Effect of infrahepatic inferior vena cava clamping on bleeding during hepatic resection: A meta-analysis

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis

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.

Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure - First technical report

Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.

Infrahepatic Inferior Vena Cava Clamping Reduces Blood Loss during Liver Transection for Cholangiocarcinoma

BACKGROUND

Major hepatectomy is the mainstay of the treatment for cholangiocarcinoma. Infrahepatic inferior vena cava (IVC) clamping is an effective maneuver for reducing blood loss during liver transection. The impact of this procedure on major hepatectomy for cholangiocarcinoma is unknown. This study evaluated the effect of infrahepatic IVC clamping on blood loss during liver transection.

METHODS

Clinical and pathological data were collected retrospectively for 116 cholangiocarcinoma patients who underwent major hepatectomy between January 2015 and December 2016, to investigate the benefit of infrahepatic IVC clamping. Two of five surgeons adapted the policy performing infrahepatic IVC clamping during liver transection in all cases. Patients, therefore, were divided into those (n = 39; 33.6%) who received infrahepatic IVC clamping during liver transection (C1) and those (n = 77; 66.4%) who did not (C0).

RESULTS

The patients' backgrounds, operative parameters, and extent of hepatectomy did not differ significantly between the 2 groups, except for gender. A significantly lower blood loss (p = 0.028), blood transfusion (p = 0.011), and rate of vascular inflow occlusion requirement (p < 0.001) were observed in the C1 group. The respective blood losses in the C1 group and the C0 group were 498.9 (95% CI: 375.8-622.1) and 685.6 (95% CI: 571-800.2) millilitres.

CONCLUSIONS

The current study found infrahepatic IVC clamping during liver transection for cholangiocarcinoma reduces blood loss, blood transfusion, and rate of vascular inflow occlusion requirement.

Infrahepatic Inferior Vena Cava Clamping does not Increase the Risk of Pulmonary Embolism Following Hepatic Resection

BACKGROUND

Infrahepatic inferior vena cava (IVC) clamping reduces central venous pressure. However, controversies remain regarding its impact on postoperative complications, particularly, the incidence of postoperative pulmonary embolism (PE). The aim of the study was to determine the impact of IVC clamping on the incidence of PE in patients undergoing hepatectomy.

METHODS

A pooled analysis of five prospective trials on patients who underwent hepatic resection over a period of 10 years was performed. Patients with infrahepatic IVC clamping were compared to patients without infrahepatic IVC clamping. Outcomes were studied by univariate and multivariate analyses.

RESULTS

Of 505 included patients, 141 patients had IVC clamping and 364 patients served as control group. The rate of postoperative PE was comparable between groups (3% vs. 3%; P = 0.762), as were postoperative morbidity (P = 0.932), bile leakage (P = 0.272), posthepatectomy hemorrhage (P = 0.095), and posthepatectomy liver failure (P = 0.605), respectively. No clinicopathological and intraoperative risk factors were found to predict the onset of PE. Subgroup analyses of patients with major hepatectomy and vascular resections confirmed no adverse perioperative outcomes to be associated with IVC clamping.

CONCLUSIONS

Infrahepatic IVC clamping does not increase the incidence of postoperative PE.

Efficacy and safety of infrahepatic inferior vena cava clamping under controlled central venous pressure for reducing blood loss during hepatectomy: A randomized controlled trial

BACKGROUND

The purpose of this study was to evaluate the effectiveness and safety of inferior vena cava (IVC) clamping for reducing blood loss during hepatectomy.

METHODS

In total, 120 elective hepatectomy patients who underwent surgery from May 2016 to October 2017 were enrolled and randomized into the IVC clamping group or nonclamping group. Both groups were managed by anesthesiological techniques for CVP reduction. Blood loss and clinical parameters were analyzed for 30 days after surgery.

RESULTS

Fifty-nine patients were assigned to the IVC clamping group and 61 to the non-IVC clamping group. There was a significant difference in the total blood loss between both groups, with less blood loss observed in the IVC clamping group [500 vs 600 mL, P = .006]. The transection blood loss in the IVC clamping group was also significantly lower than that in the non-IVC clamping group [300 vs 500 mL, P < .001]. However, CVP was not associated with blood loss volume. Postoperative outcomes were not significant in either group.

CONCLUSIONS

IVC clamping is beneficial for reducing blood loss during hepatectomy and is safe when combined with anesthesiological techniques. If feasible, this technique should be used regardless of the CVP value.

Effect of infrahepatic inferior vena cava partial clamping on central venous pressure and intraoperative blood loss during laparoscopic hepatectomy

BACKGROUND

Infrahepatic inferior vena cava (IVC) clamping is considered to be an effective method to reduce central venous pressure (CVP) and intraoperative bleeding in liver resection. However, its efficacy and safety during laparoscopic hepatectomy (LH) remain unclear. We perform this retrospective study to evaluate its efficacy and safety during LH.

METHODS

Consecutive patients scheduled for LH from September 2014 to August 2019 were retrospectively reviewed. The intraoperative parameters and postoperative outcomes were analyzed.

RESULTS

All patients in the infrahepatic IVC clamping group were able to tolerate partial clamping of IVC. The CVP was significantly decreased after infrahepatic IVC clamping without hemodynamic instability (8.7 ± 1.4 cmH₂O vs. 2.1 ± 1.3 cmH₂O, P = 0.000). Infrahepatic IVC clamping did not significantly reduce total blood loss (287.3 ± 112.5 mL vs. 301.4 ± 127.6 mL, P = 0.133) and blood loss during parenchymal transection (273.2 ± 107.9 mL vs. 296.5 ± 118.1 mL, P = 0.618) compared with the non-clamping group. In subgroup analysis, total blood loss and blood loss during parenchymal transection were significantly reduced in patients with moderate to severe cirrhosis in the clamping group (363.6 ± 71.2 mL vs. 473.4 ± 95.6 mL, P = 0.021), (358.7 ± 70.9 mL vs. 466.9 ± 94.5 mL, P = 0.016), respectively. The complications and hospital stay were comparable.

CONCLUSIONS

In conclusion, these data suggest that infrahepatic IVC clamping may be safe and effective.