The Effect of Erythropoietin on Allogeneic Blood Requirement in Patients Undergoing Elective Liver Resection: A Model Simulation

Pancreas and liver resection in Jehovah's Witness patients: feasible and safe

BACKGROUND

Jehovah's Witness (JW) patients undergoing liver or pancreas surgery represent a challenging ethical and medical problem, with few reports about their optimal management.

STUDY DESIGN

To analyze the perioperative outcomes of JW patients submitted to hepatic or pancreatic resection, clinicopathologic data of JW patients who underwent surgical exploration for a hepatic or pancreatic tumor between March 1996 and July 2011 were reviewed retrospectively.

RESULTS

Clinicopathologic data of 27 patients, 28 explorations, and 25 resections were included. Median age was 58 years (range 28 to 75 years) and 20 patients were female. Three patients were explored and deemed unresectable. Fifteen hepatic resections (9 segmentectomy or bi/trisegmentectomy, 6 hemi-hepatectomy or extended hepatectomy) and 10 pancreatic resections (6 pancreaticoduodenectomy, 4 distal pancreatectomy/splenectomy) were reviewed; additional organs were resected in 5 patients (2 gastrectomy, 1 colectomy, 1 nephrectomy, 1 adrenalectomy, 1 salpingoophorectomy). Median estimated blood loss for the hepatectomies was 400 mL (range 100 to 1,500 mL) and for the pancreatectomies was 400 mL (range 250 to 1,800 mL). Six patients received preoperative erythropoietin; hemodilution was used in 9 patients and 3 had Cell Saver-generated autotransfusions. Median preoperative hemoglobin was 12.5 g/dL (range 9.5 to 14.4 g/dL) and median postoperative hemoglobin was 10.4 g/dL (range 9 to 12.4 g/dL). In-hospital mortality was 0%. One patient required re-exploration for decreasing hemoglobin and refusal of transfusion; a total of 11 complications developed in 7 other patients (5 wound infection/breakdown, 1 urinary tract infection, 1 ileus, 1 nausea/vomiting, 1 lymphedema, 1 ascites, and 1 ARDS). Median hospital stay was 7 days (range 4 to 23 days).

CONCLUSIONS

Pancreatic and liver resection can be done safely in selected JW patients who refuse blood products by using a variety of blood-conservation techniques to help spare red cell mass.

Darbepoetin-α promotes neovascularization and cell proliferation in established colorectal liver metastases

BACKGROUND

The erythropoietin-analogue darbepoetin-α (DPO) improves liver function and regeneration after hepatectomy (Phx), however, also enhances Phx-induced tumor cell engraftment and neovascularization. Because it is unknown whether DPO also enhances the growth of established tumors, we herein studied the effect of DPO on established colorectal liver metastases after Phx.

METHODS

CT26.WT cells were implanted into the liver of BALB/c mice. Five days after tumor establishment, animals underwent 50% Phx and received 10 μg/kgBW DPO or saline. Non-Phx animals with DPO or saline-treatment served as controls. Seven days after Phx tumors were analyzed regarding blood vessel formation, leukocyte adhesion, cell proliferation, apoptotic cell death, and growth using intravital fluorescence microscopy, histology, and immunohistochemistry.

RESULTS

The growth of established colorectal liver metastases was slightly stimulated after DPO-treatment in hepatectomized and non-hepatectomized animals. However, tumor vessel formation and tumor cell proliferation were significantly enhanced after DPO-treatment in hepatectomized and non-hepatectomized mice compared with controls. Apoptotic cell death and leukocyte-endothelial cell interaction were significantly reduced after DPO-treatment.

CONCLUSION

Our study indicates that DPO-treatment promotes neovascularization and cell proliferation in established colorectal liver metastases of hepatectomized and non-hepatectomized mice. DPO-application in patients with colorectal liver metastases might promote tumor progression and should therefore be avoided.

Prolactin's role in the early stages of liver regeneration in rats

Liver regeneration after partial hepatectomy (PHx) is a complex process that is regulated by hemodynamic changes, the modulation of cytokines and growth factors, and the activation of immediate early transcription factors that lead to a round of hepatocyte mitosis. Among the factors involved, the pituitary hormone prolactin (PRL) has been shown to induce a hepatotrophic response after partial hepatectomy similar to that caused by phorbol esters; and in isolated hepatocytes PRL triggers a mitogenic response. However, it is becoming clear that PRL exerts a dual role acting in proliferation and differentiation processes. In this work, we have assessed the role of PRL in the early stages of liver regeneration in rats. To this end, three groups of rats were compared: Sham operated, regenerant and regenerant with PRL i.p. administration. Results show that PRL administration prior to partial hepatectomy caused an increase in the binding activity of several transcription factors involved in cell proliferation: AP-1, c-Jun and STAT-3, and in liver-specific differentiation and maintenance of energetic metabolism: CEBPalpha, HNF-1, HNF-4 at early time points and at later time points HNF-3. Hepatic sections show that PRL administration increases the number of proliferating cells within 5 h post-partial hepatectomy. The mRNA of the angiogenic and survival factors VEGF and HIF-1alpha, was also induced by PRL treatment. Data indicate that PRL triggers, either directly or indirectly, an acceleration of liver regeneration, preserving liver function and fulfilling a hepatoprotective role. J. Cell. Physiol. 219: 626-633, 2009. (c) 2009 Wiley-Liss, Inc.

Erythropoietin promotes hepatic regeneration after extended liver resection in rats

BACKGROUND AND AIM

It has been proven in various animal studies that recombinant human erythropoietin (rHuEPO) protects renal, cardiac and neuronal, as well as hepatic, tissue from ischemia, and promotes regeneration of adult central nervous system neurons. To date, no data are available as to whether rHuEPO has the ability to stimulate liver regeneration after liver resection.

METHODS

Rats undergoing 70% or 90% hepatectomy received an intraportalvenous administration (i.p.) of rHuEPO prior to resection or a subcutaneous injection (s.c.) for 3 days postoperatively, control animals were treated with surgery and saline injection only. Regeneration capacity of remnant livers was studied over 7 days by histology and immunohistochemistry (Ki-67, proliferating cell nuclear antigen [PCNA]). Polymerase chain reaction was carried out to measure transforming growth factor beta (TGF-beta), hypoxia induced factor (HIF), signal transducing activator 3 and vascular endothelial growth factor.

RESULTS

Ten-day survival in rats undergoing 90% hepatectomy significantly increased in i.p.-pretreated animals. After 70% hepatectomy the mitotic index was significantly increased in both rHuEPO-treated groups. These data were confirmed by PCNA and Ki-67 expression, which was significantly increased in the treated groups 24 h and 2 days after liver resection. TGF-beta and HIF mRNA both were upregulated in control animals 3 h after surgery.

CONCLUSION

rHuEPO effectively increased liver regeneration in rats after 70% liver resection and enhanced survival after 90% hepatectomy. Thus, rHuEPO may increase the regenerative capacity after major hepatectomy.

Perioperative parenteral tranexamic acid in liver tumor resection: a prospective randomized trial toward a "blood transfusion"-free hepatectomy

OBJECTIVE

To examine the feasibility of a real "blood transfusion"-free hepatectomy in a large group of patients with liver tumors.

SUMMARY BACKGROUND DATA

Bleeding control and blood transfusion remains problematic in liver resection. A real "blood transfusion"-free hepatectomy in a large group of patients has rarely been reported. The impact of tranexamic acid (TA), an antifibrinolytic agent, on blood transfusion in liver resection is unknown.

METHODS

A prospective double-blind randomized trial was performed on elective liver tumor resections. In group A, TA 500 mg was intravenously administered just before operation followed by 250 mg, every 6 hours, for 3 days. In group B, only placebo was given. The patients' background, blood transfusion rates, and early postoperative results in the 2 groups were compared. Factors that influenced blood requirement were analyzed.

RESULTS

There were 108 hepatectomies in group A and 106 hepatectomies in group B. The patients' backgrounds, operative procedures, and hepatectomy extent did not significantly differ between the 2 groups. Although the differences of the operative morbidity and postoperative stay were not significant, a significantly lower amount of operative blood loss, lower blood transfusion rate, shorter operative time, and lower hospital costs were found in group A patients. No patient in group A received blood transfusion. No hospital mortality occurred in either group. Tumor size and use of TA were independent factors that influenced blood transfusion.

CONCLUSIONS

Perioperative parenteral use of TA reduced the amount of operative blood loss and the need for blood transfusion in elective liver tumor resection. A real "blood transfusion"-free hepatectomy may be feasible with the assistance of parenteral TA.