Hepatic Resection Surgery Research Articles

GLP1 Receptor Agonist Liraglutide Is an Effective Therapeutic Option for Perioperative Glycemic Control in Type 2 Diabetes within Enhanced Recovery After Surgery (ERAS) Protocols

Background: Enhanced Recovery After Surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing profound stress responses following surgery [Wilmore and Kehlet: BMJ 2001; 322(7284): 473–6]. Glucagon-like peptide-1 receptor agonists (GLP-1RAgs), such as liraglutide, have recently been widely used as antidiabetic agents in patients with type 2 diabetes (T2D) because they maintain blood glucose at an ideal level throughout the day, including during postprandial periods, thereby improving hypoglycemia and body weight more than insulin therapies. Additionally, the administration of liraglutide may exert cardiovascular, renal, and cerebral protective effects in T2D patients. The use of GLP-1RAgs for perioperative glycemic control is sometimes considered to be controversial. Methods: The efficacy and safety of liraglutide therapy during perioperative glycemic control in elective surgery patients within ERAS protocols were compared with those of insulin therapy. Ninety adult T2D patients scheduled to undergo elective surgery within ERAS protocols were randomized and analyzed. Forty-nine subjects were prescribed liraglutide and 41 insulin therapy. Procedures comprised orthopedic, thoracic, urological, otolaryngological, hepatic resection, and gynecological breast surgeries. Results: Liraglutide was shown to be a more effective option than insulin therapy because (1) glycemic levels were more stable; (2) the number of patients requiring additional insulin according to the insulin sliding scale was significantly smaller (Fisher’s exact test, p = 0.005); (3) the insulin dosage required on the day of surgery was significantly smaller (Fisher’s exact, p = 0.004); (4) the additional insulin volume required was significantly less for patients throughout the perioperative period (Fisher’s exact test, p = 0.001); and (5) while lean body mass remained the same, body fat measurements, particularly visceral fat, tended to decrease. Conclusions: Based on the results of the present study and a recent large-scale clinical study showing cardiovascular and renal protective effects in T2D patients, we consider the administration of liraglutide within ERAS protocols for T2D patients to represent a more comprehensive suite of patient protection measures as a perioperative non-insulin agent, particularly in patients with limited exercise ability and those at risk of hypoglycemia.

Morphine versus fentanyl patient-controlled analgesia for postoperative pain control in major hepatic resection surgeries including living liver donors: A retrospective study.

Background:Liver resection surgery results in significant postoperative pain. However, it is still not clear which opioids used by patient-controlled analgesia (PCA) provides the best pain control and results in the least side effect in a patient with impaired liver function. Our hypothesis was that fentanyl is a better choice than morphine as it is a potent analgesic that its elimination half-life does not depend on the hepatic uptake and metabolism.The Study Purpose:Is to compare morphine and fentanyl PCA in liver resection patients as regards the degree of pain control, the consumption of opioids, and the side effects.Methods:A retrospective case–control study of hepatic resection patients who received postoperative morphine (Morph) or fentanyl (Fent) PCA. The study compared the pain scores, the morphine equivalent dose (MED), the number of demands requested as recorded by the PCA infusion pump, and the side effects every 12 h for 48 h.Results:This study yielded 40 patients; with the majority were living donor hepatic resection patients. There was no significant difference in the pain scores. However, the MED and the demands were significantly less in the Morph group. The P < 0.000, 0.0001, 0.0005, and 0.003, demands P < 0.002, 0.006, 0.014, and 0.013 at 12, 24, 48, and 36 h, respectively. The overall side effects were not different between the 2 groups at all time intervals measured; however, Morph patients were significantly more sedated in the first 12 h. There was one case of respiratory depression in the Morph group compared to two cases in the in the Fent group that needed treatment with naloxone.Conclusions:Although both groups had adequate pain control. The Morphine group reached faster pain control with less MED and PCA requests in liver resection patients, although it was more sedating in the first 12 h. However, fentanyl patients were less sedated; both drugs need close monitoring in the immediate postoperative period due to reported respiratory depressive effect and the need to use naloxone. The dosage of the PCA settings needs to be studied further to reach to the best dose with a reduced side effect. Further studies are recommended to reduce PCA dosages by introducing a multimodal approach of pain management relying on other methods with no additional sedative effects as regional anterior abdominal blocks.

Should Low Central Venous Pressure Be Maintained during Liver Transplantation?

Low central venous pressure, which indirectly reflects free hepatic venous pressure, is maintained during hepatic resection surgery to reduce intraoperative blood loss by facilitating hepatic venous outflow. However, whether the low central venous pressure protocol established for non-transplant hepatobiliary surgery should be generalized to liver transplantation is controversial because patients with cirrhosis have decreased portal and hepatic venous blood flow and vulnerability to renal failure. However, consistent with observations from hepatic resection surgeries, lowering central venous pressure during the preanhepatic phase significantly reduces blood loss and transfusion volume. Conversely, inherent study limitations and different study designs have yielded different results in terms of renal dysfunction. Although hepatic venous outflow promoted by lowering blood volume seems to facilitate a liver graft to accommodate portal blood flow increased by portal hypertension-induced splanchnic vasodilatation, the association between low central venous pressure and reduced incidence of portal hyperperfusion injury has not been demonstrated. Stroke volume variation predicts fluid responsiveness better than central venous pressure, but it has not been associated with a greater clinical benefit than central venous pressure to date. Therefore, the safety of maintaining low central venous pressure during liver transplantation has not been verified, and further randomized controlled studies are warranted to establish a fluid management protocol for each phase of liver transplantation to reduce intraoperative blood loss and transfusion rate, thereby maintaining liver graft viability. In conclusion, low central venous pressure reduces intraoperative blood loss but does not guarantee renoprotection or graft protection.

Morphine vs. Fentanyl Patient Controlled Analgesia for Postoperative Pain Control in Major Hepatic Resection Surgeries Including Living Liver Donors

Background: Liver resection surgery results in significant postoperative pain. However, it is still not clear which opioids used by Patient Controlled Analgesia (PCA) provides the best pain control and results in the least side effect in a patient with impaired liver function. Our hypothesis was that fentanyl is a better choice than morphine as it is a potent analgesic that its elimination half-life does not depend on the hepatic uptake and metabolism. The Study Purpose: Is to compare Morphine and Fentanyl PCA in liver resection patients as regards the degree of pain control, the consumption of Opioids and the side effects. Methods: A retrospective case control study of hepatic resection patients who received postoperative morphine (Morph) or Fentanyl (Fent) (PCA). The study compared the pain scores, morphine equivalent dose (MED), the number of demands requested as recorded by the PCA infusion pump and the side effects every 12 hours for 48 hours. Results: The study yielded 40 patients; with the majority were living donor hepatic resection patients. There was no significant difference in the pain scores. However, the MED and the demands were significantly less in the Morph group. p value<0.000, 0.0001, 0.0005, 0,003, demands p<0.002, 0.006, 0.014, 0.013 at 12, 24, 48, 36 hours respectively. The overall side effects were not different between the 2 groups at all-time intervals measured, however Morph patients were significantly more sedated in the first 12 hours.

Elective hepatic resection is feasible and safe in a regional centre.

Hepatic resectional surgery remains a highly specialized area of general surgery usually reserved for completion at tertiary metropolitan referral centres. Port Macquarie, on the Mid North Coast of New South Wales, is the only regionally based hospital offering surgery of this nature in mainland Australia. The purpose of this study is to review the data for patients undergoing hepatic resectional surgery in this non-metropolitan centre in order to illustrate that these operations can be carried out safely in a regional setting with comparable results to tertiary-level centres. A retrospective review of consecutive patients undergoing elective hepatic resections at Port Macquarie from February 2008 to 31 October 2015 was completed. Pre-morbid patient clinical and demographic factors, histopathological details, post-operative complications, survival and mortality data were all noted. A total of 66 consecutive elective liver resections were performed during the study period. Metastatic colorectal cancer was the most commonly observed pathology (n = 33, 50.0%). The 90-day mortality was 4.5% (n = 3) whilst 17 patients (n = 17, 25.8%) experienced major complications (Clavien-Dindo grade 3 or 4). The median overall survival following hepatectomy for colorectal metastases was 48 months (95% confidence interval 37-59 months). Our study shows excellent morbidity, mortality and survival for hepatic resectional surgery performed in a regional centre and is comparable data to major metropolitan centres. Our study confirms that major hepatic resectional surgery in this setting is safe and effective.

How could we image the future in hepatic surgery.

On June 1952, 11 years before the first liver transplantation by Thomas Starzl and 40 years before the first use of a partial graft from a living donor, Jean Louis Lortat Jacob, in his publication reporting the first anatomic right hepatectomy, anticipated that “ once the problems of tolerance to tissue grafts and their rejection have been solved, this procedure might be indicated for some hepatic diseases… ”. The idea to use a partial graft in patients with “hepatic diseases” will then open the concept of the minimal liver function required to survive using its unique potential of regeneration, even under immunosuppression. Anatomic resection with primary control of both inflow and outflow pedicles leaving an autonomous remnant parenchyma allowed the standardization of major hepatectomies. This approach of liver surgery ushered the modern era of hepatic resectional surgery, which aims at defining the optimal plan of resection with minimal blood loss (1).

The effects of intraoperative lung protective ventilation with positive end-expiratory pressure on blood loss during hepatic resection surgery: A secondary analysis of data from a published randomised control trial (IMPROVE).

During high-risk abdominal surgery the use of a multi-faceted lung protective ventilation strategy composed of low tidal volumes, positive end-expiratory pressure (PEEP) and recruitment manoeuvres, has been shown to improve clinical outcomes. It has been speculated, however, that mechanical ventilation using PEEP might increase intraoperative bleeding during liver resection. To study the impact of mechanical ventilation with PEEP on bleeding during hepatectomy. Post-hoc analysis of a randomised controlled trial. Seven French university teaching hospitals from January 2011 to August 2012. Patients scheduled for liver resection surgery. In the Intraoperative Protective Ventilation trial, patients scheduled for major abdominal surgery were randomly assigned to mechanical ventilation using low tidal volume, PEEP between 6 and 8 cmH2O and recruitment manoeuvres (lung protective ventilation strategy) or higher tidal volume, zero PEEP and no recruitment manoeuvres (non-protective ventilation strategy). The primary endpoint was intraoperative blood loss volume. A total of 79 (19.8%) patients underwent liver resections (41 in the lung protective and 38 in the non-protective group). The median (interquartile range) amount of intraoperative blood loss was 500 (200 to 800) ml and 275 (125 to 800) ml in the non-protective and lung protective ventilation groups, respectively (P = 0.47). Fourteen (35.0%) and eight (21.5%) patients were transfused in the non-protective and lung protective groups, respectively (P = 0.17), without a statistically significant difference in the median (interquartile range) number of red blood cells units transfused [2.5 (2 to 4) units and 3 (2 to 6) units in the two groups, respectively; P = 0.54]. During hepatic surgery, mechanical ventilation using PEEP within a multi-faceted lung protective strategy was not associated with increased bleeding compared with non-protective ventilation using zero PEEP. The current study was not registered. The original Intraoperative Protective Ventilation study was registered on clinicaltrials.gov; number NCT01282996.

Cardiopulmonary exercise testing for predicting postoperative morbidity in patients undergoing hepatic resection surgery

ObjectivesCardiopulmonary exercise testing (CPET) may predict which patients are at risk for adverse outcomes after major abdominal surgery. The primary aim of this study was to determine whether CPET variables are predicative of morbidity. MethodsHigh‐risk patients undergoing elective, one‐stage, open hepatic resection were preoperatively assessed using CPET. Morbidity, as defined by the Postoperative Morbidity Survey (POMS), was assessed on postoperative day 3. ResultsA total of 104 patients underwent preoperative CPET and were included in the analysis. Of these, 73 patients (70.2%) experienced postoperative morbidity. Oxygen consumption at anaerobic threshold (VO2 at AT, ml/kg/min) was the only CPET predictor of postoperative morbidity on multivariable analysis, with an area under the curve (AUC) of 0.66 [95% confidence interval (CI) 0.55–0.76]. In patients requiring a major hepatic resection (three or more segments), a VO2 at AT of <10.2 ml/kg/min gave an AUC of 0.79 (95% CI 0.68–0.86) with 83.9% sensitivity and 52.0% specificity, 80.6% positive predictive value and 62.5% negative predictive value. ConclusionsThe application of a cut‐off value for VO2 at AT of <10.2 ml/kg/min in patients undergoing major hepatic resection may be useful for predicting which patients will experience morbidity.

Predictors of postoperative morbidity after cytoreduction for advanced ovarian cancer: Analysis and management of complications in upper abdominal surgery

ObjectiveTo evaluate the complication rate and its impact in patients who have undergone upper abdominal surgery for treatment of advanced ovarian cancer. MethodsPatients who have undergone upper abdominal surgery including diaphragm surgery, splenectomy, distal pancreatectomy, gastric resection, liver resection and biliary surgery were considered for the study. Perioperative complications were evaluated and graded according to Clavien–Dindo. ResultsOne hundred and twenty one patients were included. Two hundred and twelve surgical procedures were performed. Thirty-six patients reported at least one complication, but 61.1% of these the complication was mild. Median hospital stay for patients with and without complication was 7 vs. 13days respectively (p<0.001). There was a significant correlation between post-operative hospital stay and the total number of surgical procedures (R=0.445, p<0.001). At multivariate analysis, diaphragmatic resection and pancreatic resection were associated with a significant increase of postoperative hospital stay, furthermore diaphragmatic resection (p=0.004), hepatic resection (p=0.004), pancreatectomy (p=0.011) and biliary surgery (p=0.049) were independent predictors of severe (G3–G4) complication. ConclusionsRate of complications of patients submitted to upper abdominal surgery for ovarian cancer is acceptable. Prediction of severe complications is the goal for its optimal management. Extensive procedures should be avoided with those patients in which optimal residual tumor could not be reached.

HEMORRHAGE PREVENTION AND COMPENSATION IN HEPATIC RESECTION SURGERY

Aim. To improve the results of surgery in patients with focal hepatic diseases using rational surgical tactics, purposeful transfusion therapy and effective hemostatic means. Materials and methods. During the period from 1995 to 2003, 398 patients with focal hepatic diseases were treated. 257 patients (64,6%) underwent hepatic resection including 98 (38,1%) – large hepatic resections (3 segments), 159 (61,9%) – minor hepatic resections. Patients were divided into two groups – the main group ( n =137) and the comparison group ( n =120). In the main group, 54 (39,4%) patients underwent large resections, 83 (60,6%) – minor ones. In the comparison group, 44 (36,7%) had large hepatic resections, 76 (63,3%) – minor ones. In the main group the following means were applied: preoperative autoblood reservation, principle of operation from the vessels, hepatic tissue dissection by means of ultrasonic destructor-aspirator and harmonic Ultracision «Johnson&Johnson» scalpel, Pringle manoeuvre, argonoplasmic coagulation of resected hepatic stump surface, local hemostatic means. In the comparison group, hepatic-duodenal ligament compression, isolation of vasculosecretory elements by resection line using digitoclasy, hepatic stump suturing was used by indications so as to prevent hemorrhage. Results. The volume of intraoperative hemorrhage in the main group reached 1100±20 ml, in the comparison group – 2700±250 ml ( p <0,001). The average number of transfused doses of allogenic blood in the main group was 2,1±0,3, in the comparison group – 12,5±1,3 ( p <0,001). The average volume of previously prepared transfused autoblood in the main group was 0,83±0,1 dose, in the comparison group it was not used. After preoperative autoblood reservation was included into the program, the average volume of transfused allogenic blood decreased from 11,1±1,6 to 1,5±1,1 doses ( p <0,001) in case of large hepatic resections and from 3,6±1,1 doses to 0 – in minor resections ( p <0,001). The postoperative lethality in the main group was 2,2% ( n =3), in the comparison group – 9,2% ( n =11). Conclusion. Introduction of modern equipment into surgical practice for the purpose of performing hepatic parenchyma dissection permits to reduce the volume of hemorrhage and the number of doses of infused donor erythromass. Local hemostatic means applied decrease the risk of developing hemorrhage and biliary excretion from the wound surface of hepatic stump in the postoperative period. The developed system of intraoperative and perioperative safety in hepatic resection surgery allows to reduce the risk of operative intervention, to lower the number of postoperative complications.

Appraisal of simultaneous laparoscopic splenectomy and hepatic resection in the treatment of hepatocellular carcinoma with hypersplenic thrombocytopenia.

The management of hepatocellular carcinoma with hypersplenic thrombocytopenia remains controversial, because of the high surgical morbidity and mortality. Splenectomy has been reported to be useful for patients with hypersplenic thrombocytopenia, but the timing and route of splenectomy and hepatic resection remains unclear. This report evaluated the efficacy of laparoscopic surgery for simultaneous splenectomy and hepatic resection in the treatment of hepatocellular carcinoma with hypersplenic thrombocytopenia. Among 65 patients with hypersplenic thrombocytopenia who underwent hepatic resection for hepatocellular carcinoma, 20 patients underwent simultaneous splenectomy and hepatic resection. Initially, ten patients underwent the procedure by conventional laparotomy (open group) and ten patients underwent by laparoscopy (laparoscopic group). The clinicopathological results from the two groups were compared retrospectively. The blood loss in the laparoscopic group was significantly less and the postoperative morbidity rate in the laparoscopic group was lower than that in the open group. The duration of the postoperative hospital stay in the laparoscopic group was significantly shorter and rate of patients administered interferon in the laparoscopic group was significantly higher than that in open group. Simultaneous splenectomy and hepatic resection under laparoscopy is a safe and useful in the treatment of hepatocellular carcinoma with hypersplenic thrombocytopenia.

Epidural versus intravenous multimodal analgesia in hepatic resection surgery

Epidural versus intravenous multimodal analgesia in hepatic resection surgery

Anesthetic Management for Resection of Hepatic Paraganglioma Metastatic From the Donor Organ in an Orthotopic Liver Transplant Recipient: A Case Report

This is a case report of the anesthetic management for the hepatic resection of a metastatic paraganglioma in a patient with a history of prior orthotopic liver transplantation. Of interest, the metastatic paraganglioma originated from the donor organ. The patient is an 80-year-old woman with multiple medical problems including a history of cryptogenic cirrhosis who underwent successful orthotopic liver transplantation 9 years prior. She later presented with signs and symptoms of catecholamine excess suggestive of a catecholamine-producing tumor (paraganglioma or pheochromocytoma). Elevated urine catecholamine levels and radiographic evidence of a paraganglioma in the transplanted liver metastatic from the donor organ confirmed the diagnosis. Radiofrequency ablation of the tumor and surgical resection was previously attempted without success. We describe the anesthetic management for the successful resection of the metastatic hepatic paraganglioma, which was complicated by profound intraoperative hypertension and hypotension that necessitated the use of multiple vasoactive infusions, extensive surgical blood loss requiring blood transfusion, and difficult glycemic control in an insulin-dependent diabetic patient. The postoperative course is also described. This unique case presented the anesthesia team with challenges specific to both surgery for hepatic resection as well as for catecholamine-secreting tumors. We are not aware of any reports of paragangliomas of either donor or recipient origin involving a transplanted liver, making this the first such report to the best of our knowledge.

Operative terminology and post-operative management approaches applied to hepatic surgery: Trainee perspectives

Outcomes in hepatic resectional surgery (HRS) have improved as a result of advances in the understanding of hepatic anatomy, improved surgical techniques, and enhanced peri-operative management. Patients are generally cared for in specialist higher-level ward settings with multidisciplinary input during the initial post-operative period, however, greater acceptance and understanding of HRS has meant that care is transferred, usually after 24-48 h, to a standard ward environment. Surgical trainees will be presented with such patients either electively as part of a hepatobiliary firm or whilst covering the service on-call, and it is therefore important to acknowledge the key points in managing HRS patients. Understanding the applied anatomy of the liver is the key to determining the extent of resection to be undertaken. Increasingly, enhanced patient pathways exist in the post-operative setting requiring focus on the delivery of high quality analgesia, careful fluid balance, nutrition and thromboprophlaxis. Complications can occur including liver, renal and respiratory failure, hemorrhage, and sepsis, all of which require prompt recognition and management. We provide an overview of the relevant terminology applied to hepatic surgery, an approach to the post-operative management, and an aid to developing an awareness of complications so as to facilitate better confidence in this complex subgroup of general surgical patients.

Evaluation of Hemostatic Factors in Patients Undergoing Major Hepatic Resection and Other Major Abdominal Surgeries

The aim of this study was to evaluate the role for additional testing of coagulation in perioperative management of patients undergoing major hepatic resection. Major outcome measures were perioperative measurements of hemostatic factors (activated partial prothrombin time [aPTT], prothrombin time/international normalized ratio, fibrinogen, antithrombin-III). We conducted a prospective, single-blind study comparing hemostatic factors in patients undergoing major hepatectomy, Whipple procedures, and other gastrointestinal operations. Ninety-five consecutive patients were enrolled. No values differed significantly at baseline. Immediately postoperative, only international normalized ratio was significantly lower comparing major hepatectomy with Whipple (P < 0.005) and other procedures (P < 0.0032). Twenty-four hours postoperative, antithrombin-III was lower for major hepatectomy than Whipple (P < 0.028) and others (P < 0.0001); fibrinogen was lower compared with Whipple (P < 0.014) and others (P < 0.0009); international normalized ratio was lower to compared with Whipple (P < 0.0001) and others (P < 0.0001). aPTT measurements never differed significantly between groups at any time. Antithrombin-III and fibrinogen only correlated with international normalized ratio and aPTT for the other procedures. Additional hemostatic values beyond the standard evaluations of aPTT and international normalized ratio are needed to better assess patients undergoing major hepatic surgery.

Robotic Liver Surgery

Although minimally invasive hepatic resection surgery has shown decreased morbidity in select patients, conventional laparoscopic liver resection has inherent limitations with reduced freedom of movement within the abdominal cavity and 2-dimensional view of the operative field. Robotic liver surgery allows surgeons to perform advanced procedures with a potential for improved precision and ergonomics as well as a 3-dimensional view of the surgical site. However, use of the robot entails a steep learning curve and additional equipment. The purpose of this article is to summarize the emerging field of robotic liver surgery and include the authors' early experience with these operations.

Robotic Liver Resection as a Bridge to Liver Transplantation

The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentation. Robotic surgery for hepatic resection has not yet been extensively reported. The aim of this article is to report the first known case of liver resection with the use of a robot in France. A 61-year-old male with hepatitis C liver cirrhosis and hepatocellular carcinoma was referred for surgical treatment. Preoperative clinical evaluation and laboratory data disclosed a Child-Pugh class A5 patient. Magnetic resonance imaging showed a 3.4-cm tumor in segment III. Liver size was normal, and there were not signs of portal hypertension. Five trocars were used. Liver transection was achieved with Harmonic scalpel and bipolar forceps without pedicle clamping. Hemostasis of raw surface areas was accomplished with interrupted stitches. Operative time was 180 minutes. Blood loss was minimal, and the patient did not receive transfusion. The recovery was uneventful, and the patient was discharged on the fifth postoperative day without ascites formation. The robotic approach may enable liver resection in patients with cirrhosis. The da Vinci robotic system allowed for technical refinements of laparoscopic liver resection due to 3-dimensional visualization of the operative field and instruments with wrist-type end-effectors.

Fisiopatología de la lesión hepática por isquemia-reperfusión

Hepatic ischemia-reperfusion injury is an underlying complication that occurs in clinical conditions such as hepatic resection surgery, liver transplantation and the states of shock. Such injury has classically been attributed to the joint deleterious action of both neutrophils and reactive oxygen species. However, there is increasing evidence that T lymphocytes are also key players in the acute reperfusion injury of diverse organs. They seem to act mainly by promoting the recruitment of inflammatory cells. The purpose of this review is to summarize the molecular and cellular mechanisms that participate in the pathophysiology of liver reperfusion injury.

Surgical aspects in management of hepato-pancreatico-biliary tumours in the elderly

Hepato-pancreatico-biliary (HPB) surgery encompasses major hepatic resection and pancreatic surgery, both procedures of high complexity with a potentially high complication rate. The establishment of centres of excellence with a high patient volume has lowered the complication and increased the resection rate. Besides this, increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Because elderly patients have more co-morbidities and decreased life expectancy, the benefit of these procedures must be critically evaluated in such patients. Analysis of the literature on this subject demonstrated that pancreatico-duodenectomy can be performed safely in selected elderly patients (80 years of age or older), with morbidity and mortality rates approaching those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumour or gallbladder carcinoma. Nevertheless, those elderly patients who will benefit from surgery must be critically selected.

Haemostatic problems in liver surgery: A review

Massive blood loss requiring allogenic blood product transfusion has been a major problem during liver resection and transplantation surgery. The transfusion of red blood cell units (RBCs) and plasma has been adversely linked to 1-year survival rates. In a series of 1 803 consecutive cases undergoing hepatic resection surgery, total blood loss and the number of liver segments resected were the only independent predictors of morbidity and mortality. Improved surgical and anaesthetic techniques have resulted in a dramatic reduction of blood product requirements during orthotopic liver transplantation (OLT) and liver resection surgery compared to historical controls. Recent publications report that between 17.5% and 81% of OLT operations and > 90% of hepatic resections can now be performed without red blood cell transfusions. In both groups, reduction in blood transfusions has led to improved outcome. Severe bleeding still occurs in a minority of cases and efforts to define clinical and blood test predictors for major bleeding during liver surgery remain elusive.