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Ding L, Duan Y, Yao L, Gao Z. Efficacy and safety of terlipressin infusion during liver surgery: a protocol for systematic review and meta-analysis. BMJ Open 2024; 14:e080562. [PMID: 38553072 PMCID: PMC10982717 DOI: 10.1136/bmjopen-2023-080562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Liver disease causes 2 million deaths annually, accounting for 4% of all deaths worldwide. Liver surgery is one of the effective therapeutic options. Bleeding is a major complication during liver surgery. Perioperative bleeding and allogeneic blood transfusion may deteriorate the prognosis. Terlipressin (TP), a synthetic analogue of the antidiuretic hormone, may reduceblood loss during abdominal surgery. Several clinical centres have attempted to use TP during liver surgery, but the evidence for its effectiveness in reducing blood loss and the need for allogeneic blood transfusion, as well as its safety during the perioperative period, remains unclear. The aim of this systematic review and meta-analysis is to evaluate the efficacy and safety of TP in reducing blood loss and allogeneic blood transfusion needs during liver surgery. METHODS AND ANALYSIS We will search PubMed, EMBASE, the Cochrane Library and Web of Science for studies on perioperative use of TP during liver surgery from inception to July 2023. We will limit the language to English, and two reviewers will independently screen and select articles. The primary study outcomes are estimated blood loss and the need for allogeneic blood transfusion. Secondary outcomes include operating time, intensive care unit stay, length of stay, intraoperative urine output, acute kidney injury rate, postoperative complications, hepatic and renal function during follow-up, and TP-related adverse effects. We will include studies that met the following criteria: (1) randomised controlled trials (RCTs), cohort studies or case-control studies; (2) the publication time was till July 2023; (3) adult patients (≥18 years old) undergoing elective liver surgery; (4) comparison of TP with other treatments and (5) the study includes at least one outcome. We will exclude animal studies, case reports, case series, non-original articles, reviews, paediatric articles, non-controlled trials, unpublished articles, non-English articles and other studies that are duplicates. We will use Review Manager V.5.3 software for meta-analysis and perform stratification analysis for the study quality of RCTs based on the Jadad score. For cohort or case-control studies, the study quality will be analysed based on Newcastle-Ottawa Scale scores. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess confidence in the cumulative evidence. For primary outcomes, we will conduct subgroup analyses based on meta-regression. We will also perform leave-one-out sensitivity analyses to evaluate the effect of each individual study on the combined results by removing the individual studies one by one for outcomes with significant heterogeneity. The protocol follows the Cochrane Handbook for Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. ETHICS AND DISSEMINATION This study is a secondary analysis of existing data; therefore, it does not require ethical approval. We will disseminate the results through peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42023450333.
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Affiliation(s)
- Lin Ding
- Department of Anaesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anaesthesiology, Peking University International Hospital, Beijing, China
| | - Yi Duan
- Department of Anaesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lan Yao
- Department of Anaesthesiology, Peking University International Hospital, Beijing, China
| | - Zhifeng Gao
- Department of Anaesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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Accardo C, Gruttadauria S, Decarlis L, Agnes S, Schmeding M, Avolio AW, Buscemi V, Ardito F, Kienlein S, Mbuvi PM, Giuliante F. 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. J Laparoendosc Adv Surg Tech A 2024; 34:99-105. [PMID: 38294895 DOI: 10.1089/lap.2023.0467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
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.
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Affiliation(s)
- Caterina Accardo
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), University of Pittsburgh Medical Center (UPMC), Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), University of Pittsburgh Medical Center (UPMC), Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - Luciano Decarlis
- Department of General Surgery and Abdominal Transplantation, Niguarda-Cà Granda Hospital, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Salvatore Agnes
- Department of General Surgery and Liver Transplantation, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Alfonso W Avolio
- Department of General Surgery and Liver Transplantation, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vincenzo Buscemi
- Department of General Surgery and Abdominal Transplantation, Niguarda-Cà Granda Hospital, Milan, Italy
| | - Francesco Ardito
- Department of Hepatobiliary Surgery, Foundation "Policlinico Universitario A. Gemelli", IRCCS, Catholic University, Rome, Italy
| | - Stefan Kienlein
- Department of Surgery, Clinic Dortmund gGmbH, Dortmund, Germany
| | - Phoebe M Mbuvi
- Global Medical Affairs at Integra LifeSciences, Baltimora, Maryland, USA
| | - Felice Giuliante
- Department of Hepatobiliary Surgery, Foundation "Policlinico Universitario A. Gemelli", IRCCS, Catholic University, Rome, Italy
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Huang Y, Xu L, Wang N, Pu X, Wang W, Wen T, Xu M, Jiang L. Preoperative dexamethasone administration in hepatectomy of 25-min intermittent Pringle's maneuver for hepatocellular carcinoma: protocol for a randomized controlled trial. Trials 2023; 24:774. [PMID: 38037035 PMCID: PMC10691107 DOI: 10.1186/s13063-023-07820-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 11/22/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Our previous randomized controlled trial (RCT) have demonstrated that intermittent Pringle's maneuver (IPM) with a 25-min ischemic interval can be applied safely and efficiently in open or laparoscopic hepatectomy in patients with hepatocellular carcinoma (HCC) patients. But prolonging the hepatic inflow blocking time will inevitably aggravate the ischemia-reperfusion injury (IRI) caused by systemic response. This RCT aims to evaluate the effect of administration of dexamethasone versus placebo before clamping the hilar pedicle on postoperative liver function, inflammatory response, and perioperative outcomes among HCC patients undergoing liver resection with 25-min hepatic inflow occlusion. METHODS AND ANALYSIS This will be a randomized, dual-arm, parallel-group, double-blinded trial. All eligible and consecutive patients are coming from a regional medical center who are diagnosed with HCC and underwent radical R0/R1 resection. All participates are randomly allocated in dexamethasone group or placebo group. All surgeons, anesthesiologists, and outcome assessors will be blinded to allocation status. Primary endpoints are transaminase-based postoperative hepatic injury on seven consecutive days after surgery and assessed by their peak values as well as area under the curve (AUC) of the postoperative course of aminotransferases. Secondary endpoints are postoperative total bilirubin (TBil), coagulation function, inflammatory cytokines and their respective peaks, intraoperative blood loss, postoperative hospital stay, morbidity, and mortality. The above parameters will be compared using the corresponding statistical approach. Subgroup analysis will be performed according to the liver cirrhosis and major hepatectomy. DISCUSSION Based on our previous study, we will explore further the effect of glucocorticoid administration on attenuating the surgical stress response in order to follow securely 25-min hepatic inflow occlusion. Therefore, the trial protocol is reasonable and the results of the trial may be clinically significant. TRIAL REGISTRATION This trial was registered on 3 December 2022, in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), ChiCTR2200066381. The protocol version is V1.0 (20221104).
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Affiliation(s)
- Yang Huang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Liangliang Xu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Ning Wang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Xingyu Pu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Wentao Wang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Tianfu Wen
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China
| | - Mingqing Xu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China.
| | - Li Jiang
- Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Sichuan Province, Chengdu, 610041, China.
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Yang J, Zhang J, Luo J, Ouyang J, Qu Q, Wang Q, Si Y. Safe and Effective Blood Preservation Through Acute Normovolemic Hemodilution and Low-Dose Tranexamic Acid in Open Partial Hepatectomy. J Pain Res 2023; 16:3905-3916. [PMID: 38026458 PMCID: PMC10657755 DOI: 10.2147/jpr.s426872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/21/2023] [Indexed: 12/01/2023] Open
Abstract
Objective In this study, we evaluated the efficacy of tranexamic acid (TXA) and acute normovolemic hemodilution (ANH) with 6% hydroxyethyl starch (130/0.4) in minimizing blood loss during open partial liver resection. Coagulation function was assessed using thromboelastography (TEG) and hemostasis tests, while renal function changes were tracked through serum creatinine values post-surgery. Methods Thirty patients undergoing open partial liver resection were allocated to two groups: Group T received TXA + ANH, and Group A received ANH alone. Blood was drawn from the radial artery under general anesthesia. Both groups received peripheral vein injections of 6% hydroxyethyl starch 130/0.4. Group T additionally received intravenous TXA. Primary outcomes included blood loss and allogeneic blood transfusions. TEG assessed coagulation status and renal function was monitored. Results Group T demonstrated superior outcomes compared to Group A. Group T had significantly lower intraoperative blood loss (700 mL vs 1200 mL) and a lower bleeding rate per kilogram of body weight (13.3 mL/kg vs 20.4 mL/kg). Coagulation parameters favored Group T, with higher TEG maximum amplitude (55.91 mm vs 45.88 mm) and lower activated partial thromboplastin time (38.04 seconds vs 41.49 seconds). Neither group experienced acute renal injury or kidney function deficiency during hospitalization. Conclusion TXA and ANH in a small dose during liver resection stabilize clotting, reduce blood loss by 6% compared to hydroxyethyl starch 130/0.4, and do not affect renal function.
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Affiliation(s)
- Jian Yang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Jing Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Jiayan Luo
- Department of Anesthesiology, People’s Hospital of Yanting, Sichuan, 621600, People’s Republic of China
| | - Jie Ouyang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Qicai Qu
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Qitao Wang
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Yongyu Si
- Department of Anesthesiology, Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
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Rhaiem R, Sommacale D, Zimmermann P, Amroun K, Tashkandi A, Laurent A, Amaddeo G, Calderaro J, Luciani A, Heurgue A, Thiefin G, Piardi T, Kianmanesh R, Brustia R. Anterior Versus Classical Approach During Right Hepatectomy for Hepatocellular Carcinoma: Inverse Propensity Score Weighted Analysis. J Gastrointest Surg 2023; 27:2092-2102. [PMID: 37407897 DOI: 10.1007/s11605-023-05741-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 06/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Eastern data highlight the oncological benefits of the anterior approach (AA) during right hepatectomy (RH) for hepatocellular carcinoma (HCC). However, to our knowledge, previous western data on this topic are scarce. In this study, the oncological outcomes of AA and classical approach (CA) during RH for HCC were compared. METHODS A retrospective inverse propensity score-weighted fashion (IPTW) case-control study was performed in two French hepatobiliary surgery departments. Overall survival (OS), disease-free survival (DFS), and early recurrence rate (within 2 years after surgery) were analyzed. RESULTS Survival analysis was performed for 114 patients (CA group,60 patients; AA group, 54 patients). Before IPTW adjustment, the 3-year DFS rates were 29.4% (AA group) and 44% (CA group), respectively. No significant differences were found in DFS (HR = 1.1, 95%CI:0.62-1.9, p = 0.77) and OS (HR = 1.2, 95%CI:0.54-2.6, p = 0.66). After IPTW, DFS and OS analyses showed no differences between the two groups (p = 0.77 and p = 0.46, respectively). Early recurrence rates were similar before and after IPTW. Satellite nodules were the only significant independent risk factor for recurrence. CONCLUSION AA and CA did not result in significant differences in DFS, OS, or early recurrence after right hepatectomy for HCC before and after IPTW.
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Affiliation(s)
- Rami Rhaiem
- Department of Hepatobiliary, Pancreatic and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France.
- Reims Champagne-Ardenne University, Reims, France.
- INSERM U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", Assistance Publique-Hôpitaux de Paris, Créteil, France.
| | - Daniele Sommacale
- INSERM U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", Assistance Publique-Hôpitaux de Paris, Créteil, France
- Department of Digestive and Hepatobiliary and Pancreatic Surgery, AP-HP, Hôpital Henri-Mondor, F-94010, Créteil, France
| | - Perrine Zimmermann
- Department of Hepatobiliary, Pancreatic and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France
- Reims Champagne-Ardenne University, Reims, France
| | - Koceila Amroun
- Department of Hepatobiliary, Pancreatic and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France
- Reims Champagne-Ardenne University, Reims, France
| | - Ahmad Tashkandi
- Department of Hepatobiliary, Pancreatic and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France
- Reims Champagne-Ardenne University, Reims, France
| | - Alexis Laurent
- INSERM U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", Assistance Publique-Hôpitaux de Paris, Créteil, France
- Department of Digestive and Hepatobiliary and Pancreatic Surgery, AP-HP, Hôpital Henri-Mondor, F-94010, Créteil, France
| | - Giuliana Amaddeo
- INSERM U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", Assistance Publique-Hôpitaux de Paris, Créteil, France
- Department of Hepatology, AP-HP, Hôpital Henri-Mondor, F-94010, Créteil, France
| | - Julien Calderaro
- INSERM U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", Assistance Publique-Hôpitaux de Paris, Créteil, France
- Pathology Department, AP-HP, Hôpital Henri-Mondor, F-94010, Créteil, France
| | - Alain Luciani
- INSERM U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", Assistance Publique-Hôpitaux de Paris, Créteil, France
- Department of Diagnostic Radiology, AP-HP, Hôpital Henri-Mondor, F-94010, Créteil, France
| | - Alexandra Heurgue
- Reims Champagne-Ardenne University, Reims, France
- Department of Hepatology, Robert Debré University Hospital, Reims, France
| | - Gérard Thiefin
- Reims Champagne-Ardenne University, Reims, France
- Department of Hepatology, Robert Debré University Hospital, Reims, France
| | - Tullio Piardi
- Department of Hepatobiliary, Pancreatic and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France
- Reims Champagne-Ardenne University, Reims, France
- Hepatobiliary, Pancreatic and Endocrine Surgery Department, Simon Veil Hospital, Troyes, France
| | - Reza Kianmanesh
- Department of Hepatobiliary, Pancreatic and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France
- Reims Champagne-Ardenne University, Reims, France
| | - Raffaele Brustia
- INSERM U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", Assistance Publique-Hôpitaux de Paris, Créteil, France
- Department of Digestive and Hepatobiliary and Pancreatic Surgery, AP-HP, Hôpital Henri-Mondor, F-94010, Créteil, France
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Malik AK, Amer AO, Tingle SJ, Thompson ER, White SA, Manas DM, Wilson C. Fibrin-based haemostatic agents for reducing blood loss in adult liver resection. Cochrane Database Syst Rev 2023; 8:CD010872. [PMID: 37551841 PMCID: PMC10411946 DOI: 10.1002/14651858.cd010872.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Liver resection is the optimal treatment for selected benign and malignant liver tumours, but it can be associated with significant blood loss. Numerous anaesthetic and surgical techniques have been developed to reduce blood loss and improve perioperative outcomes. One such technique is the application of topical fibrin-based haemostatic agents (FBHAs) to the resection surface. There is no standard practice for FBHA use, and a variety of commercial agents and devices are available, as well as non-FBHAs (e.g. collagen-based agents). The literature is inconclusive on the effectiveness of these methods and on the clinical benefits of their routine use. OBJECTIVES To evaluate the benefits and harms of fibrin-based haemostatic agents in reducing intraoperative blood loss in adults undergoing liver resection. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science up to 20 January 2023. We also searched online trial registries, checked the reference lists of all primary studies, and contacted the authors of included trials for additional published or unpublished trials. SELECTION CRITERIA We considered for inclusion all randomised clinical trials evaluating FBHAs versus no topical intervention or non-FBHAs, irrespective of publication type, publication status, language of publication, and outcomes reported. Eligible participants could have any liver pathology and be undergoing major or minor liver resections through open or laparoscopic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of the literature search and used data extraction forms to collate the results. We expressed dichotomous outcome results as risk ratios (RRs) and continuous outcome results as mean differences (MDs), each with their corresponding 95% confidence interval (CI). We used a random-effects model for the main analyses. Our primary outcomes were perioperative mortality, serious adverse events, haemostatic efficacy, and health-related quality of life. Our secondary outcomes were efficacy as sealant, adverse events considered non-serious, operating time, and length of hospital stay. We assessed the certainty of the evidence with GRADE and presented results in two summary of findings tables. MAIN RESULTS We included 22 trials (2945 participants) evaluating FBHAs versus no intervention or non-FBHAs; 19 trials with 2642 participants provided data for the meta-analyses. Twelve trials reported commercial funding, one trial reported no financial support, and nine trials provided no information on funding. Below we present the most clinically relevant outcome results, also displayed in our summary of findings table. Fibrin-based haemostatic agents versus no intervention Six trials (1001 participants) compared FBHAs with no intervention. One trial was at low risk of bias in all five domains, and all other trials were at high or unclear risk of bias in at least one domain. Two trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with no intervention have an effect on perioperative mortality (RR 2.58, 95% CI 0.89 to 7.44; 4 trials, 782 participants), serious adverse events (RR 0.96, 95% CI 0.88 to 1.05; 4 trials, 782 participants), postoperative transfusion (RR 1.04, 95% CI 0.77 to 1.40; 5 trials, 864 participants), reoperation (RR 2.92, 95% CI 0.58 to 14.61; 2 trials, 612 participants), or postoperative bile leak (RR 1.00, 95% CI 0.67 to 1.48; 4 trials, 782 participants), as the certainty of evidence was very low for all these outcomes. Fibrin-based haemostatic agents versus non-fibrin-based haemostatic agents Sixteen trials (1944 participants) compared FBHAs with non-FBHAs. All trials had at least one domain at high or unclear risk of bias. Twelve trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with non-FBHAs have an effect on perioperative mortality (RR 1.03, 95% CI 0.62 to 1.72; 11 trials, 1436 participants), postoperative transfusion (RR 0.92, 95% CI 0.68 to 1.25; 7 trials, 599 participants), reoperation (RR 0.48, 95% CI 0.25 to 0.90; 3 trials, 358 participants), or postoperative bile leak (RR 1.15, 95% CI 0.60 to 2.21; 9 trials, 1115 participants), as the certainty of evidence was very low for all these outcomes. FBHAs compared with non-FBHAs may have little or no effect on the risk of serious adverse events (RR 0.99, 95% CI 0.95 to 1.03; 9 trials, 1176 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence for the outcomes in both comparisons (FBHAs versus no intervention and FBHAs versus non-FBHAs) was of very low certainty (or low certainty in one instance) and cannot justify the routine use of FBHAs to reduce blood loss in adult liver resection. While the meta-analysis showed a reduced risk of reoperation with FBHAs compared with non-FBHAs, the analysis was confounded by the small number of trials reporting the event and the risk of bias in all these trials. Future trials should focus on the use of FBHAs in people undergoing liver resection who are at particularly high risk of bleeding. Investigators should evaluate clinically meaningful and patient-important outcomes and follow the SPIRIT and CONSORT statements.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Aimen O Amer
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Steven A White
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
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7
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Lv H, Xiong C, Wu B, Lan Z, Xu D, Duan D, Huang X, Guo J, Yu S. Effects of targeted mild hypercapnia versus normocapnia on cerebral oxygen saturation in patients undergoing laparoscopic hepatectomy under low central venous pressure: a prospective, randomized controlled study. BMC Anesthesiol 2023; 23:257. [PMID: 37525100 PMCID: PMC10388477 DOI: 10.1186/s12871-023-02220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Laparoscopic hepatectomy under low central venous pressure (LCVP) is associated with intraoperative organ hypoperfusion, including cerebral hypoperfusion. We hypothesized that a ventilation strategy designed to achieve targeted mild hypercapnia (TMH) (end-tidal carbon dioxide partial pressure [PetCO2] of 45 ± 5 mmHg) rather than targeted normocapnia (TN) (PetCO2 of 30 ± 5 mmHg) would increase regional cerebral oxygen saturation (rSO2) during laparoscopic hepatectomy under LCVP. METHODS Eighty patients undergoing laparoscopic hepatectomy under LCVP were randomly divided into the TMH group (n = 40) and the TN group (n = 40). Mechanical ventilation was adjusted to maintain the PetCO2 within the relevant range. Cerebral oxygenation was monitored continuously using the FORE-SIGHT system before anesthetic induction until the patient left the operating room. Patient and surgical characteristics, rSO2, intraoperative hemodynamic parameters (CVP, mean artery blood pressure [MAP], and heart rate), PetCO2, intraoperative blood gas analysis results, and postoperative complications were recorded. RESULTS No significant differences were observed in CVP, MAP, and heart rate between the two groups during surgery. The rSO2 was significantly lower in the TN group on both the left and right sides during the intraoperative period (P < 0.05), while the TMH group had a stable rSO2. In the TN group, the mean rSO2 decreased most during liver parenchymal transection when compared with the baseline value (P < 0.05). The mean (standard deviation) percentage change in rSO2 from baseline to parenchymal transection was - 7.5% (4.8%) on the left and - 7.1% (4.6%) on the right. The two groups had a similar incidence of postoperative complications (P > 0.05). CONCLUSION Our findings demonstrate that rSO2 is better maintained during laparoscopic hepatectomy under LCVP when patients are ventilated to a PetCO2 of 45 ± 5 mmHg (TMH) than a PetCO2 of 30 ± 5 mmHg (TN). TRIAL REGISTRATION ChiCTR2100051130(14/9/2021).
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Affiliation(s)
- Huayan Lv
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Chang Xiong
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Bo Wu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Zhijian Lan
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Duojia Xu
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Dingnan Duan
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Xiaoxia Huang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Jun Guo
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
| | - Shian Yu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
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8
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Ye H, Wu H, Li B, Zuo P, Chen C. Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:89. [PMID: 36949393 PMCID: PMC10032024 DOI: 10.1186/s12871-023-02042-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Perioperative bleeding and allogeneic blood transfusion are generally thought to affect the outcomes of patients. This meta-analysis aimed to determine the benefits and risks of several cardiovascular interventions in patients undergoing hepatectomy. METHODS In this systematic review and meta-analysis, randomised controlled trials (RCTs) were searched in the Cochrane Library, Medline, Embase, and Web of Science to February 02, 2023. RCTs focused on cardiovascular interventions aimed at reducing blood loss or blood transfusion requirements during hepatectomy were included. The primary outcomes were perioperative blood loss amount, number of patients requiring allogeneic blood transfusion and overall occurrence of postoperative complications. The secondary outcomes were operating time, perioperative mortality rate, postoperative liver and kidney function and length of hospital stay. RESULTS Seventeen RCTs were included in the analysis. A total of 841 patients who underwent hepatectomy in 10 trials were included in the comparative analysis between low central venous pressure (CVP) and control groups. The forest plots showed a low operative bleeding volume [(mean difference (MD): -409.75 mL, 95% confidence intervals (CI) -616.56 to -202.94, P < 0.001], reduced blood transfusion rate [risk ratio (RR): 0.47, 95% CI 0.34 to 0.65, P < 0.001], shortened operating time (MD: -13.42 min, 95% CI -22.59 to -4.26, P = 0.004), and fewer postoperative complications (RR: 0.76, 95% CI 0.58 to 0.99, P = 0.04) in the low CVP group than in the control group. Five and two trials compared the following interventions, respectively: 'acute normovolaemic haemodilution (ANH) vs control' and 'autologous blood donation vs control'. ANH and autologous blood donation could not reduce the blood loss amount but greatly decreased the number of patients requiring allogeneic blood transfusion. No benefits were found in the rate of mortality and length of postoperative hospital stay in any of the comparisons. CONCLUSION Lowering the CVP seems to be effective and safe in adult patients undergoing hepatectomy. ANH and autologous blood donation should be used as a part of blood management for suitable patients in certain circumstances. TRIAL REGISTRATION PROSPERO, CRD42022314061.
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Affiliation(s)
- Hui Ye
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China.
| | - Hanghang Wu
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Bin Li
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China
| | - Pengfei Zuo
- Department of Cardiology, ZhongDa Hospital, Southeast University, Nanjing, China
| | - Chaobo Chen
- Department of General Surgery, Xishan People's Hospital of Wuxi city, No. 1128 Dacheng Road, Xishan District, Wuxi, 214105, China.
- Department of Hepatic-Biliary-Pancreatic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
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9
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Martel G, Lenet T, Wherrett C, Carrier FM, Monette L, Workneh A, Brousseau K, Ruel M, Chassé M, Collin Y, Vandenbroucke-Menu F, Hamel-Perreault É, Perreault MA, Park J, Lim S, Maltais V, Leung P, Gilbert RWD, Segedi M, Abou-Khalil J, Bertens KA, Balaa FK, Ramsay T, Fergusson DA. Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial. Trials 2023; 24:38. [PMID: 36653812 PMCID: PMC9848035 DOI: 10.1186/s13063-022-07008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.
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Affiliation(s)
- Guillaume Martel
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Tori Lenet
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christopher Wherrett
- grid.28046.380000 0001 2182 2255Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON Canada
| | - François-Martin Carrier
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada ,grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Leah Monette
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Aklile Workneh
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Karine Brousseau
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Monique Ruel
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Michaël Chassé
- grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Yves Collin
- grid.411172.00000 0001 0081 2808Division of General Surgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Franck Vandenbroucke-Menu
- grid.410559.c0000 0001 0743 2111Hepato-Pancreato-Biliary and Liver Transplantation Surgery Unit, Department of Surgery - Centre Hospitalier de l’Université de Montréal, Montréal, QC Canada
| | - Élodie Hamel-Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Michel-Antoine Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Jeieung Park
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Shirley Lim
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Véronique Maltais
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Philemon Leung
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Richard W. D. Gilbert
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Maja Segedi
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Jad Abou-Khalil
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A. Bertens
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Fady K. Balaa
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Tim Ramsay
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Dean A. Fergusson
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
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Chawla A, Afridi F, Prasath V, Chokshi R, Ahlawat S. Analysis of pancreatic pseudocyst drainage procedural outcomes: a population based study. Surg Endosc 2023; 37:156-64. [PMID: 35879571 DOI: 10.1007/s00464-022-09427-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND A pancreatic pseudocyst is a collection of fluid surrounded by a well-defined wall that contains no solid material. Studies on outcomes of pancreatic pseudocyst drainage have largely been limited to small cohorts. This study aims to take a population based approach to evaluate differences in inpatient outcomes among laparoscopic, percutaneous, and endoscopic drainage for pancreatic pseudocysts. METHODS The National Inpatient Sample database was used to identify inpatient stays for pancreatic pseudocysts in which a single drainage approach was conducted. Baseline characteristic differences were compared with Rao-Scott chi squared and Mann-Whitney U tests. Propensity score matching controlling for clinical and demographic covariates followed by multivariable regression was used to pairwise compare drainage outcomes. Primary outcomes were length of stay, total charge, mortality, and disposition. Secondary outcomes were procedure related complication rates. RESULTS Among a total of 35,640 weighted pancreatic pseudocyst cases, 3235 underwent drainage via a single procedure. Percutaneous was the most frequent drainage method performed (44.5%) and was more likely to be performed at nonteaching hospitals than laparoscopic (17% vs 9%, p = 0.04). Percutaneous drainage was associated with longer LOS (aIRR 1.42, 95% CI 1.07-1.86, p = 0.01) versus endoscopic and lower rates of routine disposition (aOR 0.45, 95% CI 0.23-0.89, p = 0.02) relative to endoscopic and laparoscopic (aOR 0.41, 95% CI 0.27-0.61, p < 0.01) drainage. There were no differences in primary outcomes in laparoscopic versus endoscopic drainage. Percutaneous drainage was associated with higher rates of septic shock than laparoscopic drainage (aOR 2.59, 95% CI 1.15-5.82, p = 0.02). CONCLUSIONS Endoscopic and laparoscopic pancreatic pseudocyst drainage are associated with the least short term procedure related complications and more favorable in-hospital outcomes compared to percutaneous approaches. However, percutaneous drainage was the most commonly performed method in the 2017 NIS database.
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11
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Maki J, Sumie M, Ide T, Nagamatsu M, Matsushita K, Shirozu K, Higashi M, Yamaura K. A pressure-resistant peripherally inserted central catheter is as useful as a central venous catheter for rapid fluid infusion: an in vitro study. BMC Anesthesiol 2022; 22:205. [PMID: 35787789 PMCID: PMC9252047 DOI: 10.1186/s12871-022-01738-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/20/2022] [Indexed: 11/21/2022] Open
Abstract
Background Although peripherally inserted central catheters (PICCs) have been widely used, they have not been frequently used in anesthesia practice. The central venous pressure measured via PICCs are reportedly as accurate as that measured via central venous catheters (CVCs), but the findings concerning rapid infusion are unclear. This study examined whether or not pressure-resistant PICCs could be used for rapid fluid infusion. Methods The in-line pressure was measured in similar-sized double-lumen catheters—4-Fr PICC (55, 45 and 35 cm) and 17-G CVC (20 and 13 cm)—at flow rates of saline decided using a roller pump system. We also examined the flow rate at an in-line pressure of 300 mmHg, which is the critical pressure at which hemolysis is considered to occur during blood transfusion. Results The pressure-resistant PICCs obtained a high flow rate similar to that of CVCs, but the in-line pressures increased in proportion to the flow rate and catheter length. Flow rates at an intra-circuit pressure of 300 mmHg were not significantly different between the 45-cm PICC and 20-cm CVC. Conclusion Pressure-resistant PICCs can be used for rapid fluid infusion. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01738-x.
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Affiliation(s)
- Jun Maki
- Intensive Care Unit, Kyushu University Hospital, Fukuoka, Japan
| | - Makoto Sumie
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tomoko Ide
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masako Nagamatsu
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Katsuyuki Matsushita
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kazuhiro Shirozu
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Midoriko Higashi
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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12
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Pfitzmaier P, Schwarzbach M, Ronellenfitsch U. The Evaluation of the 1318 nm Diode Laser in Open Liver Surgery. Cancers (Basel) 2022; 14:cancers14051191. [PMID: 35267499 PMCID: PMC8909064 DOI: 10.3390/cancers14051191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 02/21/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Numerous dissection instruments are available for liver resection. So far, there has been no evidence in favor of a specific dissection device effecting a reduction in postoperative mortality and morbidity or a reduction in intraoperative blood loss. The aim of the study was to evaluate the safety of liver resection with the 1318 nm surgical laser. (2) Methods: 151 consecutive patients who underwent liver resection using the 1318 nm surgical laser (n = 119) or conventional dissection methods (n = 32) were evaluated retrospectively. As primary outcome, postoperative complications were assessed using the Clavien–Dindo classification. Secondary outcomes were postoperative mortality, reoperations and reinterventions, intraoperative blood loss, the need for vascular control using the Pringle maneuver and oncological safety assessed through histopathological evaluation of resection margins. (3) Results: For liver resections using the 1318 nm surgical laser, the postoperative morbidity (41.2% vs. 59.4%, p = 0.066), mortality (1.7% vs. 3.1%, p = 0.513) and the reoperation rate (2.5% vs. 3.1%, p = 1.000) were not significantly different from conventional liver resections. In the laser group, a lower reintervention rate (9.2% vs. 21.9%, p = 0.050) was observed. The oncological safety demonstrated by a tumor-free resection margin was similar after laser and conventional resection (93.2% vs. 89.3%, p = 0.256). The median intraoperative blood loss was significantly lower in the laser group (300 mL vs. 500 mL, p = 0.005) and there was a significantly lower need for a Pringle maneuver (3.4% vs. 15.6%, p = 0.021). (4) Conclusions: Liver resections using the 1318 nm surgical laser can be routinely performed with a favorable risk profile. Compared to alternative resection methods, they are associated with low blood loss, appear adequate from an oncological point of view, and are not associated with increased mortality and morbidity.
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Affiliation(s)
- Patrick Pfitzmaier
- Department of General, Visceral, Vascular and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929 Frankfurt, Germany; (P.P.); (M.S.)
| | - Matthias Schwarzbach
- Department of General, Visceral, Vascular and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929 Frankfurt, Germany; (P.P.); (M.S.)
| | - Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
- Correspondence:
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13
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Koh A, Adiamah A, Gomez D, Sanyal S. Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Hepatic Surgery: A Systematic Review and Meta-Analysis. World J Surg 2021; 46:441-449. [PMID: 34762141 DOI: 10.1007/s00268-021-06355-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Perioperative bleeding poses a major risk during liver surgery, which can result in increased transfusion requirements, morbidity, and mortality. Tranexamic acid (TXA) effectively reduces perioperative bleeding and transfusion requirements in trauma patients. However, there remains a lack of evidence of its use in liver surgery. This meta-analysis of randomised controlled trials evaluated the efficacy and safety of TXA in liver resection and transplantation. METHOD A comprehensive search of Medline, Embase, CENTRAL and Clinicaltrials.gov databases was undertaken to identify studies from January 1947 to September 2021. The outcomes of the need for blood transfusion, thromboembolic events and mortality were extracted from the included studies. Quantitative pooling of data was based on the random effects model. RESULTS Six studies reporting on 429 patients were included. TXA reduced the need for perioperative blood transfusion in liver resection and transplantation (OR 0.09; 95% CI 0.01 to 0.72). More importantly, TXA did not increase the incidence of thromboembolic events (OR 2.22; 95% CI 0.47 to 10.43) and mortality (OR 0.60; 95% CI 0.13 to 2.76). CONCLUSION TXA safely reduces the need for blood transfusion in patients undergoing liver resection and transplantation.
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Affiliation(s)
- Amanda Koh
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Dhanwant Gomez
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Sudip Sanyal
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
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14
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Leeratanakachorn N, Luvira V, Tipwaratorn T, Theeragul S, Jarearnrat A, Titapun A, Srisuk T, Kamsa-Ard S, Pugkhem A, Khuntikeo N, Pairojkul C, Bhudhisawasdi V. Infrahepatic Inferior Vena Cava Clamping Reduces Blood Loss during Liver Transection for Cholangiocarcinoma. Int J Hepatol 2021; 2021:1625717. [PMID: 34484836 DOI: 10.1155/2021/1625717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/14/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Major hepatectomy is the mainstay of the treatment for cholangiocarcinoma. Infrahepatic inferior vena cava (IVC) clamping is an effective maneuver for reducing blood loss during liver transection. The impact of this procedure on major hepatectomy for cholangiocarcinoma is unknown. This study evaluated the effect of infrahepatic IVC clamping on blood loss during liver transection. METHODS Clinical and pathological data were collected retrospectively for 116 cholangiocarcinoma patients who underwent major hepatectomy between January 2015 and December 2016, to investigate the benefit of infrahepatic IVC clamping. Two of five surgeons adapted the policy performing infrahepatic IVC clamping during liver transection in all cases. Patients, therefore, were divided into those (n = 39; 33.6%) who received infrahepatic IVC clamping during liver transection (C1) and those (n = 77; 66.4%) who did not (C0). RESULTS The patients' backgrounds, operative parameters, and extent of hepatectomy did not differ significantly between the 2 groups, except for gender. A significantly lower blood loss (p = 0.028), blood transfusion (p = 0.011), and rate of vascular inflow occlusion requirement (p < 0.001) were observed in the C1 group. The respective blood losses in the C1 group and the C0 group were 498.9 (95% CI: 375.8-622.1) and 685.6 (95% CI: 571-800.2) millilitres. CONCLUSIONS The current study found infrahepatic IVC clamping during liver transection for cholangiocarcinoma reduces blood loss, blood transfusion, and rate of vascular inflow occlusion requirement.
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Bodur MS, Tomas K, Topaloğlu S, Oğuz Ş, Küçükaslan H, Dohman D, Karabulut E, Çalık A. Effects of intraoperative blood loss during liver resection on patients’ outcome: a single- center experience. Turk J Med Sci 2021; 51:1388-1395. [PMID: 33576585 PMCID: PMC8283449 DOI: 10.3906/sag-2008-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/11/2021] [Indexed: 12/04/2022] Open
Abstract
Background/aim Operative bleeding is one of the major determinants of outcome in liver surgery. This study aimed to describe the impact of intraoperative blood loss on the postoperative course of liver resection (LR). Materials and methods The data of 257 patients who were treated with LR between January 2007 and October 2018 were retrospectively analyzed. LRs were performed via intermittent portal triad clamping (PTC) under low central venous pressure. Results LRs were performed for 67.7% of patients with a malignant disease and 32.3% of patients with a benign disease. Major LR was performed in 89 patients (34.6%). The mean PTC period was 20.32 min (±13.7). The median intraoperative bleeding amount was 200 mL (5–3500 mL), the 30-day mortality rate was 4.3%, and the morbidity rate was 31.9%. The hospital stay (p = 0.002), morbidity (p = 0.009), and 30-day mortality (p = 0.041) of patients with a bleeding amount of more than 500 mL significantly increased. Conclusion Surgeons should consider the adverse effects of intraoperative bleeding during liver resection on patients’ outcome. Favorable outcomes would be obtained with diligent postoperative care.
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Affiliation(s)
- Muhammed Selim Bodur
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Kadir Tomas
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Serdar Topaloğlu
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Şükrü Oğuz
- Department of Radiology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Hakan Küçükaslan
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Davut Dohman
- Department of Anesthesiology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erdem Karabulut
- Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Adnan Çalık
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
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Rocca A, Cipriani F, Belli G, Berti S, Boggi U, Bottino V, Cillo U, Cescon M, Cimino M, Corcione F, De Carlis L, Degiuli M, De Paolis P, De Rose AM, D'Ugo D, Di Benedetto F, Elmore U, Ercolani G, Ettorre GM, Ferrero A, Filauro M, Giuliante F, Gruttadauria S, Guglielmi A, Izzo F, Jovine E, Laurenzi A, Marchegiani F, Marini P, Massani M, Mazzaferro V, Mineccia M, Minni F, Muratore A, Nicosia S, Pellicci R, Rosati R, Russolillo N, Spinelli A, Spolverato G, Torzilli G, Vennarecci G, Viganò L, Vincenti L, Delrio P, Calise F, Aldrighetti L. The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology. Updates Surg 2021; 73:1247-65. [PMID: 34089501 DOI: 10.1007/s13304-021-01100-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.
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Makdissi FF, de Mattos BVH, Kruger JAP, Jeismann VB, Coelho FF, Herman P. A Combined "Hanging Liver Maneuver" and "Intrahepatic Extra-Glissonian Approach" for Anatomical Right Hepatectomy: Technique Standardization, Results, and Correlation With Portal Pedicle Anatomy. Front Surg 2021; 8:690408. [PMID: 34095213 PMCID: PMC8175898 DOI: 10.3389/fsurg.2021.690408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The hanging liver maneuver and intrahepatic extra-Glissonian approach are distinct modalities to facilitate safe anatomical liver resections. This study reports a standardized combination of these techniques focusing on safety, results and correlation with portal pedicle anatomy in oncological patients. Method: Combined hanging liver maneuver and intrahepatic extra-Glissonian approach for anatomic right hepatectomy was described stepwise. Portal pedicle anatomy was correlated with the Glissonian approach failure and complications. Clinical characteristics of patients, perioperative outcomes, short and long-term survival rates were analyzed. Results: Thirty colorectal liver metastases patients submitted to the combined approach were evaluated. Anatomical variations of the right portal pedicle were present in 26.6%. Hanging liver maneuver was feasible in 100%, and Glissonian approach in 96.7% despite portal pedicle variations. Mean operative time was 326 min. Mean blood loss was 507 ml. Mean hospital stay was 8 days. There was no 90-day operative mortality and no significant morbidity. Oncological surgical margins were free. Overall and disease-free 5-year survival were 59 and 37%. Conclusion: Regardless of frequent anatomical variations of the right portal pedicle, the hanging liver maneuver, and intrahepatic extra-Glissonian approach can be combined, being useful for anatomical right hepatectomies in a safe and reproducible way in most patients.
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Affiliation(s)
- Fabio Ferrari Makdissi
- Digestive Surgery Division, Department of Gastroenterology, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo (ICESP), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Bruno Vinicius Hortences de Mattos
- Digestive Surgery Division, Department of Gastroenterology, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo (ICESP), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Jaime Arthur Pirola Kruger
- Digestive Surgery Division, Department of Gastroenterology, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo (ICESP), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Vagner Birk Jeismann
- Digestive Surgery Division, Department of Gastroenterology, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo (ICESP), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Fabricio Ferreira Coelho
- Digestive Surgery Division, Department of Gastroenterology, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo (ICESP), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Paulo Herman
- Digestive Surgery Division, Department of Gastroenterology, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo (ICESP), University of São Paulo School of Medicine, São Paulo, Brazil
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18
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Al Khaldi M, Gryspeerdt F, Carrier FM, Bouchard C, Simoneau È, Rong Z, Plasse M, Létourneau R, Dagenais M, Roy A, Lapointe R, Massicotte L, Vandenbroucke-Menu F, Rioux-Massé B, Turcotte S. Effect of intraoperative hypovolemic phlebotomy on transfusion and clinical outcomes in patients undergoing hepatectomy: a retrospective cohort study. Can J Anaesth 2021; 68:980-90. [PMID: 33945107 DOI: 10.1007/s12630-021-01958-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/03/2020] [Accepted: 12/23/2020] [Indexed: 11/13/2022] Open
Abstract
Background There is no consensus on how to best achieve a low central venous pressure during hepatectomy for the purpose of reducing blood loss and red blood cell (RBC) transfusions. We analyzed the associations between intraoperative hypovolemic phlebotomy (IOHP), transfusions, and postoperative outcomes in cancer patients undergoing hepatectomy. Methods Using surgical and transfusion databases of patients who underwent hepatectomy for cancer at one institution (11 January 2011 to 22 June 2017), we retrospectively analyzed associations between IOHP and RBC transfusion on the day of surgery (primary outcome), and with total perioperative transfusions, intraoperative blood loss, and postoperative complications (secondary outcomes). We fitted logistic regression models by inverse probability of treatment weighting to adjust for confounders and reported adjusted odds ratio (aOR). Results There were 522 instances of IOHP performed during 683 hepatectomies, with a mean (standard deviation) volume of 396 (119) mL. The IOHP patients had a 6.9% transfusion risk on the day of surgery compared with 12.4% in non-IOHP patients (aOR, 0.53; 95% confidence interval [CI], 0.29 to 0.98; P = 0.04). Total perioperative RBC transfusion tended to be lower in IOHP patients compared with non-IOHP patients (14.9% vs 22.4%, respectively; aOR, 0.72; 95% CI, 0.44 to 1.16; P = 0.18). In patients with a predicted risk of ≥ 47.5% perioperative RBC transfusion, 24.6% were transfused when IOHP was used compared with 56.5% without IOHP. The incidence of severe postoperative complications (Clavien–Dindo scores ≥ 3) was similar in patients whether or not IOHP was performed (15% vs 16% respectively; aOR, 0.97; 95% CI, 0.53 to 1.54; P = 0.71). Conclusions The use of IOHP during hepatectomy was associated with less RBCs transfused on the same day of surgery. Trials comparing IOHP with other techniques to reduce blood loss and transfusion are needed in liver surgery. Supplementary Information The online version of this article (10.1007/s12630-021-01958-8) contains supplementary material, which is available to authorized users.
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Danker Iii W, DeAnglis A, Ferko N, Garcia D, Hogan A. Comparison of fibrin sealants in peripheral vascular surgery: A systematic review and network meta-analysis. Ann Med Surg (Lond) 2020; 61:161-168. [PMID: 33425351 PMCID: PMC7782199 DOI: 10.1016/j.amsu.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/02/2020] [Indexed: 01/26/2023] Open
Abstract
Background Evidence comparing fibrin sealants (FSs) in surgery are limited. This study evaluated the efficacy and safety of FSs, and manual compression in peripheral vascular surgery. Methods A systematic review of randomized trials was conducted in Medline, Embase, and Cochrane databases within the last 15 years. Data were available to conduct a network meta-analysis (NMA) in peripheral vascular surgery. Fibrin sealant treatment arms were further broken-down and assessed by clotting time (i.e., 2-min [2C] or 1-min [1C]). The primary efficacy outcome was the proportion of patients achieving hemostasis by 4 min (T4). Treatment-related serious and non-serious adverse events (AEs) were qualitatively assessed. Results Five studies (n = 693), were included in the NMA. Results predicted VISTASEAL 2C, followed by EVICEL 1C, had the highest probability of achieving T4. Compared with manual compression, significant improvements in T4 were found with VISTASEAL 2C (relative risk [RR] = 2.67, 95% CrI: 2.13–3.34), EVICEL 1C (RR = 2.58, 95% CrI: 2.04–3.23), VISTASEAL 1C (RR = 2.00, 95% CrI: 1.45–2.65), and TISSEEL 2C (RR = 1.99, 95% CrI: 1.48–2.60). TISSEEL 1C was not significantly different than manual compression (RR = 1.40, 95% CrI: 0.70–2.33). Among FSs, VISTASEAL 2C was associated with a significant improvements in T4 compared with VISTASEAL 1C (RR = 1.33, 95% CrI: 1.02–1.82), TISSEEL 2C (RR = 1.34, 95% CrI: 1.05–1.77), and TISSEEL 1C (RR = 1.90, 95% CrI: 1.18–3.74). Treatment-related serious and non-serious AE rates were typically lower than 2%. Conclusions In peripheral vascular surgeries, VISTASEAL 2C and EVICEL 1C were shown to have the highest probabilities for achieving rapid hemostasis among the treatments compared. Future studies should expand networks across surgery types as data become available. Fibrin sealants can control perioperative bleeding, yet comparative evidence is limited. This network meta-analysis compared fibrin sealants and compression in peripheral vascular surgery. VISTASEAL and EVICEL had the highest probability of achieving hemostasis by 4 min. These results show differences exist between fibrin sealants in peripheral vascular surgery.
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Affiliation(s)
| | | | - Nicole Ferko
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - David Garcia
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - Andrew Hogan
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
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20
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Bösch F, Belyaev O, Brunner M, Müller-Debus CF, Grützmann R, Keck T, Uhl W, Witzigmann H, Werner J; Olga Radulova-Mauersberger. [Indications for the Surgical Management of Pancreatic Neuroendocrine Neoplasms]. Zentralbl Chir 2020; 145:365-73. [PMID: 32599635 DOI: 10.1055/a-1168-7103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neuroendocrine neoplasms of the pancreas (pNEN) have an increasing incidence and prevalence. Thus, this entity is of increasing clinical significance. Patients with pNEN become clinically apparent due to different and unspecific symptoms. Some tumours secrete hormones and peptides and become clinically symptomatic. In general, these tumours can metastasise early and even small tumours lead to distant metastases. Nonetheless, primary tumour size and grading are important prognostic factors. On the basis of a systematic literature research and the formulation of key issues according to the PICO system, therapeutic concepts were established. These concepts were evaluated with a Delphi process among the members of the pancreas research group and the indications for surgery group of the German Society of General and Visceral Surgery. Thus this article gives an overview of the surgical treatment modalities and indications for the treatment of pNEN. Surgery is still the gold standard in treatment and the only potential chance of cure. Surgery is indicated for sporadic as well as hereditary pNEN > 2 cm independent of the functional activity. A so called "wait and see" strategy might be indicated in smaller pNEN; however, there is little evidence for this approach. In this respect, pNEN of 1 - 2 cm represent a surgical indication. The treatment of hereditary pNEN is challenging and should be interdisciplinary. Even in the case of distant metastases, a curative approach might be feasible and multimodal treatment is indicated.
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21
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Al-Saeedi M, Ghamarnejad O, Khajeh E, Shafiei S, Salehpour R, Golriz M, Mieth M, Weiss KH, Longerich T, Hoffmann K, Büchler MW, Mehrabi A. Pringle Maneuver in Extended Liver Resection: A propensity score analysis. Sci Rep 2020; 10:8847. [PMID: 32483357 DOI: 10.1038/s41598-020-64596-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/12/2020] [Indexed: 01/13/2023] Open
Abstract
Despite the ongoing decades-long controversy, Pringle maneuver (PM) is still frequently used by hepatobiliary surgeons during hepatectomy. The aim of this study was to investigate the effect of PM on intraoperative blood loss, morbidity, and posthepatectomy hemorrhage (PHH). A series of 209 consecutive patients underwent extended hepatectomy (EH) (≥5 segment resection). The association of PM with perioperative outcomes was evaluated using multivariate analysis with a propensity score method to control for confounding. Fifty patients underwent PM with a median duration of 19 minutes. Multivariate analysis revealed that risk of excessive intraoperative bleeding (≥1500 ml; odds ratio [OR] 0.27, 95%-confidence interval [CI] 0.10–0.70, p = 0.007), major morbidity (OR 0.41, 95%-CI 0.18–0.97, p = 0.041), and PHH (OR 0.22, 95%-CI 0.06–0.79, p = 0.021) were significantly lower in PM group after EH. Furthermore, there was no significant difference in 3-year recurrence-free-survival between groups. PM is associated with lower intraoperative bleeding, PHH, and major morbidity risk after EH. Performing PM does not increase posthepatectomy liver failure and does not affect recurrence rate. Therefore, PM seems to be justified in EH.
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22
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Wang F, Sun D, Zhang N, Chen Z. The efficacy and safety of controlled low central venous pressure for liver resection: a systematic review and meta-analysis. Gland Surg 2020; 9:311-320. [PMID: 32420255 DOI: 10.21037/gs.2020.03.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Application of controlled low central venous pressure (LCVP) in liver resection growing in popularity, but its efficacy and safety are still controversial. Our objectives were to assess and compare the efficacy, feasibility, and safety of controlled LCVP in patients undergoing liver resection. Methods The PubMed, Cochrane library, and EMBASE databases were systematically searched for all the relevant studies regardless of study design. We evaluated the methodological quality of the included studies and excluded studies of poor quality. Moreover, we applied a systematic review and meta-analysis by using RevMan 5.3 software to compare the efficacy and safety of LCVP vs. standard CVP for liver resection. Outcomes included operation time, blood loss, blood infusion, fluid infusion, urinary volume, postoperative complication rates, and hospital stay. Results In total, 10 studies, involving 324 patients undergoing liver resection with controlled LCVP, were identified. Meta-analysis displayed that blood loss in the LCVP group was dramatically less than that in the control group (standard CVP group, mean difference (MD): -581.68; 95% CI: -886.32 to -277.05; P=0.0002). Moreover, blood transfusion in the LCVP group was also markedly less than that in the control group (MD: -179.16; 95% CI: -282.00 to -76.33; P=0.0006). However, there was no difference between LCVP group and control group in operation time (MD: -16.24; 95% CI: -39.56 to 7.09; P=0.17), fluid infusion (MD: -287.89; 95% CI: -1,054.47 to 478.69; P=0.46), urinary volume (MD: -26.88; 95% CI: -87.14 to 33.37; P=0.38), ALT (MD: -58.66; 95% CI: -153.81 to 36.50; P=0.23), TBIL (MD: -0.32; 95% CI: -3.93 to 3.28; P=0.86), BUN (MD: -0.13; 95% CI: -0.73 to 0.47; P=0.67), CR (MD: 1.87; 95% CI: -4.90 to 8.63; P=0.59), postoperative complication rates (MD: 0.62; 95% CI: 0.44 to 0.90; P=0.01) and hospital stay (MD: -0.61; 95% CI: -1.68 to 0.46; P=0.26). Conclusions Compared with the control, controlled LCVP showed comparable efficacy and safety for the treatment during liver resection.
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Affiliation(s)
- Feiran Wang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Dongwei Sun
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Nannan Zhang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Zhong Chen
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
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23
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Barth RJ Jr, Mills JB, Suriawinata AA, Putra J, Tosteson TD, Axelrod D, Freeman R, Whalen GF, LaFemina J, Tarczewski SM, Kinlaw WB. Short-term Preoperative Diet Decreases Bleeding After Partial Hepatectomy: Results From a Multi-institutional Randomized Controlled Trial. Ann Surg 2019; 269:48-52. [PMID: 29489484 DOI: 10.1097/SLA.0000000000002709] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Our previous case series suggested that a 1-week, low-calorie and low-fat diet was associated with decreased intraoperative blood loss in patients undergoing liver surgery. OBJECTIVE The current study evaluates the effect of this diet in a randomized controlled trial. METHODS We randomly assigned 60 patients with a body mass index ≥25 kg/m(2) to no special diet or an 800-kcal, 20 g fat, and 70 g protein diet for 1 week before liver resection. Surgeons were blinded to diet assignment. Hepatic glycogen stores were evaluated using periodic acid Schiff (PAS) stains. RESULTS Ninety four percent of the patients complied with the diet. The diet group consumed fewer daily total calories (807 vs 1968 kcal, P < 0.001) and fat (21 vs 86 g, P < 0.001) than the no diet group. Intraoperative blood loss was less in the diet group: mean blood loss 452 vs 863 mL (P = 0.021). There was a trend towards decreased transfusion in the diet group (138 vs 322 mL, P = 0.06). The surgeon judged the liver to be easier to manipulate in the diet group: 1.86 versus 2.90, P = 0.004. Complication rate (20% vs 17%), length of stay (median 5 vs 4 days) and mortality did not differ between groups. There was no difference in hepatic steatosis between groups. There was less glycogen in hepatocytes in the diet group (PAS stain score 1.61 vs 2.46, P < 0.0001). CONCLUSIONS A short-course, low-fat, and low-calorie diet significantly decreases bleeding and makes the liver easier to manipulate in hepatic surgery.
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24
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Sultan AM, Shehta A, Salah T, Elshoubary M, Fathy O, Wahab MA. Response to: Effective and Safe Living Donor Hepatectomy Under Intermittent Inflow Occlusion and Outflow Pressure Control. J Gastrointest Surg 2019; 23:1290-1291. [PMID: 30887294 DOI: 10.1007/s11605-019-04191-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Ahmad Mohamed Sultan
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed Shehta
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt.
| | - Tarek Salah
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Elshoubary
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Omar Fathy
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Abdel Wahab
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
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25
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Tan HL, Goh BKP. The effect of preoperative low-calorie diets on liver resection outcomes. Transl Gastroenterol Hepatol 2019; 4:29. [PMID: 31231696 DOI: 10.21037/tgh.2019.04.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 12/30/2022] Open
Affiliation(s)
- Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore
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26
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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: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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27
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Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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Jayant K, Sodergren MH, Reccia I, Kusano T, Zacharoulis D, Spalding D, Pai M, Jiao LR, Huang KW. A Systematic Review and Meta-Analysis Comparing Liver Resection with the Rf-Based Device Habib™-4X with the Clamp-Crush Technique. Cancers (Basel) 2018; 10:E428. [PMID: 30413094 DOI: 10.3390/cancers10110428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/25/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023] Open
Abstract
Liver cancer is the sixth most common cancer and third most common cause of cancer-related mortality. Presently, indications for liver resections for liver cancers are widening, but the response is varied owing to the multitude of factors including excess intraoperative bleeding, increased blood transfusion requirement, post-hepatectomy liver failure and morbidity. The advent of the radiofrequency energy-based bipolar device Habib™-4X has made bloodless hepatic resection possible. The radiofrequency-generated coagulative necrosis on normal liver parenchyma provides a firm underpinning for the bloodless liver resection. This meta-analysis was undertaken to analyse the available data on the clinical effectiveness or outcomes of liver resection with Habib™-4X in comparison to the clamp-crush technique. The RF-assisted device Habib™-4X is considered a safe and feasible modality for liver resection compared to the clamp-crush technique owing to the multitude of benefits and mounting clinical evidence supporting its role as a superior liver resection device. The most intriguing advantage of the RF-device is its ability to induce systemic and local immunomodulatory changes that further expand the boundaries of survival outcomes following liver resection.
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Janeczek M, Świderski J, Czerski A, Żywicka B, Bujok J, Szymonowicz M, Bilewicz E, Dobrzyński M, Korczyński M, Chrószcz A, Rybak Z. Preliminary Evaluation of Thulium Doped Fiber Laser in Pig Model of Liver Surgery. Biomed Res Int 2018; 2018:3275284. [PMID: 30410925 DOI: 10.1155/2018/3275284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/16/2018] [Indexed: 12/14/2022]
Abstract
Partial liver resection is a treatment of choice for liver tumors; the range of parenchyma excision varies from a small part of the tissue surrounding the neoplasm up to 70% of the organ. One of the major concerns during liver resection is blood loss. Thulium lasers which are characterized by the length of emission wave corresponding to a peak absorption of water create a new possibility of cutting tissues efficiently with minimal thermal damage and concurrently providing a good hemostasis control. The aim of our study was to evaluate an impact of liver transection with thulium doped fiber laser on an intraoperative bleeding and histopathological changes during postoperative period in swine model. Ten animals were subjected to open surgery partial liver resection and an incision of liver tissue with an all-fiber, diode-pumped, and continuous-wave Tm3+-doped fiber laser emitting 37.4 W of output power at ~1.94 μm wavelength. The macroscopic and histopathological evaluation was performed intraoperatively as well as 7 and 14 days after surgery. Macroscopically almost no bleeding was observed during surgery and no signs of bleeding were stated after 7 and 14 days. Histopathological analysis of the transection margin revealed a thermal damage area ranging in depth from 620.23 ± 23.82 μm on the day of surgery to 1817.70 ± 211.98 μm after 7 days. In the samples taken intraoperatively and after 7 days a superficial zone of carbonization was visibly separated from the deeper changes. After 14 days one 765.35 μm deep zone characterized by a granulation was present. In conclusion, thulium doped fiber laser is efficacious in cutting with a narrow zone of thermal injury and provides a good hemostasis during liver transection, thus being a potential tool for oncotic liver surgery.
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Abstract
Central venous pressure (CVP) is deemed to be an important parameter of anesthesia management in liver surgery. To reduce blood loss during liver resections, a low target value of CVP is often propagated. Although current meta-analyses have shown a connection between low CVP and a reduction in blood loss, the underlying studies show methodological weaknesses and advantages with respect to morbidity and mortality can hardly be proven. The measurement of the CVP itself is associated with numerous limitations and influencing factors and the measures to reduce the CVP have been insufficiently investigated with respect to hepatic hemodynamics. The definition of a generally valid target area for the CVP must be called into question. The primary objective is to maintain adequate oxygen supply and euvolemia. The CVP should be regarded as a mosaic stone of hemodynamic management.
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Affiliation(s)
- C R Behem
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Deutschland.
| | - M F Gräßler
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Deutschland
| | - C J C Trepte
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Deutschland
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31
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Bleszynski MS, Bressan AK, Joos E, Morad Hameed S, Ball CG. Acute care and emergency general surgery in patients with chronic liver disease: how can we optimize perioperative care? A review of the literature. World J Emerg Surg 2018; 13:32. [PMID: 30034510 PMCID: PMC6052581 DOI: 10.1186/s13017-018-0194-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/10/2018] [Indexed: 12/15/2022] Open
Abstract
The increasing prevalence of advanced cirrhosis among operative candidates poses a major challenge for the acute care surgeon. The severity of hepatic dysfunction, degree of portal hypertension, emergency of surgery, and severity of patients’ comorbidities constitute predictors of postoperative mortality. Comprehensive history taking, physical examination, and thorough review of laboratory and imaging examinations typically elucidate clinical evidence of hepatic dysfunction, portal hypertension, and/or their complications. Utilization of specific scoring systems (Child-Pugh and MELD) adds objectivity to stratifying the severity of hepatic dysfunction. Hypovolemia and coagulopathy often represent major preoperative concerns. Resuscitation mandates judicious use of intravenous fluids and blood products. As a general rule, the most expeditious and least invasive operative procedure should be planned. Laparoscopic approaches, advanced energy devices, mechanical staplers, and topical hemostatics should be considered whenever applicable to improve safety. Precise operative technique must acknowledge common distortions in hepatic anatomy, as well as the risk of massive hemorrhage from porto-systemic collaterals. Preventive measures, as well as both clinical and laboratory vigilance, for postoperative hepatic and renal decompensation are essential.
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Affiliation(s)
| | - Alexsander K Bressan
- 2Department of Surgery, University of Calgary, Foothills Medical Centre, 1403 - 29 Street NW, Calgary, Alberta Canada
| | - Emilie Joos
- 1Department of Surgery, University of British Columbia, Vancouver, Canada
| | - S Morad Hameed
- 1Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Chad G Ball
- 2Department of Surgery, University of Calgary, Foothills Medical Centre, 1403 - 29 Street NW, Calgary, Alberta Canada
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Fancellu A, Petrucciani N, Melis M, Porcu A, Feo CF, Zorcolo L, Nigri G. Usefulness of Infra-hepatic Inferior Vena Cava Clamping During Liver Resection: a Meta-analysis of Randomized Controlled Trials. J Gastrointest Surg 2018; 22:941-951. [PMID: 29508216 DOI: 10.1007/s11605-018-3720-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/11/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Infra-hepatic vena cava clamping (IIVCC) may reduce blood losses during liver resection. However, available literature is limited to reports from single institutions with a small sample size. To overcome those limitations, we performed a meta-analysis to examine the association between IIVCC and surgical outcomes. METHODS A systematic literature review was conducted to identify RCTs reporting on quantitative data on IIVCC. Random effects logistic regression calculated the pooled odds ratio (OR) for each surgical outcome. RESULTS Six studies were identified that included 714 patients, of whom 359 received IIVCC and 355 did not. Patients receiving IIVCC had significantly less total blood loss (MD - 353.08, 95% CI - 393.36 to 312.81, P < 0.00001), blood loss during parenchymal transection (MD - 243.28, 95% CI - 311.67 to - 174.88, P < 0.0001), blood loss volume per transection area (MD - 1.63, 95% CI - 2.14 to - 1.13, P < 0.00001), and intraoperative blood transfusion (OR 0.45, 95% CI 0.23 to 0.89, P = 0.02). Operative time was similar in the two groups (MD - 2.89, 95% CI - 18.45 to 12.68, P = 0.72). No differences between groups were observed in central venous pressure, heart rate, and mean arterial pressure before, after, and during parenchymal transection. Rates of overall morbidity (OR 0.79, 95% CI 0.56-1.13, P = 0.20), major complications (OR 0.89, 95% CI 0.47-1.80, P = 0.73), and perioperative mortality (OR 1.32, 95% CI 0.29-6.09, P = 0.72) were similar in the two groups. CONCLUSIONS IIVCC was associated to decreased blood loss (overall, during parenchymal transection, and per transection area) and decreased intraoperative transfusions, in the absence of increased operative times.
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Affiliation(s)
- Alessandro Fancellu
- Department of Medical, Surgical and Experimental Sciences, Unit of General Surgery 2 - Clinica Chirurgica, University of Sassari, V.le San Pietro 43, 07100, Sassari, Italy.
| | - Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Marcovalerio Melis
- Department of Surgery, Division of Surgical Oncology, New York University School of Medicine, NY Harbor Healthcare System VAMC, New York, NY, USA
| | - Alberto Porcu
- Department of Medical, Surgical and Experimental Sciences, Unit of General Surgery 2 - Clinica Chirurgica, University of Sassari, V.le San Pietro 43, 07100, Sassari, Italy
| | - Claudio F Feo
- Department of Medical, Surgical and Experimental Sciences, Unit of General Surgery 2 - Clinica Chirurgica, University of Sassari, V.le San Pietro 43, 07100, Sassari, Italy
| | - Luigi Zorcolo
- Department of Surgery, Colorectal Surgery Center, University of Cagliari, Cagliari, Italy
| | - Giuseppe Nigri
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Mathis R, Stodghill J, Shaver T, Younan G. Cholecystectomy of an Intrahepatic Gallbladder in an Ectopic Pelvic Liver: A Case Report and Review of the Literature. Case Rep Surg 2017; 2017:3568768. [PMID: 29225990 DOI: 10.1155/2017/3568768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/03/2017] [Indexed: 12/29/2022] Open
Abstract
Introduction Ectopic pelvic liver is an exceedingly rare condition usually resulting after repair of congenital abdominal wall defects. Intrahepatic gallbladder is another rare condition predisposing patients to cholelithiasis and its sequelae. We describe a cholecystectomy in a patient with an intrahepatic gallbladder in a pelvic ectopic liver. Presentation of Case A 33-year-old woman with a history of omphalocele repair as an infant presented with signs and symptoms of symptomatic cholelithiasis and chronic cholecystitis, however, in an unusual location. After extensive workup and symptomatic treatment, cholecystectomy was recommended and performed via laparotomy and hepatotomy using microwave technology for parenchymal hepatic transection. Discussion Given the rare combination of an intrahepatic gallbladder and an ectopic pelvic liver, advanced surgical techniques must be employed for cholecystectomies, in addition to involvement of hepatobiliary experienced surgeons due to the distortion of the biliary and hepatic vascular anatomy. Conclusion Cholecystectomy by experienced hepatobiliary surgeons is a safe and effective treatment for cholecystitis in patients with intrahepatic gallbladders in ectopic pelvic livers.
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Yoshino O, Perini MV, Christophi C, Weinberg L. Perioperative fluid management in major hepatic resection: an integrative review. Hepatobiliary Pancreat Dis Int 2017; 16:458-469. [PMID: 28992877 DOI: 10.1016/s1499-3872(17)60055-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 04/10/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms "surgery", "anesthesia", "starch", "hydroxyethyl starch derivatives", "albumin", "gelatin", "liver resection", "hepatic resection", "fluids", "fluid therapy", "crystalloid", "colloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "acetate", and "lactate". Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed. CONCLUSIONS Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.
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Affiliation(s)
- Osamu Yoshino
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia.
| | - Marcos Vinicius Perini
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Surgery, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia; Anaesthesia Perioperative Pain Medicine Unit, University of Melbourne, Melbourne, Victoria, Australia
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