|
1
|
Malik AK, Amer AO, Tingle SJ, Thompson ER, White SA, Manas DM, Wilson C. Fibrin-based haemostatic agents for reducing blood loss in adult liver resection. Cochrane Database Syst Rev 2023; 8:CD010872. [PMID: 37551841 PMCID: PMC10411946 DOI: 10.1002/14651858.cd010872.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Liver resection is the optimal treatment for selected benign and malignant liver tumours, but it can be associated with significant blood loss. Numerous anaesthetic and surgical techniques have been developed to reduce blood loss and improve perioperative outcomes. One such technique is the application of topical fibrin-based haemostatic agents (FBHAs) to the resection surface. There is no standard practice for FBHA use, and a variety of commercial agents and devices are available, as well as non-FBHAs (e.g. collagen-based agents). The literature is inconclusive on the effectiveness of these methods and on the clinical benefits of their routine use. OBJECTIVES To evaluate the benefits and harms of fibrin-based haemostatic agents in reducing intraoperative blood loss in adults undergoing liver resection. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science up to 20 January 2023. We also searched online trial registries, checked the reference lists of all primary studies, and contacted the authors of included trials for additional published or unpublished trials. SELECTION CRITERIA We considered for inclusion all randomised clinical trials evaluating FBHAs versus no topical intervention or non-FBHAs, irrespective of publication type, publication status, language of publication, and outcomes reported. Eligible participants could have any liver pathology and be undergoing major or minor liver resections through open or laparoscopic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of the literature search and used data extraction forms to collate the results. We expressed dichotomous outcome results as risk ratios (RRs) and continuous outcome results as mean differences (MDs), each with their corresponding 95% confidence interval (CI). We used a random-effects model for the main analyses. Our primary outcomes were perioperative mortality, serious adverse events, haemostatic efficacy, and health-related quality of life. Our secondary outcomes were efficacy as sealant, adverse events considered non-serious, operating time, and length of hospital stay. We assessed the certainty of the evidence with GRADE and presented results in two summary of findings tables. MAIN RESULTS We included 22 trials (2945 participants) evaluating FBHAs versus no intervention or non-FBHAs; 19 trials with 2642 participants provided data for the meta-analyses. Twelve trials reported commercial funding, one trial reported no financial support, and nine trials provided no information on funding. Below we present the most clinically relevant outcome results, also displayed in our summary of findings table. Fibrin-based haemostatic agents versus no intervention Six trials (1001 participants) compared FBHAs with no intervention. One trial was at low risk of bias in all five domains, and all other trials were at high or unclear risk of bias in at least one domain. Two trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with no intervention have an effect on perioperative mortality (RR 2.58, 95% CI 0.89 to 7.44; 4 trials, 782 participants), serious adverse events (RR 0.96, 95% CI 0.88 to 1.05; 4 trials, 782 participants), postoperative transfusion (RR 1.04, 95% CI 0.77 to 1.40; 5 trials, 864 participants), reoperation (RR 2.92, 95% CI 0.58 to 14.61; 2 trials, 612 participants), or postoperative bile leak (RR 1.00, 95% CI 0.67 to 1.48; 4 trials, 782 participants), as the certainty of evidence was very low for all these outcomes. Fibrin-based haemostatic agents versus non-fibrin-based haemostatic agents Sixteen trials (1944 participants) compared FBHAs with non-FBHAs. All trials had at least one domain at high or unclear risk of bias. Twelve trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with non-FBHAs have an effect on perioperative mortality (RR 1.03, 95% CI 0.62 to 1.72; 11 trials, 1436 participants), postoperative transfusion (RR 0.92, 95% CI 0.68 to 1.25; 7 trials, 599 participants), reoperation (RR 0.48, 95% CI 0.25 to 0.90; 3 trials, 358 participants), or postoperative bile leak (RR 1.15, 95% CI 0.60 to 2.21; 9 trials, 1115 participants), as the certainty of evidence was very low for all these outcomes. FBHAs compared with non-FBHAs may have little or no effect on the risk of serious adverse events (RR 0.99, 95% CI 0.95 to 1.03; 9 trials, 1176 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence for the outcomes in both comparisons (FBHAs versus no intervention and FBHAs versus non-FBHAs) was of very low certainty (or low certainty in one instance) and cannot justify the routine use of FBHAs to reduce blood loss in adult liver resection. While the meta-analysis showed a reduced risk of reoperation with FBHAs compared with non-FBHAs, the analysis was confounded by the small number of trials reporting the event and the risk of bias in all these trials. Future trials should focus on the use of FBHAs in people undergoing liver resection who are at particularly high risk of bleeding. Investigators should evaluate clinically meaningful and patient-important outcomes and follow the SPIRIT and CONSORT statements.
Collapse
Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Aimen O Amer
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Steven A White
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| |
Collapse
|
|
2
|
Ding Z, Fang H, Huang M, Yu T. Laparoscopic versus open in right posterior sectionectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:25. [PMID: 36637531 DOI: 10.1007/s00423-023-02764-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 11/17/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) is now widely adopted for the treatment of liver tumors due to its minimally invasive advantages. However, multicenter, large-sample population-based laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. We aimed to assess the advantages and drawbacks of right posterior sectionectomy compared with laparoscopic and open surgery by meta-analysis. METHODS Relevant literature was searched using the PubMed, Embase, Cochrane, Ovid Medline, and Web of Science databases up to September 12, 2021. Quality assessment was performed based on a modified version of the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. The data were calculated by odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI) for fixed-effects and random-effects models. RESULTS The meta-analysis included seven studies involving 739 patients. Compared with open right posterior sectionectomy (ORPS), the LRPS group had lower intraoperative blood loss (MD - 135.45; 95%CI - 170.61 to - 100.30; P < 0.00001) and shorter postoperative hospital stays (MD - 2.17; 95% CI - 3.03 to - 1.31; P < 0.00001). However, there were no statistically significant differences between LRPS and ORPS regarding operative time (MD 44.97; P = 0.11), pedicle clamping (OR 0.65; P = 0.44), clamping time (MD 2.72; P = 0.31), transfusion rate (OR 1.95; P = 0.25), tumor size (MD - 0.16; P = 0.13), resection margin (MD 0.08; P = 0.63), R0 resection (OR 1.49; P = 0.35), recurrence rate (OR 2.06; P = 0.20), 5-year overall survival (OR 1.44; P = 0.45), and 5-year disease-free survival (OR 1.07; P = 0.88). Furthermore, no significant difference was observed in terms of postoperative complications (P = 0.08), bile leakage (P = 0.60), ascites (P = 0.08), incisional infection (P = 0.09), postoperative bleeding (P = 0.56), and pleural effusion (P = 0.77). CONCLUSIONS LRPS has an advantage in the length of hospital stay and blood loss. LRPS is a very useful technology and feasible choice in patients with the right posterior hepatic lobe tumor.
Collapse
Affiliation(s)
- Zigang Ding
- Department of Hepatobiliary Pancreatic Surgery, The Jiujiang University Affiliated Hospital, No. 57, Xunyang East Road, Jiujiang, 332000, Jiangxi Province, China
| | - Hongcai Fang
- Department of Hepatobiliary Pancreatic Surgery, The Jiujiang University Affiliated Hospital, No. 57, Xunyang East Road, Jiujiang, 332000, Jiangxi Province, China
| | - Mingwen Huang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Tao Yu
- Department of Hepatobiliary Pancreatic Surgery, The Jiujiang University Affiliated Hospital, No. 57, Xunyang East Road, Jiujiang, 332000, Jiangxi Province, China.
| |
Collapse
|
|
3
|
Liu J, Wang W, Shi C, Li C, Xue F, Hu L, Wang Y, Ge R. The difference in prolonged continuous and intermittent Pringle maneuver during complex hepatectomy for hepatocellular carcinoma patients with chronic liver disease: A retrospective cohort study. Cancer Med 2021; 10:8507-8517. [PMID: 34658153 PMCID: PMC8633214 DOI: 10.1002/cam4.4361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/07/2021] [Accepted: 09/23/2021] [Indexed: 01/20/2023] Open
Abstract
Purpose To explore the differences between prolonged continuous Pringle maneuver (CPM) and prolonged intermittent Pringle maneuver (IPM) in patients with hepatocellular carcinoma (HCC), who underwent complex hepatectomy. Methods This retrospective cohort study performed between June 2014 and May 2016 included 142 patients who underwent complex hepatectomy for HCC and concomitant chronic liver disease but with good liver function. Patients were categorized into CPM (n = 69) and IPM groups (n = 73). The differences in these aspects were compared between the two groups which include operation time, intraoperative bleeding, perioperative transfusion, postoperative complications, liver function injury, postoperative overall survival (OS), and tumor recurrence. Results The cumulative clamping time, operation time, intraoperative bleeding, and perioperative transfusion rates were 38.0, 132 min, 300 ml, and 17.4% in CPM and 40.0, 145 min, 400 ml, and 32.9% in IPM, respectively. There were significant intergroup differences in operation time (p = 0.018), intraoperative bleeding (p < 0.001), and perioperative transfusion rates (p = 0.034). Besides, the postoperative complications and postoperative liver function injury of the CPM group were better than those of IPM. There was no significant intergroup difference in OS (p = 0.908) and tumor recurrence (p = 0.671) between two groups. Conclusion Compared with IPM, CPM with a cumulative clamping time between 30 and 50 min can shorten operation time, reduce intraoperative bleeding and perioperative transfusion, and reduce postoperative complications and postoperative liver function injury in patients who underwent complex hepatectomy for HCC and concomitant liver disease but with good liver function. There was no significant difference in OS and tumor recurrence between two groups.
Collapse
Affiliation(s)
- Jianwei Liu
- Department of Hepatic Surgery II, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Wei Wang
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Chunchao Shi
- Department of Hepatic Surgery II, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Chenqi Li
- Department of Nutrition, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Feng Xue
- Department of Hepatic Surgery II, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Lei Hu
- Department of Hepatic Surgery II, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Yi Wang
- Department of Hepatic Surgery II, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| | - Ruiliang Ge
- Department of Outpatient, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China
| |
Collapse
|
|
4
|
Wassmer CH, Moeckli B, Berney T, Toso C, Orci LA. Shorter Survival after Liver Pedicle Clamping in Patients Undergoing Liver Resection for Hepatocellular Carcinoma Revealed by a Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040637. [PMID: 33562666 PMCID: PMC7916026 DOI: 10.3390/cancers13040637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Hepatocellular carcinoma (HCC) is the most prevalent tumor of the liver and represents the second most common cause of oncological-related deaths worldwide. Despite all progress made in the field, surgical resection or liver transplantation are, at the moment, the only curative therapies available. Liver resection, especially for large, central tumors, are at risk of important bleeding. Significative hemorrhage during HCC resections have been linked to an increased rate of post-operative complications and tumor recurrence. Therefore, hepatic pedicle clamping during surgery has been used in order to reduce the bleeding risks. However, this method induces ischemia/reperfusion injuries, which has also been associated with tumor recurrence. For this reason, we aimed to evaluate if pedicle clamping is indeed associated with tumor recurrence and shorter survival, by performing a systematic review of the literature and meta-analysis. Abstract Liver pedicle clamping minimizes surgical bleeding during hepatectomy. However, by inducing ischemia-reperfusion injury to the remnant liver, pedicle clamping may be associated with tumor recurrence in the regenerating liver. Hepatocellular carcinoma (HCC) having a high rate of recurrence, evidences demonstrating an eventual association with pedicle clamping is strongly needed. We did a systematic review of the literature until April 2020, looking at studies reporting the impact of liver pedicle clamping on long-term outcomes in patients undergoing liver resection for HCC. Primary and secondary outcomes were overall survival (OS) and disease-free survival, respectively. Results were obtained by random-effect meta-analysis and expressed as standardized mean difference (SMD). Eleven studies were included, accounting for 8087 patients. Results of seven studies were pooled in a meta-analysis. Findings indicated that, as compared to control patients who did not receive liver pedicle clamping, those who did had a significantly shorter OS (SMD = −0.172, 95%CI: −0.298 to −0.047, p = 0.007, I2 = 76.8%) and higher tumor recurrence rates (odds ratio 1.36 1.01 to 1.83. p = 0.044, I2 = 50.7%). This meta-analysis suggests that liver pedicle clamping may have a deleterious impact on long-term outcomes. An individual patient-data meta-analysis of randomized trials evaluating liver pedicle clamping is urgently needed.
Collapse
Affiliation(s)
| | - Beat Moeckli
- Correspondence: (C.-H.W.); (B.M.); Tel.: +41-7866-82206 (C.-H.W.)
| | | | | | | |
Collapse
|
|
5
|
Lee KF, Chong CCN, Cheung SYS, Wong J, Fung AKY, Lok HT, Lai PBS. Impact of Intermittent Pringle Maneuver on Long-Term Survival After Hepatectomy for Hepatocellular Carcinoma: Result from Two Combined Randomized Controlled Trials. World J Surg 2020; 43:3101-3109. [PMID: 31420724 DOI: 10.1007/s00268-019-05130-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hepatectomy remains an important curative treatment for hepatocellular carcinoma (HCC). Intermittent Pringle maneuver (IPM) is commonly applied during hepatectomy for control of bleeding. Whether the ischemia/reperfusion injury brought by IPM adversely affects the operative outcomes is controversial. This study aims to examine whether the application of IPM during hepatectomy affects the long-term outcomes. METHODS Two randomized controlled trials (RCT) have been carried out previously to evaluate the short-term outcomes of IPM. The present study represented a post hoc analysis on the HCC patients from the first RCT and all patients from the second RCT, and the long-term outcomes were evaluated. RESULTS There were 88 patients each in the IPM group and the no-Pringle-maneuver (NPM) group. The patient demographics, type and extent of liver resection and histopathological findings were comparable between the two groups. The 1-, 3-, 5-year overall survival in the IPM and NPM groups was 92.0%, 82.0%, 72.1% and 93.2%, 68.8%, 58.1%, respectively (P = 0.030). The 1-, 3-, 5-year disease-free survival in the IPM and NPM groups was 73.6%, 56.2%, 49.7% and 71.6%, 49.4%, 40.3%, respectively (P = 0.366). On multivariable analysis, IPM was a favorable factor for overall survival (P = 0.035). Subgroup analysis showed that a clamp time of 16-30 min (P = 0.024) and cirrhotic patients with IPM (P = 0.009) had better overall survival. CONCLUSION IPM provided a better overall survival after hepatectomy for patients with HCC. Such survival benefit was noted in cirrhotic patients, and the beneficial duration of clamp was 16-30 min. TRIAL REGISTRATION NCT00730743 and NCT01759901 ( http://www.clinicaltrials.gov ).
Collapse
Affiliation(s)
- Kit Fai Lee
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Sunny Y S Cheung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Hon Ting Lok
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China.
| |
Collapse
|
|
6
|
He P, He K, Zhong F, Su S, Fang C, Qin S, Pen F, Xia X, Li B. Meta-analysis of infrahepatic inferior vena cava clamping combined with the pringle maneuver during hepatectomy. Asian J Surg 2020; 44:18-25. [PMID: 32624397 DOI: 10.1016/j.asjsur.2020.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/21/2020] [Accepted: 04/05/2020] [Indexed: 10/23/2022] Open
Abstract
This meta-analysis was conducted to evaluate the effectiveness and safety of infrahepatic inferior vena cava clamping combined with the Pringle maneuver during. hepatectomies. Clinical studies were retrieved from the PubMed, Embase, Cochrane Library, Medline and Web of Science databases. Study-specific effect sizes and their 95% confidence intervals (CIs) were combined to calculate the pooled value using a fixed-effects or random-effects model.Nine studies with 1008 patients in total were included. The infrahepatic inferior vena cava clamping combined with Pringle maneuver group experienced less total operative blood loss (mean difference [MD] = -327.11; 95% CI: -386.50-267.72; P < 0.00001), less blood loss during transection (MD = -270.19; 95% CI: -344.99-195.38; P < 0.00001), fewer blood transfusions (odds ratio [OR] = 0.36; 95% CI: 0.25-0.53;P < 0.00001) and fewer postoperative complications (OR = 0.70; 95% CI: 0.52-0.95; P = 0.02) than did the control group. Operative time (MD = 8.54; 95% CI: 4.68-12.40; P < 0.0001) was similar in both groups. liver transection time,hospital stay, postoperative liver function and renal function did not differ between groups.Applying infrahepatic inferior vena cava clamping combined with the Pringle maneuver can effectively reduce intraoperative bleeding, blood transfusion rates, and postoperative complications, while adding minimal time to the operation.
Collapse
Affiliation(s)
- Pan He
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China; Department of Nuclear Medicine, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China; Academician(Expert)Workstation of Sichuan Province, Luzhou, 646000, China; Department of Anesthesiology, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China
| | - Kai He
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China
| | - Furui Zhong
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China
| | - Song Su
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China
| | - Cheng Fang
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China
| | - Shu Qin
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China
| | - Fangyi Pen
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China
| | - Xianming Xia
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China; Academician(Expert)Workstation of Sichuan Province, Luzhou, 646000, China.
| | - Bo Li
- Department of Hepatobiliary Surgery, Affiliated Hospital, Southwest Medical University, Luzhou, 646000, China; Academician(Expert)Workstation of Sichuan Province, Luzhou, 646000, China.
| |
Collapse
|
|
7
|
Mangieri CW, Strode MA, Bandera BC. Improved hemostasis with major hepatic resection in the current surgical era. Hepatobiliary Pancreat Dis Int 2019; 18:439-445. [PMID: 31307940 DOI: 10.1016/j.hbpd.2019.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 07/02/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections. METHODS Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era. RESULTS A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era (P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era (P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001). CONCLUSIONS The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.
Collapse
Affiliation(s)
- Christopher W Mangieri
- Department of Surgery, Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA 30809, USA.
| | - Matthew A Strode
- Department of Surgery, Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA 30809, USA; Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY 14203, USA
| | - Bradley C Bandera
- Department of Surgery, Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA 30809, USA
| |
Collapse
|
|
8
|
Dou L, Liang HF, Yang HY, Ji R, Chen YF, Chen XP. Clinical Value of Trans-parenchymal Compressing Suture to Decrease the Cutting Surface Related Complications after Non-anatomical Liver Resection. Curr Med Sci 2019; 39:270-277. [PMID: 31016521 DOI: 10.1007/s11596-019-2030-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 01/21/2019] [Indexed: 10/27/2022]
Abstract
Non-anatomical liver resection with appropriate resection margin is regarded as a potential curative treatment for selected major hepatic carcinoma due to preserving maximal normal liver, especially in cirrhotic patients. But occurrence of cutting surface related complications becomes a main challenge. From June 2010 to June 2016, 448 patients with major hepatic carcinoma received non-anatomical liver resection in our liver surgery center. After excluding 66 cases that were incongruent with the purpose of study, 235 patients undergoing transparenchymal compressing suture (TCS) to "not good" cutting surface were allocated as study group; 147 patients with exposed surface (ES) were matched as control group. The characteristics of postoperative drainage, postoperative hepatic and renal functions, hospital days, and outcomes were collected retrospectively. We further compared cutting surface related complications under different levels of liver cirrhosis between the two groups. Compared with ES group, patients in TCS group had a decreased incidence of cutting surface related complications (14.3% vs. 6.8%, P=0.011) and a decreased probability of interventions for cutting surface related complications (8.2% vs. 3.4%, P=0.042). TCS application was much more effective to prevent cutting surface related complications in patients with moderate and severe cirrhosis (5.4% vs. 15.8%, P=0.003). Postoperative hepatic and renal function, hospital days and mortality did not differ between the two groups. In conclusion, TCS decreases the probability of cutting surface related complications and postoperative interventions for related complications, especially in patients with moderate and severe cirrhosis.
Collapse
Affiliation(s)
- Lei Dou
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Department of Gerontology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hui-Fang Liang
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hui-Yuan Yang
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ran Ji
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yi-Fa Chen
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Xiao-Ping Chen
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Department of Gerontology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| |
Collapse
|
|
9
|
Zhang XP, Gao YZ, Chen ZH, Wang K, Cheng YQ, Guo WX, Shi J, Zhong CQ, Zhang F, Cheng SQ. In-hospital Mortality after Surgical Resection in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombus. J Cancer 2019; 10:72-80. [PMID: 30662527 PMCID: PMC6329847 DOI: 10.7150/jca.27102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 10/03/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Survival benefit of surgical resection for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) has been approved recently. However, risk factors for in-hospital mortality in these patients remain unclear. We aimed to determine risk factors and reduce the mortality of these patients. Methods: We analyzed data for 521 of all 1531 HCC patients with PVTT underwent surgery. The primary outcome measure was in-hospital mortality after surgical resection. Univariate and Multivariate cox-regression were performed to identify independent predictors of in-hospital mortality. The methods of Kaplan-Meier, bootstrap and ten-fold-cross validation were applied to validate the risk factors. Results: 521 of 1531 patients in 2004-2012 occurred for the diagnosis of HCC associated with PVTT and underwent surgical resection as a training cohort. Other 325 patients in 2013-2016 were included as a validation cohort. Overall mortality of postoperative in-patients was 3.3% (17/521) and 2.8 % (9/325), respectively. Univariate analysis of mortality revealed that frequency of hospitalization, total albumin, different types of PVTT, bleeding volume, blood transfusion, resection volume, and tumor volume were related with mortality. Therefore, the bootstrap validation reflected that the risk factors of multivariate cox regression in model1(frequency of hospitalization, bleeding volume, and tumor volume) and model 2 (frequency of hospitalization, bleeding volume and total albumin) were stable with mortality in hospital. Ten-fold cross-validation of cox regression analysis showed that the mean C-statistic with 95%CI of model1 and model2 respectively were 0.887(0.779-0.976) and 0.867(0.789-0.966) for predicting in-hospital mortality. Consistency results of models were in the training cohort and validation cohort. Conclusion: Total albumin, tumor volume, intraoperative bleeding and frequency of hospitalization were independent predictive factors for in-hospital mortality in HCC patients with PVTT under surgery. Further study is warranted to utilize these factors to lower in-hospital mortality.
Collapse
Affiliation(s)
- Xiu-Ping Zhang
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University. Shanghai, China
| | - Yu-Zhen Gao
- Department of Molecular Diagnosis, Clinical Medical School, Yangzhou University, Yangzhou, China
| | - Zhen-Hua Chen
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University. Shanghai, China
| | - Kang Wang
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University. Shanghai, China
| | - Yu-Qiang Cheng
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University. Shanghai, China
| | - Wei-Xing Guo
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University. Shanghai, China
| | - Jie Shi
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University. Shanghai, China
| | - Cheng-Qian Zhong
- LongYan First Hospital, Affiliated to Fujian Medical University, FuJian, China
| | - Fan Zhang
- Department of Hepatic Surgery, BinZhou medical University Hospital, BinZhou, China
| | - Shu-Qun Cheng
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University. Shanghai, China
| |
Collapse
|
|
10
|
Fonouni H, Kashfi A, Majlesara A, Stahlheber O, Konstantinidis L, Gharabaghi N, Kraus TW, Mehrabi A, Oweira H. Hemostatic efficiency of modern topical sealants: Comparative evaluation after liver resection and splenic laceration in a swine model. J Biomed Mater Res B Appl Biomater 2017. [DOI: 10.1002/jbm.b.33937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hamidreza Fonouni
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Arash Kashfi
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Ali Majlesara
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Oliver Stahlheber
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Lukas Konstantinidis
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Negin Gharabaghi
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Thomas W. Kraus
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| | - Hani Oweira
- Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelberg Germany
| |
Collapse
|
|
11
|
Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2016. [PMID: 26897031 DOI: 10.1007/s00423-016-1382-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
PURPOSE Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results. METHODS A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals. RESULTS Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results. CONCLUSIONS The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.
Collapse
|
|
12
|
Hüttner FJ, Mihaljevic AL, Hackert T, Ulrich A, Büchler MW, Diener MK. Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2016; 401:151-9. [PMID: 26897031 DOI: 10.1007/s00423-016-1382-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 02/08/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results. METHODS A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals. RESULTS Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results. CONCLUSIONS The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.
Collapse
Affiliation(s)
- Felix J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Study Center of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Study Center of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
|
13
|
Zhu P, Zhang B, Wang R, Mei B, Cheng Q, Chen L, Wei G, Xu DF, Yu J, Xiao H, Zhang BX, Chen XP. Selective Inflow Occlusion Technique Versus Intermittent Pringle Maneuver in Hepatectomy for Large Hepatocellular Carcinoma: A Retrospective Study. Medicine (Baltimore) 2015; 94:e2250. [PMID: 26683942 PMCID: PMC5058914 DOI: 10.1097/md.0000000000002250] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Selective inflow occlusion (SIO) maneuver preserved inflow of nontumorous liver and was supposed to protect liver function. This study aims to evaluate whether SIO maneuver is superior to Pringle maneuver in patients undergoing partial hepatectomy with large hepatocellular carcinomas (HCCs). Between January 2008 and May 2012, 656 patients underwent large HCC resections and were divided into 2 groups: intermittent Pringle maneuver (IP) group (n = 336) and SIO group (n = 320). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed. In comparison to the IP maneuver, the SIO maneuver significantly decreased intraoperative blood loss (473 vs 691 mL, P = 0.001) and transfusion rates (11.3% vs 28.6%, P = 0.006). The rate of major complication between the 2 groups was comparable (22.6% vs 18.8%, P = 0.541). Patients with moderate/severe cirrhosis, total bilirubin > 17 μmol/L, or HBV DNA> = 104 copy/mL in SIO group resulted in lower major complication rates. The SIO maneuver is a safe and effective technique for large HCC resections. In patients with moderate/severe cirrhosis, total bilirubin > 17 μmol/L, or HBV DNA> = 104 copy/mL, the SIO technique is preferentially recommended.
Collapse
Affiliation(s)
- Peng Zhu
- From the Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
14
|
Nouri S, Sharif MR, Afzali H, Sharif A, Satkin M. The Advantages and Disadvantages of Methods Used to Control Liver Bleeding: A Review. Trauma Mon 2015; 20:e28088. [PMID: 26839866 PMCID: PMC4727474 DOI: 10.5812/traumamon.28088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 08/15/2015] [Accepted: 08/17/2015] [Indexed: 01/22/2023] Open
Abstract
Context: Despite advancements in the science of surgery, minimizing bleeding from parenchymal tissue of the liver continues to be one of the challenges surgeons are facing to protect patients’ lives. However, the number of surgeries needing incisions in the liver tissue, e.g. metastatectomy, is constantly increasing. Evidence Acquisition: A MEDLINE and conventional search of the past 50 years of the medical literature was performed to identify relevant articles on hemostasis in the liver parenchymal tissue. Results: The studies that have been published on hemostasis in the liver parenchymal tissue can be classified into 3 categories: 1. surgical procedures; 2. methods affecting body hemodynamic; 3. pharmacological methods. The purpose of these studies are to identify the best therapeutic approaches that not only minimize the bleeding, but also save the maximum amount of the liver tissue and minimize the use of partial liver resections. Conclusions: The excessive blood loss and the long time needed to control the bleeding during liver surgery impose several side effects and complications on patients. Topical hemostatic agents such as ferric chloride, potassium aluminum sulfate (alum) and aluminum chloride are safely applicable in patients. These agents might be used along with other current methods to minimize the blood loss and the need for blood products during liver surgeries.
Collapse
Affiliation(s)
- Saeed Nouri
- Department of Neurology, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Reza Sharif
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
- Corresponding author: Mohammad Reza Sharif, Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran. Tel: +98-9123788713, Fax: +98-3615558900, E-mail:
| | - Hasan Afzali
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Alireza Sharif
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Mojtaba Satkin
- Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| |
Collapse
|
|
15
|
Hibi T, Cherqui D, Geller DA, Itano O, Kitagawa Y, Wakabayashi G. Expanding indications and regional diversity in laparoscopic liver resection unveiled by the International Survey on Technical Aspects of Laparoscopic Liver Resection (INSTALL) study. Surg Endosc 2015; 30:2975-83. [DOI: 10.1007/s00464-015-4586-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 09/19/2015] [Indexed: 02/07/2023]
|
|
16
|
Tsang ME, Karanicolas PJ, Habashi R, Cheng E, Hanna SS, Coburn NG, Law CHL, Hallet J. The impact of portal pedicle clamping on survival from colorectal liver metastases in the contemporary era of liver resection: a matched cohort study. HPB (Oxford) 2015; 17:796-803. [PMID: 26278322 PMCID: PMC4557654 DOI: 10.1111/hpb.12458] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/25/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Portal pedicle clamping (PPC) may impact micro-metastases' growth. This study examined the association between PPC and survival after a hepatectomy for colorectal liver metastases (CRLM). METHODS A matched cohort study was conducted on hepatectomies for CRLM at a single institution (2003-2012). Cohorts were selected based on PPC use, with 1:1 matching for age, time period and the Clinical Risk Score. Outcomes were overall and recurrence-free survival (OS and RFS). Cox regression was performed to assess the association between PPC and survival. RESULTS Of 481 hepatectomies, 26.9% used PPC. One hundred and ten pairs of patients were matched in the cohorts. There was no significant difference in OS [hazard ratio (HR) 1.18; 95% confidence interval (CI): 0.76-1.83], with a 5-year OS of 57.8% (95%CI: 52.4-63.2%) with PPC versus 62.3% (95%CI: 57.1-67.5%) without. Five-year RFS did not differ (HR 0.98; 95%CI: 0.71-1.35) with 29.7% (95%CI: 24.9-34.5%) with PPC versus 28.0% (95%CI: 23.2-32.8%) without. When adjusting for extent of resection, transfusion, operative time and surgeon, there was no difference in OS (HR 0.91; 95%CI: 0.52-1.60) or RFS (HR: 0.86; 95%CI: 0.57-1.30). CONCLUSIONS PPC was not associated with a significant difference in OS or RFS in a hepatectomy for CRLM. PPC remains a safe technique during hepatectomy.
Collapse
Affiliation(s)
- Melanie E Tsang
- Department of Surgery, University of TorontoToronto, ON, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of TorontoToronto, ON, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada
| | - Rogeh Habashi
- Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - Eva Cheng
- Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - Sherif S Hanna
- Department of Surgery, University of TorontoToronto, ON, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, University of TorontoToronto, ON, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada
| | - Calvin H L Law
- Department of Surgery, University of TorontoToronto, ON, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, University of TorontoToronto, ON, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre – Odette Cancer CentreToronto, ON, Canada
| |
Collapse
|
|
17
|
Pandanaboyana S, Bell R, Shah N, Lodge JPA, Hidalgo E, Toogood GJ, Prasad KR. A cost-effective analysis of fibrin sealants versus no sealant following open right hemihepatectomy for colorectal liver metastases. ANZ J Surg 2014; 87:E11-E14. [DOI: 10.1111/ans.12948] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2014] [Indexed: 01/06/2023]
Affiliation(s)
- Sanjay Pandanaboyana
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - Richard Bell
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - Nehal Shah
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - J. Peter A. Lodge
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - Ernest Hidalgo
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - Giles J. Toogood
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - K. Raj Prasad
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| |
Collapse
|
|
18
|
Amer AO, Wilson CH, White SA, Manas DM. Fibrin-based haemostatic agents for reducing blood loss in adult liver resection. Hippokratia 2013. [DOI: 10.1002/14651858.cd010872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Aimen O Amer
- Institute of Cellular Medicine, Newcastle University; Newcastle upon Tyne Tyne and Wear UK NE7 7DN
| | - Colin H Wilson
- The Freeman Hospital; Institute of Transplantation; Freeman Road High Heaton Newcastle upon Tyne Tyne and Wear UK NE7 7DN
| | - Steven A White
- Institute of Cellular Medicine, Newcastle University; Newcastle upon Tyne Tyne and Wear UK NE7 7DN
| | - Derek M Manas
- The Freeman Hospital; Institute of Transplantation; Freeman Road High Heaton Newcastle upon Tyne Tyne and Wear UK NE7 7DN
| |
Collapse
|
|
19
|
Lochan R, Ansari I, Coates R, Robinson SM, White SA. Methods of haemostasis during liver resection--a UK national survey. Dig Surg 2013; 30:375-82. [PMID: 24107508 DOI: 10.1159/000354036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/25/2013] [Indexed: 12/10/2022]
Abstract
BACKGROUND Although haemorrhage is a major cause of morbidity and mortality in liver surgery, there is very little available guidance on its management. METHODS The aim of this study was to identify current practice in the UK in this regard. An online survey was created and hepatobiliary (HPB) specialists who were members of a specialist society and others who were known practitioners were invited by e-mail to complete the survey anonymously. RESULTS Fifty-one percent responded (n = 36/70), and most of these respondents worked at large HPB centres (>100 liver resections/year; n = 24, 66%). Not all questionnaires were fully completed by the individual surgeons. Thirty-eight percent of the surgeons routinely used Pringle's manoeuvre. Most surgeons used ligation of the inflow vessels (n = 16, 44%) and stapled the outflow vessels (n = 15, 42%). The Cavitron ultrasonic surgical aspirator (CUSA; 54%, 13/24) was preferred for parenchymal transection. The majority routinely used haemostatic adjuncts (n = 22, 62%), whilst 33% (n = 12) used them occasionally. Twenty-three (64%) felt manufactured haemostatic adjuncts played a major role in maintaining haemostasis and 19 preferred fibrin-based products. CONCLUSION The Pringle manoeuvre is a popular technique amongst specialist UK liver surgeons and the CUSA is used by nearly half of the surgeons. Despite the absence of definitive evidence for their benefit, manufactured haemostatic adjuncts are still widely used, especially the fibrin-based adjuncts.
Collapse
Affiliation(s)
- R Lochan
- Department of Hepato-Pancreato-Biliary and Transplantation Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | | | | |
Collapse
|
|
20
|
Mise Y, Sakamoto Y, Ishizawa T, Kaneko J, Aoki T, Hasegawa K, Sugawara Y, Kokudo N. A worldwide survey of the current daily practice in liver surgery. Liver Cancer 2013; 2:55-66. [PMID: 24159597 PMCID: PMC3747552 DOI: 10.1159/000346225] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Liver resection remains the mainstay of curative treatment for liver malignancies. A variety of preoperative assessments and surgical techniques have improved the short- and long-term outcomes of liver resection in patients with liver tumors. Recently, laparoscopic hepatectomies have been increasingly performed. The aim of the present study is to survey the current practice of liver surgery in high-volume centers in the world. METHODS A questionnaire on the preoperative assessment for liver surgery, open hepatectomy, and laparoscopic hepatectomy was sent to 94 liver centers in the world. RESULTS Forty-two centers (45%) responded to this survey (29 Asian, 9 European, and 4 North American centers). All but one of the centers evaluated the future liver remnant (FLR) volume, and 95% of them performed preoperative portal vein embolization to increase the FLR volume. In half of the centers, the required FLR volume was over 30% in patients with normal liver and 50% in patients with cirrhotic liver. To reduce the intraoperative blood loss, half of the centers routinely used Pringle's maneuver, and 85% restricted the intraoperative fluid infusion to reduce the central venous pressure. More than 10 laparoscopic hepatectomies were performed per year in 62% of the centers, and more than 30 were performed in 26%, respectively. Laparoscopic major hepatectomies were performed in 24%. Two-thirds answered that the laparoscopic approach would be feasible in donor hepatectomy. CONCLUSION The evaluation of FLR volume in patients with normal or cirrhotic liver and the usage of preoperative portal vein embolization have become essential practice in more than 90% of the centers. Reduced blood loss has been achieved using Pringle's maneuver, restriction of fluid infusion, and a variety of surgical devises. The laparoscopic approach is increasingly extended to major hepatectomy or donor hepatectomy.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Norihiro Kokudo
- *Norihiro Kokudo, MD, PhD, Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655 (Japan), E-Mail
| |
Collapse
|
|
21
|
Fibrin Sealant for Prevention of Resection Surface-Related Complications After Liver Resection. Ann Surg 2012; 256:229-34. [DOI: 10.1097/sla.0b013e3182602819] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
|
22
|
Allard MA, Dondero F, Sommacale D, Dokmak S, Belghiti J, Farges O. Liver packing during elective surgery: an option that can be considered. World J Surg 2012; 35:2493-8. [PMID: 21597886 DOI: 10.1007/s00268-011-1156-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Packing is a life-saving procedure in patients undergoing emergency surgery for blunt hepatic trauma, especially when massive blood transfusions, acidosis, or hypothermia have resulted in coagulation disorders. The purpose of this study was to apply this concept to the setting of elective liver surgery. METHODS Elective packing was performed in 7 patients who had sustained prolonged bleeding mainly related to partial outflow obstruction during the course of liver resection (n = 3) or transplantation (n = 4). At the time of packing, conventional methods of hemostasis had failed and surgery had lasted for 490 (range, 380-695) minutes, blood loss was 5,700 (range, 2,100-13,700) ml, and all patients had coagulation disorders (prothrombin time PT <30%, platelets <45 g/l), hypothermia (body temperature 35.4 °C), acidosis (median blood pH 7.24; serum lactate 6.5 mmol/l) and required catecholamine support. RESULTS Unpacking was performed after a median of 37 (range, 26-60) hours. At that time, all patients were normothermic, with platelet counts >45 g/l, PT >30%, and restored acid-base balance. Active bleeding had stopped, and secondary fascia closure was feasible. With a minimum follow-up of 6 months, all patients are alive without sequel. CONCLUSIONS Packing is a safe and efficient means to control venous bleeding when conventional methods of hemostasis have failed, knowing that commonly the reason for failure of conventional method of hemostasis is partial outflow obstruction.
Collapse
Affiliation(s)
- Marc Antoine Allard
- Department of Hepato-Biliary Surgery, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris 7, 100 bld du Général Leclerc, 92118, Clichy, France
| | | | | | | | | | | |
Collapse
|
|
23
|
Zhu P, Lau WY, Chen YF, Zhang BX, Huang ZY, Zhang ZW, Zhang W, Dou L, Chen XP. Randomized clinical trial comparing infrahepatic inferior vena cava clamping with low central venous pressure in complex liver resections involving the Pringle manoeuvre. Br J Surg 2012; 99:781-8. [PMID: 22389136 DOI: 10.1002/bjs.8714] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Control of bleeding remains key to successful hepatic resection. The present randomized clinical trial compared infrahepatic inferior vena cava (IVC) clamping with low central venous pressure (CVP) during complex hepatectomy using portal triad clamping (PTC). METHODS Consecutive patients undergoing complex hepatectomy were allocated randomly to PTC combined with infrahepatic IVC clamping or to PTC with low CVP. Primary outcome was blood loss during parenchymal transection. Secondary outcomes were intraoperative surgical and haemodynamic parameters, postoperative recovery of liver and renal function, postoperative morbidity and mortality, and duration of hospital stay. RESULTS Between January 2008 and September 2010, 192 patients were randomized. Compared with low CVP, infrahepatic IVC clamping significantly decreased blood loss during parenchymal transection (mean(s.e.m.) 243(158) versus 372(197) ml; P < 0·001), was associated with faster recovery of liver function, and caused less impairment in renal function and fewer haemodynamic changes. The degree of cirrhosis correlated positively with CVP (R(2) = 0·963, P = 0·019) and with infrahepatic IVC pressure (R(2) = 0·950, P = 0·025). For patients with moderate or severe cirrhosis, infrahepatic IVC clamping was more efficacious in controlling blood loss during parenchymal transection (mean(s.e.m.) 2·9(1·8) versus 6·1(2·4) ml/cm(2); P < 0·001). CONCLUSION PTC combined with infrahepatic IVC clamping is more efficacious in controlling bleeding during complex hepatectomy than PTC with low CVP, especially in patients with moderate to severe cirrhosis. REGISTRATION NUMBER NCT01355887 (http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- P Zhu
- Hepatic Surgery Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | | | | | | | | | | | | |
Collapse
|
|
24
|
Ischemic preconditioning prior to intermittent Pringle maneuver in liver resections. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 19:159-70. [DOI: 10.1007/s00534-011-0402-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
|
25
|
Ishizuka M, Kubota K, Kita J, Shimoda M, Kato M, Sawada T. Duration of hepatic vascular inflow clamping and survival after liver resection for hepatocellular carcinoma. Br J Surg 2011; 98:1284-90. [PMID: 21633950 DOI: 10.1002/bjs.7567] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2011] [Indexed: 12/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the influence of the duration of hepatic vascular inflow clamping (Pringle time) on the survival of patients with any type of liver background (not only cirrhosis) undergoing liver resection for hepatocellular carcinoma (HCC). METHODS Patients who underwent liver resection between April 2000 and December 2008 for HCC using the Pringle manoeuvre were identified retrospectively from an institutional database and divided into two groups: group 1 had a Pringle time of 60 min or less, and group 2 a Pringle time of more than 60 min. Univariable and multivariable analyses were performed to identify predictors of postoperative survival. Kaplan-Meier analysis was used to compare overall survival between the groups. RESULTS A total of 357 patients were enrolled; 242 patients had a Pringle time of 60 min or less (group 1), and 115 patients had a Pringle time of more than 60 min (group 2). Patients in group 2 had a shorter overall survival than those in group 1 (P = 0·010). Univariable analyses showed that type of HCC (primary versus recurrent), maximum tumour diameter, hepatic venous infiltration, platelet count, serum protein induced by vitamin K absence or antagonist II level, blood loss (700 ml or less versus more than 700 ml), duration of operation (300 min or less versus more than 300 min) and Pringle time (60 min or less versus more than 60 min) were predictive of postoperative survival. Multivariable analysis indicated that only Pringle time was associated with postoperative survival (odds ratio 1·83, 95 per cent confidence interval 1·08 to 3·10; P = 0·024). CONCLUSION Longer Pringle time is an important predictor of shorter postoperative survival in patients undergoing liver resection for HCC.
Collapse
Affiliation(s)
- M Ishizuka
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi 321-0293, Japan.
| | | | | | | | | | | |
Collapse
|
|
26
|
Abstract
BACKGROUND Massive bleeding during hepatectomy is a risk for mortality and morbidity. We examined the risk factors for massive bleeding and their correlations with outcomes. METHODS The study was a retrospective case series. Among 353 consecutively hepatectomized patients, the mean estimated blood loss (EBL) was 825 ml. Ten patients (2.8%) experienced EBL of between 3000 and 5000 ml. Five patients (1.4%) experienced massive EBL defined as more than 5000 ml, and all five patients had undergone right major hepatectomy (RMH) for primary liver cancer (PLC). All the patients with PLC who underwent RMH were divided into two groups: group I with EBL < or = 5000 ml (n = 19) and group II with EBL > 5000 ml (n = 5). Perioperative factors regarding massive bleeding and operative mortality and morbidity were compared between the two groups. RESULTS Among the ten patients who experienced EBL of between 3000 and 5000 ml, three had partial hepatectomy of no more than subsegmentectomy of the paracaval portion of the caudate lobe and three had central bisegmentectomy. The mean tumor size was 7.9 +/- 4.7 cm in group I and 15.1 +/- 2.2 cm in group II (P = 0 .0034). Tumor compression of the inferior vena cava (IVC) on CT scans was observed in all patients in group II, but in no patients in group I (P < 0.0001). Four of five patients in group II received surgery through an anterior approach. The liver-hanging maneuver (LHM) was applied in 14 of 19 patients (74%) in group I but could not be applied in group II (P = 0.0059). No postoperative and in-hospital mortalities occurred in group II and there were no significant differences in the incidence of mortality and morbidity between the groups. CONCLUSIONS RMH for large PLCs, tumor compression of the IVC, and an anterior approach without the LHM are risks for massive bleeding during hepatectomy. Preparation of rapid infusion devices in these cases is necessary to avoid prolonged hypotension.
Collapse
|
|
27
|
Abstract
BACKGROUND/AIM Linear radiofrequency device (LRFD) is disposable tool designed for liver parenchyma transection using controlled radiofrequency to "seal" blood vessels and bile ducts, making liver resection easier and safer compared to classical resectional techniques. The aim of this study was to determine real value of the LRFD compared to the standard "keliclasia" technique. METHODS This prospective study analyzed the significant intraoperative parameters and postoperative results of the 200 patients who underwent surgery at the Surgery Clinic of Clinical Centre in Nis, between January 1, 2001, and January 1, 2009. The patients were divided into two groups: the control Keli group (144 patients) with the "keliclasia" resection technique and the control RF group (with resection performed using LRFD--Tissue Link / Dissection Sealer (DS-3.0) (56 patients). The following parameters were analyzed: duration of liver ischemia, liver parenchyma transection time, intraoperative blood loss, significant intraoperative and postoperative complication rate-duration of hospitalization and mortality. RESULTS . LRFD was used in 56 liver resections. The average duration of liver ischemia in the RF group was shorter than in the Keli group (7 versus 22 minutes). Parenchymal liver transection was significantly slower in the RF group than in the Keli group (2.05 versus 4.34 cm2/minutes, respectively). There was less intraoperative bleeding using LRFD "Keliclasia" technique than in the control group (390 mL compared to 420 mL, respectively). After the use of LRFD two cases of biliary leak and 4 pleural effusions were registered. CONCLUSION LRFD is simple device for safe liver transection with decreased need for liver ischemia and significant reducing of the intraoperative blood loss. High price for disposable device and slow parenchyma transection are disadvantages of this device.
Collapse
|
|
28
|
Does Hepatic Pedicle Clamping Affect Disease-Free Survival Following Liver Resection for Colorectal Metastases? Ann Surg 2010; 252:1020-6. [DOI: 10.1097/sla.0b013e3181f66918] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
|
29
|
Abstract
BACKGROUND Vascular occlusion to prevent haemorrhage during liver resection causes ischaemia-reperfusion (IR) injury. Insights into the mechanisms of IR injury gathered from experimental models have contributed to the development of therapeutic approaches, some of which have already been tested in randomized clinical trials. METHODS The review was based on a PubMed search using the terms 'ischemia AND hepatectomy', 'ischemia AND liver', 'hepatectomy AND drug treatment', 'liver AND intermittent clamping' and 'liver AND ischemic preconditioning'; only randomized controlled trials (RCTs) were included. RESULTS Twelve RCTs reported on ischaemic preconditioning and intermittent clamping. Both strategies seem to confer protection and allow extension of ischaemia time. Fourteen RCTs evaluating pharmacological interventions, including antioxidants, anti-inflammatory drugs, vasodilators, pharmacological preconditioning and glucose infusion, were identified. CONCLUSION Several strategies to prevent hepatic IR have been developed, but few have been incorporated into clinical practice. Although some pharmacological strategies showed promising results with improved clinical outcome there is not sufficient evidence to recommend them.
Collapse
Affiliation(s)
- R Bahde
- Surgical Research, Department of General and Visceral Surgery, Muenster University Hospital, Waldeyer Strasse 1, D-48149 Muenster, Germany
| | | |
Collapse
|
|
30
|
Chouillard EK, Gumbs AA, Cherqui D. Vascular clamping in liver surgery: physiology, indications and techniques. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2010; 4:2. [PMID: 20346153 PMCID: PMC2857838 DOI: 10.1186/1750-1164-4-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 03/26/2010] [Indexed: 12/13/2022]
Abstract
This article reviews the historical evolution of hepatic vascular clamping and their indications. The anatomic basis for partial and complete vascular clamping will be discussed, as will the rationales of continuous and intermittent vascular clamping.Specific techniques discussed and described include inflow clamping (Pringle maneuver, extra-hepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the pre-operative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.
Collapse
Affiliation(s)
- Elie K Chouillard
- Department of Surgery, Centre Hospitalier Intercommunal, Poissy, France
| | - Andrew A Gumbs
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Daniel Cherqui
- Digestive Surgery Department, Hôpital Henri Mondor - University Paris-XII, Créteil, France
| |
Collapse
|
|
31
|
Fu X, Lu C, Chu K, Yao X, Cheng S, Gao C, Shen F, Wu M. The hepatoprotective effect of hypothermic perfusion of normal saline in period of inflow occlusion of liver in rats. J Surg Res 2009; 166:104-8. [PMID: 19922945 DOI: 10.1016/j.jss.2009.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 05/04/2009] [Accepted: 06/12/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND Liver damage in hepatic surgery from warm ischemia and reperfusion (I/R), especially in patients with underlying chronic liver disease, is still challenging. We propose a new method of perfusion of the liver by catheterizing the umbilical vein in the period of hepatic inflow occlusion, and evaluate the influence of transfusion of normal saline (NS) on liver injury in a modified I/R rat model. METHODS Twenty-eight rats were randomized into four groups (n=7): group I (sham-operated group): no I/R or transfusion; group II (I/R group): I/R + no transfusion; group III (37°C NS group): I/R + transfusion of 37°C NS ; group IV(24°C NS group): I/R + transfusion of 24°C NS. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), as well as lactate dehydrogenase (LDH) were measured in rat serum. Light and electron microscopic examinations were performed on the liver tissues. RESULTS Perfusion of 24°C NS in the period of inflow occlusion resulted in significant reductions of liver enzymes levels compared to the I/R alone group and 37°C NS group (P<0.001 and P<0.001, respectively). Histologic evaluation revealed the injury grade to be relatively lower in group IV compared to group II and III (P<0.001 and P<0.001, respectively). CONCLUSION This new hypothermic perfusion technique may be very useful in preserving the hepatocytes in hepatic surgery; it is an inexpensive and easy method, which makes it possible to increase its application.
Collapse
Affiliation(s)
- Xiaohui Fu
- Eastern Hepatobiliary Surgery Hospital, Shanghai, People's Republic of China
| | | | | | | | | | | | | | | |
Collapse
|
|
32
|
Abstract
BACKGROUND Worldwide, partial liver resections are increasingly being performed for primary or secondary hepatic malignancies. There are various techniques to reduce blood loss during liver surgery. Several topical haemostatic agents have been developed to improve haemostasis of the resection surface and these agents are used more and more, even although the true effects remain unclear. METHODS The present literature about the use of topical haemostatic agents in liver surgery was reviewed. Furthermore we conducted a Dutch national survey to explore the use of and belief in these agents in liver surgery. RESULTS The Dutch national survey among surgeons showed that topical haemostatic agents are frequently used not only to lower intra-operative blood loss or shorten time to haemostasis, but even more importantly, to reduce resection surface related complications such as bile leakage, postoperative haemorrhage and abscess formation. Although various topical haemostatic agents have been shown to reduce intra-operative time to haemostasis at the resection surface after liver resections, there is no scientific proof that these topical haemostatic agents really reduce resection surface related complications. CONCLUSION This review highlights the need for more randomized clinical trials to investigate the efficacy of topical haemostatic agents in reducing resection surface related complications.
Collapse
Affiliation(s)
- Elizabeth A Boonstra
- Department of Surgery, Division Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | |
Collapse
|
|
33
|
Abstract
OBJECTIVE To report our experience on the safety and efficacy of hepatic resection under selective hepatic vascular exclusion (SHVE). METHODS SHVE was used in 246 consecutive patients undergoing major or complex liver resection in our center. Preoperative demographic and clinical data, details of the surgical procedure, pathologic diagnosis, postoperative course, and complications were collected prospectively. RESULTS From January 2000 to July 2007, liver resections were performed under SHVE in 246 patients; total SHVE, right partial SHVE, and left partial SHVE in 145, 54, and 47 patients, respectively. SHVE was converted to total hepatic vascular exclusion in 3 patients because the tumor invaded the wall of the inferior vena cava. Hemodynamic tolerance to SHVE was excellent, with only a slight increase in systemic and pulmonary vascular resistance during clamping. There were no deaths and the morbidity rate was 24.8%. The mean hospital stay was 9.6 days (range, 8-18). CONCLUSION Our study showed that SHVE was safe, efficacious, and it was applicable to liver tumors which were near, but had not invaded into the inferior vena cava.
Collapse
|
|
34
|
Abstract
Intraoperative blood loss and transfusion of blood products are negatively associated with postoperative outcome after liver surgery. Blood loss can be minimized by surgical methods, including vascular clamping techniques, the use of dissection devices, and the use of topical hemostatic agents. Preoperative correction of coagulation tests with blood products has not been shown to reduce intraoperative bleeding and it may, in fact, enhance the bleeding risk. Maintaining a low central venous pressure has been shown to be effective in reducing blood loss during partial liver resections, and volume contraction rather than prophylactic transfusion blood products seems justified in patients undergoing major liver surgery. Although antifibrinolytic drugs have proved to be effective in reducing blood loss during liver transplantation, systemic hemostatic drugs are of limited value in reducing blood loss in patients undergoing partial liver resections.
Collapse
Affiliation(s)
- Edris M Alkozai
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Ton Lisman
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
| |
Collapse
|
|
35
|
Wong KHV, Hamady ZZR, Malik HZ, Prasad R, Lodge JPA, Toogood GJ. Intermittent Pringle manoeuvre is not associated with adverse long-term prognosis after resection for colorectal liver metastases. Br J Surg 2008; 95:985-9. [PMID: 18563791 DOI: 10.1002/bjs.6129] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intermittent clamping of the porta hepatis, or the intermittent Pringle manoeuvre (IPM), is often used to control inflow during parenchymal liver transection. The aim of this study was to determine whether IPM is associated with an adverse long-term outcome after liver resection for colorectal liver metastasis (CRLM). METHODS All patients undergoing resection for CRLM in 1993-2006, for whom data on IPM were recorded, were included in the study. A total of 563 patients was available for analysis. RESULTS IPM was performed in 289 (51.3 per cent) of the patients. The duration of IPM ranged from 2 to 104 (median 22) min. There were no differences in clinicopathological features or postoperative morbidity between patients who had an IPM and those who did not. The median survival of patients undergoing IPM was 55.7 months compared with 48.9 months in those not having an IPM (P = 0.406). There was no difference in median disease-free survival between the two groups (22.1 versus 19.9 months respectively; P = 0.199). CONCLUSION IPM is not associated with an adverse long-term prognosis in patients undergoing liver resection for CRLM.
Collapse
Affiliation(s)
- K H V Wong
- Hepatopancreatobiliary and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, UK
| | | | | | | | | | | |
Collapse
|
|
36
|
Petrowsky H, McCormack L, Trujillo M, Selzner M, Jochum W, Clavien PA. A prospective, randomized, controlled trial comparing intermittent portal triad clamping versus ischemic preconditioning with continuous clamping for major liver resection. Ann Surg 2007; 244:921-8; discussion 928-30. [PMID: 17122617 PMCID: PMC1856627 DOI: 10.1097/01.sla.0000246834.07130.5d] [Citation(s) in RCA: 170] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate whether ischemic preconditioning (IP) with continuous clamping or intermittent clamping (IC) of the portal triad confers better protection during liver surgery. SUMMARY BACKGROUND DATA IP and IC are distinct protective approaches against ischemic injury. Since both strategies proved to be superior in randomized controlled trials (RCTs) to continuous inflow occlusion alone, we designed a RCT to compare IP and IC in patients undergoing major liver resection. METHODS Noncirrhotic patients undergoing major liver resection were randomized to receive IP with inflow occlusion (n = 36) or IC (n = 37). Primary endpoints were postoperative liver injury and intraoperative blood loss. Postoperative liver injury was assessed by peak values of AST (alanine aminotransferase) and ALT (aspartate aminotransferase), as well as the area under the curve (AUC) of the postoperative transaminase course. Secondary endpoints included resection time, the need of blood transfusion, ICU, and hospital stay as well as postoperative complications and mortality. RESULTS Both groups were comparable regarding demographics, ASA score, type of hepatectomy, duration of inflow occlusion (range, 30-75 minutes), and resection surface. The transection-related blood loss was 146 versus 250 mL (P = 0.008), and when standardized to the resection surface 1.2 versus 1.8 mL/cm (P = 0.01) for IP and IC, respectively. Although peak AST, AUCAST, and AUCALT were lower for IC, the differences did not reach statistical significance. Overall (42% vs. 38%) and major (33 vs. 27%) postoperative complications as well as median ICU (1 vs. 1 day) and hospital stay (10 vs. 11 days) were similar between both groups. CONCLUSIONS Both IP and IC appear to be equally effective in protecting against postoperative liver injury in noncirrhotic patients undergoing major liver resection. However, IP is associated with lower blood loss and shorter transection time. Therefore, both strategies can be recommended for noncirrhotic patients undergoing liver resection.
Collapse
Affiliation(s)
- Henrik Petrowsky
- Swiss Hepato-Pancreato-Biliary (HPB) Center, Department of Visceral & Transplantation Surgery, University Hospital, Zurich, Switzerland
| | | | | | | | | | | |
Collapse
|
|
37
|
Fiegel HC, Lange C, Kneser U, Lambrecht W, Zander AR, Rogiers X, Kluth D. Fetal and adult liver stem cells for liver regeneration and tissue engineering. J Cell Mol Med 2007; 10:577-87. [PMID: 16989722 PMCID: PMC3933144 DOI: 10.1111/j.1582-4934.2006.tb00422.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
For the development of innovative cell-based liver directed therapies, e.g. liver tissue engineering, the use of stem cells might be very attractive to overcome the limitation of donor liver tissue. Liver specific differentiation of embryonic, fetal or adult stem cells is currently under investigation. Different types of fetal liver (stem) cells during development were identified, and their advantageous growth potential and bipotential differentiation capacity were shown. However, ethical and legal issues have to be addressed before using fetal cells. Use of adult stem cells is clinically established, e.g. transplantation of hematopoietic stem cells. Other bone marrow derived liver stem cells might be mesenchymal stem cells (MSC). However, the transdifferentiation potential is still in question due to the observation of cellular fusion in several in vivo experiments. In vitro experiments revealed a crucial role of the environment (e.g. growth factors and extracellular matrix) for specific differentiation of stem cells. Co-cultured liver cells also seemed to be important for hepatic gene expression of MSC. For successful liver cell transplantation, a novel approach of tissue engineering by orthotopic transplantation of gel-immobilized cells could be promising, providing optimal environment for the injected cells. Moreover, an orthotopic tissue engineering approach using bipotential stem cells could lead to a repopulation of the recipients liver with healthy liver and biliary cells, thus providing both hepatic functions and biliary excretion. Future studies have to investigate, which stem cell and environmental conditions would be most suitable for the use of stem cells for liver regeneration or tissue engineering approaches.
Collapse
Affiliation(s)
- H C Fiegel
- Pediatric Surgery, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
| | | | | | | | | | | | | |
Collapse
|
|
38
|
Chen XP, Zhang ZW, Zhang BX, Chen YF, Huang ZY, Zhang WG, He SQ, Qiu FZ. Modified technique of hepatic vascular exclusion: effect on blood loss during complex mesohepatectomy in hepatocellular carcinoma patients with cirrhosis. Langenbecks Arch Surg 2006; 391:209-15. [PMID: 16565854 DOI: 10.1007/s00423-006-0043-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 01/29/2006] [Indexed: 01/18/2023]
Abstract
BACKGROUND Hepatic veins remain patent during complete inflow occlusion (CIO) and bleeding from them may continue. Occlusion of the inferior vena cava (ICV) during CIO may reduce blood loss from hepatic veins. This study was designed to compare the overall outcomes after application of CIO with or without occlusion of the ICV below the liver in complex mesohepatectomy for hepatocellular carcinoma (HCC) patients with cirrhosis. MATERIALS AND METHODS One hundred and eighteen (118) patients were randomly assigned to CIO or a modified technique of hepatic vascular exclusion (MTHVE). Hemodynamic parameters were evaluated and the amount of blood loss, measurement of liver enzymes, and postoperative progress were recorded. RESULTS Blood loss during liver transection in CIO groups was significantly greater than that in MTHVE group (P=0.046). Thus, incidence of blood transfusion was significantly greater in patients of the CIO group (P=0.041). There were no significant differences in liver enzyme changes, bilirubin, or morbidity in the postoperative period between the two groups. CONCLUSIONS CIO with occlusion of the ICV below the liver is a safe, effective, and feasible technique during mesohepatectomy in HCC patients with cirrhosis. Excellent results were obtained with minimized bleeding, limited hepatic function damage, and low rate of postoperative complications.
Collapse
Affiliation(s)
- Xiao-ping Chen
- Hepatic Surgery Center, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
| | | | | | | | | | | | | | | |
Collapse
|
|
39
|
Nagano Y, Matsuo K, Kunisaki C, Ike H, Imada T, Tanaka K, Togo S, Shimada H. Practical usefulness of ultrasonic surgical aspirator with argon beam coagulation for hepatic parenchymal transection. World J Surg 2005; 29:899-902. [PMID: 15951928 DOI: 10.1007/s00268-005-7784-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The objective of this study was to evaluate the effectiveness and feasibility of using the Cavitron ultrasonic surgical aspirator (CUSA) with argon beam coagulation (ABC) during hepatic resection, in comparison with a conventional method using CUSA with bipolar cautery. Between April 2003 and March 2004, a series of 14 consecutive patients underwent hepatic resection of normal liver. Hepatectomies were performed using CUSA and bipolar irrigation electrocautery (BP) in eight patients between April 2003 and December 2003. CUSA and an ABC were used in six patients between January 2004 and March 2004. There were no differences in patient characteristics between the two groups. Blood loss per area of transected liver surface was significantly lower for CUSA with ABC than for CUSA with BP (2.9 +/- 1.44 vs. 6.33 +/- 3.14 ml/cm2). Furthermore, the speed of resection, defined as resection time per area of transected liver surface, was significantly greater for CUSA with ABC than for CUSA with BP (0.53 +/- 0.14 vs. 2.18 +/- 1.73 min/cm2). This new technique of combining CUSA with ABC can decrease blood loss during hepatic parenchymal transection and shorten the resection time.
Collapse
Affiliation(s)
- Yasuhiko Nagano
- Gastroenterological Center, Yokohama City University Medical Center, Minami-ku, Yokohama, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
|
40
|
Eder F, Meyer F, Nestler G, Halloul Z, Lippert H. Sealing of the hepatic resection area using fibrin glue reduces significant amount of postoperative drain fluid. World J Gastroenterol 2005; 11:5984-7. [PMID: 16273610 PMCID: PMC4436721 DOI: 10.3748/wjg.v11.i38.5984] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether the routine use of fibrin glue applied onto the hepatic resection area can diminish postoperative volume of bloody or biliary fluids drained via intraoperatively placed perihepatic tubes and can thus lower the complication rate.
METHODS: Two groups of consecutive patients with a comparable spectrum of recent hepatic resections were compared: (1) 13 patients who underwent application of fibrin glue immediately after resection of liver parenchyma; (2) 12 patients who did not. Volumes of postoperative drainage fluid were determined in 4-h intervals through 24 h indicating the intervention caused bloody and biliary segregation.
RESULTS: Through the first 8 h postoperatively, there was a tendency of higher amounts of fluids in patients with no additional application of fibrin glue while through the following intervals, a significant increase of drainage volumes was documented in comparison with the first two 4-h intervals, e.g., after 12 h, 149.6 mL +/-110 mL vs 63.2 mL +/-78 mL. Using fibrin glue, postoperative fluid amounts were significantly lower through the postoperative observation period of 24 h (851 mL +/-715 mLvs 315 mL +/-305 mL).
CONCLUSION: For hepatic resections, the use of fibrin glue appears to be advantageous in terms of a significant decrease of surgically associated segregation of blood or bile out of the resection area. This might result in a better outcome.
Collapse
Affiliation(s)
- Frank Eder
- Department of Surgery, University Hospital, Leipziger Strasse 44, Magdeburg D-39120, Germany.
| | | | | | | | | |
Collapse
|
|
41
|
Arita J, Hasegawa K, Kokudo N, Sano K, Sugawara Y, Makuuchi M. Randomized clinical trial of the effect of a saline-linked radiofrequency coagulator on blood loss during hepatic resection. Br J Surg 2005; 92:954-9. [PMID: 16034832 DOI: 10.1002/bjs.5108] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Use of a saline-linked radiofrequency coagulator (dissecting sealer) has been suggested to reduce blood loss during hepatic resection. A randomized clinical trial was conducted to assess the effects of using the device on the amount of blood loss. METHODS Patients scheduled to undergo hepatic resection were randomly assigned to either use of the dissecting sealer or the clamp crushing method. The primary outcome measure was blood loss during liver parenchymal division. Multivariate analysis was also performed. RESULTS Ninety-four consecutive patients underwent hepatic resection and 40 patients were assigned to each group. There were no significant differences between the dissecting sealer and clamp crushing groups in blood loss during liver parenchymal division (median 373 versus 535 ml; P = 0.252) or total intraoperative blood loss (665 versus 733 ml; P = 0.450). Multivariate analysis revealed that use of the dissecting sealer offered no protection against blood loss compared with the clamp crushing method (odds ratio 1.17 (95 per cent confidence interval 0.39 to 3.53); P = 0.777), whereas number of resections, thoracotomy and type of resection had a significant effect. CONCLUSION Use of a dissecting sealer offered no substantial benefit over the clamp crushing method in reducing blood loss during hepatic resection.
Collapse
Affiliation(s)
- J Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | | | | | | | | | | |
Collapse
|
|
42
|
Dixon E, Vollmer CM, Bathe OF, Sutherland F. Vascular occlusion to decrease blood loss during hepatic resection. Am J Surg 2005; 190:75-86. [PMID: 15972177 DOI: 10.1016/j.amjsurg.2004.10.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2004] [Revised: 10/05/2004] [Accepted: 10/05/2004] [Indexed: 02/06/2023]
Abstract
BACKGROUND Historically, the primary hazard with liver surgery has been intraoperative blood loss. This led to the refinement of inflow and outflow occlusive techniques. The utility of the different methods of inflow and outflow techniques for hepatic surgery were reviewed. METHODS A search of the English literature (Medline, Embase, Cochrane library, Cochrane clinical trials registry, hand searches, and bibliographic reviews) using the terms "liver," "hepatic," "Pringle," "total vascular exclusion," "ischemia," "reperfusion," "inflow," and "outflow occlusion" was performed. RESULTS A multitude of techniques to minimize blood loss during hepatic resection have been studied. The evidence suggests that inflow occlusion techniques are generally well tolerated. These should be used with caution in patients with cirrhosis, fibrosis, steatosis, cholestasis, and recent chemotherapy, and for prolonged time intervals. CONCLUSIONS Harmful effects of intraoperative blood loss and transfusion occur during hepatic resection. Portal triad clamping (PTC) is associated with less blood loss compared with no clamping. In procedures with ischemic times <1 hour in length, PTC-C (continuous) is likely equal to PTC-I (intermittent). In patients with chronic liver disease or undergoing lengthy operations, PTC-I is likely superior to PTC-C. PTC is superior to total vascular exclusion except in patients with tumors that are large and deep seated, hypervascular, and/or abutting the hepatic veins or vena cava and in patients with increased right-sided heart pressures.
Collapse
Affiliation(s)
- Elijah Dixon
- Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | | | | | | |
Collapse
|
|
43
|
Kraus TW, Mehrabi A, Schemmer P, Kashfi A, Berberat P, Büchler MW. Scientific evidence for application of topical hemostats, tissue glues, and sealants in hepatobiliary surgery. J Am Coll Surg 2005; 200:418-427. [PMID: 15737854 DOI: 10.1016/j.jamcollsurg.2004.09.047] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Revised: 09/30/2004] [Accepted: 09/30/2004] [Indexed: 10/25/2022]
Affiliation(s)
- Thomas W Kraus
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | | | | | | | | | | |
Collapse
|
|
44
|
Frilling A, Stavrou GA, Mischinger HJ, de Hemptinne B, Rokkjaer M, Klempnauer J, Thörne A, Gloor B, Beckebaum S, Ghaffar MFA, Broelsch CE. Effectiveness of a new carrier-bound fibrin sealant versus argon beamer as haemostatic agent during liver resection: a randomised prospective trial. Langenbecks Arch Surg 2005; 390:114-20. [PMID: 15723234 DOI: 10.1007/s00423-005-0543-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Accepted: 12/28/2004] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS A new carrier-bound fibrin sealant, TachoSil, is expected to be efficacious and safe as a haemostatic treatment in hepatic resection. DESIGN A prospective, randomised, open and controlled multicentre trial with intraoperative as well as postoperative assessment of efficacy and a 1 month follow-up period. SETTING Tertiary care centres. PATIENTS/METHODS One hundred and twenty-one patients requiring secondary haemostasis during planned liver resection. Patients with coagulation disorders and patients with persistent major bleeding after primary haemostatic measures were excluded. INTERVENTION Application of either carrier-bound fibrin sealant (n=59) or argon beamer (argon beam coagulator) (n=62) as secondary haemostatic treatment. MAIN OUTCOME MEASURE Time to intraoperative haemostasis. RESULTS There was a significant superiority of TachoSil over argon beamer with regard to time to haemostasis (3.9 min, median 3.0, range 3-20 min vs 6.3 min, median 4.0, range 3-39 min) (P=0.0007). Haemoglobin concentration of drainage fluid was significantly lower on day 2 after surgery in TachoSil patients (1.1 mmol/l) than in argon beamer patients (2.3 mmol/l) (P=0.012). Overall, the frequency and causality of adverse events did not differ between the two treatment groups. CONCLUSION TachoSil is superior to argon beamer in obtaining effective and fast intraoperative haemostasis. The safety data show TachoSil to be tolerable and safe for haemostatic treatment in liver resection.
Collapse
Affiliation(s)
- Andrea Frilling
- Department of General Surgery and Transplantation, University Hospital of Essen, Hufelandstrasse 55, 45147 Essen, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|