1
|
Azoulay D, Salloum C, Allard MA, Serrablo A, Moussa M, Romano P, Pietraz D, Golse N, Lim C. Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept. Ann Surg Oncol 2024:10.1245/s10434-024-15227-7. [PMID: 38592622 DOI: 10.1245/s10434-024-15227-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion. PATIENTS AND METHODS The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range). RESULTS Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero. CONCLUSIONS This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.
Collapse
Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France.
| | - Chady Salloum
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Marc-Antoine Allard
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Maya Moussa
- Centre Hépato-Biliaire, Department of Anesthesiology, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Pierluigi Romano
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Daniel Pietraz
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Chetana Lim
- Department of Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| |
Collapse
|
2
|
Mobarak S, Stott MC, Tarazi M, Varley RJ, Davé MS, Baltatzis M, Satyadas T. Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Hepatectomy: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:860721. [PMID: 35465416 PMCID: PMC9026334 DOI: 10.3389/fsurg.2022.860721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesMortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion (SHVE) compared to a Pringle maneuver in hepatic resection reduces rates of morbidity and mortality.MethodsA systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and SCOPUS for comparative studies meeting the inclusion criteria. Pooled odds ratios or mean differences were calculated for outcomes using either fixed- or random-effects models.ResultsSix studies were identified: three randomised controlled trials and three observational studies reporting a total of 2,238 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, blood loss, transfusion requirements, air embolism, liver failure and multi-organ failure in the SHVE group. Rates of hepatic vein rupture, post-operative hemorrhage, operative and warm ischemia time, length of stay in hospital and intensive care unit were not statistically significant between the two groups.ConclusionPerforming SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle maneuver. The results of this meta-analysis are based on studies where tumors were adjacent to major vessels. Further RCTs are required to validate these results.Clinical Trial RegistrationPROSPERO (CRD42020212372) https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=212372.
Collapse
Affiliation(s)
- Shahd Mobarak
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Martyn C. Stott
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Munir Tarazi
- Department of Surgery and Cancer, Imperial College London, London, UK
- Correspondence: Munir Tarazi
| | - Rebecca J. Varley
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Madhav S. Davé
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Minas Baltatzis
- Department of Upper GI Surgery, Salford Royal Hospital, Salford, UK
| | - Thomas Satyadas
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| |
Collapse
|
3
|
Yang Y, Zhao LH, Fu SY, Lau WY, Lai ECH, Gu FM, Wang ZG, Zhou WP. Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Partial Hepatectomy for Liver Hemangioma Compressing or Involving the Major Hepatic Veins. Am Surg 2020. [DOI: 10.1177/000313481408000317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Massive blood loss remains a problem during resection for giant liver hemangioma. This present study was designed to compare selective hepatic vascular exclusion (SHVE) versus Pringle maneuver in surgery for liver hemangioma compressing the major (right, middle, or left) hepatic veins. From January 2003 to December 2011, 589 consecutive patients with hemangioma underwent liver resection in our department, and 273 patients had their tumors compressing at least one of the three major hepatic veins (right, middle, or left). Either SHVE (n = 120 patients) or Pringle maneuver (n = 153 patients) was used to minimize blood loss during resection. Data regarding the intraoperative and postoperative courses of these patients were retrospectively analyzed. There was no significant difference between the two groups of patients regarding age, sex, tumor size, types of hepatectomy, and extent of tumor involvement of the major hepatic veins. Intraoperative blood loss, transfusion requirements, and transfusion volume were significantly less in the SHVE group ( P < 0.01). For the Pringle group, major hepatic veins were lacerated in 19 patients during hepatic parenchymal transection. For the SHVE group, a major hepatic vein was lacerated during extrahepatic dissection of the hepatic vein in two patients and during hepatic parenchymal transection in 14 patients. SHVE was more efficacious in minimizing intraoperative bleeding during liver resection for hemangiomas compressing the major hepatic veins. It prevented intraoperative major bleeding and air embolism and significantly decreased postoperative liver failure and in-hospital mortality.
Collapse
Affiliation(s)
- Yuan Yang
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, National Innovation Alliance for Hepatitis & Liver Cancer, Second Military Medical University, Shanghai, China; the
- Department of Health Statistics, Second Military Medical University, Shanghai, China; the
| | - Ling-Hao Zhao
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, National Innovation Alliance for Hepatitis & Liver Cancer, Second Military Medical University, Shanghai, China; the
| | - Si-Yuan Fu
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, National Innovation Alliance for Hepatitis & Liver Cancer, Second Military Medical University, Shanghai, China; the
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Eric C. H. Lai
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Fang-Ming Gu
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, National Innovation Alliance for Hepatitis & Liver Cancer, Second Military Medical University, Shanghai, China; the
| | - Zhen-Guang Wang
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, National Innovation Alliance for Hepatitis & Liver Cancer, Second Military Medical University, Shanghai, China; the
| | - Wei-Ping Zhou
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, National Innovation Alliance for Hepatitis & Liver Cancer, Second Military Medical University, Shanghai, China; the
- National Innovation Alliance for Hepatitis & Liver Cancer, Shanghai, China
| |
Collapse
|
4
|
Dou L, Yu ZP, Yang HY, Ran J, Chen YF, Chen XP. Personalized stepwise vascular control during complex hepatectomy involving hepatocaval confluence. ANZ J Surg 2017; 88:E606-E609. [PMID: 29224239 DOI: 10.1111/ans.14301] [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] [Received: 08/08/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study introduces an innovative stepwise vascular control technique to address the high risk of massive bleeding from main hepatic veins and the retro-hepatic inferior vena cava during hepatectomy involving hepatocaval confluence. METHODS From January 2010 to July 2016, 80 patients underwent stepwise vascular occlusion during complex liver resection involving hepatocaval confluence. Relevant clinical data were collected and compared with those obtained in parallel studies. The protocol has been registered in the Protocol Registration and Results System as protocol NCT02996006. RESULTS All 80 patients underwent portal triad (PT), infra-hepatic inferior vena cava (IIVC) and supra-hepatic inferior vena cava (SIVC) preparation for occlusion in that order; PT, PT + SIVC and PT + IIVC + SIVC occlusions were performed during liver resection for six, 42 and 32 patients, respectively. The PT, IIVC and SIVC clamping times were 12.9 ± 2.5, 9.1 ± 2.1 and 5.1 ± 1.4 min, respectively. The mean blood loss was 504.1 ± 234.5 mL. Sixteen patients received blood transfusions. Haemodynamic parameters remained stable. No patients had life-threatening complications or died (Clavien-Dindo grade IV or V). Compared with other techniques used in parallel studies, this technique has the advantage of decreased blood loss in less warm ischaemia time. CONCLUSION For complex hepatectomy involving hepatocaval confluence, this newly described stepwise vascular control technique was efficacious and feasible for controlling intraoperative bleeding.
Collapse
Affiliation(s)
- Lei Dou
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China.,Department of Gerontology, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Zong-Ping Yu
- Department of Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hui-Yuan Yang
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Ji Ran
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Yi-Fa Chen
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Ping Chen
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China.,Department of Gerontology, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
5
|
Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy. J Surg Res 2016; 206:106-112. [PMID: 27916348 DOI: 10.1016/j.jss.2016.07.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/26/2016] [Accepted: 07/07/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy. MATERIALS AND METHODS Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality. RESULTS Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm (n = 229, 44%), primary hepatic neoplasm (n = 108, 21%), primary extra-hepatic biliary neoplasm (n = 23, 4%), and nonmalignant indications (n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870). CONCLUSIONS Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.
Collapse
|
6
|
Zhu P, Zhang B, Wang R, Mei B, Cheng Q, Chen L, Wei G, Xu DF, Yu J, Xiao H, Zhang BX, Chen XP. Selective Inflow Occlusion Technique Versus Intermittent Pringle Maneuver in Hepatectomy for Large Hepatocellular Carcinoma: A Retrospective Study. Medicine (Baltimore) 2015; 94:e2250. [PMID: 26683942 PMCID: PMC5058914 DOI: 10.1097/md.0000000000002250] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Selective inflow occlusion (SIO) maneuver preserved inflow of nontumorous liver and was supposed to protect liver function. This study aims to evaluate whether SIO maneuver is superior to Pringle maneuver in patients undergoing partial hepatectomy with large hepatocellular carcinomas (HCCs). Between January 2008 and May 2012, 656 patients underwent large HCC resections and were divided into 2 groups: intermittent Pringle maneuver (IP) group (n = 336) and SIO group (n = 320). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed. In comparison to the IP maneuver, the SIO maneuver significantly decreased intraoperative blood loss (473 vs 691 mL, P = 0.001) and transfusion rates (11.3% vs 28.6%, P = 0.006). The rate of major complication between the 2 groups was comparable (22.6% vs 18.8%, P = 0.541). Patients with moderate/severe cirrhosis, total bilirubin > 17 μmol/L, or HBV DNA> = 104 copy/mL in SIO group resulted in lower major complication rates. The SIO maneuver is a safe and effective technique for large HCC resections. In patients with moderate/severe cirrhosis, total bilirubin > 17 μmol/L, or HBV DNA> = 104 copy/mL, the SIO technique is preferentially recommended.
Collapse
Affiliation(s)
- Peng Zhu
- From the Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Abstract
Hepatocellular carcinomas are well-vascularized tumors; the endothelial cells in these tumors have a specific phenotype. Our aim was to develop a new approach for tumor-specific drug delivery with monoclonal antibody targeting of endothelial ligands. CD146, a molecule expressed on the endothelial surface of hepatocellular carcinoma, was identified as a promising candidate for targeting. In the present study, endothelial cells immediately captured circulating anti-CD146 (ME-9F1) antibody, while antibody binding in tumors was significantly higher than in hepatic endothelium. Macroscopically, after intravenous injection, there were no differences in the mean accumulation of anti-CD146 antibody in tumor compared to liver tissue, due to a compensating higher blood vessel density in the liver tissue. Additional blockade of nontumoral epitopes and intra-arterial administration, improved selective antibody capture in the tumor microvasculature and largely prevented antibody distribution in the lung and liver. The potential practical use of this approach was demonstrated by imaging of radionuclide-labeled ME-9F1 antibody, which showed excellent tumor-selective uptake. Our results provide a promising principle for the use of endothelial markers for intratumoral drug delivery. Tumor endothelium–based access might offer new opportunities for the imaging and therapy of hepatocellular carcinoma and other liver malignancies.
Collapse
|
8
|
Si-Yuan F, Yee LW, Yuan Y, Sheng-Xian Y, Zheng-Guang W, Gang H, Meng-Chao W, Wei-Ping Z. Pringle manoeuvre versus selective hepatic vascular exclusion in partial hepatectomy for tumours adjacent to the hepatocaval junction: a randomized comparative study. Int J Surg 2014; 12:768-73. [PMID: 24907420 DOI: 10.1016/j.ijsu.2014.05.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 04/20/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare the efficacy of selective hepatic vascular exclusion versus Pringle manoeuvre in partial hepatectomy for tumours adjacent to the hepatocaval junction. METHODS A randomized comparative trial was carried out. The primary endpoint was intraoperative blood loss. The secondary endpoints were operation time, blood transfusion, postoperative liver function recovery, procedure-related morbidity and in-hospital mortality. RESULTS 160 patients were randomized into 2 groups: the Pringle manoeuvre group (n = 80) and the selective hepatic vascular exclusion (SHVE) group (n = 80). Intraoperative blood loss and transfusion requirements were significantly less in the SHVE group. In the SHVE group, laceration of hepatic veins happened in 18 patients. Profuse intraoperative blood loss of over 2 L happened in 2 patients but no patient suffered from air embolism because the hepatic veins were controlled. In the Pringle group, the hepatic veins were lacerated in 20 patients, with profuse blood loss of over 2 L in 7 patients and air embolism in 3 patients. The rates of postoperative bleeding, reoperation, liver failure and mortality were significantly higher and the ICU stay and hospital stay were significantly longer in the Pringle group. CONCLUSIONS SHVE was more efficacious than Pringle manoeuvre for partial hepatectomy in patients with tumours adjacent to the hepatocaval junction.
Collapse
Affiliation(s)
- Fu Si-Yuan
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Lau Wan Yee
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China; Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Yang Yuan
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Sheng-Xian
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Wang Zheng-Guang
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Huang Gang
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Wu Meng-Chao
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Zhou Wei-Ping
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
| |
Collapse
|
9
|
Lochan R, Ansari I, Coates R, Robinson SM, White SA. Methods of haemostasis during liver resection--a UK national survey. Dig Surg 2013; 30:375-82. [PMID: 24107508 DOI: 10.1159/000354036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/25/2013] [Indexed: 12/10/2022]
Abstract
BACKGROUND Although haemorrhage is a major cause of morbidity and mortality in liver surgery, there is very little available guidance on its management. METHODS The aim of this study was to identify current practice in the UK in this regard. An online survey was created and hepatobiliary (HPB) specialists who were members of a specialist society and others who were known practitioners were invited by e-mail to complete the survey anonymously. RESULTS Fifty-one percent responded (n = 36/70), and most of these respondents worked at large HPB centres (>100 liver resections/year; n = 24, 66%). Not all questionnaires were fully completed by the individual surgeons. Thirty-eight percent of the surgeons routinely used Pringle's manoeuvre. Most surgeons used ligation of the inflow vessels (n = 16, 44%) and stapled the outflow vessels (n = 15, 42%). The Cavitron ultrasonic surgical aspirator (CUSA; 54%, 13/24) was preferred for parenchymal transection. The majority routinely used haemostatic adjuncts (n = 22, 62%), whilst 33% (n = 12) used them occasionally. Twenty-three (64%) felt manufactured haemostatic adjuncts played a major role in maintaining haemostasis and 19 preferred fibrin-based products. CONCLUSION The Pringle manoeuvre is a popular technique amongst specialist UK liver surgeons and the CUSA is used by nearly half of the surgeons. Despite the absence of definitive evidence for their benefit, manufactured haemostatic adjuncts are still widely used, especially the fibrin-based adjuncts.
Collapse
Affiliation(s)
- R Lochan
- Department of Hepato-Pancreato-Biliary and Transplantation Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | | | | |
Collapse
|