Hepatic parenchymal transection with vascular staplers: a comparative analysis with the crush-clamp technique

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

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

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

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

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

Predictors of complications after liver surgery: a systematic review of the literature

BACKGROUND

Numerous potential predictors of adverse outcomes have been reported but their performance and utilization in practice seem heterogenous. This study aimed to systematically review the literature on the role and value of predictors of complications after hepatectomy.

METHODS

A systematic review following the PRISMA guidelines was performed. Studies on liver transplant were excluded. Only studies assessing overall or major complications were included.

RESULTS

A total of 10'965 abstracts were screened. After application of exclusion criteria, 72 articles including 68'480 patients were included. A total of 72 markers with 48 pre-, 9 intra- and 15 postoperative factors were identified as predictors of complications. Preoperative and intraoperative predictive markers retrieved several times with the highest odds ratios (OR) were ASA score (OR range: 1.3-7.5, significant in 8 studies) and intraoperative need for red blood cell transfusion (OR range: 1.2-17.1, significant in 24 studies), respectively.

CONCLUSION

Numerous markers have been described to predict the complication risk after hepatectomy. Because of their intrinsic characteristics, most markers such as ASA score and need for red blood cell transfusion are of limited clinical interest. There is a clear need to identify new biomarkers and to develop scores that could easily be implemented in clinical practice.

Anterior approach for right hepatectomy using the 5-steps stapling technique: A preliminary study

INTRODUCTION

Right hepatectomy via the anterior approach without prior liver mobilization is an accepted technique and the liver hanging maneuver facilitates this procedure. Hepatic parenchymal transection remains a critical part of this operation during which excessive blood loss can occur. Control of blood loss is important in hepatectomy as excessive bleeding and blood transfusion are associated with increased postoperative morbidity/mortality rates and compromised long-term oncological outcomes in these patients.

METHODS

A 5-steps stapling technique was developed to decrease blood loss during right hepatectomy using the anterior approach with the liver hanging maneuver. All consecutive patients who underwent elective right hepatectomy in our center using this technique from January 2014 to June 2015 were retrospectively studied. This study aimed to describe this technique and report the preliminary outcomes.

RESULTS

Eleven patients with hepatitis B-related hepatocellular carcinoma (HCC) with cirrhosis underwent the 5-steps stapling technique for right hepatectomy using the anterior approach with the liver hanging maneuver. The mean blood loss, liver parenchymal transection time and operation time were 227.3 ± 91.4 ml (SD), 40.0 ± 7.8 min, and 261.8 ± 48.5 min, respectively. No patients developed postoperative bleeding or bile leak. There was no 90-day mortality.

CONCLUSION

The preliminary results of this 5-steps stapling technique for right hepatectomy using the liver hanging maneuver are encouraging as the technique resulted in little intraoperative blood loss and short operation time, and it caused no major complications and mortality.

Evaluation of stapler hepatectomy during a laparoscopic liver resection

METHODS

An international database of 1499 laparoscopic liver resections was analysed using multivariate and Kaplan-Meier analysis.

RESULTS

In total, 764 stapler hepatectomies (SH) were compared with 735 electrosurgical resections (ER). SH was employed in larger tumours (4.5 versus 3.8 cm; P < 0.003) with decreased operative times (2.6 versus 3.1 h; P < 0.001), blood loss (100 versus 200 cc; P < 0.001) and length of stay (3.0 versus 7.0 days; P < 0.001). SH incurred a trend towards higher complications (16% versus 13%; P = 0.057) including bile leaks (26/764, 3.4% versus 16/735, 2.2%: P = 0.091). To address group homogeneity, a subset analysis of lobar resections confirmed the benefits of SH. Kaplan-Meier analysis in non-cirrhotic and cirrhotic patients confirmed equivalent patient (P = 0.290 and 0.118) and disease-free survival (P = 0.120 and 0.268). Multivariate analysis confirmed the parenchymal transection technique did not increase the risk of cancer recurrence, whereas tumour size, the presence of cirrhosis and concomitant operations did.

CONCLUSIONS

A SH provides several advantages including: diminished blood loss, transfusion requirements and shorter operative times. In spite of the smaller surgical margins in the SH group, equivalent recurrence and survival rates were observed when matched for parenchyma and extent of resection.

Minimizing blood loss during hepatectomy: a literature review

There are numerous techniques surgeons employ to reduce blood loss during partial hepatectomy. In this literature review, prospective studies from the last 20 years are examined to determine the techniques that are best supported by the literature. Some of the techniques include vascular control, multiple parenchymal transection techniques, various hemostatic agents, low central venous pressure, and hemodilution. The strategies supported most convincingly by the literature include low CVP and total hepatic inflow occlusion.

Techniques of hepatic resection

Liver resections are high risk procedures performed by experienced surgeons. The role of liver resection in malignant disease has changed over the last 100 years with great improvement in morbidity, mortality and long term survival. New understanding in liver anatomy, improved perioperative care, anesthesia techniques, and technological advances has improved this aspect of patient care. With improved techniques, patients previously considered unresectable have an opportunity to undergo curative surgery. This review article describes the various approaches and techniques for liver resection. The relevant anatomy and terminology of hepatic resections is discussed, as well as the role of anatomic vs. nonanatomic resection. Methods of vascular control are examined and the multiple strategies of parenchymal transection are compared, as well as minimally-invasive techniques. Finally, a brief review of the authors' practice in terms of surgical technique is offered.

Hepatic resection nomenclature and techniques

Nomenclature describing liver anatomy and liver resection has been standardized with the Brisbane 2000 terminology. When performing liver resection, blood loss should be minimized by using low central venous pressure (CVP) anesthesia and vascular occlusion as appropriate. There are many options for transection of the liver parenchyma, and although no technique has been shown to be superior to clamp-crushing, hepatic surgeons should be familiar with the techniques available.