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Semin Thromb Hemost 2012; 38(03): 244-249
DOI: 10.1055/s-0032-1302440
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Prohemostatic Interventions in Liver Surgery

Menno Stellingwerff
1   Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
,
Amarins Brandsma
1   Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
,
Ton Lisman
1   Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
,
Robert J. Porte
1   Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
› Author Affiliations
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Publication History

Publication Date:
17 February 2012 (online)

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Abstract

Surgical procedures of the liver, such as partial liver resections and liver transplantation, are major types of abdominal surgery. Liver surgery can be associated with excessive intraoperative blood loss, not only because the liver is a highly vascularized organ, but also because it plays a central role in the hemostatic system. Intraoperative blood loss and transfusion of blood products have been shown to be negatively associated with postoperative outcome after liver surgery. Dysfunction of the liver is frequently accompanied with a dysfunctional hemostatic system. However, in general, there is a poor correlation between preoperative coagulation tests and the intraoperative bleeding risk in patients undergoing liver surgery. Strategies to avoid excessive blood loss in liver surgery have been an active field of research and include three different areas: surgical methods, anesthesiological methods, and pharmacological agents.

Surgeons can minimize blood loss by clamping the hepatic vasculature, by using specific dissection devices, and by using topical hemostatic agents. Anesthesiologists play an important role in minimizing blood loss by avoiding intravascular fluid overload. Maintaining a low central venous pressure has shown to be very effective in reducing blood loss during partial liver resections. Prophylactic transfusion of blood products such as fresh frozen plasma (FFP) has not been shown to reduce intraoperative bleeding and even seems counterproductive as it results in an increase of the intravascular filling status, which may enhance the bleeding risk. In patients with liver cirrhosis, there is increasing evidence that factors such as portal hypertension and the hyperdynamic circulation play a more important role in the bleeding tendency than changes in the coagulation system. Therefore, intravenous fluid restriction rather than prophylactic administration of large volumes of blood products (i.e., FFP) is recommended in patients undergoing major liver surgery. Pharmacological agents such as antifibrinolytic drugs or recombinant factor VIIa may be indicated in selected individual patients, but these agents do not have a routine role in the management of patients undergoing liver surgery.

Keywords

blood loss - coagulation - hemostasis - liver surgery - liver resection - central venous pressure - fibrin sealants - aprotinin - tranexamic acid
 

  • References

  • 1 Alkozai EM, Lisman T, Porte RJ. Bleeding in liver surgery: prevention and treatment. Clin Liver Dis 2009; 13 (1) 145-154
    CrossrefPubMedGoogle Scholar
  • 2 de Boer MT, Christensen MC, Asmussen M , et al. The impact of intraoperative transfusion of platelets and red blood cells on survival after liver transplantation. Anesth Analg 2008; 106 (1) 32-44
    CrossrefPubMedGoogle Scholar
  • 3 Hendriks HG, van der Meer J, de Wolf JT , et al. Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation. Transpl Int 2005; 17 (11) 673-679
    CrossrefPubMedGoogle Scholar
  • 4 de Boer MT, Molenaar IQ, Porte RJ. Impact of blood loss on outcome after liver resection. Dig Surg 2007; 24 (4) 259-264
    CrossrefPubMedGoogle Scholar
  • 5 de Boer MT, Molenaar IQ, Hendriks HG, Slooff MJ, Porte RJ. Minimizing blood loss in liver transplantation: progress through research and evolution of techniques. Dig Surg 2005; 22 (4) 265-275
    CrossrefPubMedGoogle Scholar
  • 6 Lisman T, Caldwell SH, Burroughs AK , et al; Coagulation in Liver Disease Study Group. Hemostasis and thrombosis in patients with liver disease: the ups and downs. J Hepatol 2010; 53 (2) 362-371
    CrossrefPubMedGoogle Scholar
  • 7 Lisman T, Leebeek FW. Hemostatic alterations in liver disease: a review on pathophysiology, clinical consequences, and treatment. Dig Surg 2007; 24 (4) 250-258
    CrossrefPubMedGoogle Scholar
  • 8 Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood 2010; 116 (6) 878-885
    CrossrefPubMedGoogle Scholar
  • 9 Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011; 365 (2) 147-156
    CrossrefPubMedGoogle Scholar
  • 10 Steib A, Freys G, Lehmann C, Meyer C, Mahoudeau G. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Can J Anaesth 2001; 48 (11) 1075-1079
    CrossrefPubMedGoogle Scholar
  • 11 Massicotte L, Beaulieu D, Thibeault L , et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation 2008; 85 (7) 956-962
    CrossrefPubMedGoogle Scholar
  • 12 Couinaud C. Le Foie: Etudes Anatomiques et Chirurgicales. Paris, France: Masson; 1957
    Google Scholar
  • 13 Clavien PA, Petrowsky H, DeOliveira ML, Graf R. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med 2007; 356 (15) 1545-1559
    CrossrefPubMedGoogle Scholar
  • 14 Bismuth H, Castaing D, Garden OJ. Major hepatic resection under total vascular exclusion. Ann Surg 1989; 210 (1) 13-19
    CrossrefPubMedGoogle Scholar
  • 15 Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg 1998; 85 (8) 1058-1060
    CrossrefPubMedGoogle Scholar
  • 16 Smyrniotis V, Kostopanagiotou G, Theodoraki K, Tsantoulas D, Contis JC. The role of central venous pressure and type of vascular control in blood loss during major liver resections. Am J Surg 2004; 187 (3) 398-402
    CrossrefPubMedGoogle Scholar
  • 17 van Gulik TM, de Graaf W, Dinant S, Busch OR, Gouma DJ. Vascular occlusion techniques during liver resection. Dig Surg 2007; 24 (4) 274-281
    CrossrefPubMedGoogle Scholar
  • 18 van der Bilt JD, Livestro DP, Borren A, van Hillegersberg R, Borel Rinkes IH. European survey on the application of vascular clamping in liver surgery. Dig Surg 2007; 24: 423-435
    CrossrefPubMedGoogle Scholar
  • 19 Nakajima Y, Shimamura T, Kamiyama T, Matsushita M, Sato N, Todo S. Control of intraoperative bleeding during liver resection: analysis of a questionnaire sent to 231 Japanese hospitals. Surg Today 2002; 32 (1) 48-52
    CrossrefPubMedGoogle Scholar
  • 20 Lesurtel M, Selzner M, Petrowsky H, McCormack L, Clavien PA. How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies. Ann Surg 2005; 242 (6) 814-822, discussion 822–823
    CrossrefPubMedGoogle Scholar
  • 21 Takayama T, Makuuchi M, Kubota K , et al. Randomized comparison of ultrasonic vs clamp transection of the liver. Arch Surg 2001; 136 (8) 922-928
    CrossrefPubMedGoogle Scholar
  • 22 Ozier Y, Pessione F, Samain E, Courtois F ; French Study Group on Blood Transfusion in Liver Transplantation. Institutional variability in transfusion practice for liver transplantation. Anesth Analg 2003; 97 (3) 671-679
    PubMedGoogle Scholar
  • 23 Lisman T, Caldwell SH, Porte RJ, Leebeek FW. Consequences of abnormal hemostasis tests for clinical practice. J Thromb Haemost 2006; 4 (9) 2062-2063
    CrossrefPubMedGoogle Scholar
  • 24 Westerkamp AC, Lisman T, Porte RJ. How to minimize blood loss during liver surgery in patients with cirrhosis. HPB (Oxford) 2009; 11 (6) 453-458
    CrossrefPubMedGoogle Scholar
  • 25 Lopez-Plaza I. Transfusion guidelines and liver transplantation: time for consensus. Liver Transpl 2007; 13 (12) 1630-1632
    CrossrefPubMedGoogle Scholar
  • 26 Schroeder RA, Collins BH, Tuttle-Newhall E , et al. Intraoperative fluid management during orthotopic liver transplantation. J Cardiothorac Vasc Anesth 2004; 18 (4) 438-441
    CrossrefPubMedGoogle Scholar
  • 27 Massicotte L, Lenis S, Thibeault L, Sassine MP, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl 2006; 12 (1) 117-123
    CrossrefPubMedGoogle Scholar
  • 28 Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol 2006; 12 (6) 935-939
    PubMedGoogle Scholar
  • 29 Porte RJ, Leebeek FW. Pharmacological strategies to decrease transfusion requirements in patients undergoing surgery. Drugs 2002; 62 (15) 2193-2211
    CrossrefPubMedGoogle Scholar
  • 30 Berrevoet F, de Hemptinne B. Use of topical hemostatic agents during liver resection. Dig Surg 2007; 24 (4) 288-293
    CrossrefPubMedGoogle Scholar
  • 31 Chapman WC, Clavien PA, Fung J, Khanna A, Bonham A. Effective control of hepatic bleeding with a novel collagen-based composite combined with autologous plasma: results of a randomized controlled trial. Arch Surg 2000; 135 (10) 1200-1204, discussion 1205
    CrossrefPubMedGoogle Scholar
  • 32 Schwartz M, Madariaga J, Hirose R , et al. Comparison of a new fibrin sealant with standard topical hemostatic agents. Arch Surg 2004; 139 (11) 1148-1154
    CrossrefPubMedGoogle Scholar
  • 33 Carless PA, Henry DA, Anthony DM. Fibrin sealant use for minimising peri-operative allogeneic blood transfusion. Cochrane Database Syst Rev 2003; (2) CD004171
    PubMedGoogle Scholar
  • 34 Figueras J, Llado L, Miro M , et al. Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients. Ann Surg 2007; 245 (4) 536-542
    CrossrefPubMedGoogle Scholar
  • 35 De Boer MT, Klaase JM, Verhoef C, van Dam RM, van Gulik TM, Molenaar IQ, Bosscha K, Dejong CHC, van der Jagt EJ, Porte RJ , for the FRESCO Trial Group. Fibrin sealant for prevention of resection surface-related complications after liver resection: A randomized controlled trial. Ann Surg 2012; in press
    PubMedGoogle Scholar
  • 36 Ozier Y, Schlumberger S. Pharmacological approaches to reducing blood loss and transfusions in the surgical patient. Can J Anaesth 2006; 53 (6) (Suppl) S21-S29
    CrossrefPubMedGoogle Scholar
  • 37 Henry DA, Carless PA, Moxey AJ , et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2007; (4) CD001886
    PubMedGoogle Scholar
  • 38 Molenaar IQ, Warnaar N, Groen H, Tenvergert EM, Slooff MJ, Porte RJ. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. Am J Transplant 2007; 7 (1) 185-194
    CrossrefPubMedGoogle Scholar
  • 39 Fergusson DA, Hébert PC, Mazer CD , et al; BART Investigators. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med 2008; 358 (22) 2319-2331
    CrossrefPubMedGoogle Scholar
  • 40 Warnaar N, Mallett SV, de Boer MT , et al. The impact of aprotinin on renal function after liver transplantation: an analysis of 1,043 patients. Am J Transplant 2007; 7 (10) 2378-2387
    CrossrefPubMedGoogle Scholar
  • 41 Lentschener C, Benhamou D, Mercier FJ , et al. Aprotinin reduces blood loss in patients undergoing elective liver resection. Anesth Analg 1997; 84 (4) 875-881
    PubMedGoogle Scholar
  • 42 Wu CC, Ho WM, Cheng SB , et al. Perioperative parenteral tranexamic acid in liver tumor resection: a prospective randomized trial toward a “blood transfusion”-free hepatectomy. Ann Surg 2006; 243 (2) 173-180
    CrossrefPubMedGoogle Scholar
  • 43 Pereboom IT, de Boer MT, Porte RJ, Molenaar IQ. Aprotinin and nafamostat mesilate in liver surgery: effect on blood loss. Dig Surg 2007; 24 (4) 282-287
    CrossrefPubMedGoogle Scholar
  • 44 Lodge JP, Jonas S, Oussoultzoglou E , et al. Recombinant coagulation factor VIIa in major liver resection: a randomized, placebo-controlled, double-blind clinical trial. Anesthesiology 2005; 102 (2) 269-275
    CrossrefPubMedGoogle Scholar
  • 45 Planinsic RM, van der Meer J, Testa G , et al. Safety and efficacy of a single bolus administration of recombinant factor VIIa in liver transplantation due to chronic liver disease. Liver Transpl 2005; 11 (8) 895-900
    CrossrefPubMedGoogle Scholar
  • 46 Lodge JP, Jonas S, Jones RM , et al; rFVIIa OLT Study Group. Efficacy and safety of repeated perioperative doses of recombinant factor VIIa in liver transplantation. Liver Transpl 2005; 11 (8) 973-979
    CrossrefPubMedGoogle Scholar
  • 47 Lisman T, Porte RJ. Recombinant factor VIIa to treat severe bleeding in patients with liver disease: pitfalls and possibilities. J Hepatol 2011; 55 (4) 950-951
    CrossrefPubMedGoogle Scholar