Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

Abstract

Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.

Perioperative screening and management in elective complex hepatobiliary surgery

“…are available for preoperative volumetric evaluation. In addition to providing volumetric data, newer software-based imaging devices can produce a three-dimensional reconstruction of the hepatic anatomy, tumour extent and its relation to vital structures [4 ▪▪ ,27,28 ▪▪ ]. It should nonetheless be highlighted that despite being a strong predictor of postoperative outcomes, liver volume is basically a surrogate marker for function.…”

“…Perioperative blood transfusions are associated with poor long-term survival in liver cancers and measures to reduce blood loss are always sought [4 ▪▪ ,42,43]. RCTs have shown that intraoperative terlipressin reduced portal pressures and blood loss without any adverse effects.…”

“…Despite these studies, routine use of terlipressin is not a common practice. Several series have looked into the differences between crystalloids and colloids [4 ▪▪ ,39,40 ▪ ,42,43]. No meaningful differences in outcomes have been observed but balanced salt solutions are always recommended against isotonic saline or dextrose solutions.…”

“…Advances in anaesthetic and surgical management of patients undergoing complex hepatobiliary (HPB) surgery have led to substantial reductions in postoperative complications. Although elective, it remains an onerous undertaking and multiple factors contribute to the attendant increased risks [1,2,3 ▪ ,4 ▪▪ ]. An accurate preoperative risk stratification of these patients allows their treatment plans to be adjusted according to the severity and nature of the underlying liver disease, as well as to the type of surgery being undertaken [5 ▪▪ ,6 ▪▪ ].…”

Anesthesiologic Management During Surgery for Hepatocellular Carcinoma

“…The normal range of SVV under controlled ventilation is less than 10-13%. During the resection phase, a SVV of 10-15% can be accepted, while a SVV ≤10% after liver resection represents the target [18,19].…”