Related Literature

J Gastrointest Surg. 2003 Sep-Oct;7(6):797-801

Radiofrequency-assisted liver resection.

Stella M, Percivale A, Pasqualini M, Profeti A, Gandolfo N, Serafini G, Pellicci R.
Department of Surgery, Santa Corona Hospital, Pietra Ligure, Savona, Italy.

Radiofrequency (RF)-assisted thermal ablation has been used with increasing frequency for unresectable hepatic tumors. This new approach employs RF energy to coagulate the liver at the hepatic resection line after which hepatic resection is performed with the use of a common scalpel. This procedure was used in three patients with hepatocellular carcinoma and in five patients with colorectal metastasis to the liver. These eight patients underwent a total of two left bisegmentectomies, three segmentectomies, and seven wedge resections. Mean operative time was 220 minutes. A mean of 78 sessions of RF-assisted ablation were required for these resections. Mean blood loss was 46 ml; no device other than RF ablation was required to obtain hemostasis. None of the patients needed a blood transfusion. Preoperative hemoglobin was 12.8 gm/dl and postoperative hemoglobin was 11.3 gm/dl. There were no perioperative deaths. Postoperative complications occurred in two patients: a liver abscess in one and heart failure in the other. The mean hospital stay was 9.4 days. This new approach, integrated with other techniques, reduces blood loss and coagulates the margins of resection during liver surgery. This new technique has two limitations: (1) it cannot be applied near main portal pedicles, and (2) it requires a long operative time. The best indication for this technique is when segmentectomy is required in patients with cirrhosis. Its role in major hepatic resections has yet to be determined. Further progress in the development of thermal ablation techniques and experience gained during the learning curve should help reduce the operative time, thereby improving the safety and efficacy of this procedure.

J Surg Oncol. 1998 Oct;69(2):88-93

Results of 136 curative hepatectomies with a safety margin of less than 10 mm for colorectal metastases.

Elias D, Cavalcanti A, Sabourin JC, Pignon JP, Ducreux M, Lasser P.
Department of Oncologic Surgery, Institut Gustave Roussy, Comprehensive Cancer Centre, Villejuif, France. elias@igr.fr

BACKGROUND AND OBJECTIVES: It is now established that liver resection is beneficial for metastases from colorectal cancer. Nevertheless, a surgical margin estimated at less than 10 mm at preoperative imaging is considered an absolute contraindication to surgery by some, and a relative contraindication by others. The true impact of the width of the margin on the prognosis is unclear. METHODS: From 1984 to 1996, 196 patients underwent curative hepatectomy for liver metastases and were studied prospectively. Surgery was to be curative (or a complete R0 resection) and mortality was to be avoided. Of these 196 patients, 136 had surgical margins of less than 10 mm. Sixty-eight percent had multiple liver metastases and 15% had extrahepatic metastatic lesions. Clinical and pathological factors were studied specifically and a multivariate analysis was carried out.
RESULTS: Overall 5-year survival rate of these 136 patients (taking into account postoperative mortality which attained 1.5%) was 27.8% and the disease-free survival was 22.9%. The surgical margin was 0 mm in 30 cases. The sole prognostic factor was the discovery of unsuspected (resectable) extrahepatic lesions at laparotomy (P < 0.001) ; the width of the free margin had no significant effect. However, in the multivariate analysis of prognostic factors for the entire series (269 hepatectomies), three powerful parameters were identified : (1) the curative nature of resection (P = 0.0007), (2) less than 20% of liver involvement (P = 0.002), and (3) a free margin exceeding 9 mm (P = 0.02). A correlation was found between narrow margins and extensive disease (high number of metastases, bilateral sites, and extended hepatectomy). There was also a greater likelihood of microscopic satellite lesions within 10 mm around the metastases.
CONCLUSIONS: The prognostic impact of the width of the surgical margin should not be overestimated. Hepatectomy for liver metastases can procure long-term survival, even in patients with supposedly poor prognostic factors. Resection is justified as long as it is complete and the risks are minimal.

Eur J Surg Oncol. 1995 Apr;21(2):183-7.

A comparison of different techniques for liver resection: blunt dissection, ultrasonic aspirator and jet-cutter.

Rau HG, Schardey HM, Buttler E, Reuter C, Cohnert TU, Schildberg FW.
Surgical Department, University Hospital Grosshadern, Munich, Germany.

In a prospective study 116 patients underwent liver resection. Three different resection techniques, blunt dissection (n = 61), ultrasonic aspirator (CUSA) (n = 27) and jet-cutter (n = 28) were compared. Speed of resection, blood loss, transfusion rate, liver hilus clamping time and tissue damage were evaluated on the basis of area of transected liver surface. Liver resection with the jet-cutter was significantly faster with a resection time of 0.33 min/cm2 in comparison to blunt dissection (0.57 min/cm2) and CUSA (0.50 min/cm2) (P < 0.01) and associated with lower blood loss of 17.7 ml/cm2 (P < 0.01) than the other techniques (blunt dissection 32.5 ml/cm2, CUSA 24.3 ml/cm2). Tissue damage with respect to transaminases SGOT and SGPT was comparable to the other techniques. The jet-cutter is a promising new instrument in liver surgery.

Am J Surg. 2003 Aug;186(2):164-6.

How we do a bloodless partial splenectomy.

Habib NA, Spalding D, Navarra G, Nicholls J.
Department of Gastrointestinal Surgery, Hammersmith Hospitals NHS Trust, Du Cane Rd., London W12 0HS, United Kingdom. nagy.habib@ic.ac.uk

Partial splenectomy and Tru-cut biopsy are not routinely practiced because of the lack of vascular control to arrest bleeding. Using radiofrequency energy to coagulate the resection margin and biopsy tract, a 74-year-old woman with a tumor in the lower pole of the spleen underwent partial splenectomy and Tru-Cut biopsy of the spleen. Hemostasis was excellent. Blood loss was minimal and the patient was discharged with a functioning spleen. This new technique may allow safe and bloodless partial splenic resection and Tru-cut biopsy of the spleen, which might reduce the number of splenectomies performed and the consequent difficulties for the patient that can arise.

Arch Surg. 1994 Oct;129(10):1050-6.

One hundred consecutive hepatic resections. Blood loss, transfusion, and operative technique.

Cunningham JD, Fong Y, Shriver C, Melendez J, Marx WL, Blumgart LH.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.

BACKGROUND: Hepatic resection is prone to significant blood loss. Adverse effects of blood loss and transfusion mandate improvements in surgical techniques to reduce blood loss and transfusion requirements.
METHODS: One hundred hepatic resections were carried out using a standard surgical technique that includes control of the hilar structures, extrahepatic control of the hepatic veins, and use of the Pringle maneuver. Low central venous pressure and Trendelenburg positioning were used during parenchymal transection. Data were collected retrospectively in the first 36 patients, whereas data were collected prospectively in the remaining 64 patients.
RESULTS: Hospital mortality was 3%. Median blood loss was 450, 700, 1000, 1100, and 1500 mL for segmental, nonanatomic, lobar, extended right, and extended left resections, respectively. Major resections were more likely than minor resections to be transfused with albumin (P = .008), fresh frozen plasma (P = .009), and packed red blood cells or whole blood (P = .04). Overall transfusion of packed red blood cells or whole blood occurred in 59 of 100 patients. In the 64 patients who were followed up prospectively, the predeposit of autologous blood decreased the need for homologous transfusions from 56% to 38%. A further reduction in the transfusion rate of 25% could have been possible if all patients in the prospective group had donated 2 U of autologous blood. Patients who predeposited blood were more likely to receive transfusions and to have had a transfusion more than 24 hours after surgery than were patients who did not donate blood.
CONCLUSIONS: The surgical techniques used results in acceptable blood loss and transfusion requirements for hepatic resection. This approach is safe, cost-effective, reproducible, and applicable for widespread use.

Br J Surg. 1995 Aug;82(8):1105-10.

Liver resection without blood transfusion.

Gozzetti G, Mazziotti A, Grazi GL, Jovine E, Gallucci A, Gruttadauria S, Frena A, Morganti M, Ercolani G, Masetti M, et al.
Second Department of Surgery, University of Bologna, Italy.

A retrospective study was carried out of 522 elective liver resections to determine the impact of blood transfusion on the immediate postoperative outcome and on long-term survival. The number of liver resections without transfusion has increased in recent years, as a result of improvement in surgical technique with less blood loss during operation and more careful choice of the timing of transfusion. In resections carried out in the past 5 years, the indication for intraoperative transfusion was restricted and the decision was made jointly by the surgeon and anaesthetist, and in any case only if the haematocrit was below 25 per cent. Of resections carried out in the past 2 years, 59 per cent did not require intraoperative transfusion. Postoperative deaths and complications were related to blood transfusion, particularly in patients with cirrhosis, in whom stepwise logistic regression analysis showed that transfusion was the only factor that correlated significantly with complications. Transfusion also affected the long-term survival of patients operated on for hepatocellular carcinoma and colorectal carcinoma metastases in univariate analysis and was the only factor shown by multivariate analysis to correlate with survival for hepatocellular carcinoma in patients with cirrhosis.

Br J Surg. 1996 Nov;83(11):1526-9.

One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery.

Rees M, Plant G, Wells J, Bygrave S.
Hepatobiliary Unit, North Hampshire Hospital, Basingstoke, UK.

A technique of hepatic resection is described and the results of 150 resections are reviewed. Hepatic transection was performed, under intermittent portal inflow occlusion, using ultrasonic aspiration to skeletonize portal branches and venous tributaries. Control of venous haemorrhage during resection was optimized by argon beam coagulation and lowering central venous pressure to between 0 and 4 cmH2O by extradural blockade and systemic nitroglycerine infusion. One patient with jaundice died in hospital, giving a mortality rate of 0.7 per cent. There were no deaths in patients without jaundice and cirrhosis. Fifteen patients (10.0 per cent) had significant complications, nine medical and six surgical, including three bile leaks (2.0 per cent). Mean blood loss was 814 ml for the whole study but only 434 ml in the last 4 years. During this latter period mean blood transfusion in hospital was 0.5 units and mean postoperative haemoglobin value fell by 0.7 g per 100 ml. Hepatic resection can be performed with the same degree of confidence and similar low morbidity as any other major surgical procedure.

Br J Surg. 1998 Aug;85(8):1058-60.

Central venous pressure and its effect on blood loss during liver resection.

Jones RM, Moulton CE, Hardy KJ.
University of Melbourne Department of Surgery, Victoria, Australia.

BACKGROUND: Any strategy to reduce blood loss in liver resection and decrease blood transfusion would be of benefit to the patient and surgeon. This study evaluates the association of central venous pressure (CVP) with blood loss and blood transfusion during liver resection
METHODS: One hundred consecutive hepatic resections in the period 1986-1996 were studied prospectively concerning CVP, volume of blood lost, and volume of blood transfused. Blood loss volume and blood transfusion were analysed for those with a CVP less than or equal to 5 cmH2O, and greater than 5 cmH2O. A multivariate analysis assessed potential confounding factors in the comparison.
RESULTS: The median blood loss in patients with a CVP of 5 cmH2O or less was 200 ml (n=40) and that in those with a CVP above 5 cmH2O was 1000 ml (n=52) (P=0.0001). Only two of 40 patients with a CVP of 5 cmH2O or less had a blood transfusion whereas 25 of 52 patients with a CVP greater than 5 cmH2O required a transfusion (P=0.0008). A multivariate analysis did not show confounding factors.
CONCLUSION: The volume of blood lost during liver resection correlates with the CVP. Lowering the CVP to less than 5 cmH2O is a simple and effective way to reduce blood loss during liver surgery.

Colon Rectum. 1990 May;33(5):408-13

Morbidity and mortality of hepatic resection for metastatic colorectal carcinoma.

Vetto JT, Hughes KS, Rosenstein R, Sugarbaker PH.
Department of Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts 01805.

Hepatic resection is the only curative therapy currently available for colorectal cancer metastases to the liver. However, concern over high morbidity and mortality of the procedure has limited referral of patients for resection. The authors report on 58 patients undergoing hepatic resection for colorectal metastases at the National Cancer Institute between the years 1976 and 1985. Thirty-two patients underwent a major hepatic resection, and 26 patients underwent one or more wedge resections. Mean anesthesia time was 448 minutes, mean estimated blood loss was 3663 ml, and mean hospital stay was 17.5 days. Operative mortality was 3 percent, and morbidity was 62 percent. Using a grading scale for complications, 24 percent of patients had inconsequential complications, 16 percent had moderate complications, and 19 percent had severe complications. Complications were clearly related to extent of procedure. Factors that correlated best with morbidity were high blood loss and trisegmentectomy. The authors conclude that while hepatic resection can carry a high morbidity, much of this morbidity is minor and operative mortality is low. Recent improvements in anesthesia, improved resection technique, and a better understanding of hepatic anatomy have made possible correspondingly lower morbidity and mortality rates. Careful selection of patients can make hepatic resection a safe procedure.

Ann Surg. 1994 Jan;219(1):13-7

Perioperative predictors of morbidity following hepatic resection for neoplasm. A multivariate analysis of a single surgeon experience with 105 patients.

Sitzmann JV, Greene PS.
Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.

OBJECTIVE: Factors that predict mortality or morbidity risk in consecutive hepatic resections for neoplasm were examined, with controlled variables of surgical technique and experience. SUMMARY BACKGROUND DATA: Hepatic resection has become the therapy of choice for the management of metastatic or primary neoplasms of the liver. Although mortality for this procedure has steadily decreased, associated morbidity remains high.
METHODS: One hundred five patients undergoing hepatic resection for malignancy over a 4-year period by a single surgeon to identify preoperative, intraoperative, or postoperative predictors of morbid outcomes were studied. Variables were analyzed using multiple regression in a stepwise, logistic model.
RESULTS: Sixty-day hospital mortality was 2.8%, with morbidity occurring in 33%. A significant preoperative predictor of morbidity was serum bilirubin (p > 0.005). Notably, preoperative renal function, or medical illness, did not increase morbid risk. Operative variables increasing risk included extent of resection, blood loss, and operative time (p > 0.005).
CONCLUSIONS: Complex hepatic resection can be performed with low mortality, and serum bilirubin