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Azoulay D, Salloum C, Allard MA, Serrablo A, Moussa M, Romano P, Pietraz D, Golse N, Lim C. Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept. Ann Surg Oncol 2024:10.1245/s10434-024-15227-7. [PMID: 38592622 DOI: 10.1245/s10434-024-15227-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion. PATIENTS AND METHODS The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range). RESULTS Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero. CONCLUSIONS This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France.
| | - Chady Salloum
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Marc-Antoine Allard
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Maya Moussa
- Centre Hépato-Biliaire, Department of Anesthesiology, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Pierluigi Romano
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Daniel Pietraz
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Chetana Lim
- Department of Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Villejuif, France
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Peri-hepatic gauze packing for the control of haemorrhage during liver transplantation: A retrospective study. Dig Liver Dis 2016; 48:414-22. [PMID: 26725163 DOI: 10.1016/j.dld.2015.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/11/2015] [Accepted: 11/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Albeit accepted in the trauma setting, use of peri-hepatic gauze packing has been rarely reported during liver transplantation. AIMS To assess the results of packing in liver transplantation. METHODS We reviewed clinical characteristics, intraoperative events and postoperative outcome of consecutive adult liver transplantation recipients between 2003 and 2013. Patients treated with packing were compared to no-packing patients and to matched controls selected using a propensity score. RESULTS Of 1396 recipients, 107 were treated with packing for peri-hepatic bleeding (76.6%), allograft damage (12.1%) or partial outflow obstruction (11.2%). Urgent reoperation for ongoing haemorrhage was required in 6 (5.6%). Correction of haemodynamic and coagulation parameters was constantly achieved. Overall, patient (90% vs. 98%, p<0.001) and graft (83.2% vs. 94.7%, p<0.001) 3-month survival was significantly reduced in packing patients. However, after matching, no significant difference was observed in patient (89.3% vs. 95.2%, p=0.12) and graft (83.5% vs. 92.2%, p=0.06) 3-month survival. Patient survival was associated with recipient age (HR 2.59; p=0.04) and donor age × recipient MELD (HR 2.04; p=0.02), but not with packing (HR 1.81; p=0.29). CONCLUSIONS In our experience, packing was a valuable adjunct to conventional means of haemostasis during liver transplantation and, after accounting for confounding covariates, was not associated with inferior outcomes.
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Gayer G, Lubner MG, Bhalla S, Pickhardt PJ. Imaging of abdominal and pelvic surgical and postprocedural foreign bodies. Radiol Clin North Am 2014; 52:991-1027. [PMID: 25173655 DOI: 10.1016/j.rcl.2014.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Every form of medical and surgical treatment, even the most trivial one, carries with it some chance of complications. This risk is usually small, and the benefit of the treatment should clearly outweigh the risk. Treatment-related complications may occur, however, presenting either soon after the intervention or remote from it. In this review, the focus is on imaging findings of surgical materials used in abdominal surgery, and of a wide array of implanted abdominal devices. The pertinent complications of these devices and of retained surgical objects are highlighted and illustrated.
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Affiliation(s)
- Gabriela Gayer
- Department of Radiology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, 2 Derech Sheba, Ramat-Gan 52621, Israel; Department of Radiology, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94304, USA.
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792-3252, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway, St Louis, MO 63110, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792-3252, USA
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Asfar S, Khoursheed M, Al-Saleh M, Alfawaz AA, Farghaly MM, Nur AM. Management of liver trauma in Kuwait. Med Princ Pract 2014; 23:160-6. [PMID: 24457986 PMCID: PMC5586862 DOI: 10.1159/000358126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 12/19/2013] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES The aim of this study was to introduce the concept of non-operative management (NOM) for blunt liver trauma by establishing a protocol and a prospective Liver Trauma Registry in Kuwait. SUBJECTS AND METHODS A prospective Liver Trauma Registry was started in 4 hospitals and it included 117 patients who had sustained blunt liver trauma (94 men and 23 women). Unstable patients were taken to surgery while stable patients were managed conservatively regardless of the grade of liver injury. High-grade (III-VI) liver injuries were managed in collaboration with the liver surgery specialist. RESULTS The mean age of the 117 patients was 29.02 ± 11.18 years (range 7-63). NOM was successful in 94 (96%) patients and failed in 4 (4%) (these 4 then underwent successful surgery). Nineteen (16.2%) were unstable and underwent surgery immediately; 15 (79%) of them survived (they had had grade III-V injuries) and 4 died (2 with grade V injuries and 2 with grade VI injuries). Perihepatic packing was necessary in 8/19 (42%) patients. The overall mortality was 3.4% (4/117). CONCLUSIONS This study showed that NOM was successful in a majority of patients with blunt liver trauma. In addition, it confirmed that the magnitude of liver injury and haemoperitoneum did not preclude NOM as long as the patient was haemodynamically stable.
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Affiliation(s)
- Sami Asfar
- Department of Surgery, The Liver Surgery Unit, Kuwait, Kuwait
- Department of Surgery, Mubarak Al-Kabeer Hospital, Kuwait, Kuwait
- Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
- *Prof. Sami Asfar, Department of Surgery, Faculty of Medicine, Kuwait University, PO Box 23924, Safat 13110 (Kuwait), E-Mail
| | - Mousa Khoursheed
- Department of Surgery, Mubarak Al-Kabeer Hospital, Kuwait, Kuwait
- Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
| | - Mervat Al-Saleh
- Department of Surgery, Mubarak Al-Kabeer Hospital, Kuwait, Kuwait
- Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
| | | | | | - Ali M. Nur
- Department of Surgery, Al-Jahra Hospital, Kuwait, Kuwait
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Vrochides D, Kardassis D, Ntinas A, Miliaras D, Papalois A, Magnissalis E, Metrakos P. A novel liver parenchyma transection technique using locking straight rigid ties. An experimental study in pigs. J INVEST SURG 2013; 27:106-13. [PMID: 24063662 DOI: 10.3109/08941939.2013.832825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Technological advances have led to the development of many devices used in liver resections. However, no single transection tool is uniformly considered to be better than the others. This study aimed to develop an effective, fast, and cost-efficient technique for hepatic parenchymal transection. MATERIALS AND METHODS A liver parenchyma compression device in the form of a locking straight rigid tie (LoStRiT) was newly developed. Twelve pigs were distributed into two groups. The control group ( n = 6) comprised animals that underwent hepatectomy using the standard Kelly-clysis technique. The study group (n = 6) comprised animals that underwent hepatectomy using sequential LoStRiT mechanisms. The transection speed, blood loss, and biloma formation were recorded. RESULTS The mean parenchymal transection speed was 1.27 ± 0.27 cm(2)/min for the control group and 2.39 ± 0.56 cm(2)/min for the LoStRiT group ( p = .003). The mean blood loss per kilogram of body weight was 9.8 ± 5.2 ml/kg for the control group and 3.9 ± 0.9 ml/kg for the LoStRiT group ( p = .040). No bilomas were identified. CONCLUSION LoStRiT hepatectomy appears to be effective, fast, and reproducible in a porcine model of liver resection. Further development of this novel and potentially cost-efficient technique includes construction of the device using absorbable materials.
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Affiliation(s)
- Dionisios Vrochides
- Hepato-Pancreato-Biliary & Transplant Division, Department of Surgery, McGill University , Montreal, QC , Canada
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Influences on the amount of intraperitoneal haemorrhage after blunt liver injury: a retrospective autopsy study. Eur J Gastroenterol Hepatol 2012; 24:1333-40. [PMID: 22872075 DOI: 10.1097/meg.0b013e3283579445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The amount of intraperitoneal blood loss due to traumatic liver injury is rarely addressed in correlation with concomitant injuries or pre-existing liver disease. METHODS We carried out a retrospective review of autopsy reports from 1995 until 2007 at the Institute of Forensic Medicine (Bern, Switzerland), and evaluated 126 cases of blunt liver trauma for the amount of blood in the abdominal cavity, severity of liver injury, pre-existing liver disease and concomitant injuries. RESULTS Grades IV and V liver injuries (American Association for the Surgery of Trauma classification) showed greater blood loss than grades I and II liver injuries. Grade III liver injuries showed no significant difference in the amount of intraperitoneal blood compared with grades IV and V liver injuries and 53 cases of liver injuries (42%) did not bleed at all. The amount of blood found in the abdominal cavity ranged from 0 to 4500 ml. Pre-existing liver steatosis showed no significant difference in injury pattern or bleeding from the liver. Three cases with liver haemangiomas and one with a liver cyst showed no lesion to their focal alteration. Because of the small number of cases, no statistical analysis was made concerning concomitant injuries such as head, thoracic or limb trauma. CONCLUSION Higher grades of liver injury severity are associated with higher blood loss into the abdominal cavity. In addition, a patient with pre-existing liver steatosis seems not to be at any greater risk of having a larger rupture or having stronger bleeding from the liver after a blunt impact compared with a patient with a normal liver.
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Cata JP, Gottumukkala V. Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know? ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/918938] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive oncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state; however, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant drugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication of all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood transfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor embolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to prevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is largely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus, recommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted.
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Affiliation(s)
- Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
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Which Is the Last Stage before Packing in Elective Liver Surgery? World J Surg 2011; 35:2360-1; author reply 2362. [DOI: 10.1007/s00268-011-1184-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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