The effect of hepatectomy on coagulation: an evaluation by thromboelastography

Epidural Hematoma in Minor Hepatic Metastasectomy

Liver resection poses many challenges for the anesthesiologist, including intraoperative hemodynamic instability, postoperative pain, and risk of coagulopathy. We report a case of epidural hematoma after epidural catheter removal, following a minor liver single metastasectomy. The main purpose of this case report is to bring to light the false security provided by traditional coagulation parameters and whether further investigation should be considered in selected cases, before handling neuraxial catheters. Alterations in coagulation after a partial hepatectomy remain poorly understood; thus, we believe that additional hemostatic values such as viscoelastic testing might be considered to better assess these patients.

Non-operative management of isolated liver trauma

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

Management of post-hepatectomy complications

Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management. This review article focuses on the major postoperative issues after hepatic resection and presents the current management.

Transcriptome temporal and functional analysis of liver regeneration termination

Decades of liver regeneration studies still left the termination phase least elucidated. However regeneration ending mechanisms are clinicaly relevant. We aimed to analyse the timing and transcriptional control of the latest phase of liver regeneration, both controversial. Male Wistar rats were subjected to 2/3 partial hepatectomy with recovery lasting from 1 to 14 days. Time-series microarray data were assessed by innovative combination of hierarchical clustering and principal component analysis and validated by real-time RT-PCR. Hierarchical clustering and principal component analysis in agreement distinguished three temporal phases of liver regeneration. We found 359 genes specifically altered during late phase regeneration. Gene enrichment analysis and manual review of microarray data suggested five pathways worth further study: PPAR signalling pathway; lipid metabolism; complement, coagulation and fibrinolytic cascades; ECM remodelling and xenobiotic biotransformation. Microarray findings pertinent for termination phase were substantiated by real-time RT-PCR. In conclusion, transcriptional profiling mapped late phase of liver regeneration beyond 5(th) day of recovery and revealed 5 pathways specifically acting at this time. Inclusion of longer post-surgery intervals brought improved coverage of regeneration time dynamics and is advisable for further works. Investigation into the workings of suggested pathways might prove helpful in preventing and managing liver tumours.

Epidural anaesthesia and analgesia for liver resection

Although epidural analgesia is routinely used in many institutions for patients undergoing hepatic resection, there are unresolved issues regarding its safety and efficacy in this setting. We performed a review of papers published in the area of anaesthesia and analgesia for liver resection surgery and selected four areas of current controversy for the focus of this review: the safety of epidural catheters with respect to postoperative coagulopathy, a common feature of this type of surgery; analgesic efficacy; associated peri-operative fluid administration; and the role of epidural analgesia in enhanced recovery protocols. In all four areas, issues are raised that question whether epidural anaesthesia is always the best choice for these patients. Unfortunately, the evidence available is insufficient to provide definitive answers, and it is clear that there are a number of areas of controversy that would benefit from high-quality clinical trials.

Rotational thromboelastometry and standard coagulation tests for live liver donors

PURPOSE

To study coagulation of live liver donors with standard coagulation tests (SCT) and rotational thromboelastometry (ROTEM) and investigate their relationship.

METHODS

A descriptive prospective study involving 50 right hepatotomy donors with epidural catheters. ROTEM (EXTEM, INTEM, and FIBTEM represent extrinsic and intrinsic pathways of coagulation and fibrinogen activity, respectively) was measured perioperatively and on days 1, 3, 5, 10, and 30. SCTs include prothrombin time (PT), international normalized ratio (INR) of PT, activated partial thromboplastin time (aPPT), fibrinogen, and platelets.

RESULTS

PT and INR reflect hypocoagulability reaching maximum on day one (16.9 ± 2.5 s, 1.4 ± 0.2, p < 0.05 compared with baseline). ROTEM was in normal ranges till day 30 with no hypercoagulability. Fibrinogen showed no correlation with maximum clot firmness (MCF) of FIBTEM (r = 0.35, p > 0.05). CFT of EXTEM was not in significant correlation with PT and INR (r = 0.16, 0.19, p > 0.05), respectively. Significant correlation between platelets and both MCF (EXTEM; r = 0.59, p = 0.004) and MCF (INTEM; r = 0.48, p = 0.027).

CONCLUSION

ROTEM disagreed with SCTs and did not show the temporary hypocoagulability suggested by SCTs. Both ROTEM and SCTs showed no signs of hypercoagulability. Future studies involving ROTEM could help develop new guidelines for coagulation monitoring.

Evaluation of Hemostatic Factors in Patients Undergoing Major Hepatic Resection and Other Major Abdominal Surgeries

The aim of this study was to evaluate the role for additional testing of coagulation in perioperative management of patients undergoing major hepatic resection. Major outcome measures were perioperative measurements of hemostatic factors (activated partial prothrombin time [aPTT], prothrombin time/international normalized ratio, fibrinogen, antithrombin-III). We conducted a prospective, single-blind study comparing hemostatic factors in patients undergoing major hepatectomy, Whipple procedures, and other gastrointestinal operations. Ninety-five consecutive patients were enrolled. No values differed significantly at baseline. Immediately postoperative, only international normalized ratio was significantly lower comparing major hepatectomy with Whipple ( P < 0.005) and other procedures ( P < 0.0032). Twenty-four hours postoperative, antithrombin-III was lower for major hepatectomy than Whipple ( P < 0.028) and others ( P < 0.0001); fibrinogen was lower compared with Whipple ( P < 0.014) and others ( P < 0.0009); international normalized ratio was lower to compared with Whipple ( P < 0.0001) and others ( P < 0.0001). aPTT measurements never differed significantly between groups at any time. Antithrombin-III and fibrinogen only correlated with international normalized ratio and aPTT for the other procedures. Additional hemostatic values beyond the standard evaluations of aPTT and international normalized ratio are needed to better assess patients undergoing major hepatic surgery.