Outcomes of Hepatic Resection Using Intermittent Hepatic Vascular Inflow Occlusion with Low Central Venous Pressure / 한국간담췌외과학회지

PURPOSE: Blood loss and transfusions during a liver resection are associated with higher morbidity and mortality rates. With applying hepatic vascular inflow occlusion (Pringle maneuver), persistent bleeding during a hepatic transection is caused by back flow from the hepatic veins. Therefore, low central venous pressure facilitates to reduce-bleeding from the hepatic veins by lowering the back flow pressure gradient. An intermittent hepatic vascular inflow occlusion was applied, with a lowering of the central venous pressure, during a hepatic resection in our series of patient. The effect of these maneuvers in reducing bleeding and the postoperative complication rates were analyzed. METHODS: Between December 2000 and September 2003, in 153 hepatic resection patients, where this technique was used, the intermittent vascular inflow occlusion and maintenance of the central venous pressure as low as possible were accrued in this study. The overall outcomes of patients that had a hepatic resection, focusing on the amount of bleeding, blood product transfusion and complication rates, were analyzed. RESULTS: The median blood loss was 652.5 ml, and 111 patients (72.5%) required no perioperative blood transfusion. The median units of blood required in the patients who needed a transfusion were 2.3 U. There was no evidence of renal derangement related with low blood flow into the kidney by keeping central venous pressure as low as possible. There were minor complications in 34 patients (22.4%) and two in-hospital mortalities (1.3%) associated with hepatic failure in cirrhotics. CONCLUSION: A hepatic resection, with an intermittent Pringle maneuver and a low central venous pressure, is a very simple and effective modality to reduce bleeding during a hepatic transection, with low morbidity and mortality rates and without hepatic and renal dysfunctions.

Surgical Treatment of Pancreatitis

PURPOSE: The most common cause of acute pancreatitis is alcohol abuse, followed by gallstones and pancreatic trauma. Pancreatitis is treated nonoperatively by inhibiting the causes, which include prohibition of alcohol abuse and cholecystectomy for the removal of gallstones. However, in case of a pseudocyst formation, necrotizing pancreatitis or abscesses remained as the complications of severe pancreatitis. Adequate surgical drainage is very important for the treatment of the complications. Adequate surgical procedure for treatment of chronic pancreatitis, causing intractable pain, pseudocyst, and obstruction of pancreatic or bile ducts, should be considered, not only for the patients physical and psychological recovery from a chronically debilitating status, but also in its differentiation from a malignancy. METHODS: Between July 1997 and January 2002, a review and analysis was undertaken of 33 pancreatitis patients, who had been treated, by surgical intervention, for the complications of acute pancreatitis, chronic pancreatitis, and benign pancreatic disease. RESULTS: For the treatment of the various complications in the 33 patients, 20 drainage procedures and 13 surgical resections were used. There were minor complications in 6 patients (21%), and two mortalities, one from multiple organ failure, due to necrotizing pancreatitis, and the other from a surgical complication, due to a duodenum preserving pancreatic head resection. CONCLUSION: The timely surgical drainage, and/or debridement, is critical for patients with complications due to acute pancreatitis. It is difficult to differentiate chronic pancreatitis from a malignancy. Adequate surgical procedures for the different stati ('type oriented surgery') are required for chronic pancreatitis. A resection of cystic lesions, with the possibility of a malignancy, should be considered. We can confirm the diagnosis, and treat the disease, by adequate operative and drainage procedures, or by resection of the main lesion.