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Relationship between hepatic venous anatomy and hepatic venous blood loss during hepatectomy. Surg Today 2021; 51:1953-1968. [PMID: 34129114 DOI: 10.1007/s00595-021-02314-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/25/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE Predicting increased blood loss based on anatomical intervascular relationships is essential in major hepatectomy. METHODS We assessed 63 consecutive patients undergoing anatomical hepatectomy exposing the hepatic vein (HV) trunk at two institutes. Correlations between anatomical alterations of the hepatic inferior vena cava (IVC), HV, hepatic IVC, or right atrium (RA) and the blood loss per standard weight (BLSW) or blood transfusion (n = 18) were analyzed. The results of IVC partial clamping (PC) were additionally examined. RESULTS The BLSW in type V-up anatomical morphology was significantly higher than that in straight type (p < 0.05). The parameters associated with an increased BLSW (> 13.5 mL/kg) were tumor size (> 4 cm), prothrombin activity (< 87%), CVP (> 7 mmHg), area of suprahepatic IVC (< 360 mm2), IVC-RA gap (> 28 mm), longitudinal angle of IVC (< 160°), and axial angle of the MHV (< 55°). A multivariate analysis revealed that a high IVC-RA gap was a significant independent risk factor (odds ratio; 4.32, p < 0.05). Among 25 patients undergoing IVC-PC, only three showed a remarkable decrease in hepatic venous bleeding. No other statistically significant differences in the surgical records were observed in most cases. CONCLUSION The IVC-RA gap might be a promising novel predictive parameter reflecting increased blood loss leading to blood transfusion in anatomical hepatectomy.
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Knaak C, Spies C, Schneider A, Jara M, Vorderwülbecke G, Kuhlmann AD, von Haefen C, Lachmann G, Schulte E. Epidural Anesthesia in Liver Surgery-A Propensity Score-Matched Analysis. PAIN MEDICINE 2020; 21:2650-2660. [PMID: 32651587 DOI: 10.1093/pm/pnaa130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the effects of epidural anesthesia (EA) on patients who underwent liver resection. DESIGN Secondary analysis of a prospective randomized controlled trial. SETTING This single-center study was conducted at an academic medical center. METHODS A subset of 110 1:1 propensity score-matched patients who underwent liver resection with and without EA were analyzed. Outcome measures were pain intensity ≥5 on a numeric rating scale (NRS) at rest and during movement on postoperative days 1-5, analyzed with logistic mixed-effects models, and postoperative complications according to the Clavien-Dindo classification, length of hospital stay (LOS), and one-year survival. One-year survival in the matched cohorts was compared using a frailty model. RESULTS EA patients were less likely to experience NRS ≥5 at rest (odds ratio = 0.06, 95% confidence interval [CI] = 0.01 to 0.28, P < 0.001). These findings were independent of age, sex, Charlson comorbidity index, baseline NRS, and surgical approach (open vs laparoscopic). The number and severity of postoperative complications and LOS were comparable between groups (P = 0.258, P > 0.999, and P = 0.467, respectively). Reduced mortality rates were seen in the EA group one year after surgery (9.1% vs 30.9%, hazard ratio = 0.32, 95% CI = 0.11 to 0.90, P = 0.031). No EA-related adverse events occurred. Earlier recovery of bowel function was seen in EA patients. CONCLUSIONS Patients with EA had better postoperative pain control and required fewer systemic opioids. Postoperative complications and LOS did not differ, although one-year survival was significantly improved in patients with EA. EA applied in liver surgery was effective and safe.
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Affiliation(s)
- Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alice Schneider
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Maximilian Jara
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Dorothea Kuhlmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clarissa von Haefen
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Erika Schulte
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Gasteiger L, Eschertzhuber S, Tiefenthaler W. Perioperative management of liver surgery-review on pathophysiology of liver disease and liver failure. Eur Surg 2018; 50:81-86. [PMID: 29875796 PMCID: PMC5968074 DOI: 10.1007/s10353-018-0522-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/23/2018] [Indexed: 12/17/2022]
Abstract
An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.
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Affiliation(s)
- Lukas Gasteiger
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
- Department of Anaesthesia and Intensive Care, General Hospital Hall in Tirol, Hall in Tirol, Austria
| | - Werner Tiefenthaler
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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Ramspoth T, Roehl AB, Macko S, Heidenhain C, Junge K, Binnebösel M, Schmeding M, Neumann UP, Rossaint R, Hein M. Risk factors for coagulopathy after liver resection. J Clin Anesth 2014; 26:654-62. [PMID: 25468574 DOI: 10.1016/j.jclinane.2014.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 08/09/2014] [Accepted: 08/22/2014] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE To identify risk factors for coagulopathy in patients undergoing liver resection. DESIGN A retrospective cohort study. SETTING Patients who underwent liver resection at a university hospital between April 2010 and May 2011 were evaluated within seven days after surgery. PATIENTS One hundred forty-seven patients were assessed for eligibility. Thirty needed to be excluded because of incomplete data (23) or a preexisting coagulopathy (7). MEASUREMENTS Coagulopathy was defined as 1 or more of the following events: international normalized ratio ≥1.4, platelet count <80,000/μL, and partial thromboplastin time >38 seconds. Related to the time course and coagulation profile thresholds, 3 different groups could be distinguished: no coagulopathy, temporary coagulopathy, and persistent coagulopathy. MAIN RESULTS Seventy-seven patients (65.8%) had no coagulopathy, whereas 33 (28.2%) developed temporary coagulopathy and 7 (6%) developed persistent coagulopathy until day 7. Preoperative international normalized ratio (P = .001), postoperative peak lactate levels (P = .012), and resected liver weight (P = .005) were identified as independent predictors. Preoperative liver transaminases and transfusion volumes of red blood cells and fresh frozen plasma were significantly higher in patients with persistent coagulopathy. CONCLUSIONS Epidural anesthesia is feasible in patients scheduled for liver resection. Caution should be observed for patients with extended resection (≥3 segments) and increased postoperative lactate. In patients with preexisting liver disease, epidural catheters should be avoided.
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Affiliation(s)
- Tina Ramspoth
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Anna B Roehl
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Stephan Macko
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Cristoph Heidenhain
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Karsten Junge
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Marcel Binnebösel
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Maximilian Schmeding
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Ulf P Neumann
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Marc Hein
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany.
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Beckmann J, Bein B, Steinfath M, Becker T. [Intraoperative surgical and anesthesiological problems and the consequences for surgery]. Chirurg 2012; 83:617-25. [PMID: 22692374 DOI: 10.1007/s00104-011-2213-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Although the procedures for severe intraoperative complications have largely been defined, in everyday life less dramatic but equally important problems and issues arise which are controversially debated between treating surgeons and the anesthesiologists. Preoperative anemia, transfusion therapy, fluid management, patient positioning, hypothermia and neuromuscular blockade are the focus of the occasionally conflicting interests of anesthesiologists and surgeons. Good reciprocal communication and mutual understanding are a requirement for proactive management of complications. The overall objective is the reduction of intraoperative risks thereby reducing morbidity and mortality. This can be achieved through modern fluid management, blood conserving techniques and maintenance of normothermia. Surgeons further require an optimal view during minimally invasive surgery even by complex patient positioning and adequate neuromuscular blockade.
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Affiliation(s)
- J Beckmann
- Klinik für Allgemeine Chirurgie und Thoraxchirurgie, Universitätsklinikum Schleswig Holstein, Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Deutschland.
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Bleyl JU. [Vital borderline situations mastered together]. Anaesthesist 2011; 60:101-2. [PMID: 21311853 DOI: 10.1007/s00101-011-1853-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- J U Bleyl
- Klinik für Anästhesiologie und Intensivtherapie, Carl Gustav Carus Universitätsklinikum, Fetscherstrasse 74, Dresden, Germany.
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