How to conclude a right hepatectomy

1. How to conclude a right hepatectomy Sorina Cornateanu Maximilliano Gelli CHB-Hopital Paul-Brousse ACHBT Jeunes, 14.09.2012, Rouen

2. Introduction John Hopkins Hospital Database (1986 – 2005) 9957 pt Complication rate 34.9% - Postoperative hemorrhage 3.2% - Blood transfusion 11.5% - Re-operation 5.2% - Postoperative infection 2.3% Gastrointestinal complications 6.3% Cardiac complications 3.2% Mortality 7.3% Mortality according to the type of liver resection: 1. extended right hepatectomy 8.7% 2. right hepatectomy 6.6% … Segmentectomy 1.8% Schneider, Am Coll Surg 2012 (in press)

3. « Standard » procedure Fixation of remnant liver Doppler US control Portal inflow evaluation Hemostatic break Methilen blue dye test Biological glue Drainage Continuous wound analgesic instillation

4. Remnant liver rotation Ogata, Br J Surg 2005 • Impairment of venous outflow could be underestimated after right liver resection • Fixing the liver whether the triangular ligament has been divided or not and whatever the extent of the right hepatectomy Poon, Hepatogastroenterology 1998Belghiti, Br J Surg 1992

5. Remnant liver rotation Macroscopic hepatic venous congestion Biological cholestasis Jaundice, Ascites Lower extremity oedema Wang, J Gastrointest Surg 2010 Di Domenico, Abdomin Imaging 2012

6. Control of vascular elements by US Advantages: Readily available and inexpensive tool Fast Reproducible Objective data ++ Left and Middle Hepatic Vein - Doppler trifasic waveforms in both HVs - Good velocity - Absence of HV thrombus High risk: exposure of HV > 3 cm along transection plane Arita, Surgery 2007 Left Portal Vein - Portal flow direction and velocity -Regular laminary flow Left branch of Hepatic Artery - Systolic peak

7. Intraoperative CEUS

8. Portal inflow evaluation Transplantation Portal hyperperfusion is correlated with poor postoperative outcomes: - SFSS - Vascular complications - Graft regeneration impairment Troisi, Ann Surg 2003 Eguchi, Liver Transp 2003 Fan, Liver Transp 2011 Portal Flow Modulation - PF > 250 ml/100 gr GW - PP > 20 mmHg PP < 15 mmHg • Different procedures: • Splenic Artery ligation/embolization • Splenectomy • - Portosystemicshunts Hori, Transp 2012

9. 277 patients Paul BroussePostoperativeliverfailure Allard MA, Vibert E. et al. Submitted

10. Portal inflow evaluation Oncological surgery SOS and CASH increase morbidity and liver failure Prolonged preoperative chemotherapy increases the risk of hepatic injury and morbidity Narita, Surg Today 2011 Karoui, Ann Surg 2006 Chun, Lancet Oncol 2009 Experimental data Michaloupulos, AJP 2010 Marubashy Surgery 2004

11. Portal inflow evaluation Transplantation Oncological surgery Experimental Data Cirrhotic liver

12. Hemostatic Break …No scientific data

13. Abdominal drainage Key points: 1. biliary leakage 2. symptomatic fluid collections But.. 3. ascending intraabdominal infection

14. Abdominal drainage 4 RCT in elective liver surgery • sample size and incidence of events • definition of biliary fistula and leakage • - duration of drainage < 7 POD Limits

15. Abdominal drainage Makuuchi, J Hepatobiliary Pancreat Sci 2010 Routine and systematic protocol of drainage management

16. Abdominal drainage Tanaka, Surg Today 2012 < 200 Ablation at POD 2 > 200 Ablation at POD 4 Biliary concentration drainage X Volume of drainage fluid at POD 2 Biliary concentration serum

17. Continuous wound analgesic instillation Chan, Anesthesia 2010

18. Conclusions Systematic Fixation of remnant liver YES Doppler US control YES Portal inflow evaluation YES Hemostatic break ??? Drainage ??? Continuous wound analgesic instillation YES

19. Thank you…