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Imai D, Rokop ZP, Yokoyama M, Sharma A, Mihaylov P, Powelson J, Lee SD, Saeed MI, Kumar D, Sharfuddin A, Holmes R, Lacerda M, Wedd J, Bruno JM, Swensson JK, Bruno DA, Kubal CA, Kumaran V. Renal Function in Sequential Living Kidney-Then-Liver Donors Undergoing Right Lobe Donation: A Two-Center Case Study. Clin Transplant 2025; 39:e70168. [PMID: 40305485 DOI: 10.1111/ctr.70168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/04/2025] [Accepted: 04/13/2025] [Indexed: 05/02/2025]
Abstract
BACKGROUND There are concerns regarding the potential impact of living donor hepatectomy on the kidney function of prior kidney donors. The current literature lacks comprehensive data on living liver following living kidney donation. Furthermore, the focus on left lobe donation in the literature does not fully represent the prevalent use of the right lobe graft for living liver transplants in the United States. METHODS We performed a retrospective chart review on all living liver donors who had previously donated a kidney at two US centers. RESULTS There were 14 sequential living kidney-then-liver donors. The median donor age was 49 years (range 35-59). Most of these (12 donors) were nondirected donations. The median follow-up period was 24 months (range 1-129). The median interval between the donations was 32 months (range 17-154 months). All donors donated the right lobe with 43.5% (range 31.4%-49.9 %) of remnant liver volume. The overall donor complication rate was 43%, seen in six donors, with one Clavien-Dindo Grade IIIa complication (suture granuloma removal under local anesthesia). Two donors (14%) experienced stage 1 AKI, both resolving with supportive care. A decrease in eGFR greater than 10 mL/min/1.73 m2 over the follow-up was observed in only one donor, who gained weight and was lost to follow-up. Compensatory kidney hypertrophy was observed, with kidney volumetry showing an increase of 1.27 (1.09-1.39) times pre- versus post-kidney donation and 1.08 times pre- versus post-liver donation (1.01-1.16). CONCLUSIONS Right lobe living liver donation in previous kidney donors might be safely performed in terms of midterm kidney function. Longer-term assessment in a larger cohort would be necessary to have better insight into this unique donor group.
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Affiliation(s)
- Daisuke Imai
- Department of Surgery, Division of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Zachary P Rokop
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Masaya Yokoyama
- Department of Surgery, Division of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amit Sharma
- Department of Surgery, Division of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Plamen Mihaylov
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Powelson
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Seung Duk Lee
- Department of Surgery, Division of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Muhammad I Saeed
- Department of Surgery, Division of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Dhiren Kumar
- Department of Internal Medicine, Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Asif Sharfuddin
- Department of Internal Medicine, Division of Transplant Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel Holmes
- Department of Internal Medicine, Division of GI and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marco Lacerda
- Department of Internal Medicine, Division of GI and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joel Wedd
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jill M Bruno
- Department of Radiology, Division of Diagnostic Radiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jordan K Swensson
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David A Bruno
- Department of Surgery, Division of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Chandrashekhar A Kubal
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Vinay Kumaran
- Department of Surgery, Division of Transplant Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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Feng J, Fu R, Zhang L, Yang D, Wang H. The significance of the modified surgical apgar score in predicting postoperative acute kidney injury among patients undergoing hepatectomy. Dig Liver Dis 2025:S1590-8658(25)00221-X. [PMID: 39984402 DOI: 10.1016/j.dld.2025.01.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 01/27/2025] [Accepted: 01/30/2025] [Indexed: 02/23/2025]
Abstract
AIM The incidence of acute kidney injury (AKI) following hepatectomy ranges from 0.9 % to 21.6 %. Postoperative AKI is associated with increased mortality, prolonged hospital stays, and more healthcare costs. Previous predictive models either neglected intraoperative factors or were excessively complicated for application. Based on estimated blood loss, minimum heart rate, and minimum mean arterial pressure, the Surgical Apgar Score (SAS) has been validated as an indicator of major complications and outcomes following surgeries. Furthermore, previous studies have linked hematocrit levels to the incidence of AKI. Our aim was to determine whether the modified SAS, calculated using both SAS and hematocrit, could accurately predict AKI following hepatectomy. METHODS This retrospective study ultimately enrolled 960 patients who underwent hepatectomy. The study included a total of 28 preoperative and intraoperative variables. Univariate and multivariate logistic regression analyses were performed to determine the predictive ability of the modified SAS. RESULTS We demonstrated significant associations between the modified SAS and the incidence of AKI (OR 0.65, 95 % CI 0.54-0.78, p < 0.001). A lower total score increases the likelihood of postoperative AKI, with a cutoff value set at 9. CONCLUSIONS The modified SAS appears to be a valid predictive factor for AKI following hepatectomy.
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Affiliation(s)
- Jiayu Feng
- Department of Anesthesiology, the First People's Hospital of Foshan, Foshan, People's Republic of China.
| | - Rongdang Fu
- Department of Hepatic Surgery, the First People's Hospital of Foshan, Foshan, People's Republic of China.
| | - Lei Zhang
- Department of Anesthesiology, the First People's Hospital of Foshan, Foshan, People's Republic of China.
| | - Dong Yang
- Guangzhou AID Cloud Technology Co., LTD, Guangzhou, People's Republic of China.
| | - Hanbing Wang
- Department of Anesthesiology, the First People's Hospital of Foshan, Foshan, People's Republic of China.
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Lv H, Jiang X, Huang X, Wang W, Wu B, Yu S, Lan Z, Zhang L, Lao Y, Guo J, Yang N, YangNo N. Nitroglycerin versus milrinone for low central venous pressure in patients undergoing laparoscopic hepatectomy: a double-blinded randomized controlled trial. BMC Anesthesiol 2024; 24:244. [PMID: 39026144 PMCID: PMC11256614 DOI: 10.1186/s12871-024-02631-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Conventional anesthesia used to reduce central venous pressure (CVP) during hepatectomy includes fluid restriction and vasodilator drugs, which can lead to a reduction in blood perfusion in vital organs and may counteract the benefits of low blood loss. In this study, we hypothesized that milrinone is feasible and effective in controlling low CVP (LCVP) during laparoscopic hepatectomy (LH). Compared with conventional anesthesia such as nitroglycerin, milrinone is beneficial in terms of intraoperative blood loss, surgical environment, hemodynamic stability, and patients' recovery. METHODS In total, 68 patients undergoing LH under LCVP were randomly divided into the milrinone group (n = 34) and the nitroglycerin group (n = 34). Milrinone was infused with a loading dose of 10 µg/kg followed by a maintenance dose of 0.2-0.5 µg/kg/min and nitroglycerin was administered at a rate of 0.2-0.5 µg/kg/min until the liver lesions were removed. The characteristics of patients, surgery, intraoperative vital signs, blood loss, the condition of the surgical field, the dosage of norepinephrine, perioperative laboratory data, and postoperative complications were compared between groups. Blood loss during LH was considered the primary outcome. RESULTS Blood loss during hepatectomy and total blood loss were significantly lower in the milrinone group compared with those in the nitroglycerin group (P < 0.05). Both the nitroglycerin group and milrinone group exerted similar CVP (P > 0.05). Nevertheless, the milrinone group had better surgical field grading during liver resection (P < 0.05) and also exhibited higher cardiac index and cardiac output during the surgery (P < 0.05). Significant differences were also found in terms of fluids administered during hepatectomy, urine volume during hepatectomy, total urine volume, and norepinephrine dosage used in the surgery between the two groups. The two groups showed a similar incidence of postoperative complications (P > 0.05). CONCLUSION Our findings indicate that the intraoperative infusion of milrinone can help in maintaining an LCVP and hemodynamic stability during LH while reducing intraoperative blood loss and providing a better surgical field compared with nitroglycerin. TRIAL REGISTRATION ChiCTR2200056891,first registered on 22/02/2022.
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Affiliation(s)
- Huayan Lv
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Xiaofeng Jiang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Xiaoxia Huang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Wei Wang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Bo Wu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Shian Yu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Zhijian Lan
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Lei Zhang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Yuwen Lao
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Jun Guo
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Na Yang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
- , No. 365, Renmin East Road, Wucheng District, Jinhua, Zhejiang Province, 321000, People's Republic of China.
| | - Na YangNo
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
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Yang W, Peng Y, Yang Y, Liang B, Li B, Wei Y, Liu F. Caudo-dorsal approach combined with the occlusion of right hepatic vein and Pringle maneuver in laparoscopic anatomical resection of segment 7. Surg Endosc 2024; 38:3455-3460. [PMID: 38755463 DOI: 10.1007/s00464-024-10908-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 05/03/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Laparoscopic anatomical resection of segment 7 (LARS7) remains a technically challenging procedure due to the deep anatomical location and the potential risk of injury to the right hepatic vein (RHV). Herein, we initiated an innovative technique of caudo-dorsal approach combined with the occlusion of the RHV and Pringle maneuver for LARS7 and presented the outcomes of our initial series. METHOD Since January 2021, the patients who underwent LARS7 by using this novel technique were enrolled in this study. The critical aspect of this technique was the interruption of communication between the RHV and the inferior vena cava. Meanwhile, the Pringle maneuver was adopted to control the hepatic inflow. RESULT A total of 11 patients underwent LARS7 by using this novel technique, which included 8 hepatocellular carcinoma, 2 bile duct adenocarcinoma and one focal nodular hyperplasia. The median operative time was 199 min (range of 151-318 min) and the median blood loss was 150 ml (range of 50-200 ml). The main trunk of the RHV was fully exposed on the cutting surface in all cases and no patient received perioperative blood transfusion. No procedure was converted to open surgery. Of note, no indications of CO2 gas embolism were observed in these cases after the introduction of double occlusion. Only one patient suffered from postoperative complications and healed after treatment. The median postoperative stay was 5 days (range of 4-7 days). The 90-day mortality was nil. At a median follow-up period of 19 months, all of the patients were alive without any evidence of tumor recurrence. CONCLUSION The caudo-dorsal approach combined with the occlusion of RHV and the Pringle maneuver may be a feasible and expected technique for safe exposure of RHV in LARS7. Further validation of the feasibility and efficacy of this technique is needed.
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Affiliation(s)
- Wugui Yang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guoxuegang, Chengdu, 610041, Sichuan, China
| | - Yufu Peng
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guoxuegang, Chengdu, 610041, Sichuan, China
| | - Yubo Yang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guoxuegang, Chengdu, 610041, Sichuan, China
| | - Bin Liang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guoxuegang, Chengdu, 610041, Sichuan, China
| | - Bo Li
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guoxuegang, Chengdu, 610041, Sichuan, China
| | - Yonggang Wei
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guoxuegang, Chengdu, 610041, Sichuan, China
| | - Fei Liu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guoxuegang, Chengdu, 610041, Sichuan, China.
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Patel A, Tan J, Lambert J, Kitching S, Iqbal A, Satyadas T. Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver during hepatectomy: a meta-analysis. Langenbecks Arch Surg 2024; 409:160. [PMID: 38758232 PMCID: PMC11101571 DOI: 10.1007/s00423-024-03344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE 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 PM alone in terms of intraoperative outcomes and perioperative complications. METHODS 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. RESULTS Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PM alone 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 PM alone. 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 PM alone group. CONCLUSION 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 PM alone.
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Affiliation(s)
- Agastya Patel
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK.
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland.
| | - Jacob Tan
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Joel Lambert
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Samuel Kitching
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Affan Iqbal
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Thomas Satyadas
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
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Namba Y, Kobayashi T, Hashimoto M, Onoe T, Mashima H, Oishi K, Honmyo N, Abe T, Kuroda S, Ohdan H. The efficacy and safety of pure laparoscopic liver resection for hepatocellular carcinoma in super-elderly patients over 80 years: A multicenter propensity analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:234-242. [PMID: 38009434 DOI: 10.1002/jhbp.1395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Very few reports have evaluated the safety of laparoscopic liver resection in super-elderly patients. We assessed the short-term outcomes of laparoscopic liver resection in patients with hepatocellular carcinoma aged ≥80 years, using propensity score matching. METHODS We retrospectively analyzed the data of 287 patients (aged ≥80 years) who underwent liver resection for hepatocellular carcinoma at eight hospitals belonging to Hiroshima Surgical study group of Clinical Oncology, between January 2012 and December 2021. The perioperative outcomes were compared between laparoscopic and open liver resection, using propensity score matching. RESULTS Of the 287 patients, 83 and 204 were included in the laparoscopic and open liver resection groups, respectively. Propensity score matching was performed, and 52 patients were included in each group. The operation (p = .68) and pringle maneuver (p = .11) time were not different between the groups. There were no significant differences in the incidences of bile leakage or organ failure. The laparoscopic liver resection group had significantly less intraoperative bleeding and a lower incidence of cardiopulmonary complications (both p < .01). CONCLUSIONS Laparoscopic liver resection can be safely performed in elderly patients aged ≥80 years.
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Affiliation(s)
- Yosuke Namba
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masakazu Hashimoto
- Department of Gastroenterological-Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Takashi Onoe
- Department of Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroaki Mashima
- Department of Surgery and Endoscopic Surgery, JA Onomichi General Hospital, Hiroshima, Japan
| | - Koichi Oishi
- Department of Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Naruhiko Honmyo
- Department of Surgery, Hiroshima City North Medical Center, Asa Citizens Hospital, Hiroshima, Japan
| | - Tomoyuki Abe
- Department of Surgery and Gastroenterological Surgery, East Hiroshima Medical Hospital, Hiroshima, Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Li S, Yin Y, Wang P, Jiang L, Yan H, Cang J. Goal-directed fluid therapy during post-resection phase in low central venous pressure assisted laparoscopic hepatectomy: a randomized controlled superiority trial. J Anesth 2024; 38:77-85. [PMID: 38091035 DOI: 10.1007/s00540-023-03282-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 10/30/2023] [Indexed: 01/25/2024]
Abstract
PURPOSE The purpose of this prospective single blinded randomized controlled trial was to find out whether goal-directed fluid therapy (GDFT) strategy in post-transection period in low central venous pressure (CVP) assisted laparoscopic hepatectomy (LH) has more benefit than traditional fluid strategy. METHODS Between April 2020 and Dec 2021, patients who were scheduled for laparoscopic liver resection surgery were eligible to participate in the study. Patients were randomly divided into two groups: control group that received traditional fluid strategy in post-transection period in low CVP assisted laparoscopic hepatectomy and GDFT strategy group that received GDFT strategy in post-transection period. The primary outcome parameter is the incidence of postoperative complications. Secondary outcome parameters include perioperative clinical outcomes, postoperative clinical outcomes, length of hospital stay after surgery, postoperative lactic acid, fluids and vasoactive medications during the operation. RESULTS A total of 159 patients in the control group and 160 patients in the GDFT were included. Two groups had no significant difference in the incidence of postoperative complications including pneumonia (P = 0.34), acute kidney injury (P = 0.72), hepatic insufficiency (P = 0.25), pleural effusion (P = 0.08) and seroperitoneum (P = 1.00), respectively. The amount of perioperative urine output is fewer in GDFT group than in the control group (P = 0.0354), while other perioperative variables and postoperative variables were comparable between two groups. CONCLUSIONS The results show the implementation of GDFT strategy is not associated with fewer postoperative complications. GDFT strategy did not result in improved outcomes in low CVP-assisted laparoscopic hepatectomy.
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Affiliation(s)
- Shichao Li
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yue Yin
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Pei Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Long Jiang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Huan Yan
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Jing Cang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Yang J, Zhang J, Luo J, Ouyang J, Qu Q, Wang Q, Si Y. Safe and Effective Blood Preservation Through Acute Normovolemic Hemodilution and Low-Dose Tranexamic Acid in Open Partial Hepatectomy. J Pain Res 2023; 16:3905-3916. [PMID: 38026458 PMCID: PMC10657755 DOI: 10.2147/jpr.s426872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/21/2023] [Indexed: 12/01/2023] Open
Abstract
Objective In this study, we evaluated the efficacy of tranexamic acid (TXA) and acute normovolemic hemodilution (ANH) with 6% hydroxyethyl starch (130/0.4) in minimizing blood loss during open partial liver resection. Coagulation function was assessed using thromboelastography (TEG) and hemostasis tests, while renal function changes were tracked through serum creatinine values post-surgery. Methods Thirty patients undergoing open partial liver resection were allocated to two groups: Group T received TXA + ANH, and Group A received ANH alone. Blood was drawn from the radial artery under general anesthesia. Both groups received peripheral vein injections of 6% hydroxyethyl starch 130/0.4. Group T additionally received intravenous TXA. Primary outcomes included blood loss and allogeneic blood transfusions. TEG assessed coagulation status and renal function was monitored. Results Group T demonstrated superior outcomes compared to Group A. Group T had significantly lower intraoperative blood loss (700 mL vs 1200 mL) and a lower bleeding rate per kilogram of body weight (13.3 mL/kg vs 20.4 mL/kg). Coagulation parameters favored Group T, with higher TEG maximum amplitude (55.91 mm vs 45.88 mm) and lower activated partial thromboplastin time (38.04 seconds vs 41.49 seconds). Neither group experienced acute renal injury or kidney function deficiency during hospitalization. Conclusion TXA and ANH in a small dose during liver resection stabilize clotting, reduce blood loss by 6% compared to hydroxyethyl starch 130/0.4, and do not affect renal function.
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Affiliation(s)
- Jian Yang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Jing Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Jiayan Luo
- Department of Anesthesiology, People’s Hospital of Yanting, Sichuan, 621600, People’s Republic of China
| | - Jie Ouyang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Qicai Qu
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Qitao Wang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Yongyu Si
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
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Kuang L, Lin W, Chen B, Wang D, Zeng Q. A nomogram for predicting acute kidney injury following hepatectomy: A propensity score matching analysis. J Clin Anesth 2023; 90:111211. [PMID: 37480714 DOI: 10.1016/j.jclinane.2023.111211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/21/2023] [Accepted: 07/09/2023] [Indexed: 07/24/2023]
Abstract
STUDY OBJECTIVE The low central venous pressure (LCVP) technique is a key technique in hepatectomy, but its impact on acute kidney injury (AKI) is unclear. The purpose of this study was to explore risk factors (in particular LCVP time) for AKI following hepatectomy. DESIGN A retrospective case-control study with propensity score matching. SETTING Operating room. PATIENTS A total of 1949 patients who underwent hepatectomy were studied. INTERVENTIONS The patients were grouped with or without AKI within 7 days after surgery. Univariable and multivariable analyses were performed, including recognized intraoperative predictors. The final result is represented as a nomogram. MEASUREMENTS Preoperative, intraoperative and postoperative data were collected. LCVP is monitored directly through a central venous catheter via the right internal jugular vein. MAIN RESULTS AKI occurred in 148 patients (7.59%). Surgery time, minimum SBP, furosemide administration and norepinephrine were identified as independent risk factors. The area under the curve for the receiver operating characteristic curves was 0.726 (95% CI 0.668-0.783). CONCLUSION Intraoperative parameters can be used to predict the probability of postoperative AKI. Although AKI increases the length of stay, it may not increase in-hospital mortality. LCVP time was not confirmed to be a risk factor for AKI.
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Affiliation(s)
- Liting Kuang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Weibin Lin
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.
| | - Bin Chen
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dahui Wang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qingliang Zeng
- Internet Hospital Office, Department of Medical Affairs, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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10
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Lv H, Xiong C, Wu B, Lan Z, Xu D, Duan D, Huang X, Guo J, Yu S. Effects of targeted mild hypercapnia versus normocapnia on cerebral oxygen saturation in patients undergoing laparoscopic hepatectomy under low central venous pressure: a prospective, randomized controlled study. BMC Anesthesiol 2023; 23:257. [PMID: 37525100 PMCID: PMC10388477 DOI: 10.1186/s12871-023-02220-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Laparoscopic hepatectomy under low central venous pressure (LCVP) is associated with intraoperative organ hypoperfusion, including cerebral hypoperfusion. We hypothesized that a ventilation strategy designed to achieve targeted mild hypercapnia (TMH) (end-tidal carbon dioxide partial pressure [PetCO2] of 45 ± 5 mmHg) rather than targeted normocapnia (TN) (PetCO2 of 30 ± 5 mmHg) would increase regional cerebral oxygen saturation (rSO2) during laparoscopic hepatectomy under LCVP. METHODS Eighty patients undergoing laparoscopic hepatectomy under LCVP were randomly divided into the TMH group (n = 40) and the TN group (n = 40). Mechanical ventilation was adjusted to maintain the PetCO2 within the relevant range. Cerebral oxygenation was monitored continuously using the FORE-SIGHT system before anesthetic induction until the patient left the operating room. Patient and surgical characteristics, rSO2, intraoperative hemodynamic parameters (CVP, mean artery blood pressure [MAP], and heart rate), PetCO2, intraoperative blood gas analysis results, and postoperative complications were recorded. RESULTS No significant differences were observed in CVP, MAP, and heart rate between the two groups during surgery. The rSO2 was significantly lower in the TN group on both the left and right sides during the intraoperative period (P < 0.05), while the TMH group had a stable rSO2. In the TN group, the mean rSO2 decreased most during liver parenchymal transection when compared with the baseline value (P < 0.05). The mean (standard deviation) percentage change in rSO2 from baseline to parenchymal transection was - 7.5% (4.8%) on the left and - 7.1% (4.6%) on the right. The two groups had a similar incidence of postoperative complications (P > 0.05). CONCLUSION Our findings demonstrate that rSO2 is better maintained during laparoscopic hepatectomy under LCVP when patients are ventilated to a PetCO2 of 45 ± 5 mmHg (TMH) than a PetCO2 of 30 ± 5 mmHg (TN). TRIAL REGISTRATION ChiCTR2100051130(14/9/2021).
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Affiliation(s)
- Huayan Lv
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Chang Xiong
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Bo Wu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Zhijian Lan
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Duojia Xu
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Dingnan Duan
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Xiaoxia Huang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Jun Guo
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
| | - Shian Yu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
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11
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Shin J, Suh SW. Influence of fluid balance on postoperative outcomes after hepatic resection in patients with left ventricular diastolic dysfunction. Front Surg 2022; 9:1036850. [PMID: 36468074 PMCID: PMC9709119 DOI: 10.3389/fsurg.2022.1036850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/31/2022] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE The maintenance of low central venous pressure (CVP) during hepatic resection is associated with a reduction in estimated blood loss. After completion of the hepatic parenchymal transection, fluid is rapidly administered to replace the surgical blood loss and fluid deficit to prevent subsequent organ injury risk. However, this perioperative fluid strategy may influence on the postoperative outcomes of patients with left ventricular diastolic dysfunction (LVDD) who cannot tolerate volume adjustment. METHOD A total of 206 patients with who underwent hepatic resection between March 2015 and February 2021 were evaluated. LVDD was defined according to the American Society of Echocardiography and the European Association of Cardiovascular Imaging 2016 recommendations as LVDD (group A, n = 39), or normal LV diastolic function and indeterminate decision (group B, n = 153). We compared the clinical outcomes of patients between two groups, and then analyzed the risk factors for postoperative complications. RESULT Postoperative acute kidney injury (AKI, 10.3% vs. 1.3%, P = 0.004) and pleural effusion or edema (51.3% vs. 30.1%, P = 0.013) were more common in group A than in group B. Further, creatinine levels from postoperative day 1 to day 7 were significantly higher and daily urine outputs at postoperative day 1 (P = 0.038) and day 2 (P = 0.025) were significantly lower in group A than in group B. LVDD was the only significant risk factor for postoperative AKI after hepatic resection (odds ratio, 10.181; 95% confidence interval, 1.570-66.011, P = 0.015). CONCLUSIONS The rates of renal dysfunction and pulmonary complications after hepatic resection are higher in patients with LVDD than in those with normal LV diastolic function. Thus, these patients require individualized fluid management.
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Affiliation(s)
- Jungho Shin
- Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Suk-Won Suh
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
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12
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Suh SW. Bioelectrical Impedance Analysis for Preoperative Volemia Assessment in Living Donor Hepatectomy. J Pers Med 2022; 12:jpm12111755. [PMID: 36573727 PMCID: PMC9693392 DOI: 10.3390/jpm12111755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 12/30/2022] Open
Abstract
Donor safety remains an important concern. We introduced preoperative bioelectrical impedance analysis (BIA) in living donor hepatectomy, as it is a practical method for volemia assessment with the advantages of noninvasiveness, rapid processing, easy handling, and it is relatively inexpensive. We analyzed 51 living donors who underwent right hemihepatectomy between July 2015 and May 2022. The ratio of extracellular water:total body water (ECW/TBW; an index of volemic status) was measured. ECT/TBW < 0.378 was correlated to central venous pressure (CVP) < 5 mm Hg in a previous study and we used this value for personalized preoperative management. In the BIA group (n = 21), donors with ECW/TBW ≥ 0.378 (n = 12) required whole-day nothing by mouth (NPO), whereas those with ECW/TBW < 0.378 (n = 9) required midnight NPO, similar to the control group (n = 30). In comparison with the control group, the BIA group had a significantly lower central venous pressure (p < 0.001) from the start of surgery to the end of surgery, leading to a better surgical field grade (p = 0.045) and decreased operative duration (240.5 ± 45.6 vs. 276.5 ± 54.0 min, p = 0.016). A cleaner surgical field (surgical field grade 1) was significantly associated with decreased operative duration (p = 0.001) and estimated blood loss (p < 0.001). Preoperative BIA was the only significant predictor of a cleaner surgical field (odds ratio, 6.914; 95% confidence interval, 1.6985−28.191, p = 0.007). In conclusion, preoperative volemia assessment using BIA can improve operative outcomes by creating a favorable surgical environment in living donor hepatectomy.
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Affiliation(s)
- Suk-Won Suh
- Department of Surgery, Chung-Ang University College of Medicine, Chung-Ang University Hospital, 224-1, Heuk Seok-Dong, Dongjak-Ku, Seoul 156-755, Korea
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13
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Diagnostic timing dependent characteristics of acute kidney injury following hepatectomy: a retrospective historical cohort analysis. HPB (Oxford) 2021; 23:1897-1905. [PMID: 34092494 DOI: 10.1016/j.hpb.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The timing of diagnosis of post-hepatectomy acute kidney injury (AKI) has rarely been investigated. The aim of this retrospective study was to reveal the differences between AKI subtypes following hepatectomy, as classified by timing of diagnosis. METHOD Post-hepatectomy AKI was classified as very transient AKI (vtAKI; criteria satisfied by the serum creatinine value immediately after surgery) or non-transient AKI (ntAKI; all other AKI types except for vtAKI). Multivariate logistic regression analyses for both AKI types were performed separately to identify differences in known perioperative AKI risk factors. The impacts of each AKI subtype on postoperative complications, hospital stay and renal outcome at discharge were also evaluated. RESULTS AKI was diagnosed in 135 of 750 patients (18.0%); 82 and 53 patients were classified as vtAKI and ntAKI, respectively. In multivariate analysis, even among the perioperative factors associated with whole AKI, there were distinct relationships depending on vtAKI or ntAKI. Furthermore, only ntAKI was associated with postoperative complications, longer hospital stays and impaired renal function at discharge. CONCLUSIONS Based on the results of this study, future post-hepatectomy AKI studies should only include ntAKI and exclude vtAKI, as vtAKI has minimal clinical impact despite accounting for a significant proportion of AKI patients. CLINICAL TRIAL REGISTRATIONS None.
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14
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Krasnodębski M, Grąt K, Morawski M, Borkowski J, Krawczyk P, Zhylko A, Skalski M, Kalinowski P, Zieniewicz K, Grąt M. Skin autofluorescence as a novel predictor of acute kidney injury after liver resection. World J Surg Oncol 2021; 19:276. [PMID: 34526025 PMCID: PMC8444415 DOI: 10.1186/s12957-021-02394-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/03/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Skin autofluorescence (SAF) reflects accumulation of advanced glycation end-products (AGEs). The aim of this study was to evaluate predictive usefulness of SAF measurement in prediction of acute kidney injury (AKI) after liver resection. METHODS This prospective observational study included 130 patients undergoing liver resection. The primary outcome measure was AKI. SAF was measured preoperatively and expressed in arbitrary units (AU). RESULTS AKI was observed in 32 of 130 patients (24.6%). SAF independently predicted AKI (p = 0.047), along with extent of resection (p = 0.019) and operative time (p = 0.046). Optimal cut-off for SAF in prediction of AKI was 2.7 AU (area under the curve [AUC] 0.611), with AKI rates of 38.7% and 20.2% in patients with high and low SAF, respectively (p = 0.037). Score based on 3 independent predictors (SAF, extent of resection, and operative time) well stratified the risk of AKI (AUC 0.756), with positive and negative predictive values of 59.3% and 84.0%, respectively. In particular, SAF predicted AKI in patients undergoing major and prolonged resections (p = 0.010, AUC 0.733) with positive and negative predictive values of 81.8%, and 62.5%, respectively. CONCLUSIONS AGEs accumulation negatively affects renal function in patients undergoing liver resection. SAF measurement may be used to predict AKI after liver resection, particularly in high-risk patients.
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Affiliation(s)
- Maciej Krasnodębski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.
| | - Karolina Grąt
- Second Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Morawski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jan Borkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Andriy Zhylko
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Skalski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Kalinowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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15
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Lee KF, Lo EYJ, Wong KKC, Fung AKY, Chong CCN, Wong J, Ng KKC, Lai PBS. Acute kidney injury following hepatectomy and its impact on long-term survival for patients with hepatocellular carcinoma. BJS Open 2021; 5:6380640. [PMID: 34601569 PMCID: PMC8487667 DOI: 10.1093/bjsopen/zrab077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/19/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) is increasingly being recognized after hepatectomy. This study aimed to identify factors predicting its occurrence and its impact on long-term outcome among patients with hepatocellular carcinoma (HCC). Methods This was a retrospective analysis of the incidence of AKI, factors predicting its occurrence, and its impact on patients undergoing hepatectomy between September 2007 and December 2018. A subgroup analysis included patients with histologically proven HCC. Results The incidence of AKI was 9.2 per cent in 930 patients. AKI was associated with increased mortality, morbidity, posthepatectomy liver failure (PHLF), and a longer hospital stay. On multivariable analysis, study period December 2013 to December 2018, diabetes mellitus, mean intraoperative BP below 72.1 mmHg, operative blood loss exceeding 377ml, high Model for End-Stage Liver Disease (MELD) score, and PHLF were predictive factors for AKI. Among 560 patients with HCC, hypertension, BP below 76.9 mmHg, blood loss greater than 378ml, MELD score, and PHLF were predictive factors. The 1-, 3-, and 5-year overall survival rates were 74.1, 59.2, and 51.6 per cent respectively for patients with AKI, and 91.8, 77.9, and 67.3 per cent for those without AKI. Corresponding 1-, 3-, and 5-year disease-free survival rates were 56.9, 42.3, and 35.4 per cent respectively in the AKI group, and 71.7, 54.5, and 46.2 per cent in the no-AKI group. AKI was an independent predictor of survival in multivariable analysis. Conclusion AKI is associated with longer hospital stay, and higher morbidity and mortality rates. It is also associated with shorter long-term survival among patients with HCC. To avoid AKI, control of blood loss and maintaining a reasonable BP (72–77 mmHg) during hepatectomy is important.
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Affiliation(s)
- K F Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - E Y J Lo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - K K C Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - A K Y Fung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - C C N Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - J Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - K K C Ng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - P B S Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
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16
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Wisén E, Almazrooa A, Sand Bown L, Rizell M, Ricksten S, Kvarnström A, Svennerholm K. Myocardial, renal and intestinal injury in liver resection surgery-A prospective observational pilot study. Acta Anaesthesiol Scand 2021; 65:886-894. [PMID: 33811772 DOI: 10.1111/aas.13823] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Post-operative organ complications in liver resection surgery are not uncommon. This prospective observational pilot study was performed to evaluate the incidence, degree and timing of myocardial, renal and intestinal injury in patients undergoing liver resection surgery using the low central venous pressure (LCVP) technique and the Pringle manoeuvre. METHODS Blood samples were obtained before, during and after elective liver resection until post-operative day (POD) 5. High-sensitive troponin T (hs-TnT), serum creatinine, urea, intestinal fatty acid binding protein (I-FABP), D-lactate, arterial lactate, portal lactate, amylase, as well as urine N-acetyl-ß-D-glucosaminidase (NAG) were analysed. Systemic haemodynamics were measured intraoperatively. RESULTS Eighteen patients fulfilled the protocol. The Pringle manoeuvre was used in all but 1 patient. hs-TnT increased significantly over time (P < .001) and 5 patients (28%) developed myocardial injury. Five patients had a pre-operative elevation of hs-TnT, four of those developed myocardial injury. Serum creatinine increased significantly over time (P = .015). Acute kidney injury (AKI) occurred in 5 patients (28%), while NAG, as a marker of tubular injury, was not affected. I-FABP increased over time (P < .001) with a maximal 75% increase at 3 hours after resection. D-lactate was below detection level at all measuring points. CONCLUSIONS In patients undergoing liver resection surgery, using LCVP technique and Pringle manoeuvre, myocardial injury was seen in approximately 30% of the patients post-operatively and almost 30% developed transient AKI in the early post-operative period with no tubular injury. Furthermore, a transient increase of the enterocyte damage marker I-FABP was demonstrated with no signs of gut barrier dysfunction.
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Affiliation(s)
- Ellinor Wisén
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Abdulrahman Almazrooa
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Lena Sand Bown
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Magnus Rizell
- Department of Transplantation and Liver Surgery Sahlgrenska academyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Andreas Kvarnström
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
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17
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Liu TS, Shen QH, Zhou XY, Shen X, Lai L, Hou XM, Liu K. Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis. J Clin Anesth 2021; 75:110467. [PMID: 34343737 DOI: 10.1016/j.jclinane.2021.110467] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE Previous studies reported that controlled low central venous pressure (CVP) can reduce blood loss during liver resection. This systematic review and meta-analysis sought to explore the efficacy and safety of low CVP in patients undergoing hepatectomy. DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs). REVIEW METHODS RCTs were searched in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical database, Chinese Scientific Journals Database, and Wanfang database from inception to April 30, 2021. Subgroup analyses were performed based on different surgical methods (open hepatectomy vs laparoscopic hepatectomy) and published countries (China vs other countries). The quality of evidence was assessed by Grading of Recommendations, Assessment, Development, and Evaluation. MAIN RESULTS Eighteen RCTs containing 1285 participants (626 patients in the low CVP group and 659 patients in the control group) were included in this study. The forest plot showed that low CVP effectively reduced blood loss during liver resection compared with the control group (MD = -311.92 mL, 95% CI [-429.03, -194.81]; P < 0.001, I2 = 96%). Furthermore, blood transfusion volume (MD = -158.85 mL, 95% CI [-218.30, -99.40]; P < 0.001, I2 = 55%) and the number of patients requiring transfusion (RR 0.41, 95% CI 0.27-0.65, P < 0.001, I2 = 0%) were decreased in the low CVP group. Subgroup analyses showed similar results. Notably, the alanine transaminase level was significantly lower in the low CVP group during the first five postoperative days. However, no significant differences were observed for other postoperative liver function indicators (aspartate aminotransferase, total bilirubin, serum albumin, and prothrombin time), renal function indicators (blood urea nitrogen and serum creatinine) and perfusion parameters (heart rate, mean arterial pressure, and urine volume). The incidence of complications was similar between the two groups. CONCLUSION The findings of this study showed that low CVP is effective and safe during hepatectomy. Therefore, this technique is recommended to reduce blood loss during hepatectomy. PROSPERO registration number: CRD42021232829.
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Affiliation(s)
- Tie-Shuai Liu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310020, China
| | - Qi-Hong Shen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China.
| | - Xu-Yan Zhou
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Xu- Shen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Lan Lai
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Xiao-Min Hou
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Ke Liu
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
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18
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Wu G, Chen T, Chen Z. Effect of controlled low central venous pressure technique on postoperative hepatic insufficiency in patients undergoing a major hepatic resection. Am J Transl Res 2021; 13:8286-8293. [PMID: 34377318 PMCID: PMC8340195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/23/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the effect of controlled low central venous pressure (CLCVP) technique on postoperative hepatic insufficiency in patients undergoing major hepatic resection. METHODS In this single-center, propensity score matching, retrospective study, 331 patients who underwent laparoscopic major hepatectomy consecutively from October 1, 2014 to October 30, 2020 were enrolled and divided into a CLCVP group [0≤ central venous pressure (CVP) ≤5 cmH2O] and normal CVP (NCVP) group (5< CVP ≤10 cmH2O). The propensity score matching was used to adjust the differences in the data and was matched 1:1 to evaluate the impact of CLCVP on the incidence of liver insufficiency. RESULTS After propensity score matching, 84 patients were included in each group, with a good balance of preoperative baseline and intraoperative data between the two groups. The incidence of postoperative hepatic insufficiency was 21.23% in the CLCVP group, which did not differ from that in the NCVP group (21.54%) (P>0.05). CONCLUSION In patients undergoing laparoscopic major hepatectomy, CLCVP technique did not increase the incidence of postoperative hepatic insufficiency.
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Affiliation(s)
- Gu Wu
- Department of Anesthesiology, The First People's Hospital of Chongqing Liang Jiang New Area Chongqing 401121, China
| | - Tinghong Chen
- Department of Anesthesiology, The First People's Hospital of Chongqing Liang Jiang New Area Chongqing 401121, China
| | - Zongjie Chen
- Department of Anesthesiology, The First People's Hospital of Chongqing Liang Jiang New Area Chongqing 401121, China
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19
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Liao P, Zhao S, Lyu L, Yi X, Ji X, Sun J, Jia Y, Zhou Z. Association of intraoperative hypotension with acute kidney injury after liver resection surgery: an observational cohort study. BMC Nephrol 2020; 21:456. [PMID: 33138788 PMCID: PMC7607844 DOI: 10.1186/s12882-020-02109-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/14/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a major complication following liver resection. The aim of this study was to determine the risk factors for AKI after hepatic resection and whether intraoperative hypotension (IOH) was related to AKI. METHODS Adult patients (≥ 18 years) undergoing liver resection between November 2017 and November 2019 at our hospital were retrospectively reviewed. AKI was defined as ≥50% increase in serum creatinine from baseline value within 48 h after surgery. IOH was defined as the lowest absolute mean arterial pressure (MAP) < 65 mmHg for more than 10 cumulative minutes during the surgery. Patients were divided into AKI group and non-AKI group, and were stratified by age ≥ 65 years. RESULTS 796 patients who met our inclusion and exclusion criteria were analyzed. After multivariable regression analysis, the IOH (OR, 2.565; P = 0.009) and age ≥ 65 years (OR, 2.463; P = 0.008) were risk factors for AKI. The IOH (OR, 3.547; P = 0.012) and received red blood cell (OR, 3.032; P = 0.036) were risk factors of AKI in age ≥ 65 years patients. CONCLUSIONS The IOH and age ≥ 65 years were risk factors for postoperative AKI, and IOH was associated with AKI in age ≥ 65 years patients following liver resection.
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Affiliation(s)
- Pingping Liao
- Department of Geriatric Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Shuo Zhao
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.16 Jiangsu Road, Qingdao, 266000, Shandong, China
| | - Lin Lyu
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.16 Jiangsu Road, Qingdao, 266000, Shandong, China.
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.59 Haier Road, Qingdao, 266000, Shandong, China.
| | - Xuanlong Yi
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.16 Jiangsu Road, Qingdao, 266000, Shandong, China
| | - Xiangyu Ji
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.16 Jiangsu Road, Qingdao, 266000, Shandong, China
| | - Jian Sun
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.16 Jiangsu Road, Qingdao, 266000, Shandong, China
| | - Yanfang Jia
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.16 Jiangsu Road, Qingdao, 266000, Shandong, China
| | - Zangong Zhou
- Department of Anesthesiology, the Affiliated Hospital of Qingdao University, No.16 Jiangsu Road, Qingdao, 266000, Shandong, China.
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20
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Wang F, Sun D, Zhang N, Chen Z. The efficacy and safety of controlled low central venous pressure for liver resection: a systematic review and meta-analysis. Gland Surg 2020; 9:311-320. [PMID: 32420255 DOI: 10.21037/gs.2020.03.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Application of controlled low central venous pressure (LCVP) in liver resection growing in popularity, but its efficacy and safety are still controversial. Our objectives were to assess and compare the efficacy, feasibility, and safety of controlled LCVP in patients undergoing liver resection. Methods The PubMed, Cochrane library, and EMBASE databases were systematically searched for all the relevant studies regardless of study design. We evaluated the methodological quality of the included studies and excluded studies of poor quality. Moreover, we applied a systematic review and meta-analysis by using RevMan 5.3 software to compare the efficacy and safety of LCVP vs. standard CVP for liver resection. Outcomes included operation time, blood loss, blood infusion, fluid infusion, urinary volume, postoperative complication rates, and hospital stay. Results In total, 10 studies, involving 324 patients undergoing liver resection with controlled LCVP, were identified. Meta-analysis displayed that blood loss in the LCVP group was dramatically less than that in the control group (standard CVP group, mean difference (MD): -581.68; 95% CI: -886.32 to -277.05; P=0.0002). Moreover, blood transfusion in the LCVP group was also markedly less than that in the control group (MD: -179.16; 95% CI: -282.00 to -76.33; P=0.0006). However, there was no difference between LCVP group and control group in operation time (MD: -16.24; 95% CI: -39.56 to 7.09; P=0.17), fluid infusion (MD: -287.89; 95% CI: -1,054.47 to 478.69; P=0.46), urinary volume (MD: -26.88; 95% CI: -87.14 to 33.37; P=0.38), ALT (MD: -58.66; 95% CI: -153.81 to 36.50; P=0.23), TBIL (MD: -0.32; 95% CI: -3.93 to 3.28; P=0.86), BUN (MD: -0.13; 95% CI: -0.73 to 0.47; P=0.67), CR (MD: 1.87; 95% CI: -4.90 to 8.63; P=0.59), postoperative complication rates (MD: 0.62; 95% CI: 0.44 to 0.90; P=0.01) and hospital stay (MD: -0.61; 95% CI: -1.68 to 0.46; P=0.26). Conclusions Compared with the control, controlled LCVP showed comparable efficacy and safety for the treatment during liver resection.
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Affiliation(s)
- Feiran Wang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Dongwei Sun
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Nannan Zhang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Zhong Chen
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
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21
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Ohta J, Kadoi Y, Murooka Y, Matsuoka H, Kanamoto M, Tobe M, Takazawa T, Saito S. Hemodynamically adjusted infrahepatic inferior venous cava clamping can reduce postoperative deterioration in renal function: a retrospective observational study. J Anesth 2020; 34:320-329. [PMID: 32040624 DOI: 10.1007/s00540-020-02742-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 01/24/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE 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. METHODS 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. RESULTS 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). CONCLUSION Hemodynamically adjustable IIVC clamping might be superior to uniformly fixed clamping in preserving renal function without compromising the desired effect on hemostasis.
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Affiliation(s)
- Jo Ohta
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan.
| | - Yuji Kadoi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Yukie Murooka
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Hiroaki Matsuoka
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Masafumi Kanamoto
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Masaru Tobe
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Tomonori Takazawa
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
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22
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Joliat GR, Labgaa I, Demartines N, Halkic N. Acute kidney injury after liver surgery: does postoperative urine output correlate with postoperative serum creatinine? HPB (Oxford) 2020; 22:144-150. [PMID: 31431415 DOI: 10.1016/j.hpb.2019.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/29/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) after hepatectomy occurs in around 10% of cases. AKI is often defined based only on postoperative serum creatinine increase. This study aimed to assess if postoperative urine output (UO) correlated with serum creatinine after hepatectomy. METHODS All consecutive hepatectomy patients (2010-2016) were assessed. AKI was defined according to KDIGO criteria: serum creatinine increase ≥26.5 μmol/l, creatinine increase ≥1.5x baseline creatinine, or postoperative oliguria. Oliguria was defined as daily mean UO <0.5 mL/kg/h. AKI was subdivided into creatinine-based or oliguria-based AKI according to the defining criterion. RESULTS Out of 285 patients, AKI was observed in 79 cases (28%). Creatinine-based AKI occurred in 25 patients (9%) and oliguria-based only AKI in 54 patients (19%). Ten patients fulfilled both criteria (4%). Postoperative UO correlated poorly with postoperative serum creatinine level in both whole cohort (rho = -0.34, p <0.001) and AKI subgroup (rho = -0.189, p = 0.124). No association was found between postoperative oliguria and postoperative serum creatinine increase (HR = 0.5, 95%CI: 0.2-1.9, p = 0.341). On multivariable analysis, operation duration >360 minutes was the only predictor of creatinine increase (HR = 3.6, 95%CI: 1.1-11.4, p = 0.032). CONCLUSION Postoperative UO showed poor correlation with postoperative serum creatinine both in all patients and AKI patients. Surgery duration >360 minutes appeared as the only independent predictor of postoperative serum creatinine increase.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland.
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
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23
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Bressan AK, James MT, Dixon E, Bathe OF, Sutherland FR, Ball CG. Acute kidney injury following resection of hepatocellular carcinoma: prognostic value of the acute kidney injury network criteria. Can J Surg 2019; 61:E11-E16. [PMID: 30247865 DOI: 10.1503/cjs.002518] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Acute kidney injury (AKI) is associated with increased morbidity and mortality after liver resection. Patients with hepatocellular carcinoma (HCC) have a higher risk of AKI owing to the underlying association between hepatic and renal dysfunction. Use of the Acute Kidney Injury Network (AKIN) diagnostic criteria is recommended for patients with cirrhosis, but remains poorly studied following liver resection. We compared the prognostic value of the AKIN creatinine and urine output criteria in terms of postoperative outcomes following liver resection for HCC. Methods All patients who underwent a liver resection for HCC from January 2010 to June 2016 were included. We used AKIN urine output and creatinine criteria to assess for AKI within 48 hours of surgery. Results Eighty liver resections were performed during the study period. Cirrhosis was confirmed in 80%. Median hospital stay was 9 (interquartile range 7–12) days, and 30-day mortality was 2.5%. The incidence of AKI was higher based on the urine
output than on the creatinine criterion (53.8% v. 20%), and was associated with prolonged hospitalization and 30-day postoperative mortality when defined by serum creatinine (hospital stay: 11.2 v. 20.1 d, p = 0.01; mortality: 12.5% v. 0%, p < 0.01), but not urine output (hospital stay: 15.6 v. 10 d, p = 0.05; mortality: 2.3% v. 2.7%, p > 0.99). Conclusion The urine output criterion resulted in an overestimation of AKI and compromised the prognostic value of AKIN criteria. Revision may be required to account for the exacerbated physiologic postoperative reduction in urine output in patients with HCC.
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Affiliation(s)
- Alexsander K. Bressan
- From the Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (Bressan, Dixon,
Bathe, Sutherland, Ball); and the Department of Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (James)
| | - Matthew T. James
- From the Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (Bressan, Dixon,
Bathe, Sutherland, Ball); and the Department of Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (James)
| | - Elijah Dixon
- From the Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (Bressan, Dixon,
Bathe, Sutherland, Ball); and the Department of Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (James)
| | - Oliver F. Bathe
- From the Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (Bressan, Dixon,
Bathe, Sutherland, Ball); and the Department of Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (James)
| | - Francis R. Sutherland
- From the Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (Bressan, Dixon,
Bathe, Sutherland, Ball); and the Department of Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (James)
| | - Chad G. Ball
- From the Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (Bressan, Dixon,
Bathe, Sutherland, Ball); and the Department of Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alta. (James)
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24
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Kim M, Kiran RP, Li G. Acute kidney injury after hepatectomy can be reasonably predicted after surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:144-153. [PMID: 30793845 DOI: 10.1002/jhbp.615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatectomy presents unique challenges potentially heightening acute kidney injury (AKI) risk, but the full spectrum of risk factors has not been identified. METHODS Data for hepatectomy patients in the 2016 American College of Surgeons National Surgical Quality Improvement Program (n = 3,814) was randomly split into derivation (70%) and validation (30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dl or ≥1.5-fold above the preoperative value within 30 days of surgery. Multivariable logistic regression assessed preoperative and intraoperative risk factors for AKI. RESULTS Of 2,692 patients (derivation cohort), 432 (16%) developed AKI. Risk factors were the following: age (years; adjusted odds ratio [aOR] 1.016 [95% confidence interval 1.006-1.026], female sex (aOR 0.65 [0.51-0.82]), body mass index (kg/m2 ; aOR 1.043 [1.024-1.062]), diabetes (aOR 1.71 [1.31-2.24]), hypertension (aOR 1.66 [1.30-2.13]), hematocrit (%; aOR 0.944 [0.924-0.966]), operative time (min; aOR 1.004 [1.003-1.004]), planned open procedure (aOR 2.00 [1.47-2.73]), and Pringle maneuver (aOR 1.36 [1.07-1.72]). The areas under the curve of the receiver operating characteristic curves were 0.74 (95% CI 0.71-0.76) and 0.71 (95% CI 0.67-0.75) in the derivation and validation cohorts, respectively. CONCLUSIONS Postoperative AKI affects one in six hepatectomy patients; preoperative and intraoperative factors can predict the risk of postoperative AKI.
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Affiliation(s)
- Minjae Kim
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, PH 5, Suite 505C, New York, NY 10032, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ravi P Kiran
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, PH 5, Suite 505C, New York, NY 10032, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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25
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Agarwal V, Divatia JV. Enhanced recovery after surgery in liver resection: current concepts and controversies. Korean J Anesthesiol 2019; 72:119-129. [PMID: 30841029 PMCID: PMC6458514 DOI: 10.4097/kja.d.19.00010] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/05/2019] [Indexed: 12/21/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.
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Affiliation(s)
- Vandana Agarwal
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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26
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Garnier J, Faucher M, Marchese U, Meillat H, Mokart D, Ewald J, Delpero JR, Turrini O. Severe acute kidney injury following major liver resection without portal clamping: incidence, risk factors, and impact on short-term outcomes. HPB (Oxford) 2018; 20:865-871. [PMID: 29691124 DOI: 10.1016/j.hpb.2018.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/20/2018] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) following major hepatectomy (MH) remains inadequately investigated. This retrospective study aimed to assess the risk factors and prognostic value of AKI on short-term outcomes following MH without portal pedicle clamping. METHODS From January 2014 through June 2017, 111 consecutive patients underwent MH without portal pedicle clamping, but with intraoperative low-crystalloid infusion. Kidney Disease Improving Global Outcomes stages II and III were classified as severe AKI. RESULTS A total of 102 patients did not develop AKI or only AKI stage I (92%, control group), whereas 9 patients developed severe AKI (8%, severe AKI group). Hepatectomy (P = 0.002) and surgery (P = 0.011) durations were longer in the severe AKI group. Clavien-Dindo grades 3 to 5 morbidity (55% versus 9%, P = 0.001), liver failure (P = 0.017), and 90-day mortality (33% versus 2%, P = 0.003) were significantly higher in the severe AKI group. After a multivariate analysis, the duration of hepatectomy (cut-off: 250 min; P = 0.029) and urea serum levels on postoperative day 3 (P = 0.006) were identified as independent predictors of severe AKI. DISCUSSION Severe AKI, is common with increased duration of hepatectomy, was associated with poor short-term outcomes, and can be predicted by operative duration greater than 250 minutes.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France.
| | - Marion Faucher
- Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
| | - Hélène Meillat
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
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27
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Gasteiger L, Eschertzhuber S, Tiefenthaler W. Perioperative management of liver surgery-review on pathophysiology of liver disease and liver failure. Eur Surg 2018; 50:81-86. [PMID: 29875796 PMCID: PMC5968074 DOI: 10.1007/s10353-018-0522-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/23/2018] [Indexed: 12/17/2022]
Abstract
An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.
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Affiliation(s)
- Lukas Gasteiger
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
- Department of Anaesthesia and Intensive Care, General Hospital Hall in Tirol, Hall in Tirol, Austria
| | - Werner Tiefenthaler
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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28
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Tao W, Shi X, Wang G. Acute kidney injury following the first stage of the ALPPS procedure: A case report. Exp Ther Med 2018; 15:2990-2993. [PMID: 29599836 DOI: 10.3892/etm.2018.5789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/03/2017] [Indexed: 11/06/2022] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel approach for performing liver resection, and the number of clinical applications of this technique has rapidly increased within recent years. ALPPS is important in patients who have insufficient residual liver volume and cannot undergo radical hepatic resection. The most common postoperative complications of ALPPS include biliary fistula and infection. To date, postoperative acute kidney injury following ALPPS has not been reported. The current study reports the case of a 63-year-old patient with hepatitis B-induced cirrhosis who underwent the first stage of ALPPS without completion of the second step. The patient developed postoperative acute kidney injury following ALPPS. The present case study suggests that the use of ALPPS in patients at risk of chronic renal damage should be approached with caution in order to avoid postoperative acute kidney injury. Furthermore, improvements in surgical techniques and skills of the surgeons performing the procedure are required to reduce the surgery duration and improve patient outcomes.
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Affiliation(s)
- Weijie Tao
- Department of Hepatobiliary Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Xiaoju Shi
- Department of Hepatobiliary Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Guangyi Wang
- Department of Hepatobiliary Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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29
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Gameiro J, Fonseca JA, Neves M, Jorge S, Lopes JA. Acute kidney injury in major abdominal surgery: incidence, risk factors, pathogenesis and outcomes. Ann Intensive Care 2018; 8:22. [PMID: 29427134 PMCID: PMC5807256 DOI: 10.1186/s13613-018-0369-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/05/2018] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery. Various recent studies using modern standardized classifications for AKI reported a variable incidence of AKI after major abdominal surgery ranging from 3 to 35%. Several patient-related, procedure-related factors and postoperative complications were identified as risk factors for AKI in this setting. AKI following major abdominal surgery has been shown to be associated with poor short- and long-term outcomes. Herein, we provide a contemporary and critical review of AKI after major abdominal surgery focusing on its incidence, risk factors, pathogeny and outcomes.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.
| | - José Agapito Fonseca
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Marta Neves
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
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30
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Ryckx A, Christiaens C, Clarysse M, Vansteenkiste F, Steelant PJ, Sergeant G, Parmentier I, Pottel H, D'Hondt M. Central Venous Pressure Drop After Hypovolemic Phlebotomy is a Strong Independent Predictor of Intraoperative Blood Loss During Liver Resection. Ann Surg Oncol 2017; 24:1367-1375. [PMID: 28054191 DOI: 10.1245/s10434-016-5737-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraoperative hypovolemic phlebotomy (HP) has been suggested to reduce central venous pressure (CVP) before hepatectomy. This study aimed to analyze the impact of CVP drop after HP on intraoperative blood loss and postoperative renal function. METHODS A retrospective review of a prospective database including 100 consecutive patients (43 males and 57 females; mean age, 65 years; range 23-89 years) undergoing liver resection with HP was performed. The primary outcome variable was estimated blood loss (EBL), and the secondary outcome was postoperative serum creatinin (Scr). A multivariate linear regression analysis was performed to identify predictors of intraoperative blood loss. RESULTS The median CVP before blood salvage was 8 mmHg (range 4-30 mmHg). The median volume of hypovolemic phlebotomy was 400 ml (range 200-1000 ml). After HP, CVP decreased to a median of 3 mmHg (range -2 to 16 mmHg), resulting in a median CVP drop of 5.5 mmHg (range 2-14 mmHg). The median EBL during liver resection was 165 ml (range 0-800 ml). The median preoperative serum creatinin (Scr) was 0.82 g/dl (range 0.5-1.74 g/dl), and the postoperative Scr on day 1 was 0.74 g/dl (range 0.44-1.68 g/dl). The CVP drop was associated with EBL (P < 0.001). There was no significant impact of CVP drop on postoperative Scr. CONCLUSION A CVP drop after HP is a strong independent predictor of EBL during liver resection. The authors advocate the routine use of HP to reduce perioperative blood loss and transfusion rates in liver surgery. As a predictive tool, CVP drop might help surgeons decide whether a laparoscopic approach is safe.
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Affiliation(s)
- Andries Ryckx
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Mathias Clarysse
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Franky Vansteenkiste
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Gregory Sergeant
- Department of Abdominal and Hepatobiliary Surgery, Jessa Hospital, Hasselt, Belgium
| | - Isabelle Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, Kortrijk, Belgium
| | - Hans Pottel
- Interdisciplinary Research Center, Leuven University Campus, Kortrijk, Belgium
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
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31
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Wax D, Zerillo J, Tabrizian P, Schwartz M, Hill B, Lin HM, DeMaria S. A retrospective analysis of liver resection performed without central venous pressure monitoring. Eur J Surg Oncol 2016; 42:1608-13. [DOI: 10.1016/j.ejso.2016.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 03/11/2016] [Accepted: 03/22/2016] [Indexed: 12/11/2022] Open
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Avellan S, Uhr I, McKelvey D, Sondergaard S. Identifying the position of the right atrium to align pressure transducer for CVP : Spirit level or 3D electromagnetic positioning? J Clin Monit Comput 2016; 31:943-949. [PMID: 27510178 DOI: 10.1007/s10877-016-9918-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 08/02/2016] [Indexed: 01/20/2023]
Abstract
The central venous pressure, CVP, is an important variable in the management of selected perioperative and intensive care cases and in clinical decision support systems, CDSS. In current routine, when measuring CVP the health care provider may use anatomical landmarks and a spirit level, SL, to adjust the pressure transducer to the level of the tricuspid valve, i.e. the phlebostatic axis. The aim of the study was to assess the agreement in the postoperative setting between the SL method and electromagnetic 3D positioning (EM). CVP was measured with patients in positions dictated by nursing routines. The staff members measured CVP using SL to position the transducer at the perceived phlebostatic level. This position was compared to coordinates based on an electromagnetic field with external sensors at anatomical landmarks and an internal sensor in the CV catheter for 3D determination of the phlebostatic axis. An electronic survey took bearing on the accepted error in measurement among colleagues at the department. There was a clinically relevant difference between the CVP measured by the staff members and the CVP based on the 3D EM positioning. The limits of agreement extended in excess of ±8 mmHg and half of the measurements had deviations outside an accepted error range of ±2.5 mmHg. There was a large variation in CVP measurements when assessing the agreement with the current method. This may indicate the need for improvement in accuracy, e.g. using the electromagnetic field positioning system, in association with routine monitoring and clinical decision support systems.
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Affiliation(s)
- S Avellan
- Medical School, University of Gothenburg, 405 40, Gothenburg, Sweden
| | - I Uhr
- Medical School, University of Gothenburg, 405 40, Gothenburg, Sweden
| | - D McKelvey
- Chalmers University of Technology, Chalmersplatsen 4, 412 96, Gothenburg, Sweden
| | - Soren Sondergaard
- Centre of Elective Surgery, Silkeborg Regional Hospital, 8600, Silkeborg, Denmark.
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Peres LAB, Bredt LC, Cipriani RFF. Acute renal injury after partial hepatectomy. World J Hepatol 2016; 8:891-901. [PMID: 27478539 PMCID: PMC4958699 DOI: 10.4254/wjh.v8.i21.891] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 06/02/2016] [Accepted: 06/27/2016] [Indexed: 02/06/2023] Open
Abstract
Currently, partial hepatectomy is the treatment of choice for a wide variety of liver and biliary conditions. Among the possible complications of partial hepatectomy, acute kidney injury (AKI) should be considered as an important cause of increased morbidity and postoperative mortality. Difficulties in the data analysis related to postoperative AKI after liver resections are mainly due to the multiplicity of factors to be considered in the surgical patients, moreover, there is no consensus of the exact definition of AKI after liver resection in the literature, which hampers comparison and analysis of the scarce data published on the subject. Despite this multiplicity of risk factors for postoperative AKI after partial hepatectomy, there are main factors that clearly contribute to its occurrence. First factor relates to large blood losses with renal hypoperfusion during the operation, second factor relates to the occurrence of post-hepatectomy liver failure with consequent distributive circulatory changes and hepatorenal syndrome. Eventually, patients can have more than one factor contributing to post-operative AKI, and frequently these combinations of acute insults can be aggravated by sepsis or exposure to nephrotoxic drugs.
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Affiliation(s)
- Luis Alberto Batista Peres
- Luis Alberto Batista Peres, Department of Nephrology, University Hospital of Western Paraná, State University of Western Paraná, Cascavel, Paraná 85819-110, Brazil
| | - Luis Cesar Bredt
- Luis Alberto Batista Peres, Department of Nephrology, University Hospital of Western Paraná, State University of Western Paraná, Cascavel, Paraná 85819-110, Brazil
| | - Raphael Flavio Fachini Cipriani
- Luis Alberto Batista Peres, Department of Nephrology, University Hospital of Western Paraná, State University of Western Paraná, Cascavel, Paraná 85819-110, Brazil
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34
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Lim C, Audureau E, Salloum C, Levesque E, Lahat E, Merle JC, Compagnon P, Dhonneur G, Feray C, Azoulay D. Acute kidney injury following hepatectomy for hepatocellular carcinoma: incidence, risk factors and prognostic value. HPB (Oxford) 2016; 18:540-8. [PMID: 27317959 PMCID: PMC4913133 DOI: 10.1016/j.hpb.2016.04.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/19/2016] [Accepted: 04/10/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) following hepatectomy remains understudied in terms of diagnosis, severity, recovery and prognostic value. The aim of this study was to assess the risk factors and prognostic value of AKI on short- and long-term outcomes following hepatectomy for hepatocellular carcinoma (HCC). METHOD This is a retrospective analysis of a single-center cohort of 457 consecutive patients who underwent hepatectomy for HCC. The KDIGO criteria were used for AKI diagnosis. The incidence, risk factors, and prognostic value of AKI were investigated. RESULTS AKI occurred in 67 patients (15%). The mortality and major morbidity rates were significantly higher in patients with AKI (37% and 69%) than in those without (6% and 22%; p < 0.001). Renal recovery was complete in 35 (52%), partial in 25 (37%), and absent in 7 (11%) patients. Advanced age, an increased MELD score, major hepatectomy and prolonged duration of operation were identified as independent predictors of AKI. AKI was identified as the strongest independent predictor of postoperative mortality but did not impact survival. CONCLUSION AKI is a common complication after hepatectomy for HCC. Although its development is associated with poor short-term outcomes, it does not appear to be predictive of impaired long-term survival.
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Key Words
- aki, acute kidney injury
- kdigo, kidney disease improving global outcomes
- hcc, hepatocellular carcinoma
- scr, serum creatinine
- rrt, renal replacement therapy
- cki, chronic kidney injury
- egfr, estimated glomerula filtration rate
- icu, intensive care unit
- auroc, area under the receiver operating curve
- os, overall survival
- meld, model for end stage liver disease
- or, odds ratio
- ci, confidence interval
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Affiliation(s)
- Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U965, Paris, France
| | - Etienne Audureau
- Department of Public Health, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eric Levesque
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Jean Claude Merle
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Gilles Dhonneur
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Cyrille Feray
- INSERM, U955, Créteil, France,Department of Hepatology, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France,Correspondence: Daniel Azoulay, Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor hospital, 51 avenue de Lattre de Tassigny, 94010 Créteil, France. Tel: + 33 1 49 81 25 48. Fax. + 33 1 49 81 24 32.Department of Hepatobiliary and Pancreatic Surgery and Liver TransplantationHenri Mondor hospital51 avenue de Lattre de TassignyCréteil94010France
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Lemke M, Eeson G, Lin Y, Tarshis J, Hallet J, Coburn N, Law C, Karanicolas PJ. A decision model and cost analysis of intra-operative cell salvage during hepatic resection. HPB (Oxford) 2016; 18:428-35. [PMID: 27154806 PMCID: PMC4857067 DOI: 10.1016/j.hpb.2016.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 02/02/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intraoperative cell salvage (ICS) can reduce allogeneic transfusions but with notable direct costs. This study assessed whether routine use of ICS is cost minimizing in hepatectomy and defines a subpopulation of patients where ICS is most cost minimizing based on patient transfusion risk. METHODS A decision model from a health systems perspective was developed to examine adoption and non-adoption of ICS use for hepatectomy. A prospectively maintained database of hepatectomy patients provided data to populate the model. Probabilistic sensitivity analysis was used to determine the probability of ICS being cost-minimizing at specified transfusion risks. One-way sensitivity analysis was used to identify factors most relevant to institutions considering adoption of ICS for hepatectomies. RESULTS In the base case analysis (transfusion risk of 28.8%) the probability that routine utilization of ICS is cost-minimizing is 64%. The probability that ICS is cost-minimizing exceeds 50% if the patient transfusion risk exceeds 25%. The model was most sensitive to patient transfusion risk, variation in costs of allogeneic blood, and number of appropriate cases the device could be used for. CONCLUSIONS ICS is cost-minimizing for routine use in liver resection, particularly when used for patients with a risk of transfusion of 25% or greater.
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Affiliation(s)
- Madeline Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Gareth Eeson
- Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Natalie Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Calvin Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Paul J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada.
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Abstract
Liver anatomy can be variable, and understanding of anatomic variations is crucial to performing hepatic resections, particularly parenchymal-sparing resections. Anatomic knowledge is a critical prerequisite for effective hepatic resection with minimal blood loss, parenchymal preservation, and optimal oncologic outcome. Each anatomic resection has pitfalls, about which the operating surgeon should be aware and comfortable managing intraoperatively.
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Affiliation(s)
- Michael C Lowe
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Michael I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Weill Cornell University School of Medicine, New York, NY 10065, USA.
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Mattar RE, Al-alem F, Simoneau E, Hassanain M. Preoperative selection of patients with colorectal cancer liver metastasis for hepatic resection. World J Gastroenterol 2016; 22:567-581. [PMID: 26811608 PMCID: PMC4716060 DOI: 10.3748/wjg.v22.i2.567] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/24/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
Surgical resection of colorectal liver metastases (CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin (R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis.
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O’Connor ME, Kirwan CJ, Pearse RM, Prowle JR. Incidence and associations of acute kidney injury after major abdominal surgery. Intensive Care Med 2015; 42:521-530. [DOI: 10.1007/s00134-015-4157-7] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/17/2015] [Indexed: 12/31/2022]
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Goal-Directed Fluid Therapy Using Stroke Volume Variation for Resuscitation after Low Central Venous Pressure-Assisted Liver Resection: A Randomized Clinical Trial. J Am Coll Surg 2015. [PMID: 26206652 DOI: 10.1016/j.jamcollsurg.2015.03.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal perioperative fluid resuscitation strategy for liver resections remains undefined. Goal-directed therapy (GDT) embodies a number of physiologic strategies to achieve an ideal fluid balance and avoid the consequences of over- or under-resuscitation. STUDY DESIGN In a prospective randomized trial, patients undergoing liver resection were randomized to GDT using stroke volume variation as an end point or to standard perioperative resuscitation. Primary outcomes measure was 30-day morbidity. RESULTS Between 2012 and 2014, one hundred and thirty-five patients were randomized (GDT: n = 69; standard perioperative resuscitation: n = 66). Median age was 57 years and 56% were male. Metastatic disease comprised 81% of patients. Overall (35% GDT vs 36% standard perioperative resuscitation; p = 0.86) and grade 3 morbidity (28% GDT vs 18% standard perioperative resuscitation; p = 0.22) were equivalent. Patients in the GDT arm received less intraoperative fluid (mean 2.0 L GDT vs 2.9 L standard perioperative resuscitation; p < 0.001). Perioperative transfusions were required in 4% (6% GDT vs 2% standard perioperative resuscitation; p = 0.37) and boluses in the postanesthesia care unit were administered to 24% (29% GDT vs 20% standard perioperative resuscitation; p = 0.23). Mortality rate was 1% (2 of 135 patients; both in GDT). On multivariable analysis, male sex, age, combined procedures, higher intraoperative fluid volume, and fluid boluses in the postanesthesia care unit were associated with higher 30-day morbidity. CONCLUSIONS Stroke volume variation-guided GDT is safe in patients undergoing liver resection and led to less intraoperative fluid. Although the incidence of postoperative complications was similar in both arms, lower intraoperative resuscitation volume was independently associated with decreased postoperative morbidity in the entire cohort. Future studies should target extensive resections and identify patients receiving large resuscitation volumes, as this population is more likely to benefit from this technique.
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