Hemodynamic and biochemical monitoring during major liver resection with use of hepatic vascular exclusion.

Twenty-four resections under hepatic vascular exclusion (HVE) have been performed in patients with massive liver tumors. The procedure of HVE was used to minimize blood loss and the chance of gas embolism; it included clamping of the portal triad and occlusion of the inferior vena cava above and below the liver. In 12 of these patients the HVE was associated with clamping of the abdominal aorta above the celiac axis (AoC). During the "anhepatic" phase, which lasted 24 to 65 minutes (mean 39 minutes), neither venous shunt nor refrigeration was used. When HVE was associated with AoC, the circulation to the lower part of the body was completely excluded so that the systemic circulation was reduced to a small upper compartment in which the mean arterial pressure increased by 33% while the cardiac index decreased by 40%. The diastolic pulmonary arterial pressure remained unchanged. When HVE was not associated with AoC, the body was divided into an upper vascular compartment with normal venous resistance and a lower vascular compartment with increased resistance to the venous return and increased blood volume. The cardiac index, which was distributed to these two compartments, decreased by 40% to 50% but the mean arterial pressure decreased by only 14%. The good hemodynamic tolerance to HVE without AoC that was observed in these patients confirms the efficiency of collateral venous channels in the circumstances reported. AoC appears to be unnecessary in most patients if accurate fluid volume loading has been achieved before HVE. The study of acid-base balance demonstrates the ability of the human body to correct spontaneously the acidosis that follows the release of the clamps, provided a stable hemodynamic state is maintained. Only minor disorders of coagulation, without abnormal bleeding, were observed, and no prophylactic treatment was necessary. There were no deaths during operation, but a 25% postoperative mortality rate was observed mainly related to the underlying disease and the status of the remnant liver parenchyma. Despite its apparent sophistication, HVE is a simple and safe procedure for performing otherwise hazardous liver resections for tumors of large size or that are located close to the inferior vena cava and the suprahepatic veins. Its hemodynamic and metabolic consequences appear to be moderate.

[Acid-base equilibrium and vascular exclusion of the liver: study of 30 extensive hepatectomies]. / Equilibre acido-basique et exclusion vasculaire du foie: étude de 30 hépatectomies étendues.

The acid-base disorders after hepatic vascular exclusion (HVE) were studied in 30 major liver resections. HVE included portal triad clamping and occlusion of the inferior vena cava below and above the liver, without venous shunt nor cooling. Clamping of the supra-coeliac abdominal aorta (AoC) was associated with HVE in 12 patients. HVE lasted 18 to 65 min (mean 37 min). Liver ischemia and splanchnic blood pooling resulted in metabolic acidosis and hyperlactatemia. In order to prevent his acidosis, prophylactic administration of NaHCO23 was used during the first 19 cases. This induced significant metabolic alkalosis during HVE and the early postoperative period; increasing experience made us reduce the amount of NaHCO3. After the release of the clamps, Paco2 increased 25% following HVE without AoC (p less than 0.001) and 53% following HVE with AoC (p less than 0.001). In an attempt to distinguish between the effects of the metabolic acidosis and the rise of Paco2 in the fall of pH which occurred after removal of the clamps, NAaHCO3 was deliberately not given in the last 11 patients. Acidosis appeared to be greater with AoC than without and mainly related to the rise of Paco2. A fall of Paco2 to its initial value was always followed by the return of pH to the normal range. This study demonstrated the human ability to correct spontaneously the acidosis which followed HVE. The need for NaHCO3 after HVE reflected a poor hemodynamic state after major liver resection rather than a metabolic consequence of hepatic ischaemia.

[Pseudo-tumoral haematoma of the iliac fossa in haemophiliacs (author's transl)]. / Hématomes d'allure tumorale, de localisation iliaque, chez les hémophiles.

Pseudo-tumoral blood collections in haemophiliacs are uncommon but must be borne in mind because of their severity and of the need for timely and appropriate treatment. Surgical excision appears to be required as soon as the tendency towards enlargement is recognized and before the volume and complications of the tumour increase the difficulties, particularly in the iliac fossa. Other treatments, especially puncture-aspiration, seem to be ineffective and/or dangerous. A better knowledge of the pathogenic processes involved might lead to new therapeutic approaches.

[Anaphylactic shock to pentothal induction]. / Un choc anaphylactique au pentothal à l'induction

In a patient who had been anaesthetised twice with penthiobarbitone, who had contracted a localised then a generalised eczema, collapse appeared during a third anaesthetic induction, 30 minutes after the injection of penthiobarbitone which was revealed by Shelley's test to be the most positive product.

[Allergy and anesthesia: environment and psychological factors]. / Allergie et anesthésie: environnement et facteurs psychologiques

The assessment of so-called risk "carriers" is difficult from the standpoint of true allergy and consideration must be given to the following:- the psychology and environment of the patient to be anaesthesia, with regard to any warning signs. -also, though, the psychology and environment of the anaesthetist; himself alerted in the presence of a presumptive allergy. Such an attitude will lead to more rapid assessment of the true nature of the complication occurring. In most instances, acquired presumptions can only lead to widened prevention. A formal anaesthetic consultation, including a careful history, will aid in the detection of problems. It is also of significant value from a legal standpoint, at the same time ensuring application by the anaesthetist of appropriate therapy as early as possible.

[Effects of postoperative decurarization with neostigmine on digestive anastomoses]. / Effets de la décurarisation post-opératoire par la néostigmine sur les anastomoses digestives

A prospective study was undertaken to assess the influence of neostigmine, a reversal agent for curarimimetic myorelaxants, on the incidence of postoperative disruption of anastomotic sites. Over a period of one year, 400 patients had surgery, including anastomosis, on the digestive tract for a variety of surgical conditions (Table II). At the end of anaesthesia, 200 patients received doses of atropine and neostigmine, usually 1 mg and 2.5 mg of each, as indicated on clinical basis and neuromuscular stimulation. The other patients did not recieve these drugs and were ventilated till the myorelaxation vanished spontaneously. During the postoperative period of incidence of anastomotic breakdown was assessed by the surgeon, unaware of the use or the omission of neostigmine in his patients. Anastomotic leakage was classified in four groups, namely: proved, absent, likely and unlikely. In this series and according to these clinical criteria, both groups had an incidence of anastomotic breakdown which was not significantly different (Table III). Neostigmine as used in this work does not seem to compromise the normal healing of anastomotic sites on the digestive tract.

[Place of anti-inflammatory agents in the prevention of deep phlebitis]. / La place des anti-inflammatoires dans la prévention des phébites profondes

The inflammatory reaction includes, after an initial tissue lesion, a catabolic phase with proteolysis, an exudative reaction phase, and finally an anabolic phase with the formation of an inflammatory granuloma. The reaction should be considered, however, as an initial inflammation, rapid and limited to the affected tissues, and a secondary inflammation induced at a distance by a humoral mechanism with the appearance of pathological globulins. Only certain anti-inflammatory agents act at these two levels : steroids and non-steroids. Corticosteroids can be used effectively in small doses. Courses of salicylates are difficult to manage and are not standardized. Fenamates and indometacine lead to psychiatric disorders. The only useful drugs are phenylbutazone and hydroxyphenylbutazone. These two drugs can be used alone, or in combination, or eventually being superseded by anti-coagulants. As they are derived from pyrazolidine, they are above all preventive. Their absorption in the digestive tract is rapid and almost complete ; the maximum plasma concentration occurs 2-4 h. after injection. Delayed accidents occur 7-15 days after the last dose. Suppotanderil and suppophenylbutazone are used at the dose of 250ml, 2 or 3 times a day. They may be combined with AVK depending on the clinical signs and the prothrombin and Howell's time. These drugs are contraindicated in patients with ulcers, with haematological diseases, and with severe cirrhosis. They should always be replaced straight away by anti-coagulants in patients with valve prostheses or with severe rhythm disorders.