Liver resection. Preoperative and postoperative care

Liver Damage after Transarterial Chemoembolization without Embolizing Agent in Unresectable Hepatocellular Carcinoma

Aim and Background

Transarterial chemoembolization represents a therapy for hepatocellular carcinoma, but in cirrhotic patients affected by large or multifocal HCC with poor hepatic functional reserve, the procedure can damage normal parenchyma. We analyzed the effects on hepatic function of a modified chemoembolization consisting of ethiodized oil (Lipiodol Ultra Fluid) and epirubicin without gelatine sponge (C-LIP).

Methods

Of 90 patients with hepatocellular carcinoma observed from January 1995 to December 1999, 16 with a diagnosis of advanced (large or multifocal) disease underwent 19 C-LIP. The 30th post-C-LIP day was considered as a checkpoint of the biochemical parameters for a possible hepatic failure. The value of alpha-fetoprotein and the clinical finding of ascites were also considered after 30 days.

Results

Postoperative values of serum aspartate aminotrasferases, as well as alanine aminotransferase, were significantly higher than preoperative values (P = 0.002 and P = 0.019, respectively) (Table 1). In all patients, there was a significant increase in postoperative total serum bilirubin (P = 0.003). Statistical analysis showed a significant finding of postoperative ascites (P = 0.035) and the effectiveness of C-LIP on neoplastic tissue by a decrease of alpha-fetoprotein values at 30 days (P = 0.067).

Conclusions

Transcatether arterial chemoembolization could represent an effective therapy against multifocal or advanced hepatocellular carcinoma, and its effectiveness is probably not decreased by using a modified procedure without embolizing agent (C-LIP). However, even when performing such a safe procedure, the hepatic functional reserve of the individual patient needs to be accurately evaluated in order to avoid liver failure.

Retrospective analysis of post-operative coagulopathy after major hepatic resection at a tertiary care centre in Northern India

Background and Aims:

Hepatic resection is a major surgery associated with intraoperative massive fluid shifts, blood loss, haemodynamic instability and risk of development of post-hepatectomy liver failure. Hepatic resection predisposes the patient to coagulopathy as well as venous thrombosis. However, due to the development of deranged coagulation profile post-operatively, there is a dilemma in starting thromboprophylaxis. Our aim in this study was to determine the incidence of coagulopathy in patients undergoing major hepatectomy.

Methods:

In this retrospective study, we included 86 patients who had undergone major hepatectomy between January 2010 and December 2015 at our centre. Intraoperatively, we noted the number of liver segments resected, details of epidural catheter insertion, estimated blood loss, transfusion requirement and need for mechanical ventilation post-operatively. Trends of international normalised ratio (INR) and platelet values were recorded until post-operative day 5.

Results:

Of the 86 patients, 6 (7%) had an abnormal coagulation profile pre-operatively and 39 (45.34%) patients developed a derangement in their coagulation profile on 1^st post-operative day (POD). Platelet count was significantly lower and INR values were significantly higher than the pre-operative values on all 5 PODs. Sixty-seven (78%) patients had pre-operative epidural catheter insertion for post-operative pain management. Mechanical thrombophylaxis was used routinely.

Conclusions:

The incidence of post-operative coagulopathy in our patients who underwent major liver resection was 45.34%. Epidural catheters could be removed safely without transfusion between POD 5 and 7. There was no incidence of venous thrombosis or thromboembolism.

Risk factors for coagulopathy after liver resection

STUDY OBJECTIVE

To identify risk factors for coagulopathy in patients undergoing liver resection.

DESIGN

A retrospective cohort study.

SETTING

Patients who underwent liver resection at a university hospital between April 2010 and May 2011 were evaluated within seven days after surgery.

PATIENTS

One hundred forty-seven patients were assessed for eligibility. Thirty needed to be excluded because of incomplete data (23) or a preexisting coagulopathy (7).

MEASUREMENTS

Coagulopathy was defined as 1 or more of the following events: international normalized ratio ≥1.4, platelet count <80,000/μL, and partial thromboplastin time >38 seconds. Related to the time course and coagulation profile thresholds, 3 different groups could be distinguished: no coagulopathy, temporary coagulopathy, and persistent coagulopathy.

MAIN RESULTS

Seventy-seven patients (65.8%) had no coagulopathy, whereas 33 (28.2%) developed temporary coagulopathy and 7 (6%) developed persistent coagulopathy until day 7. Preoperative international normalized ratio (P = .001), postoperative peak lactate levels (P = .012), and resected liver weight (P = .005) were identified as independent predictors. Preoperative liver transaminases and transfusion volumes of red blood cells and fresh frozen plasma were significantly higher in patients with persistent coagulopathy.

CONCLUSIONS

Epidural anesthesia is feasible in patients scheduled for liver resection. Caution should be observed for patients with extended resection (≥3 segments) and increased postoperative lactate. In patients with preexisting liver disease, epidural catheters should be avoided.

Abnormal coagulation profile after hepatic resection: the effect of chronic hepatic disease and implications for epidural analgesia

STUDY OBJECTIVE

To evaluate the effect of chronic hepatic disease on postoperative coagulation.

DESIGN

Retrospective cohort study.

SETTING

Operating room with postoperative inpatient followup.

MEASUREMENTS

The records of 153 patients who underwent elective open hepatic resection were reviewed. The perioperative coagulation profile of each patient was assessed. The postoperative period was subdivided into the early [postoperative day (POD) 0-3] and late (POD 4 - POD 7) periods.

MAIN RESULTS

68 (44.4%) patients had chronic hepatic disease and 50 (32.7%) had cirrhosis. Eighty-four (54.9%) patients had an abnormal early postoperative coagulation profile and 46 (30.1%) had an abnormal late postoperative coagulation profile. The proportion of patients having an abnormal coagulation profile peaked on POD 2, at 39.2%. Only 5.3% of patients had an abnormal coagulation profile on POD 7. The independent predictors of abnormal early and late postoperative coagulation profiles were preexisting hepatic cirrhosis [early: odds ratio (OR) 3.73(1.49 - 9.29), late: OR 6.84(2.11 - 22.21)], abnormal preoperative coagulation profile [early: OR 9.68 (1.97 - 47.5), late: OR 11.71 (3.61- 38.02)], major hepatic resection [early: OR 4.15 (1.66 - 10.4), late: OR 5.43 (1.68 - 17.47)], and intraoperative blood loss.

CONCLUSIONS

An abnormal postoperative coagulation profile after hepatic surgery is common in a patient population with chronic hepatic disease.

Factors associated with changes in coagulation profiles after living donor hepatectomy

BACKGROUND

Hepatic resection may be associated with postoperative coagulopathy. However, there is limited information about the predictors affecting coagulopathy after donor hepatectomy. We evaluated the contributors of maximal changes in prothrombin time (PT), activated thromboplastin time (aPTT), and platelet count in the development of postoperative coagulopathy.

METHODS

We retrospectively analyzed 864 living donors, all of whom received general anesthesia using desflurane, isoflurane, or sevoflurane. A coagulation derangement was defined as one or more of the following events postoperatively: peak PT >1.5 international normalized ratio (INR; highest quartile of PT), peak aPTT >46 seconds (highest quartile of aPTT), or nadir platelet count <100 × 10(9)/L. Factors were evaluated by univariate and multivariate logistic regression analysis to identify predictors of coagulopathy.

RESULTS

Mean postoperative peak PT, peak aPTT, and nadir platelet count were 1.4 ± 0.2 INR, 43.8 ± 23.7 seconds, and 155.9 ± 37.3 × 10(9)/L, respectively, with 39.4% of donors being at the risk for coagulation derangement. Multivariate logistic regression analysis revealed that predictors of such derangement included anesthesia duration, remnant liver volume, and body mass index (BMI). However, coagulation derangement was not independently associated with age, gender, volatile anesthetics, central venous pressure, fatty change in the liver, estimated blood loss, or intraoperative hypotensive episodes.

CONCLUSION

We found that long anesthesia duration, low BMI, and small remnant liver volume were predictors of coagulation derangement. These results provide a better understanding of risk factors affecting changes in coagulation profiles after living donor hepatectomy.

Postoperative changes in prothrombin time following hepatic resection: implications for perioperative analgesia

Disorders of coagulation may occur after uncomplicated hepatic resection in patients who have normal preoperative coagulation profiles and liver function tests. We present a retrospective study performed in a tertiary care university teaching hospital examining changes in liver function tests and coagulation profiles in patients undergoing hepatic resection. Data were obtained for 124 patients. When compared to the preoperative values, prothrombin times were significantly increased throughout the postoperative period. Prolongation of the prothrombin time was related to both duration of surgery and hepatic resection weight. There was no relationship between prothrombin time and patient age. Disorders of coagulation occur after hepatic resection even in patients who have normal preoperative coagulation and liver function tests. This has implications for anaesthetic practice, particularly when considering the use of an indwelling epidural catheter in patients undergoing hepatic resection.

KUPFFER CELL???DEPLETED RATS HAVE A DIMINISHED ACUTE-PHASE RESPONSE FOLLOWING MAJOR LIVER RESECTION

Partial hepatectomy (PH)-induced Kupffer cell (KC) activation results in a rapid release of cytokines inducing the acute-phase response (APR). This study was done to evaluate the role of Kupffer cells (KCs) in the course of the APR following PH and a consecutive endotoxin challenge. KC depletion was performed in rats by i.v. administration of 1 mL liposome-encapsulated dichloromethylene diphosohonate (Cl2MDP). Control rats received 1 mL NaCl 0.9%. Forty-eight hours later, PH was performed. At 24 h after PH, rats were randomized to receive either 1 mL NaCl 0.9% (saline) or 50 microg/kg LPS i.v. in 1 mL. Animals were sacrificed at 4 h after LPS or saline infusion. The APR was determined by measuring hepatic gene expression of alpha 2-macroglobulin, alpha 1-acid glycoprotein, and IL-6 and expression of hepatic albumin. The APR was significantly depressed in KC-depleted rats. Despite increased IL-6 mRNA synthesis in response to low-dose LPS, no enhancement of acute-phase protein synthesis (APP) was found in KC-depleted rats. Hepatic failure was most profound in KC-depleted rats, as indicated by elevated plasma levels of liver transaminases and ammonia. We conclude that after PH, KC function in the remnant liver is important for the acute-phase reaction and reduces endotoxin-induced hepatocyte damage.

Improved functional reserve of hypertrophied contra lateral liver after portal vein ligation in rats

BACKGROUND/AIMS

We assessed the functional capacity of hypertrophied liver after portal vein ligation (PL) in a test group of rats compared to a control group (without PL) having the same size liver.

METHODS

The portal veins of the left and median lobes in the test group were ligated in an initial operation. Four days after the PL, the liver volume of the posterior caudate lobe (5%) increased two-fold, accounting for 10% of the liver. Then a 90% hepatectomy was performed, leaving only the hypertrophied posterior caudate lobe. Rats in a sham group underwent a 90% hepatectomy 4 days after having laparotomy, leaving the normal anterior and posterior caudate lobes (10%).

RESULTS

The survival rate for the PL group was significantly higher than for the sham group at 4 days after hepatectomy (56.3 and 26.7%, P<0.05). The regeneration ratio and the proliferating cell nuclear antigen (PCNA) labeling index in the PL group was markedly higher than in the sham group 24h after hepatectomy.

CONCLUSIONS

Hypertrophied liver at 4 days after PL still showed liver regeneration. Regenerating liver provided greater tolerance for extended hepatectomy than normal liver. This is because of the induced rapid regeneration of the remaining liver after hepatectomy.

Epidural catheter and increased prothrombin time after right lobe hepatectomy for living donor transplantation

IMPLICATIONS

Donor right hepatic lobectomy for the purpose of living liver transplantation may be associated with postoperative abnormalities in tests of clotting function. This study explores the possible causes and anesthetic implications of this phenomenon.

Hepatobiliary surgery

The transformation of liver and biliary tract surgery into a full speciality began with the application of functional anatomy to segmental surgery in the 1950's, reinforced by ultrasound and new imaging techniques. The spectrum of gall-stone disease encountered by the hepatobiliary surgeon has changed with the laparoscopic approach to cholecystectomy. There is increased need for conservation techniques to repair the bile duct injuries that arise more often in the laparoscopic approach to cholecystectomy. These and other surgical interventions on the bile ducts should be selected as a function of risk versus benefit in relation to the patient's requirements and the institutional expertise. Bile duct cancers, including hilar cholangiocarcinoma, and gallbladder cancers have a dismal reputation, but evidence is accumulating for better survivals from aggressive approaches performed by specialist hepatobiliary surgeons. Hepatic surgery has increased in safety and effectiveness, largely due to the segmental approach, but also to experience with techniques for vascular control and exclusion used in liver transplantation. Techniques such as portal vein embolisation, which induces hypertrophy of the future remnant liver, percutaneous local tumour destruction using cryotherapy or radiofrequency tumour coagulation and more effective chemotherapy are beginning to increase the number of patients who can undergo curative resection. In liver transplantation, segmental surgery has been applied to graft reduction and to split liver grafts, and is opening new perspectives for living donor transplantation. Today the limitation to survival in primary and metastatic liver cancer lies not in the surgical technique but in the difficulty of dealing with microscopic and extrahepatic disease. Progress in these fields will enable the hepatobiliary surgeon to further extend the possibilities for proposing curative resections.

Total vascular exclusion for liver resections: pros and cons

Dramatic improvements in morbidity and mortality rates following liver resections have been reported in the past decade. Consequently, the indications for hepatectomy are becoming more liberal. Many techniques of liver resection with or without vascular clamping have been reported with excellent clinical results. Total vascular exclusion (TVE) of the liver during parenchymal transection has been advocated susceptible to increase the resectability of tumors that might not be safely approached by other techniques. Cirrhotic livers are probably more vulnerable to ischemic injury related to TVE than normal livers. The indications and technical and metabolic aspects of the technique are reviewed.

Advantage of preoperative portal vein occlusion for hepatectomy that exceeds portal vein occluded lobes

BACKGROUND

The purpose of our study was to examine the effect of preoperative portal vein (PV) occlusion on hepatic reserve function after extended hepatectomy that is an excision of areas beyond the PV occluded lobes.

METHODS

Male Wistar rats were divided into three groups and underwent a two-stage operation: a PVL-hepatectomy group (ligation of the PV [PVL] of the left and median lobes followed by hepatectomy of the right lobes together with the PV occluded lobes), a sham-88% hepatectomy group (sham operation without PVL followed by hepatectomy corresponding to the lobes excised in the PVL-hepatectomy group), and a sham-67% hepatectomy group (sham operation followed by hepatectomy of the left and median lobes to approximate the volume excised in the PVL-hepatectomy group). In all subjects, hepatectomy was carried out 7 days after the PVL or sham operation. On days 0, 1, 2, and 3 after hepatectomy, liver weight, histologic elements, DNA synthesis rates, energy charge, adenine nucleotides, and lipoperoxide levels of the remaining liver were determined.

RESULTS

In the sham-88% hepatectomy group, the volume of resected liver was 88.2% +/- 0.5%. In the PVL-hepatectomy group it was 69.1% +/- 0.8%, although anatomically identical lobes were excised. At the time of hepatectomy, DNA synthesis, hepatic concentrations of adenine nucleotides and lipoperoxide, and serum liver function tests showed similar results in all three groups. The survival rate 3 days after hepatectomy was significantly low (53%) in the sham-88% hepatectomy group, whereas it was 100% in the PVL-hepatectomy and sham-67% hepatectomy groups. The gain in liver weight per day was significantly lower in the sham-88% hepatectomy group than in the other two groups. The decline in hepatic energy charge after hepatectomy was less, with less activated DNA synthesis, in the PVL-hepatectomy group compared with the sham-88% hepatectomy and sham-67% hepatectomy groups. Lipoperoxide concentration in the PVL-hepatectomy group was significantly lower than that in the sham-88% hepatectomy and sham-67% hepatectomy groups.

CONCLUSIONS

Preoperative PV occlusion not only increases the remaining liver volume but also is advantageous to hepatic reserve after hepatectomy that exceeds PV occluded lobes.

Is radical hepatic surgery safe?

BACKGROUND

A prospective review of 200 consecutive liver resections performed for benign and malignant disease, between 1989 and 1995 at the Hammersmith Hospital, was undertaken to evaluate the safety of radical hepatic resection.

METHODS

The indications for operation were: hepatocellular carcinoma (n = 39), cholangiocarcinoma (n = 21), gall bladder carcinoma (n = 8), colorectal secondaries (n = 75), noncolorectal secondaries (n = 35), and benign disease (n = 26). Twenty patients were cirrhotic and 36 were jaundiced. Major resections were performed in 74% of cases and included 63 extended hepatectomies, 17 repeated resections for recurrent colorectal metastases, and 17 resections combined with vascular reconstruction. Total vascular exclusion of the liver was used in the majority of cases.

RESULTS

The overall mortality rate was 5%. Thirty-day mortality was 2.5%. Sepsis and not hemorrhage was the most common cause of death. There were 101 complications that occurred in 37% of the patients. The main complications were subphrenic abscess and biliary leak. The extent of liver resection (major versus minor) significantly increased the risk of morbidity (46% versus 16%). Blood loss greater than 100 mL increased the risk of morbidity from 12% to 25%.

CONCLUSIONS

Major hepatic resection can be achieved with acceptable mortality but high morbidity rates.

Surgical critical care for cancer patients

Progress in cancer surgery and changes in philosophy have resulted in greater numbers of critically ill surgical oncology patients. The effects of cancer and prior exposure to cancer therapies increase the risks for postsurgical problems. Life-threatening cardiopulmonary sequela and patients undergoing liver resections and transplantation are examples of problems that require the knowledge and skill of critical care nurses. Critical care surgical nurses face new challenges by merging their surgical nursing expertise with principles of cancer care.

Liver resection with total vascular exclusion for malignant tumours

The records of 47 patients with no cirrhosis who underwent 56 liver resections under total vascular exclusion (TVE) for malignant tumours, both primary and secondary, were reviewed to study the effects of TVE. The mean (s.e.m.) blood loss was 1651(233) (median 1200 (range 200-8500)) ml and the mean(s.e.m.) intraoperative blood transfusion 930(100) (median 700 (range 0-2800)) ml. In 18 liver resections (32 per cent) no blood transfusion was administered. The mean(s.e.m.) postoperative hospital stay was 19.7(14.2) days. The 30-day operative mortality rate was nil but the hospital mortality rate was 4 per cent. Postoperative prothrombin time was influenced by the amount of liver resected and the duration of TVE but not by the amount of blood transfused. Postoperative serum levels of aspartate aminotransferase and bilirubin were not influenced by either the amount of liver resected or the duration of TVE.

Hepatic resections for primary liver cancer

The medical records of 399 patients who underwent hepatic resection between January 1981 and December 1990 were reviewed. Information regarding the results of the hepatic resection in terms of the operative indication, operative procedure, operative morbidity, and mortality was abstracted. As of the end of 1990, a total of 402 hepatic resections had been completed, including those of 319 primary malignancies, 4 secondary malignancies, 2 gallbladder carcinomas, 42 cases of intrahepatic cholelithiasis, and 35 benign masses. Major hepatic resections were performed on 117 patients (29%), of whom 60 (51%) had histologically proven liver cirrhosis. Minor hepatic resections were performed on the remaining 285 patients (71%). Sepsis was the most frequent complication, which manifested primarily as wound infection (71 cases) or intra-abdominal infection (25 cases). Nonfatal hepatic failure occurred in nine patients with cirrhosis and one patient without cirrhosis. There were 38 operative deaths among the 402 hepatic resections, for an overall operative mortality of 9.4%; 25 of those deaths were due to hepatic failure after the operation, accounting for 66% of the total operative mortality. There was an increasing frequency of hepatic resection during the last 5 years. The indication for resection due to hepatocellular carcinoma increased from 87 to 195 cases. The cumulative data show a decrease in the incidence of complications and the operative mortality rate. In the most recent period, nonlethal postoperative complications occurred in 135 of 286 patients (47%). The overall 1-, 3-, and 5-year survival rates for 172 patients, excluding cases of operative mortality, palliative resection, and re-resection, were 71.0%, 39.8%, and 28.3%, respectively.

Indocyanine green clearance as a predictor of successful hepatic resection in cirrhotic patients

Twenty-two cirrhotic patients who underwent hepatic resection from July 1989 to March 1991 at Vancouver General Hospital were analyzed prospectively in order to determine whether there was any preoperative evaluation of liver function that would help identify those patients who would not survive hepatic resection. Patients were analyzed on the basis of age, type of resection, and a variety of so-called standard liver function tests. In addition, all patients were evaluated preoperatively with an indocyanine green (ICG) clearance test, a relatively new test that we attempted to evaluate in terms of its role in hepatic resection in cirrhotic patients. Parametric statistical evaluation used included Student's t-test and multivariate regression, as well as discriminate analysis. The nonparametric evaluation used was the Wilcoxon rank sum test. Overall, the 30-day mortality rate was 18%, with those patients who did not survive resection having a significantly lower ICG clearance than those who underwent successful resection (p less than 0.0001). No other liver function test was useful in determining the outcome of resection. Similarly, neither age nor type of resection appeared to influence outcome. Use of discriminate analysis (p = 0.0029) allowed the identification of a cutoff point for ICG clearance below which hepatic resection should not be attempted.

'Natural history' of hepatectomy

The aim of this study was to describe biochemical and liver function test changes after hepatectomy in 33 patients with the following characteristics: absence of underlying liver disease, no blood or plasma transfusion during the perioperative period, uneventful postoperative course. Resection with a temporary pedicle inflow occlusion (10-45 min) consisted of unisegmentectomy or less in 15 patients and bisegmentectomy or more in 18. Blood tests showed: a correlation between aminotransferase rise and duration of ischaemia, and a fall in prothrombin time and factor V levels correlating with the weight of resected specimen at day 1; a moderate gamma-glutamyl transpeptidase and alkaline phosphatase elevation and a rise in fibrinogen level correlating with the extent of resection at day 7. Changes in haemoglobin level, white cell count, platelet count, prothrombin time, factor V level and serum bilirubin level tended to return to preoperative levels by day 7. For gamma-glutamyl transpeptidase and alkaline phosphatase, increased levels persisted for 8-12 weeks after resection. These results, in this selected group of patients, allow a description of the 'natural history' of hepatectomy. The knowledge of these 'natural' changes may contribute to the early detection of postoperative complications.