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Liu TS, Shen QH, Zhou XY, Shen X, Lai L, Hou XM, Liu K. Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis. J Clin Anesth 2021; 75:110467. [PMID: 34343737 DOI: 10.1016/j.jclinane.2021.110467] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE Previous studies reported that controlled low central venous pressure (CVP) can reduce blood loss during liver resection. This systematic review and meta-analysis sought to explore the efficacy and safety of low CVP in patients undergoing hepatectomy. DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs). REVIEW METHODS RCTs were searched in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical database, Chinese Scientific Journals Database, and Wanfang database from inception to April 30, 2021. Subgroup analyses were performed based on different surgical methods (open hepatectomy vs laparoscopic hepatectomy) and published countries (China vs other countries). The quality of evidence was assessed by Grading of Recommendations, Assessment, Development, and Evaluation. MAIN RESULTS Eighteen RCTs containing 1285 participants (626 patients in the low CVP group and 659 patients in the control group) were included in this study. The forest plot showed that low CVP effectively reduced blood loss during liver resection compared with the control group (MD = -311.92 mL, 95% CI [-429.03, -194.81]; P < 0.001, I2 = 96%). Furthermore, blood transfusion volume (MD = -158.85 mL, 95% CI [-218.30, -99.40]; P < 0.001, I2 = 55%) and the number of patients requiring transfusion (RR 0.41, 95% CI 0.27-0.65, P < 0.001, I2 = 0%) were decreased in the low CVP group. Subgroup analyses showed similar results. Notably, the alanine transaminase level was significantly lower in the low CVP group during the first five postoperative days. However, no significant differences were observed for other postoperative liver function indicators (aspartate aminotransferase, total bilirubin, serum albumin, and prothrombin time), renal function indicators (blood urea nitrogen and serum creatinine) and perfusion parameters (heart rate, mean arterial pressure, and urine volume). The incidence of complications was similar between the two groups. CONCLUSION The findings of this study showed that low CVP is effective and safe during hepatectomy. Therefore, this technique is recommended to reduce blood loss during hepatectomy. PROSPERO registration number: CRD42021232829.
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Affiliation(s)
- Tie-Shuai Liu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310020, China
| | - Qi-Hong Shen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China.
| | - Xu-Yan Zhou
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Xu- Shen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Lan Lai
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Xiao-Min Hou
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Ke Liu
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
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Dou L, Meng WS, Su BD, Zhu P, Zhang W, Liang HF, Chen YF, Chen XP. Step-by-step Vascular Control for Extracapsular Resection of Complex Giant Liver Hemangioma Involving the Inferior Vena Cava. Am Surg 2020. [DOI: 10.1177/000313481408000111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Massive hemorrhage remains an important clinical problem in extracapsular resection of giant liver hemangiomas (GLHs), especially for those involving the proximal hepatic veins and/or inferior vena cava. Between July 2004 and March 2012, 87 patients with a complex GLH scheduled for surgical treatment were included in this study. All patients were underwent vascular preparation (Step 1), advanced hepatic artery clamping (Step 2), and stepwise vascular occlusion (Step 3). Intraoperative blood loss, blood transfusion volume, degree of ischemia–reperfusion injury, and postoperative complications were recorded. No patients required urgent vascular preparation to manage intraoperative bleeding. In total, 87, 64, and 21 patients had portal triad (PT), infra-hepatic inferior vena cava (IVC), and suprahepatic IVC preparation; and 17, 43, and 11 patients had PT, PTand suprahepatic IVC, and all three (PT, infra-, and suprahepatic IVC) occlusions. The PT, infrahepatic IVC, and SIVC occlusion times were 12.1 ± 3.7 minutes, 7.9 ± 2.4 minutes, and 3.2 ± 1.4 minutes, respectively. Mean blood loss was 291.9 ± 124.5 mL, and only four patients received blood transfusions. No patients had life-threatening complications or died (Clavien-Dindo Grade 4, 5). Compared with paralleled studies, this technique has an advantage to decrease the blood loss in less liver ischemia time. For complex GLH resections, the described step-by-step vascular control technique was efficacious and feasible for controlling intraoperative bleeding.
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Affiliation(s)
- Lei Dou
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Wei-Shan Meng
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Bao-Dong Su
- Department of Hepato-biliary Surgery, Weifang Renmin Hospital, Weifang, China
| | - Peng Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Hui-Fang Liang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Yi-Fa Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, China
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Wang F, Sun D, Zhang N, Chen Z. The efficacy and safety of controlled low central venous pressure for liver resection: a systematic review and meta-analysis. Gland Surg 2020; 9:311-320. [PMID: 32420255 DOI: 10.21037/gs.2020.03.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Application of controlled low central venous pressure (LCVP) in liver resection growing in popularity, but its efficacy and safety are still controversial. Our objectives were to assess and compare the efficacy, feasibility, and safety of controlled LCVP in patients undergoing liver resection. Methods The PubMed, Cochrane library, and EMBASE databases were systematically searched for all the relevant studies regardless of study design. We evaluated the methodological quality of the included studies and excluded studies of poor quality. Moreover, we applied a systematic review and meta-analysis by using RevMan 5.3 software to compare the efficacy and safety of LCVP vs. standard CVP for liver resection. Outcomes included operation time, blood loss, blood infusion, fluid infusion, urinary volume, postoperative complication rates, and hospital stay. Results In total, 10 studies, involving 324 patients undergoing liver resection with controlled LCVP, were identified. Meta-analysis displayed that blood loss in the LCVP group was dramatically less than that in the control group (standard CVP group, mean difference (MD): -581.68; 95% CI: -886.32 to -277.05; P=0.0002). Moreover, blood transfusion in the LCVP group was also markedly less than that in the control group (MD: -179.16; 95% CI: -282.00 to -76.33; P=0.0006). However, there was no difference between LCVP group and control group in operation time (MD: -16.24; 95% CI: -39.56 to 7.09; P=0.17), fluid infusion (MD: -287.89; 95% CI: -1,054.47 to 478.69; P=0.46), urinary volume (MD: -26.88; 95% CI: -87.14 to 33.37; P=0.38), ALT (MD: -58.66; 95% CI: -153.81 to 36.50; P=0.23), TBIL (MD: -0.32; 95% CI: -3.93 to 3.28; P=0.86), BUN (MD: -0.13; 95% CI: -0.73 to 0.47; P=0.67), CR (MD: 1.87; 95% CI: -4.90 to 8.63; P=0.59), postoperative complication rates (MD: 0.62; 95% CI: 0.44 to 0.90; P=0.01) and hospital stay (MD: -0.61; 95% CI: -1.68 to 0.46; P=0.26). Conclusions Compared with the control, controlled LCVP showed comparable efficacy and safety for the treatment during liver resection.
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Affiliation(s)
- Feiran Wang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Dongwei Sun
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Nannan Zhang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Zhong Chen
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
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Dong ZT, Luo KL, Wu GZ, Li JM, Zhou MT. Application of selective semi-hepatic vascular occlusion combined with low central venous pressure in hepatectomy. Shijie Huaren Xiaohua Zazhi 2013; 21:541-546. [DOI: 10.11569/wcjd.v21.i6.541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the application of selective semi-hepatic vascular occlusion combined with low central venous pressure (LCVP) in hepatectomy, and to analyze its effect on liver and kidney function and systemic haemodynamics.
METHODS: The clinical data for 44 patients with liver diseases who underwent hepatectomy from January 2008 to January 2011 at our hospital were retrospectively analyzed. The patients were randomly divided into an experimental group (group A, n = 22) and a control group (Group B, n = 22). When patients in Group A underwent hepatectomy, the central venous pressure (CVP) was controlled between 2-4 mm Hg (1 mmHg = 0.133 kPa) and blood pressure ≥ 90 mmHg, and selective semi-hepatic vascular occlusion was performed. Conventional surgical treatment was given to patients in group B. Intraoperative blood loss, blood pressure, heart rate, changes in liver and kidney function, postoperative hospital stay, and postoperative complications were compared between the two groups.
RESULTS: Intraoperative blood loss was significantly lower in group A than in group B (350.2 mL ± 175.4 mL vs 450.3 mL ± 135.1 mL, P < 0.05). Serum alanine aminotransferase (ALT) was significantly better in group A than in group B on postoperative days 1 and 3 (day 1: 514.3 U/L ± 215.6 U/L vs 720.2 U/L ± 350.7 U/L, P < 0.05; day 3: 360.1 U/L ± 146.4 U/L vs 489.1 U/L ± 231.5 U/L, P < 0.05). Serum albumin (ALB) on postoperative day 1 was significantly higher in group A than in group B (37.5 g/L ± 2.2 g/L vs 35.4 g/L ± 3.9 g/L, P < 0.05). There were no statistical differences in intraoperative blood pressure (131.1 mmHg ± 18.8 mmHg vs 129.2 mmHg ± 14.7 mmHg, P > 0.05), heart rate (83.1 times/min ± 11.2 times/min vs 75.4 times/min ± 12.3 times/min, P > 0.05), postoperative renal function (P > 0.05), hospital stay (11.3 d ± 2.4 d vs 12.1 d ± 2.2 d, P > 0.05) or rate of complications (18.2% vs 22.7%, P > 0.05) between the two groups.
CONCLUSION: During hepatectomy, selective semi-hepatic vascular occlusion combined with low central venous pressure is effective in reducing intraoperative blood loss, protecting liver function, reducing ischemia-reperfusion injury, and has no significant influence on renal function, postoperative hospital stay and systemic hemodynamics.
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Cata JP, Gottumukkala V. Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know? ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/918938] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive oncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state; however, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant drugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication of all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood transfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor embolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to prevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is largely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus, recommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted.
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Affiliation(s)
- Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA
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Ezzat TM, Dhar DK, Newsome PN, Malagó M, Olde Damink SWM. Use of hepatocyte and stem cells for treatment of post-resectional liver failure: are we there yet? Liver Int 2011; 31:773-84. [PMID: 21645208 DOI: 10.1111/j.1478-3231.2011.02530.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Post-operative liver failure following extensive resections for liver tumours is a rare but significant complication. The only effective treatment is liver transplantation (LT); however, there is a debate about its use given the high mortality compared with the outcomes of LT for chronic liver diseases. Cell therapy has emerged as a possible alternative to LT especially as endogenous hepatocyte proliferation is likely inhibited in the setting of prior chemo/radiotherapy. Both hepatocyte and stem cell transplantations have shown promising results in the experimental setting; however, there are few reports on their clinical application. This review identifies the potential stem cell sources in the body, and highlights the triggering factors that lead to their mobilization and integration in liver regeneration following major liver resections.
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Affiliation(s)
- Tarek M Ezzat
- HPB and Liver Transplantation Surgery, Royal Free Hospital, University College London, Pond Street, London, UK
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Reddy SK, Barbas AS, Turley RS, Steel JL, Tsung A, Marsh JW, Geller DA, Clary BM. A standard definition of major hepatectomy: resection of four or more liver segments. HPB (Oxford) 2011; 13:494-502. [PMID: 21689233 PMCID: PMC3133716 DOI: 10.1111/j.1477-2574.2011.00330.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND While commonly used to describe liver resections at risk for post-operative complications, no standard definition of 'major hepatectomy' exists. The objective of the present retrospective study is to specify the extent of hepatic resection that should describe a major hepatectomy. METHODS Demographics, diagnoses, surgical treatments and outcomes from patients who underwent a liver resection at two high-volume centres were reviewed. RESULTS From 2002 to 2009, 1670 patients underwent a hepatic resection. Post-operative mortality and severe, overall and hepatic-related morbidity occurred in 4.4%, 29.7%, 41.6% and 19.3% of all patients. Mortality (7.4% vs. 2.7% vs. 2.6%) and severe (36.7% vs. 24.7% vs. 24.1%), overall (49.3% vs. 40.6% vs. 35.9%) and hepatic-related (25.6% vs. 16.4% vs. 15.2%) morbidity were more common after resection of four or more liver segments compared with after three or after two or fewer segments (all P < 0.001). There were no significant differences in any post-operative outcome after resection of three and two or fewer segments (all P > 0.05). On multivariable analysis, resection of four or more liver segments was independently associated with post-operative mortality and severe, overall, and hepatic-related morbidity (all P < 0.01). CONCLUSIONS A major hepatectomy should be defined as resection of four or more liver segments.
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Affiliation(s)
- Srinevas K Reddy
- University of Pittsburgh Medical Center, Liver Cancer CenterPittsburgh, PA
| | - Andrew S Barbas
- Duke University Medical Center, Department of Surgery, Searle CenterDurham, NC, USA
| | - Ryan S Turley
- Duke University Medical Center, Department of Surgery, Searle CenterDurham, NC, USA
| | - Jennifer L Steel
- University of Pittsburgh Medical Center, Liver Cancer CenterPittsburgh, PA
| | - Allan Tsung
- University of Pittsburgh Medical Center, Liver Cancer CenterPittsburgh, PA
| | - J Wallis Marsh
- University of Pittsburgh Medical Center, Liver Cancer CenterPittsburgh, PA
| | - David A Geller
- University of Pittsburgh Medical Center, Liver Cancer CenterPittsburgh, PA
| | - Bryan M Clary
- Duke University Medical Center, Department of Surgery, Searle CenterDurham, NC, USA
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