Effectiveness of acute normovolemic hemodilution to minimize allogeneic blood transfusion in major liver resections

BACKGROUND: Liver resection is a major operation for which, even with the improvements in surgical and anesthetic techniques, the reported rate of blood transfusion was rarely less than 30%. About 60% of transfused patients require only 1 or 2 units of blood, a blood requirement that may be accommodated by the use of acute normovolemic hemodilution (ANH). METHODS: The efficacy, hemodynamic effects, and safety of ANH were investigated in a randomized, active-control study in patients with American Society of Anesthesiologists status I-II who were undergoing major liver resection with fentanyl-nitrous oxide-isoflurane anesthesia. Patients were randomized to the ANH (n = 39) or control group (n = 39). Patients in the ANH group underwent hemodilution to a target hematocrit of 24%. The indication for blood transfusion was standardized. In both groups transfusion was started at a hematocrit of 20%. The primary efficacy endpoint was the avoidance of allogeneic blood transfusion in the intraoperative period and first 72 h after surgery. Various laboratory and hemodynamic parameters as well as postoperative morbidity were monitored to define the safety of ANH in this patient population. RESULTS: During the perioperative period, 14 control patients (36%) received at least one unit of allogeneic blood compared with 4 patients (10%) in the ANH group ( < 0.05). The hemodilution process was not associated with significant changes in patients' hemodynamics. Morbidity was similar between the control and the ANH groups. Postoperative hematocrit levels and biochemical liver, renal, and standard coagulation test results were similar in both groups. CONCLUSIONS: Acute normovolemic hemodilution in patients with American Society of Anesthesiologists status I-II undergoing major liver resection may allow a significant number of patients to avoid exposure to allogeneic blood.     

Effectiveness of Acute Normovolemic Hemodilution to Minimize Allogeneic Blood Transfusion in Major Liver Resections

Background: Liver resection is a major operation for which, even with the improvements in surgical and anesthetic techniques, the reported rate of blood transfusion was rarely less than 30%. About 60% of transfused patients require only 1 or 2 units of blood, a blood requirement that may be accommodated by the use of acute normovolemic hemodilution (ANH).

Methods: The efficacy, hemodynamic effects, and safety of ANH were investigated in a randomized, active-control study in patients with American Society of Anesthesiologists status I-II who were undergoing major liver resection with fentanyl-nitrous oxide-isoflurane anesthesia. Patients were randomized to the ANH (n = 39) or control group (n = 39). Patients in the ANH group underwent hemodilution to a target hematocrit of 24%. The indication for blood transfusion was standardized. In both groups transfusion was started at a hematocrit of 20%. The primary efficacy endpoint was the avoidance of allogeneic blood transfusion in the intraoperative period and first 72 h after surgery. Various laboratory and hemodynamic parameters as well as postoperative morbidity were monitored to define the safety of ANH in this patient population.

Results: During the perioperative period, 14 control patients (36%) received at least one unit of allogeneic blood compared with 4 patients (10%) in the ANH group (P < 0.05). The hemodilution process was not associated with significant changes in patients' hemodynamics. Morbidity was similar between the control and the ANH groups. Postoperative hematocrit levels and biochemical liver, renal, and standard coagulation test results were similar in both groups.     

Comparison of two transfusion strategies after elective operations for myocardial revascularization.

We performed a prospective, randomized trial of two different strategies for postoperative packed red blood cell replacement in 39 autologous blood donors undergoing elective myocardial revascularization. The "liberal" group received blood to achieve a hematocrit value of 32%, and the "conservative" group received transfusions for a hematocrit value less than 25%. Although the groups had significantly different mean hematocrit values from the fourth postoperative hour (28.7% versus 31.2%) through the fifth postoperative day (28.4% versus 31.3%), there were no significant differences in fluid requirement, hemodynamic parameters, or hospital complications. Significantly fewer units of packed cells were required in the conservatively transfused group (20 units/20 patients) compared with the liberally transfused group (37 units/18 patients) (p = 0.012). Exercise tests were performed on the fifth and sixth postoperative days, with a transfusion being given to the conservative group between tests. Although a significant improvement in exercise endurance occurred in the conservative group receiving a transfusion (p = 0.008), no significant difference in duration or degree of exercise was demonstrated between the two groups on either day. In comparing these two groups of profoundly anemic patients, we identified no adverse consequence associated with the greater degree of hemodilution and could identify no correlation between hematocrit value and exercise capacity. We conclude that although the limits of hemodilution are still poorly defined, postoperative blood transfusion in revascularized patients should be guided by clinical indications and not by specific hematocrit values.     

Hypervolemic hemodilution: an alternative to acute normovolemic hemodilution? A mathematical analysis.

BACKGROUND: Hypervolemic hemodilution has been proposed as an alternative to normovolemic hemodilution to reduce homologous blood transfusions. So far, convincing data supporting this concept are unknown. MATERIALS AND METHODS: We therefore present a mathematical model calculating the efficacy of hypervolemic, normovolemic, and "no" hemodilution. Hypervolemic hemodilution constituted volume expansion (20% of estimated blood volume) maintained throughout surgery. Normovolemic hemodilution contained isovolemic exchange of blood (40% of estimated blood volume) vs colloid as well as retransfusing blood plus colloid to maintain minimal acceptable hematocrit, e.g., transfusion trigger. To determine the efficacy of each technique maximal allowable blood loss and final postoperative hematocrit were calculated. Maximal allowable blood loss referred to the amount of blood lost during surgery after which homologous blood transfusion became necessary. RESULTS: Recalculating published clinical data strongly validated the formulas used for our model. Hypervolemic hemodilution always revealed lowest maximal allowable blood losses. Normovolemic hemodilution constantly ensured highest maximal allowable blood losses. For blood losses <40% of blood volume, hypervolemic and normovolemic hemodilution provided almost identical final postoperative hematocrits. But in contrast to normovolemic hemodilution, hypervolemic hemodilution did not carry the risk of severe transient, retransfusion-induced hypervolemia. "No" hemodilution always gave lowest final postoperative hematocrits. CONCLUSIONS: Thus, hypervolemic hemodilution cannot replace normovolemic hemodilution to reduce homologous transfusions, but for blood losses <40% of blood volume hypervolemic hemodilution appears to be superior.     

Influence of hemodilution on hepatic energy metabolism in rat

The effects and safety limits of acute hemodilution on hepatic energy status were investigated in relation to arterial blood ketone body ratio and hepatic energy charge in a hemodilution rat model. As long as the hematocrit value was maintained above 20%, ketone body ratio and energy charge level at 6 h after hemodilution remained at the same levels as those of the sham-diluted groups. However, when hematocrit value was less than 15%, the ketone body ratio markedly decreased from the control value of 0.686 +/- 0.044 to 0.278 +/- 0.048 (p less than 0.001), and energy charge decreased from the control value of 0.856 +/- 0.012 to 0.0806 +/- 0.011 (p less than 0.01). From these results, it was suggested that hemodilution exerts no influence on the energy status of the liver as long as hematocrit is maintained above 20%.     

Determinants of cardiac output during experimental therapeutic hemodilution.

In 20 dogs, blood loss of 20 ml/kg during thoracotomy was immediately replaced with 40 ml/kg of 2.5% dextran-40 or dextran-70 in saline. An immediate rise in blood volume, associated with a decrease in hematocrit and blood viscosity, produced a marked rise in cardiac output. This effect was slightly greater with dextran-40. During the first four hours after infusion of dextran-40, both blood volume and cardiac output fell below control levels. Blood volume and cardiac output remained at or near control levels during this period in the group receiving dextran-70. In both groups, blood viscosity and hematocrit remained low throughout the study, but cardiac output increased only in response to an increase in blood volume. Twenty-four hours after infusion of either dextran-40 or dextran-70, hematocrit had decreased further, presumably due to postoperative blood loss while blood volume and cardiac output remained at or near control levels. During isovolemic hemodilution in this experimental setting, cardiac output responded primarily to changes in blood volume rather than blood viscosity. Therefore, decreased oxygen availability during hemodilution was compensated only by a rise in oxygen extraction.     

前入路绕肝提拉法与常规法在右半肝切除术中的应用对比研究

目的:比较前入路绕肝提拉法和常规法肝切除在右半肝切除术中应用的安全性和临床可行性。方法:选择2008年1月—2011年6月间收治的拟行右半肝切除患者40例,随机分为常规肝切除组(n=20)和前入路绕肝提拉法肝切除组(n=20),比较两组患者术前情况、肝切除范围、术中情况、术后并发症及各项生化指标的变化。结果:两组患者术前一般资料和肝切除范围具有可比性;术中大出血发生率两组间无差异(P>0.05),但绕肝提拉法组术中出血量和输血量均明显少于常规法组[(340.0±241.4)mLvs.(725.0±386.6)mL;(290.0±397.2)mL vs.(615.0±722.7)mL,均P<0.05],且绕肝提拉法组中未输血患者比例明显高于常规法组(16/20 vs.10/20,P<0.05);两组患者ICU时间、住院时间及术后并发症发生率无差异(均P>0.05);两组间术前及术后第1天肝功能指标[总胆红素(TBIL),谷丙转氨酶(ALT),谷草转氨酶(AST),前白蛋白(PA),凝血酶原时间(PT)]差异均无统计学意义(均P>0.05),但常规法组术后第1天C反应蛋白(CRP),术后第3,5,7天TBIL,ALT,AST,PT均明显高于前入路绕肝提拉法组,PA明显低于前入路绕肝提拉法组(均P<0.05);两组间肾功能指标(尿素氮,肌酐)术前、术后均无明显差异(均P<0.05)。结论:前入路绕肝提拉法应用于右半肝切除术较常规法在术中安全及保护术后肝功能方面更有优势。     

Combination of acute normovolemic hemodilution technique with preoperative autologous blood donation prevented allogeneic blood transfusion against 4000 g surgical blood loss in a patient undergoing left partial nephrectomy

A 41-year-old male patient with well-controlled hypertension underwent a partial nephrectomy under total intravenous anesthesia with propofol, fentanyl and ketamine. To avoid allogeneic blood transfusion, preoperative autologous blood donation (400 g) a week before the surgery and acute normovolemic hemodilution (800 g) after induction of anesthesia were performed. As surgical blood loss was more than 4000 g, blood hemoglobin (Hb) level decreased to 6.4 g.dl-1. However, as intraoperative hemodynamics was relatively stable with no ischemic changes in ECG and arterial blood gas analysis did not show metabolic acidosis, autologous blood transfusion was withheld till hemostasis had been done. After returning the autologous blood, Hb increased to 9.4 g.dl-1. On the 2nd postoperative day, Hb decreased to 7.6 g.dl-1. As the patient's vital signs did not show any severe complications, blood transfusion was not performed. Then, the Hb level increased gradually to 13.9 g.dl-1, 3 month later without allogenic blood transfusion. In addition, any postoperative complications by low Hb level were not recognized so far. This case suggests that combination of autologous transfusion techniques may be effective to avoid allogeneic blood transfusion even against massive hemorrhage. However, to avoid disadvantage of these technique, we should always evaluate preoperative patient conditions.     

Hemoglobin-based oxygen carrier HBOC-201 provides higher and faster increase in oxygen tension in skeletal muscle of anemic dogs than do stored red blood cells

BACKGROUND: Increasing need for and potential shortage of blood products have intensified the search for alternative oxygen carriers. A solution to this problem could be use of the bovine hemoglobin-based oxygen carrier HBOC-201. While hemodynamic reactions to cell-free hemoglobin have been studied, little knowledge exists about tissue oxygenation properties of hemoglobin solutions, especially in comparison with red blood cells (RBCs). STUDY DESIGN AND METHODS: Tissue oxygenation in skeletal muscle of 12 anesthetized dogs was examined after decrease of hemoglobin concentrations by means of hemodilution to hematocrit 10% and subsequent transfusion with either HBOC-201 or autologous banked RBCs. In addition to hemodynamic parameters, blood gas concentrations and oxygen content in arterial and muscular venous blood, tissue oxygen tension (tPO(2)) were measured in the gastrocnemius muscle with a polarographic needle probe. RESULTS: Hemodilution increased muscular blood flow and oxygen extraction and decreased tPO(2). Transfusion decreased muscular oxygen extraction in the RBC group but not in the HBOC-201 group (P <.01). The 10th percentile of tPO(2) increased by 400% after the first dose of HBOC-201 (P <.001 vs posthemodilution) but only by 33% after equivalent RBC transfusion (P <.01 vs HBOC-201). Increases in the 50th (120%, P <.05) and 90th (31%) percentiles and all percentiles of tPO(2) after the second and third HBOC-201 dose were less pronounced but higher than in the RBC group. CONCLUSION: Compared with RBC transfusion, infusion of low doses of HBOC-201 maintain enhanced oxygen extraction after extended hemodilution and provide faster and higher increase in muscular tissue PO(2).     

丹参对大鼠缺血后残肝有效血流量的影响

目的　探讨丹参对大鼠缺血后残肝有效血流量的影响。方法　应用ＳＰＥＣＴ测定鼠残肝有效血流量变化。结果　肝部分切除术后残肝有效血流量下降（ Ｐ＜ ０ ．００１） ;缺血组残肝有效血流量明显低于对照组（ Ｐ＜０ ．００１）,术后第７ 天仍低于术前水平（Ｐ＜ ０．０５）;丹参组残肝有效血流量明显高于缺血组（ Ｐ＜ ０．００１）,术后第７ 天达正常水平。结论　缺血残肝有效血流量下降,丹参能增加缺血残肝有效血流量,对残肝再生产生有益的影响。     

No release of cardiac troponin I during major orthopedic surgery after acute normovolemic hemodilution

Background : Normovolemic hemodilution is a well-accepted method for intraoperative blood salvage. However, some controversy exists concerning the possible risk of myocardial fiber injury as a consequence of the reduced oxygen content. Laboratory diagnosis of perioperative myocardial fiber injury is difficult, since biochemical markers are elevated postoperatively due to the surgical trauma. Cardiac troponin I (cTnI) is a new, highly sensitive and specific cardiac marker for the detection of myocardial injury. The aim of our study was to investigate whether normovolemic hemodilution in patients with major orthopedic surgery (13 hemodiluted patients, 15 controls) induces a release of cTnI.
Methods : cTnI as a highly specific and sensitive cardiac parameter, as well as total creatine kinase (CK), creatine kinase isoenzyme MB mass (CKMB mass) and myoglobin were measured after induction of anesthesia, after normovolemic hemodilution, prior to retransfusion of blood components, 3 h after surgery, and on the first and third postoperative days. Results: Prior to retransfusion of blood components the hematocrit was decreased to 25.4±1.2% (mean±SEM; range: 18%–34%) in the control group and to 20.2±0.8% (mean±SEM; range: 17%-24%) in the hemodilution group. Total CK, CKMB mass as well as myoglobin concentration increased significantly in both groups, reaching their maxima within the first day of surgery. In contrast, cTnI was below the detection limit of the assay (<0.5 μg/L) at any time.
Conclusions : We suggest that pre- and intraoperative hemodilution to a hematocrit of approximately 20% by maintaining normovolemia does not induce myocardial fiber injury in patients without preexisting cardiac diseases.     

ASA 评分在肝癌患者外科治疗风险评估中的作用

目的：探讨ASA评分对肝癌患者外科治疗风险评估的价值。 方法：回顾2006年1月—2010年12月419例原发性肝癌肝切除患者围手术期临床资料,分析患者ASA评分与临床因素的关系,并对可能的相关因素作单因素筛选后行多因素回归分析,分析肝癌术后并发症及术中输血有关的影响因素。 结果：统计分析显示,肝癌患者术前并发症及术前血红蛋白影响ASA评分;随着ASA评分上升,患者术中失血量、输血量、术后并发症及住院天数明显高增加（均P<0.05）。多因素回归分析结果显示,ASA评分、失血量、肝硬化、年龄、丙氨酸转氨酶（ALT）水平是术后并发症发生的独立影响因素（均P<0.05）;ASA评分、手术时间、肿瘤直径是术中输血的独立影响因素（均P<0.05）。 结论：ASA评分是肝癌患者围手术期风险较好的早期预测指标。     

Measurement of the portal blood flow in man by continuous local thermodilution method: II. Portal hemodynamics before and after hepatectomy

We found that measurements of portal blood flow by continuous thermodilution were highly reproducible even after hepatectomy. Our subjects numbered 59 in all: In these patients having diseases of the liver and biliary tract, we studied portal hemodynamics during percutaneous transhepatic portography. Of these, 37 underwent hepatectomy. We chose 19 subjects from this group, and measured again both portal venous flow and portal venous pressure many times, continuing for 14 more days. In all 19 patients checked after hepatectomy, portal hemodynamics became hypodynamic, and this change was greater when the amount of liver resected was large. In 18 of these patients, hemodynamics started to improve after the 7th postoperative day. Changes in hemodynamics were not significantly different in patients with or without cirrhosis. In one patient who died of hepatic failure, the portal hypodynamic state did not improve. With this exception, in patients with major resections, portal venous flow per liver volume had increased after surgery and continued to increase. This was not true for patients with minor resections. Portal hemodynamics are important in the functioning and regeneration of the remaining liver, and it is necessary to understand and medically correct portal hemodynamics before and after hepatectomy.     

Intraoperative normovolemic hemodilution

We have studied the cardiopulmonary hemodynamics of acute hemodilution in a group of patients with cancer. The majority of patients had multisystem disease; including chronic lung disease, liver disease, sepsis, and malnutrition. The only patients who were excluded were those with a recent history of myocardial ischemia. Acute intraoperative hemodilution to a hematocrit of 22% was well tolerated provided blood volume was maintained with crystalloid solution. Hemodilution led to improved cardiac output by enhancing venous return which helped to compensate for the diminished oxygen content of the blood. There were no adverse cardiopulmonary effects in hemodiluted patients compared to patients undergoing similar operations without hemodilution. Acute normovolemic hemodilution is an effective clinical means of reducing the use of bank blood and avoiding the risks of blood transfusion in patients undergoing major surgery.     

Two cases of extreme hemodilution caused by massive hemorrhage immediately after start of operation

We describe two cases of extreme hemodilution due to large amounts of fluid infusion for unexpected massive hemorrhage. In both cases, unexpected hemorrhage with difficult hemostasis occurred within 60 min after the start of the operation. For lack of transfused blood, large amounts of fluid infusion using crystalloid and colloid solutions including 5% albumin, plasma expander and lactated Ringer's solution were administered to maintain circulatory blood volume. The hemoglobin concentration and hematocrit had been below 2.0 g.dl-1 and 10% for approximately one hour, respectively. The extreme hemodilution improved by the urgent blood transfusion. In one case, intraoperative autotransfusion with Cell-Saver was performed. In spite of intraoperative extreme hemodilution, their postoperative courses were uneventful. Intraoperative awareness was present in both cases.     

围手术期肠内免疫营养对肝硬化肝切除大鼠肝再生的影响

目的：探讨围手术期内使用肠内免疫营养支持对肝硬化肝切除大鼠肝再生功能的影响。方法：48只肝硬化大鼠随机均分为两组。A组为标准肠内营养组，B组为肠内免疫营养组。依标本采集时间的先后， A, B组再各分为4个亚组。两组大鼠用等热量肠内营养剂喂养8d 后行68％肝切除术，术后再喂养至取标本时间。分别于术前、术后1, 4和8d 取相应亚组大鼠肝组织标本，检测肝细胞有丝分裂指数(MI)和增殖细胞核抗原(PCNA)阳性细胞数。结果：两组大鼠肝切除术后残肝表现出一定的再生能力。B组肝细胞MI和PCNA阳性细胞计数在术后4d 和8d 显著高于A组(P<0.05)。结论：围手术期肠内免疫营养支持较之标准肠内营养支持更能增强肝硬化肝切除大鼠残肝再生能力，使肝再生在术后较长时间内保持高水平。     

Acute normovolemic hemodilution and nitroglycerin-induced hypotension: comparative effects on tissue oxygenation and allogeneic blood transfusion requirement in total hip arthroplasty.

STUDY OBJECTIVES: To study the comparative effects of acute normovolemic hemodilution and nitroglycerin-induced hypotension on tissue oxygenation and blood transfusion requirement. DESIGN: Prospective, randomized study. PATIENTS: 30 ASA physical status I and II patients scheduled for primary total hip arthroplasty. INTERVENTIONS: Patients were randomized to one of three groups of 10 patients each, to receive acute normovolemic hemodilutin (Group 1) or nitroglycerin-based hypotension (Group 2); Group 3 served as the control group. In Group 1, 2 U of blood was collected and replaced with an equal volume of hydroxyethyl starch (200/0.56%) immediately after anesthesia induction. In Group 2, nitroglycerin was infused at a rate sufficient to reduce mean arterial pressures to 60 to 65 mmHg before initiation of surgery. When hematocrit was reduced to 25%, at first autologous blood and then, if necessary, allogeneic blood was transfused to Group 1, and allogeneic blood was transfused to the other two groups, until hematocrit reached 30% for 5 days postoperatively. MEASUREMENTS AND MAIN RESULTS: Total transfused allogeneic units of blood were determined by the fifth postoperative day. Arterial oxygen content (CaO2), venous oxygen content (CvO2), and oxygen extraction ratios (EO2) were calculated by standard formulas. The mean allogeneic transfusion requirement was significantly lower in Group 1 (1.3 +/- 0.8 U) than in Group 2 (2.3 +/- 0.8 U) or Group 3 (2.7 +/- 1.1 U) (p < 0.05). In Group 1, CaO2 and CvO2 were decreased at all times, but EO2 was significantly increased from 15 +/- 3.9% to 33.3 +/- 5.3% (p < 0.001). As for the other two groups, although CaO2 and CvO2 were decreased, EO2 was not significantly increased. CONCLUSIONS: Acute normovolemic hemodilution is more effective than nitroglycerin-induced hypotension in reducing allogeneic blood transfusion requirement in total hip replacement surgery, without significant metabolic changes.     

Effects of hemodilution and phenylephrine on cerebral blood flow and metabolism during cardiopulmonary bypass

OBJECTIVE: Hypotension resulting from hemodilution on cardiopulmonary bypass is often treated by pressor (eg, phenylephrine) infusion. The effect of phenylephrine on cerebral blood flow (CBF) in this setting is not clear. It was hypothesized that phenylephrine might decrease CBF. MEASUREMENTS and MAIN RESULTS: Six different radioactively labeled microspheres (15 microm) were used to measure CBF at 6 time points (T) in 9 pigs (mean body weight 11.3 +/- 1.2 kg): T1 baseline before bypass (mean arterial pressure [MAP] 76 +/- 5 mmHg), T2 on mildly hypothermic CPB (34 degrees C, pump flow 100 mL/kg/min, hematocrit 30%, MAP 79 +/- 7 mmHg), T3 after moderate hemodilution with crystalloid (hematocrit 20%, resulting MAP 62 +/- 6 mmHg), T4 after phenylephrine administration to increase MAP to baseline values (hematocrit 20%), T5 after severe hemodilution (hematocrit 10%, resulting MAP 41 +/- 4 mmHg), and T6 after phenylephrine administration to normalize MAP (hematocrit 10%). In addition, blood flow to liver, small bowel and skeletal muscle, and pH of jugular venous blood were measured at each time point. After institution of CPB, the CBF (mL/min/100 g tissue) increased significantly to 53 +/- 9 (baseline levels 44 +/- 8, T1 v T2, p = 0.03). Hemodilution resulted in significant increases in CBF on CPB to 65 +/- 9 and 90 +/- 9 at hematocrit 20% and hematocrit 10%, respectively (T2 v T3, p = 0.03; T3 v T5, p = 0.01) and a progressive fall in jugular venous pH. At each level of hemodilution, phenylephrine resulted in an additional increase in CBF (T4, 74 +/- 8; T6, 108 +/- 12; T3 v T4, p = 0.04; T5 v T6, p = 0.01) but did not improve jugular venous pH. Changes in liver blood flow after hemodilution and vasopressor injection showed a similar pattern to CBF. However, the blood flow to small bowel and skeletal muscle increased with hemodilution but decreased significantly with phenylephrine administration. CONCLUSIONS: Phenylephrine redirects blood flow from the bowel and muscle to the brain and liver. Hemodilution increases CBF and pressor administration further increases CBF by elevating perfusion pressure. Maintenance of a higher hematocrit on CPB increases MAP and should decrease the need for vasopressor administration.     

Normal hepatic hemodynamics during early postoperative period in recipients with adult live donor liver transplantation

To recognize "normal" hepatic hemodynamics after live donor liver transplantation (LDLT), we analyzed Doppler parameters on recipients with a right liver graft and donors after extended left hepatectomy. Theoretically these values should be the same. From April 2000 to October 2004, 20 LDLTs were performed using a right liver graft. The 10 recipients without postoperative complications and their donors were included in this study. Portal venous velocity (PVV; cm/s), hepatic arterial peak systolic velocity (cm/s), and hepatic venous peak velocity (HVPV; cm/s) were measured during the first 2 weeks. In donors PVV and HVPV after LDLT were significantly higher after than before left hepatectomy: 19.2 +/- 4.2 vs. 31.5 +/- 13.0 cm/s (P = .013) and 23.0 +/- 7.2 vs. 41.8 +/- 10.3 cm/s respectively (P = .010). However, there were mild degrees of increased PVV and HVPV. In recipients, a markedly increased PVV (106.3 +/- 45.2 cm/s on day 1) was significantly higher than that in donors on each postoperative day. The hepatic arterial resistive index in recipients was also significantly higher than that in donors on each postoperative day, for example, 0.72 +/- 0.11 vs 0.62 +/- 0.04 on day 1 (P = .0326). In conclusion, we have shown "abnormal" hepatic hemodynamics in even those recipients without complications during the early postoperative period after LDLT.     

Blood concentration of granulocytic elastase, surgical invasion and postoperative complications--with special reference to surgical resection of liver cirrhosis

The blood concentrations of granulocytic elastase (PMN-E), alpha 1-antitrypsin and alpha 2-macroglobulin were examined to evaluate their clinical significance in patients who underwent hepatectomy due to liver cancer with liver cirrhosis (n = 31, Group A), due to liver cancer with chronic hepatitis (n = 5, Group B) and without hepatic complications (n = 6, Group C) and other major surgeries (n = 10, Group D). In all groups, on the first postoperative day, blood PMN-E increased rapidly more than three times of the preoperative levels. Despite a decreasing tendency from postoperative Day 3, the value in Group A reincreased on Day 5. The peak PMN-E values within 24 postoperative hours showed significant positive correlations (p less than 0.01) with the amounts of hemorrhage and blood transfusion during operation in all groups. Even in 18 cases without blood transfusion, peak PMN-E was positively correlated (p less than 0.05) with the operative time and the amount of blood loss during operation. In Group A, patients in whom blood PMN-E increased after postoperative Day 3 developed infection and adult respiratory distress syndrome. After temporary reduction after operation except for Group C, blood alpha 1-antitrypsin increased from postoperative Day 3. However, alpha 1-antitrypsin in Group A was significantly low (p less than 0.01), compared to the increased levels in Group C and D. Blood alpha 2-macroglobulin showed no tendency of postoperative increase in all groups.