Laparoscopic hepatectomy for primary hepatocellular carcinoma doesn’t affect rate of delayed recovery after anesthesia: a retrospective study

doi:10.21203/rs.3.rs-5318517/v1

Purpose

Despite the expansion of laparoscopic approach in the treatment of liver tumors, only a few studies referred to the effects that pneumoperitoneum might be associated with delayed recovery after anesthesia. This study aimed to evaluate the two surgical procedures to see if laparoscopic hepatectomy (LH) has less effects on post-anesthesia recovery and other short-term outcomes.

Methods

We retrospectively compared the postoperative intubation time and short-term outcomes of laparoscopic hepatectomy (LH) with those of open hepatectomy (OH) for hepatocellular carcinoma (HCC) in patients from January 2015 to December 2020. Data of patients’ baseline characteristics, intraoperative data and short-term postoperative data were collected.

Results

There were 218 and 356 patients in LH and OH groups, respectively. Factors associates with delayed anesthesia recovery included diameter of tumor (P=0.010), preoperative pulmonary function (P=0.023), preoperative ASA grade (P=0.050), area of resection (P=0.000), preoperative Child-Pugh score (P=0.006), duration of operation (P=0.000), intraoperation blood loss (P=0.000), total fluid intake (P=0.000) and intraoperative urea volume (P=0.008). LH took longer operating time, however, caused less blood loss and less infusion. Rate of postoperative complications was less than OH group, and post-operation stay was shorter.

Conclusion

Method of surgery was not one of the factors that accounts for delayed emergence. LH doesn’t prolong time of intubation and on the contrary, given its advantages of minimally invasive abdominal operation compared with open techniques, reduced time to initiation of oral diet, faster return of gastrointestinal function, and shorter hospital stay, LH is the better choice.

laparoscopic hepatectomy

delayed recovery

general anesthesia

Liver resection represents the first choice for curing early hepatocellular carcinoma (HCC) allowing a curative chance also in selected patients with intermediate stage tumors. When feasible, hepatic resection is the best treatment option for most primary and secondary liver tumors. Primary liver cancer is one of the most common malignant tumors in clinical practice and is the leading cause of death worldwide. Liver cancer treatments are developing rapidly, including local therapy, targeted system therapy, new technologies of internal and external radiotherapy and liver transplantation(1, 2). The main treatment for primary liver cancer is partial hepatectomy, which can be divided into two surgical methods, laparoscopic hepatectomy (LH) and open hepatectomy (OH). The criteria for liver resectability by laparoscopy remain the same for open surgery, which is oncological criteria (absence of extrahepatic tumor location; completely resectable R0 resection), anatomic (resectability of involved segment with its own blood supply and biliary drainage; absence of vascular invasion of portal or hepatic veins) and technical (possibility of leave in place a residual volume ≥ 40%). Anatomic resections being more challenging than wedged resections, were initially performed mainly for lesions located in the left liver.

With increasing improvements in laparoscopic techniques and the development of new technology, LH can be performed safely in more and more centers. This was also because of the unequivocal anatomical structure, and fewer requirements for liver mobilization, inferior vena cava exposure, or management of hepatic veins when performing the surgery. However, with laparoscopic instruments, it’s still controversial that operation time gets shorter. What’s more, both the surgical and anesthesia teams must be aware of specific anesthetic considerations to achieve optimal patient outcomes after LH. Up to now, only a few studies referred to the effects that pneumoperitoneum during and after LH might be associated with delayed recovery after anesthesia. Delayed recovery leads to prolonged PACU stay which affects prognosis. Delayed recovery will not only prolong mechanical ventilation time and monitor time, but also increase rates of complications and economic burden.

Therefore, to evaluate the two surgical procedures, we collected data of the operation time, hospital stays, intubation time after operation and time of post-anesthesia care unit (PACU) stay, postoperative analgesia and postoperative complications and so on to see if LH has less effects on post-anesthesia recovery and other short-term outcomes.

Study design

From January 2015 to December 2020, patients who were admitted in Hepatobiliary Surgery Department, 1st hospital of Xi’an Jiaotong University, and met the following criteria were enrolled in this study: regardless of age or gender, normal vital organ function, no or mild underlying diseases, the ability to tolerate general anesthesia, no extrahepatic metastasis, Child-Pugh grade A or B. Patients were excluded with a severe organic disease or hepatic cirrhosis, or a conversion from a laparoscopic to an open surgery. Surgical and oncological outcomes in the 2 groups of patients were compared. Primary observation target was to the intubation time in PACU after hepatectomy. Define delayed emergence after anesthesia as 90 minutes. The second observation targets were postoperative short-term outcomes including postoperative complications, total hospital stay and other parameters. Ethical approval was obtained from the 1st hospital of Xi’an Jiaotong University Research Ethics Committee (Approval No. XJTU1AF2023LSK-562), and written informed consent was obtained from each patient.

Anesthesia management

General endotracheal anesthesia was adopted in all the patients. Anesthesia was induced with etomidate, rocuronium bromide and sufentanil, and maintained with propofol, cisatracurium, remifentanil and sevoflurane. Doses were modulated by BIS index. The basic anesthetic principles and techniques used in these two groups are similar including low CVP to limit operative blood loss.

Surgical procedure and operative management

LH procedures

This procedure was performed according to the Chinese expert consensus on laparoscopic hepatectomy. Briefly, patients were placed in supine position with the head and right side lifted. Intravenous and inhalational general anesthesia was performed. Intra-abdominal pressure was maintained at 13–15 mmHg (1 mmHg = 0.133kPa). One 10-mm trocar was inserted above the umbilicus for camera use and other four trocars were usually used for hepatic anatomy. The vessel and parenchyma tissue were dissected by harmonic scalpel (Kangji, China) and laparoscopic cavitron ultrasonic surgical aspirator (Kangji, China). Hemolock clips (Kangji, China) were used for vessels (≥ 5 mm in diameter). Intraoperative ultrasonography (Olympus, Japan) was used to identify the location of tumor and major intrahepatic ducts, including their relationships, and to search for any metastatic site or tumor thrombus. For the area of resection, lobe hepatectomy equals to one or two segments resection. According to nomenclature of Brisbane 2000, hemi-hepatectomy equals to the left three segments or the right three segments resection. Extended hemi-hepatectomy equals to hemi-hepatectomy plus one of the segments of the other side.

OH procedures

The same anesthesia way with LH was performed. Patients were placed in supine position and the laparotomy was performed through right subcostal incision. Cavitron ultrasonic surgical aspirator was used for vessel and parenchyma tissue dissection. Bipolar electrocoagulation was applied for intraoperative hemostasis.

Postoperative care

Postoperatively, most patients were transferred to post-anesthesia care unit (PACU) for anesthesia recovery and observation. Steward score was used to assess the recovery of patients and determine if they were eligible for discharge of PACU or not.

Patient-Controlled Intravenous Analgesia (PCIA) was applied in PACU. The PCIA protocol: Sufentanil 1.5 ug/kg + Dezocine 4 mg/kg + 0.9% normal saline (NS) to 100 ml. Some patients were transferred to surgical intensive care unit (SICU) according to the surgeon’s judgment, based on the intraoperation blood loss and patients’ conditions, such as underlying diseases and poor cooperation in PACU. All patients were taken of by the same care and monitors. Other care and monitoring were conducted according to the routines of Hepatobiliary Surgery Department. Postoperative complications included local and systemic infection, pleural and abdominal fluid, hepatic and renal failure, biliary fistula, pulmonary complications and others. Treatments were given once it happened and needed.

Statistical analysis

Comparisons of numerical data between the two groups were performed with t-test or Mann-Whitney U test. And categorical data was compared with the Chi-squared test or Fisher’s exact test. Data were expressed as mean ± standard deviation (SD) or median value for numerical variables and percentages for nominal variables. The most relevant factors associated with delayed emergence analysis. The inclusion of variables into the final multivariate logistic regression analysis to evaluate independent factors associated with delayed emergence was based on biological plausibility, clinical importance, and statistical considerations. SPSS software (SPSS 20.0) was used for data analysis and a statistically significant difference was considered for a value of P < 0.05.

Characteristics of patients included

The characteristics of 574 patients (218 undergoing LH vs. 356 undergoing OH) are summarized in table 1. Data of age, sex, body mass index (BMI), hepatitis B positive rate, alpha fetoprotein positive rate (AFP), Child-Pugh grade and other data were collected. Patients’ underlying diseases included pulmonary diseases, cardiovascular diseases, cyst of kidney, asymptomatic cerebral infarction and so on. Preoperative data were comparable in both groups. No significant differences were found between the two groups among these factors (Table 1).

Intraoperative and postoperative outcomes

Intraoperative data of the two groups are shown in table 2. All the patients of the two groups were carried out liver resection in a way of segment hepatectomy (57.0% vs 59.9%), lobe hepatectomy (31.8% vs 24.6%), semi-hepatectomy (9.3% vs 14.3%) or extended semi-hepatectomy (1.9% vs 1.1%) (P=0.115). The average duration of operating time was longer in LH group with a significant difference (P=0.029). the rates of R0 resection were similar in the two groups, which means the two types of liver resection can achieve the same result from oncological perspective. Patients who had gone through LH tend to have smaller tumors though no significant statistical difference P=0.900). The intraoperative blood loss and blood products transfusion were less in LH group (both P<0.01). The total fluid volume intake during operation was also less in LH group with a significant difference (P=0.009). However, there was no significant difference of the urine volume between the two groups (P=0.254). Though different surgical types, there was no significant difference on the duration of hepato-occlusion between the two groups (P=0.834).

Short-time perioperative outcomes in PACU

Data showed that, there was no significant difference between the two groups of patients on total time in PACU, neither the intubation time. Rates of patients that were transferred to ICU showed no significant difference. (Table 3)

Tables 4 showed infectors that associated with delayed extubation after hepatectomy including diameter of tumor, preoperative pulmonary function, preoperative ASA grade, area of resection, Child-Pugh score, operation duration, blood loss and total fluid intake. More blood loss means more total fluid intake and they two gave the same explanation. Type of hepatectomy was not one of the infectors that is associated with delayed extubation (P=0.069).

Table 5 showed multiple logistic regression analysis of factors associating with delayed extubation. Operation duration, preoperative pulmonary function, and method of resection were responsible for delayed extubation.

Table 6 showed postoperative outcomes of all the patients of the two groups. Duration of antibiotic usage tended to be shorter in patients who received LH and their defecation function recovered sooner than the other group which means shorter time of intestine function recovery. Patients received LH had less complications and their postoperative stay as well as their total hospital stay were shorter than patients who received OH. To be specified, though smaller incision, patients received LH didn’t show less pain according to data of PCA frequency.

The present study provided information about a clinical situation that is associated with surgical procedure. To date, only few published studies have analyzed the association between different methods of hepatectomy and delayed recovery after anesthesia(3, 4).

Hepatectomy remains the first-line therapy for early- and intermediate-stage HCC due to extreme donor shortage in liver transplantation around the world(5). With the technological advancements for hepatectomy, laparoscopic liver resection as a minimally invasive surgery is now widely used in liver surgery(6). Previous studies have confirmed the technical feasibility of laparoscopic technique, postoperative benefit and oncological safety of this technique(7, 8), and reported better short- and long-term efficacy achieved with the laparoscopic liver resection than open hepatectomy(9, 10). However, this procedure remains challenging and technologically complex, especially for cirrhotic patients, who are at exceptionally high risk for postoperative complications(11, 12). However, HCC>5 cm, regardless of the tumor location, is of great challenging for laparoscopic resection due to fear of rupture and difficulty in mobilization(13). Even though indications for laparoscopy in liver surgery initially included solitary lesions, peripheral locations, and lesion < 5 cm in size(14), these indications have been gradually expanded to include more complex cases as a consequence of several technical and instrumental refinements.

In our center, LH cases dramatically increased these years, and the increase in the application of LH was associated with the development and standardization of the technique that enabled laparoscopic anatomical resection, including major hepatectomy. Principles of laparoscopic approach for HCC in our center are entirely consistent with those of open approach, especially for patients who have severe cardiovascular diseases that may not sustain pneumoperitoneum. During the period of this study, LH and OH were both applied due to the proficiency and skillfulness of different surgeons. There were also certain patient selection criteria involved, as the resection of each segment poses a different degree of challenge, which in magnitude is much more significant compared to that in open surgery. In general, there was no statistical significance in terms of tumor diameter nor the area of resection.

LH has its obvious advantages such as a local fine magnified view and less damage to the surrounding environment. It is likely that major LH remains in the exploration phase with a steep learning curve as its risks are incompletely understood. However, the movement restriction of the instruments prolongs operations time and pneumoperitoneum pressure has a bad impact on airway pressure and results in carbon dioxide absorption which may lead to delayed anesthesia recovery. Therefore, extending the indications for LH should be carefully considered(15). Between LH and OH for HCC, there is no significant difference in tumor number. As to tumor size, LH tended to be more performed for smaller lesions according to this study. Actually, prior to 2016, LH was not performed for lesions larger than 5 cm in diameter because of manipulation difficulties, the risk of tumor rupture, and the fear of subsequent bleeding and tumor spreading. In recent years, with the accumulation of experience, its indication has expanded to lesions much larger even to more than 10 cm. In addition, lesions located in segments 1, 7, and 8, can also be sectioned using laparoscopy.

We had thought that the incisions were much smaller in LH group than in OH group, so the duration of operating time should have been shorter. However, the result was opposite. It took longer operation time in LH group. Maybe because the laparoscopic instruments were not that convenient than traditional apparatus. With less intraoperative blood loss and fluid intake, patients in LH showed a better short-term outcome with less complications and less antibiotics use. During LH, the carbon dioxide might be cumulated as a result of pneumoperitoneum. However, there was no significant difference of the intubation time and stay in PACU. That means pneumoperitoneum didn’t cause more complications, especially pulmonary complications such as carbon dioxide embolism and pneumonia. However, though smaller incisions in LH group, the PCIA consumption and frequency of PCA showed no significant difference between the two groups. That’s maybe because the pain did not only come from the wound in abdominal wall, but also come from the transected nerves during operation.

Delayed emergence is a well-known occurrence. Most published studies comparing laparoscopic vs. open hepatectomies focus mainly in blood loss, transfusion rate, and hepatic specific complications. From the anesthetic point, delayed emergence could also be an indicator of postoperative outcomes. There are some obvious reasons such as overdosing of narcotics and altered pharmacokinetics in elderly patients responsible for delayed emergence. Besides deteriorated liver function, there are still other factors that may associate with delayed emergence in hepatectomy.

Pulmonary function is positively correlated with postoperative intubation time. Poorer pulmonary function, longer intubation time. Standard preoperative assessment of pulmonary function should be performed as indicated by the patient’s medical condition. Two weeks at least smoking cessation and asymptomatic respiratory infection are necessary. Longer duration of operation leads to longer postoperative time of intubation. In LH, though shorter incision of usually 10–12 cm, operating time associated with the learning curve in a surgeon’s early experience with LH might be considerably longer. While in experienced hands, LH may be associated with shorter operative time than open liver resection.

Metabolic disorder is one of the common reasons of delayed recovery. In patients receiving hepatectomy, metabolism is mainly related to liver function. There are several tools to assess preoperative liver function of patients. Child-Turcotte-Pugh (CTP) score is used commonly to predict surgical mortality in patients with cirrhosis. Generally, patients with CTP score of A or B may be possible to receive liver resection. The indocyanine green (ICG) clearance test remains to be the most commonly used for the assessment of hepatic functional reserve. In the clinical setting, ICG retention frequently utilized quantitative indicator. Generally, an ICG-R15 value of ≤ 10 can be tolerant of major hepatectomy. The surgeons associates ICG -R15 with CTP score as the reference and finally decide specific patient get the segment resection or lobe resection. ICG-R15 reflects the level of cirrhosis to some extent. The liver itself is an organ with a several function in metabolic homeostasis, detoxification, and immunity and it is frequently exposed to various injuries, which can cause cell death and hepatic dysfunction(16). Many hepatocytes die during the resection and its function get injured dramatically. All these adverse factors delayed emergence from anesthesia. In our data, ICG-R15 was not one of the factors that accounts for delayed emergence partly because of missing data. What’s more, CTP score and ICG-R15 overlapped each other. Selective vascular inflow occlusion with or without hepatic vascular isolation is an approach used in both LH and OH. Intermittent inflow occlusion may be associated with decreased blood loss during the parenchymal transection and is well tolerated(17). There are hemodynamic changes associated with vascular inflow occlusion and the anesthesia team would use vasoactive agents to keep arterial pressure in moderate level. A mount of acidic molecules which are detrimental would be released after occlusion loosened up. Ischemia reperfusion injury is adverse for the recovery of liver function. It was considered that the longer total duration of occlusion, the longer recovery after anesthesia. In our study, duration of occlusion isn’t one of the factors that associates with delayed emergence with the P value of 0.09 which is a critical value and it might be interfered by other factors.

Pneumoperitoneum is one of the most important factors for the anesthesia team to consider for LH. Pneumoperitoneum has effects on both pulmonary and cardiovascular system. Pneumoperitoneum offers a theoretical technical advantage in LH, in which CO₂ insufflation may diminish liver inflow and provide good view, however, increase airway pressure. CO₂ can be absorbed by peritoneum and leads to subcutaneous emphysema which prolongs time of recovery from anesthesia. Concerns have been raised that CO₂ gas embolism can occur from the pneumoperitoneum. However, we didn’t have cases reported in our study. In the multiple logistic regression analysis of factors associating with delayed extubation, method of resection was responsible for delayed extubation. The result showed that LH was one of the protective factors for anesthesia recovery compared to OH which means LH could reduce risk of delayed emergence. Variables may have synergistic effect. Given multiple-factor of logistic regression is more powerful, we concluded that LH could reduce the risk of delayed recover from general anesthesia.

As to postoperative outcomes, perioperative use of opioids is strongly associated with delayed recovery of gastrointestinal function. In the context of liver resection, this is particularly important as the bioavailability of opioids is increased secondary to decreased drug metabolism and drug accumulation. It also depends on the volume of functioning liver remnant and liver function after surgery. Therefore, when opioids are used, they should be used cautiously with appropriate drug, dosage, lockout frequency, and breakthrough doses. Traditional perspective thought that smaller invasion, less pain. However, our data shows that there was no difference of postoperative PCA frequency in the two types of hepatectomy. It means these two surgical modalities cause similar pain severity and similar time for recovery of gastrointestinal function.

Minimally invasive operations are associated with improved recovery in general and specific benefits in LH. Patients received less antibiotics and needed shorter time to get bowel recovery, reduction of intravenous fluids and early initiation of oral feeding. With less postoperative complications, total in-hospital time was shorter than in OH group.

Our study has several strengths. First, we compared these two types of hepatectomy from the anesthetic viewpoint and concluded that different surgical methods don’t have an impact on short-term postoperative recovery. Enhanced recovery protocols are performed better in LH group.

Our study has several important limitations. First, our study is retrospective, and although we aimed to carefully control for potential confounders, it still faces the inherent limitations of such studies. We intended to do a propensity score match analysis, however, we included too many elements which might be relevant with delayed emergence that the sample size would be very small after the match. Second, we do not have data on serum drug levels and hence cannot confirm that the association is indeed due to altered metabolism. Third, we just collected all the postoperative complications instead of according to the the Clavien-Dindo classification which is more authoritative. Finally, our data are from a single center and require confirmation before they can be generalized with confidence.

In this study, we have enumerated a many of factors of anesthetic considerations that may affect the outcome of patients undergoing LH and OH. In summary, we demonstrated that LH doesn’t prolong time of intubation and on the contrary, given its advantages of minimally invasive abdominal operation compared with open techniques, reduced time to initiation of oral diet, faster return of gastrointestinal function, and shorter hospital stay, LH is the better choice.

LH, laparoscopic hepatectomy; OH, open hepatectomy; HCC, hepatocellular carcinoma; PACU, post-anesthesia care unit; CVP, central venous pressure; BIS, bispectral index; PCIA, patient-controlled intravenous analgesia; SICU, surgical intensive care unit; ASA grade: grade of American society of anesthesiologists grade;

Ethics approval

This trial has been approved by the Ethics Committee of our hospital and the ethical lot number is XJTU1AFF2023LSK-562. Patients’ consent for participate is not applicable.

Consent for publication

All the authors have reviewed the manuscript and consented it for publication.

Availability of data and materials

All of the material and data is owned by the authors and have not been published elsewhere.

Competing interests

All the authors have no competing interests as defined by BMC, or other interest that might be perceived to influence the results and/or discussion reported in this paper.

Funding information

National Natural Science Foundation of China, Grant/Award Number: 82300664.

Authors’ contributions

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Table 1 patients’ baseline characteristics

Parameters	LH groups (n=218)	OH groups (n=356)	t/c²	P
Age (years)	55.83(±10.86)	57.25(±10.84)	1.519	0.129
Gender (%)
Female	22.9	19.4	0.834	0.361
Male	77.1	80.6	0.834	0.361
BMI	22.96	23.14	0.688	0.492
HBsAg(%)
Positive	88.1	84.8	0.930	0.335
Negative	11.9	15.2	0.930	0.335
AFP(ug/L)	2417.98	2424.38	0.008	0.993
Hgb counts (g/L)
	136.5	138.98	0.592	0.327
WBC counts (10⁹/L)
	5.16	6.37	0.803	0.278
ALB (g/L)
	39.08	39.76	1.534	0.491
Child-Pugh grade
A	94.4	91.7	0.999	0.317
B	5.6	8.3	0.999	0.317
Diabetes(%)
Positive	15.1	12.9	0.388	0.533
Negative	84.9	87.1	0.388	0.533
Cardiovascular diseases(%)
Positive	25.2	23.9	0.071	0.790
Negative	74.8	76.1	0.071	0.790
Other underlying diseases(%)
Positive	11.0	14.0	0.856	0.355
Negative	89.0	86.0	0.856	0.355
ASA(%)
I	1.9	0.9	35198.000	0.062
II	73.6	67.9
III	24.5	31.2
Pulmonary function(%)
Normal	77.5	77.1	18596.000	0.994
Mild dysfunction	16.2	17.9
Medium-severe dysfunction	6.3	5.0
Smoking index (pack×year)	8.13±15.76	8.73±15.07	0.452	0.651
ICG 15min(%)	7.88±6.71	7.36±7.33	-0.630	0.529

ICG 15min: indocyanine green retention rate at 15 minnute; BMI: Body Mass Index; ASA: American Society of Anesthesiologists (physical status score)

Table 2 Intraoperative results of patients undergoing liver resection

Parameters	LH group	OH group	t/c²	P
Range of resection(%)
Segment hepatectomy	57.0	59.9	5.865	0.115
Lobe hepatectomy	31.8	24.6
Hemi-hepatectomy	9.3	14.3
Extended hemi-hepatectomy	1.9	1.1
Tumor size (mm)	36.47±20.03	45.90±18.63	5.578	0.900
Number of lesions	1.21	1.24	0.579	0.563
Pathological type
Hepatocarcinoma	93.9	91.7	1.616	0.447
Cholangiocarcinoma	4.7	5.1
Mixed type	1.4	3.1
Grade of malignancy (%)
High differentiation	5.2	6.9	2.798	0.251
Medium differentiation	76.8	70.2
Low differentiation	18	22.9
Operating time (min)	263.96±110.26	244.54±88.90	-2.186	0.029
Blood loss (ml)	517.13±457.12	761.57±654.13	5.228	0.000
RBC infusion (Unit)	0.77±1.69	1.45±2.35	3.966	0.000
Plasma infusion	75.83±172.19	162.57±267.11	4.674	0.000
Total fluid intake (ml)	3232.79±1208.77	3500.92±1153.18	2.610	0.009
Urine volume	691.48±433.79	647.09±473.43	-1.142	0.254
R0 resection (%)
No	42.4	48.6	2.014	0.156
Yes	57.6	51.4	2.014	0.156
Portal vein thrombus (%)
Positive	31.2	36.6	1.763	0.184
Negative	68.8	63.4	1.763	0.184
Time of hepatic inflow occlusion (min)	11.00	10.6	-0.210	0.834

RBC: red blood cell; R0 resection: negative surgery margin

Table 3 perioperative outcomes in PACU

Parameters	LH group	OH group		t/c²	P
Total time in PACU (min)	93.87	99.43	1.577		0.115
Intubation time in PACU (min)	54.85±26.68	55.91±30.76	0.368		0.713
Patients transferred to ICU
Yes	20.7	27.4	3.197		0.074
No	79.3	72.6	3.197		0.074

Table 4 Logistic regression analysis of factors that associated with delayed extubation after hepatectomy

parameters		B	S.E,	Wals	df	Sig.	Exp (B)
	Diameter of tumor	.012	.004	6.646	1	.010	1.012
	Method of resection	-.341	.187	3.315	1	.069	.711
	Pulmonary function	.408	.179	5.194	1	.023	1.504
	ASA grade	.365	.188	3.770	1	.050	1.441
	Area of resection	.422	.116	13.306	1	.000	1.525
	Occlusion duration	.008	.005	2.880	1	.090	1.008
	Child-Pugh score Operation duration	.375 .075	.137 .014	7.543 26.751	1 1	.006 .000	1.456 1.077
	Blood loss	.001	.000	23.885	1	.000	1.001
	Total fluid intake	.339	.076	19.717	1	.000	1.404
	urea	.001	.000	7.105	1	.008	1.001

Table 5 multiple-factor of logistic regression analysis of factors associated with extubation
parameters		B	S.E,	Wals	df	Sig.	Exp (B)
	Duration of operation	.073	.019	15.182	1	.000	1.076
	Pulmonary function	.384	.192	3.998	1	.046	1.469
	Method of resection	-.635	.259	6.030	1	.014	.530

Table 6 postoperative outcomes

Parameters	LH group	OH group	t/c²	P
Types of antibiotics	1.3±0.56	1.37±0.62	1.493	0.136
Days of antibiotics usage	4.79±3.57	6.03±5.24	3.374	0.001
Defecation time (days)	2.91±1.63	3.96±2.18	6.549	0.000
Rates of complications(%)
Yes	11.5	20.2	7.383	0.007
No	88.5	79.8	7.383	0.007
Use of PCIA analgesia (ml)	86.21±25.98	84.38±24.32	-0.574	0.566
Frequency of PCA	5.87±8.33	5.89±9.83	0.012	0.991
Post-operation stay (days)	8.13±3.72	11.17±5.24	8.111	0.000
Hospital stay (days)	14.49±5.57	18.10±6.39	6.895	0.000

PCA: Patient-controlled Analgesia

No competing interests reported.

Laparoscopic hepatectomy for primary hepatocellular carcinoma doesn’t affect rate of delayed recovery after anesthesia: a retrospective study

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Abstract

Introduction

Materials and Methods

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

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References

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Additional Declarations

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