Hepatocellular carcinoma (HCC) is the most common type of primary liver malignancy and a major cause of cancer-related mortality worldwide. According to GLOBOCAN 2022, liver cancer remains a major oncological burden globally, and Vietnam remains among the countries with a high disease burden (1). The burden is particularly high in Asia, where chronic hepatitis B virus infection and underlying cirrhosis remain dominant etiological factors. Since early-stage HCC is often asymptomatic and surveillance is inconsistently implemented, numerous patients present with intermediate or advanced disease, requiring treatment decisions that balance oncological control with preservation of hepatic functional reserve (1-4).

Surgical resection is potentially curative and remains a cornerstone treatment for patients with adequate liver function and resectable tumors. However, hepatectomy is technically demanding and may be complicated by substantial postoperative morbidity, particularly in patients with chronic liver disease. Post-hepatectomy liver failure (PHLF) and bile leakage are among the most clinically relevant adverse events, as they are associated with prolonged hospitalization, increased resource utilization and impaired short-term recovery. Standardized definitions from the International Study Group of Liver Surgery (ISGLS) (5,6) facilitate comparisons across studies, yet complication rates still vary widely according to patient selection, extent of resection, perioperative management and institutional experience (3,4,7,8).

Although outcomes have improved in high-volume centers, data from Vietnam and other low- and middle-income countries remain limited. Local evidence is required to benchmark early surgical safety and to describe pathological, as well as operative findings, and to identify potentially modifiable risk factors that can inform clinical decision-making. Therefore, the present study aimed to describe the clinical, laboratory, imaging, pathological and operative characteristics of patients undergoing hepatectomy for HCC at Da Nang Oncology Hospital (Da Nang, Vietnam), and to explore factors associated with early post-operative complications.

The baseline characteristics of the patients are summarized in Tables I and II. The cohort was predominantly male (78.9%), with a mean age of 57.0±12.1 years. The majority of the patients had a normal BMI (18.5-24.9 kg/^m2, 77.2%) and preserved liver function (Child-Pugh A, 100%). Chronic hepatitis B virus infection was the predominant viral background, and 42.1% of patients had an α-fetoprotein level ≥400 ng/ml.

The tumor characteristics are presented in Table III. Typical HCC imaging features on contrast-enhanced CT/MRI were present in 75.4% of the patients. A solitary tumor of >5 cm in size was the most common pattern (43.9%). The mean tumor size on imaging (6.5±3.0 cm) was similar to that on gross pathology (6.6±3.0 cm). As per the histopathological examination, the majority of tumors were moderately differentiated (70.2%), whereas 19.3% were poorly differentiated.

Operative details and early outcomes of the patients are presented in Table IV. Posterior sectionectomy was the most frequent procedure (28.1%), followed by left hepatectomy (21.1%). The mean operative time was 156.6±34.8 min, and the mean estimated blood loss was 399.0±212.6 ml. Intraoperative adverse events occurred in 5.3% of patients. Overall, 15.8% of patients developed ≥1 post-operative complications, most commonly PHLF (7.0%) and bile leak (5.3%). No post-operative mortality was observed.

The factors associated with any post-operative complications are summarized in Table V. Complications occurred more frequently in patients with pre-operative hypoalbuminemia (<35 g/l; 36.4 vs. 10.9%; P=0.0389), BCLC stage B (17.6 vs. 0% for BCLC A; P=0.0016) and those undergoing major hepatectomy (28.6 vs 8.3%; P=0.0451). Although thrombocytopenia exhibited a numerically higher complication rate, the association was not statistically significant (30.0 vs. 12.8%; P=0.1786).

In the present retrospective cohort of 57 patients undergoing open hepatectomy for HCC at a tertiary oncology center in Vietnam, early outcomes were acceptable, with an overall complication rate of 15.8% and no post-operative mortality. All patients had Child-Pugh A liver function, and the majority had chronic viral hepatitis, reflecting the epidemiological profile of HCC in Vietnam (2).

Notably, almost 90% of the patients were classified as BCLC stage B. Although transarterial chemoembolization is commonly recommended for intermediate-stage HCC, multidisciplinary selection and treatment stage migration may identify subsets with resectable disease and preserved liver reserve who could still be considered for surgery (3,4,8). The findings of the present study suggest that hepatectomy can be performed with acceptable short-term safety in carefully selected patients in this category; however, the present study did not include a non-surgical comparator group or long-term oncological follow-up. Therefore, these findings should not be interpreted as support for routine resection in all patients with stage B HCC.

PHLF (7.0%) and bile leak (5.3%) were the most frequent complications. These events are clinically important as they can prolong recovery and increase resource utilization. The observed rates are within the range reported in contemporary hepatectomy series, noting that incidence varies with baseline liver disease, the extent of resection and application of standardized definitions such as those from the ISGLS (5,6,11-13).

Operation time and blood loss in the present study cohort indicated technically feasible open resections in this setting. While minimally invasive liver surgery is increasingly adopted worldwide, open hepatectomy remains the primary approach in numerous centers due to tumor complexity, cirrhotic background and resource or training constraints. Ensuring consistent perioperative pathways and timely recognition and management of complications therefore remains essential (14,15).

Among the evaluated factors, pre-operative hypoalbuminemia was associated with a higher complication rate. Serum albumin reflects nutritional status, systemic inflammation and hepatic synthetic function; low values may identify patients with limited physiological reserve. Preoperative nutritional assessment and optimization, when feasible, may help reduce postoperative risk. Since the present analysis was limited to univariable comparisons, this association should be regarded as exploratory rather than an independent predictor.

Major hepatectomy was also associated with complications, consistent with the pivotal role of resection extent and future liver remnant in postoperative safety. In settings where quantitative volumetry or functional testing is not routinely available, cautious selection, meticulous operative technique and intensive post-operative monitoring are particularly important. The association between BCLC stage and complications may reflect greater tumor burden and operative complexity rather than stage alone. In addition, the predominance of moderately differentiated tumors on pathology provides useful context for interpreting the surgical case mix in the present cohort.

Although open hepatectomy remains the mainstay in numerous low- and middle-income settings, minimally invasive liver resection (laparoscopic or robotic) has expanded rapidly and is increasingly supported for appropriately selected patients (16,17). Recent systematic reviews and meta-analyses suggest that minimally invasive approaches can reduce blood loss and shorten recovery while maintaining comparable short-term safety and oncological adequacy vs. conventional resection when performed in experienced centers (15,18). Current practice guidelines continue to endorse surgical resection as a potentially curative treatment for selected patients with preserved liver function and resectable disease (3,4,8). In this context, the data of the present study provide a critical benchmark for open hepatectomy outcomes, and may inform stepwise adoption of advanced techniques (such as laparoscopy) through structured training and careful case selection.

In addition, perioperative optimization could further improve outcomes in similar real-world environments. The Enhanced Recovery After Surgery (ERAS) Society recommendations for liver surgery emphasize standardized pathways, including multimodal analgesia, goal-directed fluid therapy, early mobilization and early enteral nutrition, which have been associated with lower morbidity and a more rapid functional recovery (19). Using standardized ISGLS definitions for PHLF and bile leakage facilitates transparent benchmarking across studies (5,6). Given the association between hypoalbuminemia and post-operative complications in the present study cohort, targeted pre-habilitation, the optimization of hepatic reserve and parenchymal-sparing strategies for borderline patients may be particularly valuable (12).

These findings provide local benchmark data for the early outcomes of patients undergoing hepatectomy in Vietnam and highlight potentially actionable risk factors. Patients with hypoalbuminemia or those planned for major hepatectomy may benefit from enhanced perioperative optimization and closer post-operative surveillance.

The present study has several limitations which should be mentioned. Its retrospective single-center design is susceptible to incomplete documentation and may undercapture complications occurring following discharge. The sample size and event number were limited, and only 9 complication events were observed; consequently, only univariable analyses were performed and residual confounding cannot be excluded. The archived screening log did not permit reliable reconstruction of the exact number of exclusions in each category. In addition, the study did not assess several important long-term oncological outcomes, including resection margin status, recurrence, disease-free survival and overall survival. Therefore, future prospective studies with standardized complication grading, more comprehensive pathology datasets and longer follow-up are warranted.

In conclusion, open hepatectomy for HCC in carefully selected patients in the present study was associated with acceptable early post-operative outcomes and no 30-day mortality. Hypoalbuminemia, BCLC stage B disease and major hepatectomy were associated with post-operative complications in univariable analysis; however, these findings should be interpreted with caution due to the limited sample size and event number. Larger prospective studies with detailed pathological assessment and long-term follow-up are required to corroborate the present findings.