Impact of energy devices during liver parenchymal transection: a multicenter randomized controlled trial

Safety and Feasibility of Laparoscopic Liver Resection with the Clamp-Crush Method Using the BiSect

BACKGROUND

Various energy devices are available for resection of the liver parenchyma during laparoscopic liver resection (LLR). We have historically performed liver resections using the Cavitron Ultrasonic Surgical Aspirator (CUSA). More recently, we have used new bipolar forceps (BiSect; Erbe Elektromedizin GmbH, Tübingen, Germany) to perform clamp-crush dissection with good results. The BiSect is a reusable bipolar forceps with a laparoscopic dissecting forceps tip and both an incision mode and coagulation mode. We evaluated the perioperative clinical course of patients who underwent LLR using the clamp-crush method with the BiSect compared with the CUSA.

METHODS

This single-center case control study involved patients with liver metastasis from colorectal cancer who underwent LLR using either the BiSect or CUSA at our hospital from January 2019 to December 2022. We performed the LLR using CUSA from January 2019 to early October 2020. After introduction of the BiSect in late October 2020, we used BiSect for the LLR. Before surgery, the three-dimensional liver was constructed based on computed tomography images, and a preoperative simulation was performed. We evaluated the results of LLR using the BiSect versus the CUSA and assessed the short-term results of LLR.

RESULTS

During the study period, we performed partial liver resection using the BiSect in 26 patients and the CUSA in 16 patients. In the BiSect group, the median bleeding volume was 55 mL, the median operation time was 227 minutes, and the median postoperative length of hospital stay was 9 days. In the CUSA group, the median bleeding volume was 87 mL, the median operation time was 305 minutes, and the median postoperative length of hospital stay was 10 days. There were no statistically significant differences in the clinical course including bile leakage, bile duct stenosis, and post operative hospital stay between the two groups.

CONCLUSIONS

Compared with LLR using the CUSA, the clamp-crush method using the BiSect in LLR is a safe and useful liver transection technique. Further study should be conducted to clarify whether BiSect is safe and useful in LLR for patients with other tumor types and patients who undergo other procedures.

A Multicenter, Open-Label, Single-Arm Phase I Trial of Dual-Wield Parenchymal Transection: A New Technique of Liver Resection Using the Cavitron Ultrasonic Surgical Aspirator and Water-Jet Scalpel Simultaneously (HiSCO-14 Trial)

PURPOSE

This study evaluated the safety and feasibility of a technique of liver resection named dual-wield parenchymal transection technique (DWT), using cavitron ultrasonic surgical aspirator (CUSA) and water-jet scalpel simultaneously.

METHODS

This multicenter, prospective, open-label, and single-arm phase I trial included patients aged 20 years or older with hepatic tumors indicated for surgical resection and scheduled for open radical resection. This study was conducted at two institutions affiliated with the Hiroshima Surgical Study Group of Clinical Oncology (HiSCO). The primary endpoint was the proportion of massive intraoperative blood loss (≥ 1000 mL). The secondary endpoints were the amount of blood loss, operative time, parenchymal transection speed, postoperative complications, and mortality. The safety endpoints were device failure and adverse events associated with devices.

RESULTS

From June 2022 to May 2023, 20 patients were enrolled; one was excluded and 19 were included in the full analysis set (FAS). In the FAS, segmentectomy was performed in nine cases, sectionectomy in four cases, and hemihepatectomy in six cases. Radical resection was achieved in all patients. Intraoperative blood loss greater than 1000 mL was observed in five patients (26.3%). The median amount of blood loss was 545 mL (range, 180-4413), and blood transfusions were performed on two patients (10.5%). The median operative time was 346 minutes (range, 238-543) and the median parenchymal transection speed was 1.2 cm2/minute (range, 0.5-5.1). Postoperative complications of Clavien-Dindo classification ≥ Grade 3 occurred in four patients (21.1%). No mortalities occurred in this study. In the safety analysis, there were no device failures or adverse events associated with devices.

CONCLUSIONS

This study demonstrated the safety and feasibility of DWT for liver resection. The efficacy of the DWT will be evaluated in future clinical trials.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

Non-Stick Liver Parenchymal Transection With Saline-Linked Bipolar Clamp-Crush Technique in Robotic Liver Resection

Background Without satisfactory instruments, liver parenchymal transection during robotic liver resection (RLR) remains challenging. We combined the commonly used bipolar clamp-crush technique with the saline drip, achieving a comfortable liver resection without coagulated liver tissues sticking to the bipolar forceps. Methods Between December 2022 and March 2023, six RLRs were performed using the saline-linked bipolar clamp-crush method for both anatomical and non-anatomical liver resections. We assessed the safety and feasibility of our robotic liver parenchymal transection technique. Results Three of six patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), and the other with intrahepatic bile duct stricture. Three of the six patients received anatomical liver resection, and the other three underwent non-anatomical liver resection. There were no conversions to open surgery. The median operative time and estimated blood loss were 406.5 minutes (196-670 minutes) and 5 ml (5-465 ml), respectively. The median length of the postoperative hospital stay was nine days (7-10 days). Postoperative complications (Clavien-Dindo classification grade II or more) or mortality were not encountered in this cohort. Conclusion We presented here our saline-linked bipolar clamp-crush method for liver parenchymal transection in RLR. By simply adding the saline drip to the commonly used bipolar clamp-crush technique, non-stick and comfortable liver parenchymal transection is now possible. This technique may help overcome the limitations of currently available robotic instruments for liver parenchymal resection.

Laparoscopic liver resection with "ultrasonic scalpel mimic CUSA" technique

BACKGROUND

Liver parenchymal transection is the most critical step for laparoscopic liver resection (LLR). Ultrasonic scalpel (Harmonic) is a common used energy instrument in LLR; however, it is only recommended for superficial layer transection and the Cavitron Ultrasonic Surgical Aspirator (CUSA) is recommended for deep layer dissection. We herein introduce the "Harmonic mimic CUSA" technique for LLR.

METHODS

We retrospectively reviewed the medical records of the patients who underwent LLR using CUSA or the "Harmonic mimic CUSA" for parenchymal transection between July 2018 and October 2020 at West China Hospital of Sichuan University. Observation indicators included general demographic information, operative time, intraoperative blood loss, blood transfusion volume, complication rate, hospital stay, and the costs. Perioperative data was compared between the two groups by propensity score matching analysis (PSM).

RESULTS

A total of 298 patients, including 192 in Harmonic group and 106 in CUSA group, were enrolled in this study. After a 1:1 PSM, 99 patients using "Harmonic mimic CUSA" were matched with 99 patients via CUSA for parenchymal transection in LLRs. The Harmonic group had significantly less intraoperative blood loss (mean, 150 ml vs. 250 ml, P < 0.001), shorter operative time (mean 170 min vs. 250 min, P < 0.001) and less costs (mean 6723$ vs. 8307$, P < 0.001). The conversion to laparotomy, length of postoperative hospital stay, complications were comparable between the two groups. There perioperative mortality was nil.

CONCLUSION

The "Harmonic mimic CUSA" technique is safe, simple and feasible for LLR, which may be an alternative to CUSA for LLR.

Tissue pad degradation of ultrasonic device may enhance thermal injury and impair its sealing performance in liver surgery

BACKGROUND

Ultrasonic devices are widely used in many surgical fields, including hepatectomy; however, the negative effects of tissue pad degradation of ultrasonic devices, including those in liver surgery, remain unknown. The Harmonic^® 1100 (H-1100) scalpel has advanced heat control technology than previous models, such as the Harmonic^® HD1000i (H-HD1000i). We hypothesized that, because of its advanced temperature-control technology, the H-1100 scalpel would show less tissue pad degradation, resulting in superior sealing performance, compared to that with the H-HD1000i scalpel.

AIM

To elucidate ultrasonic device tissue pad degradation effects on instrument temperature and sealing performance using ex vivo porcine liver/vessel models.

METHODS

Two different harmonic scalpels were used and compared: A newer model, the H-1100 scalpel, and an older model, the H-HD1000i scalpel. Using ex vivo porcine livers, each instrument was activated until the liver parenchyma was dissected. The device temperature (passive jaw temperature) was measured after every 10 consecutive activations, until 300 transections of the porcine liver were performed. Tissue pad degradation was evaluated after 300 activations. Sealing performance was evaluated using excised porcine carotid vessels; vessel sealing speed and frequency of vessel burst pressure below 700 mmHg were determined after 300 transections of porcine liver parenchyma.

RESULTS

The temperature of the H-HD1000i scalpel was approximately 10°C higher than that of the H-1100 scalpel, and gradually increased as the number of activations increased. The median passive jaw temperature of the H-HD1000i scalpel was significantly higher than that of the H-1100 scalpel (73.4°C vs 65.1°C; P < 0.001). After 300 transections of porcine liver parenchyma, less tissue pad degradation was observed with the H-1100 scalpel than with the H-HD1000i scalpel (0.08 mm vs 0.51 mm). The H-1100 scalpel demonstrated faster vessel-sealing speed (4.9 sec. vs 5.1 sec.) and less frequent vessel burst pressure < 700 mmHg (0% vs 40%) after 300 activations than the H-HD1000i scalpel; however, the difference did not reach statistical significance (P = 0.21 and P = 0.09, respectively).

CONCLUSION

In an ex vivo porcine hepatectomy model, the H-1100 scalpel shows lower passive jaw temperature and maintains its sealing performance by avoiding tissue pad degradation compared to that with the H-HD1000i.

Prospective validation to prevent symptomatic portal vein thrombosis after liver resection

BACKGROUND

Portal vein thrombosis (PVT) after liver resection is rare but can lead to life-threatening liver failure. This prospective study evaluated patients using contrast-enhanced computed tomography (E-CT) on the first day after liver resection for early PVT detection and management.

AIM

To evaluate patients by E-CT on the first day after liver resection for early PVT detection and immediate management.

METHODS

Patients who underwent liver resection for primary liver cancer from January 2015 were enrolled. E-CT was performed on the first day after surgery in patients undergoing anatomical resection, multiple resections, or with postoperative bile leakage in the high-risk group for PVT. When PVT was detected, anticoagulant therapy including heparin, warfarin, and edoxaban was administered. E-CT was performed monthly until PVT resolved.

RESULTS

The overall incidence of PVT was 1.57% (8/508). E-CT was performed on the first day after surgery in 235 consecutive high-risk patients (165 anatomical resections, 74 multiple resections, and 28 bile leakages), with a PVT incidence of 3.4% (8/235). Symptomatic PVT was not observed in the excluded cohort. Multivariate analyses revealed that sectionectomy was the only independent predictor of PVT [odds ratio (OR) = 12.20; 95% confidence interval (CI): 2.22-115.97; P = 0.003]. PVT was found in the umbilical portion of 75.0% (6/8) of patients, and sectionectomy on the left side showed the highest risk of PVT (OR = 14.10; 95%CI: 3.17-62.71; P < 0.0001).

CONCLUSION

Sectionectomy on the left side should be chosen with caution as it showed the highest risk of PVT. E-CT followed by anticoagulant therapy was effective in managing early-phase PVT for 2 mo without adverse events.

Comparison of operative outcomes between monopolar and bipolar coagulation in hepatectomy: a propensity score-matched analysis in a single center

Background

Various hemostatic devices have been utilized to reduce blood loss during hepatectomy. Nonetheless, a comparison between monopolar and bipolar coagulation, particularly their usefulness or inferiority, has been poorly documented. The aim of this study is to reveal the characteristics of these hemostatic devices.

Methods

A total of 264 patients who underwent open hepatectomy at our institution from January 2009 to December 2018 were included. Monopolar and bipolar hemostatic devices were used in 160 (monopolar group) and 104 (bipolar group) cases, respectively. Operative outcomes and thermal damage to the resected specimens were compared between these groups using propensity score matching according to background factors. Multivariate logistic regression analysis was performed to identify predictive factors for postoperative complications.

Results

After propensity score matching, 73 patients per group were enrolled. The monopolar group had significantly lower total operative time (239 vs. 275 min; P = 0.013) and intraoperative blood loss (487 vs. 790 mL; P < 0.001). However, the incidence rates of ascites (27.4% vs. 8.2%; P = 0.002) and grade ≥ 3 intra-abdominal infection (12.3% vs. 2.7%; P = 0.028) were significantly higher in the monopolar group. Thermal damage to the resected specimens was significantly longer in the monopolar group (4.6 vs. 1.2 mm; P < 0.001). Use of monopolar hemostatic device was an independent risk factor for ascites (odds ratio, 5.626, 95% confidence interval 1.881–16.827; P = 0.002) and severe intra-abdominal infection (odds ratio, 5.905, 95% confidence interval 1.096–31.825; P = 0.039).

Conclusions

Although monopolar devices have an excellent hemostatic ability, they might damage the remnant liver. The use of monopolar devices can be one of the factors that increase the frequency of complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02231-y.

Feasibility of Microwave-Based Scissors and Tweezers in Partial Hepatectomy: An Initial Assessment on Canine Model

Purpose: This study aimed to assess the feasibility of partial hepatectomy (PH) simplified by using microwave-based devices in animal experiments.

Methods: PH was performed on 16 beagles using either Acrosurg Scissors (AS) or Acrosurg Tweezers (AT) without hepatic pedicle (HP) control. Parenchymal transection time, Glissonean pedicle (GP) seal time, bleeding volume, bile leak, and burst pressure were recorded. Probable complications were investigated after 4 weeks.

Results: Transection time (6.5 [6.0–7.6] vs. 11.8 [10.5–20.2] min, p < 0.001) with AT were significantly shorter than with AS. GP sealing times (60 [55–60] vs. 57 [46–91] s, p = 0.859) by both devices were nearly similar. Bleeding volume in the AT group was approximately one-fourth of that in the AS group (6.7 [1.4–22] vs. 28.8 [5.8–48] mL, p = 0.247). AT created higher burst pressure on the bile duct stumps (p = 0.0161). The two devices did not differ significantly in morbidity and mortality after four-week follow-up.

Conclusion: Acrosurg devices achieved a safe PH without HP control owing to microwave-based sealing. AS could be used alone in PH, whereas the clamp-crushing function of AT seemed more advantageous in reducing the transection time and blood loss.

The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.

Drain Placement After Uncomplicated Hepatic Resection Increases Severe Postoperative Complication Rate: A Japanese Multi-institutional Randomized Controlled Trial (ND-trial)

OBJECTIVE

To assess the clinical impact of a no-drain policy after hepatic resection.

SUMMARY OF BACKGROUND DATA

Previous randomized controlled trials addressing no-drain policy after hepatic resection seem inconclusive because they did not adopt appropriate study design to validate its true clinical impact.

METHODS

This unblinded, randomized controlled trial was done at 7 Japanese institutions. Patients undergoing hepatic resection without biliary reconstruction were randomized to either D group or ND group. When the risk of postoperative bile leakage or hemorrhage were considered high, the patients were excluded during the operation. Primary endpoint was the postoperative complication of C-D grade 3 or higher within 90 postoperative days. A noninferiority of ND group to D group was assessed, and if it was confirmed, a superiority was assessed.

RESULTS

Between May 2015 and July 2017, a total of 400 patients were finally included in the per-protocol set analysis: 199 patients in D group and 201 patients in ND group. Intraoperatively, 37 patients were excluded from the final enrollment because of high risk of bile leakage or hemorrhage. Postoperative complication rate of C-D grade 3 or higher was 8.0% (16/199) in the D group and 2.5% (5/201) in the ND group. The risk difference was -5.5% (95% confidence interval: -9.9% to -1.2%) and fulfilled the prescribed noninferiority margin of 4%. No postoperative mortality was experienced in both groups. Bile leakage was diagnosed in 8.0% (16/199) of the D group and none in the ND group (P < 0.001). In none of the subgroups classified based on 8 potentially relevant factors, drain placement was favored in terms of C-D grade 3 or higher complication.

CONCLUSIONS

Drains should not be placed after uncomplicated hepatic resections.

Efficiency of a radiofrequency sealer (Aquamantys) for parenchymal transection during laparoscopic hepatectomy

INTRODUCTION

The methods of liver parenchymal transection vary across institutions. In this study, we used a radiofrequency (RF) sealer (Aquamantys) as a hemostatic device during laparoscopic liver transection; we also evaluated the usefulness of RF sealers.

METHODS

From April 2016 to May 2019, 113 consecutive laparoscopic hepatectomy patients, excluding patients with combined resection of other organs, were examined. Patient characteristics, operative factors, and postoperative complications were compared between the Cavitron ultrasonic surgical aspirator (CUSA) + soft coagulation system (VIO) group; (n = 32) and the CUSA + Aquamantys group; (n = 81). The former underwent liver transection by CUSA and VIO from April 2016 to March 2017, while the latter underwent liver transection using CUSA and Aquamantys from April 2017 to May 2019.

RESULTS

The median difficulty score was significantly higher in the CUSA + VIO group (5.5 points vs 5.0 points; P = .04). Blood loss per unit area and the liver parenchymal transection speed were not significantly different between the groups. After propensity score matching, blood loss per unit area was similar between the groups, but the parenchymal transection speed of the CUSA + Aquamantys group was significantly higher (0.92 cm² /min vs 0.64 cm² /min; P = .017). Postoperative complications were similar between the groups.

CONCLUSION

In laparoscopic hepatectomy, hemostasis of the transection plane with an RF sealer did not reduce blood loss during parenchymal transection. However, the liver parenchymal transection speed was increased.

A systematic review and network meta-analysis of parenchymal transection techniques during hepatectomy: an appraisal of current randomised controlled trials

BACKGROUND

Major liver resection can lead to significant morbidity and mortality. Blood loss is one of the most important factors predicting a good outcome. Although various transection methods have been reported, there is no consensus on the best technique. This systematic review and network meta-analysis aims to characterise and identify the best reported technique for elective parenchymal liver transection based on published randomised controlled trials (RCT's).

METHODS

A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Central to identify RCT's up to 5th June 2019 that examined parenchymal transection for liver resection. Data including study characteristics and outcomes including intraoperative (blood loss, operating time) and postoperative measures (overall and major complications, bile leaks) were extracted. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analyses (NMA) which maintains randomisation within trials.

RESULTS

This study identified 22 RCT's involving 2360 patients reporting ten parenchymal transection techniques. Bipolar cautery has lower blood loss and shorter operating time than stapler (mean difference: 85 mL; 22min) and Tissue Link (mean difference: 66 mL; 29min). Bipolar cautery was ranked first for blood loss and operating time followed by stapler and TissueLink. Harmonic scalpel is associated with lower overall complications than Hydrojet (Odds ratio (OR): 0.48), BiClamp forceps (OR: 0.46) and clamp crushing (OR: 0.41).

CONCLUSION

Bipolar cautery techniques appear to best at reducing blood loss and associated with shortest operating time. In contrast, Harmonic scalpel appears best for overall and major complications. Given the paucity of data and selective outcome reporting, it is still hard to identify what is the best technique for liver resection. Therefore, further high-quality large-scale RCT's are still needed.

Efficacy of a Laparoscopic Saline-Coupled Bipolar Sealer in Minimally Invasive Hepatobiliary Surgery

Hepatic resection presents unique surgical challenges to reduce blood loss during parenchymal division. The development of saline-coupled bipolar devices, in which hemostasis is achieved at lower temperatures than electrocautery or other bipolar sealing devices, have been employed for open hepatic resection. Saline-coupled bipolar devices have now become available for minimally invasive use. The goals of this study were to evaluate the feasibility and safety of a laparoscopic saline-coupled bipolar device for minimally invasive hepatectomy. Seventeen patients (median age 66 years, range 36-81) were consented for inclusion and enrolled. Patient demographics, intraoperative data, and surgeon feedback were collected. Seven robot-assisted partial hepatectomies, 9 laparoscopic partial hepatectomies, and 1 laparoscopic cholecystectomy with liver abscess resection were performed. Average operating time was 222 ± 33 minutes (median 188 minutes; range 61-564 minutes) with no difference between robotic versus laparoscopic time. Successful seals were achieved in all cases following application of 150 to 200 J energy (average 179 ± 3 J, average time to achieve a successful seal 9.3 ± 2.7 minutes). Estimated blood loss was 362 ± 74 mL (median 300 mL, range 5-1200 mL) and 3/17 patients received intraoperative blood transfusion. No bile leaks were detected in any of the patients. Median length of stay was 5 days (range 1-20 days), and there were no readmissions within 30 days. Postoperative morbidity occurred in 5/17 patients, all of which were Clavien Grade 1. There was no mortality within 90 days or complications requiring a return to the operating room, and there were no liver-specific morbidities. These data suggest the laparoscopic Aquamantys device represents a useful device for use in minimally invasive liver resection.

Evaluation of THUNDERBEAT® in open liver resection- a single-center experience

Background

THUNDERBEAT® (TB) (Olympus Medical Systems Corp., Tokyo, Japan) is a dynamic energy system device that simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolar energy. TB is being routinely used in various operative procedures, however, less is known about its utility in liver resection. We, herein, report our early experience of using TB in open liver resection particularly in patients with normal or near-normal liver parenchyma.

Methods

We retrospectively reviewed the clinical characteristics, and evaluated the perioperative outcome of twenty-eight patients who underwent liver resection with TB, and twenty-four patients who underwent liver resection with basic procedure in our institution. The resection type was stratified into: major hepatectomy; resection of 3 or more than 3 Couinauds segments, and minor hepatectomy; resection of less than 3 Couinauds segments.

Results

Liver resection time (mean ± SD) in TB group with major hepatectomy was significantly shorter: 16.7 ± 8.8 compared to 62.8 ± 39.4 min in basic procedure group (P < 0.0001). Accordingly, the liver resection time (mean ± SD) in TB group with minor hepatectomy was also significantly shorter, 8.3 ± 2.9 min compared to 45.2 ± 23.9 min in liver resection with basic procedure (P < 0.001). No significant difference was observed between the groups in terms of intraoperative blood transfusion ratio, postoperative complication and postoperative liver dysfunction.

Conclusion

TB as a new energy device can offer a safe, reliable and substantially rapid liver resection particularly in patients with normal or near-normal liver parenchyma.

Comparative Study With Propensity Score Matching Analysis of Two Different Methods of Transection During Hemi-Right Hepatectomy: Ultracision Harmonic Scalpel Versus Cavitron Ultrasonic Surgical Aspirator

BACKGROUND

Several devices are available for liver parenchyma transection (LPT). The aim of this study was to compare the Ultracision Harmonic scalpel (UHS) with the Cavitron Ultrasonic Surgical Aspirator (CUSA) among patients who underwent hemi-right hepatectomies (RH) to homogenize transection areas.

METHODS

From September 2012 to June 2015, 24 patients who underwent the UHS surgery approach were matched with 24 patients who underwent the CUSA transection procedure for RH using propensity score matching.

RESULTS

Total operative time (TOT) was shorter in the UHS group, 240 minutes (range 172.5-298.8) versus 330 minutes (range 270-400) in the CUSA group ( P = .0002). The occurrence of hepatopathy (odds ratio = 17; 95% confidence interval = 1.02-230) and the use of the CUSA device (odds ratio = 8; 95% confidence interval = 0.98-77) were associated with a TOT exceeding 300 minutes in multivariate analysis ( P = .05).

CONCLUSIONS

The UHS is a safe and effective method of LPT as compared to the use of the CUSA system. TOT is statistically decreased.

Methods to decrease blood loss during liver resection: a network meta-analysis

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.

Impact of monopolar radiofrequency coagulation on intraoperative blood loss during liver resection: a prospective randomised controlled trial

PURPOSE

To evaluate the impact of using monopolar thermal coagulation based on radiofrequency (RF) currents on intraoperative blood loss during liver resection.

MATERIALS AND METHODS

A prospective randomised controlled trial was planned. Patients undergoing hepatectomy were randomised into two groups. In the control group (n = 10), hemostasis was obtained with a combination of stitches, vessel-sealing bipolar RF systems, sutures or clips. In the monopolar radiofrequency coagulation (MRFC) group (n = 18), hemostasis was mainly obtained using an internally cooled monopolar RF electrode.

RESULTS

No differences in demographic or clinical characteristics were found between groups. Mean blood loss during liver resection in the control group was more than twice that of the MRFC group (556 ± 471 ml vs. 225 ± 313 ml, p = .02). The adjusted mean bleeding/transection area was also significantly higher in the control group (7.0 ± 3.3 ml/cm² vs. 2.8 ± 4.0 ml/cm², p = .006). No significant differences were observed in the rate of complications between the groups.

CONCLUSIONS

The findings suggest that the monopolar electrocoagulation created with an internally cooled RF electrode considerably reduces intraoperative blood loss during liver resection.

Randomized clinical trial comparing two vessel-sealing devices with crush clamping during liver transection

Background

Previous RCTs have failed to demonstrate the usefulness of combining energy devices with the conventional clamp crushing method to reduce blood loss during liver transection. Here, the combination of an ultrasonically activated device (UAD) and a bipolar vessel-sealing device (BVSD) with crush clamping was investigated.

Methods

Patients scheduled to undergo hepatectomy at the University of Tokyo Hospital or Nihon University Itabashi Hospital were eligible for this parallel-group, single-blinded randomized study. Patients were assigned to a control group (no energy device used), an UAD group or a BVSD group. The primary endpoint was the volume of blood loss during liver transection. Outcomes of the control group and the combined energy device groups (UAD plus BVSD) were first compared. Pairwise comparisons among the three groups were made for outcomes for which the combined energy device group was superior to the control group.

Results

A total of 380 patients were enrolled between July 2012 and May 2014; 116 patients in the control group, 122 in the UAD group and 123 in the BVSD group were included in the final analysis. Median blood loss during liver transection was lower in the combined energy device group (245 patients) than in the control group (116 patients): median 190 (range 0–3575) versus 230 (range 3–1570) ml (P = 0·048). Pairwise comparison revealed that blood loss was lower in the BVSD group than in the control group (P = 0·043).

Conclusion

The use of energy devices combined with crush clamping reduced blood loss during liver transection. Registration number: C000008372 (www.umin.ac.jp/ctr/index.htm).