Selective Hepatic Vascular Exclusion Research Articles

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Hepatectomy: A Systematic Review and Meta-Analysis.

ObjectivesMortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion (SHVE) compared to a Pringle maneuver in hepatic resection reduces rates of morbidity and mortality.MethodsA systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and SCOPUS for comparative studies meeting the inclusion criteria. Pooled odds ratios or mean differences were calculated for outcomes using either fixed- or random-effects models.ResultsSix studies were identified: three randomised controlled trials and three observational studies reporting a total of 2,238 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, blood loss, transfusion requirements, air embolism, liver failure and multi-organ failure in the SHVE group. Rates of hepatic vein rupture, post-operative hemorrhage, operative and warm ischemia time, length of stay in hospital and intensive care unit were not statistically significant between the two groups.ConclusionPerforming SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle maneuver. The results of this meta-analysis are based on studies where tumors were adjacent to major vessels. Further RCTs are required to validate these results.Clinical Trial RegistrationPROSPERO (CRD42020212372) https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=212372.

720 Pringle Versus Selective Hepatic Vascular Exclusion in Major Hepatectomy: A Systematic Review and Meta-Analysis

Abstract Aim Mortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. Multiple techniques have been developed in an attempt to minimise blood loss by occluding hepatic inflow and outflow. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion compared to a Pringle manoeuvre in hepatic resection reduces rates of morbidity and mortality. Method A systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL, SCOPUS and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Intra- and post-operative outcome measures were investigated. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models. Results Five studies were identified including two randomized controlled trials and three observational studies reporting a total of 2,198 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, patients requiring blood transfusion, air embolism, warm ischaemia time, liver failure and multi-organ failure when performing SHVE compared to a Pringle manoeuvre. Rates of hepatic vein rupture and post-operative haemorrhage remained the same. Performing SHVE resulted in a significantly longer operation time. Conclusions Performing SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle manoeuvre, although may prolong operating time. The results of this meta-analysis are based on a few high-quality studies where tumours were adjacent to major vessels. Further RCTs are required to validate these results and determine the best technique for hepatic vascular control in this patient cohort.

Comparison of Early Clinical Outcomes between Intermittent Vascular Inflow Occlusion versus Intermittent Selective Hepatic Vascular Exclusion in Hepatic Resections for Cholangiocarcinoma Patients: A Prospective Randomized Controlled Trial Study

Background: There were reported benefits of selective hepatic vascular exclusion (SHVE) in reducing intraoperative blood loss (IBL), intraoperative packed red cell (PRC) transfusion, and perioperative complications over intermittent Pringle maneuver (IPM) in hepatectomies. However, there was lack of data regarding the use of SHVE in comparison with IPM in hepatectomies for cholangiocarcinoma (CCA) patients. Objective: To compare IBL, intraoperative PRC transfusion, total operative time (TOT), and perioperative complications between SHVE and IPM. Materials and Methods: Between October 2018 and September 2019, forty eligible CCA patients participated in the study. They were randomly allocated to the SHVE group (n=20) or the IPM group (n=20). Data regarding patient demographics, tumor characteristics, and the objectives of the study were gathered and analyzed with intention-to-treat principle. Results: The median IBL (range) 923.5 (101 to 4,979) versus 1,109 (413 to 5,305) ml; p=0.2, median intraoperative PRC transfusion (range) 112.5 (0 to 1,745) versus 296 (0 to 1,500) ml; p=0.22, and median TOT (range) 390 minute (220 to 915) versus 320 (240 to 930) minutes; p=0.55 between SHVE and IPM were not significantly different. There was no statistical difference in perioperative complications between SHVE and IPM. Conclusion: Routine use of SHVE during hepatectomies in CCA patients showed no significant difference in outcomes regarding the objectives of the study. Keywords: Selective hepatic vascular exclusion (SHVE), Hepatic vascular exclusion with preservation of caval flow (HVEPV), Hepatic resection, Cholangiocarcinoma, Intraoperative blood loss, Perioperative complications

Application of liver visualization technologies in hilar tumor resection at the second hepatic portal area

To discuss the application of liver visualization technology in complex liver tumor resection at the second hepatic portal area. Clinical data of 80 cases who received surgery at the second hepatic portal area from August 2014 to September 2015 in the Third Department of Hepatic Surgery of Eastern Hepatobiliary Surgery Hospital were analyzed retrospectively. There were 58 male and 22 female patients aged from 21 to 70 years with median age of 52 years. Median maximum diameter of tumor was 7.6 cm (3.0 to 17.0 cm). Before surgery, liver dimensional graphics produced by liver visualization technology were taken on all patients to observe the relationship between intrahepatic vasculars and the liver tumor, and to calculate the intended resection range and the remaining liver volume in order to make a proper surgery plan. Suitable hepatic vascular occlusion was applied in the tumor resection. Intrahepatic vessel shape and variation, surgical operation, surgical operation time, manner and time of hepatic vascular occlusion, blood loss, liver resection volume, postoperative complications were observed. There were 23 patients who changed surgery plan after liver visualization technology.There were 44 cases with single main hepatic vein compressed by tumors, 32 cases with 2 main hepatic veins, 4 cases with 3 main hepatic veins compressed by tumors.And there were 58 cases with both hepatic vein and inferior vena cava compressed by tumor. Hepatic segments 6 and 7 was removed in 12 cases, 14 cases, hepatic segments 4, 5 and 8 were removed in 8 cases.Right hepatectomy was carried out in 9 patients and left hepatectomy was carried out in 8 patients. Right trisectionectomy was carried out in 3 patients and left trisectionectomy was applied in 5 patients.Local hepatectomy was performed in 12 patients. Nine patients received associating liver partition and portal vein ligation for staged hepatectomy. Four patients underwent total hepatic vascular exclusion, while 16 patients underwent selective hepatic vascular exclusion. The median surgical time was 132 minutes(80 to 240 minutes). Median blood loss volume was 580 ml(100-5 000 ml). Median volume of hepatic resection was 750 ml(30 to 2 000 ml). One patient needed secondary surgery to stop bleeding as a result of postoperative abdominal bleeding.Complication of postoperative bile leakage occurred in 14 cases.Five patients had pleural effusion requiring invasive therapy.Four patients had ascites requiring invasive therapy. Besides, 5 patients had incisive infection while 2 patients were found with pulmonary infection after surgery and two patients occurred biliary obstruction. There was no death case occurred a result of surgery. Using liver visualization technology to make surgical operation plan can improve surgical safety of the second hepatic portal area and optimize the operation plan. It can also reduce the risk of blood loss and postoperative complications such as liver failure.

Cost-Effective Surgical Management of Liver Disease Amidst a Financial Crisis.

Intraoperative use of specialized equipment and disposables contributes to the increasing cost of modern liver surgery. As a response to the recent severe financial crisis in our country we have employed a highly standardized protocol of liver resection that minimizes intraoperative and postoperative costs. Our goal is to evaluate cost-effectiveness of this protocol. We evaluated retrospectively all patients who underwent open hepatic resections for 4years. All resections were performed by the same surgical team under selective hepatic vascular exclusion, i.e., occlusion of the hepatoduodenal ligament and the major hepatic veins, occasionally combined with extrahepatic ligation of the ipsilateral portal vein. Sharp parenchymal transection was performed with a scalpel and hemostasis was achieved with sutures without the use of energy devices. In each case we performed a detailed analysis of costs and surgical outcomes. Our cohort included 146 patients (median age 63years). 113 patients were operated for primary or metastatic malignancies and 33 for benign lesions. Operating time was 121±21 min (mean±SD), estimated blood loss was 310±159 ml (mean±SD), and hospital stay was 7±5 days (mean±SD). Six patients required admission in the ICU postoperatively. 90-day mortality was 2.74%, and 8.9% of patients developed grade III/IV postoperative complications (Clavien-Dindo classification). Total in-hospital cost excluding physician fees was 6987.63±3838.51 USD (mean±SD). Our analysis suggests that, under pressing economic conditions, the proposed surgical protocol can significantly lessen the financial burden of liver surgery without compromising patient outcomes.

Intraoperative air embolism during hepatectomy.

Sir, Vascular air embolism (VAE) is a rare and lethal complication of partial hepatectomy with a relative risk of <5%.[1] Even in the absence of intracardiac abnormalities, paradoxical embolism can occur in cirrhotic patients undergoing liver resection because of abnormal arteriovenous communications in the pulmonary circulation.[2] Anaesthetic vigilance along with thorough knowledge of surgical interventions and ensuing physiological perturbations is essential for ensuring patient survival. A 56-year-old female diagnosed with hilar cholangiocarcinoma was posted for extensive right hepatectomy. Clinical examination was normal except for the presence of jaundice with elevated bilirubin and liver enzymes. Anaesthetic technique included general anaesthesia with thoracic epidural block. Electrocardiogram (ECG), oxygen saturation, blood pressure and end-tidal carbon dioxide (ETCO2) were monitored. Left radial artery was cannulated for invasive blood pressure (IBP) monitoring and right internal jugular vein for central venous pressure (CVP), with double lumen 7 Fr central venous catheter (CVC). To reduce the blood loss and transfusion requirements, a low CVP (≈5 mmHg) was targeted. Hepatic resection using cavitron ultrasonic surgical aspirator (CUSA) began after clamping the branches of portal vein and hepatic artery to the right lobe. Three hours into the surgery, surgeon informed accidental opening of a branch of hepatic vein which got retracted into liver parenchyma. Simultaneously, a distinct sucking-in sound was heard, following which IBP dropped to 50/40 mmHg and ETCO2 to 22 mmHg from 34 mmHg while oxygen saturation and CVP (8 mmHg) remained stable. VAE was suspected and nitrous oxide was cut off and the patient ventilated with 100% oxygen. Surgical field was immediately covered with saline-soaked gauze, and then flooded with saline. Resuscitative measures were initiated rapidly with fluid resuscitation, dopamine infusion at 10μg/kg/min and adopting a Trendelenburg position. Aspiration of CVC produced 3 ml of frothy blood. As IBP remained low, epidural infusion was discontinued and a bolus of 50μg adrenaline was administered intravenously. Once vitals stabilised, surgery proceeded with 100% oxygen after giving fentanyl and midazolam. Fifteen minutes later, a second episode of VAE occurred and was accompanied by a fall in oxygen saturation, IBP, ETCO2 and a rise in CVP to 18 mmHg. ECG showed frequent atrial ectopic beats. Dopamine infusion rate was increased and CVC aspirated to obtain 3–4 ml of air. Two more episodes of haemodynamic instability occurred which was treated similarly. At the end of the procedure, her vitals were stable with dopamine support. She was shifted to intensive care unit and was weaned from haemodynamic and ventilator support next day. Factors predisposing to VAE during liver resection include surgical technique, size and site of the tumour, blood loss and low CVP.[3] There are reports of increased incidence and severity of VAE during hepatic resection using CUSA.[4,5] Resection of large tumours situated in the right lobe close to inferior vena cava or the cavo-hepatic junction increases the risk of VAE.[3] Low CVP further enhances the negative pressure gradient and increases the possibility of VAE. Hepatic vascular control using selective hepatic vascular exclusion (SHVE) technique reduces both blood loss and risk of VAE.[3] In our case, site of the tumour, resection using CUSA and lack of SHVE technique along with low CVP anaesthesia all contributed to the incident. Although lethal volume of venous air for adults is about 200–300 ml, the proximity of the entraining vessel to the heart makes even smaller volumes fatal in liver resection.[1,3] Management consists of steps to prevent further entrainment of air and haemodynamic support with inotropic agents.[1,2,3,4] To conclude, both surgeons and anaesthesiologists should be aware of the risk for VAE during hepatectomy and employ appropriate surgical techniques and levels of monitoring to ensure patient safety. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Pringle manoeuvre versus selective hepatic vascular exclusion in partial hepatectomy for tumours adjacent to the hepatocaval junction: A randomized comparative study

ObjectiveTo compare the efficacy of selective hepatic vascular exclusion versus Pringle manoeuvre in partial hepatectomy for tumours adjacent to the hepatocaval junction. MethodsA randomized comparative trial was carried out. The primary endpoint was intraoperative blood loss. The secondary endpoints were operation time, blood transfusion, postoperative liver function recovery, procedure-related morbidity and in-hospital mortality. Results160 patients were randomized into 2 groups: the Pringle manoeuvre group (n = 80) and the selective hepatic vascular exclusion (SHVE) group (n = 80). Intraoperative blood loss and transfusion requirements were significantly less in the SHVE group. In the SHVE group, laceration of hepatic veins happened in 18 patients. Profuse intraoperative blood loss of over 2 L happened in 2 patients but no patient suffered from air embolism because the hepatic veins were controlled. In the Pringle group, the hepatic veins were lacerated in 20 patients, with profuse blood loss of over 2 L in 7 patients and air embolism in 3 patients. The rates of postoperative bleeding, reoperation, liver failure and mortality were significantly higher and the ICU stay and hospital stay were significantly longer in the Pringle group. ConclusionsSHVE was more efficacious than Pringle manoeuvre for partial hepatectomy in patients with tumours adjacent to the hepatocaval junction.

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Partial Hepatectomy for Liver Hemangioma Compressing or Involving the Major Hepatic Veins

Massive blood loss remains a problem during resection for giant liver hemangioma. This present study was designed to compare selective hepatic vascular exclusion (SHVE) versus Pringle maneuver in surgery for liver hemangioma compressing the major (right, middle, or left) hepatic veins. From January 2003 to December 2011, 589 consecutive patients with hemangioma underwent liver resection in our department, and 273 patients had their tumors compressing at least one of the three major hepatic veins (right, middle, or left). Either SHVE (n = 120 patients) or Pringle maneuver (n = 153 patients) was used to minimize blood loss during resection. Data regarding the intraoperative and postoperative courses of these patients were retrospectively analyzed. There was no significant difference between the two groups of patients regarding age, sex, tumor size, types of hepatectomy, and extent of tumor involvement of the major hepatic veins. Intraoperative blood loss, transfusion requirements, and transfusion volume were significantly less in the SHVE group (P < 0.01). For the Pringle group, major hepatic veins were lacerated in 19 patients during hepatic parenchymal transection. For the SHVE group, a major hepatic vein was lacerated during extrahepatic dissection of the hepatic vein in two patients and during hepatic parenchymal transection in 14 patients. SHVE was more efficacious in minimizing intraoperative bleeding during liver resection for hemangiomas compressing the major hepatic veins. It prevented intraoperative major bleeding and air embolism and significantly decreased postoperative liver failure and in-hospital mortality.

A prospective randomized controlled trial to compare two methods of selective hepatic vascular exclusion in partial hepatectomy

Background and aimSelective hepatic vascular exclusion (SHVE) has not been widely used because of difficulty in extrahepatic isolation of hepatic veins. This study aims to compare the results of SHVE using tourniquets or Satinsky clamps on major hepatic veins in partial hepatectomy for liver tumors involving the roots of hepatic veins. MethodsBetween June 2008 and March 2012, a randomized controlled trial was performed on patients undergoing liver resection to compare selective hepatic vascular exclusion using tourniquets or Satinsky clamps in partial hepatectomy. In the tourniquet group, the hepatic veins were completely isolated and occluded with tourniquets. In the Satinsky clamp group, the hepatic veins were dissected on the anterior and side walls only and they were clamped directly by Satinsky clamps. ResultsThe time for dissecting hepatic veins was significantly shorter in the Satinsky clamp group (7.5 ± 6.6 min vs 21.3 ± 7.4 min) than the tourniquet group. In the tourniquet group, 5 hepatic veins could not be completely isolated and encircled. In 4 additional patients the hepatic vein was slightly torn during dissection. These 9 patients received successful occlusion using Satinsky clamps. In the Satinsky group, all occlusion of the hepatic vein was successful. There was a significant difference in the success rate in hepatic vein occlusion using the Satinsky and the tourniquet groups 60/60 vs 51/60, P = 0.0018. ConclusionsBoth techniques of hepatic vein occlusion were safe and efficacious. As the use of Satinsky clamps is safer, easier and took less time, it is recommended.

Central hepatectomy under sequential hemihepatic control

Central hepatectomy is a complex, parenchymal-sparing procedure which has been associated with increased blood loss, prolonged operating time, and increased duration of remnant hypoxia. In this report, we compare two different techniques of vascular control, namely sequential hemihepatic vascular control (SHHVC) and selective hepatic vascular exclusion (SHVE) in central hepatectomies. From January 2000 to September 2011, 36 consecutive patients underwent a central hepatectomy. SVHE was applied in 16 consecutive patients, and SHHVC was applied in 20 patients. Both groups were comparable regarding their demographics. Total operative time and morbidity rates were similar in both groups. Warm ischemia time was significantly longer in SVHE patients (46min vs 28min, p = 0.03). Total blood loss and number of transfusions per patient were also higher in the SVHE group (650 vs. 400mL, p = 0.04 and 2.2 vs. 1.2 units, p = 0.04, respectively). AST values were significantly higher in SVHE on days 1 and 3 compared to SHHVC patients (650 vs. 400, p = 0.04 and 550 vs. 250, p = 0.001, respectively). Sequential hemihepatic vascular control is a safe technique for central hepatectomies. Decreased intraoperative blood loss and transfusions and attenuated liver injury are the main advantages of this approach.

Selective hepatic vascular exclusion versus Pringle manoeuvre in liver resection for tumours encroaching on major hepatic veins (Br J Surg 2012; 99: 973–977)

Selective hepatic vascular exclusion <i>versus</i> Pringle manoeuvre in liver resection for tumours encroaching on major hepatic veins (<i>Br J Surg</i> 2012; 99: 973–977)

Selective hepatic vascular exclusion versus Pringle manoeuvre in liver resection for tumours encroaching on major hepatic veins

Control of bleeding is crucial during liver resection, and several techniques have been developed to achieve this. This study compared the safety and efficacy of selective hepatic vascular exclusion (SHVE) and Pringle manoeuvre in partial hepatectomy for liver tumours compressing or involving major hepatic veins. All patients undergoing liver resection between January 2003 and December 2010 for liver tumours compressing or involving one or more major hepatic veins were identified retrospectively from a prospective institutional database. Either SHVE or Pringle manoeuvre was used to minimize blood loss during hepatectomy. Data on demographics and the intraoperative and postoperative course were analysed. From the database of 3900 patients, 1420 were identified who underwent liver resection for tumours encroaching on major hepatic veins using either SHVE (550) or the Pringle manoeuvre (870). Intraoperative blood loss (mean(s.d.) 480(210) versus 830(340) ml; P = 0·007) and transfusion requirements (mean(s.d.) 1·3(0·6) versus 2·9(1·4) units; P = 0·008) were significantly less in the SHVE group. In the Pringle group, hepatic vein injury resulted in major intraoperative bleeding of over 1000 ml in 65 patients (7·5 per cent) and air embolism in 14 (1·6 per cent), and three patients (0·3 per cent) died during surgery, whereas there was no major bleeding, air embolism or intraoperative death in the SHVE group. Postoperative liver failure, multiple organ failure and in-hospital death were significantly more common in the Pringle group (P = 0·019, P = 0·032 and P = 0·004 respectively). SHVE was more efficacious than the Pringle manoeuvre in minimizing intraoperative bleeding and air embolism during partial hepatectomy for tumours encroaching on major hepatic veins, and decreased the postoperative liver failure rate.

Extrahepatic Portal Vein Ligation in Major Hepatectomies Performed under Selective Vascular Exclusion: A Case–Control Study

The aim of our study is to assess the effect of extrahepatic ipsilateral portal vein branch ligation in hepatectomies conducted under selective hepatic vascular exclusion with sharp transection of the liver parenchyma. Twenty-six patients (Group A) underwent major hepatectomy from January 2007 to December 2009, and hemostasis was achieved by ligation of the ipsilateral portal vein branch in addition to suture ligation of the cut surface vessels. A control group (Group B) was composed of 26 matched patients picked from our hospital's database, in which hemostasis was achieved by suture ligation of the cut surface vessels only. Warm ischemia time, intraoperative blood loss, blood transfusions, and liver function were compared. Reduced blood loss (450 vs 680 mL, P = 0.03), less transfusions (8 vs 20% of the patients, P = 0.04), and decreased warm ischemia time (34 vs 42 minutes, P = 0.04) were observed in Group A. Extrahepatic ligation of the ipsilateral portal vein branch is simple, safe, and effective in reducing blood loss and warm ischemia time in major hepatectomies performed under selective vascular exclusion.

Anatomical liver segmentectomy 2 for combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in segment 2 portal branch

BackgroundHepatic resection is the only effective treatment for combined hepatocellular carcinoma and cholangiocarcinoma.Case presentationA 52-year-old man was preoperatively diagnosed with hepatocellular carcinoma in segment 2 with tumor thrombus in the segment 2 portal branch. Anatomical liver segmentectomy 2, including separation of the hepatic arteries, portal veins, and bile duct, enabled us to remove the tumor and portal thrombus completely. Modified selective hepatic vascular exclusion, which combines extrahepatic control of the left and middle hepatic veins with occlusion of left hemihepatic inflow, was used to reduce blood loss. A pathological examination revealed combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in the segment 2 portal branch. No postoperative liver failure occurred, and remnant liver function was adequate.ConclusionThe separation method of the hepatic arteries, portal veins, and bile duct is safe and feasible for a liver cancer patient with portal vein tumor thrombus. Modified selective hepatic vascular exclusion was useful to control bleeding during liver transection. Anatomical liver segmentectomy 2 using these procedures should be considered for a patient with a liver tumor located at segment 2 arising from a damaged liver.

Ischemic Preconditioning Attenuates Lactate Release by the Liver During Hepatectomies Under Vascular Control: A Case–Control Study

BackgroundWe have previously demonstrated lactate release by the liver itself in hepatectomies performed under selective hepatic vascular exclusion. We hypothesized that ischemic preconditioning applied in this setting might lead to a reduction of hepatic lactate production. MethodsTwenty-one patients underwent hepatectomy under inflow and outflow occlusion combined with ischemic preconditioning (IP group, n = 21). These patients were matched 1:1 with patients subjected to the same technique of hepatectomy under vascular occlusion without ischemic preconditioning (control group, n = 21). The transhepatic lactate gradient (hepatic vein–portal vein) was calculated before liver dissection and 60 min post-reperfusion. ResultsIn the control group, the transhepatic lactate gradient before liver resection was negative indicating consumption by the liver. After 60 min post-reperfusion, this gradient became positive, indicating net lactate production by the liver (0.2±0.3 vs. −0.3±0.2 mmol/L, P < 0.001). In the IP group, the liver consumed lactate both before resection and 60 min post-reperfusion (gradients −0.2±1.1 and −0.1±0.6 mmol/L, respectively). The magnitude of lactate release by the liver correlated with systemic hyperlactatemia post-reperfusion and 24 h postoperatively (r2 = 0.54, P < 0.001 and r2 = 0.67, P < 0.001, respectively). Significant correlations between the transhepatic lactate gradient post-reperfusion and peak postoperative AST as well as the apoptotic response of the liver remnant were also demonstrated (r2 = 0.72, P < 0.001 and r2 = 0.66, P < 0.001, respectively). ConclusionThe microcirculatory derangement and cellular aerobic metabolism breakdown elicited by ischemia–reperfusion insults can be prevented with hepatoprotective measures such as ischemic preconditioning. The transhepatic lactate gradient could act as a monitoring and prognostic tool of the efficacy of ischemic preconditioning.

Ischemic Preconditioning Confers Antiapoptotic Protection During Major Hepatectomies Performed Under Combined Inflow and Outflow Exclusion of the Liver. A Randomized Clinical Trial

Extensive experimental studies and a few clinical series have shown that ischemic preconditioning (IPC) attenuates oxidative ischemia/reperfusion (I/R) injuries in liver resections performed under inflow vascular control. Selective hepatic vascular exclusion (SHVE) employed during hepatectomies completely deprives the liver of blood flow, as it entails simultaneous clamping of the portal triad and the main hepatic veins. The aim of the present study was to identify whether IPC can also protect hepatocytes during liver resections performed under SHVE. Patients undergoing major liver resection were randomly assigned to have either only SHVE (control group, n = 43) or SHVE combined with IPC--10 min of ischemia followed by 15 min of reperfusion before SHVE was applied (IPC group, n = 41). The two groups were comparable with regard to age, liver resection volume, blood loss and transfusions, warm ischemic time, and total operative time. In liver remnant biopsies obtained 60 min post-reperfusion, IPC patients had significantly fewer cells stained positive by TUNEL compared to controls (19% +/- 8% versus 45% +/- 12%; p < 0.05). Also IPC patients had attenuated hepatocyte necrosis, systemic inflammatory response, and oxidative stress as manifested by lower postoperative peak values of aspartate transaminase, interleukin-6, interleukin-8, and malondialdehyde compared to controls. Morbidity was similar for the two groups, as were duration of intensive care unit stay and extent of total hospital stay. In major hepatectomies performed under SHVE, ischemic preconditioning appears to attenuate apoptotic response of the liver remnant, possibly through alteration of inflammatory and oxidative pathways.

The introduction of a simple maneuver to reduce the risk of postoperative bleeding after major hepatectomies

In major hepatectomies, postoperative increases in central venous pressure (CVP) may cause suture failure and massive bleeding. The aim of our study is to test the application of an intraoperative maneuver to reduce the risk of postoperative bleeding. Our study included 172 consecutive patients who had major liver resection with selective hepatic vascular exclusion and sharp transection of the liver parenchyma. An intraoperative maneuver (5 s occlusion of the hepatic vein) was applied in an alternating way, and the patients were assigned to two groups: Cohort A (n = 86), that was granted the maneuver, and Cohort B (n = 86), that was used as a control group. In Cohort A, application of the maneuver was successful in demonstrating bleeders under low CVP levels. Cohort A had lower rate of massive bleeding requiring emergency reoperation (2.3 vs 5.8%, P = 0.049), less postoperative blood transfusions (13 vs 24%, P = 0.042), lower morbidity (20 vs 35%, P < 0.045) and shorter hospital stay compared to Cohort B. Hepatectomies conducted under low CVP are prone to postoperative hemorrhage which can be prevented if the final bleeding control is performed under high pressure in the hepatic veins. Application of our testing maneuver effectively unmasked previously undetectable bleeding veins.

Liver Resection With Selective Hepatic Vascular Exclusion

To report our experience on the safety and efficacy of hepatic resection under selective hepatic vascular exclusion (SHVE). SHVE was used in 246 consecutive patients undergoing major or complex liver resection in our center. Preoperative demographic and clinical data, details of the surgical procedure, pathologic diagnosis, postoperative course, and complications were collected prospectively. From January 2000 to July 2007, liver resections were performed under SHVE in 246 patients; total SHVE, right partial SHVE, and left partial SHVE in 145, 54, and 47 patients, respectively. SHVE was converted to total hepatic vascular exclusion in 3 patients because the tumor invaded the wall of the inferior vena cava. Hemodynamic tolerance to SHVE was excellent, with only a slight increase in systemic and pulmonary vascular resistance during clamping. There were no deaths and the morbidity rate was 24.8%. The mean hospital stay was 9.6 days (range, 8-18). Our study showed that SHVE was safe, efficacious, and it was applicable to liver tumors which were near, but had not invaded into the inferior vena cava.

Comparison of Two Methods of Selective Hepatic Vascular Exclusion for Liver Resection Involving the Roots of the Hepatic Veins

BackgroundSelective hepatic vascular exclusion (SHVE) is an effective hepatic vascular exclusion in controlling both inflow and outflow without interruption of caval flow, as it combines Pringle maneuver with extrahepatic selective occlusion of hepatic veins. But SHVE has not been widely used due to difficulty in extrahepatic dissection of hepatic veins. When the tumor is very close to the roots of the hepatic veins, dissecting the posterior wall of the hepatic vein may lead to rupture and massive bleeding of the hepatic vein. With our experience, clamping hepatic veins with Satinsky clamps is a safer and easier occlusion method by which the posterior wall of the hepatic veins does not need to be separated and encircled. In this report, we compared the results of selective hepatic vascular occlusion with tourniquet and Satinsky clamp for major liver resection involving the roots of the hepatic veins. MethodsBetween January 2003 to June 2006, 180 patients who underwent major liver resection with SHVE were divided into two groups according to different methods of hepatic vascular occlusion: occlusion with tourniquet (tourniquet group, n = 95) and occlusion with Satinsky clamp (Satinsky clamp group, n = 85). In the tourniquet group, the hepatic veins were encircled and occluded with tourniquet. In the Satinsky clamp group, the hepatic veins were not encircled and clamped directly by Satinsky clamp. ResultsIntraoperative and postoperative consequences of the patients were analyzed. The dissecting time for each hepatic vein was significantly shorter in the Satinsky group (6.2±2.4 min vs 18.3±6.2 min) than in the tourniquet group. In the tourniquet group, five hepatic veins (one right hepatic vein and four common trunk of left-middle hepatic veins) could not be dissected and encircled because the tumors involved the cava hepatic junction, and another common trunk of the left-middle hepatic vein had a small rupture during the dissection. These six patients then received successful occlusion with Satinsky clamp. There was no difference between the two groups regarding the operation duration, ischemia time, intraoperative blood loss, and postoperative complication rate. ConclusionBoth methods of the hepatic vein occlusion have the same effect on controlling hepatic vein bleeding, but occlusion with Satinsky clamp is safer, easier, and consumes less time in dissecting.

Early results of liver resection due to metastases of colorectal carcinoma

Liver metastases are most frequently the result of colorectal carcinoma. The aim of this study was to analyse early results of operative treatment of the patients with the liver metastases of colorectal carcinoma. This retrospective, prospective study included 387 patients with colorectal carcinoma operated during the period from 2005-2007. All the patients were submitted to oncologic surgery protocol. The functional state of the liver was assessed, especially in the patients with hemotherapy. Diagnostic protocol further included color Doppler ultrasonography of the liver and port system, as well as spiral computed tomography includy angiography. Nine (5.7%) of the patients were submitted to explorative laparotomy. Of all the patients 157 (40.6%) had metastases in the liver, synhronous 78 (20.15%) and metachronous 79 (20.45%), Forty two (26.7%) patients were indicated for the liver resection. In 33 (21%) of them it was performed successfully. There were 18 females and 15 males of the average age 60.09 (42-81) years. Up to 4 metastases had 90.9% of the patients and in 9.09% had up to 5 and more metastases. On average, metastases occupied 2.6 of the liver segments. There were 21.2% of solitary lesions (7 patients), 63.6% of multilple unilobular (21 patients) and 15.15% of multiple bilobular metastases (5 patients). Liver resection was done using ultraharmonic scalpel. At spacious liver resections we used a device for intraoperative saving of blood (cell saver) and applied a technique of selective hepatic vascular exclusion. An average disease-free interval was 16.7 months. There were 60.6% of anatomical liver resections and 39.4% of atypical resections. In 31.1% of the operated patients we made resection on up to two segments of the liver and in 30.3% we made resection of four segments. An average number of segments where resection had been performed was 2.65 and the duration of operation was 143 minutes. In 39.4% of the cases we used a technique of liver vascular isolation, an average duration was 38 minutes. In 30.3% of resections we used cell saver and 70% of operated patients were transfused. On average, 493 ml of blood was transfused. Of the total number of resections, 90.9% was of the type R0, 9.09% of the type R1. An average duration of postoperative hospitalization was 10.6 days. Operative morbidity rate was 15.15% and operative mortality 3.03%. During a six-month observing there were not any mortality or repeated metastases in liver. Anatomic liver resection including selective vascular hepatic excision by the use of an ultraharmonic scalpel and cell saver is considered to be efficient and secure method for the reduction of intraoperative and postoperative complications rendering good surgical results.