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Patel A, Tan J, Lambert J, Kitching S, Iqbal A, Satyadas T. Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver during hepatectomy: a meta-analysis. Langenbecks Arch Surg 2024; 409:160. [PMID: 38758232 PMCID: PMC11101571 DOI: 10.1007/s00423-024-03344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Intraoperative bleeding during hepatectomy is primarily controlled through anaesthesiological interventions or surgical techniques such as Pringle maneuver (PM). Infrahepatic IVC clamping (IIVCC) is an alternative surgical technique to reduce central venous pressure and prevent retrograde hepatic venous bleeding. The aim of the meta-analysis was to compare IIVCC+PM with PM alone in terms of intraoperative outcomes and perioperative complications. METHODS Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched for comparative studies till 16.04.2024, resulting in 679 articles, of which eight studies met inclusion criteria. Data on patient demographics, surgical technique, and perioperative outcomes was assessed. Cochrane Risk of Bias 2.0 (RoB 2.0) Tool and Newcastle-Ottawa Scale (NOS) were used for risk of bias assessment. RESULTS Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PM alone group were included. IIVCC+PM resulted in significantly greater CVP reduction, less intraoperative blood loss (MD (95% CI) = - 233.03 (- 360.48 to - 105.58), P < 0.001), and less intraoperative blood transfusion (OR (95% CI) = 0.38 (0.25 to 0.57), P < 0.001) compared to PM alone. The two groups had comparable total operative time, transection time and total intraoperative fluid infusion. Patients undergoing IIVCC+PM had significantly shorter length of stay (MD (95% CI) = - 0.63 days (- 1.21 to - 0.05 days), P = 0.03) and overall complication rates (OR (95% CI) = 0.63 (0.43-0.92), P = 0.02) compared to PM alone group. CONCLUSION The utilization of IIVCC along with PM during liver resection may be beneficial in reducing intraoperative bleeding and blood transfusion without adversely influencing operative times or perioperative outcomes compared to PM alone.
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Affiliation(s)
- Agastya Patel
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK.
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland.
| | - Jacob Tan
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Joel Lambert
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Samuel Kitching
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Affan Iqbal
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
| | - Thomas Satyadas
- Regional Hepato-Pancreato-Biliary Surgical Unit, Manchester Royal Infirmary, M13 9WL, Manchester, UK
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
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.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Chitosan Lactate Particles for Non-Compression Hemostasis on Hepatic Resection. Polymers (Basel) 2023; 15:polym15030656. [PMID: 36771957 PMCID: PMC9920132 DOI: 10.3390/polym15030656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
The liver is the most complex vascular anatomy of all human organs, with extremely rich blood flow and fragile texture. Massive liver bleeding usually occurs after traumatic liver injury, causing severe systematic issues. Thus, bleeding control is critical in hindering mortality rates and complications in patients. In this study, non-compression hemostasis materials based on chitosan lactate particles (CLP) were developed for handling liver bleeding after injuries. CLP showed good blood biocompatibility and antibacterial performance against S. aureus. Taking advantage of the vital capacity of CLP to promote red blood cell and platelet adhesion, CLP exhibited in vivo homeostasis properties as non-compression hemostasis materials for traumatic liver injury, both in SD rats, New Zealand rabbits, or in beagles. Whereas CLP has better hemostasis than the commercial hemostatic agent Celox™.
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Mir ZM, Djerboua M, Nanji S, Flemming JA, Groome PA. Predictors of Postoperative Liver Decompensation Events After Resection in Patients with Cirrhosis and Hepatocellular Carcinoma: A Population-Based Study. Ann Surg Oncol 2021; 29:288-299. [PMID: 34549362 DOI: 10.1245/s10434-021-10801-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigation of major liver-related postoperative complications. Currently, no standard prognostic tool exists to predict the risk of postoperative liver decompensation events (POLDEs) after partial hepatectomy for patients with cirrhosis and HCC. This study aimed to identify independent preoperative predictors of POLDEs for future development of prognostic tools to improve surgical decision-making. METHODS This population-based, retrospective cohort study investigated patients with cirrhosis and incident HCC between 2007 and 2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years after surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. RESULTS Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least one POLDE, and 189 (30.9%) died within 2 years after surgery. Diabetes, cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except for extent of resection, the same risk factors were associated with POLDEs in the cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. CONCLUSIONS Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used both to inform clinical practice and to advance the development of preoperative prognostic tools, which may lead to improved outcomes for this population.
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Affiliation(s)
- Zuhaib M Mir
- Division of General Surgery, Department of Surgery, Victory 3, Kingston General Hospital, Queen's University, Kingston, ON, Canada. .,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | | | - Sulaiman Nanji
- Division of General Surgery, Department of Surgery, Victory 3, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's University, Kingston, ON, Canada.,Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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Hawksworth J, Radkani P, Nguyen B, Belyayev L, Llore N, Holzner M, Mateo R, Meslar E, Winslow E, Fishbein T. Improving safety of robotic major hepatectomy with extrahepatic inflow control and laparoscopic CUSA parenchymal transection: technical description and initial experience. Surg Endosc 2021; 36:3270-3276. [PMID: 34370124 DOI: 10.1007/s00464-021-08639-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/13/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Blood loss is a major determinant of outcomes following hepatectomy. Robotic technology enables hepatobiliary surgeons to mimic open techniques for inflow control and parenchymal transection during major hepatectomy, increasing the ability to minimize blood loss and perform safe liver resections. METHODS Initial experience of 20 consecutive major robotic hepatectomies from November 2018 to July 2020 at two co-located institutions was reviewed. All cases were performed with extrahepatic inflow control and parenchymal transection with the laparoscopic cavitron ultrasonic surgical aspirator (CUSA), and a technical description is illustrated. Clinical characteristics, operative data, and surgical outcomes were retrospectively analyzed. RESULTS The median (range) patient age was 58 years (20-76) and the majority of 14 (70%) patients were ASA III-IV. There were 12 (60%) resections for malignancy and the median tumor size was 6.2 cm (1.2-14.6). Right or extended right hepatectomy was the most common procedure (12 or 60% of cases). There were 7 (35%) left or extended left hepatectomies and 1 (5%) central hepatectomy. The median operative time was 420 (177-622) minutes. Median estimated blood loss was 300 mL (25-800 mL). One (5%) case was converted to open. Two (10%) patients required blood transfusion. The median length of stay was 3 (1-6) days. Major complications included 1 (5%) Clavien-Dindo IIIa bile leak requiring percutaneous drainage placement. There was no 90-day mortality. CONCLUSION Advanced techniques to reduce blood loss in robotic hepatectomy may optimize safety and minimize morbidity in these complex minimally invasive procedures.
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Affiliation(s)
- Jason Hawksworth
- MedStar Georgetown Transplant Institute, 2 PHC, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, 20007, USA. .,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Pejman Radkani
- MedStar Georgetown Transplant Institute, 2 PHC, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, 20007, USA
| | - Brian Nguyen
- MedStar Georgetown Transplant Institute, 2 PHC, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, 20007, USA
| | - Leonid Belyayev
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Nathaly Llore
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Matthew Holzner
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Rodrigo Mateo
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Erin Meslar
- MedStar Georgetown Transplant Institute, 2 PHC, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, 20007, USA
| | - Emily Winslow
- MedStar Georgetown Transplant Institute, 2 PHC, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, 20007, USA
| | - Thomas Fishbein
- MedStar Georgetown Transplant Institute, 2 PHC, MedStar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC, 20007, USA
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6
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Bodur MS, Tomas K, Topaloğlu S, Oğuz Ş, Küçükaslan H, Dohman D, Karabulut E, Çalık A. Effects of intraoperative blood loss during liver resection on patients’ outcome: a single- center experience. Turk J Med Sci 2021; 51:1388-1395. [PMID: 33576585 PMCID: PMC8283449 DOI: 10.3906/sag-2008-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/11/2021] [Indexed: 12/04/2022] Open
Abstract
Background/aim Operative bleeding is one of the major determinants of outcome in liver surgery. This study aimed to describe the impact of intraoperative blood loss on the postoperative course of liver resection (LR). Materials and methods The data of 257 patients who were treated with LR between January 2007 and October 2018 were retrospectively analyzed. LRs were performed via intermittent portal triad clamping (PTC) under low central venous pressure. Results LRs were performed for 67.7% of patients with a malignant disease and 32.3% of patients with a benign disease. Major LR was performed in 89 patients (34.6%). The mean PTC period was 20.32 min (±13.7). The median intraoperative bleeding amount was 200 mL (5–3500 mL), the 30-day mortality rate was 4.3%, and the morbidity rate was 31.9%. The hospital stay (p = 0.002), morbidity (p = 0.009), and 30-day mortality (p = 0.041) of patients with a bleeding amount of more than 500 mL significantly increased. Conclusion Surgeons should consider the adverse effects of intraoperative bleeding during liver resection on patients’ outcome. Favorable outcomes would be obtained with diligent postoperative care.
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Affiliation(s)
- Muhammed Selim Bodur
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Kadir Tomas
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Serdar Topaloğlu
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Şükrü Oğuz
- Department of Radiology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Hakan Küçükaslan
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Davut Dohman
- Department of Anesthesiology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erdem Karabulut
- Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Adnan Çalık
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
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7
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Nanji S, Mir ZM, Karim S, Brennan KE, Patel SV, Merchant SJ, Booth CM. Perioperative blood transfusion and resection of colorectal cancer liver metastases: outcomes in routine clinical practice. HPB (Oxford) 2021; 23:404-412. [PMID: 32792307 DOI: 10.1016/j.hpb.2020.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/13/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prior work has shown associations between blood transfusion (BT) and inferior outcomes during resection for colorectal cancer liver metastases (CRLM). Herein, we describe short and long-term outcomes relating to perioperative BT in routine clinical practice. METHODS All CRLM resections in Ontario, Canada from 2002 to 2009 were identified using the Ontario Cancer Registry. Log-binomial regression and Cox regression were used to explore factors associated with receipt of BT and the association of BT with 5-year cancer specific (CSS) and overall survival (OS), respectively. RESULTS The study included 1310 patients; 31% (403/1310) had perioperative BT. Transfused patients had longer median length of stay (9 vs. 7 days, p < 0.001), higher 90-day mortality (9% vs. 1%, p < 0.001), greater 90-day readmission (28% vs. 16%, p < 0.001), and inferior 5-year CSS (41% vs. 48%, p = <0.001) and OS (38% vs. 47%, p < 0.001). Transfusion was independently associated with inferior CSS (HR = 1.35, 95% CI: 1.11-1.63) and OS (HR = 1.30, 95% CI: 1.10-1.53), however, excluding 90-day postoperative deaths showed these associations were no longer significant. CONCLUSION Perioperative BT is common in patients undergoing resection of CRLM. While transfusion is associated with greater morbidity, mortality, and inferior survival, after excluding early postoperative deaths, BT does not appear to be independently associated with CSS or OS.
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Affiliation(s)
- Sulaiman Nanji
- Department of Surgery, Queen's University, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada.
| | - Zuhaib M Mir
- Department of Surgery, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Safiya Karim
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Kelly E Brennan
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Shaila J Merchant
- Department of Surgery, Queen's University, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
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8
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Patient blood management for liver resection: consensus statements using Delphi methodology. HPB (Oxford) 2019; 21:393-404. [PMID: 30446290 DOI: 10.1016/j.hpb.2018.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/21/2018] [Accepted: 09/27/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.
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Campos-Cuerva R, Fernández-Muñoz B, Farfán López F, Pereira Arenas S, Santos-González M, Lopez-Navas L, Alaminos M, Campos A, Muntané J, Cepeda-Franco C, Gómez-Bravo MÁ. Nanostructured fibrin agarose hydrogel as a novel haemostatic agent. J Tissue Eng Regen Med 2019; 13:664-673. [PMID: 30793853 PMCID: PMC6594136 DOI: 10.1002/term.2831] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/12/2019] [Accepted: 02/21/2019] [Indexed: 12/18/2022]
Abstract
Blood loss remains a major concern during surgery and can increase the morbidity of the intervention. The use of topical haemostatic agents to overcome this issue therefore becomes necessary. Fibrin sealants are promising haemostatic agents due to their capacity to promote coagulation, but their effectiveness and applicability need to be improved. We have compared the haemostatic efficacy of a novel nanostructured fibrin‐agarose hydrogel patch, with (c‐NFAH) or without cells (a‐NFAH), against two commercially available haemostatic agents in a rat model of hepatic resection. Hepatic resections were performed by making short or long incisions (mild or severe model, respectively), and haemostatic agents were applied to evaluate time to haemostasis, presence of haematoma, post‐operative adhesions to adjacent tissues, and inflammation factors. We found a significantly higher haemostatic success rate (time to haemostasis) with a‐NFAH than with other commercial haemostatic agents. Furthermore, other relevant outcomes investigated were also improved in the a‐NFAH group, including no presence of haematoma, lower adhesions, and lower grades of haemorrhage, inflammation, and necrosis in histological analysis. Overall, these findings identify a‐NFAH as a promising haemostatic agent in liver resection and likely in a range of surgical procedures.
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Affiliation(s)
- Rafael Campos-Cuerva
- Centro de Transfusiones, Tejidos y Células de Sevilla (CTTS), Seville, Spain.,Cell Therapy and Cell Reprogramming Unit, GMP Network of the Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain.,PhD Program in Molecular Biology, Biomedicine and Clinical Research, Universidad de Sevilla, 41013, Seville, Spain
| | - Beatriz Fernández-Muñoz
- Cell Therapy and Cell Reprogramming Unit, GMP Network of the Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain
| | - Francisco Farfán López
- Servicio de Anatomía Patológica, Hospital Universitario Virgen del Rocío (HUVR), Seville, Spain
| | - Sheila Pereira Arenas
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain
| | - Mónica Santos-González
- Centro de Transfusiones, Tejidos y Células de Sevilla (CTTS), Seville, Spain.,Cell Therapy and Cell Reprogramming Unit, GMP Network of the Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain
| | - Luis Lopez-Navas
- Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain
| | - Miguel Alaminos
- Department of Histology, University of Granada, Granada, Spain.,Instituto de Investigación Biosanitaria, ibs.GRANADA, 18016 Granada, Spain
| | - Antonio Campos
- Department of Histology, University of Granada, Granada, Spain.,Instituto de Investigación Biosanitaria, ibs.GRANADA, 18016 Granada, Spain
| | - Jordi Muntané
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain.,Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Carmen Cepeda-Franco
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain.,Unidad de Cirugia Hepato-Bilio-Pancreática y Trasplantes, HUVR, Spain
| | - Miguel Ángel Gómez-Bravo
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain.,Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Unidad de Cirugia Hepato-Bilio-Pancreática y Trasplantes, HUVR, Spain
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10
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Kontis E, Pantiora E, Melemeni A, Tsaroucha A, Karvouni E, Polydorou A, Vezakis A, Fragulidis GP. Ischemic postconditioning decreases iNOS gene expression but ischemic preconditioning ameliorates histological injury in a swine model of extended liver resection. Transl Gastroenterol Hepatol 2019; 4:5. [PMID: 30854492 DOI: 10.21037/tgh.2019.01.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
Background Both pre- and postconditioning have been shown to protect the liver parenchyma from ischemia/reperfusion (I/R) injury during hepatectomy by altering the production of NO. However, to date there is no study to compare their effect on the inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) gene expression, who are the main modulators in the pathway of NO during the acute phase of I/R injury. Methods We designed a prospective experimental cohort comprising of three groups (sham group-SG, preconditioning-PrG and postconditioning group-PoG) and consisting of 10 animals per group. All animals underwent extended hepatectomy (70%) under prolonged warm ischemia either after preconditioning or followed by postconditioning or without any protective maneuver (SG). Following reperfusion blood samples and liver biopsies were obtained at the start of reperfusion (0 hours), at 6 and 12 hours post reperfusion. iNOS and eNOS gene expression was assessed on liver tissue by polymerase chain reaction (PCR); in addition, the extent of hepatocellular injury was histologically assessed. Results At the beginning of reperfusion iNOS expression was significantly reduced in the PoG in comparison to the SG (Kruskal-Wallis test, P=0.012; Mann-Whitney U test, P<0.0005 Bonferroni correction) and continued to remain at low levels until 6 hours post reperfusion (Kruskal-Wallis test, P=0.01; Mann-Whitney U test, P<0.0005-Bonferroni correction) This difference was eliminated by 12 hours. No significant differences were found in the expression of eNOS between groups and within time measurements. Aspartate aminotransferase (AST) and Alkaline phosphatase (ALP) were found increased at the start of reperfusion; their levels continued to increase by 6 hours in all groups, however only in the PoG the increase attended statistical significance at 12 hours after reperfusion. ALT levels presented only minor alterations during the course of reperfusion. The PrG was found to have more intense hepatocellular injury at the start of reperfusion than the PoG however, that appeared to gradually settle by 12 hours in contrast to PoG where the hepatocellular injury continued to deteriorate. Conclusions PoG appeared to decrease iNOS overexpression more effectively than PrG in comparison to animals who have undergone no protective maneuver (SG). However, PrG was more effective than PoG in ameliorating the hepatocellular injury observed at 12 hours after the ischemic insult.
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Affiliation(s)
- Elissaios Kontis
- Institute of Liver Studies, King's College Hospital, NHS Foundation Trust, London, UK.,Second Department of Surgery, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eirini Pantiora
- Second Department of Surgery, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Aikaterini Melemeni
- First Department of Anaesthesiology, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Athanasia Tsaroucha
- First Department of Anaesthesiology, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eleni Karvouni
- Department of Pathology, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas Polydorou
- Second Department of Surgery, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Antonios Vezakis
- Second Department of Surgery, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Georgios P Fragulidis
- Second Department of Surgery, Aretaieio Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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11
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Latchana N, Hirpara DH, Hallet J, Karanicolas PJ. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 2019; 404:1-9. [PMID: 30607533 DOI: 10.1007/s00423-018-1746-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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12
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Luo WL, Zhang J, Qiu X, Chen LJ, Fu J, Hu PY, Li X, Hu RJ, Long YZ. Electric- Field-Modified In Situ Precise Deposition of Electrospun Medical Glue Fibers on the Liver for Rapid Hemostasis. NANOSCALE RESEARCH LETTERS 2018; 13:278. [PMID: 30203107 PMCID: PMC6134859 DOI: 10.1186/s11671-018-2698-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/29/2018] [Indexed: 05/29/2023]
Abstract
Precise deposition of nanofibers is still an important issue in the applications of electrospinning (e-spinning), especially in rapid hemostasis of organs such as the liver, lung, and kidney. In this study, we propose an electric field-modified e-spinning technique with a metal cone attached to the spinning nozzle to realize controllable precise deposition of fibers. The deposition range of the e-spun fibers is tunable by changing the size of the metal cone, and the mechanism is attributed the focused electric field verified by theoretical simulations. This electric field-modified e-spinning method was further used to in situ precisely deposit medical glue N-octyl-2-cyanoacrylate (NOCA) fibers onto the resection site of rat liver to realize rapid hemostasis within 10 s. Postoperative pathological results indicate that less inflammatory response and tissue adhesion are observed in this electric field-modified e-spinning group compared with that of traditional airflow-assisted group. This technique combined with our designed handheld e-spinning device could be used in emergency medical treatment, clinics, field survival, and home care for its portability and precise deposition characteristics.
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Affiliation(s)
- Wei-Ling Luo
- Collaborative Innovation Center for Nanomaterials and Devices, College of Physics, Qingdao University, Qingdao, 266071 China
| | - Jun Zhang
- Collaborative Innovation Center for Nanomaterials and Devices, College of Physics, Qingdao University, Qingdao, 266071 China
| | - Xuan Qiu
- Medical College, Qingdao University, Qingdao, 266071 China
| | - Li-Juan Chen
- Department of Oncology, Qingdao Haici Medical Treatment Group, Qingdao, 266034 China
| | - Jie Fu
- Collaborative Innovation Center for Nanomaterials and Devices, College of Physics, Qingdao University, Qingdao, 266071 China
| | - Peng-Yue Hu
- Collaborative Innovation Center for Nanomaterials and Devices, College of Physics, Qingdao University, Qingdao, 266071 China
| | - Xin Li
- Collaborative Innovation Center for Nanomaterials and Devices, College of Physics, Qingdao University, Qingdao, 266071 China
| | - Ren-Jie Hu
- Collaborative Innovation Center for Nanomaterials and Devices, College of Physics, Qingdao University, Qingdao, 266071 China
| | - Yun-Ze Long
- Collaborative Innovation Center for Nanomaterials and Devices, College of Physics, Qingdao University, Qingdao, 266071 China
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