Infrahepatic Inferior Vena Cava Clamping Research Articles

Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver duringhepatectomy: a meta-analysis.

Intraoperative bleeding during hepatectomy is primarily controlled through anaesthesiological interventions or surgical techniques such as Pringle maneuver (PM). Infrahepatic IVC clamping (IIVCC) is an alternative surgical technique to reduce central venous pressure and prevent retrograde hepatic venous bleeding. The aim of the meta-analysis was to compare IIVCC+PM with PMalone in terms of intraoperative outcomes and perioperative complications. Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched for comparative studies till 16.04.2024, resulting in 679 articles, of which eight studies met inclusion criteria. Data on patient demographics, surgical technique, and perioperative outcomes was assessed. Cochrane Risk of Bias 2.0 (RoB 2.0) Tool and Newcastle-Ottawa Scale (NOS) were used for risk of bias assessment. Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PMalone group were included. IIVCC+PM resulted in significantly greater CVP reduction, less intraoperative blood loss (MD (95% CI) = - 233.03 (- 360.48 to - 105.58), P < 0.001), and less intraoperative blood transfusion (OR (95% CI) = 0.38 (0.25 to 0.57), P < 0.001) compared to PMalone. The two groups had comparable total operative time, transection time and total intraoperative fluid infusion. Patients undergoing IIVCC+PM had significantly shorter length of stay (MD (95% CI) = - 0.63 days (- 1.21 to - 0.05 days), P = 0.03) and overall complication rates (OR (95% CI) = 0.63 (0.43-0.92), P = 0.02) compared to PMalone group. The utilization of IIVCC along with PM during liver resection may be beneficial in reducing intraoperative bleeding and blood transfusion without adversely influencing operative times or perioperative outcomes compared to PMalone.

743 Intraoperative Outcomes Using Infrahepatic Inferior Vena Cava Clamping During Hepatectomy: A Meta-Analysis

Abstract Aim The aim of this meta-analysis is to determine the effect of infrahepatic inferior vena cava clamping (IIVCC) with Pringle maneuver (PM) compared to only PM during hepatectomy on intraoperative outcomes. Method Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched from inception till 23.11.2021 using a predefined search strategy. The initial search resulted in 615 unique articles. After screening, eight studies including 755 patients (358 in IIVCC+PM, 397 in PM group) met the inclusion criteria for this meta-analysis. Of these, two were randomized controlled trials, one prospective and five retrospective cohort studies. Data on patient demographics, surgical technique and intraoperative outcomes was collected. Summary estimates using the appropriate effect models were generated with Review Manager 5.0. Results Patients who underwent IIVCC + PM during hepatectomies experienced significantly less total intraoperative blood loss (mean difference (MD), 95% confidence interval (CI) = -233.03, -360.48 to -105.58; p = 0.0003), less blood loss during transection (MD, 95% CI = -172.91, -308.94 to -36.88; p = 0.01), and had significantly less intraoperative blood transfusion requirement (Odds ratio, 95% CI = 0.38, 0.25 to 0.57; p&amp;lt;0.0001) compared to patients who had only PM. Additionally, the total operative time was comparable between the two groups (MD, 95% CI = 8.06, 4.29 to 11.82; p&amp;lt;0.0001). There were no difference in the parenchymal transection time and total intraoperative fluid infusion between the two groups. Conclusions IIVCC + PM is beneficial in reducing intraoperative blood loss and need for transfusion without significantly affecting operative times in comparison to PM during hepatectomy.

Infrahepatic Inferior Vena Cava Clamping Reduces Blood Loss during Liver Transection for Cholangiocarcinoma.

Background Major hepatectomy is the mainstay of the treatment for cholangiocarcinoma. Infrahepatic inferior vena cava (IVC) clamping is an effective maneuver for reducing blood loss during liver transection. The impact of this procedure on major hepatectomy for cholangiocarcinoma is unknown. This study evaluated the effect of infrahepatic IVC clamping on blood loss during liver transection. Methods Clinical and pathological data were collected retrospectively for 116 cholangiocarcinoma patients who underwent major hepatectomy between January 2015 and December 2016, to investigate the benefit of infrahepatic IVC clamping. Two of five surgeons adapted the policy performing infrahepatic IVC clamping during liver transection in all cases. Patients, therefore, were divided into those (n = 39; 33.6%) who received infrahepatic IVC clamping during liver transection (C1) and those (n = 77; 66.4%) who did not (C0). Results The patients' backgrounds, operative parameters, and extent of hepatectomy did not differ significantly between the 2 groups, except for gender. A significantly lower blood loss (p = 0.028), blood transfusion (p = 0.011), and rate of vascular inflow occlusion requirement (p < 0.001) were observed in the C1 group. The respective blood losses in the C1 group and the C0 group were 498.9 (95% CI: 375.8-622.1) and 685.6 (95% CI: 571-800.2) millilitres. Conclusions The current study found infrahepatic IVC clamping during liver transection for cholangiocarcinoma reduces blood loss, blood transfusion, and rate of vascular inflow occlusion requirement.

Infrahepatic Inferior Vena Cava Clamping does not Increase the Risk of Pulmonary Embolism Following Hepatic Resection

BackgroundInfrahepatic inferior vena cava (IVC) clamping reduces central venous pressure. However, controversies remain regarding its impact on postoperative complications, particularly, the incidence of postoperative pulmonary embolism (PE). The aim of the study was to determine the impact of IVC clamping on the incidence of PE in patients undergoing hepatectomy.MethodsA pooled analysis of five prospective trials on patients who underwent hepatic resection over a period of 10 years was performed. Patients with infrahepatic IVC clamping were compared to patients without infrahepatic IVC clamping. Outcomes were studied by univariate and multivariate analyses.ResultsOf 505 included patients, 141 patients had IVC clamping and 364 patients served as control group. The rate of postoperative PE was comparable between groups (3% vs. 3%; P = 0.762), as were postoperative morbidity (P = 0.932), bile leakage (P = 0.272), posthepatectomy hemorrhage (P = 0.095), and posthepatectomy liver failure (P = 0.605), respectively. No clinicopathological and intraoperative risk factors were found to predict the onset of PE. Subgroup analyses of patients with major hepatectomy and vascular resections confirmed no adverse perioperative outcomes to be associated with IVC clamping.ConclusionsInfrahepatic IVC clamping does not increase the incidence of postoperative PE.

Efficacy and safety of infrahepatic inferior vena cava clamping under controlled central venous pressure for reducing blood loss during hepatectomy: A randomized controlled trial.

The purpose of this study was to evaluate the effectiveness and safety of inferior vena cava (IVC) clamping for reducing blood loss during hepatectomy. In total, 120 elective hepatectomy patients who underwent surgery from May 2016 to October 2017 were enrolled and randomized into the IVC clamping group or nonclamping group. Both groups were managed by anesthesiological techniques for CVP reduction. Blood loss and clinical parameters were analyzed for 30days after surgery. Fifty-nine patients were assigned to the IVC clamping group and 61 to the non-IVC clamping group. There was a significant difference in the total blood loss between both groups, with less blood loss observed in the IVC clamping group [500 vs 600mL, P=.006]. The transection blood loss in the IVC clamping group was also significantly lower than that in the non-IVC clamping group [300 vs 500mL, P<.001]. However, CVP was not associated with blood loss volume. Postoperative outcomes were not significant in either group. IVC clamping is beneficial for reducing blood loss during hepatectomy and is safe when combined with anesthesiological techniques. If feasible, this technique should be used regardless of the CVP value.

High Complexity Major Liver Resection by Thunderbeat as a Sole Device under the Pringle Maneuver and Infra-Hepatic Inferior Vena Cava Clamping (With Video)

Introduction: In addition to conventional major or minor classification in liver resection (LR), recently, a complexity classification with 3 categories (low, medium, or high) according to its technical difficulty was proposed and validated. We describe the outcomes of high complexity major LR by Thunderbeat (TB) as a sole device under the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping. Methods: Of 85 patients undergoing LR between July 2013 and November 2019, we reviewed seven patients who underwent this procedure. To evaluate the safety and rapidity, we compared the parenchymal transection time (PTT), estimated blood loss (EBL), and postoperative major complications (PMC) with nine patients who underwent medium or high complexity open major LR by the basic procedure, i.e. the clamp-crushing or the CUSA with supplemental use of energy devices. Results: Seven patients underwent extended right hepatectomy with hepaticojejunostomy (n=3), anatomical middle hepatectomy (n=2), and right trisectionectomy (n=1) or extended left hepatectomy (n=1) with IVC resection and reconstruction. Two patients experienced PMC (Clavien-Dindo classification IIIa: n=1, IIIb: n=1). There was no in-hospital mortality. Six patients are currently alive without recurrence with a median follow-up of 24 months. PTT [median (range)] in the TB group was significantly shorter: 19 (13-45) compared to 52 (18-174) min in the basic group (p=0.012). There was no significant difference in terms of EBL (p=0.918) and PMC (p=0.771). Conclusions: TB with the Pringle maneuver and infra-hepatic IVC clamping is feasible and may offer rapidity during high complexity major LR.

Evaluation of infrahepatic inferior vena cava clamping in robot-assisted laparoscopic liver resection

Objective: To evalutate the safety and efficacy of infrahepatic inferior vena cava clamping robot-assisted laparoscopic liver resection. Methods: All data about 24 patients with robotic liver resection at Hepatic Surgery Center,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology between February 2015 and December 2017 were collected and analyzed. These patients were divided into two groups based on different methods to decrease central venous pressure. Eight patients(6 males and 2 females,aged 49 years(range:50 to 56 years)) were applied with infrahepatic inferior vena cava clamping,and the other 16 matched cases (15 males and 1 female,aged 53 years(range:38 to 69 years)) were categorized into lowering central venous pressure group. Intraoperative blood loss,blood transfusion,intraoperative hemodynamic parameters,postoperative complications,and renal function were compared by t-test,non-parametric test,χ2 test,or Fisher exact test. Results: There was significantly difference in the intraoperative blood loss between the infrahepatic vena cava clamping group and the lowering central venous group(200(220) ml (range:100 to 400 ml) vs. 750(800) ml (range:100 to 2 000 ml),Z=‒2.169,P=0.030). The clamping time of portal triad and infrahepatic inferior vena cava were 24 (18) minutes and 29 (20) minutes in the infrahepatic inferior vena cava clamping group, and portal triad clamping time was 23 (23) minutes in the low central venous group. There was no significant difference between the two groups (Z=‒0.323, P=0.747). There was no intraoperative blood transfusion in the infrahepatic inferior vena cava clamping group, and 5 cases in the low central venous group, with a transfusion volume of 1.5(1.5)U. The difference between the two groups was statistically significant (Z=‒3.353, P=0.001). However, the mean arterial pressure in the infrahepatic vena cava clamping group decreased from (88.6±4.9) mmHg to (67.4±3.8) mmHg(1 mmHg=0.133 kPa), which was lower than that of lowering central venous group (72.4±3.3) mmHg (t=2.315,P=0.003). And there were no significant differences related to postoperative complications rate or hepatic and renal function in both groups. Conclusion: The infrahepatic inferior vena cava technology is safe and feasible to decrease central venous pressure during robotic liver resections,which will not affect the recovery of hepatic and renal functions.

Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure - First technical report.

Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.

Effect of infrahepatic inferior vena cava partial clamping on central venous pressure and intraoperative blood loss during laparoscopic hepatectomy.

Infrahepatic inferior vena cava (IVC) clamping is considered to be an effective method to reduce central venous pressure (CVP) and intraoperative bleeding in liver resection. However, its efficacy and safety during laparoscopic hepatectomy (LH) remain unclear. We perform this retrospective study to evaluate its efficacy and safety during LH. Consecutive patients scheduled for LH from September 2014 to August 2019 were retrospectively reviewed. The intraoperative parameters and postoperative outcomes were analyzed. All patients in the infrahepatic IVC clamping group were able to tolerate partial clamping of IVC. The CVP was significantly decreased after infrahepatic IVC clamping without hemodynamic instability (8.7 ± 1.4 cmH2O vs. 2.1 ± 1.3 cmH2O, P = 0.000). Infrahepatic IVC clamping did not significantly reduce total blood loss (287.3 ± 112.5mL vs. 301.4 ± 127.6mL, P = 0.133) and blood loss during parenchymal transection (273.2 ± 107.9mL vs. 296.5 ± 118.1mL, P = 0.618) compared with the non-clamping group. In subgroup analysis, total blood loss and blood loss during parenchymal transection were significantly reduced in patients with moderate to severe cirrhosis in the clamping group (363.6 ± 71.2mL vs. 473.4 ± 95.6mL, P = 0.021), (358.7 ± 70.9mL vs. 466.9 ± 94.5mL, P = 0.016), respectively. The complications and hospital stay were comparable. In conclusion, these data suggest that infrahepatic IVC clamping may be safe and effective.

Central hepatectomy for hepatocellular carcinoma in a patient with anti-Gerbich antibody

BackgroundAnti-Gerbich (Ge) alloantibody against high-frequency erythrocyte antigen is extremely rare. Owing to incomplete evidence regarding the degree and severity of adverse events induced by hemolytic transfusion reactions, the transfusion management often remains cumbersome in these patients. We report an anti-Ge alloantibody positive patient with hepatocellular carcinoma (HCC) who underwent central hepatectomy (CH) without the need for an allogeneic blood transfusion.Case presentationA 76-year-old Japanese woman was diagnosed with HCC measuring 9.5 × 8.0 cm in segments 4, 5, and 8 of the liver. This patient with anti-Ge alloantibody had a history of two pregnancies without transfusion. CH was planned, and based on the suggestion from the multidisciplinary team meeting, preoperative autologous donation (PAD) and acute normovolemic hemodilution (ANH) were performed. CH was successfully performed by using CUSA and Thunderbeat® with Pringle maneuver and infra-hepatic inferior vena cava clamping without perioperative need for an allogeneic blood transfusion. She has been alive without recurrence after a follow-up period of 45 months.ConclusionTo our knowledge, this is the first case report of hepatectomy in a patient with anti-Ge alloantibody. A multidisciplinary team approach, PAD and ANH, and bloodless liver surgical techniques appear to be useful for major hepatectomy in patients with extremely rare blood type.

Hemodynamically adjusted infrahepatic inferior venous cava clamping can reduce postoperative deterioration in renal function: a retrospective observational study.

Infrahepatic inferior vena cava (IIVC) clamping is beneficial for reducing the amount of bleeding during hepatic surgery, although the associated systemic circulatory deterioration is noticeable. The relationship between changes in the degree of IIVC clamping and postoperative renal function was retrospectively evaluated. A total of 59 patients who underwent elective hepatic surgery with surgical IIVC clamping in the two years were analyzed. In 2016, constant 80% clamping of the IIVC was performed (29 cases), and in 2017, hemodynamically adjusted IIVC clamping was performed (30 cases). Intraoperative parameters, including total blood loss and number of blood transfusions, were examined. The use of each vasoactive agents was analyzed. Renal function in the acute postoperative phase was evaluated using serum creatinine (Cr) and estimated glomerular filtration rate (eGFR) values. Comparison of the two groups showed that bolus doses of both ephedrine and phenylephrine were significantly higher in the 2016 group (P = 0.0221, 0.0017). Continuous doses of dopamine were significantly higher in the 2016 group, while those of noradrenaline were not. Postoperative serum Cr levels relative to baseline (%) were significantly higher in the 2016 group immediately after surgery and on postoperative day (POD) 1 (P = 0.0143, 0.0012). Postoperative eGFR relative to baseline (%) was significantly higher in the 2016 group immediately postoperatively and on PODs 1 and 2 (P = 0.0042, 0.0003, 0.0382). Hemodynamically adjustable IIVC clamping might be superior to uniformly fixed clamping in preserving renal function without compromising the desired effect on hemostasis.

Complex major hepatectomy by thunderbeat with the pringle maneuver and infra-hepatic inferior vena cava clamping

Introduction: Complex major hepatectomy (CMH) equivalent to major liver resection with high complexity classification is a demanding operation. Parenchymal transection represents a crucial step during liver resection and the use of energy devices has gained popularity for faster and safer hepatectomy. Thunderbeat (TB) is a novel device that uses both ultrasonic and advanced bipolar energies. We report the CMH with TB assisted by the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping. Method: During parenchymal transection, only the pedicles equal or larger than 3rd branches of Glissonian pedicles or main branches of major hepatic veins were ligated, the other vessels were sealed with TB. Parenchymal transection time was defined as the duration recorded from the beginning of the parenchymal resection to the removal of the en-bloc specimen of the liver. Clavien-Dindo (CD) classification ≥3a was applied to define postoperative complication. The postoperative liver dysfunction was assessed on the basis of Balzan 50-50 criteria. Result: Four patients underwent CMH with TB assisted by the Pringle maneuver and infra-hepatic IVC clamping, including extended right hepatectomy with caudate resection and hepaticojejunostomy for perihilar chalangiocarcinoma (n=2) and colon cancer liver metastasis with central biliary invasion (n=1), and anatomic middle hepatectomy for hepatocellular carcinoma (n=1). The median parenchymal transection time, operation time, and estimated blood loss was 16.5 (range: 13-45) min, 415 (range: 260-596) min, and 1,928 (range: 1,380-2,730) mL, respectively Postoperative complications were hepaticojejunostomy failure in one (CD 3a) and heparin-induced postoperative bleeding (CD 3b) in one. There were no postoperative liver dysfunction, pulmonary embolism, and hospital mortality. Conclusion: TB assisted by the Pringle maneuver and infra-hepatic IVC clamping can be feasible and offer the combination of simplicity and rapidity during CMH.

Infrahepatic inferior vena cava clamping during liver transection for cholangiocarcinoma: a quasi – experimental study

Introduction: Major hepatectomy is the mainstay of treatment of cholangiocarcinoma. Infrahepatic inferior vena cava (IVC) clamping is effective maneuver for reducing central venous pressure (CVP), may lead to reducing in blood loss during liver transection. The impact of this procedure on major hepatectomy for cholangiocarcinoma is unknown. This study evaluated the effect of infrahepatic IVC clamping on blood loss during liver transection. Method: Clinical and pathological data were retrospectively collected for 116 cholangiocarcinoma patients who underwent major hepatectomy between January 2015 and December 2016, to investigate the benefit of infrahepatic IVC clamping. Two of five surgeons adopt the policy performing infrahepatic IVC clamping during liver transection in all cases. Patients, therefore, were divided into those (n = 39; 33.6%) who received infrahepatic IVC clamping during liver transection (C1) and those (n = 77; 66.4%) who did not (C0). Result: The patient backgrounds, operative parameters, and extent of hepatectomy did not significantly differ between the 2 groups except for gender of patients. A significant lower in blood loss (p=0.028), blood transfusion (p=0.011) and rate of portal clamping (p<0.001) were observed in C1 group. The respective blood loss in C1 group and C0 group was 498.9 (95%CI: 375.8- 622.1) and 685.6 (95%CI:571-800.2) milliliter. Conclusion: The current study found infrahepatic IVC clamping during liver transection reduce blood loss, blood transfusion and rate of portal clamping.

Evaluation of infrahepatic inferior vena cava clamping in robotic liver resection: a pair-matched comparison study

Evaluation of infrahepatic inferior vena cava clamping in robotic liver resection: a pair-matched comparison study

Infrahepatic inferior vena cava clamping with Pringle maneuvers for laparoscopic extracapsular enucleation of giant liver hemangiomas

BackgroundThis study aimed to determine the feasibility of the extracapsular enucleation method for giant liver hemangiomas by infrahepatic inferior vena cava (IVC) clamping and the Pringle maneuver to control intraoperative bleeding under laparoscopic hepatectomy.MethodsFrom January 2012 to January 2016, 36 patients underwent laparoscopic extracapsular enucleation of giant liver hemangiomas. Patients were divided into two groups: infrahepatic IVC clamping + Pringle maneuvers group (IVCP group, n = 15) and the Pringle maneuvers group (Pringle group, n = 21). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed.ResultsThe mean size of liver hemangiomas was 13.3 cm (range 10–25 cm). Infrahepatic IVC clamping + the Pringle maneuvers with laparoscopic extracapsular enucleation significantly reduced intraoperative blood loss (586.7 vs 315.3 mL, p < 0.001) and transfusion rates (23.8 vs 6.7%, p = 0.001), compared with the Pringle maneuver alone. The gallbladder was retained in both groups. The mean arterial pressure (MAP) in Pringle group remained virtually stable before and after clamping of hepatic portal, while it was significantly decreased after IVC clamping in IVCP group than that pre-clamping (p < 0.001). The heart rate of all patients was significantly increased after clamping when compared to pre-clamping heart rates (p < 0.001). Once vascular occlusion was released, MAP returned to normal levels within a few minutes. There were no significant differences in postoperative complications between two groups. The vascular occlusion techniques in both groups had no serious effect on postoperative of hepatic and renal function.ConclusionsExtracapsular enucleation with infrahepatic IVC clamping + the Pringle maneuver is a safe and effective surgical treatment to control bleeding for giant liver hemangiomas in laparoscopic hepatectomy.

Partial clamping of the infrahepatic inferior vena cava for blood loss reduction during anatomic liver resection: A prospective, randomized, controlled trial

Anatomic liver resection often requires the exposure of the hepatic vein on its cut surface, and theoretically, lower central venous pressure aids in reducing blood loss. Therefore, we hypothesized that manipulating the central venous pressure by partially clamping the infrahepatic inferior vena cava might reduce blood loss during anatomic liver resection. Patients undergoing planned anatomic liver resections were allocated randomly to the partial infrahepatic inferior vena cava clamping or nonclamping groups. Hepatocellular carcinoma diagnosis was set as a stratifying factor because of underlying liver disease. The primary outcome was intraoperative blood loss. Secondary outcomes were intraoperative parameters and postoperative safety. We submitted the detailed protocol to the University Hospital Medical Information Network Clinical Trials Registry (Registration number: UMIN000007339 [http://www.umin.ac.jp.]). Between August 2011 and August 2015, 90 patients were allocated randomly. Both groups had comparable baseline characteristics. The central venous pressure was reduced from 6.0 to 3.0mm Hg in the partial inferior vena cava clamping group without any complications (P<.001). Among all eligible patients, median values for total blood loss, blood loss during liver resection, and blood loss per transected area (nonclamping vs clamping groups) were 360 vs 350mL(P=.19), 310 vs 250mL(P=.045), and 4.9 vs 3.6mL/cm2 (P=.15), respectively. However, among the subgroup of patients with hepatocellular carcinoma, these median values were 460 vs 290mL(P=.06), 365 vs 217mL(P=.007), and 5.2 vs 3.6mL/cm2 (P=.03), respectively. Morbidities and laboratory data were comparable in both groups. Partial infrahepatic inferior vena cava clamping safely reduced central venous pressure and may reduce blood loss in patients with hepatocellular carcinoma when central venous pressure is >5mm Hg at hepatic parenchymal transection.

New concepts and techniques of hepato-pancreato-biliary surgery

Surgery is the most effective and preferred treatment for hepato-pancreato-biliary (HPB) tumors. The improvement of HPB surgery technique mainly focus on reducing the amount of bleeding, improving the safety of operation, simplifying the operation, reducing the complications and mortality all the time. As one of the largest HPB centers in China, hepatic center of Tongji hospital has set up a series of new concepts and new techniques of HPB surgery since 1980s. We proposed a new classification standard of hepatocellular carcinoma (HCC) to guide the surgical procedures and evaluation of prognosis. According to this method, HCCs lager than 5 cm were defined as lager (>5 cm and ³ 10 cm). Traditionally, the large/huge HCC patients were thought can’t tolerate hepatectomy because of the insufficient residual liver volume. However, we confirmed the feasibility and safety of the resection of large/huge HCC and applied it in clinic concurrently in 1990s, which greatly extended the inclusion criteria for operation. Serious intraoperative bleeding is another constraint for resection of large/huge HCC. In order to reduce the intraoperative bleeding and increase the safety of major hepatectomies, three new bleeding control techniques for hepatectomy were established: Infrahepatic inferior vena cava clamping combine with occlusion of the portal triad; tying up of inflow and outflow vessels without dissecting the hilus of the liver; and implementation of the liver double-hanging maneuver through the retrohepatic avascular tunnel on the right side of the inferior vena cava. According to the AASLD and the EASL guidelines for HCC management, patients with portal vein tumor thrombosis (PVTT) are excluded from either surgical treatment or TACE, and only palliative therapies are recommended. However, our studies confirmed treating PVTT patient by indicated surgical protocol according to the location and extension of PVTT is safety and effective. Based on the guideline set by western countries, liver resection is contraindicated in patients with portal hypertension. But in China, 85%–90% patients with HCC showed various degrees of liver cirrhosis, and a large proportion of these patients presented clinical signs of portal hypertension. Thus, we set up a surgical treatment strategy (limited liver resection plus splenectomy with or without devascularization of gastroesophageal varices) for HCC combined with portal hypertension. There are still controversies on the optimal extent of hepaticresection to achieve a high percentage of R0 resection for hilarcholangiocarcinoma. We proposed a new concept that treats hilar cholangiocarcinoma using minor liver resection which showed lower operative morbidity and good prognosis. We also created new surgical procedures such as new intrahepatic cholangiojujunostomy for multiple intrahepatic biliary ductal openings and the inserting bilio- jejunostomy for iatrogenic bile duct injury were all invented and proved to be available in clinic. In order to diminish pancreatic leakage, we established Chen’s U-suture technique for end-to-end invaginated pancreaticojejunostomy following pancreaticoduodenectomy. Many end-stage liver disease patients died due to severe shortage of organ donors. To address the shortage, we are the first to establish auxiliary partial orthotopic liver transplantation technique in the world and applied it in clinic successfully.

Infrahepatic inferior vena cava clamping reduce blood loss during laparoscopic hepatectomy

Infrahepatic inferior vena cava clamping reduce blood loss during laparoscopic hepatectomy

Reverse Trendelenburg position is a safer technique for lowering central venous pressure without decreasing blood pressure than clamping of the inferior vena cava below the liver.

Bleeding remains an important intraoperative complication in patients who undergo hepatectomy. It is generally believed that a reduction in central venous pressure will decrease bleeding from the hepatic venous system. To our knowledge, however, no study has compared the effectiveness of these techniques for controlling bleeding. So we compared the effectiveness of central venous pressure control techniques, such as infrahepatic inferior vena cava clamping, changes in surgical position of the patient, and hypoventilation anesthesia, for lowering central venous pressure. The study group comprised 50 patients who underwent hepatectomy in our department from 2012 through 2013. A central venous catheter was inserted into the right internal jugular vein, and the tip was placed in the superior vena cava. A transducer was placed along the mid-axillary line of the left side of the chest. After opening the abdomen, changes in central venous pressure were measured during inferior vena cava clamping, the reverse Trendelenburg position, the Trendelenburg position, and hypoventilation anesthesia. The inclination relative to the transducer, as measured with an inclinometer, was -10 degrees for the Trendelenburg position and +10 degrees for the reverse Trendelenburg position. The tidal volume was set at 10 mL/kg during conventional anesthesia and 5 mL/kg during hypoventilation anesthesia. The mean central venous pressure was 8.0 cm H(2)O in the supine position during conventional anesthesia, 5.0 cm H(2)O during inferior vena cava clamping, 5.6 cm H(2)O during reverse Trendelenburg position, 10.6 cm H(2)O during Trendelenburg position, and 7.6 cm H(2)O during hypoventilation anesthesia. The mean central venous pressure during inferior vena cava clamping and reverse Trendelenburg position was significantly lower than that during supine position (P = 0.0017 and P = 0.0231, respectively). The mean central venous pressure during hypoventilation anesthesia was not significantly lower than that during supine position (P = 0.9934). Mean systolic blood pressure was significantly decreased during inferior vena cava clamping (P = 0.0024), but not during reverse Trendelenburg position (P = 0.6344). Reverse Trendelenburg position decreased central venous pressure without significantly decreasing the systolic blood pressure, suggesting that it is possible to perform hepatectomy with reverse Trendelenburg position more safely than with inferior vena cava clamping.

Effectiveness and Safety of Controlled Venous Pressure in Liver Surgery: A Systematic Review and Network Meta-Analysis

Objective. To investigate the effectiveness and safety of controlled venous pressure in liver surgery and further to compare the clinical outcomes of low central venous pressure by infrahepatic inferior vena cava clamping (IVCC) and intraoperative anesthetic control (IAC). Methods. Online databases including PubMed, Embase, Cochrane Library, Clinical trials.gov, and China biology medicine database were comprehensively searched. After identifying relevant studies out of the search results, quality assessment was performed according to the methods recommended by the Cochrane collaboration. And meta-analysis was performed by both direct comparison and indirect comparison. Results. Thirteen studies containing 1252 patients were included. Compared with control, controlled venous pressure significantly decreased central venous pressure, total blood loss, blood loss during transection, transfusion rate, and total incidence of complications. Further analysis of IVCC and IAC showed that there was no significant difference in aspects of main clinical outcomes. Conclusions. Controlled venous pressure significantly decreased central venous pressure and achieved improvement of bleeding control in liver surgery. It reduced total incidence of complications and chest infection, while it caused concerns about heart disorder. Although IVCC was not worse than IAC in therapeutic effect, a superiority between them still needs to be explored.