The present study was a retrospective analysis of all patients undergoing major hepatectomy (resection of three or more Couinaud segments) [11] for different benign and malignant liver disease at BP Koirala Institute of Health Sciences, Nepal. The institute is a 700 bedded hospital with its separate HPB and Gastrointestinal (GI) surgery division. From December 2015 until July 2017, all patients undergoing major hepatectomy in HPB unit were included. A written informed consent was obtained from all patients before surgery. All patients underwent the following to confirm the diagnosis and resectability of liver or biliary tract disease:

The variables studied included demographics, indication for surgery, need for preoperative biliary drainage, type of hepatic resections, duration of surgery, estimated blood loss, transfusion requirements, and any concomitant procedure along with hepatic resection. The type of liver resections performed was defined using the Brisbane 2000 nomenclature. Postoperative complications consistent with a Clavein-Dindo classification of surgical complication grade ≥IIIa were defined as morbidity. The “50-50” criteria was used to define Post-hepatectomy Liver Failure (PHLF), and the bile leak was graded as per International Study Group for Liver Surgery (ISGLS) [6]. Length of hospital stay, 30-day and 90-day mortality was also reviewed. Follow-up of patients was done by clinical examination, ultrasound/CECT abdomen every three to six months.

Statistical analysis was performed in Microsoft Excel 2007 and results were presented as mean±SDs for normally distributed data and median and range for the rest of the variables.

The study identified 6 (24%) adult patients out of 25 liver resections (major and minor) at BP Koirala Institute of Health Sciences, Sunsari, Nepal. The number of female patients was higher than that of male patients. The demographic profile, operative details and outcome of all the patients are summarised in [Table/Fig-1,2].

The mean age of the patients was 50.8 years. Three (50%) patients were having below normal BMI as per WHO classification with mean value of 17.7 kg/m² [Table/Fig-3]. Five patients (83.3%) were in ASA 2 category and one patient was in ASA 3 category. The associated comorbidity (Type 2 diabetes mellitus) was present in one (16.6%) patient. Obstructive jaundice was seen in three patients (50%). Five patients (83.3%) required major hepatectomy for malignant cause [Table/Fig-4,5]. Concomitant bile duct excision with reconstruction was required in three patients (50%). None of the patients in present study was in acute cholangitis or severe malnutrition requiring preoperative biliary drainage/portal vein embolisation. Two patients requiring concomitant bile duct resection and one patient with left hepatectomy for intrahepatic cholangiocarcinoma developed bile leak (Grade B) in postoperative period, which was managed with radiological percutaneous drainage (Clavin-Dindo Grade III) [Table/Fig-2,3]. None of the patient developed post-hepatectomy liver failure despite few patients with high serum bilirubin (>10 mg%) undergoing upfront surgery. There was no reoperation, readmission or mortality for any complication. Two out of the five patients with malignant aetiology underwent postoperative adjuvant chemotherapy. After mean duration of 12.8 months follow-up of all patients are performing well with one patient having disease recurrence.

[Table/Fig-4]:

Computed Tomography (CT) scan (left) and intraoperative image (right) of patients with gallbladder cancer with right portal pedicle involvement (arrow) requiring extended right hepatectomy.

[Table/Fig-5]:

Computed Tomography (CT) scan (left) and intraoperative image (right) of patients with left liver intrahepatic cholangiocarcinoma requiring left hepatectomy.

The present study is the first review of major hepatic resections in an Eastern Nepal and we have shown that this surgery is safe in terms of mortality/morbidity and is comparable to high-volume tertiary centres carrying out similar procedures [12,13].

Postoperative mortality has been well reported in large series from both low and high volume centres with available results consistently reporting inpatient and 90-day mortality rates of less than 5 to 8% [3]. Although the morbidity was high (83%), there were no mortality in present series, and the study clearly illustrates the safety of the procedure in our centre (BP Koirala Institute of Health Sciences, Sunsari, Nepal).

Bile leak is the most common complication and technical challenge to manage for surgeon after major hepatectomy. The reported incidence widely varies depending on the extent of hepatectomy and associated adjacent organ resection [14]. In one of the multi-institutional study, the proportion of patients developing bile leak was 8% after minor hepatectomy, more than 12% after major hepatectomy and the figure exceeded 30% after hepatectomy with bile duct reconstruction [15]. Bile leak after liver resection can lead to sepsis, organ space infection, prolonged hospital stay and cost, reoperation, readmission and a liver failure [16]. In the present case, we had 50% of patients with Grade B bile leak (Clavin-Dindo Class IIIa surgical complications) which was managed successfully by prolonged management of intraoperatively placed drain coupled with percutaneous radiological drainage of abdominal collection. This complication, although led to prolonged hospital stay, was devoid of any re-exploration and re-admission. The high incidence in present study could be presumed due to the small sample size and malignant pathology (hilar cholangiocarcinoma) requiring extrahepatic bile duct excision and reconstruction, a high risk group for bile leak.

Post-hepatectomy liver failure is the most dreaded complication after hepatectomy and is the major cause for increased morbidity, mortality and prolonged hospital stay. The reported incidence varies from 1% to 30%, and depends on the extent of liver resection, condition of liver, quality and quantity of the remnant liver and the intraoperative factors [6,17]. The PHLF increases in the presence of major hepatectomy in jaundiced patient, presence of portal hypertension (quantified by Child-pugh score and platelet count), associated comorbidity (diabetes mellitus) and increased intraoperative blood loss [18,19]. In the present study, there were no such complications, as none of the patients were having features suggestive of portal hypertension (low platelet count) affecting liver regeneration and all the patients were in child pugh Class A or early B. Moreover, the remnant volume was adequate for the proposed major hepatectomy, based on gross remnant liver volume on CT/MRI, BMI of the patient and associated comorbidity. Indeed it was the team proper patient selection, experience and “gut feeling” of probably patient not going to PHLF after the major resection [20].

The impact of volume-outcome effect has long been highlighted by Birkmeyer JD et al., for many surgical procedures [21]. The outcome of complex visceral procedures (pancreas, oesophagus, liver, lung and aorta) undergoing in high volume centre have been better than the low-volume procedures. However, recently, more and more studies have shown, almost similar outcome in low volume centre, compared to the high volume centre [9,22]. The improvement in mortality and morbidity cannot only be attributed to the volume effect. This has now been attenuated by the proper patient selection, surgeon experience, improvement in the perioperative and anaesthetic care, better understanding of the liver anatomy and establishment of separate skilled hepatobiliary surgical team [18,23]. Moreover, the mortality after major hepatectomy has also been due to “Failure To Rescue” (FTR) the major complication after surgery, a new metrics to assess the quality work at the institute [24]. A recent study by Ghaferi AA et al., from the University of Michigan, excellently depicted that the differences in mortality between high and low-volume cetres are not associated with large differences in complication rates. Instead, these differences seemed to be associated with the ability of a hospital to effectively rescue patients from complications [24,25]. The present study institute is a low-volume, academic institute with a dedicated surgical team and the system, where the residents, nurses and surgeons team are well versed with early detection and management of the complication, hence, mitigating the FTR and preventing the mortality.

The major limitation of the studies was small sample size, failure to derive statistical influences and survival outcome.

Major hepatectomy is a safe and feasible option at our centre (BP Koirala Institute of Health Sciences) despite limited resources and low-volume set-up. The results in terms of morbidity and mortality were comparable to other larger series from international centres. However, further care should be taken to note the increased bile leak in the present study.