Liver Resection in a Tertiary University Hospital in Damascus- trends Related to the Political Strife and Social Crisis

Liver resection is the most efficacious treatment for patients with hepatic malignancies and selected benign diseases [1,2-3]. Improvements in various aspects of hepatic resections have led to better outcomes in recent decades. Our better comprehension of liver segmental anatomy improved assessment of appropriate candidates for such a major operation, and, immense progress in techniques of resection are important factors that have made liver resection a more common and safer operation [4]. The improved selection of patients and advances in perioperative management have decreased markedly the early postoperative mortality from 13% for all resections and > 20% for major resections to less than 8% [5]. Over the recent several decades, evidence has shown that operative resection of hepatic metastases can be undertaken safely in the majority of patients with resectable disease. This is especially true for patients Abstract

Patients who had not resectable disease or had undergone radiofrequency ablation were excluded. Standard demographic and clinic data were obtained, including age, sex, place of residency, blood group, pathology, history of smoking or alcohol use, history of diabetes or hypertension, days in Intensive Care Unit and postoperative hospitalization.
On presentation, all patients underwent a full history and physical examination, ultrasonography, and a multi-slice computed tomography; Magnetic resonance imaging was not available all the time. The decision to give neoadjuvant chemotherapy was made on a case by case basis according to the expected beneficial results. Resections were undertaken by the same operative technique and performed under maintenance of a low central venous pressure. Our operative team performed only open resections with the use of a Pringle maneuver and intraoperative ultrasonography used at the discretion of the surgeon. The hepatic parenchyma was divided by the clamp-crush technique or with the use of an energy-assisted device. The condition of the patient postoperatively was used to determine whether the patient needed ICU care or could be managed on the surgical floor.
Descriptive analyses were performed using IBM SPSS statistic version 23, and the missing data were excluded from analysis. This study was approved by the Research Ethics Committee, Faculty of Medicine, Damascus University (decision number 16-02-07).
In 2009, we performed only 10 hepatic resections. But in the years to follow, 2010 through 2015, we performed annually 17,6,12,16,13, and most recently in 2016, 21 hepatic resections, respectively. The median duration of stay in the hospital was 11 days, while the median duration of stay in the ICU for the 76 patients who required ICU care was 3 days.
Of 95 patients, 61 had anatomic resection (64%) and 34 had non-anatomic resection (36%). Table 1 shows the types of resection. There were 63 patients who underwent hepatic resection for malignant neoplasms (66%) and 30 for non-malignant tumors (32%). Seven patients died during operation or within days of hospitalization. The mean number of units of blood, plasma, and platelets used during the operation and hospitalization was 3.3, 3.2, 0.6 units, respectively; 13 patients never requited any blood products.

Discussion
Hepatic resection is now firmly established as the most effective treatment for patients with primary hepatobiliary malignancies, selected patients with certain extrahepatic malignant neoplasms metastatic to the liver, and some benign disorders involving the liver [10][11].
Smoking is considered one of the most important risk factors for the development of early complications after partial hepatectomy. We have closely smokers' ratio to others studies. Alcohol is one of the Common causes of existing liver disease but we have low value compared to other studies, this could be due to our traditions [12][13].
The annual number of formal liver resections has increased since 2009. But as seen, this increase was disrupted from 2011 through 2014 during the especially difficult times for our country. Our ongoing civil war has disrupted the ready ability to refer patients to our university hospital. Despite these hardships, we have worked hard to provide the services needed to those who could find the way to present at our university hospital. Much of what we have been able to accomplish is related Figure 1

Conflict of interest
There is nothing to disclose.
to the unwavering dedication of our medical personnel whose goal is to provide the best care possible to our citizens. Patients with greater levels of postoperative pain tend to have more complications after surgery, longer hospitalization leading to higher medical costs, and lower levels of patient satisfaction [14]. The duration of hospitalization may not reflect surgeon/institution performance, because in these times of strife, the appropriate time for discharge is multifactorial and likely related to the population, patient selection, and increased high-risk cases with a surgeon's experience [15]. In this study, we achieved close and reasonable ratio to the rest of the studies [16,[17][18].
In our study, we also have identified the geographic distribution of residential areas subject to the liver and found that Damascus and its countryside is the most frequent place of residency of patients, not to forget that the main liver surgery center in Syria is in the hospital of our study in Damascus.
Consumption of banked blood may reflect the degree of blood loss [19][20]. However, the mainstay to prevent bleeding is crucial during hepatectomy . Our mean blood unit and plasma unit is less than some other studies [22].
The functional residual hepatic reserve must be considered for any liver resection [23]. This has been of course one of our considerations in doing any formal hepatic resections and post-surgery hepatic failure and deterioration in liver function were studied in our previous paper [3]. In addition, surgical stress can be decreased by non-anatomic resections when appropriate, which may affect perioperative morbidity and mortality [24][25]. Several studies reported shorter operating times and significantly less blood loss after non anatomic resections [26][27]. Thus we have tried to use these non-anatomic resections when appropriate, especially for metastatic lesions and for non-malignant conditions.
Laparoscopic resection is now carried on some countries showing similar results to open technique but unfortunately it is still not carried on in Syria due to lack of appropriate laparoscopic equipment and experience. However, Dedication of our surgeons to hepatic surgery may lead to perform this in the near future just like (the liver transplantation team in AlAssad university hospital in Damascus) performed the first liver transplantation in Syria in the beginning of 2016.
In our series, there were seven deaths during operation or hospitalization: four in the Anatomic resection group, and three in the non-anatomic resection group, which was not significantly different. There are studies suggesting more postoperative deaths After an anatomic resection [27][28].
In conclusion, liver resection surgery is still being performd and appears to be increasing in Syria despite the political and social unrest in our country. With the dedication and hard work of our health care providers, we have been able to provide the expertise needed to accomplish relativelysafe and successful liver resections with morbiditiy and mortality rates close to the rates