Liver resection in a resource-limited setting: Outcome of developed-world standards of R0 resection and 30-day mortality without a dedicated ICU or advanced technology—A real-world data analysis from Sri Lanka.

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Background: Liver resection with curative intent offers a chance of long-term survival for patients with hepatic malignancies. In many low- and middle-income countries (LMICs), including Sri Lanka, wider adoption of these procedures is limited by the scarcity of specialized centres, advanced technology, and dedicated intensive care units (ICUs). This study examines the outcomes of complex liver resections performed at a non-specialist peripheral hospital in Sri Lanka operating under significant resource constraints. Our objective was to assess whether liver resections carried out in a resource-limited centre in an LMIC can achieve R0 resection and 30-day mortality outcomes comparable to benchmarks reported from high-income settings. Methods: We conducted a retrospective study on a cohort of consecutive patients who underwent liver resection for primary or secondary hepatic malignancies at a single peripheral centre over a two-year period (February 2024 to January 2026). Patients with benign disease were excluded. All operations were performed without hepatic inflow occlusion (no Pringle maneuver). An R0 resection was defined as a microscopically clear margin of at least 1 mm. Primary outcomes were the R0 resection rate and 30-day mortality. Results: Of 41 patients identified, 39 met the inclusion criteria after exclusion of two patients with benign cysts. Overall, 57.1% had primary liver cancers and 42.9% had secondary metastases. Major liver resections were performed in 52.6% of patients and minor resections in 47.4%. Intra-operative transfusion of more than two units of blood was required in 18.0% of cases. Postoperatively, 51.4% of patients had an ICU stay of three days or less. An R0 resection was achieved in 71.8% (n = 28), while 28.2% (n = 11) had an R1 resection. The overall 30-day mortality rate was 10.3% (n = 4). 66.7% were alive at 30 days and had a R0 resection. There was no statistically significant association between R0 resection status and 30-day mortality (p = 0.307). Conclusions: In this real-world series from a resource-limited LMIC setting, complex liver resections achieved R0 resection rates and 30-day mortality outcomes comparable to published benchmarks from high-income countries. The lack of a statistically significant relationship between margin status and early mortality indicates that an assertive approach to securing clear margins appears safe and does not adversely affect short-term postoperative outcomes, even in the absence of a dedicated ICU and advanced technology.