Abstract
Background/Purpose
In major hepatectomies, postoperative increases in central venous pressure (CVP) may cause suture failure and massive bleeding. The aim of our study is to test the application of an intraoperative maneuver to reduce the risk of postoperative bleeding.
Methods
Our study included 172 consecutive patients who had major liver resection with selective hepatic vascular exclusion and sharp transection of the liver parenchyma. An intraoperative maneuver (5 s occlusion of the hepatic vein) was applied in an alternating way, and the patients were assigned to two groups: Cohort A (n = 86), that was granted the maneuver, and Cohort B (n = 86), that was used as a control group.
Results
In Cohort A, application of the maneuver was successful in demonstrating bleeders under low CVP levels. Cohort A had lower rate of massive bleeding requiring emergency reoperation (2.3 vs 5.8%, P = 0.049), less postoperative blood transfusions (13 vs 24%, P = 0.042), lower morbidity (20 vs 35%, P < 0.045) and shorter hospital stay compared to Cohort B.
Conclusions
Hepatectomies conducted under low CVP are prone to postoperative hemorrhage which can be prevented if the final bleeding control is performed under high pressure in the hepatic veins. Application of our testing maneuver effectively unmasked previously undetectable bleeding veins.
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References
Gozzetti G, Mazziotti A, Grazi GL, Gozzetti G, Mazziotti A, Grazi GL, et al. Liver resection without blood transfusion. Br J Surg. 1995;82:1105–10.
Yamamoto J, Kosuge T, Takayama T, Shimada K, Yamasaki S, Ozaki H, et al. Perioperative blood transfusion promotes recurrence of hepatocellular carcinoma after hepatectomy. Surgery. 1994;115:303–9.
Shimada M, Matsumata T, Akazawa K, Kamakura T, Itasaka H, Sugimachi K, et al. Estimation of risk of major complications after hepatic resection. Am J Surg. 1994;167:339–403.
Gurusamy KS, Kumar Y, Sharma D, Davidson BR. Methods of vascular occlusion for elective liver resections. Cochrane Database Syst Rev. 2007;17:CD006409.
Petrowsky H, McCoramack L, Trujillo M, Selzner M, Jochum W, Clavien PA. A prospective, randomized, controlled trial comparing intermittent portal triad clamping versus ischemic preconditioning with continuous clamping for major liver resection. Ann Surg. 2006;244:921–8. discussion 928-930.
Smyrniotis V, Arkadopoulos N, Kostopanagiotou G, Farantos C, Vassiliou J, Contis J, et al. Sharp liver transection versus clamp crushing technique in liver resections: a prospective study. Surgery. 2005;137(3):306–11.
Hansen P, Isla A, Habib N. Liver resection using total vascular exclusion, scalpel division of the parenchyma and a simple compression technique for hemostasis and biliary control. J Gastrointest Surg. 1999;3:537–42.
Zhou W, Li A, Pan Z, Fu S, Yang Y, Tang L, et al. Selective hepatic vascular exclusion and Pringle maneuver: A comparative study in liver resection. Eur J Surg Oncol. 2008;34:49–54.
Smyrniotis V, Kostopanagiotou G, Contis J, Farantos CI, Voros DC, Kannas DC, et al. Selective hepatic vascular exclusion versus Pringle maneuver in major liver resections: prospective study. World J Surg. 2003;27:765–9.
van Gulik TM, de Graaf W, Dinant S, Busch OR, Gouma DJ. Vascular occlusion techniques during liver resection. Dig Surg. 2007;24:274–81.
Smyrniotis V, Kostopanagiotou G, Theodoraki K, Tsantoulas D, Contis JC. The role of central venous pressure and type of vascular control in blood loss during major liver resections. Am J Surg. 2004;187:398–402.
Eid EA, Sheta SA, Mansour A. Low central venous pressure anesthesia in major hepatic resection. Middle East J Anesthesiol. 2005;18:367–77.
Melendez JA, Arslan V, Fischer ME, Wuest D, Jarnagin WR, Fong Y, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion and the risk of postoperative renal dysfunction. J Am Coll Surg. 1998;187:620–5.
Wang WP, Liang LJ, Huang XQ. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol. 2006;12:935–9.
Chen H, Merchant NB, Didolkas MS. Hepatic resection using intermittent vascular occlusion and low central venous pressure anesthesia improves morbidity and mortality. J Gastrointest Surg. 2000;4:162–7.
Torzilli G, Palmisano A, Del Fabbro D, Marconi M, Donadon M, Spinelli A, et al. Contrast-enhanced intraoperative ultrasonography during surgery for hepatocellular carcinoma in liver cirrhosis: is it useful or useless? A prospective cohort study of our experience. Ann Surg Oncol. 2007;14:1347–55.
Luck AJ, Maddern GJ. Intraoperative abdominal ultrasonography. Br J Surg. 1999;86:5–16.
Acknowledgment
The authors wish to thank Panayota Dimitrakopoulou, ICU nurse, for her contribution in data collection.
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Vassiliou, I., Arkadopoulos, N., Stafyla, V. et al. The introduction of a simple maneuver to reduce the risk of postoperative bleeding after major hepatectomies. J Hepatobiliary Pancreat Surg 16, 552–556 (2009). https://doi.org/10.1007/s00534-009-0100-z
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DOI: https://doi.org/10.1007/s00534-009-0100-z