Hepatic parenchyma resection using stapling devices: peri-operative and long-term outcome

PARTIAL HEPATECTOMY USING LINEAR CUTTER STAPLER: ARE THERE ADVANTAGES?

BACKGROUND

Morbidity of liver resections is related to intraoperative bleeding and postoperative biliary fistulas. The Endo-GIA stapler (EG) in liver resections is well established, but its cost is high, limiting its use. The linear cutting stapler (LCS) is a lower cost device.

AIMS

To report open liver resections, using LCS for transection of the liver parenchyma and en bloc stapling of vessels and bile ducts.

METHODS

Ten patients were included in the study. Four patients with severe abdominal pain had benign liver tumors (three adenomas and one focal nodular hyperplasia). Among the remaining six patients, four underwent liver resection for the treatment of colorectal liver metastases, three of which had undergone preoperative chemotherapy. The other two cases were one patient with metastasis from a testicular teratoma and the other with metastasis from a gastrointestinal neuroectodermal tumor.

RESULTS

The average length of stay was five days (range 4-7 days). Of the seven patients who underwent resections of segments II/III, two presented postoperative complications: one developed a seroma and the other a collection of abdominal fluid who underwent percutaneous drainage, antibiotic therapy, and blood transfusion. Furthermore, the three patients who underwent major resections had postoperative complications: two developed anemia and received blood transfusions and one had biloma and underwent percutaneous drainage and antibiotic therapy.

CONCLUSIONS

The use of the linear stapler in hepatectomies was efficient and at lower costs, making it suitable for use whenever EG is not available. The size of the LCS stapler shaft is more suitable for en bloc transection of the left lateral segment of the liver, which is thinner than the right one. Further studies are needed to evaluate the safety of LCS for large liver resections and resections of tumors located in the right hepatic lobe.

Grade V Liver Injury Presented With Peritonitis Treated With Stapler-Assisted Hepatic Segmentectomy: A Case Report

The liver is one of the most commonly injured solid organs in blunt abdominal trauma. In patients who are hemodynamically normal, most cases of blunt liver injuries are managed conservatively. At present, nonoperative management (NOM) is the standard of care for both minor and severe liver injuries. Usually, patients with severe liver injuries, i.e., grades IV and V, are treated with surgical intervention versus angioembolization depending if patients are hemodynamically stable or not. We present a hemodynamically stable 53-year-old male patient with a grade V blunt liver injury with complete avulsion of the left lobe of the liver after a motor vehicle collision (MVC). Very few cases of complete hepatic avulsions have been published in the literature. We discuss surgical management with stapler-assisted hepatectomy in emergency trauma laparotomy for bleeding control.

A fast and easy-to-learn technique for liver resection in a porcine model

Objective

Despite the recent advances in surgical techniques and perioperative care, liver resection (especially extended hepatectomy) is still a high-risk procedure with considerable morbidity and mortality. Experimental large animal models are the best option for studies in this regard. The present study was performed to present an easy-to-learn, fast, and multipurpose model of liver resection in a porcine model.

Method

Stepwise liver resections (resection of segments II/III, IVa/IVb, and VIII/IV) were performed in eight pigs with intraoperative monitoring of hemodynamic parameters. The technical aspects, tips, and tricks of this method are explained in detail.

Results

Based on the specific anatomical characteristics of the porcine liver, all resection types including segmental resection, hemihepatectomy, and extended hepatectomy could be performed in one animal in an easy-to-learn and fast technique. All animals were hemodynamically stable following stepwise liver resection.

Conclusion

Stepwise liver resection using stapler in a porcine model is a fast and easy-to-learn method with which junior staff and research fellows can perform liver resection up to extended hepatectomy under stable conditions.

Rationality and necessity of vascular stapler application during liver resection (Review)

Liver resection (LR) is the primary treatment method for patients with hepatocellular carcinoma (HCC). Improving surgical safety and reducing surgical morbidity and mortality is important for patients receiving LR. Various devices have been developed to facilitate vascular transection to reduce intraoperative blood loss, which is considered to be a predictor of poor surgical outcomes in patients undergoing LR. Vascular staplers have been widely applied for the division of major vascular and biliary structures in the process of LR; however, when and how to use these tools remains controversial. This review aims to report the rationality and necessity of using vascular staplers in vessel transection during liver surgery. Due to the risk of intraoperative and postoperative hemorrhage and biliary fistula, the process of transection of the portal pedicle and hepatic vein is a crucial step during LR. Stapling represents a vascular dissection technique that is widely used in laparoscopic LR and has then been popularized in open LR. Advocates argue that stapler transection methods provide several advantages, including diminished blood loss, fewer transfusion requirements and shorter operative times. However, other studies have failed to demonstrate those benefits when using these tools compared with the simple clamp-crushing technique. Using the stapler vascular transection method resulted in smaller surgical margins and similar surgical outcomes compared with those of the clamp-crushing vascular transection method. However, the intraoperative use of vascular staplers may significantly increase the financial burden of liver resection for patients with HCC, while not improving short- and long-term outcomes. Therefore, it has been suggested that vascular staplers should not be routinely used in LR. The current review discussed the above points and recommended that the stapling transection of the portal pedicle and hepatic vein should be applied during laparoscopic LR in a rational manner. However, the suturing ligation method should be routinely used in open LR.

Gastrointestinal anastomosis (GIA) stapler as a safe and efficacious damage control tool for high-grade liver injury in hemodynamically unstable patient- A case report

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GIA stapler can be effectively used for rapid non-anatomical resection of the liver in trauma.

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GIA stapler device is an effective, safe, and rapidly deployable tool for managing high grade liver injury.

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The surgical technique for performing stapled resection of liver parenchyma is simple and easy to learn.

Introduction

Liver injury occurs in approximately 5% of all trauma admissions. There are many traditional ways of controlling hemorrhage from the liver and here we report a case in which a GIA 75 stapler was successfully used to manage Grade IV liver injury in a hemodynamically unstable patient.

Presentation of case

45 years old policeman presented in the emergency, after sustaining a gunshot injury to his abdomen. At presentation, he was hemodynamically unstable and had a single entry wound in the epigastrium. He was rushed to the operating room (OR) for exploratory laparotomy which revealed a shattered left lobe of the liver. Gastrointestinal anastomosis 75 stapler device was used for non-anatomical left segmentectomy (segments I and II). Perihepatic packing was done and the patient shifted to the surgical intensive care unit (SICU). He was re-explored within 24 h. No active bleeding was seen after the packs were removed and the abdomen was closed. The next day he was moved out of SICU and was discharged on the 10th day of admission.

Discussion

The concept of damage control surgery rests on quick control of life-threatening bleeding and a GIA stapler can be effectively used for rapid non-anatomical resection of the liver in trauma. This can prevent the depletion of physiological reserves and the life-threatening death triad.

Conclusion

GIA stapler device is an effective, safe, and rapidly deployable tool for managing high-grade liver injury in a hemodynamically unstable patient.

Technical Aspects of Stapled Hepatectomy in Liver Surgery: How We Do It

There are diverse approaches to parenchymal transection and the preferred approach remains controversial among liver surgeons. Stapling devices, which were initially established for vascular control, have been the standard parenchymal transection technique in many departments for more than 15 years. This article describes the technical aspects, tips, and tricks of stapled hepatectomy using right hemihepatectomy as an example. The existing literature on this topic is also reviewed.

Randomized clinical trial of ligasure™ versus conventional splenectomy for injured spleen in blunt abdominal trauma

BACKGROUND

Spleen is the most common organ damaged in cases of blunt abdominal trauma and splenectomy and splenorrhaphy are the main surgical procedures that are used in surgical treatment of such cases. In routine open splenectomy cases, after laparotomy, application of sutures in splenic vasculature is the most widely used procedure to cease the bleeding. This clinical trial evaluates the role and benefits of the Ligasure™ system in traumatic splenectomy without using any suture materials and compares the result with conventional method of splenectomy.

METHODS

After making decision for splenectomy secondary to a blunt abdominal trauma, patients in control group (39) underwent splenectomy using conventional method with silk suture ligation of splenic vasculature. In the interventional group (41) a Ligasure™ vascular sealing system was used for ligating of the splenic vein and artery. The results of operation time, volume of intra-operation bleeding and post-operative complications were compared in both groups.

RESULTS

The mean operation times in control and interventional group were 21 and 12 min respectively (p < 0.05). The average volume of bleeding in control group during open splenectomy was 280 cc, but in the interventional group decreased significantly to 80 ml (p < 0.05) using the Ligasure system. Post-operative complications such as bleeding were non-existent in both groups.

CONCLUSION

The application of Ligasure™ in blunt abdominal trauma for splenectomy not only can decrease the operation time but also can decrease the volume of bleeding during operation without any additional increase in post-operative complications. This method is recommendable in traumatic splenic injuries that require splenectomy in order to control the bleeding as opposed to use of traditional silk sutures.

Transection Speed and Impact on Perioperative Inflammatory Response - A Randomized Controlled Trial Comparing Stapler Hepatectomy and CUSA Resection

Background

Parenchymal transection represents a crucial step during liver surgery and many different techniques have been described so far. Stapler resection is supposed to be faster than CUSA resection. However, whether speed impacts on the inflammatory response in patients undergoing liver resection (LR) remains unclear.

Materials and Methods

This is a randomized controlled trial including 40 patients undergoing anatomical LR. Primary endpoint was transection speed (cm²/min). Secondary endpoints included the perioperative change of pro- and anti-inflammatory cytokines, overall surgery duration, length of hospital stay, morbidity and mortality.

Results

Mean transection speed was significantly higher in patients undergoing stapler hepatectomy compared to CUSA resection (CUSA: 1 (0.4) cm²/min vs. Stapler: 10.8 (6.1) cm²/min; p<0.0001). Analyzing the impact of surgery duration on inflammatory response revealed a significant correlation between IL-6 levels measured at the end of surgery and the overall length of surgery (p<0.0001, r = 0.6188). Patients undergoing CUSA LR had significantly higher increase of interleukin-6 (IL-6) after parenchymal transection compared to patients with stapler hepatectomy in the portal and hepatic veins, respectively (p = 0.028; p = 0.044). C-reactive protein levels on the first post-operative day were significantly lower in the stapler cohort (p = 0.010). There was a trend towards a reduced overall surgery time in patients with stapler LR, especially in the subgroup of patients undergoing minor hepatectomies (p = 0.020).

Conclusions

Liver resection using staplers is fast, safe and suggests a diminished inflammatory response probably due to a decreased parenchymal transection time.

Trial Registration

ClinicalTrials.gov NCT01785212

Pre-resectional inflow vascular control: extrafascial dissection of Glissonean pedicle in liver resections

BACKGROUND/AIMS

We are evaluated technique of anatomic major and minor hepatic resections using suprahilar-extrafascial dissection of Glissonean pedicle with vascular stapling device for transection of hepatic vessels intending to minimize operative time, and blood loss.

METHODOLOGY

We prospectively analyzed the clinical records of 170 patients who underwent hepatic resection by suprahilar-extrafascial pedicle isolation and stapling technique in our clinic for emergency surgery in Belgrade. Patients who underwent hilar extrahepatic intrafascial dissection were excluded from the study.

RESULTS

We performed 102 minor liver resections and 68 major hepatectomies. The minor liver resections were associated with significantly shorter surgery duration (95.1±31.1 vs. 186.6±56.5) and transection time (35.9±14.5 vs. 65.3±17.2) than major hepatectomies (P<0.001 for all). The mean blood loss was 255.6±129.9 mL in minor resection and 385.7±200.1 mL in major resection (P=0.003). The mean blood transfusion requirement was 300.8±99.5 mL for the patients with minor hepatectomy and 450.9±89.6 mL for those with major liver resection (P=0.067). There was no significant difference in morbidity and mortality between the groups (P=0.989; P=0.920). Major as well as minor liver resection were a superior oncologic operation with no significant difference in the 3-year overall survival rates.

CONCLUSIONS

Extrafascial dissection of Glissonean pedicle with vascular stapling represents both an effective and safe surgical technique of anatomical liver resection. Presented approach allows early and easy ischemic delineation of appropriate anatomical liver territory to be removed (hemiliver, section, segment) with selective inflow vascular control. Also, it is not time consuming and it is very useful in re-resection, as well as oncologically reasonable.

Complications following hepatectomy

As the number of liver resections in the United States has increased, operations are more commonly performed on older patients with multiple comorbidities. The advent of effective chemotherapy and techniques such as portal vein embolization, have compounded the number of increasingly complex resections taking up to 75% of healthy livers. Four potentially devastating complications of liver resection include postoperative hemorrhage, venous thromboembolism, bile leak, and post-hepatectomy liver failure. The risk factors and management of these complications are herein explored, stressing the importance of identifying preoperative factors that can decrease the risk for these potentially fatal complications.

Morbidity and mortality in 1,174 patients undergoing hepatic parenchymal transection using a stapler device

BACKGROUND

Transection of liver parenchyma using staplers is now commonly performed. Large studies are needed to assess the usefulness of the technique as well as perioperative outcomes.

METHODS

This is a retrospective study of a prospectively maintained database. A total of 1,174 patients undergoing liver resections in routine surgical practice, using a stapler device at MD Anderson Cancer Center between January 1, 1994 and November 10, 2011 were evaluated.

RESULTS

There were 900 major resections (3 segments or more) (77 %) and 274 minor resections (<3 segments or wedge resections) (23 %). A vast majority, 1,133 (96.5 %), were indicated for an underlying malignancy (24 % primary liver or gall bladder and 72.5 % metastatic) compared with benign disease, 41 (3.5 %), with the most common indication being metastatic colorectal cancer 584 (49.7 %). Of the total 1,174 patients 128 (10.9 %) had a prior liver resection. Median OR time and blood loss was 206 min and 300 mL, respectively, with 11 % of patients requiring transfusion in the perioperative or postoperative period. Overall morbidity and mortality rate was 14 and 3.2 %, respectively, with a median hospital stay of 7 days (interquartile range [IQR], 4 days). Multivariate logistic regression demonstrated blood loss and extent of liver resection to be independent predictors of adverse outcome. A total of 13 instances (1.1 %) of misfired staplers were noted and were associated with higher blood loss (p < 0.001) and mortality (15 vs. 3.1 %, p = 0.013).

CONCLUSIONS

Use of stapler device for hepatic resection is safe and effective, but rare instances of a misfired stapler device are associated with an adverse outcome.

Non-Anatomic Hepatic Resection Using Chang's Needle for Porcelain Gallbladder

We present a simple technique of nonanatomic resection of liver parenchyma for porcelain gallbladder infiltrating gallbladder bed, that is, segments IVb and V of the liver. The resection has been carried out with the use of straight 18-gauge stainless steel multi-use needle designed for hepatic resections (Chang's needle). This simple, safe, and cost-effective technique can be used for nonanatomic liver resections by surgeons less experienced in liver surgery.

Evaluation of stapler hepatectomy during a laparoscopic liver resection

METHODS

An international database of 1499 laparoscopic liver resections was analysed using multivariate and Kaplan-Meier analysis.

RESULTS

In total, 764 stapler hepatectomies (SH) were compared with 735 electrosurgical resections (ER). SH was employed in larger tumours (4.5 versus 3.8 cm; P < 0.003) with decreased operative times (2.6 versus 3.1 h; P < 0.001), blood loss (100 versus 200 cc; P < 0.001) and length of stay (3.0 versus 7.0 days; P < 0.001). SH incurred a trend towards higher complications (16% versus 13%; P = 0.057) including bile leaks (26/764, 3.4% versus 16/735, 2.2%: P = 0.091). To address group homogeneity, a subset analysis of lobar resections confirmed the benefits of SH. Kaplan-Meier analysis in non-cirrhotic and cirrhotic patients confirmed equivalent patient (P = 0.290 and 0.118) and disease-free survival (P = 0.120 and 0.268). Multivariate analysis confirmed the parenchymal transection technique did not increase the risk of cancer recurrence, whereas tumour size, the presence of cirrhosis and concomitant operations did.

CONCLUSIONS

A SH provides several advantages including: diminished blood loss, transfusion requirements and shorter operative times. In spite of the smaller surgical margins in the SH group, equivalent recurrence and survival rates were observed when matched for parenchyma and extent of resection.

Early post-operative prediction of morbidity and mortality after a major liver resection for colorectal metastases

BACKGROUND

An early prediction of poor outcomes is essential in the management of patients after a liver resection. The aim of this study was to evaluate the role of selected biochemical parameters on post-operative day 1 (POD 1) in the prediction of morbidity and mortality after a liver resection for colorectal metastases.

METHOD

This retrospective study was based on 236 major liver resections for colorectal metastases performed between 2006 and 2011. Results of biochemical tests of blood samples obtained on POD 1 were assessed as predictors of primary outcome measures (hepatic and overall morbidity, 90-day mortality) using multiple regression and receiver-operating characteristics (ROC).

RESULTS

Hepatic morbidity, overall morbidity and 90-day mortality rates were 18.6%, 28.0% and 4.7%, respectively. On the basis of multiple regression analysis and comparisons of the prediction models, serum bilirubin was selected for the prediction of hepatic (>2.05 mg/dl, sensitivity 69.2%, specificity 71.2%) and overall (>2.05 mg/dl, sensitivity 61.1% and specificity 71.2%) morbidity, and aspartate aminotransferase (AST) was selected for the prediction of 90-day mortality (>798 U/l, sensitivity 62.5% and specificity 90.4%).

DISCUSSION

Biochemical analyses of blood on POD1 enables stratification of patients into low- and high-risk groups for negative outcomes, with serum bilirubin associated with overall and hepatic morbidity and AST associated with mortality.

Conformational technique for non-anatomic resection of liver lesions

Safe margin-negative hepatic resection with maximal preservation of normal liver parenchyma is the primary operative objective in treating patients with metastatic or primary liver malignancies. A technique to perform non-anatomic liver resection(s) for large lesions that may involve major hepatic vascular structures is herein described. This technique employs linear cutting stapler technology and specific mobilization of the liver to perform single or multiple large spherical resections of liver lesions.

Bile duct leaks from the intrahepatic biliary tree: a review of its etiology, incidence, and management

Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. In addition to posted operative bile leaks, leaks may occur following drainage of liver abscess and tumor ablation. Most bile leaks from the intrahepatic biliary tree are transient and managed conservatively by drainage alone or endoscopic biliary decompression. Selected cases may require reoperation and enteric drainage or liver resection for management.

Surgical Management of Complex Liver Trauma: A Single Liver Transplant Center Experience

Complex liver trauma often presents major diagnostic and management problems. Current operative management is mainly centered on packing, damage control, and early utilization of interventional radiology for angiography and embolization. In this retrospective observational study of patients admitted to the Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy, from 1999 to 2010, we included patients that underwent hepatic resection for complex liver injuries (grade I to Vaccording to the American Association for the Surgery of Trauma-Organ Injury Scale). Age, gender, mechanism of trauma, type of resection, surgical complications, length of hospital stay, and mortality were the variables analyzed. A total of 53 adult patients were admitted with liver injury and 29 underwent surgical treatment; the median age was 26.7 years. Mechanism was blunt in 52 patients. The overall morbidity was 30 per cent, morbidity related to liver resection was 15.3 per cent. Mortality was 2 per cent in the series of patients undergoing liver resection for complex hepatic injury, whereas in the nonoperative group, morbidity was 17 per cent and mortality 2 per cent. Liver resection should be considered a serious surgical option, as initial or delayed management, in patients with complex liver injury and can be accomplished with low mortality and liver-related morbidity when performed in specialized liver surgery/transplant centers.

Clamp-crushing versus stapler hepatectomy for transection of the parenchyma in elective hepatic resection (CRUNSH)--a randomized controlled trial (NCT01049607)

Background

Hepatic resection is still associated with significant morbidity. Although the period of parenchymal transection presents a crucial step during the operation, uncertainty persists regarding the optimal technique of transection. It was the aim of the present randomized controlled trial to evaluate the efficacy and safety of hepatic resection using the technique of stapler hepatectomy compared to the simple clamp-crushing technique.

Methods/Design

The CRUNSH Trial is a prospective randomized controlled single-center trial with a two-group parallel design. Patients scheduled for elective hepatic resection without extrahepatic resection at the Department of General-, Visceral- and Transplantation Surgery, University of Heidelberg are enrolled into the trial and randomized intraoperatively to hepatic resection by the clamp-crushing technique and stapler hepatectomy, respectively. The primary endpoint is total intraoperative blood loss. A set of general and surgical variables are documented as secondary endpoints. Patients and outcome-assessors are blinded for the treatment intervention.

Discussion

The CRUNSH Trial is the first randomized controlled trial to evaluate efficacy and safety of stapler hepatectomy compared to the clamp-crushing technique for parenchymal transection during elective hepatic resection.

Trial Registration

ClinicalTrials.gov: NCT01049607