how to conclude a right hepatectomy sorina cornateanu maximilliano gelli chb-hopital paul-brousse...
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How to conclude a right hepatectomy
Sorina CornateanuMaximilliano Gelli
CHB-Hopital Paul-BrousseACHBT Jeunes, 14.09.2012, Rouen
Introduction
Schneider, Am Coll Surg 2012 (in press)
John Hopkins Hospital Database (1986 – 2005) 9957 pt
Complication rate 34.9%- Postoperative hemorrhage 3.2%- Blood transfusion 11.5%- Re-operation 5.2%- Postoperative infection 2.3% Gastrointestinal complications 6.3% Cardiac complications 3.2%
Mortality 7.3%Mortality according to the type of liver resection:
1. extended right hepatectomy 8.7%2. right hepatectomy 6.6%… Segmentectomy 1.8%
« Standard » procedureFixation of remnant liver
Doppler US control
Portal inflow evaluation
Hemostatic break
Methilen blue dye test
Biological glue
Drainage
Continuous wound analgesic instillation
Remnant liver rotation
Poon, Hepatogastroenterology 1998Belghiti, Br J Surg 1992
Impairment of venous outflow could be underestimated after right liver resection
Fixing the liver whether the triangular ligament has been divided or not and whatever the extent of the right hepatectomy
Ogata, Br J Surg 2005
Remnant liver rotation
Wang, J Gastrointest Surg 2010
Di Domenico, Abdomin Imaging 2012
Macroscopic hepatic venous congestion
Biological cholestasisJaundice,Ascites Lower extremity oedema
Control of vascular elements by US
Left and Middle Hepatic Vein- Doppler trifasic waveforms in both HVs - Good velocity - Absence of HV thrombusHigh risk: exposure of HV > 3 cm along transection plane
Arita, Surgery 2007
Left Portal Vein - Portal flow direction and velocity -Regular laminary flow
Left branch of Hepatic Artery- Systolic peak
Advantages: Readily available and inexpensive tool Fast Reproducible Objective data ++
Intraoperative CEUS
Portal inflow evaluation
TransplantationPortal hyperperfusion is correlated with poor postoperative outcomes:
- SFSS - Vascular complications- Graft regeneration impairment
Troisi, Ann Surg 2003 Eguchi, Liver Transp 2003 Fan, Liver Transp 2011
Hori, Transp 2012
Portal Flow Modulation
- PF > 250 ml/100 gr GW- PP > 20 mmHg
Different procedures:-Splenic Artery ligation/embolization-Splenectomy- Portosystemicshunts
PP < 15 mmHg
277 patients Paul BroussePostoperative liver failure
Post hepatectomy Portal Pressure
Probability of Post-Hepatectomy Liver Failure
≥ 16 mmHg 8%≥ 18 mmHg 11%≥ 20 mmHg 14%≥ 22 mmHg 16%≥ 26 mmHg 20%≥ 30 mmHg 27%≥ 34 mmHg 36%
Allard MA, Vibert E. et al. Submitted
Oncological surgery
SOS and CASH increase morbidity and liver failure
Prolonged preoperative chemotherapy increases the risk of hepatic injury and morbidity
Narita, Surg Today 2011 Karoui, Ann Surg 2006 Chun, Lancet Oncol 2009
Portal inflow evaluation
Experimental data
Michaloupulos, AJP 2010 Marubashy Surgery 2004
Portal inflow evaluation
Oncological surgery Cirrhotic liver
Transplantation
Experimental Data
Hemostatic Break
…No scientific data
Key points:1. biliary leakage2. symptomatic fluid collections
But..3. ascending intraabdominal infection
Abdominal drainage
4 RCT in elective liver surgery
Abdominal drainage
- sample size and incidence of events- definition of biliary fistula and leakage- duration of drainage < 7 POD
Limits
Abdominal drainage
Makuuchi, J Hepatobiliary Pancreat Sci 2010
Routine and systematic protocol of drainage management
Complications Retention or Drainage salvage technique
Percutaneous procedure
Reoperation
Biliary leakage 8.6 % 77 % 10 % 12 %
Fluid collection 5.1 % 31 % 38 % 31 %
Abdominal drainage
Tanaka, Surg Today 2012
Biliary concentration drainageBiliary concentration serum
X Volume of drainage fluid at POD 2
< 200Ablation at POD 2
> 200Ablation at POD 4
Continuous wound analgesic instillation
Chan, Anesthesia 2010
ConclusionsSystematic Fixation of remnant liver YES
Doppler US control YES
Portal inflow evaluation YES
Hemostatic break ???
Drainage ???
Continuous wound analgesic instillation YES
Thank you…