Abstract
Introduction
Recently, accelerometers have received much attention around the world. This study examined whether the preoperative physical activity level measured by an accelerometer could be a useful predictor of post-hepatectomy complications.
Methods
Between December 2016 and December 2020, the physical activity levels of 185 patients were measured using an accelerometer 3 days before hepatectomy and from postoperative day 1 to 7. The patients without postoperative complications (n = 153) and those with postoperative complications (n = 32) were compared using either the χ2 test or Fisher's exact test for nominal variables; continuous variables were analyzed using either Student's t test or Mann-Whitney U test. Differences were considered statistically significant when the p value was <0.05. Risk factors for postoperative complications following hepatectomy were also investigated.
Results
The number of patients with an anatomical resection was significantly higher in patients with postoperative complications (p = 0.001). Furthermore, laparoscopic hepatectomy was performed in 65.4% of patients without postoperative complications and in 25.0% of those with postoperative complications; the difference was statistically significant (p < 0.001). The average preoperative physical activity level was 150.6 kcal/day in patients without postoperative complications and 84.5 kcal/day in those with postoperative complications (p = 0.001). Multivariate analysis identified blood loss, operative time, and preoperative physical activity level as independent risk factors for postoperative complications.
Discussion/Conclusion
Patients with lower preoperative physical activity levels are at a high risk of developing postoperative complications after hepatectomy. Hence, preoperative physical activity level measurement may be useful in predicting post-hepatectomy complications.
Keywords: Physical activity, Accelerometer, Hepatectomy, Hepatic resection, Postoperative complications
Introduction
Populations in developed countries are aging, and the number of older patients undergoing surgery, including hepatectomy, is increasing. Several reports demonstrating a relationship between age and post-hepatectomy complications have been published [1]. Elderly patients are frailer than young patients and thus have a greater risk of exacerbation once a complication occurs [2]. Hence, predicting and preventing complications after hepatectomy in elderly patients is crucial.
Predictors of postoperative complications include the American Society of Anesthesiologists physical status classification and performance status developed by the Eastern Cooperative Oncology Group [3, 4]. However, these predictors do not consider objective factors. Thus, blood biomarkers for predicting post-hepatectomy complications have received considerable attention owing to their simplicity and objectivity [5]. Nevertheless, predictors of postoperative complications that are more useful than blood tests need to be developed.
Accelerometers have gained popularity in the USA since 2010 with the increase in health consciousness of the population and have also received much attention in Japan since 2014. Accelerometers contain an acceleration sensor and can calculate exercise intensity and calorie consumption. Some accelerometers can monitor sleeping time and heart rate. Several studies on lifestyle-related diseases have reported a correlation between levels of activities of daily living (measured by accelerometer) and diseases, such as metabolic syndrome, obesity, diabetes mellitus (DM), and hyperlipidemia [6, 7]. In addition, a relationship between physical activity levels and cardiovascular disease has been reported [8]. In the surgical field, several studies on the correlation between physical activity levels and complications following orthopedic, cardiovascular, and bariatric surgeries have been conducted [9, 10, 11]. However, reports of such an investigation in gastrointestinal surgery are few. Thus, we conducted a pilot study to determine the relationship between physical activity levels and post-hepatectomy complications [12]. Subsequently, a prospective study was performed to investigate the relationship between postoperative physical activity levels and the occurrence of post-hepatectomy complications [13].
As the next step, it was necessary to investigate the relationship between preoperative physical activity levels and the occurrence of post-hepatectomy complications. Therefore, this study aimed to investigate and elucidate the utility of preoperative physical activity levels in predicting post-hepatectomy complications.
Materials and Methods
This prospective observational study included patients who underwent hepatectomy between December 2016 and December 2020, except those who also underwent resection of other organs. The physical activity levels of 185 patients were measured for 3 days prior to surgery and 7 days from postoperative day (POD) 1 to POD 7. All patients enrolled in this study wore an accelerometer on their waist for 24 h continuously, except during bath time. While wearing the accelerometer, the patients were not restricted in movement, and they were allowed to move freely in the hospital. In addition, it was prohibited to stay overnight away from hospital before surgery.
Postoperative management was performed according to our Enhanced Recovery After Surgery (ERAS) protocol. The nasogastric tube was removed immediately after the operation, and drinking water was allowed if the patient's consciousness became clear. Postoperative diet was initiated on POD 1 in all patients. Intravenous feeding was stopped when patients consumed more than half of the diet provided on POD 3. If the amount of food consumed was less than half, intravenous feeding was continued. Tramadol (112.5 mg/day) was administered for 7 days from POD 1 for pain. If the pain persisted, loxoprofen sodium hydrate (60 mg) was administered, depending on pain severity. Postoperative rehabilitation and walking training were performed by a physical therapist daily from POD 1. The urinary catheter was removed when the patients were able to go to the toilet on their own. If vomiting occurred due to delayed gastric emptying or ileus after surgery, the scheme of the ERAS protocol was abandoned.
Cefazolin sodium (1 g) was administered every 3 h during the operation and every 8 h for 24 h after the operation as prophylactic administration for postoperative infectious complications. When infectious complications occurred, selected antibiotics were readministered based on the bacterial culture test results.
Patients who developed post-hepatectomy complications (Clavien-Dindo grade ≥ III) were classified into the group with postoperative complications (n = 32) and were subsequently compared with the group without postoperative complications (n = 153) [14]. One grade 5 patient who died due to postoperative bile duct stenosis was excluded from the study.
Patient characteristics, such as age, sex, body mass index (BMI), DM, alcohol abuse, etiology, cardiovascular disease, primary disease, and frailty, were compared between the two groups. For blood tests, albumin, alanine aminotransferase, aspartate aminotransferase, total bilirubin, prothrombin activity (PT), platelet count, indocyanine green retention rate at 15 min, white blood cell count, and C-reactive protein were examined. Regarding surgical factors, laparoscopic surgery, operative methods (anatomical resection/partial resection), repeat hepatectomy, blood loss, operative time, and hospitalization after surgery were evaluated. The criteria for open hepatectomy at our hospital are tumor diameter of 5 cm or more or vascular invasion. In this study, 12 cases started with laparoscopic hepatectomy but had to change to open hepatectomy. Of these, 9 cases had to change to open hepatectomy due to adhesions and 3 cases due to hemostasis.
Alcohol abuse was defined as alcohol consumption of ≥20 g/day. Frailty was assessed using the phenotypic frailty index known as the “Kihon Checklist,” which was developed by the Japanese Ministry of Health, Labor and Welfare as part of the 2006 long-term care insurance system project to identify elderly individuals who may require care or support in the future [15]. The Kihon Checklist is a convenient, self-administered questionnaire with 25 questions. In our study, patients who scored ≥8 points preoperatively in the Kihon Checklist were considered to have frailty syndrome, as previously described [16]. The Center for Disease Control and Prevention guidelines were used for the diagnosis of surgical site infection [17]. For post-hepatectomy liver failure grading, the definition of the International Study Group of Liver Surgery was employed [18].
Accelerometer
An accelerometer (MTN-220; ACOS Co., Ltd., Nagano, Japan) was used to evaluate the physical activity of the patients. MTN-220 contains a three-dimensional acceleration sensor and can measure the basal metabolic rate, momentum, number of walks, and exercise intensity based on the inputted data on age, height, and weight of the patient. Momentum is calculated by the acceleration index (exercise intensity) divided into 64 levels by the acceleration sensor, which recognizes the amplitude and vibration frequency, and multiplied by the body weight. All measurements were performed continuously, and the values were recorded in the device every 2 min. Data were extracted from the MTN-220 device through a near-field communication interface (PaSoRi, RC-S380, Sony Co., Ltd., Tokyo, Japan) using SleepSign Act (Kissei Comtec Co., Ltd., Nagano, Japan) [19].
Statistical Analysis
The age and BMI of the patients are presented as mean ± standard deviation. Other variables are expressed as medians (25th and 75th percentiles). For the comparison between the two groups, either the χ2 test or Fisher's exact test was used for nominal variables; continuous variables were analyzed using either Student's t test or Mann-Whitney U test. The cut-off values of continuous variables were selected by receiver operating characteristic curve analysis. In addition, we chose the cut-off values that were close to the most significant difference and were easy to memorize and apply clinically. Statistically significant variables in univariate analysis were included in multivariate logistic regression analysis. Significance level was set at p values of <0.05. All statistical analyses were performed using R statistical software version 4.0.2. (The R Foundation for Statistical Computing, Vienna, Austria; https://cran.r-project.org/bin/macosx/).
Results
The group with postoperative complications included 19 patients with surgical site infection, 9 with refractory pleural effusion/ascites, 1 with ileus, 1 with cerebral hemorrhage, 1 with implant infection with methicillin-resistant Staphylococcus aureus, and 1 with post-hepatectomy liver failure grade C.
Figure 1 presents the preoperative physical activity level and postoperative physical activity level until POD 7 in each group. The results showed that the patients with postoperative complications had significantly lower preoperative physical activity levels (p < 0.05). In addition, physical activity levels of the patients without postoperative complications increased gradually from POD 1 to POD 7, whereas no evident increase in postoperative physical activity was noted in the group with postoperative complications.
Fig. 1.
Preoperative and postoperative physical activity (until POD 7) levels in each group. Compared with patients without postoperative complications, those with post-hepatectomy complications tended to have significantly lower levels of preoperative physical activity (p < 0.05). The physical activity levels of the patients without postoperative complications increased gradually after surgery, whereas no evident increase in activity levels in patients with postoperative complications was observed. POD, postoperative day.
Table 1 shows the results of the comparison between the two groups. No significant differences were found in age, sex, BMI, DM, alcohol abuse, etiology, cardiovascular diseases, or primary disease between the groups. In addition, 29.1% of the patients without postoperative complications and 34.4% of those with postoperative complications were diagnosed with frailty syndrome; no significant difference was noted (p = 0.673). Blood test results were similar between the groups, except PT activity level. The number of patients who underwent laparoscopic hepatectomy was significantly higher in the group without postoperative complications (group without complications, 65.4% vs. group with complications, 25.0%; p < 0.001). Anatomical resection was significantly more prevalent in the group with (68.8%) than in the group without (37.3%) postoperative complications (p = 0.001). Median blood loss was 127 mL in the group without postoperative complications and 753 mL in the group with postoperative complications; the difference was significant (p < 0.001). Furthermore, the median operative time was 333 and 233 min in the groups with and without postoperative complications, respectively, which indicates that the patients with postoperative complications required a significantly longer operative time (p < 0.001). Median hospitalization period after surgery was 9 days for patients without postoperative complications and 30 days for those with postoperative complications (p < 0.001).
Table 1.
Comparison of patient characteristics between the two groups
| Without complication group (n = 153) | With complication group (n = 32) | p value | |
|---|---|---|---|
| Age, years | 69.6±10.5 | 69.5±10.8 | 0.938 |
| Sex, n (%) | |||
| Female | 45 (29.4) | 8 (25.0) | 0.674 |
| Male | 108 (70.6) | 24 (75.0) | |
| BMI, kg/m2 | 23.5±3.5 | 22.5±3.3 | 0.125 |
| DM, n (%) | 46 (30.1) | 10 (31.2) | >0.999 |
| Alcohol abuse, n (%) | 48 (31.4) | 14 (43.8) | 0.217 |
| Etiology, n (%) | |||
| HBV | 9 (5.9) | 1 (3.1) | |
| HCV | 27 (17.6) | 10 (31.2) | 0.227 |
| NBNC | 117 (76.5) | 21 (65.6) | |
| Cardiovascular disease, n (%) | 16 (10.5) | 3 (9.4) | >0.999 |
| Primary disease, n (%) | |||
| HCC | 91 (59.5) | 18 (56.2) | |
| Meta | 46 (30.1) | 6 (18.8) | 0.07 |
| Others | 16 (10.5) | 8 (25.0) | |
| Albumin, g/dL | 3.9 (3.6, 4.2) | 3.9 (3.6, 4.1) | 0.469 |
| ALT, IU/L | 24 (15, 39) | 21 (14, 30) | 0.214 |
| AST, IU/L | 27 (21, 46) | 30 (22, 44) | 0.744 |
| Total bilirubin, mg/dL | 0.6 (0.5, 0.8) | 0.7 (0.5, 1.1) | 0.066 |
| PT, % | 98 (88, 108) | 89 (85, 103) | 0.016 |
| PLT, ×103/μL | 166 (124, 219) | 146 (112, 180) | 0.121 |
| ICGR15, % | 10.3 (6.5, 18.0) | 15.0 (9.1, 17.5) | 0.283 |
| WBC, ×103/μL | 4.8 (4.0, 5.7) | 4.7 (4.0, 5.9) | 0.837 |
| CRP, mg/dL | 0.12 (0.06, 0.24) | 0.11 (0.07, 0.27) | 0.804 |
| Laparoscopic hepatectomy, n (%) | 100 (65.4) | 8 (25.0) | <0.001 |
| Operative method, n (%) | |||
| Partial | 96 (62.7) | 10 (31.2) | 0.001 |
| Anatomical | 57 (37.3) | 22 (68.8) | |
| Repeat hepatectomy, n (%) | 48 (31.4) | 10 (31.2) | >0.999 |
| Blood loss, mL | 127 (0, 384) | 753 (486, 1,267) | <0.001 |
| Operative time, min | 233 (180, 290) | 333 (286, 380) | <0.001 |
| Hospitalization, days | 9 (8, 12) | 30 (14, 37) | <0.001 |
| Frailty syndrome, n (%) | 45 (29.4) | 11 (34.4) | 0.673 |
Age and BMI are expressed as mean ± standard deviation. Other data are expressed as medians (25th and 75th percentiles). BMI, body mass index; DM, diabetes mellitus; HBV, hepatitis B virus; HCV, hepatitis C virus; NBNC, negative for hepatitis B and hepatitis C virus; HCC, hepatocellular carcinoma; Meta, liver metastasis; ALT, alanine aminotransferase; AST, aspartate aminotransferase; PT, prothrombin activity; PLT, platelet; ICGR15, indocyanine green retention rate at 15 min; WBC, white blood cell; CRP, C-reactive protein.
Table 2 shows the results of the univariate and multivariate analyses to reveal independent predicting factors of postoperative complications. Univariate analysis demonstrated a significantly higher incidence of postoperative complications in patients with a low PT activity level, open surgery, anatomic resection, severe bleeding, longer operative time, and low preoperative physical activity. These factors were subsequently included in multivariate analysis. Based on the results of the multivariate analysis, low preoperative physical activity levels (risk ratio 3.61, 95% confidence interval [CI] 1.31–9.95; p = 0.0013), massive hemorrhage during hepatectomy (risk ratio 4.08, 95% CI 1.39–12.0; p = 0.011), and longer operative time (risk ratio 4.34, 95% CI 1.59–11.80; p = 0.004) were independent risk factors for post-hepatectomy complications.
Table 2.
Univariate and multivariate analyses of risk factors for post-hepatectomy complications
| Univariate analysis |
Multivariate analysis |
|||
|---|---|---|---|---|
| Odds ratio (95% CI) | p value | Odds ratio (95% CI) | p value | |
| Age ≥75 years old | 1.10 (0.50–2.42) | 0.81 | ||
| Male patients | 1.25 (0.52–2.99) | 0.62 | ||
| BMI ≥25 kg/m2 | 0.38 (0.14–1.05) | 0.062 | ||
| DM (+) | 1.06 (0.46–2.41) | 0.89 | ||
| Alcohol abuse (+) | 1.70 (0.78–3.70) | 0.18 | ||
| HBV or HCV infection | 1.70 (0.75–3.86) | 0.2 | ||
| Cardiovascular disease (+) | 0.89 (0.24–3.24) | 0.86 | ||
| HCC patients (primary disease) | 0.88 (0.41–1.89) | 0.74 | ||
| Albumin <3.5 g/dL | 1.31 (0.51–3.33) | 0.57 | ||
| ALT ≥30 IU/L | 0.55 (0.23–1.30) | 0.17 | ||
| AST ≥30 IU/L | 1.62 (0.75–3.48) | 0.22 | ||
| Total bilirubin ≥1.0 mg/dL | 1.94 (0.83–4.55) | 0.12 | ||
| PT <75% | 2.98 (1.01–8.76) | 0.047 | 3.37 (0.88–12.90) | 0.075 |
| PLT <10.0 × 104/μL | 1.14 (0.36–3.66) | 0.82 | ||
| ICGR15 ≥20% | 0.98 (0.39–2.46) | 0.97 | ||
| WBC ≥5.0 × 103/μL | 0.75 (0.35–1.63) | 0.47 | ||
| CRP ≥0.5 mg/dL | 0.90 (0.29–2.82) | 0.85 | ||
| Frailty syndrome | 1.26 (0.56–2.82) | 0.58 | ||
| Open hepatectomy | 5.66 (2.38–13.50) | 0.000088 | 2.34 (0.82–6.67) | 0.11 |
| Anatomic resection | 3.71 (1.64–8.38) | 0.0017 | 2.12 (0.81–5.53) | 0.12 |
| Repeat hepatectomy | 0.99 (0.44–2.26) | 0.99 | ||
| Blood loss ≥800 mL | 6.66 (2.79–15.90) | 0.000019 | 4.08 (1.39–12.00) | 0.011 |
| Operative time ≥360 min | 5.49 (2.35–12.80) | 0.000083 | 4.34 (1.59–11.80) | 0.004 |
| Preoperative activity level <115 kcal/day | 3.75 (1.58–8.87) | 0.0026 | 3.61 (1.31–9.95) | 0.013 |
BMI, body mass index; DM, diabetes mellitus; HBV, hepatitis B virus; HCV, hepatitis C virus; HCC, hepatocellular carcinoma; ALT, alanine aminotransferase; AST, aspartate aminotransferase; PT, prothrombin activity; PLT, platelet; ICGR15, indocyanine green retention rate at 15 min; WBC, white blood cell; CRP, C-reactive protein.
We evaluated the association between preoperative patients' background factors and preoperative physical activity levels in Table 3. The cut-off value between low preoperative physical activity levels and high preoperative physical activity levels calculated using receiver operating characteristic curve analysis was 115 kcal/day. No significant differences were found in age, sex, BMI, DM, alcohol abuse, etiology, cardiovascular disease, primary disease, and frailty syndrome between high and low preoperative physical activity level groups. Additionally, in blood test, there was no significant difference between the two groups at preoperative albumin, alanine aminotransferase, aspartate aminotransferase, total bilirubin, PT, platelet count, indocyanine green retention rate at 15 min, white blood cell count, and C-reactive protein. (Table 3)
Table 3.
Association between preoperative factors and preoperative physical activity levels
| Preoperative activity level ≥115 kcal/day (n = 93) | Preoperative activity level <115 kcal/day (n = 92) | p value | |
|---|---|---|---|
| Age, years | 70.4±9.9 | 68.7±11.0 | 0.277 |
| Sex, n (%) | |||
| Female | 28 (30.1) | 25 (27.2) | 0.745 |
| Male | 65 (69.9) | 67 (72.8) | |
| BMI, kg/m2 | 23.6±3.0 | 23.1±3.8 | 0.391 |
| DM, n (%) | 24 (25.8) | 32 (34.8) | 0.203 |
| Alcohol abuse, n (%) | 27 (29.0) | 35 (38.0) | 0.215 |
| Etiology, n (%) | |||
| HBV | 5 (5.4) | 5 (5.4) | |
| HCV | 17 (18.3) | 20 (21.7) | 0.895 |
| NBNC | 71 (76.3) | 67 (72.8) | |
| Cardiovascular disease, n (%) | 11 (11.8) | 8 (8.7) | 0.629 |
| Primary disease, n (%) | |||
| HCC | 56 (60.2) | 53 (57.6) | |
| Meta | 21 (22.6) | 31 (33.7) | 0.106 |
| Others | 16 (17.2) | 8 (8.7) | |
| Albumin, g/dL | 3.9 (3.7, 4.2) | 3.9 (3.5, 4.1) | 0.562 |
| ALT, IU/L | 24 (16, 34) | 23 (15, 41) | 0.881 |
| AST, IU/L | 28 (20, 41) | 28 (21, 50) | 0.523 |
| Total bilirubin, mg/dL | 0.7 (0.5, 0.9) | 0.6 (0.4, 0.8) | 0.066 |
| PT, % | 96 (88, 108) | 94 (86, 106) | 0.397 |
| PLT, ×103/μL | 161 (121, 214) | 158 (114, 224) | 0.806 |
| ICGR15, % | 10.3 (6.2, 18.4) | 11.7 (7.1, 16.5) | 0.957 |
| WBC, ×103/μL | 5.0 (4.0, 5.6) | 4.6 (4.1, 5.8) | 0.849 |
| CRP, mg/dL | 0.11 (0.05, 0.19) | 0.13 (0.07, 0.30) | 0.111 |
| Frailty syndrome, n (%) | 23 (24.7) | 33 (35.9) | 0.111 |
Age and BMI are expressed as mean ± standard deviation. Other data are expressed as medians (25th and 75th percentiles). BMI, body mass index; DM, diabetes mellitus; HBV, hepatitis B virus; HCV, hepatitis C virus; NBNC, negative for hepatitis B and hepatitis C virus; HCC, hepatocellular carcinoma; Meta, liver metastasis; ALT, alanine aminotransferase; AST, aspartate aminotransferase; PT, prothrombin activity; PLT, platelet; ICGR15, indocyanine green retention rate at 15 min; WBC, white blood cell; CRP, C-reactive protein.
Discussion/Conclusion
Prediction and prevention of postoperative complications is crucial. With the aging population in developed countries, the number of elderly patients undergoing surgery has been increasing. A number of studies on surgical treatment of elderly patients have been published, and most of these studies demonstrated that operations can be performed safely in the elderly population [1]. However, those elderly patients who underwent surgery safely may have been as active and energetic as the younger population. Thus, apart from age, activity levels should be considered to evaluate the condition of a patient precisely.
Preoperative assessment of frailty has received considerable attention. Frailty includes the following three components: physical frailty, such as deterioration of nutritional status and loss of skeletal muscle mass; psychological frailty, such as lack of motivation and cognitive impairment; and social frailty, such as isolation and loneliness. A comprehensive frailty assessment should include the aforementioned components [20, 21]. However, such a comprehensive evaluation with questionnaires may only give a vague indication of frailty.
This study utilized accelerometers during the perioperative period. Based on the measurements until POD 7, the postoperative physical activity levels of the patients with postoperative complications did not increase. By contrast, patients without postoperative complications had a gradual increase in activity levels. These findings may indicate that low levels of postoperative activity could induce postoperative complications or that the occurrence of postoperative complications results in low levels of physical activity. Thus, the preoperative physical activity level may be a suitable predictor of postoperative complications because it is not affected by surgery.
This study demonstrated that patients with low levels of preoperative physical activity are at a high risk of developing post-hepatectomy complications. In addition, frailty was not identified as an independent risk factor for postoperative complications. These findings suggest that preoperative physical activity is more useful in predicting the occurrence of postoperative complications than frailty.
Furthermore, this study identified operative time and blood loss as predictive factors for post-hepatectomy complications. Operations with a long duration and major bleeding are extremely invasive and could easily result in postoperative complications. However, these factors cannot be identified preoperatively and are thus not suitable predictors of postoperative complications.
Numerous studies have investigated the usefulness of perioperative rehabilitation in reducing the likelihood of postoperative complications, and the results demonstrated that postoperative rehabilitation could prevent the occurrence of respiratory complications; hence, most hospitals provide postoperative rehabilitation for surgical patients [22]. However, the effectiveness of preoperative rehabilitation in preventing postoperative complications remains uncertain [23, 24, 25]. One of the possible reasons is the challenging preoperative rehabilitation. Postoperative rehabilitation can be provided in the hospital, whereas preoperative rehabilitation should be performed outside the hospital. This study demonstrated that patients with low preoperative physical activity levels were more likely to develop complications after surgery, indicating that the risk of postoperative complications might be reduced by enhancing physical activity levels with preoperative rehabilitation.
This study has several limitations. The sample size in this study was small, as the recruited patients were from a single facility. This study considered hepatic resection only. Furthermore, in the hospital, the patients were asked to wear the accelerometer 3 days prior to surgery and were allowed to move around the hospital without restriction. Thus, the activity levels measured in this study were assumed to be correlated to some extent with the levels of activities of daily living. Nevertheless, the physical activity levels observed in this study may differ from the usual levels of activities of daily living given that the monitoring of the activity levels in this study only included the 3 days prior to surgery. To further verify the relationship between the levels of activities of daily living and postoperative complications, we are currently attempting to investigate patients who were asked to wear an accelerometer to measure their activity levels for 1 month prior to surgery. Moreover, relevant prospective studies not only on hepatectomy but also on other gastrointestinal surgeries are warranted.
In conclusion, patients with low levels of preoperative physical activity are likely to develop post-hepatectomy complications. Hence, their postoperative recovery courses should be closely observed and carefully managed to help prevent post-hepatectomy complications.
Statement of Ethics
This prospective observational study conformed to the Clinical Research Guidelines and was approved by the Shiga University of Medical Science Research Ethics Committee (approval number: R2017-191). Written informed consent was obtained from all patients.
Conflict of Interest Statement
The authors have no related conflicts of interest to declare.
Funding Sources
No funding was received for this study.
Author Contributions
Hiroya Iida and Hiromitsu Maehira designed the research and analyzed the patient data. Hiroya Iida, Hiromitsu Maehira, Haruki Mori, Katsushi Takebayashi, Masatsugu Kojima, Sachiko Kaida, Tomoyuki Ueki, Toru Miyake, and Masaji Tani performed data collection. Hiroya Iida drafted the manuscript. All the authors read and approved the final version of the manuscript.
Data Availability Statement
All data generated or analyzed during this study are included in the article. Further inquiries can be directed to the corresponding author.
Funding Statement
No funding was received for this study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in the article. Further inquiries can be directed to the corresponding author.
