Methods to decrease blood loss during liver resection: a network meta-analysis

Abstract

Many cancerous and non-cancerous growths that develop in the liver are treated by removing part of the liver (elective liver resection), which is major surgery with high risk of complications. Severe blood loss is a contributing factor to the complications since blood vessels are cut and blood entering the liver from the general circulation escapes during liver resection. Several methods have been proposed to decrease blood loss during liver resection. This includes blocking the blood supply to the liver during the operation, a process known as vascular occlusion, which could be performed continuously or intermittently. Special equipment using ultrasound waves and high-frequency alternating current called radiofrequency waves have been proposed as alternatives to using simple surgical instruments in the division of the liver. Once the liver is divided, care is taken to ensure that there is no bleeding from the cut surface of the liver remaining in the body. This can be done by simply using the heat generated by standard alternating current (diathermy machine or electrocautery) or additional glue can be applied to the cut surface to prevent and control bleeding. However, the benefits that these special methods offer in liver resection are unknown. A surgeon typically uses one method from each of these three categories, that is, vascular occlusion (including no vascular occlusion), the use of special equipment to divide the liver, and the way that the cut surface is managed. Together, one can consider this combination of methods as a treatment strategy. The optimal treatment strategy for liver resection is unknown. We sought to clarify this information by performing a literature search to seek the differences in death, complications, quality of life, blood loss and blood transfusion requirements, length of hospital stay, intensive therapy unit stay, and time taken to return to work between the different treatment strategies. We used special statistical methods to compare the different treatments simultaneously as compared to the traditional Cochrane method of comparing two treatments at a time since there are multiple treatment strategies.