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Gani RA, Teressa M, Budiman RA, Kalista KF, Lesmana CRA. Meta analysis of radiofrequency ablation versus surgical resection in small and large nodule of hepatocellular carcinoma. HPB (Oxford) 2024:S1365-182X(24)01775-1. [PMID: 39060212 DOI: 10.1016/j.hpb.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/21/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Although studies have indicated comparable outcomes between RFA and surgical resection in early HCC, there is still unclear evidence of benefit in larger tumor sizes. This study aimed to assess the efficacy and safety of RFA versus surgical resection in HCC patients, considering nodule size with a cutoff at 3 cm. METHODS A comprehensive search of multiple databases was conducted. The systematic review and meta-analysis followed the PRISMA guidelines. RESULT Surgical resection showed superior OS (HR = 1.18, 95% CI: 1.11-1.27, p = 0.008) and RFS (HR = 1.17, 95% CI: 1.11-1.25, p < 0.00001), compared to RFA. For nodules less than 3 cm or larger than 5 cm, the OS and RFS in the surgical resection group were significantly higher than those in the RFA group, while no significant differences were observed for nodules sized 3-5 cm. However, significantly more adverse events occurred following surgical resection (OR = 0.43, 95% CI: 0.33-0.56, P < 0.00001). CONCLUSION Surgical resection has better OS and RFS compared to RFA for liver tumors less than 3 cm or larger than 5 cm. For liver tumors sized 3-5 cm, RFA and surgical resection yield similar findings. RFA may become a preferable option in these 3-5 cm tumors due to its comparable efficacy and fewer adverse events for patients unsuitable for surgery.
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Affiliation(s)
- Rino A Gani
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Maria Teressa
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Refael A Budiman
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Kemal F Kalista
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Cosmas Rinaldi A Lesmana
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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2
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Yoo JJ, Koo S, Choi GH, Lee MW, Ryoo S, Park J, Park DA. Radiofrequency Ablation versus Surgical Resection in Elderly Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis. Curr Oncol 2024; 31:324-334. [PMID: 38248106 PMCID: PMC10813859 DOI: 10.3390/curroncol31010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Although the disease burden of elderly cancer patients is rapidly increasing, reliable scientific information, value and preference information of domestic patients, and standardized guidelines for determining the treatment of elderly cancer patients are lacking. The aim of this study is to compare the therapeutic effects of radiofrequency ablation (RFA) and surgery in hepatocellular carcinoma (HCC) patients aged 65 years or older. For the meta-analysis, the databases including PubMed (MEDLINE), EMBASE, OVID Medline, and the Cochrane Library were systematically searched. After the abstract-based review by two investigators, selected manuscripts were read in detail. The surgery group showed higher overall survival (OS) (HR 1.44, 95% CI 1.22-1.70) and disease-free survival (DFS) (HR 1.40, 95% CI 1.00-1.97) than the RFA group. This was also shown in small HCC of less than 3 cm (OS, HR 1.42, 95% CI 1.00-2.03; DFS, HR 1.32, 95% CI 0.91-1.91). This might be related to the high local recurrence in the RFA group (OR 4.90, 95% 2.16-11.08). On the other hand, adverse events were significantly lower in the RFA group (OR 0.22, 95% CI 0.14-0.36), which led to a decrease in the duration of hospital stay (mean difference -14.88 days, 95% CI -22.44--7.32). In elderly HCC patients, survival in the surgery group was significantly higher than in the RFA group, but various complications tended to increase; so, appropriate patient selection is required.
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Affiliation(s)
- Jeong-Ju Yoo
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon 14584, Republic of Korea;
| | - Sujin Koo
- Graduate School of Converging Clinical and Public Health, Ewha Womans University, Seoul 03760, Republic of Korea;
| | - Gi Hong Choi
- Department of General Surgery, Yonsei University School of Medicine, Seoul 03722, Republic of Korea;
| | - Min Woo Lee
- Department of Radiology, Samgsung Medical Center, Sungkyunkwan University, Seoul 06171, Republic of Korea;
| | - Seungeun Ryoo
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul 04933, Republic of Korea; (S.R.); (J.P.)
| | - Jungeun Park
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul 04933, Republic of Korea; (S.R.); (J.P.)
| | - Dong Ah Park
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul 04933, Republic of Korea; (S.R.); (J.P.)
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3
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Nigam A, Hawksworth JS, Winslow ER. Minimally Invasive Robotic Techniques for Hepatocellular Carcinoma Resection: How I Do It. Surg Oncol Clin N Am 2024; 33:111-132. [PMID: 37945137 DOI: 10.1016/j.soc.2023.06.009] [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] [Indexed: 11/12/2023]
Abstract
The adoption of minimally invasive techniques for hepatocellular resection has progressively increased in North America. Cumulative evidence has demonstrated improved surgical outcomes in patients who undergo minimally invasive hepatectomy. In this review, the authors' approach and methodology to minimally invasive robotic liver resection for hepatocellular carcinoma is discussed.
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Affiliation(s)
- Aradhya Nigam
- Department of Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Road, NW, 4PHC, Washington, DC 20007, USA
| | - Jason S Hawksworth
- Division of Abdominal Organ Transplantation, Columbia University Irving Medical Center, 622 West 168th Street, PH14-105, New York, NY 20032, USA.
| | - Emily R Winslow
- Department of Transplant Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Road, NW, 2PHC, Washington, DC 20007, USA
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Ida S, Morita Y, Matsumoto A, Muraki R, Kitajima R, Furuhashi S, Takeda M, Kikuchi H, Hiramatsu Y, Takeuchi H. Prediction of postoperative complications after hepatectomy with dynamic monitoring of central venous oxygen saturation. BMC Surg 2023; 23:343. [PMID: 37957615 PMCID: PMC10644466 DOI: 10.1186/s12893-023-02238-6] [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: 07/14/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The usefulness of static monitoring using central venous pressure has been reported for anesthetic management in hepatectomy. It is unclear whether intra-hepatectomy dynamic monitoring can predict the postoperative course. We aimed to investigate the association between intraoperative dynamic monitoring and post-hepatectomy complications. Furthermore, we propose a novel anesthetic management strategy to reduce postoperative complication. METHODS From 2018 to 2021, 93 patients underwent hepatectomy at our hospital. Fifty-three patients who underwent dynamic monitoring during hepatectomy were enrolled. Flo Trac system was used for dynamic monitoring. The baseline central venous oxygen saturation (ScvO2) was defined as the average ScvO2 for 30 min after anesthesia induction. ScvO2 fluctuation (ΔScvO2) was defined as the difference between the baseline and minimum ScvO2. Postoperative complications were evaluated using the comprehensive complication index (CCI). RESULTS Patients with ΔScvO2 ≥ 10% had significantly higher CCI scores (0 vs. 20.9: p = 0.043). In univariate analysis, patients with higher CCI scores demonstrated significantly higher preoperative C-reactive protein-to-lymphocyte ratio (7.51 vs. 24.49: p = 0.039), intraoperative bleeding (105 vs. 581 ml: p = 0.008), number of patients with major hepatectomy (4/45 vs. 3/8: p = 0.028), and number of patients with ΔScvO2 ≥ 10% (11/45 vs. 6/8; p = 0.010). Multivariate logistic regression analysis revealed that ΔScvO2 ≥ 10% (odds ratio: 9.53, p = 0.016) was the only independent predictor of elevated CCI. CONCLUSIONS Central venous oxygen saturation fluctuation during hepatectomy is a predictor of postoperative complications. Anesthetic management based on intraoperative dynamic monitoring and minimizing the change in ScvO2 is a potential strategy for decreasing the risk of post-hepatectomy complications.
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Affiliation(s)
- Shinya Ida
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Yoshifumi Morita
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan.
- Division of Surgical Care, Morimachi, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | - Akio Matsumoto
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Ryuta Muraki
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Ryo Kitajima
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Satoru Furuhashi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Makoto Takeda
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Yoshihiro Hiramatsu
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
- Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
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Kennedy L, Zamper RPC. When Insufflation Goes Awry: Massive Gas Embolism During Laparoscopic Surgery. CASE (PHILADELPHIA, PA.) 2023; 7:185-188. [PMID: 37325464 PMCID: PMC10264203 DOI: 10.1016/j.case.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Liam Kennedy
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Raffael Pereira Cezar Zamper
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Department of Anaesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Chatterejee P, Subramanian H, Panneerselvam S. Anesthetic Approach to a Case of Hepatoblastoma With Right Atrial Spread for Simultaneous Resection of Both. Cureus 2022; 14:e25796. [PMID: 35812592 PMCID: PMC9270930 DOI: 10.7759/cureus.25796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/16/2022] Open
Abstract
Hepatoblastoma is the most common primary liver tumor in childhood. However, cases involving age >5 years are extremely rare. Invasion of the inferior vena cava and right atrium in hepatoblastoma places the patient in a high-risk group, and due to the rarity of such presentation, the preferred surgical approach is not clear. We present the perioperative anesthetic management of hepatoblastoma in an eight-year-old child with right atrial invasion at diagnosis, with no regression in size of the tumor after chemotherapy, treated subsequently with combined cardiac and liver surgery. Due to the possibility of impingement of the tumor thrombus onto the tricuspid valve or superior vena cava, or systemic embolization from the right atrium, access for the cardiopulmonary bypass was kept ready at the start of surgery. Intraoperative evidence of fragmentation of a small part of the right atrial tumor was noted in trans-esophageal echocardiography midway during left hepatectomy. This necessitated the emergency institution of cardiopulmonary bypass and en-bloc removal of the tumor thrombus with the remaining left hepatectomy specimen. The anesthetic management was further compounded by the risk of peri-operative pulmonary embolization, coagulopathy, blood loss and hemodynamic instability, ischemia-reperfusion injury, and post-operative hepatic, renal and pulmonary complications inherent in hepatectomies. The case presented a unique set of challenges to both surgeons and anesthetists. What was most evident from the successful management of such a case was the need for a team approach, with adequate communication between teams managing the patient.
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Specialty-Specific Readmission Risk Models Outperform General Models in Estimating Hepatopancreatobiliary Surgery Readmission Risk. J Gastrointest Surg 2021; 25:3074-3083. [PMID: 33948862 DOI: 10.1007/s11605-021-05023-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population. METHODS Pancreatectomy and hepatectomy operation-specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC). RESULTS A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58). CONCLUSION HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies.
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8
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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: 9] [Impact Index Per Article: 1.8] [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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Golriz M, Abbasi S, Fathi P, Majlesara A, Brenner T, Mehrabi A. Does acid-base equilibrium correlate with remnant liver volume during stepwise liver resection? Am J Physiol Gastrointest Liver Physiol 2017. [PMID: 28642298 DOI: 10.1152/ajpgi.00110.2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Small for size and flow syndrome (SFSF) is one of the most challenging complications following extended hepatectomy (EH). After EH, hepatic artery flow decreases and portal vein flow increases per 100 g of remnant liver volume (RLV). This causes hypoxia followed by metabolic acidosis. A correlation between acidosis and posthepatectomy liver failure has been postulated but not studied systematically in a large animal model or clinical setting. In our study, we performed stepwise liver resections on nine pigs to defined SFSF limits as follows: step 1: segment II/III resection, step 2: segment IV resection, step 3: segment V/VIII resection (RLV: 75, 50, and 25%, respectively). Blood gas values were measured before and after each step using four catheters inserted into the carotid artery, internal jugular vein, hepatic artery, and portal vein. The pH, [Formula: see text], and base excess (BE) decreased, but [Formula: see text] values increased after 75% resection in the portal and jugular veins. EH correlated with reduced BE in the hepatic artery. Pco2 values increased after 75% resection in the jugular vein. In contrast, arterial Po2 increased after every resection, whereas the venous Po2 decreased slightly. There were differences in venous [Formula: see text], BE in the hepatic artery, and Pco2 in the jugular vein after 75% liver resection. Because 75% resection is the limit for SFSF, these noninvasive blood evaluations may be used to predict SFSF. Further studies with long-term follow-up are required to validate this correlation.NEW & NOTEWORTHY This is the first study to evaluate acid-base parameters in major central and hepatic vessels during stepwise liver resection. The pH, [Formula: see text], and base excess (BE) decreased, but [Formula: see text] values increased after 75% resection in the portal and jugular veins. Extended hepatectomy correlated with reduced BE in the hepatic artery. Because 75% resection is the limit for small for size and flow syndrome (SFSF), postresection blood gas evaluations may be used to predict SFSF.
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; and
| | - Sepehr Abbasi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; and
| | - Parham Fathi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; and
| | - Ali Majlesara
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; and
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; and
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Cauchy F, Brustia R, Perdigao F, Bernard D, Soubrane O, Scatton O. In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements. World J Surg 2017; 40:1448-53. [PMID: 26830907 DOI: 10.1007/s00268-016-3431-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION While total vascular exclusion (TVE) with veno-venous bypass and hypothermia may be undertaken to increase liver tolerance for complex liver resection, these procedures are still associated with elevated rates of postoperative complications and mortality. In particular, one of the main issues of this strategy is the management of bleeding after declamping, which is enhanced by both hypothermic state and acidosis. To overcome this high risk of morbidity, several technical refinements might be undertaken and here described (with video). METHODS All patients, requiring TVE >60 min and liver cooling during hepatectomy, were retrospectively included in this study. Technical key points as (a) patient selection, (b) anesthetic management, (c) two-surgeon's technique, (d) preparation for clamping, (e) veno-venous bypass, (f) cooling of the liver, and (g) parenchymal transection, rewarming, and declamping are described and detailed. RESULTS From 2011 to 2013, we included 8 cases of liver resection with TVE, veno-venous bypass, and hypothermia for malignant disease. Due to the technical refinements, median observed overall blood loss of 550 ml (300-900) including 200 ml (50-300) at declamping and transfusion of packed red blood cell (PRBC) units was required in 5 patients with a mean of 1.25 PRBC/patient. CONCLUSION The association of TVE, veno-venous bypass, and liver cooling can reduce the time of transection, and blue dye injection and liver rewarming before declamping can reduce blood loss and coagulopathy. Altogether, limited blood loss can be achieved for these complex procedures and may allow to decreasing morbidity.
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Affiliation(s)
- François Cauchy
- Department of Hepato-Pancreatic-Biliary Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Clichy, France
| | - Raffaele Brustia
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France.
| | - Fabiano Perdigao
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France
| | - Denis Bernard
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France
| | - Olivier Soubrane
- Department of Hepato-Pancreatic-Biliary Surgery, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Clichy, France
| | - Olivier Scatton
- Department of Digestive, Hepatobiliary and Liver transplantation Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, 47-83 Boulevard de l' Hôpital, Paris, 75013, France
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11
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Cuéllar-Guzmán LF, Pérez-González ÓR. Consideraciones perioperatorias en el paciente oncológico sometido a hepatectomía. GACETA MEXICANA DE ONCOLOGÍA 2016. [DOI: 10.1016/j.gamo.2016.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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12
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Zhou ZJ, Wang X, Song Z, Dong KR, Zheng S. Effect of sevoflurane anaesthesia on hepatic blood flow in infants with obstructive hepatobiliary disease. Acta Anaesthesiol Scand 2016; 60:1067-74. [PMID: 27137481 DOI: 10.1111/aas.12733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 02/29/2016] [Accepted: 03/08/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Currently most studies on anaesthetic effects on hepatic blood flow of cirrhotic patients have been performed on adults or experimental animals. We performed this study to evaluate the effect of sevoflurane anaesthesia on hepatic blood flow in infants with obstructive jaundice by Doppler ultrasound. METHODS Forty-four infants with biliary atresia (1-3 months of age) scheduled for a Kasai procedure were enrolled. Hepatic blood flow was calculated by Doppler ultrasound measurements before induction, and after inhalation of 2% and 3% sevoflurane. Infants were allocated to three groups according to baseline portal blood flow/hepatic artery blood flow: group A (portal blood flow/hepatic artery blood flow < 1), group B (1 ≤ portal blood flow/hepatic artery blood flow < 2) and group C (portal blood flow/hepatic artery blood flow ≥ 2). Changes in portal blood flow, hepatic artery blood flow and hepatic blood flow were compared among groups. RESULTS In group A (n = 9), the median (IQR) hepatic blood flow increased after inhalation of 2% sevoflurane compared to that before induction (from 49.7 (32.0-89.0) to 116.1 (40.4-159.1) ml/min; P = 0.035). Whereas in groups B and C in whom the ratio of portal blood flow and hepatic artery blood flow was normal or mildly changed, the increases in hepatic blood flow after sevoflurane anaesthesia were not significant. CONCLUSIONS For infants with obstructive jaundice that had reduced portal blood flow and compensatory increase in hepatic artery blood flow, sevoflurane may produce a protective effect on hepatic blood flow.
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Affiliation(s)
- Z-J Zhou
- Department of Anaesthesiology, Children's Hospital of Fudan University, Shanghai, China
| | - X Wang
- Department of Anaesthesiology, Children's Hospital of Fudan University, Shanghai, China
| | - Z Song
- Department of Anaesthesiology, Children's Hospital of Fudan University, Shanghai, China
| | - K-R Dong
- Department of Anaesthesiology, Children's Hospital of Fudan University, Shanghai, China
| | - S Zheng
- Department of Anaesthesiology, Children's Hospital of Fudan University, Shanghai, China
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Brustia R, Granger B, Scatton O. An update on topical haemostatic agents in liver surgery: systematic review and meta analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:609-621. [PMID: 27580747 DOI: 10.1002/jhbp.389] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/29/2016] [Indexed: 12/31/2022]
Abstract
Mortality and morbidity in hepatic surgery are affected by blood loss and transfusion. Topical haemostatic agents (THA) are composed by a matrix and/or fibrin sealants, and their association known as "carrier-bound fibrin sealant" (CBFS): despite widely used for secondary haemostasis, the level of evidence remains low. To realize a meta-analysis on the results of CBFS on haemostasis and postoperative complications. Searches in PubMed, PubMed Central, Cochrane and Google Scholar using keywords: "topical_haemostasis" OR "haemostatic_agents" OR "sealant_patch" OR "fibrin_sealant" OR "collagen_sealant" AND "liver_surgery" OR "hepatic_surgery" OR "liver_transplantation". Randomized clinical trials, large retrospective cohort studies, case control studies evaluating THA on open/laparoscopic liver surgery and transplantation. From 1993 to 2016 were found 22 studies for qualitative synthesis and 13 for quantitative meta-analysis. The time to haemostasis was lower in the CBFS group (mean difference -2.33 min; P = 0.00001). The risk of receiving blood transfusion, developing collections and bile leak was not influenced by the use of CBFS (OR 0.75; P = 0.25), (OR 0.72; P = 0.52), (OR 0.74; P = 0.30) respectively. The use of CBFS in liver surgery significantly reduce the time to haemostasis, but does not decrease transfusion, postoperative collection and bile leak.
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Affiliation(s)
- Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié Salpetriere Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l' Hôpital, Paris, 75013, France.,Université Pierre et Marie Curie, Paris, France
| | - Benjamin Granger
- Department of Biostatistics, Public Health and Medical Information, Pitié Salpetriere Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié Salpetriere Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l' Hôpital, Paris, 75013, France. .,Université Pierre et Marie Curie, Paris, France.
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14
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Egger ME, Gottumukkala V, Wilks JA, Soliz J, Ilmer M, Vauthey JN, Conrad C. Anesthetic and operative considerations for laparoscopic liver resection. Surgery 2016; 161:1191-1202. [PMID: 27545995 DOI: 10.1016/j.surg.2016.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/06/2016] [Accepted: 07/09/2016] [Indexed: 02/06/2023]
Abstract
We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.
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Affiliation(s)
- Michael E Egger
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jonathan A Wilks
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Soliz
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthias Ilmer
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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15
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Lim C, Audureau E, Salloum C, Levesque E, Lahat E, Merle JC, Compagnon P, Dhonneur G, Feray C, Azoulay D. Acute kidney injury following hepatectomy for hepatocellular carcinoma: incidence, risk factors and prognostic value. HPB (Oxford) 2016; 18:540-8. [PMID: 27317959 PMCID: PMC4913133 DOI: 10.1016/j.hpb.2016.04.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/19/2016] [Accepted: 04/10/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) following hepatectomy remains understudied in terms of diagnosis, severity, recovery and prognostic value. The aim of this study was to assess the risk factors and prognostic value of AKI on short- and long-term outcomes following hepatectomy for hepatocellular carcinoma (HCC). METHOD This is a retrospective analysis of a single-center cohort of 457 consecutive patients who underwent hepatectomy for HCC. The KDIGO criteria were used for AKI diagnosis. The incidence, risk factors, and prognostic value of AKI were investigated. RESULTS AKI occurred in 67 patients (15%). The mortality and major morbidity rates were significantly higher in patients with AKI (37% and 69%) than in those without (6% and 22%; p < 0.001). Renal recovery was complete in 35 (52%), partial in 25 (37%), and absent in 7 (11%) patients. Advanced age, an increased MELD score, major hepatectomy and prolonged duration of operation were identified as independent predictors of AKI. AKI was identified as the strongest independent predictor of postoperative mortality but did not impact survival. CONCLUSION AKI is a common complication after hepatectomy for HCC. Although its development is associated with poor short-term outcomes, it does not appear to be predictive of impaired long-term survival.
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Key Words
- aki, acute kidney injury
- kdigo, kidney disease improving global outcomes
- hcc, hepatocellular carcinoma
- scr, serum creatinine
- rrt, renal replacement therapy
- cki, chronic kidney injury
- egfr, estimated glomerula filtration rate
- icu, intensive care unit
- auroc, area under the receiver operating curve
- os, overall survival
- meld, model for end stage liver disease
- or, odds ratio
- ci, confidence interval
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Affiliation(s)
- Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U965, Paris, France
| | - Etienne Audureau
- Department of Public Health, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eric Levesque
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Jean Claude Merle
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Gilles Dhonneur
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Cyrille Feray
- INSERM, U955, Créteil, France,Department of Hepatology, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France,Correspondence: Daniel Azoulay, Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor hospital, 51 avenue de Lattre de Tassigny, 94010 Créteil, France. Tel: + 33 1 49 81 25 48. Fax. + 33 1 49 81 24 32.Department of Hepatobiliary and Pancreatic Surgery and Liver TransplantationHenri Mondor hospital51 avenue de Lattre de TassignyCréteil94010France
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16
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Complex Liver Resection Using Standard Total Vascular Exclusion, Venovenous Bypass, and In Situ Hypothermic Portal Perfusion. Ann Surg 2015; 262:93-104. [DOI: 10.1097/sla.0000000000000787] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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