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Jin W, Jiang S, Chen A, Chen Y. Effect of Preoperative Malnutrition Based on Albumin and BMI on Hepatocellular Carcinoma Surgery and Prediction of Risk Factors of Complications. J Gastrointest Cancer 2024; 55:511-518. [PMID: 38165605 DOI: 10.1007/s12029-023-01008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND To investigate the correlation between preoperative malnutrition and perioperative variables in patients with hepatocellular carcinoma (HCC) and to analyze the risk factors of complications after HCC resection. METHODS All patients who underwent hepatectomy because of HCC in the First Affiliated Hospital of Chongqing Medical University from June 1, 2018, to December 1, 2021, were analyzed retrospectively. Preoperative malnutrition was defined as body mass index (BMI) < 18.5 kg/m2 or serum albumin level < 3.5 g/dL within 30 days before operation. RESULTS A total of 415 patients with HCC hepatectomy were included, and 75 (18.1%) were classified as malnutrition group. In the malnutrition group, blood loss (662.1 ± 748.1 VS 404.6 ± 681.9, P = 0.002), transfusion rate (36.0% VS 13.5%, P < 0.001), postoperative hospital stays (13.3 ± 9.6 VS 10.1 ± 4.2, P < 0.001), 30-day postoperative mortality (4.0 VS 0.6%, P = 0.043), complications rate (68% VS 34.8%, P < 0.001), and severe complication rate (17.3% VS 2.4%, P < 0.001) were significantly higher than those in the well-nourished group. Multivariate analysis showed that age (HR 1.037, 95% CI 1.015-1.059, P = 0.001), preoperative malnutrition (HR 2.933, 95% CI 1.515-5.679, P = 0.001), simultaneous cholecystectomy (HR 2.004, 95% CI 1.168-3.440, P = 0.012), cirrhosis (HR 4.997, 95% CI 2.864-8.718, P < 0.001), and transfusion (HR 5.166, 95% CI 2.272-11.748, P < 0.001) were independent risk factors for postoperative complications. In addition, preoperative malnutrition (HR 8.209, 95% CI 2.711-24.864, P < 0.001) and operation time (HR 1.088, 95% CI 1.003-1.103, P = 0.004) were independent risk factors for severe complications. CONCLUSION Preoperative malnutrition can adversely affect the outcome of HCC resection. For patients with advanced age, cirrhosis, and malnutrition, preoperative planning is very important, and we should be more careful during the operation to avoid transfusion caused by bleeding and not to carry out preventive cholecystectomy, which are helpful to reduce the occurrence of postoperative complications.
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Affiliation(s)
- Weiqiang Jin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Shiming Jiang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Anke Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Yong Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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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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Giehl-Brown E, Geipel E, Löck S, Dehlke K, Schweipert J, Weitz J, Riediger C. Transfusions of packed red blood cells in surgery for liver cancer: predictor of impaired overall survival but not recurrence-free survival - impact of blood transfusions in liver surgery. J Gastrointest Surg 2024; 28:402-411. [PMID: 38583890 DOI: 10.1016/j.gassur.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/01/2023] [Accepted: 12/16/2023] [Indexed: 04/09/2024]
Abstract
BACKGROUND Liver surgery remains a cornerstone of potentially curative multimodal treatments for primary malignancies of the liver and hepatic metastases. Improving perioperative safety is a prerequisite in this context. Perioperative blood transfusions negatively influence postoperative recovery. This study aimed to identify risk factors for perioperative packed red blood cell (PRBC) transfusion and to elucidate its effect on postoperative outcomes. METHODS This was an observational study of a prospective data collection. A monocentric, retrospective analysis of 1118 hepatectomies at the University Hospital Carl Gustav Carus between 2013 and 2020 was conducted to compare postoperative short- and long-term outcomes in patients undergoing curative intended liver resection of hepatic primary or secondary malignancies. The outcomes were compared between 356 patients (31.8%) who received PRBC transfusions during surgery or within 7 days after surgery and 762 patients (68.2%) who did not receive PRBC transfusions. RESULTS Preoperative anemia could be observed in 45.0% of the whole cohort: 65.7% in the PRBC transfusion group and 35.3% in the nontransfused group. Postoperative complications were significantly more common in the PRBC transfusion group in association with prolonged lengths of hospital stay and increased 30-day mortality than in the nontransfused group. After adjustment for possible confounders, preexisting kidney failure, preoperative hemoglobin and albumin levels outside of the reference range, intraoperative plasma transfusions, and overall surgery time were recognized as negative predictors for perioperative PRBC transfusions. PRBC transfusion increased the risk of death by approximately 38.8% (hazard ratio, 1.388; 95% CI, 1.027-1.876; P = .033), whereas no influence on recurrence-free survival (RFS) was observed. CONCLUSION PRBC transfusions were associated with postoperative morbidity and mortality after curative-intended surgery for liver cancers and represented an independent poor prognostic indicator for overall survival but not for RFS.
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Affiliation(s)
- Esther Giehl-Brown
- Department of Visceral, Thoracic, and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases/University Cancer Center, Dresden, Germany; Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Eileen Geipel
- Department of Visceral, Thoracic, and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Steffen Löck
- National Center for Radiation Research in Oncology, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Karolin Dehlke
- Department of Visceral, Thoracic, and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases/University Cancer Center, Dresden, Germany; Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Johannes Schweipert
- Department of Visceral, Thoracic, and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases/University Cancer Center, Dresden, Germany; Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic, and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases/University Cancer Center, Dresden, Germany; Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic, and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases/University Cancer Center, Dresden, Germany; Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Duque P, Perez-Peña JM, Alarcon-Perez L, Olmedilla L, Varela JA, Pascual C, Rodriguez-Huerta AM, Asencio JM, Lopez-Baena JÁ, Garutti I. The link between high factor VIII to protein C ratio values and poor liver function after major hepatectomy. Blood Coagul Fibrinolysis 2024; 35:82-93. [PMID: 38305104 DOI: 10.1097/mbc.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Our goal was to assess the coagulation profile in the immediate postoperative time after major liver surgery and its association with the liver function. Our hypothesis is that a decreased synthesis of the coagulation factor levels reflects an impaired liver synthesis following hepatic resection and will be associated with poor outcomes. This is a prospective, observational study recruiting consecutive patients scheduled for major liver resection in a tertiary hospital. Coagulation profile was assessed by conventional assays, viscoelastic assays and coagulation factor levels preoperatively and, on postoperative days 1, 2 and 6. Factor VIII to protein C (FVIII/PC) ratio has been used as a surrogate marker of hemostatic imbalance. Liver function was measured with conventional and indocyanine green (ICG) clearance tests, which were obtained preoperatively and on postoperative days 1 and 2. Sixty patients were recruited and 51 were included in the study. There is a clear increase in FVIII/PC ratio after surgery, which was significantly associated with low liver function, being more pronounced beyond postoperative day 2 and in patients with poorer liver function ( P < 0.001). High FVIII/PC ratio values were significantly associated with higher postoperative morbidity, prolonged ICU and hospital stay and less survival ( P < 0.05). High FVIII/PC ratio on postoperative day 2 was found to be predictor of posthepatectomy liver failure (PHLF; area under the ROC curve = 0.8129). Early postoperative high FVIII/PC ratio values are associated with low liver function, PHLF and poorer outcomes in patients undergoing major hepatic resection.
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Affiliation(s)
- Patricia Duque
- Anesthesiology Department
- Gregorio Marañon Health Research Institute
| | | | | | - Luis Olmedilla
- Anesthesiology Department
- Gregorio Marañon Health Research Institute
| | | | | | | | - José Manuel Asencio
- General Surgery Department, Gregorio Marañon Hospital
- Gregorio Marañon Health Research Institute
- Medical Faculty, Complutense University, Madrid, Spain
| | - Jose Ángel Lopez-Baena
- General Surgery Department, Gregorio Marañon Hospital
- Gregorio Marañon Health Research Institute
| | - Ignacio Garutti
- Anesthesiology Department
- Gregorio Marañon Health Research Institute
- Medical Faculty, Complutense University, Madrid, Spain
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Nanashima A, Hiyoshi M, Imamura N, Hamada T, Tsuchimochi Y, Shimizu I, Ota Y, Furukawa K, Tsuneyoshi I. Measuring intraoperative anesthetic parameters during hepatectomy with inferior vena cava clamping. Langenbecks Arch Surg 2023; 408:455. [PMID: 38049533 DOI: 10.1007/s00423-023-03172-0] [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: 07/18/2023] [Accepted: 11/04/2023] [Indexed: 12/06/2023]
Abstract
PURPOSE Uncontrollable bleeding remained problematic in anatomical hepatectomy exposing hepatic veins. Based on the inferior vena cava (IVC) anatomy, we attempted to analyze the hemodynamic and surgical effects of the combined IVC-partial clamp (PC) accompanied with the Trendelenburg position (TP). METHODS We prospectively assessed 26 consecutive patients who underwent anatomical hepatectomies exposing HV trunks between 2020 and 2023. Patients were divided into three groups: use of IVC-PC (group 1), no use of IVC-PC (group 2), and use of IVC-PC accompanied with TP (group 3). In 10 of 26 patients (38%), hepatic venous pressure was examined using transhepatic catheter insertion. RESULTS IVC-PC was performed in 15 patients (58%). Operating time and procedures did not significantly differ between groups. A direct hemostatic effect on hepatic veins was evaluated in 60% and 70% of patients in groups 1 and 3, respectively. Group 1 showed significantly more unstable vital status and vasopressor use (p < 0.01). Blood or fluid transfusion and urinary output were similar between groups. Group 2 had a significantly lower baseline central venous pressure (CVP), while group 3 showed a significant increase in CVP in TP. CVP under IVC-PC seemed lower than under TP; however, not significantly. Hepatic venous pressure did not significantly differ between groups. Systolic arterial blood pressure significantly decreased via IVC-PC in group 1 and to a similar extent in group 3. Heart rate significantly increased during IVC-PC (p < 0.05). CONCLUSION IVC-PC combined with the TP may be an alternative procedure to control intrahepatic venous bleeding during anatomical hepatectomy exposing hepatic venous trunks.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan.
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
| | - Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
| | - Yuuki Tsuchimochi
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
| | - Ikko Shimizu
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
| | - Yusuke Ota
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
| | - Koji Furukawa
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
| | - Isao Tsuneyoshi
- Department of Anesthesiology, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, 5200, Japan
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Lima CMDF, Rebouças TO, Carlos LMDB, Oliveira JBF, Silva ELD, Alves JS, Lima CAD, Mesquita FP, Ribeiro JKC, Aquino PEAD, Brunetta DM, Garcia JHP, Viana Júnior AB. Assessment of the need for routine intraoperative cell salvage in liver transplantation. Acta Cir Bras 2023; 38:e386423. [PMID: 38055399 DOI: 10.1590/acb386423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/19/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE This study aimed to assess the necessity of routine intraoperative cell salvage in liver transplantations. METHODS A total of 327 liver transplants performed between 2014 and 2016 was included in the analysis. Patient data, including pre-transplant examinations, intraoperative red blood cell transfusions, and procedural information, were collected. RESULTS The median age of the patients was 54 years old, with 67% (219) being male. The most prevalent ABO blood type was O, accounting for 48% (155) of cases. The leading causes of liver disease were hepatitis C (113 cases, 34.6%) and alcohol-related liver disease (97 cases, 29.7%). Out of the 327 liver transplants, allogeneic red blood cell transfusions were administered in 110 cases (34%) with a median of two units of red blood cells per case. Cell salvage was employed in 237 transplants (73%), and successful blood recovery was achieved in 221 cases (93%). Among the group that recovered more than 200 mL of blood, the median volume of recovered blood was 417 mL, with no transfusion of allogeneic blood required. A total of 90 transplants was performed without utilizing cell salvage, and, among these cases, 19 required blood transfusions, with a median of zero units transfused. CONCLUSIONS This study suggests that routine cell salvage is unnecessary for all liver transplantations. The most suitable indication for its use is in patients presenting with portal vein thrombosis and abnormal creatinine levels.
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Affiliation(s)
| | | | | | | | | | | | - Clébia Azevedo de Lima
- Universidade Federal do Ceará - Hospital Universitário Walter Cantídio - Fortaleza (CE), Brazil
| | | | | | | | - Denise Menezes Brunetta
- Centro de Hematologia e Hemoterapia do Ceará - Fortaleza (CE), Brazil
- Universidade Federal do Ceará - Hospital Universitário Walter Cantídio - Fortaleza (CE), Brazil
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7
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Ye H, Wu H, Li B, Zuo P, Chen C. Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:89. [PMID: 36949393 PMCID: PMC10032024 DOI: 10.1186/s12871-023-02042-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Perioperative bleeding and allogeneic blood transfusion are generally thought to affect the outcomes of patients. This meta-analysis aimed to determine the benefits and risks of several cardiovascular interventions in patients undergoing hepatectomy. METHODS In this systematic review and meta-analysis, randomised controlled trials (RCTs) were searched in the Cochrane Library, Medline, Embase, and Web of Science to February 02, 2023. RCTs focused on cardiovascular interventions aimed at reducing blood loss or blood transfusion requirements during hepatectomy were included. The primary outcomes were perioperative blood loss amount, number of patients requiring allogeneic blood transfusion and overall occurrence of postoperative complications. The secondary outcomes were operating time, perioperative mortality rate, postoperative liver and kidney function and length of hospital stay. RESULTS Seventeen RCTs were included in the analysis. A total of 841 patients who underwent hepatectomy in 10 trials were included in the comparative analysis between low central venous pressure (CVP) and control groups. The forest plots showed a low operative bleeding volume [(mean difference (MD): -409.75 mL, 95% confidence intervals (CI) -616.56 to -202.94, P < 0.001], reduced blood transfusion rate [risk ratio (RR): 0.47, 95% CI 0.34 to 0.65, P < 0.001], shortened operating time (MD: -13.42 min, 95% CI -22.59 to -4.26, P = 0.004), and fewer postoperative complications (RR: 0.76, 95% CI 0.58 to 0.99, P = 0.04) in the low CVP group than in the control group. Five and two trials compared the following interventions, respectively: 'acute normovolaemic haemodilution (ANH) vs control' and 'autologous blood donation vs control'. ANH and autologous blood donation could not reduce the blood loss amount but greatly decreased the number of patients requiring allogeneic blood transfusion. No benefits were found in the rate of mortality and length of postoperative hospital stay in any of the comparisons. CONCLUSION Lowering the CVP seems to be effective and safe in adult patients undergoing hepatectomy. ANH and autologous blood donation should be used as a part of blood management for suitable patients in certain circumstances. TRIAL REGISTRATION PROSPERO, CRD42022314061.
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Affiliation(s)
- Hui Ye
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China.
| | - Hanghang Wu
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Bin Li
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China
| | - Pengfei Zuo
- Department of Cardiology, ZhongDa Hospital, Southeast University, Nanjing, China
| | - Chaobo Chen
- Department of General Surgery, Xishan People's Hospital of Wuxi city, No. 1128 Dacheng Road, Xishan District, Wuxi, 214105, China.
- Department of Hepatic-Biliary-Pancreatic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
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8
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Martel G, Lenet T, Wherrett C, Carrier FM, Monette L, Workneh A, Brousseau K, Ruel M, Chassé M, Collin Y, Vandenbroucke-Menu F, Hamel-Perreault É, Perreault MA, Park J, Lim S, Maltais V, Leung P, Gilbert RWD, Segedi M, Abou-Khalil J, Bertens KA, Balaa FK, Ramsay T, Fergusson DA. Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial. Trials 2023; 24:38. [PMID: 36653812 PMCID: PMC9848035 DOI: 10.1186/s13063-022-07008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.
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Affiliation(s)
- Guillaume Martel
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Tori Lenet
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christopher Wherrett
- grid.28046.380000 0001 2182 2255Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON Canada
| | - François-Martin Carrier
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada ,grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Leah Monette
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Aklile Workneh
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Karine Brousseau
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Monique Ruel
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Michaël Chassé
- grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Yves Collin
- grid.411172.00000 0001 0081 2808Division of General Surgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Franck Vandenbroucke-Menu
- grid.410559.c0000 0001 0743 2111Hepato-Pancreato-Biliary and Liver Transplantation Surgery Unit, Department of Surgery - Centre Hospitalier de l’Université de Montréal, Montréal, QC Canada
| | - Élodie Hamel-Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Michel-Antoine Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Jeieung Park
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Shirley Lim
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Véronique Maltais
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Philemon Leung
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Richard W. D. Gilbert
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Maja Segedi
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Jad Abou-Khalil
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A. Bertens
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Fady K. Balaa
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Tim Ramsay
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Dean A. Fergusson
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
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ERGENOĞLU P, ERSOY Z, ARIBOGAN A. Mesane kanserinde radikal sistektomi üriner diversiyon operasyonu yapılan hastalarda perioperatif parametrelerin değerlendirilmesi. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1053426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose: The aim of this study was to evaluate the effect of red blood cell transfusion and/or inotropic/vasopressor agent infusion during intraoperative and postoperative first 24-hour period on 30-day and one-year survival.
Materials and Methods: In the final analysis, 133 patients who underwent radical cystectomy and urinary diversion surgery between November 2011 and January 2019 were included in this study. Perioperative anesthesia management early postoperative intensive care patient follow-ups were based on.
Results: A statistically significant relationship was found between intraoperative red blood cell transfusion and one-year mortality rates. A statistically significant relationship was found between red blood cell transfusion in the intensive care unit and postoperative 30-day mortality rates. The relationship between vasopressor/inotrope agent infusion in intensive care unit and postoperative 30-day mortality was statistically significant.
Conclusion: In radical cystectomy and urinary diversion, intraoperative red blood cell and/or inotrope/vasopressor drug administration, and red blood cell transfusion within first 24 postoperative hours in intensive care unit are associated with lower survival rates in both early and late periods. Future studies should focus on developing and implementing different strategies for perioperative blood management and maintenance of patient hemodynamics that may affect early and late outcomes.
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Pulmonary infection after hepatic resection: Associated factors and impact on outcomes. Clin Res Hepatol Gastroenterol 2022; 46:101733. [PMID: 34146724 DOI: 10.1016/j.clinre.2021.101733] [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] [Received: 11/16/2020] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Postoperative pulmonary complications are frequent after hepatectomy. The aim of this retrospective study was to use preoperative and intraoperative data to establish specific factors associated with post-hepatectomy pneumonia (PHPN). METHODS Patients underwent minor or major hepatectomy for cancer or non-cancer treatment. Surgical procedure was performed by laparoscopy or laparotomy. PHPN was defined as a new radiologic finding associated with fever, leucocytosis and purulent bronchial secretions. The incidence, associated factors and prognosis of PHPN were investigated. RESULTS In 399 patients undergoing planned hepatectomy, 49 (12.3%) developed pneumonia. Of 81 patients (20.3%) with cirrhosis, 77 were Child-Pugh A and 4 were Child-Pugh B. Hepatectomy indication was cancer in 331 patients (of which metastasis in 213). Laparoscopy rate was 31.3%. In multivariate analysis, the main factors statistically associated with PHPN were: chronic obstructive pulmonary disease (COPD) (odds ratio [OR] = 4.17; 95% confidence interval [CI], 1.60-10.84; P = 0.003), intraoperative blood transfusion (OR = 2.46; 95% CI 1.01-5.70; P = 0.001), laparotomy (OR = 3.01; 95% CI 1.09-8.27; P = 0.03), and nasogastric tube maintained at day 1 (OR = 2.09; 95% CI 1.03-4.22; P = 0.04). Length of stay was significantly different between groups without PHPN (10.2 days) versus with PHPN (26.4 days; P < 0.001). Intra-hospital and one-year mortality were greater in the PHPN group than the pneumonia-free group (8.16 vs 0% and 18.4 vs 3.4%, respectively; P < 0.001). CONCLUSIONS COPD, transfusion and laparotomy (versus laparoscopy) are factors associated with PHPN and impaired survival.
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Muraki R, Morita Y, Ida S, Kitajima R, Furuhashi S, Takeda M, Kikuchi H, Hiramatsu Y, Fukazawa A, Sakaguchi T, Fukushima M, Okada E, Takeuchi H. Comparison of operative outcomes between monopolar and bipolar coagulation in hepatectomy: a propensity score-matched analysis in a single center. BMC Gastroenterol 2022; 22:154. [PMID: 35351001 PMCID: PMC8962169 DOI: 10.1186/s12876-022-02231-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/21/2022] [Indexed: 11/20/2022] Open
Abstract
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.
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Cao B, Hao P, Guo W, Ye X, Li Q, Su X, Li L, Zeng J. A predictive model for blood transfusion during liver resection. Eur J Surg Oncol 2022; 48:1550-1558. [DOI: 10.1016/j.ejso.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 01/07/2022] [Accepted: 01/14/2022] [Indexed: 10/19/2022] Open
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Kemper M, Heumann A, Freiwald-Bibiza E, Stüben BO, Izbicki JR, Li J. Liver surgery-specific complications are an independent factor influencing long-term survival following major hepatectomy. HPB (Oxford) 2021; 23:1496-1505. [PMID: 33865711 DOI: 10.1016/j.hpb.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/06/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND A severity grading system for liver surgery-specific complications, given the acronym FABIB, has been standardized to increase the feasibility and comparability of academic reports in liver surgery. Whether the FABIB score is associated with long-term survival following major hepatectomy has not been previously investigated. METHODS 297 consecutive patients who had undergone major hepatectomy between 2012 and 2019 were recruited. The postoperative complications were documented according to the FABIB system and, for comparison purposes, Clavien-Dindo classification. Their influence on 90-day mortality and long-term survival was analyzed retrospectively. RESULTS Taking the relevant confounders into account, the FABIB score was a robust factor associated with long-term survival after major hepatectomy: patients with high FABIB scores (≥6) had a 2.415-fold higher risk of death compared to patients with low FABIB scores (≤2) (P = 0.002). In contrast to that, the Clavien-Dindo Classification (grade III + IV vs. grade I + II) was not associated with survival in our cohort (P = 0.873). CONCLUSION Liver surgery-specific complications, measured by the FABIB system, impact long-term survival after major hepatectomy independent of relevant confounders. We propose the FABIB score as a composite endpoint for randomized controlled trials and a quality assessment tool in liver surgery.
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Affiliation(s)
- Marius Kemper
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Germany
| | - Asmus Heumann
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Germany
| | - Eric Freiwald-Bibiza
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Björn-Ole Stüben
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Germany
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Germany.
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Lee S, Namgoong JM, Kim Y, Cha J, Kim JK. Multimodal imaging of laser speckle contrast imaging combined with mosaic filter-based hyperspectral imaging for precise surgical guidance. IEEE Trans Biomed Eng 2021; 69:443-452. [PMID: 34260344 DOI: 10.1109/tbme.2021.3097122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To enable a real-time surgical guidance system that simultaneously monitors blood vessel perfusion, oxygen saturation, thrombosis, and tissue recovery by combining multiple optical imaging techniques into a single system: visible imaging, mosaic filter-based snapshot hyperspectral imaging (HSI), and laser speckle contrast imaging (LSCI). METHODS The multimodal optical imaging system was demonstrated by clamping blood vessels in the small intestines of rats to create areas of restricted blood flow. Subsequent tissue damage and regeneration were monitored during procedures. Using LSCI, vessel perfusion was measured, revealing the biological activity and survival of organ tissues. Blood oxygen saturation was monitored using HSI in the near-infrared region. Principal component analysis was used over the spectral dimension to identify an HSI wavelength combination optimized for hemodynamic biomarker visualization. HSI and LSCI were complimentary, identifying thrombus generation and tissue recovery, which was not possible in either modality alone. RESULTS AND CONCLUSION By analyzing multimodal tissue information from visible imaging, LSCI perfusion imaging, and HSI, a recovery prognosis could be determined based on the blood supply to the organ. The unique combination of the complementary imaging techniques into a single surgical microscope holds promise for improving the real-time determination of blood supply and tissue prognosis during surgery. SIGNIFICANCE Precise real-time monitoring for vascular anomalies promises to reduce the risk of organ damage in precise surgical operations such as tissue resection and transplantation. In addition, the convergence of label-free imaging technologies removes delays associated with the injection and diffusion of vascular monitoring dyes.
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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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Qi Q, Qian X, Zhu X, Cai J, Xia R, Zhang Q. Perioperative Transfusion is Related to the Length of Hospital Stays in Primary Liver Cancer Patients. Cancer Manag Res 2021; 13:4947-4954. [PMID: 34188547 PMCID: PMC8233480 DOI: 10.2147/cmar.s296022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Blood loss may be corrected with red blood cell transfusion, but may ultimately contribute to negative impacts. This study was a retrospective analysis to assess the impact of perioperative blood transfusion on hospital stay days in liver cancer patients. Methods We retrospectively examined data from patients with primary liver cancer who underwent curative resection. Patients were divided into perioperative blood transfusion (PBT) and non-PBT groups. Data were given as means and SDs for continuous variables and as counts and percentage for categorical variables. The correlation between blood transfusion and hospital stay days was analyzed by Fisher's exact test. Multivariable logistic regression analyses were used to identify independent predictors of length of hospital stays. Results Totally 206/1031 patients (20.3%) were given perioperative transfusion. The mean length of hospital stay was 17.8 days in PBT and 13.9 days in non-PBT groups. Our multivariable logistic regression showed transfusion, total bilirubin, indirect bilirubin, and the ratio of albumin to bilirubin were all indicators of the length of hospital stay days. Perioperative transfusion was also associated with prolonged length of hospital stays (95% CI: 0.395-0.811, p = 0.002). Transfusion also affected intrinsic coagulation factors (activated partial thromboplastin time, fibrinogen, platelet), inflammatory index (neutrocyte to lymphocyte ratio, monocyte), albumin and bilirubin levels. Conclusion Perioperative transfusion of blood was associated with a significantly increased length of hospital stays probably via changing intrinsic coagulation and inflammatory factors and bilirubin levels in plasma.
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Affiliation(s)
- Qi Qi
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Xuemeng Qian
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Xinfang Zhu
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Jiajing Cai
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Rong Xia
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Qi Zhang
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
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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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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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The impact of tranexamic acid on administration of red blood cell transfusions for resection of colorectal liver metastases. HPB (Oxford) 2021; 23:245-252. [PMID: 32641281 DOI: 10.1016/j.hpb.2020.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Red blood cell transfusions (RBCT) remain a concern for patients undergoing hepatectomy. The effect of tranexamic acid (TXA), an anti-fibrinolytic, on receipt of RBCT in colorectal liver metastases (CRLM) resection was examined. METHODS Hepatectomies for CRLM over 2009-2014 were included. Primary outcome was 30-day receipt of RBCT. Secondary outcomes were 30-day major morbidity (Clavien-Dindo III-V) and 90-day mortality. Multivariable modelling examined the adjusted association between TXA and outcomes. RESULTS Of 433 included patients, 146 (34%) received TXA. TXA patients were more likely to have inflow occlusion (41.8% vs. 23.1%; p < 0.01) and major hepatectomies (56.1% vs. 45.6%; p = 0.0193). TXA was independently associated with lower risk of RBCT (Relative risk (RR) 0.59; 95% confidence interval (95%CI): 0.42-0.85), but not with 30-day major morbidity (adjusted RR 1.02; 95%CI: 0.64-1.60) and 90-day mortality (univariable RR 0.99; 95%CI: 0.95-1.03). CONCLUSION Intraoperative TXA was associated with a 41% reduction in risk of 30 -day receipt of RBCT after hepatectomy for CRLM. This finding is important to potentially improve healthcare resource allocation and patient outcomes. Pending further evidence, intraoperative TXA may be an effective method of reducing RBCT in hepatectomy for CRLM.
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Koraki E, Mantzoros I, Chatzakis C, Gkiouliava A, Cheva A, Lavrentieva A, Sifaki F, Argiriadou H, Kesisoglou I, Galanos-Demiris K, Bitsianis S, Tsalis K. Metalloproteinase expression after desflurane preconditioning in hepatectomies: A randomized clinical trial. World J Hepatol 2020; 12:1098-1114. [PMID: 33312433 PMCID: PMC7701968 DOI: 10.4254/wjh.v12.i11.1098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/26/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatectomy with inflow occlusion results in ischemia-reperfusion injury; however, pharmacological preconditioning can prevent such injury and optimize the postoperative recovery of hepatectomized patients. The normal inflammatory response after a hepatectomy involves increased expression of metalloproteinases, which may signal pathologic hepatic tissue reformation.
AIM To investigate the effect of desflurane preconditioning on these inflammatory indices in patients with inflow occlusion undergoing hepatectomy.
METHODS This is a single-center, prospective, randomized controlled trial conducted at the 4th Department of Surgery of the Medical School of Aristotle University of Thessaloniki, between August 2016 and December 2017. Forty-six patients were randomized to either the desflurane treatment group for pharmacological preconditioning (by replacement of propofol with desflurane, administered 30 min before induction of ischemia) or the control group for standard intravenous propofol. The primary endpoint of expression levels of matrix metalloproteinases and their inhibitors was determined preoperatively and at 30 min posthepatic reperfusion. The secondary endpoints of neutrophil infiltration, coagulation profile, activity of antithrombin III (AT III), protein C (PC), protein S and biochemical markers of liver function were determined for 5 d postoperatively and compared between the groups.
RESULTS The desflurane treatment group showed significantly increased levels of tissue inhibitor of metalloproteinases 1 and 2, significantly decreased levels of matrix metalloproteinases 2 and 9, decreased neutrophil infiltration, and less profound changes in the coagulation profile. During the 5-d postoperative period, all patients showed significantly decreased activity of AT III, PC and protein S (vs baseline values, P < 0.05). The activity of AT III and PC differed significantly between the two groups from postoperative day 1 to postoperative day 5 (P < 0.05), showing a moderate drop in activity of AT III and PC in the desflurane treatment group and a dramatic drop in the control group. Compared to the control group, the desflurane treatment group also had significantly lower international normalized ratio values on all postoperative days (P < 0.005) and lower serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase values on postoperative days 2 and 3 (P < 0.05). Total length of stay was significantly less in the desflurane group (P = 0.009).
CONCLUSION Desflurane preconditioning can lessen the inflammatory response related to ischemia-reperfusion injury and may shorten length of hospitalization.
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Affiliation(s)
- Eleni Koraki
- Department of Anaesthesiology, “G Papanikolaou” General Hospital, Thessaloniki 57010, Greece
| | - Ioannis Mantzoros
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
| | - Christos Chatzakis
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
| | - Anna Gkiouliava
- Department of Anaesthesiology, “G Papanikolaou” General Hospital, Thessaloniki 57010, Greece
| | - Angeliki Cheva
- Department of Pathology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Athina Lavrentieva
- First Department of Intensive Care Unit, "G Papanikolaou" General Hospital, Thessaloniki 57010, Greece
| | - Freideriki Sifaki
- Department of Anaesthesiology, “G Papanikolaou” General Hospital, Thessaloniki 57010, Greece
| | - Helena Argiriadou
- Department of Anaesthesiology and Intensive Care Unit, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Isaak Kesisoglou
- Third Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | | | - Stefanos Bitsianis
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
| | - Konstantinos Tsalis
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
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David M, Levy E, Barshtein G, Livshits L, Arbell D, Ben Ishai P, Feldman Y. The dielectric spectroscopy of human red blood cells during 37-day storage: β-dispersion parameterization. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2020; 1862:183410. [PMID: 32687816 DOI: 10.1016/j.bbamem.2020.183410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 11/17/2022]
Abstract
This study exploits dielectric spectroscopy to monitor the kinetics of red blood cells (RBC) storage lesions, focusing on those processes linked to cellular membrane interface known as β-dispersion. The dielectric response of RBC suspensions, exposed to blood-bank cold storage for 37 days, was studied using time-domain dielectric spectroscopy in the frequency range 500 kHz to 200 MHz. The measured dielectric processes are characterized by their dielectric strength (Δε) and their relaxation times (τ). Changes in the dielectric properties of the RBC suspensions, due to storage-related biophysical changes, were evaluated. For a quantitative characterization of RBC vitality, we characterized the shape of fresh and stored RBC and measured their deformability as expressed by their average elongation ratio, which was achieved under a shear stress of 3.0 Pa. During the second week of storage, an increment in the evolution of the relaxation times and in the dielectric permittivity strength of about 25% was observed. We propose that the characteristic increment of ATP, during the second and third weeks of storage, is responsible for the raise of the specific capacitance of cell membrane, which in turn explains the changes observed in the dielectric response when combined with the influence of the shape changes.
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Affiliation(s)
- Marcelo David
- The Hebrew University of Jerusalem, Applied Physics Department, Jerusalem, Israel.
| | - Evgeniya Levy
- The Hebrew University of Jerusalem, Applied Physics Department, Jerusalem, Israel
| | - Gregory Barshtein
- The Hebrew University of Jerusalem, Faculty of Medicine, Department of Biochemistry & Molecular Biology, Jerusalem, Israel
| | - Leonid Livshits
- The Hebrew University of Jerusalem, Faculty of Medicine, Department of Biochemistry & Molecular Biology, Jerusalem, Israel
| | - Dan Arbell
- Pediatric Surgery, Hadassah Medical Center, Israel
| | - Paul Ben Ishai
- Department of Physics, Ariel University, P.O.B. 3, Ariel 40700, Israel
| | - Yuri Feldman
- The Hebrew University of Jerusalem, Applied Physics Department, Jerusalem, Israel.
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22
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Lammi JP, Eskelinen M, Tuimala J, Selander T, Saarnio J, Rantanen T. Perioperative changes in hemoglobin levels during major hepatopancreatic surgery in transfused and non-transfused patients. Scand J Surg 2020; 110:407-413. [PMID: 33118472 PMCID: PMC8551432 DOI: 10.1177/1457496920964362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Several studies have shown that restrictive transfusion policies are safe. However, in clinical practice, transfusion policies seem to be inappropriate. In order to assist in decision-making concerning red blood cell transfusions, we determined perioperative hemoglobin (Hb) levels during major pancreatic and hepatic operations. Methods: Patients who underwent major pancreatic or hepatic resections between 2002 and 2011 were classified into the transfused (TF+) and non-transfused (TF) groups. The perioperative Hb values of these patients were evaluated at six points in time. Results: The study included 1596 patients, of which 785 underwent pancreatoduodenectomy, 79 total pancreatectomy, and 732 partial hepatectomy. Similar perioperative changes in Hb levels were seen in all patients regardless of whether they received a blood transfusion. In patients undergoing pancreatoduodenectomy and total pancreatectomy, the median of the lowest measured hemoglobin values was 89.2 g/L and in partial hepatectomy patients 92.6 g/L, and these were assumed to be the trigger points for red blood cell transfusion. Conclusions: Despite guidelines on blood transfusion thresholds, restrictive blood transfusion policies were not observed during our study period. After major pancreatic and hepatic surgery, Hb levels recovered without transfusions. This should encourage clinicians to obey the restrictive blood transfusion policies after major hepatopancreatic surgery.
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Affiliation(s)
- J P Lammi
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Matti Eskelinen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland.,School of Medicine, University of Eastern Finland, Kuopio, Finland
| | | | - Tuomas Selander
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Juha Saarnio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tuomo Rantanen
- School of Medicine, University of Eastern Finland, P.O. Box 100, FI-70029 KYS, Finland
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23
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Jia LH, Ma XM, Yan QL, Wu XS, Chen Y, Ye QH, Wang ZJ, Qiu MM, Zhu JH. Autologous Blood Transfusion and Pringle Maneuver in Laparoscopic Segmental Hepatectomy for Benign Hepatic Neoplasms: A Retrospective Study. J Laparoendosc Adv Surg Tech A 2019; 29:1571-1576. [PMID: 31682205 DOI: 10.1089/lap.2019.0407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives: To investigate the effect of autologous blood transfusion (ABT) and Pringle maneuver (PM) on postoperative early liver function and short-term postoperative results following laparoscopic liver resection in patients with benign hepatic neoplasms. Materials and Methods: We retrospectively analyzed the clinical data for 125 consecutive patients who underwent laparoscopic segmental hepatectomy from January 2015 to May 2018 (68 in the ABT group versus 57 in the PM group). We compared patients' characteristics and intra- and postoperative short-term outcomes between the groups. Results: The 2 groups were well matched regarding patients' clinical characteristics, types of liver resection, operative time, and histopathological findings (P > .05). Median blood loss was significantly lower in the PM group versus the ABT group (200 mL versus 750 mL, respectively; P < .01), and overall complication rates were similar (n = 12 [17%] versus n = 9 [16%], respectively; P > .05). The ABT group had significantly lower mean levels of total bilirubin, indirect bilirubin, aspartate transaminase, and alanine aminotransferase on postoperative days 1 and 3 (P < .05). The ABT group had a shorter hospital stay compared with the PM group (5.8 days versus 7.7 days, respectively; P < .05) and lower hospitalization costs (55,400 ± 15,400 versus 667,000 ± 21,600 CN dollars, respectively; P < .05). Conclusions: Compared with Pringle's maneuver, laparoscopic hepatectomy with ABT promoted early recovery of liver function and reduced hospitalization costs in select patients with benign hepatic neoplasms.
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Affiliation(s)
- Li-Hua Jia
- Department of General Surgery, Jinhua Hospital of TCM, Jinhua, China
| | - Xiao-Ming Ma
- Department of General Surgery, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qiu-Liang Yan
- Department of General Surgery, Jinhua People's Hospital, Jinhua, China
| | - Xiang-Song Wu
- Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Chen
- Department of General Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qing-Huang Ye
- Department of General Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhi-Jiang Wang
- Department of General Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Man-Man Qiu
- Department of General Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jin-Hui Zhu
- Department of General Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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24
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Troisi RI, Pegoraro F, Giglio MC, Rompianesi G, Berardi G, Tomassini F, De Simone G, Aprea G, Montalti R, De Palma GD. Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints? Surg Oncol 2019; 33:239-248. [PMID: 31759794 DOI: 10.1016/j.suronc.2019.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023]
Abstract
The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.
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Affiliation(s)
- Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy; Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium.
| | - Francesca Pegoraro
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | | | - Giammauro Berardi
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Federico Tomassini
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Giuseppe De Simone
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Roberto Montalti
- Department of Public Health, Federico II University Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
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25
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MacGillivray DC. Invited Commentary. J Am Coll Surg 2019; 228:908-909. [PMID: 31128673 DOI: 10.1016/j.jamcollsurg.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
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26
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Tan HL, Goh BKP. The effect of preoperative low-calorie diets on liver resection outcomes. Transl Gastroenterol Hepatol 2019; 4:29. [PMID: 31231696 DOI: 10.21037/tgh.2019.04.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 12/30/2022] Open
Affiliation(s)
- Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore
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