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…