New technique in hepatic parenchymal transection for living related liver donor and liver neoplasms

The CUSA Clarity Soft Tissue Removal Study: Clinical Performance Investigation of the CUSA Clarity Ultrasonic Surgical Aspirator System for Soft Tissue Removal During Liver Surgery

Background: Intraoperative blood loss has an unfavorable impact on the outcome of patients undergoing liver surgery. Today, the use of devices capable of minimizing this risk with high technical performance becomes mandatory. Into this scenario fits the CUSA® Clarity Ultrasonic Surgical Aspirator System. This prospective survey involving five liver surgery centers had the objective of investigating whether this innovative ultrasonic surgical aspirator is safe and effective in the transection of the liver parenchyma. Materials and Methods: This clinical study was a prospective, multicenter, single-arm Post-Market Clinical Follow-up study investigating 100 subjects who underwent liver surgery using the CUSA Clarity Ultrasonic Surgical Aspirator System at five centers during a period of 1 year and 8 months. After collecting all the patient's clinical information and instrument usage details, surgeons completed a brief survey giving their opinions on the performance of CUSA. Therefore, safety and efficacy outcomes were evaluated. Results: Surgeons had a 95% success rate in complete removal of the mass with an average overall operative time of 4 hours and 34 minutes. Overall, there were no complications or device deficiencies. Conclusion: The CUSA Clarity Ultrasonic Surgical Aspirator System performs well during liver surgery with a low complication rate. ClinicalTrials.gov Identifier: NCT04298268.

Liver resection using cavitron ultrasonic surgical aspirator (CUSA) versus harmonic scalpel: a retrospective cohort study

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of two device combinations used in parenchymal division during hepatic resections in non-cirrhotic patients and without inflow vascular occlusion.

METHODS

We retrospectively analyzed 47 patients who underwent liver resection at our Institution from 2004 to 2010 using the TissueLink with either the Cavitron Ultrasonic Surgical Aspirator (CUSA) or the Harmonic Scalpel. The TissueLink was used with the CUSA in 27 patients and with the Harmonic Scalpel in 20 patients.

RESULTS

Median estimated blood loss (EBL) in the Harmonic Scalpel and CUSA groups was 250 and 1035 mL respectively (p < 0.05). Three patients were transfused banked blood perioperatively in the Harmonic Scalpel group and 11 in the CUSA group (p < 0.05). Median operative time in the Harmonic Scalpel and CUSA groups was 185 and 290 min respectively. Length of stay (LOS) was shorter in the Harmonic Scalpel group at 6 days compared to 7 days in the CUSA group (p < 0.05). Perioperative complications were documented in 20% and 26% in the Harmonic Scalpel and CUSA groups, respectively.

CONCLUSIONS

Our results show the Harmonic Scalpel with TissueLink to be a safe, effective method of parenchymal division with significantly less EBL and LOS when compared to CUSA with TissueLink.

Surgical Management of Complex Liver Trauma: A Single Liver Transplant Center Experience

Complex liver trauma often presents major diagnostic and management problems. Current operative management is mainly centered on packing, damage control, and early utilization of interventional radiology for angiography and embolization. In this retrospective observational study of patients admitted to the Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy, from 1999 to 2010, we included patients that underwent hepatic resection for complex liver injuries (grade I to Vaccording to the American Association for the Surgery of Trauma-Organ Injury Scale). Age, gender, mechanism of trauma, type of resection, surgical complications, length of hospital stay, and mortality were the variables analyzed. A total of 53 adult patients were admitted with liver injury and 29 underwent surgical treatment; the median age was 26.7 years. Mechanism was blunt in 52 patients. The overall morbidity was 30 per cent, morbidity related to liver resection was 15.3 per cent. Mortality was 2 per cent in the series of patients undergoing liver resection for complex hepatic injury, whereas in the nonoperative group, morbidity was 17 per cent and mortality 2 per cent. Liver resection should be considered a serious surgical option, as initial or delayed management, in patients with complex liver injury and can be accomplished with low mortality and liver-related morbidity when performed in specialized liver surgery/transplant centers.

Extra-Glissonian approach in liver resection

BACKGROUND

In this study we analyzed our most recent experience in the use of the extraglissonian approach to the hilar structures in two circumstances: pedicle transection during major liver resections, and selective clamping in minor hepatectomies.

METHODS

The major liver resections study group consisted of 89 cases. Extraglissonian approach and stapler transection of hilar structures was used in 61 (69%). The study group of minor liver resections consisted of 103 cases. Extraglissonian approach and selective clamping was used in 27 cases (26%).

RESULTS

In major hepatectomies pedicle stapling and hilar dissection demonstrated a similar operative time (240 vs. 260 min; P = 0.230); no differences were observed in the amount of haemorrhage (800 ml vs. 730 ml; P = 0.699), number of patients transfused (16 vs. 6; P = 0.418) and volume of blood transfused (4 PRC vs. 4 PRC; P = 0.521). Duration of vascular pedicle occlusion was 35 vs. 30 min respectively (P = 0.293). Major complications (grade >or=3a) occurred in 18 (20%) patients and mortality rates (4.9% vs. 3.5%; P = 0.882) were similar for both group. In minor liver resections there were no differences between Pringle and selective clamping in operative time (240 vs. 240 min; P = 0.321), haemorrhage (435 ml vs. 310 ml; P = 0.575), number of patients transfused (18 vs. 7; P = 0.505) and volume blood transfused (4 PRC vs. 3 PRC; P = 0.423). Major complications (grade >or=3a) occurred in 14 (14%) patients, and mortality (2.6% vs. 3.7%; P = 0.719) were similar for both groups. However, the duration of pedicle clamping was significantly longer in the selective clamping group (26 +/- 21 minutes vs. 44 +/- 18 minutes) (P = 0.001).

CONCLUSIONS

The extraglissonian approach can be extremely useful in liver surgery. Selective clamping with extraglissonian approach avoids ischemia to the other hemiliver. Selective clamping it is also important from the homodynamic point of view because there is no splanchnic stasis and low fluid replacement.

Extending the frontiers of surgical therapy for hepatic colorectal metastases: is there a limit?

Hepatic resection for colorectal metastases, limited to the liver, has become the standard of care, and currently remains the only potentially curative therapy. Numerous single institutional reports have demonstrated long-term survival, and there are no other treatment options that have shown a survival plateau. However, curative resection is possible in less than 25% of patients with disease limited to the liver, which consequently translates into only 5% to 10% of the original group developing colorectal cancer. To increase the number of patients who could benefit from hepatic resection, the last decade has seen considerable effort directed towards the following areas, (1) refining prognostic factors that would improve patient selection, (2) advancements in surgical technique such as, use of intraoperative ultrasonography, controlling hemorrhage through use of vascular clamping techniques supplemented with low central venous pressure anesthesia, availability of novel devices for parenchymal transection, and controlled anatomic hepatectomy with Glissonian technique, and (3) novel approaches to permit curative hepatic resection such as, preoperative portal vein embolization for hypertrophy of future liver remnant and staged hepatic resection. This article reviews development of these innovative multidisciplinary modalities and the aggressive surgical approach that has been adopted to extend the frontiers of surgical therapy for colorectal hepatic metastases.

Hepatic resection in 170 patients using saline-cooled radiofrequency coagulation

BACKGROUND

Hepatic resection for malignancies or symptomatic benign liver lesions remains the standard of treatment. Historically, the principal cause of mortality during liver resection was intraoperative bleeding. Advances in surgical and anesthetic techniques, along with application of new technologies, have decreased blood loss and dramatically improved the outcomes for major liver surgery.

METHODS

The purpose of this prospective study was to determine the utility of a saline-cooled radiofrequency coagulation device (TissueLink Medical, Inc.) for hepatic resection. Intraoperative bleeding, blood transfusion, postoperative bile leak, and other complications were noted.

RESULTS

The results are described for 170 patients undergoing hepatic resection over a three-year period. There were no intraoperative or postoperative deaths. Six patients in the series received blood transfusions for a transfusion rate of 3.5%. Four patients experienced a transient postoperative bile leak. Three of the four closed spontaneously prior to discharge home, and the fourth closed promptly after ERCP. There were no episodes of postoperative hemorrhage, hepatic failure, liver abscess, or reoperation.

CONCLUSIONS

The saline-cooled radiofrequency coagulation device is very effective in achieving intraoperative hemostasis and facilitates liver parenchymal transection during hepatic resection.