Bloodless liver resection using radiofrequency energy

BACKGROUND: Liver surgery carries the risk of intraoperative bleeding. In order to avoid bleeding, transection of the liver can be performed after coagulating the parenchyma by using monoplolar or bipolar radiofrequency energy. METHODS: 236 consecutive patients underwent liver resection with the radiofrequency-assisted technique using either a monopolar or a bipolar device. Data were collected prospectively to assess the outcome including, intraoperative blood loss, blood transfusion requirement, morbidity and mortality rates. RESULTS: There were 41 major hepatectomies and 195 minor resections. Overall mean intraoperative blood loss was 157 +/- 240 ml, while mean blood loss during liver transection was 90 +/- 105 ml. 10 patients (4%) received blood transfusion. 50 patients (21%) developed postoperative complications including 5 bile leaks (2%). The mortality rate was 2.1%. No patient was reoperated for postoperative haemorrhage or bile leak. The mean postoperative stay was 11 +/- 10 days. CONCLUSION: The radiofrequency-assisted liver resection technique offers hepatobiliary surgeons an additional method for performing liver resections with minimal blood loss, low transfusion requirement, and low morbidity and mortality rates.     

A radiofrequency-assisted minimal blood loss liver parenchyma dissection technique

BACKGROUND/AIMS: Intraoperative blood loss is still a major concern for surgeons operating on the liver since it is associated with a significantly higher rate of postoperative complications and shorter long-term survival. An original radiofrequency (RF)-assisted minimal blood loss technique for transecting liver parenchyma is presented. METHODS: In a prospective study, starting November 2001 and ending December 2005, a total of 90 RF-assisted liver resections were done. Pre-cut coagulative desiccation was produced by the Cool-tip (Valleylab, Tyco) water-cooled, single, RF tumor ablation electrode connected to a 480-kHz 200 W generator (Valleylab Cool-tip RF System). Vascular occlusion techniques and low central venous pressure anesthesia were not used. RESULTS: Only 14 (15.5%) patients received blood transfusion (mean transfused blood volume 397 ml; mode 310 ml) and 10 of 14 patients received <310 ml of blood. There was no statistical difference between the patients who underwent major and minor liver resection in frequency of blood transfusion. Blood loss was associated with dense adhesions and difficult liver mobilization and not with liver transection. CONCLUSION: The 'sequential coagulate-cut' RF-assisted liver resection technique is a safe liver transection technique associated with minimal blood loss and it has facilitated tissue-sparing liver resection.     

A prospective evaluation of ultrasound-directed transparenchymal vascular control with linear cutting staplers in major hepatic resections

BACKGROUND: We prospectively evaluated a novel ultrasound-directed technique of major hepatic resection using transparenchymal application of vascular staplers intending to minimize blood loss, operative time, and hepatic warm ischemia time. METHODS: Beginning in 1998 many major hepatic resections for hepatic tumors were performed with ultrasound-directed transparenchymal application of vascular linear cutting staplers. An endoscopic flexible neck vascular linear cutting stapler was used for control of the hepatic veins. RESULTS: From December 1998 to April 2003, 346 patients undergoing hepatic resection using this technique were identified from a prospective hepatobiliary tumor surgery database. Records were reviewed for blood loss, transfusion requirement, inflow occlusion (Pringle maneuver) time, overall operative time, and perioperative and postoperative complications. The average blood loss for all patients was 396 +/- 28.4 mL. The inflow occlusion time was 13.7 +/- .64 minutes with a total operative time of 140.7 +/- 3.7 minutes. Additional liver-related procedures were performed in 52% of the patients. The overall complication rate was 29.5% with a 90-day mortality rate of 1.4%. CONCLUSIONS: Ultrasound-directed transparenchymal application of vascular staplers to control inflow and outflow during major liver resection minimizes blood loss, warm ischemia time, and operative time compared to published reports of patients undergoing resection using other techniques.     

Radiofrequency-Assisted Liver Resection: Higher Incidence of Infectious Complications ?

Aim : To evaluate clinical experience with radiofrequency (RF)-assisted liver resection in non-cirrhotic and non-cholestatic patients with metastatic liver disease.

Methods: A group of consecutive patients who underwent RF-assisted liver resection for metastatic liver disease was prospectively followed.

Results : Between July 2005 and April 2008, 95 liver RF-assisted liver resections were performed, 71 of them for metastatic liver disease. The mean hospital stay was 14 (range 5–40) days. The mean operation time was 141 (range 64233) minutes. The mean duration of RF coagulation was 10 (range 9–12) minutes. A total of 37 complications in 24 (33%) patients were recorded, including 12 (16.9%) infected collections in resection line that had to be drained percutaneously. The 30-day postoperative mortality was zero.

Conclusion : This study indicates that RF-assisted resection may have a benefit in decreasing peroperative blood loss and the number of blood transfusions. Nevertheless, an increased incidence of infectious complications and pleural effusions that required evacuation was noted.     

The surgical treatment of liver metastases from colorectal carcinoma: our experience

Data from twelve patients who had hepatic resections for colorectal liver metastases were retrospectively analyzed to determine: 1) whether the use of the ultrasonic surgical dissector and the Argon laser can significantly simplify major hepatic resections and decrease both perioperative blood loss and postoperative morbidity and mortality, and 2) whether an adequate patients selection for surgery can effectively determine an improvement in recurrence rate. We performed 4 bisegmentectomies (2 of V and VI; 2 of VI and VII); 1 trisegmentectomy (V, VI, VII); 2 left lobectomies; 1 right hepatectomy and 4 wedge resections, using both the ultrasonic surgical dissector to fractionate and aspirate the hepatic parenchyma and to clear major vascular and biliary structures and the Argon laser for the coagulation of minor vascular and biliary vessels. The resected metastases averaged 5.5 cm (range: 1.5-7.5); blood transfusion requirements were significantly reduced from previous reports, averaging only 1.25 units (range: 0.3); the average operative time was 238 minutes (110 to 420 minutes). There were no operative deaths, operative morbidity rate was 16.6. The results indicate that the ultrasonic surgical dissector and the Argon laser have made a significant contribution to our marked decrease in the average blood loss and transfusion requirement. The long-term results seems to be improved by an adequate patients selection.     

Complete versus selective portal triad clamping for minor liver resections: a prospective randomized trial

OBJECTIVE: To evaluate the feasibility, safety, efficacy, amount of hemorrhage, postoperative complications, and ischemic injury of selective clamping in patients undergoing minor liver resections. SUMMARY BACKGROUND DATA: Inflow occlusion can reduce blood loss during hepatectomy. However, Pringle maneuver produces ischemic injury to the remaining liver. Selective hemihepatic vascular occlusion technique can reduce the severity of visceral congestion and total liver ischemia. PATIENTS AND METHODS: Eighty patients undergoing minor hepatic resection were randomly assigned to complete clamping (CC) or selective clamping (SC). Hemodynamic parameters, including portal pressure and the hepatic venous pressure gradient (HVPG), were evaluated. The amount of blood loss, measurements of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and postoperative evolution were also recorded. RESULTS: No differences were observed in the amount of hemorrhage (671 +/- 533 mL versus 735 +/- 397 mL; P = 0.54) or the patients that required transfusion (10% versus 15%; P = 0.55). There were no differences on postoperative morbidity between groups (38% versus 29%; P = 0.38). Cirrhotic patients with CC had significantly higher ALT (7.7 +/- 4.6 versus 4.5 +/- 2.7 mukat/L, P = 0.01) and AST (10.2 +/- 8.7 versus 4.9 +/- 2.1 mukat/L; P = 0.03) values on the first postoperative day than SC. The multivariate analysis demonstrated that high central venous pressure, HVPG >10 mm Hg, and intraoperative blood loss were independent factors related to morbidity. CONCLUSIONS: Both techniques of clamping are equally effective and feasible for patients with normal liver and undergoing minor hepatectomies. However, in cirrhotic patients selective clamping induces less ischemic injury and should be recommended. Finally, even for minor hepatic resections, central venous pressure, HVPG, and intraoperative blood loss are factors related to morbidity and should be considered.     

Vascular occlusions for liver resections. Operative management and tolerance to hepatic ischemia: 142 cases.

The intra- and early postoperative courses of 142 consecutive patients who underwent liver resections using vascular occlusions to reduce bleeding were reviewed. In 127 patients, the remnant liver parenchyma was normal, and 15 patients had liver cirrhosis. Eighty-five patients underwent major liver resections: right, extended right, or left lobectomies. Portal triad clamping (PTC) was used alone in 107 cases. Complete hepatic vascular exclusion (HVE) combining PTC and occlusion of the inferior vena cava below and above the liver was used for 35 major liver resections. These 35 patients had large or posterior liver tumors, and HVE was used to reduce the risks of massive bleeding or air embolism caused by an accidental tear of the vena cava or a hepatic vein. Duration of normothermic liver ischemia was 32.3 +/- 1.2 minutes (mean +/- SEM) and ranged from 8 to 90 minutes. Amount of blood transfusion was 5.5 +/- 0.5 (mean +/- SEM) units of packed red blood cells. There were eight operative deaths (5.6%). Overall, postoperative complications occurred in 46 patients (32%). The patients who experienced complications after surgery had received more blood transfusion than those with an uneventful postoperative course (p less than 0.001). The length of postoperative hospital stay was also correlated with the amount of blood transfused during surgery (p less than 0.001). On the other hand, there was no correlation between the durations of liver ischemia of up to 90 minutes and the lengths of postoperative hospital stay. The longest periods of ischemia were not associated with increased rates of postoperative complications, liver failures, or deaths. There was no difference in mortality or morbidity after major liver resections performed with the use of HVE as compared with major liver resections carried out with PTC alone, although the lesions were larger in the former group. It is concluded that the main priority during liver resections is to reduce operative bleeding. Vascular occlusions aim at achieving this goal and can be extended safely for up to 60 minutes.     

"Radical but conservative" is the main goal for ultrasonography-guided liver resection: prospective validation of this approach

BACKGROUND: Despite higher blood loss, morbidity, and mortality, rate of major resection is still high in most surgical institutions because of fear of incomplete tumor removal. To verify whether intraoperative ultrasonography (IOUS) minimizes the rate of major hepatectomies while maintaining treatment radicality, we have prospectively validated our policy, based on extensive use of IOUS resection guidance. STUDY DESIGN: Ninety-three consecutive patients with liver tumors were prospectively enrolled. There were 61 men and 32 women with a mean age of 65.6 years. Fifty-nine patients had hepatocellular carcinoma and 34 had colorectal cancer liver metastases. Surgical strategy was based on the relationship between the tumor and intrahepatic vascular structures at IOUS. Rates of major and minor resection, mortality, morbidity, and rate of local recurrences were evaluated. RESULTS: There was no hospital mortality; major morbidity occurred in 2.2% of patients and minor complications in 17%. Six (6.5%) patients required blood transfusion. Major resections (two or more segments) were accomplished in 14 patients (15%), and 5 (5.4%) patients had more than three segments removed. Major vascular invasion was present in 16 patients (17%), and contact without infiltration with major vessels was present in another 16; part of the wall of the inferior vena cava was resected in 1 patient. Surgical clearance was achieved in all patients without local recurrence at a mean followup of 18 months (median 13, range 6 to 52 months). CONCLUSIONS: This study shows that liver operations performed under IOUS guidance are safe and radical and reduce need for major hepatectomies.     

Pre-resectional inflow vascular control: extrafascial dissection of Glissonean pedicle in liver resections

Background/aims

We are evaluated technique of anatomic major and minor hepatic resections using suprahilar-extrafascial dissection of Glissonean pedicle with vascular stapling device for transection of hepatic vessels intending to minimize operative time, and blood loss.

Methodology

We prospectively analyzed the clinical records of 170 patients who underwent hepatic resection by suprahilar-extrafascial pedicle isolation and stapling technique in our clinic for emergency surgery in Belgrade. Patients who underwent hilar extrahepatic intrafascial dissection were excluded from the study.

Results

We performed 102 minor liver resections and 68 major hepatectomies. The minor liver resections were associated with significantly shorter surgery duration (95.1±31.1 vs. 186.6±56.5) and transection time (35.9±14.5 vs. 65.3±17.2) than major hepatectomies (P<0.001 for all). The mean blood loss was 255.6±129.9 mL in minor resection and 385.7±200.1 mL in major resection (P=0.003). The mean blood transfusion requirement was 300.8±99.5 mL for the patients with minor hepatectomy and 450.9±89.6 mL for those with major liver resection (P=0.067). There was no significant difference in morbidity and mortality between the groups (P=0.989; P=0.920). Major as well as minor liver resection were a superior oncologic operation with no significant difference in the 3-year overall survival rates.

Conclusions

Extrafascial dissection of Glissonean pedicle with vascular stapling represents both an effective and safe surgical technique of anatomical liver resection. Presented approach allows early and easy ischemic delineation of appropriate anatomical liver territory to be removed (hemiliver, section, segment) with selective inflow vascular control. Also, it is not time consuming and it is very useful in re-resection, as well as oncologically reasonable.     

Laparoscopic liver resection using radiofrequency coagulation

Background The use of radiofrequency (RF) energy has been described to perform open liver resection safely and with minimal blood loss. Yet no data are available on the potential contribution of RF energy to the limitation of intraoperative blood loss during laparoscopic liver resection (LLR). The aim of this prospective, nonrandomized study was to investigate the potential contribution of RF energy to the limitation of intraoperative blood loss in patients undergoing LLR. Methods Forty-five patients [male/female ratio 22/23, age 57 years (26–80)] underwent LLR. Eleven benign and 47 malignant lesions (mostly colorectal metastases) were resected. Median number [1 (1–3)] and maximum diameter [40 mm (8–170)] of tumors as well as median tumor free margins [10mm (1–30)] were comparable in patients undergoing LLR with (20 patients) or without (25 patients) RF-assistance. Thirty-eight minor (≤2 segments) and 9 major (>3 segments) resections were performed. Eighteen patients simultaneously underwent additional surgery. Results No mortality occurred. Median intraoperative blood loss was 200 (5–4000) ml and was similar in patients undergoing LLR with or without RF-assistance. The type of surgical procedure was a determinant for the amount of intraoperative blood loss (p = 0.0002). Significant bleeding occurred from large hepatic vessels at major resections. Median operation time was 115 (45–360) minutes. RF-assistance didn’t seem to reduce perioperative morbidity. Conclusions LLR can be performed with minimal intraoperative blood loss, which is determined by the type of hepatectomy. Significant intraoperative bleeding occurs from large hepatic vessels during major resections. RF-assisted parenchymal transection in LLR doesn’t seem to reduce blood loss, operation time, or perioperative morbidity.     

Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction

Background: We have previously demonstrated that maintenance of a low central venous pressure (LCVP) combined with extrahepatic control of venous outflow reduced the overall blood loss during major hepatic resections. This study examined the overall outcomes and, in particular, renal morbidity associated with a large series of consecutive major liver resections performed with this approach. In addition, the rationale for the anesthetic management to maintain LCVP was carefully reviewed.

Study Design: All major hepatectomies performed between December 1991 and April 1997 were reviewed. The prospective Hepatobiliary Surgical Service database was merged with the Memorial Hospital Laboratory and Blood Bank databases to yield the nature of the operation, blood loss, blood product transfusions, outcomes, and levels of preoperative, postoperative, and discharge serum creatinine and blood urea nitrogen.

Results: A total of 496 LCVP-assisted major liver resections were performed, with no intraoperative deaths and an in-hospital mortality rate of 3.8%. The median blood loss was 645 mL. Sixty-seven percent of the patients did not require perioperative blood transfusion during surgery and the immediate 12 hours after surgery. The median number of blood transfusions was 2. Only 3% of the patients experienced a persistent and clinically significant increase in serum creatinine possibly attributable to the anesthetic technique. Renal failure directly attributable to the anesthetic technique did not occur.

Conclusions: Major resection with LCVP allowed easy control of the hepatic veins before and during parenchymal transection. The anesthetic technique, designed to maintain LCVP during the critical stages of hepatic resection, not only helped to minimize blood loss and mortality but also preserved renal function.     

Radiofrequency-Assisted Liver Resection in Patients With Hepatocellular Carcinoma and Cirrhosis: Preliminary Results

Radiofrequency (RF)-assisted liver resection has been shown to allow virtually bloodless procedures without the need for vascular exclusion maneuvers. The aim of this study was to evaluate the safety and feasibility of RF-assisted liver resection in cirrhotic patients with hepatocellular carcinoma (HCC) and, moreover, to assess whether the RF-assisted procedure influenced the outcomes in terms of morbidity and mortality. This retrospective study included 39 cirrhotic patients who underwent RF-assisted liver resection for HCC between September 2001 and March 2006. In this period, we performed 17 monosegmentectomies, 16 bisegmentectomies, 4 trisegmentectomies, and 2 right hepatectomies. We never performed vascular exclusion maneuvers. Blood transfusion was necessary in 3 cases. One patient died postoperatively because of untreatable hepatorenal syndrome. The morbidity rate was 23%. Among patients without postoperative morbidity (n = 30), the 4-year survival rate was 61% versus 23% in patients who experienced postoperative morbidity (n = 9; P < .05). The 4-year disease-free survival rate was 40% in patients without postoperative morbidity versus 10% in patients who experienced postoperative morbidity (P = .05). Tumor dimension, number of lesions, and Child-Pugh class at surgery did not seem to significantly influence the 4-year overall survival (P > .05). In conclusion, RF-assisted liver resection was a safe, feasible procedure associated with low morbidity and hospital mortality rates even in cases of liver cirrhosis. It is, in our opinion, highly recommended for patients with HCC not suitable for liver transplantation.     

No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach.

BACKGROUND: Low resectability rates and significant morbidity and mortality rates often make surgery for hepatocellular carcinomas (HCCs) unfeasible. HYPOTHESIS: Our policy for surgical treatment of cirrhotic and noncirrhotic patients with HCC is adequate and safe. DESIGN: Prospective validation cohort study. SETTING: University hospital. PATIENTS: One hundred seven consecutive patients with HCCs. Associated cirrhosis was present in 64 (59.8%), and only 7 (6.5%) had normal livers. INTERVENTIONS: The presence of ascites, serum bilirubin level, and indocyanine green retention rate at 15 minutes were considered when selecting patients for surgery. Preoperative recovery of liver function was achieved with portal venous branch embolization, liver volumetry, bed rest, and control of serum aminotransferase levels. The surgical techniques mainly involved bloodless dissection using intraoperative ultrasonography and intermittent warm ischemia. The main perioperative care regimen was fresh frozen plasma infusion and strict limitation of blood transfusion. MAIN OUTCOME MEASURES: The 30-day postoperative mortality and morbidity rates. RESULTS: All the patients underwent surgery (37 major resections, 45 segmentectomies, and 25 limited resections), with no 30-day postoperative mortality, overall morbidity of 26.2%, and no major complications. Multiple logistic regression analysis revealed that only the type of operation was associated with a significantly higher morbidity risk (P = .05). CONCLUSION: With high resectability, low morbidity, and no mortality, our policy represents a solution to the drawbacks of surgical resection for treatment of HCCs, especially in patients with associated liver cirrhosis.     

Impact of age on the outcome of liver resections

The purpose of this study was to evaluate the influence of age on the outcome of liver resections. One hundred five consecutive hepatic resections were divided into two groups: > or = 65 years old [old group (O-group)] and < 65 years old [young group (Y-group)]. The two groups were first compared to evaluate the distribution of the variables potentially affecting the postoperative course, including primary diagnosis, concomitant diseases, previous upper abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of hepatic resections in the two groups was comparatively evaluated in terms of postoperative mortality, morbidity, transfusions, and length of postoperative hospitalization. The Y-group included 61 resections in 60 patients, mean age 52 +/- 10 years (mean +/- SD), range 23-64 years, whereas the O-group included 44 resections in 43 patients, mean age 71 +/- 4 years (mean +/- SD ), range 65-82 years. The O-group included more hepatocellular carcinomas (45.4% vs 18.0%, P = 0.002) and chronic liver diseases (40.9% vs 18.7%, P = 0.017); the median length of operation was slightly higher in the Y-group (300 minutes vs 270 minutes, P = 0.003). Both O-group and Y-group were comparable (P = n.s.) when evaluated for all other listed variables. As far as concerns the outcome of hepatic resections in the two groups, the length of postoperative hospitalization was identical (median 9 days, 5-60 days), whereas transfusions of packed red cells (O-group vs Y-group: 25.0% vs 16.3%, P = 0.30) or fresh frozen plasma (O-group vs Y-group: 13.6% vs 6.5%, P = 0.053) were not statistically different. Postoperative mortality included one case among young patients whereas no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (31.5% vs 20.5%, P = 0.59). The age factor does not negatively affect the outcome of liver resections.     

Radiofrequency-assisted liver resection

Radiofrequency (RF)-assisted thermal ablation has been used with increasing frequency for unresectable hepatic tumors. This new approach employs RF energy to coagulate the liver at the hepatic resection line after which hepatic resection is performed with the use of a common scalpel. This procedure was used in three patients with hepatocellular carcinoma and in five patients with colorectal metastasis to the liver. These eight patients underwent a total of two left bisegmentectomies, three segmentectomies, and seven wedge resections. Mean operative time was 220 minutes. A mean of 78 sessions of RF-assisted ablation were required for these resections. Mean blood loss was 46 ml; no device other than RF ablation was required to obtain hemostasis. None of the patients needed a blood transfusion. Preoperative hemoglobin was 12.8 gm/dl and postoperative hemoglobin was 11.3 gm/dl. There were no perioperative deaths. Postoperative complications occurred in two patients: a liver abscess in one and heart failure in the other. The mean hospital stay was 9.4 days. This new approach, integrated with other techniques, reduces blood loss and coagulates the margins of resection during liver surgery. This new technique has two limitations: (1) it cannot be applied near main portal pedicles, and (2) it requires a long operative time. The best indication for this technique is when segmentectomy is required in patients with cirrhosis. Its role in major hepatic resections has yet to be determined. Further progress in the development of thermal ablation techniques and experience gained during the learning curve should help reduce the operative time, thereby improving the safety and efficacy of this procedure. Presented at the Third International Meeting, "Hepatocellular Carcinoma: Eastern and Western Experience," Lodi, Italy, November 21–22, 2002.     

Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection

BACKGROUND: Recent reports highlighting reduced mortality rates to less than 1% after hepatic resections have evaluated the management of selected patients. The current risk of liver resection in unselected patients needs to be more clearly defined to appreciate the actual risk of new indications. STUDY DESIGN: From 1990 to 1997, 747 consecutive patients, including 16 operated in emergency, underwent hepatic resection. Resection was indicated for malignancy in 473 patients (63%). Major resections were performed in 333 patients (45%). An underlying liver disease, including cirrhosis (n = 239) and obstructive jaundice (n = 4), was present in 253 patients (35%). Multivariate analysis of the risk factors for postoperative mortality, morbidity, and transfusion after stratifying patients for the circumstance of the operation and the pathological changes of the remnant liver was performed. RESULTS: There was no intraoperative death and the overall mortality rate was 4.4%. This rate was 25% after emergency liver resection and 3.9% after elective liver resection (p < 0.001). After elective resection, mortality was significantly higher in patients with cirrhosis (8.7%) or obstructive jaundice (21%) than in patients with a normal liver (1%; p < 0.001). Analysis of this subgroup of 478 patients with normal liver showed that the mortality rate was 0% in 220 patients operated for a benign disease and in 263 patients who underwent minor resections. All five deaths occurred in patients with a malignancy and resulted from extrahepatic complications. In patients with a malignancy, the only independent predictor of death was an associated extrahepatic procedure. The incidence of postoperative complications was 22% and was influenced by the American Society of Anaesthesiology (ASA) score, extent of resection, presence of a steatosis, and an associated extrahepatic procedure. The incidence of major complications was 8% and of reoperation 3%. Perioperative blood transfusion was required in 112 of 478 (23%) and was not associated with increased mortality. CONCLUSIONS: The 1% basic risk of elective liver resection on normal liver suggests that indications of resection for malignancy could be extended, unless an associated extrahepatic procedure is needed. Because of this low basic risk, future studies evaluating resection on normal liver should not consider in-hospital mortality as the only end point.     

Liver resections with or without pedicle clamping

BACKGROUND: Decreasing operative bleeding during liver resection, and thus extent of transfusions, has become a main criterion to evaluate operative results of hepatectomies. Hepatic pedicle clamping (HPC) is widely used for this purpose. The aim of the study was to evaluate safety, efficacy, technique, and contraindications of HPC during liver resections, comparing results of resections performed with or without HPC. METHODS: Data from 245 liver resections were analyzed. In all, 125 resections were performed with HPC (group A), continuous in 100 cases and intermittent in 25 cases. The average duration of ischemia in group A was 39 +/- 20 minutes (range 7 to 107). In 20 cases (16%) ischemia was prolonged for 60 minutes or more. A total of 120 resections were performed without HPC (group B). Major resections were 53.6% in group A (67 cases) and 38.3% in group B (46 cases). Cirrhosis was present in 36 cases, 19 in group A and 17 in group B. RESULTS: Operative mortality was nil. Postoperative mortality was 2.9%, morbidity 22.4%. Percentage of transfused cases (34.4% versus 60.0%; P <0.001) and number of blood units per transfused case (2 +/- 1 versus 4 +/- 3; P <0.001) were lower in group A versus group B. Similar figures were found by considering only major resections. Postoperative blood chemistries did not show important differences between the two groups, and postoperative alterations were related more to extent and complexity of the operation than to length of HPC. CONCLUSIONS: HPC during liver resection is a safe and effective technique. This is demonstrated in a context where HPC is used continuously in most cases, intermittently in cases with impaired liver function and for more prolonged ischemia, and avoided in cases with limited bleeding, jaundice, and simultaneous bowel anastomoses.     

Low central venous pressure anesthesia in major hepatic resection

Blood loss and transfusion requirements are major determinants of morbidity and mortality following liver resection. This study evaluates the association of low central venous pressure [LCVP] with blood loss and blood transfusion during liver resection. Thirty consecutive hepatic resections were studied prospectively concerning CVP, volume of blood loss and volume of blood transfusion and renal outcome. Data were analyzed for those with a CVP < or = 5 mmHg, and > 5 mmHg. A multivariate analysis assessed potential confounding factors in the comparison. The mean blood loss in patients with a CVP of 5 mmHg or less was < 500 ml and that in those with a CVP > 5 mmHg was > 2000 ml. (p <0.001). Only two patients with a CVP of < or = 5 mmHg had a blood transfusion whereas 11 patients with a CVP > 5 mmHg required transfusion. No incidences of air embolism or permanent renal shutdown have been reported. It is concluded that the volume of blood loss and blood transfusion during liver resection correlates with the CVP during parenchymal transection. Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss during liver resection and delete the need for blood transfusion with its hazards.     

Impact of blood loss on outcome after liver resection

Partial liver resections are the treatment of choice for patients with a malignant liver or bile duct tumor. The most frequent indications for partial liver resections are colorectal metastasis, hepatocellular carcinoma (HCC) and cholangiocarcinoma. Liver resection is the only therapy with a chance for cure in these patients. Refinements in surgical technique and increasing experience have contributed to a reduction in perioperative morbidity and mortality in recent years. Despite these improvements, partial liver resections remain a major surgical procedure and carry the risk for excessive blood loss and a subsequent need for blood transfusion. Blood transfusions have been associated with systemic side effects, such as depression of the immune system. Several studies have suggested that perioperative blood loss or transfusions have a negative impact on postoperative outcome. However, it has been debated whether this is due to a real cause-effect relationship or merely the result of more complicated surgery. We have reviewed the literature concerning studies focusing on the relationship between blood loss and blood transfusion during liver surgery for malignant tumors and postoperative outcome. Most studies were based on a retrospective analysis of single center experiences, using uni- and multivariate statistical methods. Most studies have demonstrated a significant and clinically relevant association between blood transfusion and postoperative mortality and morbidity, especially postoperative infectious complications. The effect of blood transfusions on tumor recurrence and more long-term mortality is much less clear and evidence varies depending on the type of malignancy. The strongest indication that blood transfusion may have an impact on tumor recurrence has been found for patients with early stages of HCC. However, overall, no such effect could be demonstrated for patients undergoing partial liver resection for late stages of HCC, colorectal liver metastasis or cholangiocarcinoma.     

Improving operative safety for cirrhotic liver resection

BACKGROUND: Liver resection in a patient with cirrhosis carries increased risk. The purposes of this study were to review the results of cirrhotic liver resection in the past decade and to propose safe strategies for cirrhotic liver resection. METHODS: Based on the date of operation, 359 cirrhotic liver resections in 329 patients were divided into two intervals: period 1, from September 1989 to December 1994, and period 2, from January 1995 to December 1999. The patient backgrounds, operative procedures and early postoperative results were compared between the two periods. The factors that influenced surgical morbidity were analysed. RESULTS: In period 2, patient age was higher and the amounts of blood loss and blood transfused were lower. Although postoperative morbidity rates were similar, blood transfusion requirement, postoperative hospital stay and mortality rate were significantly reduced in period 2. No death occurred in 154 consecutive cirrhotic liver resections in the last 38 months of the study. Prothrombin activity and operative time were independent factors that influenced postoperative morbidity. CONCLUSION: With improving perioperative assessment and operative techniques, most complications after cirrhotic liver resection can be treated with a low mortality rate. However, more care should be taken if prothrombin activity is low or there is a long operating time.