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1
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Zhang ZY, Zhang EL, Zhang BX, Chen XP, Zhang W. Treatment for hepatocellular carcinoma with tumor thrombosis in the hepatic vein or inferior vena cava: A comprehensive review. World J Gastrointest Surg 2021; 13:796-805. [PMID: 34512903 PMCID: PMC8394384 DOI: 10.4240/wjgs.v13.i8.796] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/12/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common type of liver cancer with a high mortality rate worldwide. The percentage of HCC patients with vascular invasion is high. However, tumor thrombus in the hepatic vein (HVTT) has a lower incidence than tumor thrombus in the portal vein (PVTT). Conventionally, HCC patients with HVTT are treated the same as HCC patients with PVTT and offered sorafenib or other systemic agents. However, according to recent studies, it is evident that HCC with HVTT shows different outcomes when classified into different subgroups. In this review, we discuss the recent progress and changes in treatment of HCC with HVTT.
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Affiliation(s)
- Zun-Yi Zhang
- Research Laboratory and Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 434000, Hubei Province, China
| | - Er-Lei Zhang
- Research Laboratory and Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 434000, Hubei Province, China
| | - Bi-Xiang Zhang
- Research Laboratory and Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 434000, Hubei Province, China
| | - Xiao-Ping Chen
- Research Laboratory and Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 434000, Hubei Province, China
| | - Wei Zhang
- Research Laboratory and Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 434000, Hubei Province, China
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Laparoscopic Hepatectomy Versus Open Hepatectomy for the Management of Hepatocellular Carcinoma: A Comparative Study Using a Propensity Score Matching. World J Surg 2019; 43:615-625. [PMID: 30341471 DOI: 10.1007/s00268-018-4827-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of this study was to compare the results between laparoscopic hepatectomy and open hepatectomy in two French university hospitals, for the management of hepatocellular carcinoma (HCC) using a propensity score matching. MATERIALS AND METHODS A patient in the laparoscopic surgery group (LA) was randomly matched with another patient in the open approach group (OA) using a 1:1 allocated ratio with the nearest estimated propensity score. Matching criteria included age, presence of comorbidities, American Society of Anesthesiologists score, and resection type (major or minor). Patients of the LA group without matches were excluded. Intraoperative and postoperative data were compared in both groups. Survival was compared in both groups using the following matching criteria: number and size of lesions, alpha-fetoprotein rate, and cell differentiation. RESULTS From January 2012 to January 2017, a total of 447 hepatectomies were consecutively performed, 99 hepatectomies of which were performed for the management of hepatocellular carcinomas. Forty-nine resections were performed among the open approach (OA) group (49%), and 50 resections were performed among the laparoscopic surgery (LA) group (51%). Mortality rate was 2% in the LA group and 4.1% in the OA group. After propensity score matching, there was a statistical difference favorable to the LA group regarding medical complications (54.55% versus 27.27%, p = 0.04), and operating times were shorter (p = 0.03). Resection rate R0 was similar between both groups: 90.91% (n = 30) in the LA group and 84.85% (n =) in the OA group. There was no difference regarding overall survival (p = 0.98) and recurrence-free survival (p = 0.42). CONCLUSIONS Laparoscopic liver resection for the management of HCC seems to provide the same short-term and long-term results as compared to the open approach. Laparoscopic liver resections could be considered as an alternative and become the gold standard in well-selected patients.
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Bozzetti F, Bignami P, Baratti D. Surgical Strategies in Colorectal Cancer Metastatic to the Liver. TUMORI JOURNAL 2018; 86:1-7. [PMID: 10778758 DOI: 10.1177/030089160008600101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Surgical resection remains a milestone in the treatment of colorectal metastases to the liver. There is a distinct subset of patients who benefit from surgical resection in terms of longer survival or definitive cure. The main effort of the surgical oncological regards the safety of the procedure and the adequacy of the recommendation. Many studies, some of them including multivariate analysis, have shown the presence of prognostic determinants of long-term survival and prognostic indexes of the outcome after hepatectomy. It is now accepted that liver resection should be done when the complete excision of all demonstrable tumor with clear resection margins is feasible. Major contra-indication is represented by the presence of extra-hepatic intra-abdominal disease or of unresectable lung metastatic deposits. There is a wide literature indicating that in very selected patients liver reresection and multiorgan synchronous or metachronous resections are beneficial. The role of neoadjuvant chemotherapy and especially postoperative adjuvant local (intra-hepatic) and systemic chemotherapy is promising and supported by recent multicenter randomised clinical trials.
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Affiliation(s)
- F Bozzetti
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy.
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Appéré F, Piardi T, Memeo R, Lardière-Deguelte S, Chetboun M, Sommacale D, Pessaux P, Kianmanesh R. Comparative Study With Propensity Score Matching Analysis of Two Different Methods of Transection During Hemi-Right Hepatectomy: Ultracision Harmonic Scalpel Versus Cavitron Ultrasonic Surgical Aspirator. Surg Innov 2017; 24:499-508. [PMID: 28799459 DOI: 10.1177/1553350617723269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Several devices are available for liver parenchyma transection (LPT). The aim of this study was to compare the Ultracision Harmonic scalpel (UHS) with the Cavitron Ultrasonic Surgical Aspirator (CUSA) among patients who underwent hemi-right hepatectomies (RH) to homogenize transection areas. METHODS From September 2012 to June 2015, 24 patients who underwent the UHS surgery approach were matched with 24 patients who underwent the CUSA transection procedure for RH using propensity score matching. RESULTS Total operative time (TOT) was shorter in the UHS group, 240 minutes (range 172.5-298.8) versus 330 minutes (range 270-400) in the CUSA group ( P = .0002). The occurrence of hepatopathy (odds ratio = 17; 95% confidence interval = 1.02-230) and the use of the CUSA device (odds ratio = 8; 95% confidence interval = 0.98-77) were associated with a TOT exceeding 300 minutes in multivariate analysis ( P = .05). CONCLUSIONS The UHS is a safe and effective method of LPT as compared to the use of the CUSA system. TOT is statistically decreased.
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Affiliation(s)
- François Appéré
- 1 Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Tullio Piardi
- 1 Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | | | | | - Mikael Chetboun
- 1 Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France.,3 European Genomic Institute for Diabetes, Inserm UMR 1190, University of Lille, France
| | - Daniele Sommacale
- 1 Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | | | - Reza Kianmanesh
- 1 Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France
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Radojkovic M, Stojanovic M, Stanojevic G, Radojkovic D, Gligorijevic J, Ilic I, Stojanovic N. Ischemic preconditioning vs adenosine vs prostaglandin E1 for protection against liver ischemia/reperfusion injury. ACTA ACUST UNITED AC 2017; 50:e6185. [PMID: 28746468 PMCID: PMC5520221 DOI: 10.1590/1414-431x20176185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 05/23/2017] [Indexed: 11/21/2022]
Abstract
Ischemia/reperfusion injury is still a major cause of morbidity and mortality during liver surgery and transplantation. A variety of surgical and pharmacological therapeutic strategies have been investigated to minimize the effects of ischemia/reperfusion. The aim of our study was to analyze and compare preventive influences of ischemic preconditioning, adenosine and prostaglandin E1 in the experimental model of hepatic ischemia/reperfusion injury. Adult chinchilla rabbits were divided into four groups: 10 rabbits subjected to liver ischemic preconditioning (3-min period of inflow occlusion followed by a 5-min period of reperfusion) followed by 45 min of Pringle maneuver; 10 rabbits subjected to pre-treatment with intraportal injection of adenosine followed by 45 min of Pringle maneuver; 10 rabbits subjected to pre-treatment with intraportal injection of prostaglandin E1 followed by 45 min of Pringle maneuver; and control group of 10 rabbits subjected to 45 min of inflow liver ischemia without any preconditioning. On the second postoperative day, blood samples were obtained and biochemical parameters of liver function were measured and compared. Liver tissue samples were also obtained and histopathological changes were compared. Based on biochemical and histopathological parameters, it was demonstrated that ischemic preconditioning provided the best protection against hepatic ischemia/reperfusion injury. This was probably due to a wider range of mechanisms of action of this method oriented to reduce oxidative stress and inflammation, and restore liver microcirculation and hepatocyte energy compared to the examined pharmacological strategies.
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Affiliation(s)
- M Radojkovic
- Surgery Department, School of Medicine, University of Nis, Nis, Serbia
| | - M Stojanovic
- Surgery Department, School of Medicine, University of Nis, Nis, Serbia
| | - G Stanojevic
- Surgery Department, School of Medicine, University of Nis, Nis, Serbia
| | - D Radojkovic
- Internal Medicine Department, School of Medicine, University of Nis, Nis, Serbia
| | - J Gligorijevic
- Pathology Department, School of Medicine, University of Nis, Nis, Serbia
| | - I Ilic
- Pathology Department, School of Medicine, University of Nis, Nis, Serbia
| | - N Stojanovic
- School of Medicine, University of Nis, Nis, Serbia
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Lee JH, Park KM, Lee YJ, Kim JH, Kim SH. A New Chemical Compound, NecroX-7, Acts as a Necrosis Modulator by Inhibiting High-Mobility Group Box 1 Protein Release During Massive Ischemia-Reperfusion Injury. Transplant Proc 2016; 48:3406-3414. [PMID: 27931589 DOI: 10.1016/j.transproceed.2016.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/21/2016] [Accepted: 09/14/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Necrotic cell death is common in a wide variety of pathologic conditions, including ischemia-reperfusion (IR) injury. The aim of this study was to develop an IR injury-induced hepatic necrosis model in dogs by means of selective left hepatic inflow occlusion and to test the efficacy of a new chemical compound, NecroX-7, against the IR injury-induced hepatic damage. METHODS A group of male Beagle dogs received intravenous infusions of either vehicle or different doses of NecroX-7 (1.5, 4.5, or 13 mg/kg) for a 20-minute period before a 90-minute left hepatic inflow occlusion followed by reperfusion. RESULTS The gross morphology in the NecroX-7-treated groups after occlusion appeared to be less congested and less swollen than that in vehicle-treated control group. Circulating alanine transaminase and aspartate transaminase levels in the control group were elevated during the course of IR, and were effectively blocked in the 4.5 and 13 mg/kg NecroX-7-treated groups. The serum levels of high-mobility group box 1 protein showed a peak at 8 hours after occlusion in control group, and this elevation was significantly blunted by 4.5 mg/kg NecroX-7 treatment. Histologic analysis showed a marked ischemia or IR injury-induced hepatocytic degenerations, sinusoidal and portal vein congestions, and inflammatory cell infiltrations in the control group, whereas the treatment groups showed significantly diminished histopathology in a dose-dependent manner. CONCLUSIONS These results demonstrated that NecroX-7 attenuated the hepatocyte lethality caused by hepatic IR injury in a large animal setting. We conclude that NecroX-7 may provide a wide variety of therapeutic options for IR injury in human patients.
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Affiliation(s)
- J H Lee
- Department of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - K M Park
- Department of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.
| | - Y J Lee
- Department of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - J H Kim
- Department of Pathology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - S H Kim
- LG Life Sciences, Daejeon, Korea
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Untereiner X, Cagnet A, Memeo R, De Blasi V, Tzedakis S, Piardi T, Severac F, Mutter D, Kianmanesh R, Marescaux J, Sommacale D, Pessaux P. Short-term and middle-term evaluation of laparoscopic hepatectomies compared with open hepatectomies: A propensity score matching analysis. World J Gastrointest Surg 2016; 8:643-650. [PMID: 27721928 PMCID: PMC5037338 DOI: 10.4240/wjgs.v8.i9.643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/23/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare short-term results between laparoscopic hepatectomy and open hepatectomy using a propensity score matching.
METHODS A patient in the laparoscopic liver resection (LLR) group was randomly matched with another patient in the open liver resection (OLR) group using a 1:1 allocated ratio with the nearest estimated propensity score. Patients of the LLR group without matches were excluded. Matching criteria included age, gender, body mass index, American Society of Anesthesiologists score, potential co-morbidities, hepatopathies, size and number of nodules, preoperative chemotherapy, minor or major liver resections. Intraoperative and postoperative data were compared in both groups.
RESULTS From January 2012 to January 2015, a total of 241 hepatectomies were consecutively performed, of which 169 in the OLR group (70.1%) and 72 in the LLR group (29.9%). The conversion rate was 9.7% (n = 7). The mortality rate was 4.2% in the OLR group and 0% in the LLR group. Prior to and after propensity score matching, there was a statistically significant difference favorable to the LLR group regarding shorter operative times (185 min vs 247.5 min; P = 0.002), less blood loss (100 mL vs 300 mL; P = 0.002), a shorter hospital stay (7 d vs 9 d; P = 0.004), and a significantly lower rate of medical complications (4.3% vs 26.4%; P < 0.001).
CONCLUSION Laparoscopic liver resections seem to yield better short-term and mid-term results as compared to open hepatectomies and could well be considered a privileged approach and become the gold standard in carefully selected patients.
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Untereiner X, Cagniet A, Memeo R, Tzedakis S, Piardi T, Severac F, Mutter D, Kianmanesh R, Marescaux J, Sommacale D, Pessaux P. Laparoscopic hepatectomy versus open hepatectomy for colorectal cancer liver metastases: comparative study with propensity score matching. Hepatobiliary Surg Nutr 2016; 5:290-9. [PMID: 27500141 DOI: 10.21037/hbsn.2015.12.06] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The objective of this study was to compare the results of laparoscopic hepatectomy with those of open hepatectomy for colorectal cancer liver metastases (CCLM) using a propensity score matching (PSM) in two university hospital settings. METHODS A patient in the laparoscopic approach (LA) surgery group was randomly matched with another patient in the open approach (OA) group using a 1:1 allocated ratio with the nearest estimated propensity score. No patients of the LA group were excluded for the matching. Matching criteria included age, gender, body mass index (BMI), American society anesthesiologists score, potential co-morbidities, hepatopathies, synchronous or metachronous lesions, size and number of CCLM, preoperative chemotherapy, minor or major liver resections. Intraoperative, postoperative data, and survival were compared in both groups. RESULTS From January 2012 to January 2015, a total of 242 hepatectomies were consecutively performed, of which 119 for CCLM, namely 101 in the OA group (84.9%) and 18 in the LA group (15.1%). The conversion rate was 5.6% (n=1). The mortality rate was 1% in the OA group and 0% in the LA group. Prior to PSM, there was a statistically significant difference favorable to the LA group regarding operative time, blood loss, length of hospital stay and the rate of medical complications. After PSM, there was no difference regarding operative time or length of hospital stay. However, there was a trend towards less blood loss (P=0.066) and fewer medical complications (44.4% vs.16.7%, P=0.07). The R0 resection rate was 94.4% (n=17) in the two groups. In addition, there was no difference regarding overall survival (P=0.358) and recurrence-free survival [HR =0.99 (0.1-12.7); P=0.99]. CONCLUSIONS Laparoscopic liver resections for CCLM seem to yield short- and long-term results, which are similar to open hepatectomies, and could well be considered an alternative to open surgery and become the gold standard in carefully selected patients.
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Affiliation(s)
- Xavier Untereiner
- Department of Digestive and Liver Diseases (Pôle Hépatodigestif), Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Audrey Cagniet
- Department of General, Digestive, and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - Riccardo Memeo
- Department of Digestive and Liver Diseases (Pôle Hépatodigestif), Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France;; Research Institute Against Digestive Cancer-Institut de Recherche sur les Cancers de l'Appareil Digestif (IRCAD)-Institut Hospitalo-Universitaire de Strasbourg (IHU Mix-Surg), Strasbourg, France
| | - Stylianos Tzedakis
- Department of Digestive and Liver Diseases (Pôle Hépatodigestif), Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Tullio Piardi
- Department of General, Digestive, and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - François Severac
- Biostatistics and Computer Science Medical Laboratory, Faculty of Medicine, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Didier Mutter
- Department of Digestive and Liver Diseases (Pôle Hépatodigestif), Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France;; Research Institute Against Digestive Cancer-Institut de Recherche sur les Cancers de l'Appareil Digestif (IRCAD)-Institut Hospitalo-Universitaire de Strasbourg (IHU Mix-Surg), Strasbourg, France
| | - Reza Kianmanesh
- Department of General, Digestive, and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - Jacques Marescaux
- Department of Digestive and Liver Diseases (Pôle Hépatodigestif), Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France;; Research Institute Against Digestive Cancer-Institut de Recherche sur les Cancers de l'Appareil Digestif (IRCAD)-Institut Hospitalo-Universitaire de Strasbourg (IHU Mix-Surg), Strasbourg, France
| | - Daniele Sommacale
- Department of General, Digestive, and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - Patrick Pessaux
- Department of Digestive and Liver Diseases (Pôle Hépatodigestif), Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France;; Research Institute Against Digestive Cancer-Institut de Recherche sur les Cancers de l'Appareil Digestif (IRCAD)-Institut Hospitalo-Universitaire de Strasbourg (IHU Mix-Surg), Strasbourg, France
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Pharmacological Modulation of Ischemic-Reperfusion Injury during Pringle Maneuver in Hepatic Surgery. A Prospective Randomized Pilot Study. World J Surg 2016; 40:2202-12. [DOI: 10.1007/s00268-016-3506-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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van Riel WG, van Golen RF, Reiniers MJ, Heger M, van Gulik TM. How much ischemia can the liver tolerate during resection? Hepatobiliary Surg Nutr 2016; 5:58-71. [PMID: 26904558 DOI: 10.3978/j.issn.2304-3881.2015.07.05] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The use of vascular inflow occlusion (VIO, also known as the Pringle maneuver) during liver surgery prevents severe blood loss and the need for blood transfusion. The most commonly used technique for VIO entails clamping of the portal triad, which simultaneously occludes the proper hepatic artery and portal vein. Although VIO is an effective technique to reduce intraoperative blood loss, it also inevitably inflicts hepatic ischemia/reperfusion (I/R) injury as a side effect. I/R injury induces formation of reactive oxygen species that cause oxidative stress and cell death, ultimately leading to a sterile inflammatory response that causes hepatocellular damage and liver dysfunction that can result in acute liver failure in most severe cases. Since the duration of ischemia correlates positively with the severity of liver injury, there is a need to find the balance between preventing severe blood loss and inducing liver damage through the use of VIO. Although research on the maximum duration of hepatic ischemia has intensified since the beginning of the 1980s, there still is no consensus on the tolerable upper limit. Based on the available literature, it is concluded that intermittent and continuous VIO can both be used safely when ischemia times do not exceed 120 min. However, intermittent VIO should be the preferred technique in cases that require >120 min duration of ischemia.
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Affiliation(s)
- Wouter G van Riel
- Department of Surgery, Surgical Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rowan F van Golen
- Department of Surgery, Surgical Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Megan J Reiniers
- Department of Surgery, Surgical Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Michal Heger
- Department of Surgery, Surgical Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Surgical Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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11
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Tártaro R, Jorge G, Leonardi M, Escanhoela C, Leonardi L, Boin I. No Protective Function Found in Wistar Rats Submitted to Long Ischemia Time and Reperfusion After Intermittent Clamping of the Total Hepatic Pedicle. Transplant Proc 2015; 47:1038-41. [DOI: 10.1016/j.transproceed.2015.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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Aragon RJ, Solomon NL. Techniques of hepatic resection. J Gastrointest Oncol 2012; 3:28-40. [PMID: 22811867 DOI: 10.3978/j.issn.2078-6891.2012.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 01/13/2012] [Indexed: 12/15/2022] Open
Abstract
Liver resections are high risk procedures performed by experienced surgeons. The role of liver resection in malignant disease has changed over the last 100 years with great improvement in morbidity, mortality and long term survival. New understanding in liver anatomy, improved perioperative care, anesthesia techniques, and technological advances has improved this aspect of patient care. With improved techniques, patients previously considered unresectable have an opportunity to undergo curative surgery. This review article describes the various approaches and techniques for liver resection. The relevant anatomy and terminology of hepatic resections is discussed, as well as the role of anatomic vs. nonanatomic resection. Methods of vascular control are examined and the multiple strategies of parenchymal transection are compared, as well as minimally-invasive techniques. Finally, a brief review of the authors' practice in terms of surgical technique is offered.
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Affiliation(s)
- Robert J Aragon
- Department of Surgery, Loma Linda University, Loma Linda, California, USA
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13
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Weiss MJ, Ito H, Araujo RLC, Zabor EC, Gonen M, D'Angelica MI, Allen PJ, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Hepatic pedicle clamping during hepatic resection for colorectal liver metastases: no impact on survival or hepatic recurrence. Ann Surg Oncol 2012; 20:285-94. [PMID: 22868921 DOI: 10.1245/s10434-012-2583-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hepatic pedicle clamping is often used during liver resection. While its use reduces blood loss and transfusion requirements, the long-term effect on survival and recurrence has been debated. This study evaluates the effect of hepatic pedicle clamping [i.e., Pringle maneuver (PM)] on survival and recurrence following hepatic resection for colorectal liver metastasis (CRLM). METHODS Patients who underwent R0 resection for CRLM from 1991 to 2004 were identified from a prospectively maintained database. Operative, perioperative, and clinicopathological variables were analyzed. The primary outcomes were disease-free survival (DFS) and liver recurrence (LR). Disease extent was categorized using a well-defined clinical risk score (CRS). Subgroup analysis was performed for patients given preoperative systemic chemotherapy and postoperative pump chemotherapy. RESULTS This study included 928 consecutive patients with median follow-up of 8.9 years. PM was utilized in 874 (94%) patients, with median time of 35 min (range 1-181 min). On univariate analysis, only resection type (p<0.001) and tumor number (p=0.002) were associated with use of PM. Younger age (p=0.006), longer operative time (p<0.001), and multiple tumors (p=0.006) were associated with prolonged PM (>60 min). There was no association between DFS, overall survival (OS) or LR and Pringle time. Neither the CRS nor use of neoadjuvant therapy stratified disease-related outcome with respect to use of PM. CONCLUSIONS PM was used in most patients undergoing resection for CRLM and did not adversely influence intrahepatic recurrence, DFS, or OS.
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Affiliation(s)
- Matthew J Weiss
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Allard MA, Dondero F, Sommacale D, Dokmak S, Belghiti J, Farges O. Liver packing during elective surgery: an option that can be considered. World J Surg 2012; 35:2493-8. [PMID: 21597886 DOI: 10.1007/s00268-011-1156-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Packing is a life-saving procedure in patients undergoing emergency surgery for blunt hepatic trauma, especially when massive blood transfusions, acidosis, or hypothermia have resulted in coagulation disorders. The purpose of this study was to apply this concept to the setting of elective liver surgery. METHODS Elective packing was performed in 7 patients who had sustained prolonged bleeding mainly related to partial outflow obstruction during the course of liver resection (n = 3) or transplantation (n = 4). At the time of packing, conventional methods of hemostasis had failed and surgery had lasted for 490 (range, 380-695) minutes, blood loss was 5,700 (range, 2,100-13,700) ml, and all patients had coagulation disorders (prothrombin time PT <30%, platelets <45 g/l), hypothermia (body temperature 35.4 °C), acidosis (median blood pH 7.24; serum lactate 6.5 mmol/l) and required catecholamine support. RESULTS Unpacking was performed after a median of 37 (range, 26-60) hours. At that time, all patients were normothermic, with platelet counts >45 g/l, PT >30%, and restored acid-base balance. Active bleeding had stopped, and secondary fascia closure was feasible. With a minimum follow-up of 6 months, all patients are alive without sequel. CONCLUSIONS Packing is a safe and efficient means to control venous bleeding when conventional methods of hemostasis have failed, knowing that commonly the reason for failure of conventional method of hemostasis is partial outflow obstruction.
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Affiliation(s)
- Marc Antoine Allard
- Department of Hepato-Biliary Surgery, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris 7, 100 bld du Général Leclerc, 92118, Clichy, France
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Safety of intermittent Pringle maneuver cumulative time exceeding 120 minutes in liver resection: a further step in favor of the "radical but conservative" policy. Ann Surg 2012; 255:270-80. [PMID: 21975322 DOI: 10.1097/sla.0b013e318232b375] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE We retrospectively compared the short-term outcome of a consecutive cohort of patients who underwent hepatectomy with intermittent clamping ranging between 60 and 120 minutes with those having a clamping time exceeding 120 minutes. BACKGROUND Intermittent Pringle maneuver is widely used to minimize blood loss during hepatectomy, without an established time limit. However, many authors claim it is dangerous for patient outcome. MATERIAL AND METHODS Among 426 consecutive patients who underwent hepatectomy, we retrospectively selected 189 whose intermittent clamping time exceeded 60 minutes: 117 of these had intermittent Pringle maneuver lasting less than 120 minutes (group 1) and 72 clamping time exceeded 120 minutes (group 2). Groups were homogeneous for demographics, preoperative laboratory tests, background liver, and type of tumors. RESULTS Operation length, and number of lesions removed, was significantly higher in group 2. Conversely, the two groups experienced similar amount of blood loss, rate of blood transfusions, overall and major morbidity, and 30- and 90-day postoperative mortality. In particular, in group 2 there was no mortality at all. Mean serum total bilirubin and alanine aminotransferase level on seventh pod resulted significantly higher in group 2, conversely mean aspartate aminotransferase, cholinesterases, and prothrombin time not differed in 2 groups. CONCLUSIONS This study shows that hepatectomies done with intermittent clamping exceeding 120 minutes are as safe as those performed with shorter one despite more complex tumor presentations. This seems encouraging the diffusion of procedures done in 1 stage for extensive liver diseases despite the prolonged clamping time.
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Forty-nine colorectal cancer liver metastases in one-stage hepatectomy with cumulative Pringle time lasting 348 min. Updates Surg 2012; 64:241-3. [DOI: 10.1007/s13304-012-0142-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
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Zhu P, Lau WY, Chen YF, Zhang BX, Huang ZY, Zhang ZW, Zhang W, Dou L, Chen XP. Randomized clinical trial comparing infrahepatic inferior vena cava clamping with low central venous pressure in complex liver resections involving the Pringle manoeuvre. Br J Surg 2012; 99:781-8. [PMID: 22389136 DOI: 10.1002/bjs.8714] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Control of bleeding remains key to successful hepatic resection. The present randomized clinical trial compared infrahepatic inferior vena cava (IVC) clamping with low central venous pressure (CVP) during complex hepatectomy using portal triad clamping (PTC). METHODS Consecutive patients undergoing complex hepatectomy were allocated randomly to PTC combined with infrahepatic IVC clamping or to PTC with low CVP. Primary outcome was blood loss during parenchymal transection. Secondary outcomes were intraoperative surgical and haemodynamic parameters, postoperative recovery of liver and renal function, postoperative morbidity and mortality, and duration of hospital stay. RESULTS Between January 2008 and September 2010, 192 patients were randomized. Compared with low CVP, infrahepatic IVC clamping significantly decreased blood loss during parenchymal transection (mean(s.e.m.) 243(158) versus 372(197) ml; P < 0·001), was associated with faster recovery of liver function, and caused less impairment in renal function and fewer haemodynamic changes. The degree of cirrhosis correlated positively with CVP (R(2) = 0·963, P = 0·019) and with infrahepatic IVC pressure (R(2) = 0·950, P = 0·025). For patients with moderate or severe cirrhosis, infrahepatic IVC clamping was more efficacious in controlling blood loss during parenchymal transection (mean(s.e.m.) 2·9(1·8) versus 6·1(2·4) ml/cm(2); P < 0·001). CONCLUSION PTC combined with infrahepatic IVC clamping is more efficacious in controlling bleeding during complex hepatectomy than PTC with low CVP, especially in patients with moderate to severe cirrhosis. REGISTRATION NUMBER NCT01355887 (http://www.clinicaltrials.gov).
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Affiliation(s)
- P Zhu
- Hepatic Surgery Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Comparison of survival and quality of life of hepatectomy and thrombectomy using total hepatic vascular exclusion and chemotherapy alone in patients with hepatocellular carcinoma and tumor thrombi in the inferior vena cava and hepatic vein. Eur J Gastroenterol Hepatol 2012; 24:186-94. [PMID: 22081008 DOI: 10.1097/meg.0b013e32834dda64] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The prognosis for hepatocellular carcinoma (HCC) along with portal vein tumor thrombi (PVTT) is poor, and surgery has not been considered an option. AIMS To compare the outcomes and the quality of life (QoL) of patients with HCC and PVTT who underwent hepatic resection and thrombectomy for tumor thrombi in the inferior vena cava and hepatic vein with total hepatic vascular exclusion to the patients who received only chemotherapy. METHODS We retrospectively reviewed the medical records of patients who received hepatectomy and thrombectomy (n=65), and those who received only chemotherapy (n=50). The surgical outcomes, survival, and QoL that was determined using the Functional Assessment of Cancer Therapy-Hepatobiliary instrument were analyzed and compared. RESULTS Patients who underwent surgery had a median overall survival of 17 months, compared with patients who underwent chemotherapy for 8 months (P<0.0001). Patients who underwent surgery had a median recurrence-free survival of 14 months, as compared with patients who underwent chemotherapy for 7 months (P<0.0001). The probabilities of 1-year recurrence in the surgery and chemotherapy groups were 27.7 and 70%, respectively (P<0.0001). The QoL total score of the surgery group was significantly higher than that of the control group (P<0.0001). Surgery was slightly, though significantly more cost-effective than chemotherapy based on the quality-adjusted life years. CONCLUSION Hepatectomy and thrombectomy using the total hepatic vascular exclusion, is a viable surgical management for patients with HCC and PVTT, and is associated with longer overall survival and recurrence-free survival and better QoL than chemotherapy alone.
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Abstract
BACKGROUND Vascular occlusion to prevent haemorrhage during liver resection causes ischaemia-reperfusion (IR) injury. Insights into the mechanisms of IR injury gathered from experimental models have contributed to the development of therapeutic approaches, some of which have already been tested in randomized clinical trials. METHODS The review was based on a PubMed search using the terms 'ischemia AND hepatectomy', 'ischemia AND liver', 'hepatectomy AND drug treatment', 'liver AND intermittent clamping' and 'liver AND ischemic preconditioning'; only randomized controlled trials (RCTs) were included. RESULTS Twelve RCTs reported on ischaemic preconditioning and intermittent clamping. Both strategies seem to confer protection and allow extension of ischaemia time. Fourteen RCTs evaluating pharmacological interventions, including antioxidants, anti-inflammatory drugs, vasodilators, pharmacological preconditioning and glucose infusion, were identified. CONCLUSION Several strategies to prevent hepatic IR have been developed, but few have been incorporated into clinical practice. Although some pharmacological strategies showed promising results with improved clinical outcome there is not sufficient evidence to recommend them.
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Affiliation(s)
- R Bahde
- Surgical Research, Department of General and Visceral Surgery, Muenster University Hospital, Waldeyer Strasse 1, D-48149 Muenster, Germany
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20
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Mechanism of liver regeneration after liver resection and portal vein embolization (ligation) is different? ACTA ACUST UNITED AC 2009; 16:292-9. [PMID: 19333540 DOI: 10.1007/s00534-009-0058-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 11/09/2008] [Indexed: 12/22/2022]
Abstract
Whether or not liver regeneration after portal branch embolization (PE) (ligation, PVL) in the non-embolized (ligated) lobe is by the same mechanism as regeneration in the remnant lobe after liver resection has been reviewed. Portal vein branch embolization and heat shock protein are then discussed. Tumor growth accelerated in the remnant liver after hepatectomy. In contrast, PE or PVL resulted in marked contralateral hepatic hypertrophy and significant reduction of tumor growth in the non-embolized (non-ligated) lobes. Follistatin administration significantly increased liver regeneration after hepatectomy in rats. In contrast, regeneration of non-ligated lobes after PVL was not accelerated by exogenous follistatin. Tumor growth also was not accelerated. The liver regeneration rate peaked at 48-72 h in the nonligated lobe after PVL, a delay of 24 h compared with the remnant liver after hepatectomy. In the postoperative early stage, the expression of activin betaA, betaC, and betaE mRNAs was stronger in PVL than in hepatectomy. At 72 h the expression of activin receptor type IIA mRNA reached a peak in hepatectomy, but was significantly lower in PVL. Thus, regulation of activin signaling through receptors is one of the factors determining liver regeneration after hepatectomy and PVL. These serial experimental results imply that the mechanism of liver regeneration after portal branch ligation (embolization) is different from that after hepatectomy. Heat shock protein was induced in the liver experimentally by intermittent ischemic preconditioning and could play some beneficial role in the recovery of liver function after hepatectomy, even in cirrhotic patients. When heat shock protein following right portal vein embolization in both the embolized and non-embolized hepatic lobes was investigated in clinical cases, a two to fourfold increase in HSP70 was induced in the non-embolized lobe compared with the embolized lobe. Oral administration of geranylgeranylacetone (a non-toxic HSP inducer) suppressed inflammatory responses and improved survival after 95% hepatectomy by induction of HSP70 in rats.
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Rahbari NN, Koch M, Mehrabi A, Weidmann K, Motschall E, Kahlert C, Büchler MW, Weitz J. Portal triad clamping versus vascular exclusion for vascular control during hepatic resection: a systematic review and meta-analysis. J Gastrointest Surg 2009; 13:558-68. [PMID: 18622655 DOI: 10.1007/s11605-008-0588-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 06/16/2008] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To compare the clinical outcome of patients undergoing liver resection under portal triad clamping (PTC) versus hepatic vascular exclusion (HVE). METHODS A systematic literature search was performed following the guidelines of the Cochrane collaboration. Randomized controlled trials (RCT) comparing PTC to any technique of HVE were eligible for inclusion. Two authors independently assessed methodological quality of included trials and extracted data on overall morbidity, mortality, cardiopulmonary and hepatic morbidity, intraoperative blood loss, transfusion rates, postoperative transaminase and bilirubin levels, prothrombin time, and hospital stay. Meta-analyses were performed using a random-effects model. RESULTS Of the 1,383 identified references, four RCTs were finally included. These trials compared PTC to selective hepatic vascular exclusion (SHVE), total hepatic vascular exclusion (THVE), and a modified technique of HVE (MTHVE), respectively. Meta-analyses revealed no significant difference in morbidity and mortality between PTC and techniques of HVE. Further analyses showed significantly reduced overall morbidity for the PTC compared to the THVE group. There was a significantly lower transfusion rate for HVE compared to PTC. CONCLUSION Hepatic vascular exclusion does not offer any benefit regarding outcome of patients undergoing hepatic resection compared to PTC alone. Further, well-designed RCTs evaluating adequate vascular control in major hepatectomy and in patients with underlying liver disease appear justified.
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Affiliation(s)
- Nuh N Rahbari
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Gurusamy KS, Sheth H, Kumar Y, Sharma D, Davidson BR. Methods of vascular occlusion for elective liver resections. Cochrane Database Syst Rev 2009:CD007632. [PMID: 19160340 DOI: 10.1002/14651858.cd007632] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vascular occlusion is used to reduce blood loss during liver resection surgery. Various methods of vascular occlusion have been suggested. OBJECTIVES To compare the benefits and harms of different methods of vascular occlusion during elective liver resection. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2008. SELECTION CRITERIA We included randomised clinical trials comparing different methods of vascular occlusion during elective liver resections (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for inclusion and independently extracted the data. We calculated the risk ratio or mean difference with 95% confidence intervals using fixed-effect and random-effects models based on intention-to-treat or available data analysis. MAIN RESULTS Ten trials including 657 patients compared different methods of vascular occlusion. All trials were of high risk of bias. Only one or two trials were included under each comparison. There was no statistically significant differences in mortality, liver failure, or other morbidity between any of the comparisons.Hepatic vascular occlusion does not decrease the blood transfusion requirements. It decreases the cardiac output and increases the systemic vascular resistance. In the comparison between continuous portal triad clamping and intermittent portal triad clamping, four of the five liver failures occurred in patients with chronic liver diseases undergoing the liver resections using continuous portal triad clamping. In the comparison between selective inflow occlusion and portal triad clamping, all four patients with liver failure occurred in the selective inflow occlusion group. There was no difference in any of the other important outcomes in any of the comparisons. AUTHORS' CONCLUSIONS In elective liver resection, hepatic vascular occlusion cannot be recommended over portal triad clamping. Intermittent portal triad clamping seems to be better than continuous portal triad clamping at least in patients with chronic liver disease. There is no evidence to support selective inflow occlusion over portal triad clamping. The optimal method of intermittent portal triad clamping is not clear. There is no evidence for any difference between the ischaemic preconditioning followed by vascular occlusion and intermittent vascular occlusion for liver resection in patients with non-cirrhotic livers. Further randomised trials of low risk of bias are needed to determine the optimal technique of vascular occlusion.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Gurusamy KS, Sheth H, Kumar Y, Sharma D, Davidson BR. WITHDRAWN: Methods of vascular occlusion for elective liver resections. Cochrane Database Syst Rev 2009; 2009:CD006409. [PMID: 19160283 PMCID: PMC10654807 DOI: 10.1002/14651858.cd006409.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Vascular occlusion is used to reduce blood loss during liver resection surgery. There is considerable controversy regarding whether vascular occlusion should be used or not during elective liver resections. The method of vascular occlusion employed is also controversial. There is also considerable debate on the role of ischaemic preconditioning before vascular occlusion. OBJECTIVES To assess the advantages (decreased blood loss and peri-operative morbidity) and disadvantages (liver dysfunction from ischaemia) of vascular occlusion during liver resections. To compare the advantages (in decreasing blood loss or decreasing ischaemia-reperfusion injury) and disadvantages of different types of vascular occlusion versus total, continuous portal triad clamping. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2007. SELECTION CRITERIA We included randomised clinical trials comparing vascular occlusion versus no vascular occlusion during elective liver resections (irrespective of language or publication status). We also included randomised clinical trials comparing the different methods of vascular occlusion and those investigating the role of ischaemic preconditioning in liver resection. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, blood loss, blood transfusion requirements, liver function tests, markers of neutrophil activation, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each binary outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. For continuous outcomes, we calculated the weighted mean difference (WMD) with 95% confidence intervals. MAIN RESULTS We identified a total of 16 randomised trials. Five trials including 331 patients compared vascular occlusion (n = 166) versus no vascular occlusion (n = 165). Six trials including 521 patients compared different methods of vascular occlusion. Three trials including 210 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 105) versus no ischaemic preconditioning (n = 105). Two trials including 127 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 63) versus intermittent portal triad clamping (n = 64).The blood loss was significantly lower in vascular occlusion compared with no vascular occlusion. The liver enzymes were significantly elevated in the vascular occlusion group compared with no vascular occlusion. There was no difference in the mortality, liver failure, or other morbidities. Four of the five trials comparing vascular occlusion and no vascular occlusion used intermittent vascular occlusion. Trials comparing complete inflow and outflow occlusion to the liver, ie, hepatic vascular exclusion and portal triad clamping demonstrate significant detrimental haemodynamic changes in hepatic vascular exclusion compared to portal triad clamping. There was no significant difference in the number of units transfused and the number of patients needing transfusion. There was no difference in mortality, liver failure, or morbidity between total and selective methods of portal triad clamping. All four cases of mortality and liver failure in the comparison between the intermittent and continuous portal triad clamping occurred in the continuous portal triad clamping (statistically not significant). Intermittent portal triad clamping does not increase the total blood loss or operating time compared to continuous portal triad clamping.There was no statistically significant difference in the mortality, liver failure, morbidity, blood loss, or haemodynamic changes between ischaemic preconditioning versus no ischaemic preconditioning before continuous portal triad clamping. Liver enzymes used as markers of liver injury were significantly lower in the early post-operative period in the ischaemic preconditioning group. The intensive therapy unit stay and hospital stay were statistically significantly lower in the ischaemic preconditioning group than in the no ischaemic preconditioning group.There was no statistically significant difference in the mortality, liver failure, morbidity, intensive therapy unit stay, or hospital stay between ischaemic preconditioning before continuous portal triad clamping and intermittent portal triad clamping. The blood loss and transfusion requirements were lower in the ischaemic preconditioning group. Aspartate aminotransferase level was lower in the intermittent portal triad clamping group than the ischaemic preconditioning group on the third post-operative day. There was no difference in the peak aspartate aminotransferase levels or in the aspartate aminotransferase levels on first or sixth post-operative days of aspartate aminotransferase . AUTHORS' CONCLUSIONS Intermittent vascular occlusion seems safe in liver resection. However, it does not seem to decrease morbidity. Among the different methods of vascular occlusion, intermittent portal triad clamping has most evidence to support the clinical application. Hepatic vascular exclusion cannot be recommended routinely. Ischaemic preconditioning before continuous portal triad clamping may be of clinical benefit in reducing intensive therapy unit and hospital stay.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Gurusamy KS, Kumar Y, Ramamoorthy R, Sharma D, Davidson BR. Vascular occlusion for elective liver resections. Cochrane Database Syst Rev 2009:CD007530. [PMID: 19160336 DOI: 10.1002/14651858.cd007530] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Vascular occlusion is used to reduce blood loss during liver resection. There is considerable controversy regarding whether vascular occlusion should be used or not during elective liver resections. OBJECTIVES To assess the advantages (decreased blood loss and peri-operative morbidity) and disadvantages (ischaemia-reperfusion injury related complications like liver dysfunction) of vascular occlusion during elective liver resections. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2008. SELECTION CRITERIA We included randomised clinical trials comparing vascular occlusion versus no vascular occlusion during elective liver resections (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat or available case analysis. MAIN RESULTS We identified a total of five trials (of high bias-risk) which compared vascular occlusion (n = 166) versus no vascular occlusion (n = 165). Three of the five trials comparing vascular occlusion and no vascular occlusion used intermittent vascular occlusion. There was no difference in mortality, liver failure, or other morbidities. The blood loss was significantly lower in vascular occlusion compared with no vascular occlusion. The liver enzymes were significantly elevated in the vascular occlusion group compared with no vascular occlusion. AUTHORS' CONCLUSIONS Intermittent vascular occlusion seems safe in liver resection. However, it does not seem to decrease morbidity. More randomised trials seem to be needed.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Kannerup AS, Grønbæk H, Funch-Jensen P, Jørgensen RL, Mortensen FV. The influence of preconditioning on metabolic changes in the pig liver before, during, and after warm liver ischemia measured by microdialysis. Hepatol Int 2008; 3:310-5. [PMID: 19669382 DOI: 10.1007/s12072-008-9104-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Accepted: 09/14/2008] [Indexed: 11/30/2022]
Abstract
PURPOSE Ischemia-reperfusion injury induced by the Pringle maneuver is a well-known problem after liver surgery. The aim of this study was to monitor metabolic changes in the pig liver during warm ischemia and the following reperfusion preceded by ischemic preconditioning (IPC). METHODS Eight Landrace pigs underwent laparotomy. Two microdialysis catheters were inserted in the liver, one in the left lobe and another in the right lobe. A reference catheter was inserted in the right biceps femoris muscle. Microdialysis samples were collected every 30 min during the study. After 2 h of baseline measurement, IPC was performed by subjecting pigs to 10 min of ischemia, followed by 10 min of reperfusion. Total ischemia for 60 min was followed by 3 h of reperfusion. The samples were analyzed for glucose, lactate, pyruvate, and glycerol. Blood samples were drawn three times to determine standard liver parameters. RESULTS All parameters remained stable during baseline. Glycerol and glucose levels increased significantly during ischemia, followed by a decrease from the start of reperfusion. During the ischemic period, lactate levels increased significantly and decreased during reperfusion. The lactate-pyruvate ratio increased significantly during ischemia and decreased rapidly during reperfusion. Only minor changes were observed in standard liver parameters. CONCLUSIONS The present study demonstrated profound metabolic changes before, during, and after warm liver ischemia under the influence of IPC. Compared with a similar study without IPC, the metabolic changes seem to be unaffected by preconditioning.
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Affiliation(s)
- Anne-Sofie Kannerup
- Department of Surgical Gastroenterology L, Aarhus University Hospital, 8000, Aarhus C, Denmark,
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Elias D, Goere D, Kohneh-Sahrhi N, de Baere T. Strategies for resection using portal vein embolization: metastatic liver cancer. Semin Intervent Radiol 2008; 25:123-31. [PMID: 21326553 DOI: 10.1055/s-2008-1076680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The oncological landscape is constantly changing with the development of new curatively intended therapeutic strategies. More and more, liver metastases are amenable to resection following the progress achieved as a result of new oncological concepts (i.e., treat detectable disease with surgery and ablative therapies and treat the remaining nondetectable disease with efficient chemotherapy) as well as improved chemotherapeutic and ablation techniques. One of the major limitations to extending the indications for liver resection is the volume of the future remnant liver (FRL). To overcome these limitations, portal vein embolization (PVE) has played a key role in obtaining preoperative hypertrophy of the FRL and thus has reduced postoperative morbidity and mortality. Interestingly, thermal ablation of multiple bilateral liver metastases makes it difficult to predict the volume of parenchyma scheduled for ablation. Furthermore, prolonged chemotherapy impairs liver parenchyma function, which has a negative impact on liver hypertrophy. In the future, both volumetric and functional assessment of the FRL will be used to determine whether PVE is necessary before hepatectomy in individual patients and new strategies (e.g., PVE used alone or combined with other treatments; timing of PVE may vary) will be based on these principles. This article presents various current strategies for the use of PVE in patients with metastatic liver cancer.
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Affiliation(s)
- Dominique Elias
- Departments of Surgical Oncology and Interventional Radiology, Institut Gustave Roussy, Villejuif, France
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van der Bilt JDW, Kranenburg O, Borren A, van Hillegersberg R, Borel Rinkes IHM. Ageing and hepatic steatosis exacerbate ischemia/reperfusion-accelerated outgrowth of colorectal micrometastases. Ann Surg Oncol 2008; 15:1392-8. [PMID: 18335279 DOI: 10.1245/s10434-007-9758-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Revised: 10/14/2007] [Accepted: 10/15/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ischemia/reperfusion (I/R) injury is frequently encountered during hepatic surgery. We recently showed that I/R accelerates the outgrowth of pre-established colorectal micrometastases. The aim of this study was to assess the influence of ischemia time, gender, age, and liver steatosis on the accelerated outgrowth of colorectal metastases following I/R. METHODS Five days after tumor cell inoculation, mice were subjected to 20, 30 or 45 min of left lobar I/R. To assess the influence of age, gender, and liver steatosis on I/R-accelerated tumor growth, we compared old with young mice, male with female mice, and mice with healthy livers with mice with steatotic livers. Endpoints were extent of tissue necrosis and tumor growth. RESULTS With increasing ischemia times, tissue necrosis and I/R-accelerated tumor growth increased, with a significant stimulatory effect at 30 and 45 min of ischemia. I/R-stimulated outgrowth of micrometastases was further increased by 33% in aged mice and by 42% in steatotic livers and was associated with increased tissue necrosis. In female mice tissue necrosis had decreased by 47% and tumor growth was reduced in both control and clamped liver lobes. The stimulatory effect of I/R on metastasis outgrowth was similar in male and female mice. CONCLUSIONS I/R-accelerated outgrowth of colorectal micrometastases largely depends on the duration of the ischemic period, with a safe upper limit of 20 min in mice. The stimulatory effects of I/R on tumor growth are exacerbated in aged mice and in steatotic livers.
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Abstract
BACKGROUND Vascular occlusion is used to reduce blood loss during liver resection surgery. There is considerable controversy regarding whether vascular occlusion should be used or not during elective liver resections. The method of vascular occlusion employed is also controversial. There is also considerable debate on the role of ischaemic preconditioning before vascular occlusion. OBJECTIVES To assess the advantages (decreased blood loss and peri-operative morbidity) and disadvantages (liver dysfunction from ischaemia) of vascular occlusion during liver resections. To compare the advantages (in decreasing blood loss or decreasing ischaemia-reperfusion injury) and disadvantages of different types of vascular occlusion versus total, continuous portal triad clamping. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2007. SELECTION CRITERIA We included randomised clinical trials comparing vascular occlusion versus no vascular occlusion during elective liver resections (irrespective of language or publication status). We also included randomised clinical trials comparing the different methods of vascular occlusion and those investigating the role of ischaemic preconditioning in liver resection. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, blood loss, blood transfusion requirements, liver function tests, markers of neutrophil activation, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each binary outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. For continuous outcomes, we calculated the weighted mean difference (WMD) with 95% confidence intervals. MAIN RESULTS We identified a total of 16 randomised trials. Five trials including 331 patients compared vascular occlusion (n = 166) versus no vascular occlusion (n = 165). Six trials including 521 patients compared different methods of vascular occlusion. Three trials including 210 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 105) versus no ischaemic preconditioning (n = 105). Two trials including 127 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 63) versus intermittent portal triad clamping (n = 64). The blood loss was significantly lower in vascular occlusion compared with no vascular occlusion. The liver enzymes were significantly elevated in the vascular occlusion group compared with no vascular occlusion. There was no difference in the mortality, liver failure, or other morbidities. Four of the five trials comparing vascular occlusion and no vascular occlusion used intermittent vascular occlusion. Trials comparing complete inflow and outflow occlusion to the liver, ie, hepatic vascular exclusion and portal triad clamping demonstrate significant detrimental haemodynamic changes in hepatic vascular exclusion compared to portal triad clamping. There was no significant difference in the number of units transfused and the number of patients needing transfusion. There was no difference in mortality, liver failure, or morbidity between total and selective methods of portal triad clamping. All four cases of mortality and liver failure in the comparison between the intermittent and continuous portal triad clamping occurred in the continuous portal triad clamping (statistically not significant). Intermittent portal triad clamping does not increase the total blood loss or operating time compared to continuous portal triad clamping. There was no statistically significant difference in the mortality, liver failure, morbidity, blood loss, or haemodynamic changes between ischaemic preconditioning versus no ischaemic preconditioning before continuous portal triad clamping. Liver enzymes used as markers of liver injury were significantly lower in the early post-operative period in the ischaemic preconditioning group. The intensive therapy unit stay and hospital stay were statistically significantly lower in the ischaemic preconditioning group than in the no ischaemic preconditioning group. There was no statistically significant difference in the mortality, liver failure, morbidity, intensive therapy unit stay, or hospital stay between ischaemic preconditioning before continuous portal triad clamping and intermittent portal triad clamping. The blood loss and transfusion requirements were lower in the ischaemic preconditioning group. Aspartate aminotransferase level was lower in the intermittent portal triad clamping group than the ischaemic preconditioning group on the third post-operative day. There was no difference in the peak aspartate aminotransferase levels or in the aspartate aminotransferase levels on first or sixth post-operative days of aspartate aminotransferase. AUTHORS' CONCLUSIONS Intermittent vascular occlusion seems safe in liver resection. However, it does not seem to decrease morbidity. Among the different methods of vascular occlusion, intermittent portal triad clamping has most evidence to support the clinical application. Hepatic vascular exclusion cannot be recommended routinely. Ischaemic preconditioning before continuous portal triad clamping may be of clinical benefit in reducing intensive therapy unit and hospital stay.
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Affiliation(s)
- K S Gurusamy
- Royal Free and University College School of Medicine, University Department of Surgery, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Abstract
At some point in the natural course of colorectal cancer up to 50% of patients will develop metastasis to the liver. Historically only 20% of these patients would have to be deemed resectable, with an intent to cure, at the time of presentation. But with recent improvements in cross-sectional imaging, chemotherapeutic agents and advances in the techniques of surgical resection the emphasis of resection has now changed to 'who is not resectable' as opposed to 'who is resectable'. There are few contraindications to liver resection on the proviso that the patient is fit enough. As a result of this paradigm shift, 5 year survival rates are approaching 60%. Historically liver resection was perceived as a formidable operation but now liver resection for CRLM is safe and specialist centres are reporting mortality rates of less than 1%. This review briefly covers the standard techniques currently employed and some of the recent innovations being developed to improve resectability.
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Affiliation(s)
- R Lochan
- Department of Hepatobiliary Surgery, The Freeman Hospital, High Heaton, Newcastle upon Tyne, Tyne and Wear, NE7 7DN, UK
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Yao P, Chu F, Daniel S, Gunasegaram A, Yan T, Lindemann W, Pistorius G, Schilling M, Machi J, Zuckerman R, Morris DL. A multicentre controlled study of the InLine radiofrequency ablation device for liver transection. HPB (Oxford) 2007; 9:267-71. [PMID: 18345302 PMCID: PMC2215394 DOI: 10.1080/13651820701377091] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical resection is the most effective therapy for liver cancer. Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine radiofrequency ablation device (ILRFA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated. PATIENTS AND METHODS A total of 108 patients underwent liver resections in 4 medical centres; the prospective sequential cohort study consisted of 54 ILRFA and 54 ultrasonic surgical aspirator transections as the control group. RESULTS The type of liver resection performed was very similar in both groups. The median number of RFA deployments was 3 (range 1-12) with a median coagulation time of 9 (range 3-36) min. Median blood loss was 165+/-20 ml (range 5-675) in the ILRFA and 654+/-83 ml (range 80-3600) in the control group (p<0.001). The median transection time was 27 (2-219) min in the ILRFA group and 35 (5-62) min in controls. CONCLUSIONS Our study indicates that ILRFA device for liver transection is effective in reducing blood loss and is safe. Precoagulation before parenchymal transection appears to be a valid concept in liver surgery. The avoidance of vascular inflow occlusion during parenchymal transection could also be of value.
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Affiliation(s)
- Peng Yao
- University of New South Wales, Department of Surgery, St George HospitalSydneyAustralia
| | - Frank Chu
- University of New South Wales, Department of Surgery, St George HospitalSydneyAustralia
| | - Steve Daniel
- University of New South Wales, Department of Surgery, St George HospitalSydneyAustralia
| | - Aravin Gunasegaram
- University of New South Wales, Department of Surgery, St George HospitalSydneyAustralia
| | - Tristan Yan
- University of New South Wales, Department of Surgery, St George HospitalSydneyAustralia
| | - Werner Lindemann
- Clinic of General, Visceral, Vascular and Pediatric Surgery, University Hospital of the SaarlandHomburg/SaarGermany
| | - Georg Pistorius
- Clinic of General, Visceral, Vascular and Pediatric Surgery, University Hospital of the SaarlandHomburg/SaarGermany
| | - Martin Schilling
- Clinic of General, Visceral, Vascular and Pediatric Surgery, University Hospital of the SaarlandHomburg/SaarGermany
| | - Junji Machi
- Department of Surgery, University of Hawaii and Kuakini Medical CenterHonolulu HIUSA
| | - Randall Zuckerman
- Mithoefer Center for Rural Surgery, Bassett HealthcareCooperstown NYUSA
| | - David L. Morris
- University of New South Wales, Department of Surgery, St George HospitalSydneyAustralia
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Tanaka K, Shimada H, Togo S, Nagano Y, Endo I, Sekido H. Outcome using hemihepatic vascular occlusion versus the pringle maneuver in resections limited to one hepatic section or less. J Gastrointest Surg 2006; 10:980-6. [PMID: 16843868 DOI: 10.1016/j.gassur.2006.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 01/05/2006] [Indexed: 01/31/2023]
Abstract
Consensus is lacking concerning how to manage afferent vessels during hepatectomy, particularly as to the Pringle maneuver vs. selective hemihepatic clamping. Data for 81 hepatocellular carcinoma patients with chronic hepatitis or liver cirrhosis whose liver resection was limited to one section or less, including intraoperative data and postoperative liver function data, were analyzed retrospectively to compare two strategies. No significant differences of intraoperative data or postoperative clinical course were seen between the two groups, even in patients with chronic hepatitis or liver cirrhosis whose postoperative deterioration of liver function could be expected to be more than patients with a normal liver. The difference was evident only in serum alanine aminotransferase level on postoperative day 10 (mean +/- SEM, 64.5 +/- 5.1 IU in the Pringle group vs. 51.6 +/- 4.4 IU in the selective clamping group; P < 0.05). During liver resection limited to one section or less, even with underlying chronic hepatitis or cirrhosis, intermittent use of the Pringle maneuver preserved liver function to the same extent as selective clamping.
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Affiliation(s)
- Kuniya Tanaka
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
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Hepatocellular Cancer. Surg Oncol 2006. [DOI: 10.1007/0-387-21701-0_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kadono J, Hamada N, Fukueda M, Ishizaki N, Kaieda M, Gejima K, Nishida S, Nakamura K, Yoshida H, Sakata R. Advantage of ischemic preconditioning for hepatic resection in pigs. J Surg Res 2006; 134:173-81. [PMID: 16542680 DOI: 10.1016/j.jss.2006.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2005] [Revised: 01/25/2006] [Accepted: 02/02/2006] [Indexed: 01/14/2023]
Abstract
BACKGROUND Ischemic preconditioning (IP) and intermittent inflow occlusion (IO) have provided beneficial outcomes in hepatic resection. However, comparison of these two procedures against warm hepatic ischemia-reperfusion injury has not been studied enough. MATERIALS AND METHODS Pigs that had undergone 65% hepatectomy were subjected to Control (120 min continuous ischemia, n = 6), IP (10 min ischemia and 10 min reperfusion, followed by 120 min continuous ischemia, n = 6), and IO (120 min ischemia in the form of eight successive periods of 15 min ischemia and 5 min reperfusion, n = 6). We evaluated hepatocyte injury by aspartate aminotransferase, lactate dehydrogenase and hepaplastin test, hepatic microcirculation by hepatic tissue blood flow (HTBF) and endothelin (ET)-1, inflammatory response by tumor necrosis factor-alpha (TNF-alpha), and histopathology after reperfusion. RESULTS IP prevented hepatocyte injury, HTBF disturbance, and hepatocyte necrosis in histopathology as well as IO. These two groups showed significantly better outcomes than Control. IP produced significantly less ET-1 and TNF-alpha than IO. CONCLUSIONS IP ameliorated hepatic warm ischemia-reperfusion injury. Furthermore, IP gained more advantages in preventing chemokine production such as ET-1 and inflammatory response over IO. IP could take the place of IO for hepatectomy.
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Affiliation(s)
- Jun Kadono
- Second Department of Surgery, Faculty of Medicine, Kagoshima University, Sakuragaoka, Kagoshima, Japan.
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Smyrniotis V, Farantos C, Kostopanagiotou G, Arkadopoulos N. Vascular control during hepatectomy: review of methods and results. World J Surg 2006; 29:1384-96. [PMID: 16222453 DOI: 10.1007/s00268-005-0025-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The various techniques of hepatic vascular control are presented, focusing on the indications and drawbacks of each. Retrospective and prospective clinical studies highlight aspects of the pathophysiology, indications, and morbidity of the various techniques of hepatic vascular control. Newer perspectives on the field emerge from the introduction of ischemic preconditioning and laparoscopic hepatectomy. A literature review based on computer searches in Index Medicus and PubMed focuses mainly on prospective studies comparing techniques and large retrospective ones. All methods of hepatic vascular control can be applied with minimal mortality by experienced surgeons and are effective for controlling bleeding. The Pringle maneuver is the oldest and simplest of these methods and is still favored by many surgeons. Intermittent application of the Pringle maneuver and hemihepatic occlusion or inflow occlusion with extraparenchymal control of major hepatic veins is particularly indicated for patients with abnormal parenchyma. Total hepatic vascular exclusion is associated with considerable morbidity and hemodynamic intolerance in 10% to 20% of patients. It is absolutely indicated only when extensive reconstruction of the inferior vena cava (IVC) is warranted. Major hepatic veins/ and limited IVC reconstruction has been also achieved under inflow occlusion with extraparenchymal control of major hepatic veins or even using the intermittent Pringle maneuver. Ischemic preconditioning is strongly recommended for patients younger than 60 years and those with steatotic livers. Each hepatic vascular control technique has its place in liver surgery, depending on tumor location, underlying liver disease, patient cardiovascular status, and, most important, the experience of the surgical and anesthesia team.
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Affiliation(s)
- Vassilios Smyrniotis
- Second Department of Surgery, Athens University Medical School, Aretaieion Hospital, 76 Vassilisis Sofias Avenue, Athens 11528, Greece.
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Elias D, Liberale G, Vernerey D, Pocard M, Ducreux M, Boige V, Malka D, Pignon JP, Lasser P. Hepatic and extrahepatic colorectal metastases: when resectable, their localization does not matter, but their total number has a prognostic effect. Ann Surg Oncol 2005; 12:900-9. [PMID: 16184442 DOI: 10.1245/aso.2005.01.010] [Citation(s) in RCA: 185] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Accepted: 06/28/2005] [Indexed: 12/23/2022]
Abstract
BACKGROUND The presence of extrahepatic disease (EHD) is considered a contraindication to hepatectomy in patients with colorectal liver metastases. After resection, the prognosis is based more on the total number of resected metastases (located inside and outside the liver) than on the site of these metastases (only inside the liver or not). METHODS A total of 308 patients with colorectal cancer underwent hepatectomy, and 84 (27%) also underwent resection of miscellaneous EHD. The study was a prospective data registration and retrospective analysis. When considering the total number of resected metastases, each liver metastasis and each EHD location was counted as one lesion. Univariate and multivariate analyses were performed. RESULTS The median follow-up was 99 months. The overall 5-year survival rate was 32%. In the multivariate analysis, the total number of metastases (inside or outside the liver) had a greater prognostic value than the criterion "presence or absence of EHD." Considering the total number of resected metastases (whatever their site), 5-year survival rates were 38% (SD: 4%) in the group with one to three metastases, 29% (SD: 5%) in patients with four to six metastases, and 18% (SD: 5%) in patients with more than six metastases (P = .002). A very simple prognostic score based on sex and the total number of metastases is proposed. CONCLUSIONS EHD, when resectable, is no longer a contraindication to hepatectomy. More importantly, the total number of the metastases, whatever their location, has a stronger prognostic effect than the site of these metastases.
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Affiliation(s)
- Dominique Elias
- Department of Surgical Oncology, Institut Gustave Roussy, Comprehensive Cancer Center, 39 Rue Camille Desmoulins, Villejuif Cédex, 94805, France.
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Herman P, Machado MAC. Meso-hepatectomia: uma alternativa para a ressecção hepática alargada. Rev Col Bras Cir 2005. [DOI: 10.1590/s0100-69912005000200009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJETIVO: Discutir as indicações e resultados da meso-hepatectomia (hepatectomia central), um procedimento raro, trabalhoso e desafiador. MÉTODO: Estudo de três pacientes portadores de hepatopatia e diagnóstico de tumor de localização central no parênquima hepático, submetidos à meso-hepatectomia. Para realização do procedimento, empregou-se a abordagem glissoniana aos pedículos dos segmentos a serem ressecados, sem clampeamento do hilo hepático. RESULTADOS: Apenas um paciente necessitou de transfusão de glóbulos durante a operação. O tempo médio da operação foi de quatro horas. Não se observaram complicações pósoperatórias e o tempo médio de internação foi de seis dias. CONCLUSÕES: A meso-hepatectomia é um procedimento que apesar de trabalhoso pode ser padronizado e realizado com segurança em pacientes com tumores centrais e hepatopatia associada. A preservação do parênquima, tem papel importante na boa evolução dos pacientes e, o acesso glissoniano, é um procedimento útil, tanto do ponto de vista técnico como para evitar a isquemia do parênquima remanescente.
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Abstract
Each vascular occlusion technique has a place in major and minor hepatic resectional surgery, based on the tumor location, presence of associated underlying liver disease, patient cardiovascular status, and experience of the operating surgeon. Understanding of the potential application of different techniques, anticipation of the expected and potential hemodynamic responses, and knowledge of the limitations of each technique are fundamental to appropriate surgical planning adapted to each patient. Experience with the various clamping methods enables an aggressive but safe approach to surgical treatment of hepatobiliary diseases, with acceptable blood loss and transfusion requirements. In all cases, surgical strategy should be defined with the anesthesiologist, particularly in regard to hemodynamic monitoring, in order to optimize perioperative patient management and to minimize the risk for complications such as bleeding and air embolism. Importantly, randomized study has shown that the added dissection, operative, and postoperative risks associated with HVE are not balanced by decreased blood loss compared with hepatic pedicle clamping, except in exceptional cases when tumors involve the major hepatic veins or vena cava. In addition, dissection in preparation for clamping may be used as safe approach techniques to tumors in difficult locations, even when eventual clamping is not performed. Similarly, the liver-hanging maneuver enables resection without mobilization, compression, and manipulation of large tumors. In the future, renewed interest in the impact of hepatic ischemia and reperfusion may reveal that some clamping methods, in particular inflow occlusion, act as a means of preconditioning before a period of prolonged hepatic ischemia, for complex hepatic resection or for graft harvest from a living donor. Finally, the addition of infrahepatic caval clamping may add a new, simple, effective technique to the armamentarium of the liver surgeon, particularly as more routine hepatic surgery moves from the specialized center to the community.
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Affiliation(s)
- Eddie K Abdalla
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 444, Houston, TX 77030, USA
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Smyrniotis VE, Kostopanagiotou GG, Contis JC, Farantos CI, Voros DC, Kannas DC, Koskinas JS. Selective hepatic vascular exclusion versus Pringle maneuver in major liver resections: prospective study. World J Surg 2003; 27:765-9. [PMID: 14509502 DOI: 10.1007/s00268-003-6978-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Selective hepatic vascular exclusion (SHVE) and the Pringle maneuver are two methods used to control bleeding during hepatectomy. They are compared in a prospective randomized study, where 110 patients undergoing major liver resection were randomly allocated to the SHVE group or the Pringle group. Data regarding the intraoperative and postoperative courses of the patients are analyzed. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group, and postoperative liver function was better in that group. Although there was no difference between the two groups regarding the postoperative complications rate, patients offered the Pringle maneuver had a significantly longer hospital stay. The application of SHVE did not prolong the warm ischemia time or the total operating time. It is evident from the present study that SHVE performed by experienced surgeons is as safe as the Pringle maneuver and is well tolerated by the patients. It is much more effective than the Pringle maneuver for controlling intraoperative bleeding, and it is associated with better postoperative liver function and shorter hospital stay.
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Affiliation(s)
- Vassilios E Smyrniotis
- Second Department of Surgery and Liver Transplant Unit, Athens University Medical School, Aretaeion Hospital, 76 Vassilisis Sofias Avenue, 11528 Athens, Greece.
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Chaib E, Saad WA, Fujimura I, Saad WA, Gama-Rodrigues J. The main indications and techniques for vascular exclusion of the liver. ARQUIVOS DE GASTROENTEROLOGIA 2003; 40:131-6. [PMID: 14762485 DOI: 10.1590/s0004-28032003000200013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND: The purpose of vascular clamping during the course of liver resection is to reduce bleeding and subsequent complications. AIM: To show both step-by-step surgical techniques for vascular exclusion of the liver and their indications. METHODS: It is described the following techniques: clamping of the hepatic pedicle, ''Pringle'' maneuver; intermittent clamping of the hepatic pedicle; intermittent vascular exclusion of the liver, without vena cava clamping, and hepatic vascular exclusion with vena cava clamping. Also metabolic and homodynamic consequences as well as the technical failure of the application of each of them are discussed. CONCLUSIONS: The choice of technique to use for clamping during hepatectomy depends on the surgeon's judgment. Dogmatic or systematic attitude, is prejudiciable for the patient and liver surgeon must be able to use all kinds of clamping.
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Affiliation(s)
- Eleazar Chaib
- Liver and Portal Hypertension Surgery Unit, University of São Paulo School of Medicine, São Paulo, SP, Brazil.
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40
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Muratore A, Ribero D, Ferrero A, Bergero R, Capussotti L. Prospective randomized study of steroids in the prevention of ischaemic injury during hepatic resection with pedicle clamping. Br J Surg 2003; 90:17-22. [PMID: 12520569 DOI: 10.1002/bjs.4055] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The major drawback of hepatic pedicle clamping is ischaemia-reperfusion injury with impairment of liver function. Perioperative steroid administration has been advocated to reduce liver damage. The aim of this prospective, randomized study was to determine whether steroid administration can reduce liver injury and improve short-term outcome. METHODS Fifty-three patients undergoing liver resection were randomized to a steroid group (group 1) or to a control group (group 2); patients in group 1 received methylprednisolone 30 mg/kg 30 min before liver resection whereas those in group 2 did not. Serum levels of interleukin (IL) 6, total bilirubin, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and prothrombin time (PT) were measured. Length of stay, and type and number of complications were recorded. RESULTS Serum IL-6 levels were significantly lower in the steroid group than in the control group 24 h after surgery. Steroid administration significantly modified AST, ALT and PT levels only in patients with chronic liver disease. Overall and lung-related morbidity were not significantly different between the two groups. CONCLUSIONS Steroid administration suppresses serum IL-6 levels, but has no effect on short-term outcome.
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Affiliation(s)
- A Muratore
- Department of Surgical Oncology, Istituto per la Ricerca e la Cura del Cancro, Candiolo, Torino, Italy.
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Silva FND. Isquemia hepática normotérmica em ratos: estudo da lesão celular através do uso de clampeamento pedicular contínuo e intermitente. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000600007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar as alterações bioquímicas decorrentes da isquemia hepática normotérmica, seguida de reperfusão em duas modalidades de clampeamento da tríade portal em ratos. MÉTODO: Trinta ratos Wistar machos pesando entre 250 e 320 gramas foram divididos em três grupos de 10 animais cada. Induzimos 40 minutos de isquemia hepática por clampeamento pedicular contínuo (grupo I) ou intermitente (grupo II). No grupo controle não houve clampeamento. Como parâmetro de lesão hepatocelular adotamos a concentração plasmática de: transaminase glutâmico oxalacética (TGO), transaminase glutâmico pirúvica (TGP) e lactato desidrogenase (LDH). Colhemos as amostras de sangue no início (T1) e no final da cirurgia (T2). Todos os animais foram submetidos ao mesmo tempo operatório: 60 minutos. RESULTADOS: Não houve diferença estatística nos valores iniciais (T1) das três enzimas nos três grupos. Todos apresentaram aumento significativo das enzimas do momento 1 (T1) para o momento 2 (T2). Houve diferença estatística no aumento médio de TGO e TGP entre os três grupos, sendo o maior aumento encontrado no grupo I e o menor, no grupo controle. Não houve diferença significativa, em relação à LDH, entre o grupo II e o grupo controle. No grupo I, entretanto, houve aumento significativo em relação aos demais. Conclusão: Comparado ao clampeamento contínuo, para um período total de 40 minutos de isquemia, o clampeamento da tríade portal em ratos realizado de forma intermitente, com ciclos de 10 minutos de isquemia e 5 minutos de reperfusão, provoca menor dano hepatocelular, o que foi constatado pela menor alteração enzimática.
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Iwasaki Y, Tagaya N, Hattori Y, Yamaguchi K, Kubota K. Protective effect of ischemic preconditioning against intermittent warm-ischemia-induced liver injury. J Surg Res 2002; 107:82-92. [PMID: 12384068 DOI: 10.1006/jsre.2002.6505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although ischemic preconditioning (IPC) has been reported to protect the liver from injury when subjected to continuous hepatic ischemia, whether IPC protects rat livers against ischemia-reperfusion (I/R) injury after intermittent ischemia has not been elucidated. MATERIALS AND METHODS Five groups of Wistar rats were subjected to intermittent hepatic ischemia (I) comprising 15-min ischemia and 5-min reperfusion three times with or without prior IPC (10-min ischemia and 10-min reperfusion), 45-min continuous ischemia (C) with or without IPC, and sham operation. Serum transaminase and lactic acid levels, hepatic tissue energy charges, and hepatic blood perfusion were measured after reperfusion. Plasma tumor necrosis factor-alpha (TNF-alpha) levels were determined after reperfusion for 120 min. Histological and apoptotic findings were evaluated after reperfusion for 180 min. RESULTS IPC significantly reduced serum transaminase levels after continuous and intermittent ischemia (IPC + C, 1107 vs C, 2684 IU/l; IPC + I, 708 vs I, 1859 IU/l). After hepatic ischemia without IPC, apoptosis and necrosis with increased plasma TNF-alpha levels were observed. IPC protected livers from injury by interfering with the increase in plasma TNF-alpha (IPC + I, 27.6 vs I, 64.8 pg/ml; IPC + C, 21.6 vs C, 49.3 pg/ml). This resulted in the attenuation of hepatic necrosis after continuous ischemia and significantly reduced necrosis and apoptosis after intermittent ischemia. CONCLUSIONS IPC exerts a greater protective effect against hepatic I/R injury after intermittent hepatic ischemia than after continuous hepatic ischemia.
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Affiliation(s)
- Yoshimi Iwasaki
- Department of Gastroenterological Surgery, Dokkyo University School of Medicine, 321-0293 Tochigi, Japan.
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Abstract
The resection of primary and secondary liver tumors has become accepted as the only curative therapy that can be offered to patients with these cancers. Technical advances made over the last two decades have improved the ability of the surgeon to perform these procedures with decreased morbidity. This article reviews hepatic anatomy, the preoperative evaluation of patients and various technical aspects involved in liver resections. The latter includes the role of intraoperative ultrasound and techniques of vascular occlusion and hepatic parenchymal dissection.
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Affiliation(s)
- Ming-Hui Fan
- Division of Surgical Oncology, 3302 Cancer Center, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor 48109, USA
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Rüdiger HA, Kang KJ, Sindram D, Riehle HM, Clavien PA. Comparison of ischemic preconditioning and intermittent and continuous inflow occlusion in the murine liver. Ann Surg 2002; 235:400-7. [PMID: 11882762 PMCID: PMC1422446 DOI: 10.1097/00000658-200203000-00012] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare protection of the liver by ischemic preconditioning and intermittent inflow occlusion in a mouse model of prolonged periods of ischemia. SUMMARY BACKGROUND DATA Preconditioning (short ischemic stress prior to a prolonged period of ischemia) and intermittent inflow occlusion protect the liver against reperfusion injury. This is the first study comparing these two modalities with continuous inflow occlusion (control). METHODS Mice were subjected to 75 or 120 minutes of 70% hepatic ischemia and 3 hours of reperfusion. Each ischemic period was evaluated using three different protocols: continuous ischemia (control), preconditioning (10 minutes ischemia and 15 minutes reperfusion) prior to the prolonged ischemic insult, and intermittent clamping (cycles of 15 minutes ischemia and 5 minutes reperfusion). Organ injury was evaluated using serum levels of aspartate aminotransferase (AST), hematoxylin and eosin staining, and specific markers of apoptosis (cytochrome C release, caspase 3 activity, and TUNEL staining). Animal survival was determined using a model of total hepatic ischemia. RESULTS Intermittent inflow occlusion and ischemic preconditioning were both protective against ischemic insults of 75 and 120 minutes compared with controls (continuous ischemia only). Protection against 75 minutes of ischemia was comparable in the intermittent clamping and the ischemic preconditioning group, whereas intermittent clamping was superior at 120 minutes of ischemia. One hundred percent animal survival was observed after 75 minutes of total hepatic ischemia using both protective protocols, whereas all animals subjected to continuous ischemia died after surgery. After 120 minutes of ischemia, intermittent inflow occlusion was associated with better animal survival (71%) compared with preconditioning (14%). CONCLUSIONS Preconditioning and intermittent clamping are both protective against prolonged periods of ischemia. In the clinical setting, preconditioning is superior for ischemic periods of up to 75 minutes because it is not associated with blood loss during transection of the liver. However, for prolonged ischemic insults exceeding 75 minutes, intermittent clamping is superior to preconditioning.
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Affiliation(s)
- Hannes A Rüdiger
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Elias D, Ouellet JF, De Baère T, Lasser P, Roche A. Preoperative selective portal vein embolization before hepatectomy for liver metastases: long-term results and impact on survival. Surgery 2002; 131:294-9. [PMID: 11894034 DOI: 10.1067/msy.2002.120234] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Some patients cannot undergo curative surgical procedures for liver metastases because of the risk of severe postoperative hepatic failure, which stems from a too-small future remaining liver (FRL). Preoperative portal vein embolization (PVE) is an effective means of creating hypertrophy of the FRL, thus permitting safe hepatic resection. The aim of this retrospective study was to investigate the long-term results of this technique. METHODS Sixty-eight patients underwent PVE. Of those, 60 (88%) subsequently underwent hepatic resection. Indication for PVE was an estimated FRL ratio (assessed by volumetric computed tomography) of less than 30%. However, if the patient had undergone multiple courses of chemotherapy, the threshold was 40%. The origin of the primary neoplasm was colorectal in 41 patients (68%); in the remaining 19 (32%), the primary neoplasms originated at other sites. RESULTS Mean growth of the estimated FRL measured by computed tomography 1 month after PVE was 13%. Major complications after hepatectomy occurred in 27% of the patients, and the operative mortality rate was 3%. For the 60 patients who underwent PVE followed by hepatic resection, the 5-year overall survival rate and the disease-free survival rate were 34% and 24%, respectively. The 5-year overall survival rate and the disease-free survival rate of patients with colorectal metastases only were 37% and 21%, respectively. CONCLUSIONS The long-term survival rate after PVE followed by resection is comparable with the survival rate obtained after resection without preoperative PVE. The 5-year survival rate of patients undergoing PVE followed by hepatectomy justifies the use of this technique. This technique thus increases the suitability of resection as a treatment choice for patients with liver metastases. PVE should number among the therapeutic options available to every hepatic surgeon.
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Affiliation(s)
- Dominique Elias
- Department of Surgical Oncology and the Interventional Radiology Unit, Institut Gustave Roussy, Villejuif, Cedex, France
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Smyrniotis VE, Kostopanagiotou GG, Gamaletsos EL, Vassiliou JG, Voros DC, Fotopoulos AC, Contis JC. Total versus selective hepatic vascular exclusion in major liver resections. Am J Surg 2002; 183:173-8. [PMID: 11918884 DOI: 10.1016/s0002-9610(01)00864-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Total hepatic vascular exclusion (THVE) and selective hepatic vascular exclusion (SHVE) are two effective techniques for bleeding control in major hepatic resections. Outcomes of the two procedures were compared. METHODS Patients undergoing major liver resection were randomly allocated to the THVE and SHVE groups. Intraoperative hemodynamic changes and the postoperative course of the two groups were compared. RESULTS During vascular clamping, the THVE group showed a significant elevation in pulmonary vascular resistance, systemic vascular resistance, intrapulmonary shunts, and a significant reduction in cardiac index, compared with the SHVE group (P <0.05). Patients undergoing THVE received more crystalloids and blood, showed more severe liver, renal and pancreatic dysfunction, and had a longer hospital stay than the SHVE group (P <0.05). CONCLUSIONS Both techniques are equally effective in bleeding control in major liver resections. THVE is associated with cardiorespiratory and hemodynamic alterations and may be not tolerated by some patients. SHVE is well tolerated with fewer postoperative complications and shorter hospitalization time.
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Affiliation(s)
- Vassilios E Smyrniotis
- Department of Surgery, University of Athens Medical School, Aretaeion Hospital, 22 Hanioti St., 154 52 Athens, Greece.
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Mischinger HJ, Cerwenka H, Bacher H, Werkgartner G, El-Shabrawi A, Hoss G. Komplikationen in der Leberchirurgie und ihre Vermeidung. Eur Surg 2001. [DOI: 10.1046/j.1563-2563.2001.01152.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Nuzzo G, Giuliante F, Giovannini I, Vellone M, De Cosmo G, Capelli G. Liver resections with or without pedicle clamping. Am J Surg 2001; 181:238-46. [PMID: 11376579 DOI: 10.1016/s0002-9610(01)00555-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Decreasing operative bleeding during liver resection, and thus extent of transfusions, has become a main criterion to evaluate operative results of hepatectomies. Hepatic pedicle clamping (HPC) is widely used for this purpose. The aim of the study was to evaluate safety, efficacy, technique, and contraindications of HPC during liver resections, comparing results of resections performed with or without HPC. METHODS Data from 245 liver resections were analyzed. In all, 125 resections were performed with HPC (group A), continuous in 100 cases and intermittent in 25 cases. The average duration of ischemia in group A was 39 +/- 20 minutes (range 7 to 107). In 20 cases (16%) ischemia was prolonged for 60 minutes or more. A total of 120 resections were performed without HPC (group B). Major resections were 53.6% in group A (67 cases) and 38.3% in group B (46 cases). Cirrhosis was present in 36 cases, 19 in group A and 17 in group B. RESULTS Operative mortality was nil. Postoperative mortality was 2.9%, morbidity 22.4%. Percentage of transfused cases (34.4% versus 60.0%; P <0.001) and number of blood units per transfused case (2 +/- 1 versus 4 +/- 3; P <0.001) were lower in group A versus group B. Similar figures were found by considering only major resections. Postoperative blood chemistries did not show important differences between the two groups, and postoperative alterations were related more to extent and complexity of the operation than to length of HPC. CONCLUSIONS HPC during liver resection is a safe and effective technique. This is demonstrated in a context where HPC is used continuously in most cases, intermittently in cases with impaired liver function and for more prolonged ischemia, and avoided in cases with limited bleeding, jaundice, and simultaneous bowel anastomoses.
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Affiliation(s)
- G Nuzzo
- Department of Surgery, Hepato-Biliary Surgery Unit, Catholic University of Sacred Heart, School of Medicine, L.go A Gemelli, 8, 00168, Rome, Italy.
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Elias D, Goharin A, El Otmany A, Taieb J, Duvillard P, Lasser P, de Baere T. Usefulness of intraoperative radiofrequency thermoablation of liver tumours associated or not with hepatectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:763-9. [PMID: 11087642 DOI: 10.1053/ejso.2000.1000] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION A probe emitting radiofrequency (RF) waves is able to destroy tumour tissue by thermal ablation. The purpose of this study was to undertake a prospective estimation of the benefit of RF thermoablation of liver tumours during hepatic and extrahepatic resections aimed at obtaining an R0 status in patients in whom disease is notoriously considered unresectable. METHOD Twenty-one patients underwent surgery between January 1997 and September 1999. In 17 cases, RF was associated with a hepatectomy and in nine of these cases with resection of extrahepatic lesions. In two cases, extensive resection of extrahepatic lesions was associated with RF to treat liver metastases, and in two cases RF was ultimately performed alone. The mean number of liver metastases was 6.2+/-4.3 (range 1-15) per patient. A total of 32 lesions were treated with RF. The mean size of the 33 RF-thermoablated tumours was 13.6+/-9.7 mm (range 5-52 mm), and in all but one case, a Pringle manoeuvre was performed during the RF procedure. RESULTS A probable R0-resection was obtained in 18 cases. No operative deaths or any RF-related complications occurred. If we exclude the case in which it was clearly impossible to destroy liver metastases intraoperatively, only one local recurrence occurred (3%) among the 32 thermoablated lesions after a mean follow-up of 17.3 months. The 2-year overall and disease-free survival rates for this initially unresectable population were 94.7% and 22%, respectively. CONCLUSION Intraoperative use of RF to destroy unresectable liver tumours increases the rate of curative resections. Future progress in RF technology and adequate vascular clamping during RF should increase this rate.
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Affiliation(s)
- D Elias
- Departments of Surgical Oncology, Interventional Radiology, and Pathology, Institut Gustave Roussy, Comprehensive Cancer Center, Villejuif Cedex, 94805, France.
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Cherqui D, Husson E, Hammoud R, Malassagne B, Stéphan F, Bensaid S, Rotman N, Fagniez PL. Laparoscopic liver resections: a feasibility study in 30 patients. Ann Surg 2000; 232:753-62. [PMID: 11088070 PMCID: PMC1421268 DOI: 10.1097/00000658-200012000-00004] [Citation(s) in RCA: 458] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the feasibility and safety of laparoscopic liver resections. SUMMARY BACKGROUND DATA The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. METHODS A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. RESULTS From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. CONCLUSION Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.
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Affiliation(s)
- D Cherqui
- Departments of General and Digestive Surgery and Anesthesiology, H opital Henri Mondor-Université Paris XII, Créteil, France.
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