Cornerstones and divergencies in the implementation and use of liver hypertrophy techniques: results from a nationwide survey for the set-up of the prospective registry.

BACKGROUND: The aim of this national survey on liver hypertrophy techniques was to track the trends of their use and implementation in Italy and to detect analogies and heterogeneities among centers. METHODS: In December 2022, Italian centers with liver resection activity were specifically contacted and asked to fill an online questionnaire composed of 6 sections including a total of 51 questions. RESULTS: 46 Italian centers filled the questionnaire. The proportion of major/total number of liver resections was 27% and the use of hypertrophy techniques was required in 6,2% of cases. The most frequent reason of drop out was disease progression in 58.5% of cases. Most frequently used techniques were PVE and ALPPS with an increasing use of hepatic venous deprivation (HVD). Heterogeneous answers were provided regarding the cutoff values to indicate the need for hypertrophy techniques. Criteria to allocate a patient to different hypertrophy techniques are not standardized. CONCLUSIONS: The use of hypertrophy techniques is deep-rooted in Italy, documenting the established value of their role in improving resectability rate. While an evolution of techniques is detectable, still significant heterogeneity is perceived in terms of cutoff values, indications and managing protocols.

Anterior approach with or without liver hanging maneuver versus conventional approach in major liver resections. A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: The anterior approach (AA), whether or not associated with the liver hanging maneuver (LHM), has been advocated to improve survival and postoperative outcomes in HCC patients undergoing major liver resection. This systematic review and meta-analysis of randomized controlled trials aims to explore intra/perioperative and long-term survival outcomes of AA ± LHM compared to CA regardless of tumor histology. METHODS: The study was conducted according to the Cochrane recommendations searching the PubMed, Scopus, and EMBASE databases until January 27, 2024 (PROSPERO ID: CRD42024507060). Only English-language RCTs were included. The primary outcome, expressed as hazard ratio (HR) and 95 % confidence intervals (CI), was the overall and disease-free survival. Random effects models were developed to assess heterogeneity. The risk of bias in included studies was assessed with the RoB 2 tool. The certainty of evidence was assessed following GRADE recommendations. RESULTS: Six RCTs, for a total of 736 patients were included. A significant survival benefit was highlighted for patients undergoing AA ± LHM in terms of overall (HR: 0.65; 95 % CI: 0.62-0.68; p < 0.0001) and disease-free survival (HR: 0.65; 95 % CI: 0.63-0.68; p < 0.0001). AA ± LHM was associated with a longer duration of surgery (WMD: 29.5 min; 95 % CI: 17.72-41.27; p = 0.004), and a lower intraoperative blood loss (WMD: 24.3; 95 % CI: 31.1 to -17.5; p = 0.0014). No difference was detected for other postoperative outcomes. The risk of bias was low. CONCLUSION: AA ± LHM provides better survival outcomes compared to CA. Furthermore, AA ± LHM is related to a modest reduction in intraoperative blood loss, at the price of a slightly longer duration of hepatectomy. Regarding other postoperative outcomes, the two techniques appear comparable.

The Current Role of Single-Site Robotic Approach in Liver Resection: A Systematic Review.

BACKGROUND: Liver resection is a critical surgical procedure for treating various hepatic pathologies. Minimally invasive approaches have gradually gained importance, and, in recent years, the introduction of robotic surgery has transformed the surgical landscape, providing potential advantages such as enhanced precision and stable ergonomic vision. Among robotic techniques, the single-site approach has garnered increasing attention due to its potential to minimize surgical trauma and improve cosmetic outcomes. However, the full extent of its utility and efficacy in liver resection has yet to be thoroughly explored. METHODS: We conducted a comprehensive systematic review to evaluate the current role of the single-site robotic approach in liver resection. A detailed search of PubMed was performed to identify relevant studies published up to January 2024. Eligible studies were critically appraised, and data concerning surgical outcomes, perioperative parameters, and post-operative complications were extracted and analyzed. RESULTS: Our review synthesizes evidence from six studies, encompassing a total of seven cases undergoing robotic single-site hepatic resection (SSHR) using various versions of the da Vinci© system. Specifically, the procedures included five left lateral segmentectomy, one right hepatectomy, and one caudate lobe resection. We provide a summary of the surgical techniques, indications, selection criteria, and outcomes associated with this approach. CONCLUSION: The single-site robotic approach represents an option among the minimally invasive approaches in liver surgery. However, although the feasibility has been demonstrated, further studies are needed to elucidate its optimal utilization, long-term outcomes, and comparative effectiveness against the other techniques. This systematic review provides valuable insights into the current state of single-site robotic liver resection and underscores the need for continued research in this rapidly evolving field.

Robotic liver parenchymal transection using the SynchroSeal.

BACKGROUND: There is much heterogeneity in the instrumentation used for parenchymal transection in minimally invasive liver surgery. Instruments specifically designed for robotic parenchymal transection of the liver are lacking. We aim to gain insight into the safety and effectiveness of the SynchroSeal (Intuitive Surgical, Inc., Sunnyvale, CA), a novel bipolar electrosurgical device, in the context of liver surgery. METHODS: The present study is a post-hoc analysis of prospectively collected data from patients undergoing robotic liver resection (RLR) using the SynchroSeal in two high-volume centres. The results of the SynchroSeal were compared with that of the previous generation bipolar-sealer; Vessel Sealer Extend (Intuitive Surgical, Inc., Sunnyvale, CA) using propensity score matching, after excluding the first 25 Vessel Sealer procedures per center. RESULTS: During the study period (February 2020-March 2023), 155 RLRs meeting the eligibility criteria were performed with the SynchroSeal (after implementation in June 2021) and 145 RLRs with the Vessel Sealer. Excellent outcomes were achieved when performing parenchymal transection with the SynchroSeal; low conversion rate (n = 1, 0.6%), small amounts of intraoperative blood loss (median 40 mL [IQR 10-100]), short hospital stays (median 3 days [IQR 2-4]), and adequate overall morbidity (19.4%) as well as severe morbidity (11.0%). In a matched comparison (n = 94 vs n = 94), the SynchroSeal was associated with less intraoperative blood loss (48 mL [IQR 10-143] vs 95 mL [IQR 30-200], p = 0.032) compared to the Vessel Sealer. Other perioperative outcomes were similar between the devices. CONCLUSION: The SynchroSeal is a safe and effective device for robotic liver parenchymal transection.

6,126 hepatectomies in 2022: current trend of outcome in Italy.

PURPOSE: Whether hospital volume affects outcome of patients undergoing hepatobiliary surgery, and whether the centralization of such procedures is justified remains to be investigated. The aim of this study was to analyze the outcome of liver surgery in Italy in relationship of hospital volume. METHODS: This is a nationwide retrospective observational study conducted on data collected by the National Italian Registry "Piano Nazionale Esiti" (PNE) 2023 that included all liver procedures performed in 2022. Outcome measure were case volume and 30-day mortality. Hospitals were classified as very high-volume (H-Vol), intermediate-volume (I-Vol), low-volume (L-Vol) and very low-volume (VL-VoL). A review on centralization process and outcome measures was added. RESULTS: 6,126 liver resections for liver tumors were performed in 327 hospitals in 2022. The 30-day mortality was 2.2%. There were 14 H-Vol, 19 I-Vol, 31 L-Vol and 263 VL-Vol hospitals with 30-day mortality of 1.7%, 2.2%, 2.6% and 3.6% respectively (P < 0.001); 220 centers (83%) performed less than 10 resections, and 78 (29%) centers only 1 resection in 2022. By considering the geographical macro-areas, the median count of liver resection performed in northern Italy exceeded those in central and southern Italy (57% vs. 23% vs. 20%, respectively). CONCLUSIONS: High-volume has been confirmed to be associated to better outcome after hepatobiliary surgical procedures. Further studies are required to detail the factors associated with mortality. The centralization process should be redesigned and oversight.

Surgical management of liver tumors.

Two percent of pediatric malignancies arise primarily in the liver; roughly 60% of these cancers are hepatoblastoma (HB). Despite the rarity of these cases, international collaborative efforts have led to the consistent histological classification and staging systems, which facilitate ongoing clinical trials. Other primary liver malignancies seen in children include hepatocellular carcinoma (HCC) with or without underlying liver disease, fibrolamellar carcinoma (FLC), undifferentiated embryonal sarcoma of the liver (UESL), and hepatocellular neoplasm not otherwise specified (HCN-NOS). This review describes principles of surgical management of malignant pediatric primary liver tumors, within the context of comprehensive multidisciplinary care.

Liver Phantoms Cast in 3D-Printed Mold for Image-Guided Procedures.

INTRODUCTION: Image-guided invasive procedures on the liver require a steep learning curve to acquire the necessary skills. The best and safest way to achieve these skills is through hands-on courses that include simulations and phantoms of different complications, without any risks for patients. There are many liver phantoms on the market made of various materials; however, there are few multimodal liver phantoms, and only two are cast in a 3D-printed mold. METHODS: We created a virtual liver and 3D-printed mold by segmenting a CT scan. The InVesalius and Autodesk Fusion 360 software packages were used for segmentation and 3D modeling. Using this modular mold, we cast and tested silicone- and gelatin-based liver phantoms with tumor and vascular formations inside. We tested the gelatin liver phantoms for several procedures, including ultrasound diagnosis, elastography, fibroscan, ultrasound-guided biopsy, ultrasound-guided drainage, ultrasound-guided radio-frequency ablation, CT scan diagnosis, CT-ultrasound fusion, CT-guided biopsy, and MRI diagnosis. The phantoms were also used in hands-on ultrasound courses at four international congresses. RESULTS: We evaluated the feedback of 33 doctors regarding their experiences in using and learning on liver phantoms to validate our model for training in ultrasound procedures. CONCLUSIONS: We validated our liver phantom solution, demonstrating its positive impact on the education of young doctors who can safely learn new procedures thus improving the outcomes of patients with different liver pathologies.

The impact of geriatric-specific variables on long-term outcomes in patients with hepatopancreatobiliary and colorectal cancer selected for resection.

BACKGROUND: Preoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined. STUDY DESIGN: This observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65-74, 75-84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility. RESULTS: 577 patients were included: 62.6 % were 65-74 years old, 31.7 % 75-84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility. CONCLUSION: Geriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.

Evolution of minimally invasive liver surgery in France over the last decade.

BACKGROUND: Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). METHODS: We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. RESULTS: MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013). CONCLUSIONS: This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

Robotic Major Hepatectomy in Elderly Patient.

BACKGROUND: the role of minimally invasive liver surgery has been progressively developed, with the practice increasing in safety and feasibility also with respect to major liver resections. The aim of this study was to analyze the feasibility and safety of major liver resection in elderly patients. METHODS: data from a multicentric retrospective database including 1070 consecutive robotic liver resections in nine European hospital centers were analyzed. Among these, 131 were major liver resections. Patients were also divided in two groups (<65 years old and ≥65 years old) and perioperative data were compared between the two groups. RESULTS: a total of 131 patients were included in the study. Operative time was 332 ± 125 min. Postoperative overall complications occurred in 27.1% of patients. Severe complications (Clavien Dindo ≥ 3) were 9.9%. Hospital stay was 6.6 ± 5.3 days. Patients were divided into two groups based on their age: 75 patients < 65 years old and 56 patients ≥ 65 years old. Prolonged pain, lung infection, intensive care stay, and 90-day readmission were worse in the elderly group. The two groups were matched for ASA and Charlson comorbidity score and, after statistical adjustment, postoperative data were similar between two groups. CONCLUSIONS: robotic major liver resection in elderly patients was associated with satisfying short-term outcomes.

Safety of perioperative intravenous lidocaine in liver surgery - A pilot study.

Background and Aims: Perioperative lidocaine infusion has many interesting properties such as analgesic effects in the context of enhanced recovery after surgery. However, its use is limited in liver surgery due to its hepatic metabolism. Material and Methods: This prospective, monocentric study was conducted from 2020 to 2021. Patients undergoing liver surgery were included. They received a lidocaine infusion protocol until the beginning of hepatic transection (bolus dose of 1.5 mg kg-1, then a continuous infusion of 2 mg kg-1 h-1). Plasma concentrations of lidocaine were measured four times during and after lidocaine infusion. Results: Twenty subjects who underwent liver resection were analyzed. There was 35% of preexisting liver disease before tumor diagnosis, and 75% of liver resection was defined as "major hepatectomy." Plasmatic levels of lidocaine were in the therapeutic range. No blood sample showed a concentration above the toxicity threshold: 1.6 (1.3-2.1) µg ml-1 one hour after the start of infusion, 2.5 (1.7-2.8) µg ml-1 at the end of hepatic transection, 1.7 (1.3-2.0) µg ml-1 one hour after the end of infusion, and 1.2 (0.8-1.4) µg ml-1 at the end of surgery. Comparative analysis between the presence of a preexisting liver disease or not and the association of intraoperative vascular clamping or not did not show significant difference concerning lidocaine blood levels. Conclusion: Perioperative lidocaine infusion seems safe in the field of liver surgery. Nevertheless, additional prospective studies need to assess the clinical usefulness in terms of analgesia and antitumoral effects.

Gelatin-Based Liver Phantoms for Training Purposes: A Cookbook Approach.

Background: Patients with liver pathology benefit from image-guided interventions. Training for interventional procedures is recommended to be performed on liver phantoms until a basic proficiency is reached. In the last 40 years, several attempts have been made to develop materials to mimic the imaging characteristics of the human liver in order to create liver phantoms. There is still a lack of accessible, reproducible and cost-effective soft liver phantoms for image-guided procedure training. Methods: Starting from a CT-scan DICOM file, we created a 3D-printed liver mold using InVesalius (Centro de Tecnologia da informação Renato Archer CTI, InVesalius 3 open-source software, Campinas, Brazil) for segmentation, Autodesk Fusion 360 with Netfabb (Autodesk software company, Fusion 360 2.0.19426 with Autodesk Netfabb Premium 2023.0 64-Bit Edition, San Francisco, CA, USA) for 3D modeling and Stratasys Fortus 380 mc 3D printer (Stratasys 3D printing company, Fortus 380 mc 3D printer, Minneapolis, MN, USA). Using the 3D-printed mold, we created 14 gelatin-based liver phantoms with 14 different recipes, using water, cast sugar and dehydrated gelatin, 32% fat bovine milk cream with intravenous lipid solution and technical alcohol in different amounts. We tested all these phantoms as well as ex vivo pig liver and human normal, fatty and cirrhotic liver by measuring the elasticity, shear wave speed, ultrasound attenuation, CT-scan density, MRI signal intensity and fracture force. We assessed the results of the testing performed, as well as the optical appearance on ultrasound, CT and MRI, in order to find the best recipe for gelatin-based phantoms for image-guided procedure training. Results: After the assessment of all phantom recipes, we selected as the best recipe for transparent phantoms one with 14 g of gelatin/100 mL water and for opaque phantom, the recipes with 25% cream. Conclusions: These liver gelatin-based phantom recipes are an inexpensive, reproducible and accessible alternative for training in image-guided and diagnostic procedures and will meet most requirements for valuable training.

The impact of 3D reconstruction technology on liver surgery in changing the pathway of surgical maneuvers: A case report.

INTRODUCTION: This case report illustrates the significant role that 3D technology can play in major hepatic surgery, aiding in the determination of the optimal surgical approach. CASE PRESENTATION: We present the case of a patient with metachronous liver metastasis from rectal cancer involving segments 6 and 7, extending to retroperitoneal structures such as the inferior vena cava (IVC) and the right renal vein (RRV). DISCUSSION: After confirming the feasibility of a right hepatectomy, we opted for a traditional posterior approach, avoiding the hanging maneuver. The 3D rendering was instrumental in this decision, revealing that the mass was in close proximity to the IVC at the 11 o'clock position, a critical area for surgical instruments during the hanging maneuver. CONCLUSION: When 2D imaging fails to provide sufficient information, 3D rendering can substantially aid the decision-making process.

Efficacy and safety of robotic liver surgery for the elderly: A propensity-score matched analysis of short-term outcomes with open liver surgery at a single center in Denmark.

BACKGROUND: The incidence of liver tumors requiring surgical treatment continues to increase in elderly patients. This study compared the short-term results of robotic liver surgery (RLS) versus open liver surgery (OLS) for liver tumors in elderly patients. METHODS: A prospective database including all patients undergoing liver surgery at Copenhagen University Hospital between July 2019 and July 2022 was managed retrospectively. Short-term surgical outcomes of the two main cohorts (OLS and RLS) and subgroups were compared using propensity score matching (PSM) in elderly patients (age ≥ 70 years) with liver tumors. RESULTS: A total of 42 matched patients from each group were investigated: the RLS group had significantly larger tumor diameters, less blood loss (821.2 vs. 155.2 mL, p < .001), and shorter hospital stays (6.6 vs. 3.4 days, p < .001). Overall morbidity was comparable, while operative times were longer in the RLS group. The advantages observed with the robotic approach were replicated in the subgroup of minor liver resections. CONCLUSIONS: In patients ≥70 years, RLS for liver tumors results in significantly less blood loss and shorter hospital stays than OLS. RLS, especially minor liver resection, is safe and feasible in elderly patients with liver tumors.

Biliary tract cancer.

BACKGROUND: Biliary tract cancers comprise a heterogeneous collection of malignancies usually described as cholangiocarcinoma of the intra- or extrahepatic bile duct, including perihilar cholangiocarcinoma and gallbladder cancer. METHODS: A review of pertinent parts of the ESSO core curriculum for the UEMS diploma targets (Fellowships exam, EBSQ), based on updated and available guidelines for diagnosis, surgical treatment and oncological management of cholangiocarcinoma. RESULTS: Following the outline from the ESSO core curriculum we present the epidemiology and risk factors for cholangiocarcinoma, as well as the rationale for the current diagnosis, staging, (neo-)adjuvant treatment, surgical management, and short- and long-term outcomes. The available guidelines and consensus reports (i.e. NCCN, BGS and ESMO guidelines) are referred to. Recognition of biliary tract cancers as separate entities of the intrahepatic biliary ducts, the perihilar and distal bile duct as well as the gallbladder is important for proper management, as they each provide distinct clinical, molecular and treatment profiles to consider. CONCLUSION: Core competencies in knowledge to the diagnosis, management and outcomes of biliary tract cancers are presented.

Initial Experience With Robotic Liver Resection in the United States.

BACKGROUND: This study's aim was to show the feasibility and safety of robotic liver resection (RLR) even without extensive experience in major laparoscopic liver resection (LLR). METHODS: A single center, retrospective analysis was performed for consecutive liver resections for solid liver tumors from 2014 to 2022. RESULTS: The analysis included 226 liver resections, comprising 127 (56.2%) open surgeries, 28 (12.4%) LLR, and 71 (31.4%) RLR. The rate of RLR increased and that of LLR decreased over time. In a comparison between propensity score matching-selected open liver resection and RLR (41:41), RLR had significantly less blood loss (384 ± 413 vs 649 ± 646 mL, P = .030) and shorter hospital stay (4.4 ± 3.0 vs 6.4 ± 3.7 days, P = .010), as well as comparable operative time (289 ± 123 vs 290 ± 132 mins, P = .954). A comparison between LLR and RLR showed comparable perioperative outcomes, even with more surgeries with higher difficulty score included in RLR (5.2 ± 2.7 vs 4.3 ± 2.5, P = .147). The analysis of the learning curve in RLR demonstrated that blood loss, conversion rate, and complication rate consistently improved over time, with the case number required to achieve the learning curve appearing to be 60 cases. CONCLUSIONS: The findings suggest that RLR is a feasible, safe, and acceptable platform for liver resection, and that the safe implementation and dissemination of RLR can be achieved without solid experience of LLR.

Experiencia inicial en hepatectomías en Corrientes / Initial experience in hepatectomies in Corrientes

RESUMEN Antecedentes: la cirugía hepática ha evolucionado con el correr del tiempo. No existe bibliografía publicada sobre experiencia previa de hepatectomía en Corrientes. Nuestro grupo de trabajo se desenvuelve en el ámbito público y privado. Objetivo: describir los resultados iniciales de una serie consecutiva de pacientes con hepatectomías de distinta extensión, por el mismo equipo quirúrgico. Material y métodos: trabajo retrospectivo, observacional, descriptivo, sobre datos de las historias clínicas y libros de quirófano de pacientes con hepatectomías realizadas entre septiembre de 2019 y enero de 2023, en la práctica pública y privada. Resultados: fueron intervenidos 27 pacientes, con media de edad 53 años (25-72); 16 eran mujeres. El abordaje fue convencional en 25 casos y laparoscópico en 2. Se realizaron 4 hepatectomías mayores y 23 menores. Los diagnósticos fueron de patología maligna en 22 oportunidades y benigna en 5. La sobrevida a los 90 días fue de 96,2%. La mortalidad fue de 1 paciente (3,7%). Con respecto a las complicaciones, 2 pacientes (7,4%) presentaron abscesos hepáticos en el posoperatorio, 2 pacientes (7,4%) requirieron reintervención quirúrgica por sangrado, con buena evolución posterior y alta hospitalaria. Conclusión: la morbimortalidad en la serie descripta estuvo en relación con lo comunicado por otros autores.

ABSTRACT Background: Liver surgery has evolved over time. There are no prior publications on the experience of liver surgery in the province of Corrientes. Our work group operates in both the public and private sectors. Objective: 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 public and private institutions from September 2019 to January 2023. Results: A total of 27 patients were operated on; mean age was 53 years (25-72) and 16 were women. We used the conventional approach in 25 cases and laparoscopy in 2. Four procedures were major liver resections and 23 were minor liver resections, The diagnoses were cancer in 22 cases and benign conditions in 5. Survival at 90 days was 96.2% One patient died (3.7%). The 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. Conclusion: The morbidity and mortality in the described series were similar to those reported by other authors.