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Patel A, Tan J, Lambert J, Kitching S, Iqbal A, Satyadas T. Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver during hepatectomy: a meta-analysis. Langenbecks Arch Surg 2024; 409:160. [PMID: 38758232 PMCID: PMC11101571 DOI: 10.1007/s00423-024-03344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Intraoperative bleeding during hepatectomy is primarily controlled through anaesthesiological interventions or surgical techniques such as Pringle maneuver (PM). Infrahepatic IVC clamping (IIVCC) is an alternative surgical technique to reduce central venous pressure and prevent retrograde hepatic venous bleeding. The aim of the meta-analysis was to compare IIVCC+PM with PM alone in terms of intraoperative outcomes and perioperative complications. METHODS Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched for comparative studies till 16.04.2024, resulting in 679 articles, of which eight studies met inclusion criteria. Data on patient demographics, surgical technique, and perioperative outcomes was assessed. Cochrane Risk of Bias 2.0 (RoB 2.0) Tool and Newcastle-Ottawa Scale (NOS) were used for risk of bias assessment. RESULTS Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PM alone group were included. IIVCC+PM resulted in significantly greater CVP reduction, less intraoperative blood loss (MD (95% CI) = - 233.03 (- 360.48 to - 105.58), P < 0.001), and less intraoperative blood transfusion (OR (95% CI) = 0.38 (0.25 to 0.57), P < 0.001) compared to PM alone. The two groups had comparable total operative time, transection time and total intraoperative fluid infusion. Patients undergoing IIVCC+PM had significantly shorter length of stay (MD (95% CI) = - 0.63 days (- 1.21 to - 0.05 days), P = 0.03) and overall complication rates (OR (95% CI) = 0.63 (0.43-0.92), P = 0.02) compared to PM alone group. CONCLUSION The utilization of IIVCC along with PM during liver resection may be beneficial in reducing intraoperative bleeding and blood transfusion without adversely influencing operative times or perioperative outcomes compared to PM alone.
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Affiliation(s)
- Agastya Patel
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK.
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland.
| | - Jacob Tan
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Joel Lambert
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Samuel Kitching
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Affan Iqbal
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Thomas Satyadas
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
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Ng KKC, Cheng KC, Kung JWC, Ho KM, Lok HT, Fung AKY, Chong CCN, Cheung SYS, Lee KF, Wong J, Lai PBS. Comparison of clinical outcome between laparoscopic and open hepatectomy of high difficulty score for hepatocellular carcinoma: a propensity score analysis. Surg Endosc 2024; 38:857-871. [PMID: 38082015 DOI: 10.1007/s00464-023-10634-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/29/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) of high difficulty score is technically challenging. There is a lack of clinical evidence to support its applicability in terms of the long-term survival benefits. This study aims to compare clinical outcomes between LLR and the open liver resection of high difficulty score for hepatocellular carcinoma (HCC). MATERIALS AND METHODS From 2010 to 2020, using Iwate criteria, 424 patients underwent liver resection of high difficulty score by the laparoscopic (n = 65) or open (n = 359) approach. Propensity score (PS) matching was performed between the two groups. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival. RESULTS The laparoscopic group had significantly fewer severe complications (3% vs. 10.8%), and shorter median hospital stays (6 days vs. 8 days) than the open group. Meanwhile, the long-term oncological outcomes were comparable between the two groups, in terms of the tumor recurrence rate (40% vs. 46.1%), the 5-year overall survival rate (75.4% vs. 76.2%), and the 5-year recurrence-free survival rate (50.3% vs. 53.5%). The high preoperative serum alpha-fetoprotein level, multiple tumors, and severe postoperative complications were the independent poor prognostic factors associated with worse overall survival. The surgical approach (Laparoscopic vs. Open) did not influence the survival. CONCLUSION LLR of high difficulty score for selected patients with HCC has better short-term outcomes than the open approach. More importantly, it can achieve similar long-term survival outcomes as the open approach.
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Affiliation(s)
- Kelvin K C Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong.
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong.
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30 - 32 Ngan Shing Street, New Territories, Hong Kong.
| | - Kai-Chi Cheng
- Department of Surgery, Kwong Wah Hospital, Hong Kong, Hong Kong
| | - Janet W C Kung
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Kit-Man Ho
- Department of Surgery, Kwong Wah Hospital, Hong Kong, Hong Kong
| | - Hon-Ting Lok
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Charing C N Chong
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Sunny Y S Cheung
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Kit-Fai Lee
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Paul B S Lai
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
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Huang Y, Xu L, Wang N, Pu X, Wang W, Wen T, Xu M, Jiang L. Preoperative dexamethasone administration in hepatectomy of 25-min intermittent Pringle's maneuver for hepatocellular carcinoma: protocol for a randomized controlled trial. Trials 2023; 24:774. [PMID: 38037035 PMCID: PMC10691107 DOI: 10.1186/s13063-023-07820-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 11/22/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Our previous randomized controlled trial (RCT) have demonstrated that intermittent Pringle's maneuver (IPM) with a 25-min ischemic interval can be applied safely and efficiently in open or laparoscopic hepatectomy in patients with hepatocellular carcinoma (HCC) patients. But prolonging the hepatic inflow blocking time will inevitably aggravate the ischemia-reperfusion injury (IRI) caused by systemic response. This RCT aims to evaluate the effect of administration of dexamethasone versus placebo before clamping the hilar pedicle on postoperative liver function, inflammatory response, and perioperative outcomes among HCC patients undergoing liver resection with 25-min hepatic inflow occlusion. METHODS AND ANALYSIS This will be a randomized, dual-arm, parallel-group, double-blinded trial. All eligible and consecutive patients are coming from a regional medical center who are diagnosed with HCC and underwent radical R0/R1 resection. All participates are randomly allocated in dexamethasone group or placebo group. All surgeons, anesthesiologists, and outcome assessors will be blinded to allocation status. Primary endpoints are transaminase-based postoperative hepatic injury on seven consecutive days after surgery and assessed by their peak values as well as area under the curve (AUC) of the postoperative course of aminotransferases. Secondary endpoints are postoperative total bilirubin (TBil), coagulation function, inflammatory cytokines and their respective peaks, intraoperative blood loss, postoperative hospital stay, morbidity, and mortality. The above parameters will be compared using the corresponding statistical approach. Subgroup analysis will be performed according to the liver cirrhosis and major hepatectomy. DISCUSSION Based on our previous study, we will explore further the effect of glucocorticoid administration on attenuating the surgical stress response in order to follow securely 25-min hepatic inflow occlusion. Therefore, the trial protocol is reasonable and the results of the trial may be clinically significant. TRIAL REGISTRATION This trial was registered on 3 December 2022, in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), ChiCTR2200066381. The protocol version is V1.0 (20221104).
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Affiliation(s)
- Yang Huang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Liangliang Xu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Ning Wang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Xingyu Pu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Wentao Wang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Tianfu Wen
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Mingqing Xu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China.
| | - Li Jiang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China.
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Morino K, Seo S, Yoh T, Toda R, Yoshino K, Nishio T, Yamamoto G, Ishii T, Taura K, Hatano E. Impact of the Intermittent Pringle Maneuver for Predicting Post-hepatectomy Liver Failure: A Cohort Study of 597 Consecutive Patients. World J Surg 2023; 47:1058-1067. [PMID: 36633645 DOI: 10.1007/s00268-023-06904-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Intermittent Pringle maneuver (PM) is widely performed to reduce blood loss during hepatectomy; however, its impact on clinically relevant post-hepatectomy liver failure (PHLF) remains controversial. This study aimed to assess the impact of PM on PHLF and explore whether PM provides additional value for predicting PHLF. METHODS Consecutive patients, who underwent hepatectomy without biliary and/or vascular reconstruction between 2011 and 2018 in a single institution, were retrospectively analyzed. The main outcome was PHLF grades B/C as defined by the International Study Group of Liver Surgery. A multivariable logistic regression model of variables significantly associated with PHLF was established. The model's predictive ability was assessed by the area under the receiver operating characteristic curve (AUROC). RESULTS Among 597 patients, PHLF occurred in 42 (7.0%). PM was applied in 421 patients (70.5%) and was associated with the development of PHLF (PM vs. no-PM: 9.7 vs. 0.6%, P < 0.001). After the propensity score matching, patients with PM experienced significantly increased rates of PHLF (P = 0.010). Rem-ALPlat index (including future liver remnant, preoperative albumin level, and platelet count; P < 0.001), the number of PMs (P = 0.032), and blood loss (P = 0.007) were identified as significant predictors of PHLF. The model's AUROC combined with the intraoperative variables was higher than that of the preoperative model alone (0.877 vs. 0.789, P = 0.004). CONCLUSIONS PM was involved in the occurrence of clinically relevant PHLF. Further, intraoperative factors including PM may provide additional value to predict PHLF and may facilitate early post-hepatectomy intervention.
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Affiliation(s)
- Koshiro Morino
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Surgery, Tenri Hospital, Tenri, Japan
| | - Satoru Seo
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan.
| | - Tomoaki Yoh
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Rei Toda
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Kenji Yoshino
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Surgery, Nishikobe Medical Center, Kobe, Japan
| | - Takahiro Nishio
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Gen Yamamoto
- Department of Surgery, Shiga General Hospital, Moriyama, Japan
| | - Takamichi Ishii
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Surgery, Kitano Hospital, Osaka, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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5
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Li J, Chen S, Zhang T, Ma K. Intermittent Pringle maneuver combined with controlled low Central venous pressure prolongs hepatic hilum occlusion time in patients with hepatocellular carcinoma complicated by post hepatitis B cirrhosis: a randomized controlled trial. Scand J Gastroenterol 2022; 58:497-504. [PMID: 36384398 DOI: 10.1080/00365521.2022.2147802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The optimal occlusion and reperfusion time to balance blood loss and ischemia-reperfusion injury to the remnant liver remains unclear. The aim was to explore the clinical impact of prolonging the hepatic hilum occlusion time from 15 to 20 min using the intermittent Pringle maneuver (IPM) combined with controlled low central venous pressure (CLCVP).Methods: A total of 151 patients were included and divided into an experimental group (Group 20,75 cases) and a control group (Group 15,76 cases). In both groups, the hepatic hilum was blocked by the IPM combined with CLCVP to control intraoperative hepatic cross-sectional bleeding. The preoperative, intraoperative and postoperative parameters and safety were compared between the two groups.Results: There were no significant differences between the two groups in the postoperative aminotransferase serum levels (p > 0.05). However, the operation time in Group 20 was significantly lower than that in Group 15 (222.4 ± 87.8 vs. 250.7 ± 94.5 min, p < 0.05). The procalcitonin at 1 day after operation in Group 20 was lower than that at 1 day after operation in Group 15 (0.78 ± 0.66 vs. 1.45 ± 1.33 ng/mL, p < 0.05). There was no significant difference in the incidence of postoperative bleeding, postoperative bile leakage and postoperative infection between the two groups (p > 0.05).Conclusions: For patients with hepatocellular carcinoma after hepatitis B cirrhosis, it is feasible and safe to prolong the hepatic hilum occlusion time from 15 to 20 min using the IPM combined with CLCVP.
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Affiliation(s)
- Jinghe Li
- Department of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Shengkai Chen
- Department of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Tao Zhang
- Department of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Kuansheng Ma
- Institute of hepatobiliary surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
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6
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Sparrelid E, Olthof PB, Dasari BVM, Erdmann JI, Santol J, Starlinger P, Gilg S. Current evidence on posthepatectomy liver failure: comprehensive review. BJS Open 2022; 6:6840812. [PMID: 36415029 PMCID: PMC9681670 DOI: 10.1093/bjsopen/zrac142] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF. METHODS A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022. RESULTS Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited. DISCUSSION Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.
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Affiliation(s)
- Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pim B Olthof
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bobby V M Dasari
- Department of HPB Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jonas Santol
- Department of Surgery, HPB Center, Viennese Health Network, Clinic Favoriten and Sigmund Freud Private University, Vienna, Austria.,Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Patrick Starlinger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria.,Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, New York, USA
| | - Stefan Gilg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Nakatake R, Schulz M, Kalvelage C, Benstoem C, Tolba RH. Effects of iNOS in Hepatic Warm Ischaemia and Reperfusion Models in Mice and Rats: A Systematic Review and Meta-Analysis. Int J Mol Sci 2022; 23:ijms231911916. [PMID: 36233220 PMCID: PMC9569681 DOI: 10.3390/ijms231911916] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 12/09/2022] Open
Abstract
Warm ischaemia is usually induced by the Pringle manoeuver (PM) during hepatectomy. Currently, there is no widely accepted standard protocol to minimise ischaemia-related injury, so reducing ischaemia-reperfusion damage is an active area of research. This systematic review and meta-analysis focused on inducible nitric oxide synthase (iNOS) as an early inflammatory response to hepatic ischaemia reperfusion injury (HIRI) in mouse- and rat-liver models. A systematic search of studies was performed within three databases. Studies meeting the inclusion criteria were subjected to qualitative and quantitative synthesis of results. We performed a meta-analysis of studies grouped by different HIRI models and ischaemia times. Additionally, we investigated a possible correlation of endothelial nitric oxide synthase (eNOS) and nitric oxide (NO) regulation with iNOS expression. Of 124 included studies, 49 were eligible for the meta-analysis, revealing that iNOS was upregulated in almost all HIRIs. We were able to show an increase of iNOS regardless of ischemia or reperfusion time. Additionally, we found no direct associations of eNOS or NO with iNOS. A sex gap of primarily male experimental animals used was observed, leading to a higher risk of outcomes not being translatable to humans of all sexes.
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Affiliation(s)
- Richi Nakatake
- Institute for Laboratory Animal Science and Experimental Surgery, RWTH Aachen University, 52074 Aachen, Germany
- Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan
| | - Mareike Schulz
- Institute for Laboratory Animal Science and Experimental Surgery, RWTH Aachen University, 52074 Aachen, Germany
| | - Christina Kalvelage
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Carina Benstoem
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - René H. Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, RWTH Aachen University, 52074 Aachen, Germany
- Correspondence:
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Ortiz Galindo SA, Haber PK, Benzing C, Krenzien F, Riddermann A, Frisch O, Schöning W, Schmelzle M, Pratschke J, Feldbrügge L. Safety of intermittent Pringle maneuver during minimally invasive liver resection in patients with hepatocellular carcinoma with and without cirrhosis. Langenbecks Arch Surg 2021; 407:235-244. [PMID: 34787706 PMCID: PMC8847278 DOI: 10.1007/s00423-021-02361-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/14/2021] [Indexed: 01/22/2023]
Abstract
Purpose The aim of this study was to analyze the impact of minimally invasive intermittent Pringle maneuver (IPM) on postoperative outcomes in patients with hepatocellular carcinoma (HCC) and liver cirrhosis. Methods In this retrospective cohort study, we evaluated the safety of IPM in patients with HCC who underwent minimally invasive liver resection during five years at our center. Factors influencing the use of IPM were examined in univariate and multivariate regression analysis. Cases with use of IPM (IPM) and those without use of IPM (no IPM) were then compared regarding intraoperative and postoperative outcomes after propensity score matching (PSM) for surgical difficulty. Results One hundred fifty-one patients underwent liver resection for HCC at our center and met inclusion criteria. Of these, 73 patients (48%) received IPM with a median duration of 18 min (5–78). One hundred patients (66%) had confirmed liver cirrhosis. In multivariate analysis, patients with large tumors (≥ 3 cm) and difficult tumor locations (segments VII or VIII) were more likely to undergo IPM (OR 1.176, p = 0.043, and OR 3.243, p = 0.001, respectively). After PSM, there were no differences in intraoperative blood transfusion or postoperative complication rates between the IPM and no IPM groups. Neither did we observe any differences in the subgroup analysis for cirrhotic patients. Postoperative serum liver function tests were not affected by the use of IPM. Conclusions Based on our findings, we conclude that the use of IPM in minimally invasive liver resection is safe and feasible for patients with HCC, including those with compensated liver cirrhosis. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02361-z.
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Affiliation(s)
- Santiago A Ortiz Galindo
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Philipp K Haber
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Benzing
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Anna Riddermann
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Oliver Frisch
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Linda Feldbrügge
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany. .,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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9
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Piao C, Zhang Q, Xu J, Wang Y, Liu T, Ma H, Liu G, Wang H. Optimal intervention time of ADSCs for hepatic ischemia-reperfusion combined with partial resection injury in rats. Life Sci 2021; 285:119986. [PMID: 34592233 DOI: 10.1016/j.lfs.2021.119986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022]
Abstract
AIMS Hepatic ischemia reperfusion injury (HIRI) is a complication of liver surgery and liver transplantation. Adipose-derived stem cells (ADSCs) can inhibit oxidative stress and inflammation through a paracrine effect. This study aimed to determine the optimal time window of ADSCs transplantation to restore liver function after HIRI. MAIN METHODS A rat model of hepatic ischemia reperfusion combined with partial hepatectomy (HIR/PH) was established. The animals were injected intravenously with 2 × 106 rat ADSCs 2 h before, immediately after, or 6 h after surgery. Liver tissues and blood samples were collected for routine histological and biochemical assays. The molecular changes were analyzed by qRT-PCR and western blotting. KEY FINDINGS ADSCs significantly improved liver tissue structure and decreased the levels of AST, ALT and ALP, which was indicative of functional recovery. In addition, transplantation of ADSCs immediately after operation decreased the levels of inflammation-related cytokines such as TNF-α, IL-1β and IL-6, and significantly increased the activity of antioxidant enzymes. At the same time, the expression of MDA was decreased. Mechanistically, ADSCs activated the Keap1/Nrf2 pathway in the injured liver. Transplantation of ADSCs pre- and 6 h post-operation did not significantly affect some indices such as mRNA and protein expression of HO-1, and protein expression of NQO1. SIGNIFICANCE Transplanting ADSCs immediately after surgery accelerated tissue repair and functional recovery of the liver by activating the Keap1/Nrf2 pathway, which inhibited hepatic inflammation and oxidative stress, and restored the hepatic microenvironment.
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Affiliation(s)
- Chenxi Piao
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China
| | - Qianzhen Zhang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China
| | - Jiayuan Xu
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China
| | - Yue Wang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China
| | - Tao Liu
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China
| | - Haiyang Ma
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China
| | - Guodong Liu
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China
| | - Hongbin Wang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin 150030, PR China.
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10
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Long-Term Effects of Pedicle Clamping during Major Hepatectomy for Colorectal Liver Metastases. J Clin Med 2021; 10:jcm10132778. [PMID: 34202824 PMCID: PMC8269320 DOI: 10.3390/jcm10132778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/16/2021] [Accepted: 06/20/2021] [Indexed: 11/17/2022] Open
Abstract
The use of the Pringle maneuver (PM) varies widely among surgical departments. Its use depends on the operator and type of liver resection. The aim of this study was to determine the impact of the PM on patient outcomes when undergoing major liver resections. This retrospective study comprised 179 colorectal liver metastasis patients from two liver centers from Leeds and Warsaw. Only right or right extended hepatectomies with negative oncological margins were included. The primary outcome measure was the 5-year overall survival (OS). The PM was applied during 60 (33.5%) major hepatectomies included in the study and was associated with a higher peak 3-day postoperative bilirubin concentration (p = 0.002), yet not with the peak 3-day alanine aminotransferase activity (p = 0.415). The 5-year OS after liver resections with the PM and without the PM were 55.0% and 33.4%, respectively (p = 0.019). Following stratification by the Tumor Burden Score, after resections with the use of the PM, superior survival was particularly found in the subgroup of patients at intermediate risk of recurrence (p = 0.004). However, the use of the PM had no significant effect on the 5-year overall survival following adjustment for the confounding effect of the carcinoembryonic antigen concentration (p = 0.265). The use of the PM had no negative effects on the long-term outcomes in patients undergoing major, oncologically radical liver resections for colorectal metastases.
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11
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Fagenson AM, Gleeson EM, Nabi F, Lau KN, Pitt HA. When does a Pringle Maneuver cause harm? HPB (Oxford) 2021; 23:587-594. [PMID: 32933844 DOI: 10.1016/j.hpb.2020.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/08/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Pringle Maneuver (PM) is considered to be safe and effective. However, data regarding perioperative outcomes after a PM are conflicting. Therefore, the aim of this analysis is to compare the outcomes of patients who have and have not undergone a PM in North America. METHODS Patients undergoing major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-17 ACS-NSQIP hepatectomy database. Patients with and without a PM were compared. Propensity matching was utilized, and subgroup analyses by liver texture, hepatectomy extent and pathology were performed. RESULTS Prior to matching, 3706 (24%) of 15,748 hepatectomy patients underwent a PM. The PM was utilized in 1445 (27%) of major and 2261 (22%) of partial hepatectomies. After matching, 3295 patients with and 3295 without a PM were compared. Operative time was significantly increased for patients undergoing a PM (246 vs. 225 min, p < 0.001). Subgroup analyses revealed post-hepatectomy liver failure and septic shock to be significantly increased (both p < 0.05) for patients undergoing a PM during a partial hepatectomy or in patients with metastatic disease. CONCLUSION Patients undergoing a partial hepatectomy and those with metastatic disease have worse outcomes when a Pringle Maneuver is performed.
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Affiliation(s)
- Alexander M Fagenson
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA 19140, USA
| | - Elizabeth M Gleeson
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1259, New York, NY, 10029, USA
| | - Fatima Nabi
- Department of Surgery, Crozier-Chester Medical Center, One Medical Center Blvd, Upland, PA, 19013, USA
| | - Kwan N Lau
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA 19140, USA.
| | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA 19140, USA; Rutgers Robert Wood Johnson Medical School, 675 Hoes Ln W, Piscataway, NJ, 08854, USA
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12
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Hu Y, Lou L. A commentary on "does Intermittent Pringle maneuver loss its clinical value in reducing bleeding during hepatectomy? A systematic review and meta-analysis" (Int J Surg, 2020; 81:158-164). Int J Surg 2021; 88:105910. [PMID: 33667635 DOI: 10.1016/j.ijsu.2021.105910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Yongtao Hu
- Department of Infectious Diseases, YiWu Central Hospital, Zhejiang, 322000, China
| | - Lianqing Lou
- Department of Infectious Diseases, YiWu Central Hospital, Zhejiang, 322000, China.
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13
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Wassmer CH, Moeckli B, Berney T, Toso C, Orci LA. Shorter Survival after Liver Pedicle Clamping in Patients Undergoing Liver Resection for Hepatocellular Carcinoma Revealed by a Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040637. [PMID: 33562666 PMCID: PMC7916026 DOI: 10.3390/cancers13040637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Hepatocellular carcinoma (HCC) is the most prevalent tumor of the liver and represents the second most common cause of oncological-related deaths worldwide. Despite all progress made in the field, surgical resection or liver transplantation are, at the moment, the only curative therapies available. Liver resection, especially for large, central tumors, are at risk of important bleeding. Significative hemorrhage during HCC resections have been linked to an increased rate of post-operative complications and tumor recurrence. Therefore, hepatic pedicle clamping during surgery has been used in order to reduce the bleeding risks. However, this method induces ischemia/reperfusion injuries, which has also been associated with tumor recurrence. For this reason, we aimed to evaluate if pedicle clamping is indeed associated with tumor recurrence and shorter survival, by performing a systematic review of the literature and meta-analysis. Abstract Liver pedicle clamping minimizes surgical bleeding during hepatectomy. However, by inducing ischemia-reperfusion injury to the remnant liver, pedicle clamping may be associated with tumor recurrence in the regenerating liver. Hepatocellular carcinoma (HCC) having a high rate of recurrence, evidences demonstrating an eventual association with pedicle clamping is strongly needed. We did a systematic review of the literature until April 2020, looking at studies reporting the impact of liver pedicle clamping on long-term outcomes in patients undergoing liver resection for HCC. Primary and secondary outcomes were overall survival (OS) and disease-free survival, respectively. Results were obtained by random-effect meta-analysis and expressed as standardized mean difference (SMD). Eleven studies were included, accounting for 8087 patients. Results of seven studies were pooled in a meta-analysis. Findings indicated that, as compared to control patients who did not receive liver pedicle clamping, those who did had a significantly shorter OS (SMD = −0.172, 95%CI: −0.298 to −0.047, p = 0.007, I2 = 76.8%) and higher tumor recurrence rates (odds ratio 1.36 1.01 to 1.83. p = 0.044, I2 = 50.7%). This meta-analysis suggests that liver pedicle clamping may have a deleterious impact on long-term outcomes. An individual patient-data meta-analysis of randomized trials evaluating liver pedicle clamping is urgently needed.
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Affiliation(s)
| | - Beat Moeckli
- Correspondence: (C.-H.W.); (B.M.); Tel.: +41-7866-82206 (C.-H.W.)
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14
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Ng KKC, Cheng NMY, Huang J, Liao M, Chong CCN, Lee KF, Wong J, Cheung SYS, Lok HT, Fung AKY, Wong GLH, Wong VWS, Lai PBS. Development and validation of a novel nomogram predicting 10-year actual survival after curative hepatectomy for hepatocellular carcinoma. Surgeon 2021; 19:329-337. [PMID: 33423927 DOI: 10.1016/j.surge.2020.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/17/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Although hepatectomy is a curative treatment modality for hepatocellular carcinoma (HCC), the associated 10-year long-term actual survival are rarely reported. This study aims to develop and validate a predictive nomogram for 10-year actual survivors with HCC. MATERIALS AND METHODS From 2004 to 2009, 753 patients with curative hepatectomy for HCC (development set, n = 325; validation set, n = 428) were included. In development set, comparison of clinic-pathological data was made between patients surviving ≥10 years and those surviving <10 years. Good independent prognostic factors identified by multivariate analysis were involved in a nomogram development, which was validated internally and externally using validation set. RESULTS On multivariate analysis, five independent good prognostic factors for 10-year survival were identified, including young age (OR = 0.943), good ASA status (≤2) (OR = 2.794), higher albumin level (OR = 1.116), solitary tumor (OR = 2.531) and absence of microvascular invasion (OR = 3.367). A novel nomogram was constructed with C-index of 0.801 (95% CI 0.762-0.864). A cut-off point of 167.5 had a sensitivity of 0.794 and specificity of 0.730. Internal validation using bootstrap sampling and external validation using validation set revealed C-index of 0.792 (95% CI, 0.741-0.853) and 0.761 (95% CI, 0.718-0.817). CONCLUSION A novel nomogram for 10-year HCC survivor using age, ASA status, preoperative albumin, tumor number and presence of microvascular tumor invasion was developed and validated with high accuracy.
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Affiliation(s)
- Kelvin K C Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong; Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong.
| | - Nicole M Y Cheng
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Jiwei Huang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingheng Liao
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Charing C N Chong
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong; Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Kit-Fai Lee
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Sunny Y S Cheung
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Hon-Ting Lok
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, Prince of Wales Hospital, New Territories, Hong Kong
| | - Vincent W S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, Prince of Wales Hospital, New Territories, Hong Kong
| | - Paul B S Lai
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong; Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
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15
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Schiergens TS, Drefs M, Dörsch M, Kühn F, Albertsmeier M, Niess H, Schoenberg MB, Assenmacher M, Küchenhoff H, Thasler WE, Guba MO, Angele MK, Rentsch M, Werner J, Andrassy J. Prognostic Impact of Pedicle Clamping during Liver Resection for Colorectal Metastases. Cancers (Basel) 2020; 13:E72. [PMID: 33383844 PMCID: PMC7795154 DOI: 10.3390/cancers13010072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 12/25/2022] Open
Abstract
Pedicle clamping (PC) during liver resection for colorectal metastases (CRLM) is used to reduce blood loss and allogeneic blood transfusion (ABT). The effect on long-term oncologic outcomes is still under debate. A retrospective analysis of the impact of PC on ABT-demand regarding overall (OS) and recurrence-free survival (RFS) in 336 patients undergoing curative resection for CRLM was carried out. Survival analysis was performed by both univariate and multivariate methods and propensity-score (PS) matching. PC was employed in 75 patients (22%). No increased postoperative morbidity was monitored. While the overall ABT-rate was comparable (35% vs. 37%, p = 0.786), a reduced demand for more than two ABT-units was observed (p = 0.046). PC-patients had better median OS (78 vs. 47 months, p = 0.005) and RFS (36 vs. 23 months, p = 0.006). Multivariate analysis revealed PC as an independent prognostic factor for OS (HR = 0.60; p = 0.009) and RFS (HR = 0.67; p = 0.017). For PC-patients, 1:2 PS-matching (N = 174) showed no differences in the overall ABT-rate compared to no-PC-patients (35% vs. 40%, p = 0.619), but a trend towards reduced transfusion requirement (>2 ABT-units: 9% vs. 21%, p = 0.052; >4 ABT-units: 2% vs. 11%, p = 0.037) and better survival (OS: 78 vs. 44 months, p = 0.088; RFS: 36 vs. 24 months; p = 0.029). Favorable long-term outcomes and lower rates of increased transfusion demand were observed in patients with PC undergoing resection for CRLM. Further prospective evaluation of potential oncologic benefits of PC in these patients may be meaningful.
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Affiliation(s)
- Tobias S. Schiergens
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Moritz Drefs
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Maximilian Dörsch
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Markus Albertsmeier
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Hanno Niess
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Markus B. Schoenberg
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Matthias Assenmacher
- Department of Statistics, Ludwig-Maximilians-University Munich, Akademiestr 1, D-80799 Munich, Germany; (M.A.); (H.K.)
| | - Helmut Küchenhoff
- Department of Statistics, Ludwig-Maximilians-University Munich, Akademiestr 1, D-80799 Munich, Germany; (M.A.); (H.K.)
| | - Wolfgang E. Thasler
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Markus O. Guba
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Martin K. Angele
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Markus Rentsch
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
| | - Joachim Andrassy
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr 15, D-81377 Munich, Germany; (M.D.); (M.D.); (F.K.); (M.A.); (H.N.); (M.B.S.); (W.E.T.); (M.O.G.); (M.K.A.); (M.R.); (J.W.); (J.A.)
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16
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Fung AK, Cheng NM, Chong CC, Lee KF, Wong J, Cheung SY, Lok HT, Lai PB, Ng KK. Single-center experience on actual mid-term (≥5 years) and long-term (≥10 years) survival outcome in patients with hepatocellular carcinoma after curative hepatectomy: A bimodal distribution. Medicine (Baltimore) 2020; 99:e23358. [PMID: 33235106 PMCID: PMC7710257 DOI: 10.1097/md.0000000000023358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Analysis for actual mid-term (≥5 years) and long-term (≥10 years) survivors with hepatocellular carcinoma (HCC) following curative hepatectomy are rarely reported in the literature.This retrospective study aims to study the mid- and long-term survival outcome and associated prognostic factors following curative hepatectomy for HCC in a tertiary referral center.The clinical data of 325 patients who underwent curative hepatectomy for HCC were reviewed. They were stratified into 3 groups for comparison (Group 1, overall survival <5 years; Group 2, overall survival ≥5, and <10 years; Group 3, overall survival ≥10 years). Favorable independent prognostic factors for mid- and long-term survival were analyzed.A bimodal distribution of actual survival outcome was observed, with short-term (<5 years) survival of 52.7% (n = 171), mid-term survival of 18.1% (n = 59), and long-term survival of 29.2% (n = 95). Absence of microvascular invasion (OR 3.690, 95% CI: 1.562-8.695) was independent good prognostic factor for mid-term survival. Regarding long-term overall survival, young age (OR 1.050, 95% CI: 0.920-0.986), ASA grade ≤2 (OR 3.746, 95% CI: 1.325-10.587), high albumin level (OR 1.008, 95% CI: 0.920-0.986), solitary tumor (OR 3.289, 95% CI: 1.149-7.625) and absence of microvascular invasion (OR 4.926, 95% CI: 2.192-11.111) were independent good prognostic factors.Curative hepatectomy results in bimodal actual survival outcome with favorable long-term survival rate of 29.2%. Favorable independent prognostic factors (age, ASA grade, albumin level, tumor number, and microvascular invasion) are identified for overall survival.
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Affiliation(s)
- Andrew K.Y. Fung
- Department of Surgery, Prince of Wales Hospital, New Territories
| | | | - Charing C.N. Chong
- Department of Surgery, Prince of Wales Hospital, New Territories
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Kit-Fai Lee
- Department of Surgery, Prince of Wales Hospital, New Territories
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, New Territories
| | | | - Hon-Ting Lok
- Department of Surgery, Prince of Wales Hospital, New Territories
| | - Paul B.S. Lai
- Department of Surgery, Prince of Wales Hospital, New Territories
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Kelvin K.C. Ng
- Department of Surgery, Prince of Wales Hospital, New Territories
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
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17
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Lok HT, Fung AKY, Chong CCN, Lee KF, Wong J, Cheung SYS, Lai PBS, Ng KKC. Comparison of long-term survival outcome after curative hepatectomy between selected patients with non-colorectal and colorectal liver metastasis: A propensity score matching analysis. Asian J Surg 2020; 44:459-464. [PMID: 33229125 DOI: 10.1016/j.asjsur.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/18/2020] [Accepted: 10/25/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Liver resection is an established treatment of choice for colorectal liver metastasis (CLM). However, the role of hepatectomy for non-colorectal liver metastasis (NCLM) is less clear. PATIENTS AND METHOD From 2004 to 2017, 264 patients received curative hepatectomy for NCLM (n = 28) and CLM (n = 236). Propensity score (PS) matching was performed between two groups, with respect to the significant confounding factors. Short-term and long-term outcomes were compared between PS matched groups. Univariate analysis was performed to identify prognostic factors affecting overall and recurrence-free survival. RESULTS After PS matching, there were 28 patients in NCLM group and 56 patients in CLM group. With a median follow-up of 34 months, there was no significant difference in 5-year overall survival rate between NCLM and CLM groups (62% vs. 39%) (P = 0.370). The 5-year recurrence-free survival rate was also comparable between NCLM and CLM groups (23% vs. 22%) (P = 0.707). Use of pre-operative systemic therapy (hazard ratio: 2.335, CI 1.157-4.712), multifocal tumors (hazard ratio: 1.777, CI 1.010-3.127), tumor size (hazard ratio: 1.135, CI 1.012-1.273), R1 resection (hazard ratio: 2.484, CI 1.194-5.169) and severe complications (hazard ratio: 6.507, CI 1.454-29.124), but not tumor type (NCLM vs. CLM), were associated with poor overall survival. CONCLUSION Hepatectomy for NCLM can achieve similar oncological outcomes in selected patients as those with CLM. Significant prognostic factors were identified associating with worse overall survival.
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Affiliation(s)
- Hon-Ting Lok
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Charing C N Chong
- Department of Surgery, The Chinese University of Hong Kong; Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Kit-Fai Lee
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Sunny Y S Cheung
- Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Paul B S Lai
- Department of Surgery, The Chinese University of Hong Kong; Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong
| | - Kelvin K C Ng
- Department of Surgery, The Chinese University of Hong Kong; Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong.
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18
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Lee KF, Chong C, Cheung S, Wong J, Fung A, Lok HT, Lo E, Lai P. Robotic versus open hemihepatectomy: a propensity score-matched study. Surg Endosc 2020; 35:2316-2323. [PMID: 33185767 DOI: 10.1007/s00464-020-07645-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/13/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Minimally invasive approach has been increasingly applied in liver resection. However, laparoscopic major hepatectomy is technically demanding and is practiced only in expert centers around the world. Conversely, use of robot may help to overcome the difficulty and facilitate major hepatectomy. METHODS Between September 2010 and March 2019, 151 patients received robotic hepatectomy for various indications in our center. 36 patients received robotic hemihepatectomy: 26 left hepatectomy and 10 right hepatectomy. During the same period, 737 patients received open hepatectomy and out of these, 173 patients received open hemihepatectomy. A propensity score-matched analysis was performed in a 1:1 ratio. RESULTS After matching, there were 36 patients each in the robotic and open group. The two groups were comparable in demographic data, type of hemihepatectomy, underlying pathology, size of tumor, and background cirrhosis. Conversion was needed in 3 patients (8.3%) in the robotic group. There was no operative mortality. The operative blood loss and resection margin were similar. Though not significantly different, there was a higher rate of complications in the robotic group (36.1% vs. 22.2%) and this difference was mostly driven by higher intra-abdominal collection (16.7% vs. 5.6%) and bile leak (5.6% vs. 2.8%). Operative time was significantly longer (400.8 ± 136.1 min vs 255.4 ± 74.4 min, P < 0.001) but the postoperative hospital stay was significantly shorter (median 5 days vs 6.5 days, P = 0.040) in the robotic group. When right and left hepatectomy were analyzed separately, the advantage of shorter hospital stay remained in left but not right hepatectomy. For patients with hepatocellular carcinoma, there was no difference between the two groups in 5-year overall and disease-free survival. CONCLUSION Compared with the open approach, robotic hemihepatectomy has longer operation time but shorter hospital stay. Thus, use of robot is feasible and effective in hemihepatectomy with the benefit of shorter hospital stay.
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Affiliation(s)
- Kit-Fai Lee
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong.
| | - Charing Chong
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Sunny Cheung
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Andrew Fung
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Hon-Ting Lok
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Eugene Lo
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Paul Lai
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
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Lin N, Li J, Ke Q, Wang L, Liu J. Does intermittent pringle maneuver loss its clinical value in reducing bleeding during hepatectomy? A systematic review and meta-analysis. Int J Surg 2020; 81:158-164. [DOI: 10.1016/j.ijsu.2020.06.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 02/08/2023]
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Lee KF, Chong CCN, Cheung SYS, Wong J, Fung AKY, Lok HT, Lai PBS. Impact of Intermittent Pringle Maneuver on Long-Term Survival After Hepatectomy for Hepatocellular Carcinoma: Result from Two Combined Randomized Controlled Trials. World J Surg 2020; 43:3101-3109. [PMID: 31420724 DOI: 10.1007/s00268-019-05130-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hepatectomy remains an important curative treatment for hepatocellular carcinoma (HCC). Intermittent Pringle maneuver (IPM) is commonly applied during hepatectomy for control of bleeding. Whether the ischemia/reperfusion injury brought by IPM adversely affects the operative outcomes is controversial. This study aims to examine whether the application of IPM during hepatectomy affects the long-term outcomes. METHODS Two randomized controlled trials (RCT) have been carried out previously to evaluate the short-term outcomes of IPM. The present study represented a post hoc analysis on the HCC patients from the first RCT and all patients from the second RCT, and the long-term outcomes were evaluated. RESULTS There were 88 patients each in the IPM group and the no-Pringle-maneuver (NPM) group. The patient demographics, type and extent of liver resection and histopathological findings were comparable between the two groups. The 1-, 3-, 5-year overall survival in the IPM and NPM groups was 92.0%, 82.0%, 72.1% and 93.2%, 68.8%, 58.1%, respectively (P = 0.030). The 1-, 3-, 5-year disease-free survival in the IPM and NPM groups was 73.6%, 56.2%, 49.7% and 71.6%, 49.4%, 40.3%, respectively (P = 0.366). On multivariable analysis, IPM was a favorable factor for overall survival (P = 0.035). Subgroup analysis showed that a clamp time of 16-30 min (P = 0.024) and cirrhotic patients with IPM (P = 0.009) had better overall survival. CONCLUSION IPM provided a better overall survival after hepatectomy for patients with HCC. Such survival benefit was noted in cirrhotic patients, and the beneficial duration of clamp was 16-30 min. TRIAL REGISTRATION NCT00730743 and NCT01759901 ( http://www.clinicaltrials.gov ).
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Affiliation(s)
- Kit Fai Lee
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Sunny Y S Cheung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Hon Ting Lok
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China.
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21
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Towards Standardization of Liver Resections in India: Five Hundred Consecutive Oncological Liver Resections- Trends, Techniques and Outcomes. J Gastrointest Cancer 2020; 52:651-658. [PMID: 32602071 DOI: 10.1007/s12029-020-00444-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To study the trends, techniques, outcomes and improvisations of liver resections over the study period. METHODS We analysed prospectively maintained database of patients undergoing liver resections for oncological indications at Tata Memorial Centre, Mumbai, India from June 2010 to October 2016. RESULTS Five hundred sixteen patients were operated with median age of 55 years and male to female ratio of 1.6:1. Most commonly operated neoplasms were hepatocellular carcinoma (N = 166), cholangiocarcinoma (N = 72) and metastases from colorectal cancer (N = 129). We performed 219 major hepatic resections (≥3 segments) with overall morbidity of 22.9% (N = 118) and mortality of 4.0% (N = 21). Complex hepatectomies were performed in 78 patients. In order to study the time trends, data was divided into pre-liver clinic era and post liver clinic era. Trend analysis showed improvements in complication grade, hospital stay, blood loss, and overall survival status in post liver clinic era. Liver transection in all our patients was carried out without Pringle manoeuvre under normotensive anaesthesia, only 0.7% of our patients had significant transaminitis beyond POD 5. CONCLUSION A dedicated multidisciplinary treatment approach along with standardization of liver resections culminates into optimal treatment outcomes.
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Short-term Preoperative Diet Decreases Bleeding After Partial Hepatectomy: Results From a Multi-institutional Randomized Controlled Trial. Ann Surg 2019; 269:48-52. [PMID: 29489484 DOI: 10.1097/sla.0000000000002709] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Our previous case series suggested that a 1-week, low-calorie and low-fat diet was associated with decreased intraoperative blood loss in patients undergoing liver surgery. OBJECTIVE The current study evaluates the effect of this diet in a randomized controlled trial. METHODS We randomly assigned 60 patients with a body mass index ≥25 kg/m(2) to no special diet or an 800-kcal, 20 g fat, and 70 g protein diet for 1 week before liver resection. Surgeons were blinded to diet assignment. Hepatic glycogen stores were evaluated using periodic acid Schiff (PAS) stains. RESULTS Ninety four percent of the patients complied with the diet. The diet group consumed fewer daily total calories (807 vs 1968 kcal, P < 0.001) and fat (21 vs 86 g, P < 0.001) than the no diet group. Intraoperative blood loss was less in the diet group: mean blood loss 452 vs 863 mL (P = 0.021). There was a trend towards decreased transfusion in the diet group (138 vs 322 mL, P = 0.06). The surgeon judged the liver to be easier to manipulate in the diet group: 1.86 versus 2.90, P = 0.004. Complication rate (20% vs 17%), length of stay (median 5 vs 4 days) and mortality did not differ between groups. There was no difference in hepatic steatosis between groups. There was less glycogen in hepatocytes in the diet group (PAS stain score 1.61 vs 2.46, P < 0.0001). CONCLUSIONS A short-course, low-fat, and low-calorie diet significantly decreases bleeding and makes the liver easier to manipulate in hepatic surgery.
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Hester CA, El Mokdad A, Mansour JC, Porembka MR, Yopp AC, Zeh HJ, Polanco PM. Current Pattern of Use and Impact of Pringle Maneuver in Liver Resections in the United States. J Surg Res 2019; 239:253-260. [PMID: 30856518 DOI: 10.1016/j.jss.2019.01.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/20/2018] [Accepted: 01/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pringle maneuver (PM) is used for inflow vascular control during hepatectomy, but its use remains controversial. We aimed to report its pattern of use and association with postoperative outcomes. METHODS We identified hepatectomy patients using the liver-targeted National Surgical Quality Improvement Program database (2014-2016). Associations between PM and posthepatectomy liver failure (PHLF), receipt of blood transfusion, and total hospital length of stay (LOS) were evaluated. RESULTS We identified 7870 patients (74.9%) with no Pringle maneuver and 2632 (25.1%) with PM. PM patients were older (median age 61 versus 60 y, P = 0.002) and had higher ASA scores (76.1% versus 71.4% were ASA 3-4, P < 0.001). PM had more malignancy (83.0% versus 73.0%, P < 0.001), neoadjuvant therapy (37.7% versus 28.8%, P < 0.001), total lobectomy (30.6% versus 23.2%, P < 0.001), open resection (90.8% versus 74.9%, P < 0.001), and longer operations (246 min versus 212 min, P < 0.001). PM was associated with longer LOS (0.36 d, 95% confidence interval [CI] 0.11-0.60) and increased risk of PHLF (odds ratio [OR] 1.36, 95% CI 1.11-1.66), although not clinically significant grade B/C PHLF (OR 0.82, 95% CI 0.57-1.19), but was not associated with receipt of perioperative blood transfusions (OR 1.00, 95% CI 0.69-1.64). CONCLUSIONS PM is associated with similar clinically significant PHLF and transfusion requirements but longer LOS compared with no Pringle maneuver.
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Affiliation(s)
- Caitlin A Hester
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ali El Mokdad
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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Lee KF, Wong J, Cheung SYS, Chong CCN, Hui JWY, Leung VYF, Yu SCH, Lai PBS. Does Intermittent Pringle Maneuver Increase Postoperative Complications After Hepatectomy for Hepatocellular Carcinoma? A Randomized Controlled Trial. World J Surg 2018; 42:3302-3311. [PMID: 29696328 DOI: 10.1007/s00268-018-4637-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In a previous study, we have shown that intermittent Pringle maneuver (IPM) might increase postoperative complications after hepatectomy for various indications. Complications which thought to be related to IPM were ascites, pleural effusion, wound infection and intra-abdominal collection. The aim of this study was to test the hypothesis that applying IPM during hepatectomy for hepatocellular carcinoma (HCC) could increase postoperative complications. METHODS Between January 2013 and October 2016, eligible patients who received elective open hepatectomy for HCC were randomized to have IPM or no Pringle maneuver (NPM). Occurrence of various types of postoperative complications was specifically looked for. A routine postoperative day 5 abdominal ultrasound examination and chest X-ray were done to detect and grade any radiological ascites, pleural effusion and intra-abdominal collection. RESULTS Fifty IPM and 50 NPM patients with histological proven HCC were recruited for final analysis. Demographics and operative parameters were comparable between the two groups. The postoperative complication rates were similar (IPM 36.0 vs. NPM 28.0%, P = 0.391). However, in the IPM group, more patients developed radiological posthepatectomy ascites (42.0 vs. 22.0%, P = 0.032) and pleural effusion (66.0 vs. 38.0%, P = 0.005). In patients with histologically proven cirrhosis, there were 28 IPM and 25 NPM patients. Again, there was no difference in postoperative complication rate but more radiological posthepatectomy ascites and pleural effusion in the IPM group. CONCLUSION This trial was not able to detect a difference in postoperative complications whether IPM was applied or not, but use of IPM was associated with more subclinical ascites and pleural effusion. (ClinicalTrials.gov NCT01759901). TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT01759901.
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Affiliation(s)
- Kit Fai Lee
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China.
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Sunny Y S Cheung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Joyce W Y Hui
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Vivian Y F Leung
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Simon C H Yu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
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Garnier J, Faucher M, Marchese U, Meillat H, Mokart D, Ewald J, Delpero JR, Turrini O. Severe acute kidney injury following major liver resection without portal clamping: incidence, risk factors, and impact on short-term outcomes. HPB (Oxford) 2018; 20:865-871. [PMID: 29691124 DOI: 10.1016/j.hpb.2018.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/20/2018] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) following major hepatectomy (MH) remains inadequately investigated. This retrospective study aimed to assess the risk factors and prognostic value of AKI on short-term outcomes following MH without portal pedicle clamping. METHODS From January 2014 through June 2017, 111 consecutive patients underwent MH without portal pedicle clamping, but with intraoperative low-crystalloid infusion. Kidney Disease Improving Global Outcomes stages II and III were classified as severe AKI. RESULTS A total of 102 patients did not develop AKI or only AKI stage I (92%, control group), whereas 9 patients developed severe AKI (8%, severe AKI group). Hepatectomy (P = 0.002) and surgery (P = 0.011) durations were longer in the severe AKI group. Clavien-Dindo grades 3 to 5 morbidity (55% versus 9%, P = 0.001), liver failure (P = 0.017), and 90-day mortality (33% versus 2%, P = 0.003) were significantly higher in the severe AKI group. After a multivariate analysis, the duration of hepatectomy (cut-off: 250 min; P = 0.029) and urea serum levels on postoperative day 3 (P = 0.006) were identified as independent predictors of severe AKI. DISCUSSION Severe AKI, is common with increased duration of hepatectomy, was associated with poor short-term outcomes, and can be predicted by operative duration greater than 250 minutes.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France.
| | - Marion Faucher
- Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
| | - Hélène Meillat
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
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Moggia E, Rouse B, Simillis C, Li T, Vaughan J, Davidson BR, Gurusamy KS. Methods to decrease blood loss during liver resection: a network meta-analysis. Cochrane Database Syst Rev 2016; 10:CD010683. [PMID: 27797116 PMCID: PMC6472530 DOI: 10.1002/14651858.cd010683.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver resection is a major surgery with significant mortality and morbidity. Specialists have tested various methods in attempts to limit blood loss, transfusion requirements, and morbidity during elective liver resection. These methods include different approaches (anterior versus conventional approach), use of autologous blood donation, cardiopulmonary interventions such as hypoventilation, low central venous pressure, different methods of parenchymal transection, different methods of management of the raw surface of the liver, different methods of vascular occlusion, and different pharmacological interventions. A surgeon typically uses only one of the methods from each of these seven categories. The optimal method to decrease blood loss and transfusion requirements in people undergoing liver resection is unknown. OBJECTIVES To assess the effects of different interventions for decreasing blood loss and blood transfusion requirements during elective liver resection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Science Citation Index Expanded to September 2015 to identify randomised clinical trials. We also searched trial registers and handsearched the references lists of identified trials. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of decreasing blood loss and blood transfusion requirements in people undergoing liver resection. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and collected data. We assessed the risk of bias using Cochrane domains. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4, following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) for the binary outcomes, mean differences (MD) with 95% CrI for continuous outcomes, and rate ratios with 95% CrI for count outcomes, using a fixed-effect model or random-effects model according to model-fit. We assessed the evidence with GRADE. MAIN RESULTS We identified 67 randomised clinical trials involving a total of 6197 participants. All the trials were at high risk of bias. A total of 5771 participants from 64 trials provided data for one or more outcomes included in this review. There was no evidence of differences in most of the comparisons, and where there was, these differences were in single trials, mostly of small sample size. We summarise only the evidence that was available in more than one trial below. Of the primary outcomes, the only one with evidence of a difference from more than one trial under the pair-wise comparison was in the number of adverse events (complications), which was higher with radiofrequency dissecting sealer than with the clamp-crush method (rate ratio 1.85, 95% CrI 1.07 to 3.26; 250 participants; 3 studies; very low-quality evidence). Among the secondary outcomes, the only differences we found from more than one trial under the pair-wise comparison were the following: blood transfusion (proportion) was higher in the low central venous pressure group than in the acute normovolemic haemodilution plus low central venous pressure group (OR 3.19, 95% CrI 1.56 to 6.95; 208 participants; 2 studies; low-quality evidence); blood transfusion quantity (red blood cells) was lower in the fibrin sealant group than in the control (MD -0.53 units, 95% CrI -1.00 to -0.07; 122 participants; 2; very low-quality evidence); blood transfusion quantity (fresh frozen plasma) was higher in the oxidised cellulose group than in the fibrin sealant group (MD 0.53 units, 95% CrI 0.36 to 0.71; 80 participants; 2 studies; very low-quality evidence); blood loss (MD -0.34 L, 95% CrI -0.46 to -0.22; 237 participants; 4 studies; very low-quality evidence), total hospital stay (MD -2.42 days, 95% CrI -3.91 to -0.94; 197 participants; 3 studies; very low-quality evidence), and operating time (MD -15.32 minutes, 95% CrI -29.03 to -1.69; 192 participants; 4 studies; very low-quality evidence) were lower with low central venous pressure than with control. For the other comparisons, the evidence for difference was either based on single small trials or there was no evidence of differences. None of the trials reported health-related quality of life or time needed to return to work. AUTHORS' CONCLUSIONS Paucity of data meant that we could not assess transitivity assumptions and inconsistency for most analyses. When direct and indirect comparisons were available, network meta-analysis provided additional effect estimates for comparisons where there were no direct comparisons. However, the paucity of data decreases the confidence in the results of the network meta-analysis. Low-quality evidence suggests that liver resection using a radiofrequency dissecting sealer may be associated with more adverse events than with the clamp-crush method. Low-quality evidence also suggests that the proportion of people requiring a blood transfusion is higher with low central venous pressure than with acute normovolemic haemodilution plus low central venous pressure; very low-quality evidence suggests that blood transfusion quantity (red blood cells) was lower with fibrin sealant than control; blood transfusion quantity (fresh frozen plasma) was higher with oxidised cellulose than with fibrin sealant; and blood loss, total hospital stay, and operating time were lower with low central venous pressure than with control. There is no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements (very low-quality evidence). Radiofrequency dissecting sealer should not be used outside the clinical trial setting since there is low-quality evidence for increased harm without any evidence of benefits. In addition, it should be noted that the sample size was small and the credible intervals were wide, and we cannot rule out considerable benefit or harm with a specific method of liver resection.
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Affiliation(s)
- Elisabetta Moggia
- IRCCS Humanitas Research HospitalDepartment of General and Digestive SurgeryVia Manzoni 5620089 RozzanoMilanItalyItaly20089
| | - Benjamin Rouse
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Constantinos Simillis
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Tianjing Li
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Jessica Vaughan
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Maurer CA, Walensi M, Käser SA, Künzli BM, Lötscher R, Zuse A. Liver resections can be performed safely without Pringle maneuver: A prospective study. World J Hepatol 2016; 8:1038-1046. [PMID: 27648156 PMCID: PMC5002500 DOI: 10.4254/wjh.v8.i24.1038] [Citation(s) in RCA: 8] [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: 03/20/2016] [Revised: 05/04/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate liver resections without Pringle maneuver, i.e., clamping of the portal triad.
METHODS Between 9/2002 and 7/2013, 175 consecutive liver resections (n = 101 major anatomical and n = 74 large atypical > 5 cm) without Pringle maneuver were performed in 127 patients (143 surgeries). Accompanying, 37 wedge resections (specimens < 5 cm) and 43 radiofrequency ablations were performed. Preoperative volumetric calculation of the liver remnant preceeded all anatomical resections. The liver parenchyma was dissected by water-jet. The median central venous pressure was 4 mmHg (range: 5-14). Data was collected prospectively.
RESULTS The median age of patients was 60 years (range: 16-85). Preoperative chemotherapy was used in 70 cases (49.0%). Liver cirrhosis was present in 6.3%, and liver steatosis of ≥ 10% in 28.0%. Blood loss was median 400 mL (range 50-5000 mL). Perioperative blood transfusions were given in 22/143 procedures (15%). The median weight of anatomically resected liver specimens was 525 g (range: 51-1850 g). One patient died postoperatively. Biliary leakages (n = 5) were treated conservatively. Temporary liver failure occurred in two patients.
CONCLUSION Major liver resections without Pringle maneuver are feasible and safe. The avoidance of liver inflow clamping might reduce liver damage and failure, and shorten the hospital stay.
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Abstract
Operative blood loss is a major source of morbidity and even mortality for patients undergoing hepatic resection. This review discusses strategies to minimize blood loss and the utilization of allogeneic blood transfusion pertaining to oncologic hepatic surgery.
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Affiliation(s)
- Gareth Eeson
- Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room T2016, Toronto, ON M4N 3M5, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room T2016, Toronto, ON M4N 3M5, Canada.
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Higuchi R, Yazawa T, Uemura S, Yamamoto M. Anterior approach for perihilar cholangiocarcinoma (with video). J Surg Res 2015; 202:71-6. [PMID: 27083950 DOI: 10.1016/j.jss.2015.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/11/2015] [Accepted: 12/10/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND To evaluate the significance of the anterior approach without the Pringle maneuver during right hepatectomies with caudate lobectomies for perihilar cholangiocarcinomas (PHCs). MATERIALS AND METHODS From January 2011 to 2015, 25 consecutive patients underwent right hepatectomies with caudate lobectomies using the anterior approach without the Pringle maneuver for PHC (group A). Between 2003 and 2011, 44 patients were operated on for PHC using the classic right approach (group B). We compared the groups with respect to the patients' characteristics and the short-term surgical outcomes. RESULTS Group A had significantly lower postoperative mean maximum levels of aspartate aminotransferase (294 U/L versus 453 U/L; P = 0.044), lower frequencies of maximum aspartate aminotransferase or alanine aminotransferase levels that exceeded 500 U/L (8.0% versus 32%; P = 0.036), shorter total Pringle maneuver times (7.1 versus 46.3 min; P < 0.001), lower Pringle maneuver frequencies (0.76 maneuvers versus 5.1 maneuvers; P < 0.001), less bleeding (1237 mL versus 1646 mL; P = 0.025), and shorter postoperative systemic inflammatory response syndrome durations (2.3 h versus15.4 h; P < 0.001) compared with group B. CONCLUSIONS This approach can be performed safely, and it seems to limit the hemodynamic disturbance of the remnant left liver.
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Affiliation(s)
- Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
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Egger ME, Ohlendorf JM, Scoggins CR, McMasters KM, Martin RCG. Assessment of the reporting of quality and outcome measures in hepatic resections: a call for 90-day reporting in all hepatectomy series. HPB (Oxford) 2015; 17:839-45. [PMID: 26228262 PMCID: PMC4557660 DOI: 10.1111/hpb.12470] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/02/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this paper is to assess the current state of quality and outcomes measures being reported for hepatic resections in the recent literature. METHODS Medline and PubMed databases were searched for English language articles published between 1 January 2002 and 30 April 2013. Two examiners reviewed each article and relevant citations for appropriateness of inclusion, which excluded papers of liver donor hepatic resections, repeat hepatectomies or meta-analyses. Data were extracted and summarized by two examiners for analysis. RESULTS Fifty-five studies were identified with suitable reporting to assess peri-operative mortality in hepatic resections. In only 35% (19/55) of the studies was the follow-up time explicitly stated, and in 47% (26/55) of studies peri-operative mortality was limited to in-hospital or 30 days. The time period in which complications were captured was not explicitly stated in 19 out of 28 studies. The remaining studies only captured complications within 30 days of the index operation (8/28). There was a paucity of quality literature addressing truly patient-centred outcomes. CONCLUSION Quality outcomes after a hepatic resection are inconsistently reported in the literature. Quality outcome studies for a hepatectomy should report mortality and morbidity at a minimum of 90 days after surgery.
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Affiliation(s)
- Michael E Egger
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Joanna M Ohlendorf
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Charles R Scoggins
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Kelly M McMasters
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
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Lee A, Chiu CH, Cho MWA, Gomersall CD, Lee KF, Cheung YS, Lai PBS. Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study. BMJ Open 2014; 4:e005330. [PMID: 25011990 PMCID: PMC4120378 DOI: 10.1136/bmjopen-2014-005330] [Citation(s) in RCA: 10] [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: 12/22/2022] Open
Abstract
OBJECTIVE This study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery. SETTING AND PARTICIPANTS A retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities. OUTCOME MEASURES The primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality. RESULTS There were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003). CONCLUSIONS Smokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.
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Affiliation(s)
- Anna Lee
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chun Hung Chiu
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Mui Wai Amy Cho
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charles David Gomersall
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kit Fai Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yue Sun Cheung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul Bo San Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Wong Tze Lam – Hing Tak Centre of Surgical Outcome Research, The Chinese University of Hong Kong, Hong Kong
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Perioperative outcomes of laparoscopic and robot-assisted major hepatectomies: an Italian multi-institutional comparative study. Surg Endosc 2014; 28:2973-9. [PMID: 24853851 DOI: 10.1007/s00464-014-3560-4] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/17/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Laparoscopic major hepatectomy (LMH), although safely feasible in experienced hands and in selected patients, is a formidable challenge because of the technical demands of controlling hemorrhage, sealing bile ducts, avoiding gas embolism, and maintaining oncologic surgical principles. The enhanced surgical dexterity offered by robotic assistance could improve feasibility and/or safety of minimally invasive major hepatectomy. The aim of this study was to compare perioperative outcomes of LMH and robotic-assisted major hepatectomy (RMH). METHODS Pooled data from four Italian hepatobiliary centers were analyzed retrospectively. Demographic data, operative, and postoperative outcomes were collected from prospectively maintained databases and compared. RESULTS Between January 2009 and December 2012, 25 patients underwent LMH and 25 RMH. The two groups were comparable for all baseline characteristics including type of resection and underlying pathology. Conversion to open surgery was required in one patient in each group (4%). No difference was noted in operative time, estimated blood, and need for allogenic blood transfusions. Intermittent pedicle occlusion was required only in LMH (32% vs. 0; p = 0.004). Length of hospital stay, including time spent in intensive care unit, was similar between the two groups, but patients undergoing LMH showed quicker recovery of bowel activity, with shorter time to first flatus (1 vs. 3 days; p = 0.023) and earlier tolerance to oral liquid diet (1 vs. 2 days; p = 0.001). No difference was noted in complication rate, 90-day mortality, and readmission rate. CONCLUSIONS This retrospective multi-institution study confirms that selected patients can safely undergo minimally invasive major hepatectomy, either LMH or RMH. The fact that intermittent pedicle occlusion could be avoided in RMH suggests improved surgical ability to deal with bleeding during liver transection, but further studies are needed before any final conclusion can be drawn.
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Huntington JT, Royall NA, Schmidt CR. Minimizing blood loss during hepatectomy: a literature review. J Surg Oncol 2013; 109:81-8. [PMID: 24449171 DOI: 10.1002/jso.23455] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 09/12/2013] [Indexed: 12/13/2022]
Abstract
There are numerous techniques surgeons employ to reduce blood loss during partial hepatectomy. In this literature review, prospective studies from the last 20 years are examined to determine the techniques that are best supported by the literature. Some of the techniques include vascular control, multiple parenchymal transection techniques, various hemostatic agents, low central venous pressure, and hemodilution. The strategies supported most convincingly by the literature include low CVP and total hepatic inflow occlusion.
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Affiliation(s)
- Justin T Huntington
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Nanashima A, Abo T, Arai J, Takagi K, Matsumoto H, Takeshita H, Tsuchiya T, Nagayasu T. Usefulness of vessel-sealing devices combined with crush clamping method for hepatectomy: a retrospective cohort study. Int J Surg 2013; 11:891-7. [PMID: 23954369 DOI: 10.1016/j.ijsu.2013.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 07/10/2013] [Accepted: 07/26/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Blood loss during resection of the hepatic parenchyma in hepatectomy can be minimized using vessel-sealing (VS) devices. Some sealing devices were retrospectively compared to evaluate the efficacy of each device for controlling blood loss, transection time and postoperative complications in hepatectomy as a cohort study. METHODS Between 2005 and September 2012, hepatectomy was underwent in 150 patients using one of three types of LigaSure™ (Dolphin Tip Laparoscopic Instrument, Precise or Small Jaw) or the Harmonic Focus or Ace ultrasonic dissecting sealer. Results were compared to crush-clamping alone as the control method by the historical study (n = 81). RESULTS Irrespective of the vessel-sealing device used for underlying chronic hepatitis, blood loss, blood transfusion rate, operating time and transection time were significantly reduced in the VS group compared with controls (p < 0.05). Rates of postoperative bile leakage and intra-abdominal abscess formation were significantly lower in the VS group than in controls (p < 0.05). Comparing devices, LigaSure Small Jaw and Harmonic Focus showed lower blood loss, shorter transection time and reduced rates of post-hepatectomy complications, in turn resulting in shorter hospital stays (p < 0.05). Tendencies toward uncontrolled ascites and bile leakage were only concern with the use of Harmonic Focus. Satisfactory surgical results were achieved using the sealing device for laparoscopic hepatectomy. CONCLUSIONS The use of energy sealing devices improves surgical results and avoids hepatectomy-related complications. Adequate use of vessel sealers is necessary for safe and rapid completion of hepatic resection.
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Affiliation(s)
- Atsushi Nanashima
- Division of Surgical Oncology and Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, Japan.
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Sanjay P, Ong I, Bartlett A, Powell JJ, Wigmore SJ. Meta-analysis of intermittent Pringle manoeuvre versus no Pringle manoeuvre in elective liver surgery. ANZ J Surg 2013; 83:719-23. [PMID: 23869587 DOI: 10.1111/ans.12312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Intermittent Pringle manoeuvre (IPM) is frequently used during liver surgery. This meta-analysis aimed to review the impact on blood loss, operating time and morbidity and mortality with and without use of IPM. METHODS An electronic search was performed of the MEDLINE, EMBASE, PubMed databases using both subject headings (MeSH) and truncated word searches to identify all articles published that related to this topic. Pooled risk ratios were calculated for categorical outcomes, and mean differences (MDs) for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. RESULTS Four randomized controlled trials encompassing 392 patients were analysed to achieve a summated outcome. Pooled data analysis showed the use of IPM resulted in reduced transection time/cm(2) (MD -0.53 (-0.88, -0.18) min/cm(2) (P = 0.003)) but with comparable blood loss (mL/cm(2)) (MD -1.67 (-4.41, 1.08) mL/cm(2), P = 0.23), overall blood loss (MD -20.42 (-89.42, 48.58) mL), blood transfusion requirements (risk ratio 0.78 (0.40, 1.52, P = 0.47)) and morbidity and mortality compared to no Pringle manoeuvre. In addition, there was no significant difference in the post-operative hospital stay (MD 0.37 (-0.60, 1.34) days). CONCLUSIONS There is no evidence that the routine use of IPM improves perioperative and post-operative outcomes compared to no Pringle manoeuvre and its routine may not be recommended.
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