Effects of clamping procedures on central venous pressure during liver resection

Current insights into anaesthesia and critical care management of patients with hepatocellular carcinoma: Multifaceted implications for the anaesthesiologist and intensive care physician

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) is on the rise worldwide, due to the increasing prevalence of liver diseases associated with metabolic dysfunction and better management of cirrhosis and its complications. The diversification of HCC treatments has recently increased, with the choice of strategy based on HCC characteristics, liver function and comorbidities. The combination of new therapies has transformed the prognosis, with up to 70% survival at 5 years.

OBJECTIVE

The aim of this review was to analyse the most recent data on preoperative evaluation, peri-operative anaesthetic management of liver resection, liver transplantation and other types of procedures, and to highlight the multidisciplinary aspect of such management.

MAIN FINDINGS AND DISCUSSION

The importance of preanaesthetic evaluation will depend largely on the procedure proposed, associated co-morbidities and the stage of liver disease. This assessment should verify stabilisation of all comorbidities, and evaluate the degree of portal hypertension, cirrhosis severity and sarcopenia. Liver resection and liver transplantation for HCC present specific surgical challenges, and minimally invasive techniques improve recovery. Nonsurgical procedures considered as therapeutic (ablation) or standby (regional embolisation) are diverse, and all expose patients to specific intra-anaesthetic complications, sometimes requiring intensive care management. Peri-operative anaesthetic strategies deployed in the management of liver resection or nonsurgical procedures involve specific management of fluids, coagulation, narcosis and analgesia, which can impact on patients' overall, and cancer prognosis. Lastly, new down-staging strategies combining several types of procedure and possibly immunotherapy, also call for collegial reflection on posthepatic transplant immunosuppression, which must remain tailored to each individual patient.

Usefulness of Infra-hepatic Inferior Vena Cava Clamping During Liver Resection: a Meta-analysis of Randomized Controlled Trials

BACKGROUND

Infra-hepatic vena cava clamping (IIVCC) may reduce blood losses during liver resection. However, available literature is limited to reports from single institutions with a small sample size. To overcome those limitations, we performed a meta-analysis to examine the association between IIVCC and surgical outcomes.

METHODS

A systematic literature review was conducted to identify RCTs reporting on quantitative data on IIVCC. Random effects logistic regression calculated the pooled odds ratio (OR) for each surgical outcome.

RESULTS

Six studies were identified that included 714 patients, of whom 359 received IIVCC and 355 did not. Patients receiving IIVCC had significantly less total blood loss (MD - 353.08, 95% CI - 393.36 to 312.81, P < 0.00001), blood loss during parenchymal transection (MD - 243.28, 95% CI - 311.67 to - 174.88, P < 0.0001), blood loss volume per transection area (MD - 1.63, 95% CI - 2.14 to - 1.13, P < 0.00001), and intraoperative blood transfusion (OR 0.45, 95% CI 0.23 to 0.89, P = 0.02). Operative time was similar in the two groups (MD - 2.89, 95% CI - 18.45 to 12.68, P = 0.72). No differences between groups were observed in central venous pressure, heart rate, and mean arterial pressure before, after, and during parenchymal transection. Rates of overall morbidity (OR 0.79, 95% CI 0.56-1.13, P = 0.20), major complications (OR 0.89, 95% CI 0.47-1.80, P = 0.73), and perioperative mortality (OR 1.32, 95% CI 0.29-6.09, P = 0.72) were similar in the two groups.

CONCLUSIONS

IIVCC was associated to decreased blood loss (overall, during parenchymal transection, and per transection area) and decreased intraoperative transfusions, in the absence of increased operative times.