Total vascular exclusion for major hepatectomy in patients with abnormal liver parenchyma
J. Emond, M. E. Wachs, J. F. Renz, S. Kelley, H. Harris, J. P. Roberts, N. L. Ascher and R. C. Lim Jr
Department of Surgery, University of California, San Francisco, USA.
BACKGROUND: Total vascular exclusion (TVE) of the liver has been used to
increase the safety of hepatectomy and the feasibility of difficult
resections. Until recently, however, concern about the detrimental effect
of warm ischemia has limited the use of this technique to patients with
normal liver parenchyma. OBJECTIVE: To compare surgical outcomes of 12
patients with abnormal livers (group 1) with outcomes of 48 patients with
normal parenchyma (group 2), based on the hypothesis that uncontrolled
bleeding may be more detrimental than planned hepatic ischemia. DESIGN AND
SETTING: Retrospective analysis of 60 consecutive patients undergoing liver
resection under TVE in a university medical center. PATIENTS: All 10
patients with cirrhosis had albumin levels of 30 g/L or higher and normal
prothrombin times preoperatively; none had ascites. Two patients with
cholestasis (one with cholangiocarcinoma and one with hepatocellular
carcinoma) are included in group 1. INTERVENTION: All 12 group 1 patients
and 44 of 48 group 2 patients underwent total or extended lobectomy, with
TVE induced by clamping the hilum and the vena cava above and below the
liver during parenchyma division. MAIN OUTCOME MEASURES: Hospital survival
and selected surgical and laboratory parameters. RESULTS: Operative times,
ischemic times, and blood loss (1975 +/- 1601 vs 1255 +/- 1291 mL) (P =
.10) were comparable in both groups. Sixty-day operative mortality was zero
in both groups. There was an increased rate of complications in group 1
(44% vs 17% [P = 0.06]). Transient abnormal liver function was observed in
both groups. However, significant delay in restoration of normal function
was observed in group 1 with respect to bilirubin levels and prothrombin
time. CONCLUSIONS: Patients with cirrhosis can undergo successful resection
using TVE. This conclusion must be limited to cirrhotic patients with good
liver function. The trend toward increased blood loss may reflect greater
difficulties in establishing hemostasis after reperfusion in group 1. While
this group appears to have a higher risk for hepatic insufficiency,
successful outcomes were achieved in all cases. Prospective study will be
required to define the parameters for use of TVE in cirrhosis.