LIVER RESECTION IN BRAZIL: A NATIONAL SURVEY

FONSECA, Gilton Marques; JEISMANN, Vagner Birk; KRUGER, Jaime Arthur Pirola; COELHO, Fabricio Ferreira; MONTAGNINI, Andre Luis; HERMAN, Paulo

doi:10.1590/0102-672020180001e1355

ABSTRACT

Background:

Liver surgery has developed significantly in the past decades. In Brazil, the interest on it has grown significantly, but there is no study regarding its clinical practice. Despite intrinsic limitations, surveys are well suited to descriptive studies and allow understanding the current scenario.

Aim:

To provide an overview on the current spread of liver surgery in Brazil, focusing on groups´ profile, operative techniques and availability of resources.

Method:

From May to November 2016, was conducted a national survey about liver surgery profile in Brazil composed by 28 questions concerning surgical team characteristics, technical preferences, surgical volume, results and available institutional resources. The survey was sent by e-mail to 84 liver surgery team leaders from different centers including all regions of the country.

Results:

Forty-three study participants (51.2%), from all Brazilian regions, responded the survey. Most centers have residency/fellowship programs (86%), perform and do laparoscopic procedures (91%); however, laparoscopy is still responsible for a little amount of surgeries (1-9% of laparoscopic procedures over all liver resections in 39.5% of groups). Only seven centers (16.3%) perform more than 50 liver resections/year. Postoperative mortality rate is between 1-3% in 55% of the centers.

Conclusion:

This is the first depiction of liver surgery in Brazil. It showed a surgical practice aligned with worldwide excellence centers, concentrated on hospitals dedicated to academic practice.

HEADINGS:
Hepatectomy; Liver; Surveys and questionnaires; Laparoscopy.

[1] Correspondence: Gilton Marques Fonseca E-mail: medgilton@yahoo.com.br; figadohc@gmail.com

1. Where is your center located? (Figure 1)
2. Your institution offers:
- State funded health care:	9 (20.9%)
- Private health care	10 (23.3%)
- State funded and private health care:	24 (55.8%)
3. How many surgeons perform liver resections in your team?
- Mean: 3.37 (minimum: 1/ maximum: 6/ standard deviation: 1.33)
4. Does your team have residency/fellowship programs? (Figure 2A)
- Yes:	37 (86%)
- No:	6 (14%)
5. Does your team also perform liver transplantation?
- Yes:	21 (48.8%)
- No:	22 (51.2%)
6. How many liver resections are performed per year in your center? (Figure 2B)
- >15:	6 (14%)
- 16-30:	15 (34.8%)
- 31-50:	15 (34.8%)
- 51-80:	6 (14%)
- 81-100:	0 (0%)
- >100:	1 (2.3%)
7. What is the percentage of laparoscopic liver resections related to overall procedures? (Figure 2C)
- 0%:	4 (9.3%)
- 1-9%:	17 (39.5%)
- 10-19%:	10 (23.3%)
- 20-39%:	6 (14%)
- 40-49%:	5 (11.6%)
- >50%:	1 (2.3%)
8. What is the main indication for liver resection in your institution?
- Malignant primary tumours:	6 (14.3%)
- Benign tumours:	1 (2.4%)
- Liver metastases:	35 (83.3%)
9. What is the percentage of major hepatectomy?
- 1-10%:	0 (0%)
- 11-20%:	5 (11.9%)
- 21-40%:	15 (35.7%)
- 41-50%:	17 (40.5%)
- >50%:	5 (11.9%)
10. What is the preferred incision for major hepatectomy?
- Midline incision:	0 (0%)
- “J” incision:	27 (64.3)
- “Mercedes” incision:	5 (11.9%)
- Transverse incision:	0 (0%)
- Bilateral subcostal incision:	10 (23.8%)
- Long midline incision with transverse extension:	0 (0%)
- Other incisions:	0 (0%)
11. Do you use Pringle maneuver:
- Routinely:	2 (4.8%)
- Selective:	37 (88.1%)
- Never:	3 (7.1%)
12. Do you use Pringle maneuver in major hepatectomy:
- Routinely:	11 (26.2%)
- Selective:	29 (69%)
- Never:	2 (4.8%)
13. How is your preferred approach to hepatic pedicle?
- Dissection of all structures:	17 (40.5%)
- Extrahepatic Glissonian approach:	9 (21.4%)
- Intrahepatic Glissonian approach:	7 (16.7%)
- Pedicle clamping (Pringle/ Hemi-Pringle) plus approach during parenchyma transection:	8 (19%)
- Other:	1 (2.4%)
14. What is your preferred method for parenchyma transection in OPEN surgeries?
- Ultrasonic surgical aspirator:	14 (33.3%)
- Kelly clamp crushing:	10 (23.8%)
- Energy disposable devices (p.e. harmonic scalpel or advanced bipolar vessel sealing):	8 (19%)
- Water-jet dissection:	1 (2.4%)
- Bipolar cautery:	6 (14.3%)
- Silkclasy:	2 (4.8%)
- Digitoclasy:	0 (0%)
- Stapler:	0 (0%)
- Other:	1 (2.4%)
15. What is your preferred method for parenchyma transection in LAPAROSCOPIC surgeries?
- Ultrasonic surgical aspirator:	4 (9.5%)
- Stapler:	3 (7.1%)
- Harmonic scalpel:	17 (40.5%)
- Advanced bipolar energy:	13 (31%)
- Other:	1 (2.4%)
- We do not perform laparoscopic resections:	4 (9.5%)
16. Do you have intraoperative ultrasound available?
- Yes, for open procedures:	32 (76.2%)
- Yes, for open and laparoscopic procedures:	7 (16.7%)
- No:	3 (7.1%)
17. Do you use routinely drain in major hepatectomies?
- Yes:	38 (90.5%)
- No:	4 (9.5%)
18. If you routinely use drain in major hepatectomies, what is your preferred drain?
- Closed tubular in aspiration (i.e. Blake, Jackson-Pratt):	33 (78.6%)
- Open tubular and laminar (i.e. Waterman):	2 (4.8%)
- Open laminar (i.e. Penrose):	4 (9.5%)
- Open tubular:	3 (7.1%)
19. Do you apply routinely haemostatics or sealants on the raw surface area after hepatectomy?
- No:	27 (64.3%)
- Yes, fibrin glue:	7 (16.7%)
- Yes, topic haemostatic (sponges, plaque, mesh):	8 (19%)
20. Do you perform intraoperative test for biliary leakage after major hepatectomies?
- Always:	13 (31%)
- In selected cases:	19 (45.2%)
- Never:	10 (23.8%)
21. What is your incidence of postoperative biliary leakage?
- <10%:	33 (78.6%)
- 10-19%:	9 (21.4%)
- 20-29%:	0 (0%)
- >30%	0 (0%)
22. What is you intraoperative blood transfusion rate?
- < 10%:	23 (54.8%)
- 10-19%:	11 (26.2%)
- 20-29%:	3 (7.1%)
- 30-39%:	4 (9.5%)
- 40-49%:	0 (0%)
- >50%:	1 (2.4%)
23. What is your postoperative morbidity rate?
- <10%:	10 (23.8%)
- 10-19%:	18 (42.8%)
- 20-29%:	7 (16.7%)
- 30-39%:	5 (11.9%)
- 40-49%:	2 (4.8%)
- >50%:	0 (0%)
24. What is your postoperative mortality rate? (Figure 2D)
- <1%:	5 (11.9%)
- 1-3%:	23 (54.8%)
- 4-6%:	9 (21.4%)
- 7-10%:	5 (11.9%)
- >10%:	0 (0%)
25. Do you have percutaneous biliary drainage available in your hospital?
- Yes:	38 (90.5%)
- No:	4 (9.5%)
26. Do you have portal embolization available in your hospital?
- Yes:	37 (88.1%)
- No:	5 (11.9%)
27. Do you have transarterial chemoembolization available in your hospital?
- Yes:	33 (78.6%)
- No:	9 (21.4%)
28. Do you have endoscopic retrograde cholangiopancreatography available in your hospital?
- Yes:	41 (97.6%)
- No:	1 (2.4%)

Brasil