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Abstract
This article will focus on the perioperative management of hepatic resection for colorectal cancer (CRC) liver metastases (CLRMs) (the liver is the dominant metastatic site for CRC) within the context of the Enhanced Recovery After Surgery (ERAS) paradigm. It discusses the epidemiology and outcomes along with the history of hepatic resection surgery and pertinent anatomy. The discussion of the preoperative phase includes patient selection, assessment of liver functional status, and new developments in prehabilitation. The intraoperative phase details developments in surgical and anesthetic techniques to minimize liver hemorrhage and reduce the risk of postoperative hepatic failure. Newer analgesic options are included. Management of potential complications is outlined in the postoperative section followed by a description of current evidence for ERAS and future directions.
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Affiliation(s)
- Anton Krige
- Department of Anaesthesia and Critical Care, Royal Blackburn Teaching Hospital, Haslingden Road, Blackburn BB2 3HH, UK.
| | - Leigh J S Kelliher
- Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7AS, UK
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Nakanuma S, Tajima H, Takamura H, Sakai S, Gabata R, Okazaki M, Shinbashi H, Ohbatake Y, Makino I, Hayashi H, Miyashita T, Fushida S, Ohta T. Pretreatment with a Phosphodiesterase-3 Inhibitor, Milrinone, Reduces Hepatic Ischemia-Reperfusion Injury, Minimizing Pericentral Zone-Based Liver and Small Intestinal Injury in Rats. Ann Transplant 2020; 25:e922306. [PMID: 32661218 PMCID: PMC7380127 DOI: 10.12659/aot.922306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Severe pericentral zone (zone 3)-based liver injury (LI) may become intractable, with allograft dysfunction after liver transplantation. The phosphodiesterase-3 inhibitor, milrinone, has been reported to attenuate hepatic ischemia-reperfusion injury (IRI). This study clarified how hepatic IRI involved zone 3-based LI, in which zone milrinone was effective, and whether milrinone could improve small intestinal injury (SII) with hepatic IRI. MATERIAL AND METHODS Rats were divided into sham, ischemia-reperfusion (IR), or IR+milrinone groups (n=13 per group). Milrinone was administered intraportally via intrasplenic injection, and whole hepatic ischemia was induced for 30 min. Five hours after reperfusion, serum chemistry and histopathological findings were compared. Expression of CD34 for the detection of altered sinusoidal endothelium as sinusoidal capillarization and cleaved caspase-3 as an apoptosis marker were analyzed via immunohistochemistry. Survival rates were examined after 45 min of whole hepatic ischemia. RESULTS Serum aspartate aminotransferase and direct bilirubin levels were significantly decreased in the IR+milrinone group compared with those of the IR group. The degree of LI, sinusoidal capillarization and apoptosis at zone 3 in the IR group was significantly increased compared with those at the periportal zone (zone 1). These findings at zone 3 in the IR group were improved in the IR+milrinone group. SII with villus congestion and apoptosis in the IR group was significantly attenuated in the IR+milrinone group. The 7-day survival rate was significantly elevated in the IR+milrinone group as compared with that of the IR group. CONCLUSIONS A hepatic IRI model caused zone 3-based LI and SII, which were attenuated by intraportal administration of milrinone.
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Affiliation(s)
- Shinichi Nakanuma
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hidehiro Tajima
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Seisho Sakai
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Ryosuke Gabata
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Mitsuyoshi Okazaki
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Shinbashi
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Yoshinao Ohbatake
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Isamu Makino
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hironori Hayashi
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama City, Toyama, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Sachio Fushida
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Tetsuo Ohta
- Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
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Yoshioka M, Taniai N, Kawano Y, Shimizu T, Kondo R, Kaneya Y, Aoki Y, Yoshida H. Effectiveness of Laparoscopic Repeat Hepatectomy for Recurrent Liver Cancer. J NIPPON MED SCH 2019; 86:222-229. [DOI: 10.1272/jnms.jnms.2019_86-410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Masato Yoshioka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
| | - Nobuhiko Taniai
- Department of Gastroenterological Surgery, Nippon Medical School Musashi Kosugi Hospital
| | - Youichi Kawano
- Department of Gastroenterological Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Tetsuya Shimizu
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
| | - Ryota Kondo
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
| | - Yohei Kaneya
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
| | - Yuto Aoki
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
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Lee JH, Park KM, Lee YJ, Kim JH, Kim SH. A New Chemical Compound, NecroX-7, Acts as a Necrosis Modulator by Inhibiting High-Mobility Group Box 1 Protein Release During Massive Ischemia-Reperfusion Injury. Transplant Proc 2016; 48:3406-3414. [PMID: 27931589 DOI: 10.1016/j.transproceed.2016.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/21/2016] [Accepted: 09/14/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Necrotic cell death is common in a wide variety of pathologic conditions, including ischemia-reperfusion (IR) injury. The aim of this study was to develop an IR injury-induced hepatic necrosis model in dogs by means of selective left hepatic inflow occlusion and to test the efficacy of a new chemical compound, NecroX-7, against the IR injury-induced hepatic damage. METHODS A group of male Beagle dogs received intravenous infusions of either vehicle or different doses of NecroX-7 (1.5, 4.5, or 13 mg/kg) for a 20-minute period before a 90-minute left hepatic inflow occlusion followed by reperfusion. RESULTS The gross morphology in the NecroX-7-treated groups after occlusion appeared to be less congested and less swollen than that in vehicle-treated control group. Circulating alanine transaminase and aspartate transaminase levels in the control group were elevated during the course of IR, and were effectively blocked in the 4.5 and 13 mg/kg NecroX-7-treated groups. The serum levels of high-mobility group box 1 protein showed a peak at 8 hours after occlusion in control group, and this elevation was significantly blunted by 4.5 mg/kg NecroX-7 treatment. Histologic analysis showed a marked ischemia or IR injury-induced hepatocytic degenerations, sinusoidal and portal vein congestions, and inflammatory cell infiltrations in the control group, whereas the treatment groups showed significantly diminished histopathology in a dose-dependent manner. CONCLUSIONS These results demonstrated that NecroX-7 attenuated the hepatocyte lethality caused by hepatic IR injury in a large animal setting. We conclude that NecroX-7 may provide a wide variety of therapeutic options for IR injury in human patients.
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Affiliation(s)
- J H Lee
- Department of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - K M Park
- Department of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.
| | - Y J Lee
- Department of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - J H Kim
- Department of Pathology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - S H Kim
- LG Life Sciences, Daejeon, Korea
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Simillis C, Robertson FP, Afxentiou T, Davidson BR, Gurusamy KS. A network meta-analysis comparing perioperative outcomes of interventions aiming to decrease ischemia reperfusion injury during elective liver resection. Surgery 2016; 159:1157-69. [DOI: 10.1016/j.surg.2015.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 09/05/2015] [Accepted: 10/01/2015] [Indexed: 12/12/2022]
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Siu J, McCall J, Connor S. Systematic review of pathophysiological changes following hepatic resection. HPB (Oxford) 2014; 16:407-21. [PMID: 23991862 PMCID: PMC4008159 DOI: 10.1111/hpb.12164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Major hepatic resection is now performed frequently and with relative safety, but is accompanied by significant pathophysiological changes. The aim of this review is to describe these changes along with interventions that may help reduce the risk for adverse outcomes after major hepatic resection. METHODS The MEDLINE, EMBASE and CENTRAL databases were searched for relevant literature published from January 2000 to December 2011. Broad subject headings were 'hepatectomy/', 'liver function/', 'liver failure/' and 'physiology/'. RESULTS Predictable changes in blood biochemistry and coagulation occur following major hepatic resection and alterations from the expected path indicate a complicated course. Susceptibility to sepsis, functional renal impairment, and altered energy metabolism are important sequelae of post-resection liver failure. CONCLUSIONS The pathophysiology of post-resection liver failure is difficult to reverse and thus strategies aimed at prevention are key to reducing morbidity and mortality after liver surgery.
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Affiliation(s)
- Joey Siu
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
| | - John McCall
- Department of Surgery, Dunedin HospitalDunedin, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand,Correspondence Saxon Connor, Department of Surgery, Christchurch Hospital, Christchurch 8011, New Zealand. Tel: + 64 3 364 0640. Fax: + 64 3 364 0352. E-mail:
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Affiliation(s)
- Jin Woo Shin
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Mpabanzi L, Mierlo KMC, Malagó M, Dejong CHC, Lytras D, Olde Damink SWM. Surrogate endpoints in liver surgery related trials: a systematic review of the literature. HPB (Oxford) 2013; 15:327-36. [PMID: 23323939 PMCID: PMC3633033 DOI: 10.1111/j.1477-2574.2012.00590.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/30/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although the safety of liver surgery has improved enormously, hepatic surgery continues to face challenging complications. Therefore, improvements supported by evidence-based guidelines are still required. The conduct of randomized controlled trials in liver surgery using dichotomous outcomes requires a large sample size. The use of surrogate endpoints (SEPs) reduces sample size but SEPs should be validated before use. AIM The aim of this review was to summarize the SEPs used in hepatic surgery related trials, their definitions and recapitulating the evidence validating their use. METHOD A systematic computerized literature search in the biomedical database PubMed using the MeSH terms 'hepatectomy' or 'liver resection' or 'liver transection' was conducted. Search was limited to papers written in the English language and published between 1 January 2000 and 1 January 2010. RESULTS A total of 593 articles met the search terms and 49 articles were included in the final selection. Standard biochemical liver functions tests were the most frequently used SEP (32 of 49 the studies). The used definitions of SEPs varied greatly among the studies. Most studies referred to earlier published material to justify their choice of SEP. However, no validating studies were found. CONCLUSION Many SEPs are used in liver surgery trials however there is little evidence validating them.
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Affiliation(s)
- Liliane Mpabanzi
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands,Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK
| | - Kim MC Mierlo
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands
| | - Massimo Malagó
- Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK
| | - Cornelis HC Dejong
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands
| | - Dimitrios Lytras
- Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK
| | - Steven WM Olde Damink
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands,Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK,Correspondence Steven W.M. Olde Damink, Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands. Tel: 31 43 387 74 89. Fax: 31 43 387 54 73. E-mail:
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Page AJ, Kooby DA. Perioperative management of hepatic resection. J Gastrointest Oncol 2012; 3:19-27. [PMID: 22811866 PMCID: PMC3397643 DOI: 10.3978/j.issn.2078-6891.2012.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 01/12/2012] [Indexed: 12/19/2022] Open
Affiliation(s)
- Andrew J Page
- Department of Surgery, Emory University, Atlanta, Georgia, USA
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Nickkholgh A, Schneider H, Sobirey M, Venetz WP, Hinz U, Pelzl LH, Gotthardt DN, Cekauskas A, Manikas M, Mikalauskas S, Mikalauskene L, Bruns H, Zorn M, Weigand MA, Büchler MW, Schemmer P. The use of high-dose melatonin in liver resection is safe: first clinical experience. J Pineal Res 2011; 50:381-8. [PMID: 21480979 DOI: 10.1111/j.1600-079x.2011.00854.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Experimental data suggest that melatonin decreases inflammatory changes after major liver resection, thus positively influencing the postoperative course. To assess the safety of a preoperative single dose of melatonin in patients undergoing major liver resection, a randomized controlled double-blind pilot clinical trial with two parallel study arms was designed at the Department of General and Transplantation Surgery, Ruprecht-Karls-University, Heidelberg. A total of 307 patients, who were referred for liver surgery, were screened. One hundred and thirteen patients, for whom a major liver resection (≥3 segments) was scheduled, were eligible. Sixty-three eligible patients refused to participate, and therefore, 50 patients were randomized. A preoperative single dose of melatonin (50 mg/kg BW) dissolved in 250 mL of milk was administered through the gastric tube after the intubation for general anesthesia. Controls were given the same amount of microcrystalline cellulose. Primary endpoint was safety. Secondary endpoints were postoperative complications. Melatonin was effectively absorbed with serum concentrations of 1142.8 ± 7.2 ng/mL (mean ± S.E.M.) versus 0.3 ± 7.8 ng/mL in controls (P < 0.0001). Melatonin treatment resulted in lower postoperative transaminases over the study period (P = 0.6). There was no serious adverse event in patients after melatonin treatment. A total of three infectious complications occurred in either group. A total of eight noninfectious complications occurred in five control patients, whereas three noninfectious complications occurred in three patients receiving preoperative melatonin (P = 0.3). There was a trend toward shorter ICU stay and total hospital stay after melatonin treatment. Therefore, a single preoperative enteral dose of melatonin is effectively absorbed and is safe and well tolerated in patients undergoing major liver surgery.
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Affiliation(s)
- Arash Nickkholgh
- Department of General and Transplantation Surgery, Ruprecht-Karls-University, Heidelberg, Germany
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Yoo H, Kim JH, Ko GY, Kim KW, Gwon DI, Lee SG, Hwang S. Sequential transcatheter arterial chemoembolization and portal vein embolization versus portal vein embolization only before major hepatectomy for patients with hepatocellular carcinoma. Ann Surg Oncol 2010; 18:1251-7. [PMID: 21069467 DOI: 10.1245/s10434-010-1423-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of sequential transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) prior to surgery in hepatocellular carcinoma (HCC) patients and to compare the clinical outcome of the combined procedure with that of a matched group of patients undergoing PVE alone. PATIENTS AND METHODS From 1997 to 2008, 135 patients with HCC underwent sequential TACE and PVE (n = 71) or PVE alone (n = 64) before right hepatectomy. PVE was performed mean 1.2 months after TACE. In both groups, computed tomography (CT) and liver volumetry were performed before and 2 weeks after PVE to assess degree of left lobe hypertrophy. RESULTS Baseline patient and tumor characteristics were similar in the two groups. After PVE, the chronological changes of liver enzymes were similar in the two groups. The mean increase in percentage future liver remnant (FLR) volume was higher in the TACE + PVE group (7.3%) than in the PVE-only group (5.8%) (P = 0.035). After surgery, incidence of hepatic failure was higher in the PVE-only group (12%) than in the TACE + PVE (4%) group (P = 0.185). Overall (P = 0.028) and recurrence-free (P = 0.001) survival rates were significantly higher in the TACE + PVE group than in the PVE-only group. CONCLUSION Sequential TACE and PVE before surgery is a safe and effective method to increase the rate of hypertrophy of the FLR and leads to longer overall and recurrence-free survival in patients with HCC.
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Affiliation(s)
- Hyunkyung Yoo
- Department of Radiology, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
BACKGROUND Vascular occlusion to prevent haemorrhage during liver resection causes ischaemia-reperfusion (IR) injury. Insights into the mechanisms of IR injury gathered from experimental models have contributed to the development of therapeutic approaches, some of which have already been tested in randomized clinical trials. METHODS The review was based on a PubMed search using the terms 'ischemia AND hepatectomy', 'ischemia AND liver', 'hepatectomy AND drug treatment', 'liver AND intermittent clamping' and 'liver AND ischemic preconditioning'; only randomized controlled trials (RCTs) were included. RESULTS Twelve RCTs reported on ischaemic preconditioning and intermittent clamping. Both strategies seem to confer protection and allow extension of ischaemia time. Fourteen RCTs evaluating pharmacological interventions, including antioxidants, anti-inflammatory drugs, vasodilators, pharmacological preconditioning and glucose infusion, were identified. CONCLUSION Several strategies to prevent hepatic IR have been developed, but few have been incorporated into clinical practice. Although some pharmacological strategies showed promising results with improved clinical outcome there is not sufficient evidence to recommend them.
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Affiliation(s)
- R Bahde
- Surgical Research, Department of General and Visceral Surgery, Muenster University Hospital, Waldeyer Strasse 1, D-48149 Muenster, Germany
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Abu-Amara M, Gurusamy K, Hori S, Glantzounis G, Fuller B, Davidson BR. Systematic review of randomized controlled trials of pharmacological interventions to reduce ischaemia-reperfusion injury in elective liver resection with vascular occlusion. HPB (Oxford) 2010; 12:4-14. [PMID: 20495639 PMCID: PMC2814398 DOI: 10.1111/j.1477-2574.2009.00120.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2009] [Accepted: 07/09/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vascular occlusion during liver resection results in ischaemia-reperfusion (IR) injury, which can lead to liver dysfunction. We performed a systematic review and meta-analysis to assess the benefits and harms of using various pharmacological agents to decrease IR injury during liver resection with vascular occlusion. METHODS Randomized clinical trials (RCTs) evaluating pharmacological agents in liver resections conducted under vascular occlusion were identified. Two independent reviewers extracted data on population characteristics and risk of bias in the trials, and on outcomes such as postoperative morbidity, hospital stay and liver function. RESULTS A total of 18 RCTs evaluating 17 different pharmacological interventions were identified. There was no significant difference in perioperative mortality, liver failure or postoperative morbidity between the intervention and control groups in any of the comparisons. A significant improvement in liver function was seen with methylprednisolone use. Hospital and intensive therapy unit stay were significantly shortened with trimetazidine and vitamin E use, respectively. Markers of liver parenchymal injury were significantly lower in the methylprednisolone, trimetazidine, dextrose and ulinastatin groups compared with their respective controls (placebo or no intervention). DISCUSSION Methylprednisolone, trimetazidine, dextrose and ulinastatin may have protective roles against IR injury in liver resection. However, based on the current evidence, they cannot be recommended for routine use and their application should be restricted to RCTs.
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Affiliation(s)
- Mahmoud Abu-Amara
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Kurinchi Gurusamy
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Satoshi Hori
- Department of Urology, Addenbrooke's HospitalCambridge, UK
| | - George Glantzounis
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Barry Fuller
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Brian R Davidson
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
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Abu-Amara M, Gurusamy KS, Hori S, Glantzounis G, Fuller B, Davidson BR. Pharmacological interventions versus no pharmacological intervention for ischaemia reperfusion injury in liver resection surgery performed under vascular control. Cochrane Database Syst Rev 2009:CD007472. [PMID: 19821421 DOI: 10.1002/14651858.cd007472.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vascular occlusion to reduce blood loss is used during elective liver resection but results in significant ischaemia reperfusion injury. This, in turn, might lead to significant postoperative liver dysfunction and morbidity. Various pharmacological drugs have been used with an intention to ameliorate the ischaemia reperfusion injury in liver resections. OBJECTIVES To assess the benefits and harms of different pharmacological agents versus no pharmacological interventions to decrease ischaemia reperfusion injury during liver resections where vascular occlusion was performed during the surgery. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2009. SELECTION CRITERIA We included randomised clinical trials, irrespective of language or publication status, comparing any pharmacological agent versus placebo or no pharmacological agent during elective liver resections with vascular occlusion. DATA COLLECTION AND ANALYSIS Two authors independently identified trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis or available case analysis. MAIN RESULTS We identified a total of 15 randomised trials evaluating 11 different pharmacological interventions (methylprednisolone, multivitamin antioxidant infusion, vitamin E infusion, amrinone, prostaglandin E1, pentoxifylline, mannitol, trimetazidine, dextrose, allopurinol, and OKY 046 (a thromboxane A2 synthetase inhibitor)). All trials had high risk of bias. There were no significant differences between the groups in mortality, liver failure, or perioperative morbidity. The trimetazidine group had a significantly shorter hospital stay than control (MD -3.00 days; 95% CI -3.57 to -2.43). There were no significant differences in any of the clinically relevant outcomes in the remaining comparisons. Methylprednisolone improved the enzyme markers of liver function and trimetazidine, methylprednisolone, and dextrose reduced the enzyme markers of liver injury compared with controls. However, there is a high risk of type I and type II errors because of the few trials included, the small sample size in each trial, and the risk of bias. AUTHORS' CONCLUSIONS Trimetazidine, methylprednisolone, and dextrose may protect against ischaemia reperfusion injury in elective liver resections performed under vascular occlusion, but this is shown in trials with small sample sizes and high risk of bias. The use of these drugs should be restricted to well-designed randomised clinical trials before implementing them in clinical practice.
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Affiliation(s)
- Mahmoud Abu-Amara
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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Abu‐Amara M, Gurusamy KS, Glantzounis G, Fuller B, Davidson BR. Pharmacological interventions for ischaemia reperfusion injury in liver resection surgery performed under vascular control. Cochrane Database Syst Rev 2009; 2009:CD008154. [PMID: 19821445 PMCID: PMC7182152 DOI: 10.1002/14651858.cd008154] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Vascular occlusion used during elective liver resection to reduce blood loss results in significant ischaemia reperfusion (IR) injury. This in turn leads to significant postoperative liver dysfunction and morbidity. Various pharmacological drugs have been used in experimental settings to ameliorate the ischaemia reperfusion injury in liver resections. OBJECTIVES To assess the relative benefits and harms of using one pharmacological intervention versus another pharmacological intervention to decrease ischaemia reperfusion injury during liver resections where vascular occlusion was performed during the surgery. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2009. SELECTION CRITERIA We included randomised clinical trials, irrespective of language or publication status, comparing one pharmacological agent versus another pharmacological agent during elective liver resections with vascular occlusion. DATA COLLECTION AND ANALYSIS Two authors independently identified trials for inclusion and independently extracted data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. We planned to calculate the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis or available case analysis. However, all outcomes were only reported on by single trials, and meta-analysis could not be performed. Therefore, we performed Fisher's exact test on dichotomous outcomes. MAIN RESULTS We identified a total of five randomised trials evaluating nine different pharmacological interventions (amrinone, prostaglandin E1, pentoxifylline, dopexamine, dopamine, ulinastatin, gantaile, sevoflurane, and propofol). All trials had high risk of bias. There was no significant difference between the groups in mortality, liver failure, or perioperative morbidity. The ulinastatin group had significantly lower postoperative enzyme markers of liver injury compared with the gantaile group. None of the other comparisons showed any difference in any of the other outcomes. However, there is a high risk of type I and type II errors because of the few trials included, the small sample size in each trial, and the risk of bias. AUTHORS' CONCLUSIONS Ulinastatin may have a protective effect against ischaemia reperfusion injury relative to gantaile in elective liver resections performed under vascular occlusion. The absolute benefit of this drug agent remains unknown. None of the drugs can be recommended for routine clinical practice. Considering that none of the drugs have proven to be useful to decrease ischaemia reperfusion injury, such trials should include a group of patients who do not receive any active intervention whenever possible to determine the pharmacological drug's absolute effects on ischaemia reperfusion injury in liver resections.
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Affiliation(s)
- Mahmoud Abu‐Amara
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
| | - Kurinchi Selvan Gurusamy
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
| | - George Glantzounis
- University of IoanninaDepartment of Surgery, School of MedicineIoanninaGreece45 110
| | - Barry Fuller
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
| | - Brian R Davidson
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
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van den Broek MAJ, van Dam RM, Malagó M, Dejong CHC, van Breukelen GJP, Olde Damink SWM. Feasibility of randomized controlled trials in liver surgery using surgery-related mortality or morbidity as endpoint. Br J Surg 2009; 96:1005-14. [PMID: 19672937 DOI: 10.1002/bjs.6663] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is a shortage of randomized controlled trials (RCTs) on which to base guidelines in liver surgery. The feasibility of conducting an adequately powered RCT in liver surgery using the dichotomous endpoints surgery-related mortality or morbidity was examined. METHODS Articles published between January 2002 and November 2007 with mortality or morbidity after liver surgery as primary endpoint were retrieved. Sample size calculations for a RCT aiming to show a relative reduction of these endpoints by 33, 50 or 66 per cent were performed. RESULTS The mean operative mortality rate was 1.0 per cent and the total morbidity rate 28.9 per cent; mean rates of bile leakage and postresectional liver failure were 4.4 and 2.6 per cent respectively. The smallest numbers of patients needed in each arm of a RCT aiming to show a 33 per cent relative reduction were 15 614 for operative mortality, 412 for total morbidity, 3446 for bile leakage and 5924 for postresectional liver failure. CONCLUSION The feasibility of conducting an adequately powered RCT in liver surgery using outcomes such as mortality or specific complications seems low. Conclusions of underpowered RCTs should be interpreted with caution. A liver surgery-specific composite endpoint may be a useful and clinically relevant solution to pursue.
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Affiliation(s)
- M A J van den Broek
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Sequential preoperative ipsilateral hepatic vein embolization after portal vein embolization to induce further liver regeneration in patients with hepatobiliary malignancy. Ann Surg 2009; 249:608-16. [PMID: 19300228 DOI: 10.1097/sla.0b013e31819ecc5c] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the effect of ipsilateral hepatic vein embolization (HVE) performed after portal vein embolization (PVE) on liver regeneration. SUMMARY BACKGROUND DATA PVE induces shrinkage of the embolized lobe and compensatory enlargement of the non-embolized lobe, but it does not always induce sufficient liver regeneration. There was no effective method to accelerate liver regeneration in addition to PVE yet. METHODS During a 1-year study period, preoperative HVE were performed on 12 patients who had shown limited liver regeneration after PVE awaiting right hepatectomy. The right hepatic vein was embolized with multiple coils after insertion of vena cava filters or vascular plugs. RESULTS No HVE procedure-related complications occurred, but embolization of the wrong hepatic vein trunk occurred in 1 patient. The increase in blood liver enzymes after HVE was comparable with that after PVE alone. In 9 patients who underwent hepatectomy, the proportions of future liver remnant volume to total liver volume were 34.8% +/- 1.5% before PVE, 39.7% +/- 0.6% 1 to 2 weeks after PVE, 44.2% +/- 1.1% 2 weeks after HVE, and 64.5% +/- 6.2% 1 week after right hepatectomy. Cirrhotic livers showed lower regeneration rates following HVE after PVE and 1 patient underwent hepatectomy 17 months after HVE. Immunohistochemistry showed that apoptosis occurred more in the liver area affected by both PVE and HVE than in that affected by PVE alone. CONCLUSIONS Preoperative sequential application of PVE and HVE seems to be safe and effective in facilitating contralateral liver regeneration by inducing more severe liver damage than PVE alone.
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