Postoperative Complications Following Liver Resection

Диссертация посвящена изучению послеоперационных осложнений и факторов риска при резекции печени. Актуальность исследования обусловлена ростом заболеваемости злокачественными и паразитарными поражениями печени, расширением контингента оперируемых пациентов и сохраняющейся высокой частотой послеоперационных осложнений, составляющей 30–56%. В работе анализируется структура послеоперационных осложнений в зависимости от объема резекции, влияние компонентов терапевтического обеспечения на течение послеоперационного периода, а также динамика маркеров окислительного стресса. Клиническая база исследования включает результаты лечения 101 пациента, перенесшего резекцию печени в период с 2000 по 2005 год. Полученные данные позволяют уточнить тактику профилактики и лечения гепато-билиарных, кардио-респираторных и гнойно-септических осложнений.

The dissertation is dedicated to the study of postoperative complications and risk factors following liver resection. The relevance of the research is determined by the increasing incidence of malignant and parasitic liver diseases, the expansion of the surgical patient cohort, and the persistently high rate of postoperative complications ranging from 30% to 56%. The work analyzes the structure of postoperative complications depending on the extent of resection, the impact of therapeutic support components on the postoperative course, and the dynamics of oxidative stress markers. The clinical basis of the study comprises the outcomes of 101 patients who underwent liver resection between 2000 and 2005. The findings obtained make it possible to refine the tactics of prevention and treatment of hepatobiliary, cardiorespiratory, and pyoseptic complications.

Questions of surgical hepatology continue to remain relevant, which is determined by various factors (22, 29, 38, 64, 67, 98, 106). In recent years, there has been a significant increase in the incidence of primary and secondary liver cancer, parasitic diseases (10, 47, 63, 86, 97). The partial increase in the number of patients with focal liver lesions is associated with improved diagnosis of these diseases and the implementation of direct visualization techniques for cystic formations and tumors, which allow the detection of pathological foci at early stages and the preliminary assessment of their resectability (2, 162, 167). Over the past two decades, departments and centers of hepato-pancreato-biliary surgery have been organized in the United States, Europe, and Russia, the operation of which has improved the treatment efficacy for this patient group.

The prognosis for untreated malignant liver tumors is extremely poor — only isolated patients survive three years after this diagnosis is made, and the average survival does not exceed one year (145, 157).

Liver resection is currently widely used and is considered a radical method of treatment for malignant tumors of the hepatobiliary system (3, 4, 24, 33, 45, 46). In the treatment of liver oncological diseases, systemic and regional chemotherapy, radiofrequency ablation, and cryotherapy are increasingly applied (95, 100, 113, 200, 204, 206). However, none of these methods, when used in isolation, provides as effective an impact as the surgical treatment method (90, 126, 169, 206).

By this time, the contingent of operable patients has substantially changed. The age has increased, and it has become possible to perform surgical interventions on patients who were previously considered inoperable due to the severity of comorbid diseases (92, 175). The increase in the number of patients with comorbid cardiovascular and respiratory system diseases requires thorough diagnosis and correction of violations in the preoperative period, as well as the continuation of appropriate therapy in the postoperative period. In patients who have undergone liver resection, the problem of prevention and treatment of postoperative liver insufficiency, as a triggering mechanism of multiple organ dysfunction, is especially relevant (54). Low functional reserve of the remaining liver tissue is the main factor in the development of liver insufficiency. It is practically inaccessible to therapeutic interventions, whereas the prevention and treatment of liver ischemia resulting from deterioration of hepatic perfusion during fluctuations in systemic arterial blood pressure is a real task of intensive care (50, 70).

The use of various chemotherapy regimens has made it possible to increase the lifespan of patients with malignant neoplasms, which is an undeniable achievement in the field of treatment of malignant diseases of the hepatobiliary system (138, 186). However, the presence of systemic toxic effects of chemotherapy has determined a range of problems associated with an increased risk of developing postoperative complications during repeat liver resections for disease recurrence.

The development of medical technologies, the improvement of surgical technique for liver interventions, and the achievements of modern anesthesiology and resuscitation contribute to a significant reduction in mortality after liver resections (112, 135, 175). At present, this indicator in major surgical centers worldwide is 3–8%, however, the frequency of postoperative complications remains high — 30–56% (103, 118, 133, 142, 180, 192). The majority of fatal outcomes and postoperative complications are observed in patients who underwent resection of three or more liver segments (3, 23, 64, 101, 107, 119, 130, 133, 135, 142, 163, 180, 183, 208).

Reports on postoperative complications most often reflect surgical aspects of the hepatobiliary zone condition, whereas violations in other organs and organ systems (cardiorespiratory system dysfunction, kidney disorders, immune disturbances, etc.) are insufficiently comprehensively covered (3, 24, 101, 107, 118, 133, 163, 180).

Thus, the relevance of the problem is determined by:

• an increase in the incidence of focal liver lesions,

• a change in the patient contingent in recent years,

• the significance of the surgical treatment method as the only radical one,

• a high frequency of complication development in the postoperative period,

• the absence of generally accepted protocols for managing patients in the early period after liver resection.

Research Objective. To study postoperative complications and risk factors in liver resections.

Research Tasks:

1. To study the features of the postoperative period in patients who have undergone liver resection, using clinical data, results of laboratory and instrumental research methods.

2. To determine the frequency and study the nature of postoperative complications in patients with liver resection.

3. To assess the influence of components of therapeutic support on the course of the postoperative period in patients with liver resection.

4. To investigate the dynamics of lipid peroxidation products in the perioperative period in patients who have undergone extensive liver resection for malignant neoplasms.

Scientific Novelty:

• Based on a multifactorial analysis of a lethal-case-free series of liver resections, prognostic factors for complication development have been identified.

• The features of the postoperative period course in liver resection have been formulated, and complications have been analyzed by their frequency and nature.

• The importance and prospectiveness of using early enteral nutrition in this category of patients have been indicated.

• It has been established that the use of donor plasma preparations, non-specialized amino acid solutions, anticoagulants, and corticosteroid preparations in the early postoperative period does not affect the frequency of postoperative complication development or the duration of hospital stay.

• A direct dependence between the presence of chemotherapy in the anamnesis and an increase in the frequency of pyoseptic complications after liver resection has been demonstrated.

• The necessity of investigating lipid peroxidation after liver resections as a factor of homeostasis alteration has been revealed.

Practical Significance. Timely diagnosis and correction of identified risk factors allow for targeted prevention of hepatobiliary, cardiorespiratory, and pyoseptic postoperative complications. Risk factors that are inaccessible to therapeutic intervention are prognostic and carry information about the probability of developing a specific type of postoperative complication. The role of each type of complication in its influence on the postoperative duration of hospitalization has been specified.

The implementation in clinical practice of the developed tactics for patient management, taking into account the initial condition, volumes of resection, and blood loss, made it possible to improve the immediate results of surgical treatment with the absence of fatal outcomes.

During the work, the preoperative condition and surgical treatment results of 101 patients who underwent liver resection in the Department of Liver, Biliary Tract, and Pancreas Surgery (supervisor — D.M.Sc., Prof. O.G. Skipenko) and were treated in the Department of General Resuscitation and Intensive Care (supervisor — D.M.Sc. A.V. Bondarenko) from January 2000 to April 2005 at the State Unitary Enterprise "Russian Scientific Center of Surgery" named after Academician B.V. Petrovsky RAMN (Director — Academician B.A. Konstantinov) were studied.