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Objective To compare the effect of selective hepatic vascular exclsion ( SHVE) and total hepatic vascular exclusion ( THVE ) in the treatment of hepatic trauma with major hepatic vein injury. Methods A retrospective case control study was conducted to analyze the clinical data of 42 patients with hepatic trauma accompanied by hepatic vein injury admitted to multiple centers from April 2000 to December 2017. There were 30 males and 12 females, aged 14-65 years [(40. 2 ± 18. 8)years]. Blood flow exclusion was operated through HVE in 22 patients ( SHVE group ) and through THVE in 20 patients (THVE group). SHVE group included 22 patients (16 males and six females), aged (40. 1 ±19. 4)years. There were 10 patients with grade IV and 12 with grade V according to American Association of Traumatic Surgery ( AAST) classification of liver injury. In terms of the hepatic vein injury, there were 13 patients with type I, eight with type III, and one with type IV. THVE group included 20 patients (14 males and six females), aged (39.9 ±18.2)years. There were nine patients with grade IV and 11 with grade V according to AAST classification of liver injury. In terms of the hepatic vein injury, there were 11 patients with type I, seven with type III, and two with type IV. The operation approach, operation time, hepatic warm ischemia time, blocking time of hepatic vein blood flow, amount of abdominal hemorrhage, intraoperative blood loss, postoperative blood loss, intraoperative infusion, total blood transfusion, length of ICU stay after operation, length of hospital stay after operation, function of liver and kidney after operation, incidence of complications and mortality were compared between the two groups. Results There were no significant differences in the amount of abdominal hemorrhage, intraoperative blood loss, postoperative blood loss, perioperative blood transfusion, surgical procedure, and postoperative liver and kidney function between the two groups (P>0. 05). The THVE group had significantly longer operation time, hepatic warm ischemia time, hepatic venous blood flow blocking time, postoperative ICU time and postoperative hospital stay than the SHVE group (P<0. 05). The amount of infusion in the SHVE group was less than that in the THVE group (P <0. 05). The incidence of complications in SHVE group was 27％ (6/22), lower than that in THVE group [60％ (12/20)] (P<0. 05). The mortality of SHVE group was 14％ (3/22), lower than that of THVE group [45％ (9/20)] (P<0. 05). Conclusions SHVE and THVE can effectively control bleeding in the treatment of hepatic trauma with main hepatic vein injury. SHVE has more advantages over THVE in shortening operation time, warm ischemia time of liver, blocking time of hepatic vein blood flow, ICU stay after operation, hospital stay after operation and reducing intraoperative infusion volume, and can reduce the incidence of complications and mortality.
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The bleeding in liver resection is an important factor influencing the operation risk and postoperative out comes.Hepatic vascular exclusion technique is an effective method to control the bleeding,which has been improved after being widely used in clinical practice.In this paper,the research progress on the clinical application of various kinds of hepatic vascular exclusion techniques was reviewed.
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One hundred and ten patients with primary hepatocellular carcinoma underwent hepatectomy from 2005 to 2010.Different methods of hepatic exclusion were applied in the surgery,including 54 patients with total hepatic vascular exclusion,22 with half hepatic vascular exclusion and 34 with regional hepatic vascular exclusion.The recovery of postoperative liver function was retrospectively analyzed.The results showed that the postoperative liver function of regional hepatic vascular exclusion [ALT(311 ± 80) U/L,total bilirubin (TB) (22.2 ± 8.3) μmoL/L at 1 st day and ALT (58 ± 17) U/L,TB (11.3 ± 3.1)μmol/L at 7th day] was better than that of total hepatic vascular exclusion [ALT(874 ±299)U/L,TB (42.9± 19.1) μmol/L at 1st day (P＜0.05) and ALT (108-±52)U/L,TB (14.6±9.2) μmol/L at 7th day] (P ＜ 0.05,＞ 0.05),indicating that regional hepatic vascular exclusion can effectively reduce hepatic injury during the operation and promote recovery of liver function after operation.
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ObjectiveTo study the proper timing for radical hepatectomy after tumour-down-staging with transcatheter arterial chemoembolization for unresectable primary liver cancer.Method This is a retrospective study of 18 patients with unresectable primary liver cancer who received radical liver resection after tumour-downstaging with transcatheter arterial chemoembolization (TACE) from January 2005 to August 2010 at Zhejiang Province People's Hospital Hepatobiliary Surgery Department.The patients received TACE 1 to 3 times (once n=4,twice n=12,and thrice n=2).After tumour-downstaging,radical liver resection was carried out (right hepatectomy,n =10 ; resection of tumour in right liver + resection of right liver metastases,n=2; resection of tumnour in right liver +radiofrequency ablation of right liver metastasis,n=1; right hepatectomy + removal of portal vein tumour thrombus,n=1 ; left hepatectomy + radiofrequency ablation of right liver metastases,n=2 ;Mesohepatectomy,n=1; and left hepatectomy + excision of liver metastasis,n=1).ResultsAfter TACE,the diameter of the primary tumour reduced by over 30％ in 6 patients (6/18,33.3％);10％～30％ in 8 patients (8/18,44.4％),and 10％ in 4 patients (4/18,22.2％).Before TACE,the tumours were not encapsulated in 6 patients (33.3％).After TACE,only 1 patient (5.6％) had the tumour remained unencapsulated.After TACE in 6 patients,the primary tumour shrunk to be within a hemiliver,and ultrasound and CT showed the tumours to have defined borders and they were away from the porta hepatis and major blood vessels.In another 6 patients,there were metastases to the contralateral hemilivers but these tumours had all shrunk in size.Selective vascular inflow and outflow occlusion technique was routinely used for liver resection.ConclusionFor primary liver cancers which are not resectable,TACE should be used first.When the tumours shrink in size,radical resectional surgery should be performed as soon as possible.The surgical technique should follow the following principles:-preserve as much normal liver parenchyma as possible,use selective vascular inflow and outflow occlusion technique to avoid ischaemia/reperfusion injury to the remnant liver,and to reduce haemorrhage.The surgery should be carried out by experienced surgeon.
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Objective To explore the clinical value of total hemihepatic vascular exclusion (THHVE) in right hepatectomy for hepatocellular carcinoma (HCC). Methods One hundred and twenty-three consecutive patients who underwent right hepatectomy for HCC between February 2006 and December 2008 were studied retrospectively. THHVE was used in 58 patients (group A) and Pringle maneuver in 65 patients (group B). The patient's demographics,surgical procedure and outcome were collected and compared between the two groups.ResultsThe tumor size was significantly bigger in group A than group B (7.69±3.70 cm vs.6.08±4.07 cm,P＜0.05).The vascular occlusion time in group A was significantly longer than groupB (28.55±8.67 min vs.19.85±6.71 min,P＜0.05). However, intraoperative blood loss in group A was significantly less than group B (304.31±270.36 ml vs.542.62±876.84 ml,P＜0.05),and the elevation of serum alanine aminotransferase (ALT) on day- 1,-3 and- 7 after operation in group A were significantly lower than group B (P＜0.05).The postoperative complication rate in group A was lower than group B (18.97％ vs.38.46％,P＜0.05).ConclusionTHHVE was a safe and efficacious technique in right hepatectomy for HCC.It significantly decreased blood loss,alleviated liver injury and reduced postoperative morbidity and mortality.
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Objective To sum up experience and lessons learnt from liver separation in two thoracoventropagus twins. Method By preoperative imaging it was verified that the two twins of thoracoventropagus named as AB and CD respectively having independent portal hepatic system and the digestive tract.Intraoperatively a separation line was delineated between the porta hepatis,the second porta hepatis.Liver parenchyma of the AB conjoined twin was separated under local blood control with both sides of the seperation line.Intraoperative bleeding was about 10ml,liver rough surface was suctured together,after ligation or suturing of blood vessels and bile ducts.The livers of CD conjoined twin were separated with blocking the first hepatic hilum firstly,and partial hepatic vascular exclusion secondly by part of the liver pressed with finger.There was intraoperative bleeding of about 200 ml. Results The two cases of conjoined twins were separated successfully,and there was no bile leakage,liver failure and infection.A and B are alive and well.D died of lung infection 78 days later.C died of lung and cavitas thoracis infection 9 months later. Conclusion Liver separation is feasible in a thoracoventropagus with independent porta hepatis system.Partial blocking of hepatic vasculature occlusion,in stead of portal triad clamping is preferred.During the separation of hepatic parenchyma finger press for the control of local hepatic blood flow is not always reliable.
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It is important to reduce blood loss and protect the function of reserved liver during hepatectomy.Selective hepatic vascular occlusion can keep the blood supply of reserved liver and make blood loss less than other methods of blood occlusion, so it helps more to the recovery of liver function.In summary, promotion and application of this technology is worth while.This article reviews the developing progress and the latest studies of selective hepatic blood occlusion to introduce the latest advancement in this area.
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Objective To study hepatic blood flow exclusion for the resection of liver tumors involving hepatic hilar region. Methods The clinical data of 16 cases of liver tumors involving hepatic hilar region from January 2005 to March 2008 were retrospectively analyzed. Liver tumors were resected by the technique combining hepatic portal control ( Pringle's maneuver) and normothermie total hepatic vascular exclusion (NHVE). The relation of liver tumors to major vessels, episodes and durations of hepatic blood flow exclusion, intraoperative blood loss and blood transfusion, postoperative complications were analyzed. Results The technique combining Pringle's maneuver and NHVE was used in 16 cases. The mean episodes and durations of Pringle's maneuver were (3.8±1.6) min and (46.6±28.8) min, respectively. The mean episodes and durations of NHVE were (1.6±0.4) min and (23.5±8.2) min, respectively. The mean amount of intraoperativ blood loss was (1250±320) ml, blood transfusion (860±245) ml. Major hepatic vessel injuried were repaired intraoperatively including inferior vena cave in 4 cases, main hepatic veins in 2 cases and portal veins in 2 cases. The serum alanine transaminase(ALT) and bilirubin raised in different degrees after operation, and recovered gradually to normal level. There was no postoperative mortality and serious postoperative complications. Conclusions Alternative use of hepatic blood flow exclusion combining Pringle maneuver and NHVE reduces the time of total hepatic vascular exclusion, improves safety for resection of liver tumors involving hepatic hilar region.
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Objective To improve the resection rate of central type hepatoma. Method Under selective exclusion of hepatic blood flow and the use of caritational ultrasonic surgical aspiration (CUSA), hepatectomy of central hepatic segments was performed for liver tumors. Result There were 46 cases in this group. Preoperative hepatic function was Child A in 43 cases and Child B in 3 cases. Regional entire bloodstream was excluded ranging from 8 to 33 minutes in 39 cases, Intraoperative blood loss was 100 to 2400 ml,the average was 490 ml. Postoperative hepatic function recovery to Child A grade in 43 cases within one week, postoperative aacites developed in 3 cases, jaundice in 1 case, biliary fistula in 1 case, gastroplegia in 1 case. One patient died of myocardial infarction 3 days postoperatively. Thirty-five malignant cases were followed-up with a mean period of 9 months, one died of intraabdominal metastasis 10 months postoperatively, the other 34 cases was alive without recurrence. Conclusion Hepatic regional entire bloodstream exclusion is effective in the control of intraoperative blood loss ; Hypersound-emulsifying- attractor separates blood vessels and bile ducts in hepatic hilar region. The combination of these two techniques helps in the resection of central hepatic tumors.
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BACKGROUND: Surgical hepatic inflow obstructions such as the Pringle Maneuver (PM) or hepatic vascular exclusion (HVE) can reduce bleeding during hepatic resection, but ischemia/reperfusion injury of the liver and systemic hemodynamic changes are also inevitable during and after PM or HVE. Nitric oxide plays a pivotal role in ischemia/reperfusion injury. We evaluated hemodynamic changes and changes of nitric oxide during liver ischemia/reperfusion injury excluding the effects of intestinal ischemia. METHODS: Liver ischemia was induced by clamping of the portal triad, infrahepatic and suprahepatic inferior vena cava for 90 minutes. To exclude the effects of intestinal ischemia during liver ischemia, portal and iliac venous blood was bypassed to the jugular vein using a pump. Hemodynamic parameters and nitric oxide were measured serially; before and during ischemia, and after reperfusion. RESULTS: Mean arterial blood pressure (MAP) was well-maintained during ischemia, but after reperfusion, MAP, cardiac output (CO) and stroke volume (SV) significantly decreased (35 - 40, 30 - 40 and 30%, respectively) postischemia. Compared to preischemia, systemic vascular resistance and heart rate did not change after reperfusion. Pulmonary vascular resistance and mean pulmonary arterial blood pressure significantly increased (220 - 250% and 60 - 70%) after reperfusion. Nitric oxide (NO) did not change until 20 minutes after reperfusion, but after 40 minutes reperfusion, NO significantly decreased (20%) compared to preischemia. CONCLUSIONS: After 90 minutes warm liver ischemia/reperfusion causes hypotension induced by decreased CO and SV. Increased PVR seems to be the cause of decreased CO and SV. NO-SVR interaction does not seem to be the cause of postreperfusion hypotension.
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Arterial Pressure , Cardiac Output , Constriction , Heart Rate , Hemodynamics , Hemorrhage , Hypotension , Ischemia , Jugular Veins , Liver , Nitric Oxide , Reperfusion , Stroke Volume , Vascular Resistance , Vena Cava, InferiorABSTRACT
Objective To evaluate the effects of ischemic preconditioning(IP) on liver function,complications and hospital stays after hepatectomy under hepatic vascular exclusion by a meta-analysis.Methods Randomized controlled trials(RCTs) were identified from PUBMED,EMBASE,the Cochrane Library,VIP,CNKI and Wanfang Data according to the inclusion and exclusion criteria.Literature screening,data extraction and quality assessment were made and the meta-analysis was processed by RevMan 4.2.2.Results Eight RCTs involving a total of 511 patients were included.The methodological quality was evaluated and all the trials were in graded B.The meta-analysis revealed that the postoperative ALT peak level(weighted mean difference=-176.37;95%CI:-320.67~-30.06;P=0.02)and postoperative complications incidence(odd ratio=0.64;95%CI: 0.41~0.98;P=0.04)were lower in IP group compared with control group,but there were no significant differences in blood loss,operating time,hepatic vascular exclusion time,postoperative AST and total bilirubin peak level,and hospital stays in both groups.Conclusions IP reduces the postoperative ALT peak level and complications incidence after hepatectomy under hepatic vascular exclusion,but there is no sufficient evidence to support that the IP can protect the liver from ischemia/reperfusion injury.