Preoperative identification of intraoperative blood loss of more than 1,500 mL during elective hepatectomy

Perioperative predictive factors of failure to rescue following highly advanced hepatobiliary-pancreatic surgery: a single-institution retrospective study

BACKGROUND

Failure to rescue (FTR), defined as a postoperative complication leading to death, is a recently described outcome metric used to evaluate treatment quality. However, the predictive factors for FTR, particularly following highly advanced hepatobiliary-pancreatic surgery (HBPS), have not been adequately investigated. This study aimed to identify perioperative predictive factors for FTR following highly advanced HBPS.

METHODS

This single-institution retrospective study involved 177 patients at Gifu University Hospital, Japan, who developed severe postoperative complications (Clavien-Dindo classification grades ≥ III) between 2010 and 2022 following highly advanced HBPS. Univariate analysis was used to identify pre-, intra-, and postoperative risks of FTR.

RESULTS

Nine postoperative mortalities occurred during the study period (overall mortality rate, 1.3% [9/686]; FTR rate, 5.1% [9/177]). Univariate analysis indicated that comorbid liver disease, intraoperative blood loss, intraoperative blood transfusion, postoperative liver failure, postoperative respiratory failure, and postoperative bleeding significantly correlated with FTR.

CONCLUSIONS

FTR was found to be associated with perioperative factors. Well-coordinated surgical procedures to avoid intra- and postoperative bleeding and unnecessary blood transfusions, as well as postoperative team management with attention to the occurrence of organ failure, may decrease FTR rates.

Restrictive Pulmonary Dysfunction May Increase Blood Loss During Liver Resection

BACKGROUND

Restrictive pulmonary dysfunction (RPD) is a risk factor for perioperative complications during gastrointestinal surgery. We hypothesized that high airway pressure due to RPD results in increased intraoperative blood loss during liver surgery. Thus, we investigated the effects of RPD on perioperative outcomes for liver resection.

METHODS

This study included 496 patients who underwent curative liver resection at our hospital between April 2009 and April 2020. Perioperative outcomes for the RPD and control groups were compared. Restrictive pulmonary dysfunction was defined as % vital capacity <80%.

RESULTS

Forty-one patients (8.3%) had RPD. No significant differences were observed in intraoperative blood losses (440 mL vs 320 mL, P = .340), overall complication rates (29.3% vs 31.2%, P = .797), or pulmonary complication rates (4.9% vs 9.0%, P = .286) between the RPD and control groups. In the 256 patients who underwent anatomical liver resection, 18 patients (7.0%) had RPD. The intraoperative blood loss was significantly higher in the RPD group (925 mL vs 456 mL, P = .013), but no differences in the overall complication rates (44.4% vs 37.3%, P = .528) or pulmonary complication rates (11.1% vs 10.5%, P = .589) between the two groups were detected. A multivariate analysis showed that RPD was an independent risk factor for intraoperative blood loss ≥500 mL during anatomical liver resection (odds ratio 4.132; 95% confidence interval 1.135-15.045; P = .031).

DISCUSSION

Restrictive pulmonary dysfunction may be a risk factor for intraoperative blood loss during anatomical liver resection, which requires exposure of the main hepatic vein.

Vertical interval between hepatic segment of inferior vena cava and right atrium predicts intraoperative blood loss during hemi-hepatectomy

BACKGROUND

Intraoperative bleeding is a major issue for hepatic surgeons because large intraoperative blood loss causes poor patient outcome. The aim of this study was to identify predictors of intraoperative bleeding during hemi-hepatectomy. Methods This study enrolled 45 living donors for liver transplantation (cohort 1) and 44 patients with various conditions (cohort 2) who underwent hemi-hepatectomy at Ehime University Hospital between January 2010 and March 2019 (Approval number: 1810024). The gap between the ventral horizontal line of the inferior vena cava (IVC) confluent with the right atrium (RA) and the dorsal horizontal line of the hepatic segment of the IVC (IVC-RA gap) was determined from preoperative images. Cardiopulmonary and liver functions were investigated as potential predictors of intraoperative estimated blood loss (iEBL). Results The IVC-RA gap positively correlated with iEBL in cohorts 1 and 2 (r = 0.453, P = 0.002 and r = 0.443, P = 0.003, respectively), and multivariate analysis selected the IVC-RA gap as an independent predictor of iEBL >400 ml in cohorts 1 and 2 (odds ratios 1.177 and 1.115; 95% confidence intervals 1.041-1.330 and 1.007-1.234; P = 0.009 and P = 0.036, respectively). Conclusions The IVC-RA gap is a novel and simple predictor of iEBL.

Infrahepatic Inferior Vena Cava Semi-Clamping can Reduce Blood Loss During Hepatic Resection but Still Requires Monitoring to Avoid Acute Kidney Injury

BACKGROUND

The efficacy of infrahepatic inferior vena cava (IVC) semi-clamping for reducing blood loss during hepatic resection and its safety remain unclear. The aim of this study was to validate the effectiveness of IVC semi-clamping for reducing blood loss during hepatic resection and to confirm its safety.

METHODS

Patients who underwent anatomical hepatic resection between January 2011 and May 2018 were analysed by propensity score-matched and multivariate analyses.

RESULTS

Of 437 patients who underwent anatomical hepatic resection, IVC semi-clamping was performed in 196 patients (44.9%; clamping group). A propensity score-matched analysis demonstrated that even though there was no significant difference in the characteristics of the 141 patients in each group, IVC semi-clamping reduced the blood loss during hepatic resection (clamping group versus non-clamping group: 836 ± 123 vs. 1198 ± 124 ml, P = 0.04). Regarding post-operative complications, the multivariate analysis identified IVC semi-clamping as an independent risk factor for acute kidney injury on post-operative day 1 (P = 0.01, odds ratio = 9.23). A significant positive correlation was found between the duration of IVC semi-clamping and an increased level of serum creatinine (sCre) (P = 0.03), and a significant inverse correlation was found between the blood pressure after clamping and an increased level of sCre (P = 0.02). A receiver operating characteristic analysis revealed the duration and mean blood pressure after clamping that indicated a high risk of acute kidney injury to be 116 min and 65 mmHg, respectively.

CONCLUSION

IVC semi-clamping can reduce blood loss during hepatic resection but still necessitates monitoring in order to avoid acute kidney injury.

Postoperative intensive care unit admission does not affect outcomes in elective surgical patients with severe comorbidity

OBJECTIVE

The impact of postoperative intensive care upon patient outcomes was evaluated by retrospectively investigating the rate of poor outcomes among miscellaneous elective surgical patients with severe comorbidities.

DESIGN

A retrospective cohort study was carried out.

SETTING

University hospital.

PATIENTS

Surgical patients with severe comorbidities.

INTERVENTION

The outcomes of 1218 surgical patients treated in intensive care units (ICUs) and postsurgical wards (ICU group vs. non-ICU group) were reviewed for poor outcomes (i.e., no discharge or death). A propensity score analysis was used to generate 248 matched pairs of ICU-admitted patients and controls.

VARIABLES OF INTEREST

Poor outcome rates on postoperative day 90 and mortality on postoperative days 30 and 90.

RESULTS

No significant between-group differences were observed in terms of poor outcomes on postoperative day 90 [ICU vs. non-ICU: 33/248 (13%) vs. 28/248 (11%), respectively; ICU odds ratio (OR): 1.19, 95% confidence interval (CI), 0.71-2.01, p=0.596] or in between-group differences in terms of mortality on postoperative days 30 and 90 [ICU vs. non-ICU: 4/248 (1.6%) vs. 2/248 (0.8%) on postoperative day 30 and 5/248 (2.0%) vs. 3/248 (1.2%) on day 90, respectively; ICU OR (95% CI), 2.00 (0.37-10.9) and 1.67 (0.40-6.97) for postoperative 30- and 90-day mortality, respectively (p=0.683 and 0.724)]. Low preoperative body weight was negatively correlated to patient outcomes [OR (95% CI): 0.82/10kg (0.70-0.97), p=0.019], whereas regional analgesia combined with general anesthesia was positively correlated to patient outcomes [OR (95% CI): 0.39 (0.69-0.96), p=0.006]. Extra ICU admission was correlated to poor patient outcomes [OR (95% CI): 4.18 (2.23-7.81), p < 0.0001].

CONCLUSIONS

Postoperative ICU admission failed to demonstrate any meaningful benefits in patients with severe comorbidities undergoing miscellaneous elective surgeries.

The unnecessary application of central venous catheterization in surgical patients

Background and objectives

Methods

Results

Conclusions

Established and potential predictors of blood loss during lung transplant surgery

Lung transplantation is an established therapeutic procedure for end stage lung diseases. Its success may be impaired by perioperative complications. Intraoperative blood loss and the resulting blood transfusion are among the most common complications. The various factors contributing to increased blood loss during lung transplantation are only scarcely investigated and not yet completely understood. This is in sharp contrast to other surgical fields, as in orthopedic surgery, liver transplantation and cardiac surgery the contributors to blood loss are well identified. This narrative review article aims to highlight the acknowledged factors influencing blood loss in lung transplantation (such as double vs. single lung transplant) and to discuss potential factors that may be of interest for further research or helpful to develop strategies targeting risk factors in order to minimize blood loss during lung transplantation and finally improve patient outcome.

[The unnecessary application of central venous catheterization in surgical patients]

BACKGROUND AND OBJECTIVES

Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement.

METHODS

Using data from institutional perioperative central venous catheter surveillance, we analysed data from 1,141 patients who underwent central venous catheter placement. We reviewed the central venous catheter registry and medical charts and allocated registered patients into those with the proper or with unnecessary application of central venous catheter according to standard indications. Multivariate analysis was used to identify factors associated with the unnecessary application of central venous catheter placement.

RESULTS

In 107 patients, representing 9.38% of the overall population, we identified the unnecessary application of central venous catheter placement. Multivariate analysis identified emergencies at night or on holidays (odds ratio [OR] 2.109, 95% confidence interval [95% CI] 1.021-4.359), low surgical risk (OR=1.729, 95% CI 1.038-2.881), short duration of anesthesia (OR=0.961/10min increase, 95% CI 0.945-0.979), and postoperative care outside of the intensive care unit (OR=2.197, 95% CI 1.402-3.441) all to be independently associated with the unnecessary application of catheterization. Complications related to central venous catheter placement when the procedure consequently turned out to be unnecessary were frequently observed (9/107) compared with when the procedure was necessary (40/1034) (p=0.032, OR=2.282, 95% CI 1.076-4.842). However, the subsequent multivariate logistic model did not hold this significant difference (p=0.0536, OR=2.115, 95% CI 0.988-4.526).

CONCLUSIONS

More careful consideration for the application of central venous catheter is required in cases of emergency surgery at night or on holidays, during low risk surgery, with a short duration of anesthesia, or in cases that do not require postoperative intensive care.

Hepatic resection: a safe and effective surgery

INTRODUCTION

We analyze major liver resections performed in 10 years, with the objective of evaluating perioperative results. As secondary objectives, factors related to major complications and comparative analyses of 25-year periods are evaluated.

METHODS

Retrospective analysis of patients undergoing major hepatic resection (3 or more segments) from January 2005 to December 2014, from pre, intra and postoperative data. The Clavien classification is used for postoperative morbidity.

RESULTS

A total of 416 major hepatectomies were performed. Transfusions were performed in 38 patients (9.1%). A Pringle maneuver was used in 47.7% of the cases. Half of the patients had no complications, and only 96 patients (23%) had a major complication. Bile leakage was the most frequent complication (n=72, 17.3% of patients), especially due to malignant disease and biliary reconstruction, high risk ASA (III-IV) and prolonged surgical time. Thirteen patients met criteria for liver failure, of which 7died (5 associated a bacterial infection). The mean hospital stay was 12.5 days, with an 11,8% readmission rate. When comparing 25-year periods, at present more complex patients are operated on, with a lower incidence of transfusions and complications (ns).

CONCLUSIONS

Liver surgery has increased significantly in recent years. Surgical management of the liver now allows safe and effective surgery, with a very low complication rate. The limit of resectability depends on the residual hepatic volume.

Significance of a soft-coagulation system with monopolar electrode for hepatectomy: A retrospective two-institution study by propensity analysis

BACKGROUND

The VIO soft-coagulation system (VIO) with a monopolar electrode is a novel hemostatic device that provides hemostasis by superficial contact at the bleeding site without carbonization. Because heat injury remains a concern, surgical records and postoperative liver dysfunction were retrospectively evaluated in a cohort study.

METHODS

Between September 2010 and March 2016, 322 patients underwent hepatectomy in which hemostatic devices were used at two institutions. Surgical results with use of VIO at one institute (VIO group) were compared with those without use of VIO at a second institute (control group), and propensity analysis was performed.

RESULTS

In limited resection and segmentectomy or sectionectomy performed in the VIO group, the prevalence of liver cirrhosis was significantly higher and the operation time was significantly longer in comparison with the control group (p < 0.05). In all hepatectomies, postoperative levels of total bilirubin and aspartate or alanine transaminase tended to be increased and prothrombin activity tended to be lower in the VIO group in comparison with the control group (p < 0.05). The prevalence of hepatic failure in the VIO group was significantly higher in comparison with that in the control group (p < 0.05). In cases of segmentectomy or sectionectomy, blood loss was significantly increased in the VIO group in comparison with that in the control group (p < 0.05) Propensity score matching showed that although the surgical records and outcomes were not significantly different between the groups, postoperative liver dysfunction was significant in the VIO group in comparison with the control group (p < 0.05).

CONCLUSIONS

Mild postoperative hepatic thermal injury with VIO was confirmed, and therefore, surgeons should take care when using the VIO system to make frequent wide resected cuts on the surface of the liver.

Predicting postoperative outcomes of liver resection by magnetic resonance elastography

BACKGROUND

Cirrhosis is associated with blood loss during liver resection and postoperative complications. The liver stiffness measurement has recently become available for assessment of liver fibrosis.

METHODS

This prospective study was performed to predict postoperative outcomes of liver resection. The liver stiffness measurement was measured prospectively using magnetic resonance elastography for patients who had undergone liver resection for malignancy. We investigated whether the liver stiffness measurement by magnetic resonance elastography is correlated with liver fibrosis and postoperative outcomes.

RESULTS

The median liver stiffness measurement by magnetic resonance elastography in 175 patients was 3.4 (range: 1.5-11.3) kPa, and the pathologic grade of liver fibrosis was significantly correlated with the liver stiffness measurement (r = 0.68, P < .001). The median blood loss during transection per unit area was 4.1 mL/cm² (range: 0.1-37.0 mL/cm²), and the frequency of major complications was 16.0%. The liver stiffness measurement was the only independent prognostic factor for both blood loss (regression coefficient: 1.14, 95% confidence interval: 0.45-1.83, P = .001) and major complications (odds ratio: 2.14, 95% confidence interval: 1.63-2.93, P < .001). Receiver operating characteristic curve analysis indicated a significant correlation between the liver stiffness measurement and major complications with calculated area under the curve of 0.81 (P < .001), and the sensitivity and specificity for prediction of major complications (cutoff value: 5.3 kPa) were 64.3% and 87.8%, respectively. On the other hand, the amount of blood loss was significantly correlated with the frequency of major complications (P = .003).

CONCLUSION

The liver stiffness measurement by magnetic resonance elastography could be used as a predictive marker for the risk of major complications due to blood loss during liver resection.

The learning curves in living donor hemiliver graft procurement using small upper midline incision

The learning curve for performing living donor hemiliver procurement (LDHP) via small upper midline incision (UMI) has not been determined. Living donors (n=101) who underwent LDHP via UMI were included to investigate the learning curve using cumulative sum analysis. The cumulative sum analysis showed that nine cases for right lobe (case #23) and 19 cases for left lobe (case #32 in the whole series) are needed for stable and acceptable surgical outcomes in LDHP via UMI. The established phase (n=69, since case #33) had a significantly shorter operative time, a smaller incision size, and less blood loss than the previous learning phase (n=32, serial case number up to the last 19th left lobe case). Multivariate analysis showed that the learning phase, high body mass index ≥25 kg/m² , and left lobe graft procurement are the factors associated with surgical events including operative blood loss ≥400 mL, operative time ≥300 minutes, or surgical complications ≥Clavien-Dindo grade II. There is an obvious learning curve in performing LDHP via UMI, and 32 cases including both 19 cases for left lobe and nine cases for right lobe are needed for having stable and acceptable surgical outcomes.

Assessment of the external validity of a predictive score for blood transfusion in liver surgery

BACKGROUND

Perioperative bleeding is a predictor of morbidity following liver resection. The transfusion-related score (TRS), which is derived from five variables (cirrhosis, preoperative haemoglobin level, tumour size, vena cava exposure and associated extraliver surgical procedure), has been proposed to predict the likelihood of transfusion in liver resection.

OBJECTIVE

The purpose of this observational study was to evaluate the external validity of the TRS.

METHODS

In a retrospective, monocentre, observational cohort study of patients undergoing elective liver resection surgery, data for transfused and non-transfused patients were compared by univariate analysis. The TRS was calculated for each patient. The frequency of transfusion was calculated for each score level. The accuracy of the TRS was evaluated using the area under the receiver operator characteristic curve (AUC).

RESULTS

A total of 205 patients submitted to liver resection were included. Of these, 48 (23.4%) patients received a blood transfusion. There was no significant difference between transfused and non-transfused patients in age, American Society of Anesthesiologists (ASA) score or cirrhosis. The AUC for the TRS was 0.68 (95% confidence interval 0.59-0.77). Among TRS items, only vena cava exposure and associated surgical procedures were significantly associated with risk for transfusion.

CONCLUSIONS

In the present population, the TRS appeared to serve as a weak predictor of perioperative transfusion. This study confirms that the external validity of the transfusion predictive score should be subject to further investigation before it can be implemented in clinical use.

Risk assessment in patients undergoing liver resection

BACKGROUND

Liver resection is still a risky procedure with high morbidity and mortality. It is significant to predict the morbidity and mortality with some models after liver resection.

DATA SOURCES

The MEDLINE/PubMed, Web of Science, Google Scholar, and Cochrane Library databases were searched using the terms "hepatectomy" and "risk assessment" for relevant studies before August 2012. Papers published in English were included.

RESULTS

Thirty-four original papers were included finally. Some models, such as MELD, APACHE II, E-PASS, or POSSUM, widely used in other populations, are useful to predict the morbidity and mortality after liver resection. Some special models for liver resection are used to predict outcomes after liver resection, such as mortality, liver dysfunction, transfusion, or acute renal failure. However, there is no good scoring system to predict or classify surgical complications because of shortage of internal or external validation.

CONCLUSION

It is important to validate the models for the major complications after liver resection with further internal or external databases.

Right hepatectomy with extra-hepatic vascular division prior to transection: intention-to-treat analysis of a standardized policy

BACKGROUND

Right hepatectomy (RH) is the most common type of major hepatectomy and can be achieved without portal triad clamping (PTC) in non-cirrhotic liver. The present study reviews our standardized policy of performing RH without systematic PTC.

METHODS

One hundred and eighty-one consecutive RH were performed in non-cirrhotic patients, with division of the right afferent and efferent blood vessels prior to transection, without systematically using PTC. Prospectively collected data were analysed, focusing on the following endpoints: need for salvage PTC, ischaemic time, blood loss and post-operative outcome.

RESULTS

Extra-hepatic division of the right hepatic vessels was feasible in all patients, but was ineffective in 48 patients (26.5%) who required salvage PTC during transection. In those patients, the median ischaemic time was 20 min. The median blood loss was 500 ml (50-3000). Six patients (3.3%) experienced post-operative liver failure. Overall morbidity, severe morbidity and mortality were 42%, 12.1% and 1.6%, respectively, with peri-operative transfusion rate (16.6%) being the only factor associated with morbidity.

DISCUSSION

By performing RH with extra-hepatic vascular division prior to transection, PTC can be safely avoided in the majority of patients.