factor to
increase the rate of posthepatectomy complicaton. To keep safe in
major hepatic resection, remnant liver volumn should be > 26.5% for
normal liver function and 31% for poor liver function or the
remaining liver volume body weight ratio ≥ 1%. Small remaining
liver volume is at a high risk for postoperative liver failure. For large
tumors, deep in the abdominal cavity; major hepatectomy, dissection
technique is a challenging job, which results in damage the
diaphragm, circulatory system, lymphatic system surrounding the
liver .., therefore operative time is longer. Prolonged surgery time is
a risk factor for posthepatectomy complication.
CONCLUSION
1. Complications after hepatectomy for cancer
* The techniques of liver resection was applied in our study,
including: Right hemihepatectomy 6.94%; right extented
hemihepatectomy: 0.32%. Left hemihepatectomy 12.30%; left extended
24
hemihepatectomy: 2.21%. Central bisectionectomy (segments 4, 5, 8):
0.63%. Liver resection of three segments 5, 6, 7 or 6, 7, 8: 1.89%. Left
lateral hepatectomy: 18.61%. Right posterior sectionectomy: 13.88%.
Right anterior sectionectomy: 1.26%. Segmentectomy: 41.96%.
* Complications after hepatectomy for cancer according to Ton
That Tung’s approach: The complications rate was 23.34%; of which
pleural effusion 11.99%; ascites 8.52%; live failure 3.47%;
postoperative hemorrhage 1.26%; bile leakage 1.89%; kidney failure
0.32% and intraabdomal abscess 0.32%. 01 patients can have two or
three combined complications. One complication accounted for
19.87%; two or more than two complications were found in 3.47%.
2. Risk factors for complications after hepatectomy for
cancer according to Ton That Tung’s procedure
Univariable study, we investigated risk factors of
complications including 4 factors: males, albumin < 35 g/L; resection
of 3 or 4 liver segments and operation time ≥ 300 minutes.
Multivariable analysis indicated that only 2 factors of liver resection
of 3 or 4 segments and operation time ≥ 300 minutes were
independent risk factors of pleural effusion after posthepatectomy.
There are six factors including males, cirrhosis, tumor size >
10 cm; pre-operative platelet < 100 G/L; resection of 3 or 4 liver
segments and operation time ≥ 300 minutes are independent risk
factors of complication after operation. Nevertheless, a multivariable
analysis indicated that only four factors: cirrhosis; operative platelet
counts < 100 G/L; resection of 3 or 4 liver segments and operation
time ≥ 300 minutes were independent fisk factors for complication
after surgical hepatectomy.
LIST OF THE WRITER’S PUBLISHED RESEARCH
PROJECTS RELATED TO THE THESIS
1. Ngo Dac Sang, Le Trung Hai, Do Manh Hung (2017),
“Identifying Complications After Hepatectomy According To
Ton That Tung’s Approach”, Journal of Medicine and
Pharmacy, 42(9), pp. 78 - 83.
2. Ngo Dac Sang, Le Trung Hai, Do Manh Hung (2017),
“Assessment Of Risk Factors Of Complications After Cancer -
Induced Hepatectomy According To Ton That Tung’s
Approach”, Journal of 108 - Clinical Medicine and Pharmacy,
12(9), pp. 46 - 51.
