Prolonged normothermic ischaemia of human cirrhotic liver during hepatectomy: A preliminary report

Abstract

To evaluate the tolerance of the cirrhotic liver to extended warm ischaemia, 47 patients with cirrhosis who underwent liver resection over a 4-year period were studied retrospectively. Three groups of patients were identified. In group 1 (14 patients) liver resection was performed under conditions of portal triad occlusion ranging from 50 to 75 (mean 57.1) min. Group 2 (12 patients) was treated with portal occlusion for a period ranging from 30 to 42 (mean 33.1) min. Group 3 comprised 21 patients who underwent hepatectomy using conventional techniques. Mean blood loss was significantly reduced by portal triad occlusion (819 ml in group 1, 523 ml in group 2) compared with the conventional technique (1652 ml in group 3) (P < 0.05, group 1 versus group 3; P < 0.01, group 2 versus group 3). Hospital death occurred in three of the 21 patients in group 3 but in no patient who underwent portal triad occlusion. The morbidity rate was lower in the two occlusion groups (four of 26 patients) than in group 3 (six of 21). Bilirubin metabolism was substantially better after surgery in the occlusion groups (P < 0.05, groups 1 and 2 versus group 3 at day 14). Although the serum levels of transaminases were significantly raised until day 3 in patients undergoing long-term occlusion, the cirrhotic liver withstood the ischaemia-reperfusion insult, as assessed by changes in hepatic microcirculation, lipid peroxidation and the morphology of hepatic sinusoids. It is concluded that prolonged ischaemia during liver resection can be sustained in patients with cirrhosis and without high-risk factors.

Early-onset liver disease complicated with acute liver failure in Alstrom syndrome

“…However, hyperbilirubinemia along with increased transaminases and coagulopathy is expected almost immediately after signi®cant ischemia in cirrhotic patients. In these patients, the mean total bilirubin doubles during the ®rst 24 hours [Kim et al, 1993]. Also, patients have been found to have hyperbilirubinemia, hyperammonemia, elevated transaminases, and coagulopathy [Sivan et al, 1987], after heart surgery complicated with acute hepatic and renal failures secondary to an ischemic event.…”

The Safety of Total Hepatic Vascular Occlusion in Rabbits with Acute Extrahepatic Cholestasis

“…It is highly likely that the back wash of caval blood through the hepatic veins can sustain the metabolic func tion of the hypoperfused liver as well as cause troublesome bleeding during hepatic resec tion [2].…”

“…Tumors located centrally or close to the major veins represent to most sur geons a contraindication to resection. It was shown that the liver can withstand inflow occlusion for more than 1 h [ 1,2], The Pringle K A R G E R maneuver which interrupts the arterial and portal flow to the liver is an insufficient proce dure to control bleeding from the hepatic veins or inferior vena cava (IVC). The tech nique of normothermic total hepatic vascular occlusion (THVO) that was researched origi nally by Heaney ct al.…”

Peri-Operative Care of Patients with Hepatocellular Carcinoma Undergoing Hepatectomy

“…Although the manoeuvre was shown to be well tolerated even in cirrhotic livers in several stud ies, the patient population included in the studies were not strictly comparable. For example, in the study by Kim et al [34] the group of patients with continuous portal inflow clamping for over 1 h shown to have better postop erative outcome had actually much better pre-operative liver function than the group of patients without portal inflow clamping. It is doubtful if intermittent portal inflow clamping is ever necessary because after control of the ipsilateral branches of the portal vein and the hepatic artery bleeding occurs only from branches of the hepatic vein.…”