6-liver resection revised

Abdominal Surgery CurriculumAbdominal Surgery CurriculumJen Jen BasarabBasarab--TungTung

Liver ResectionLiver Resection

BackgroundBackground

Indications:Indications:

Primary tumorsPrimary tumors

HepatocellularHepatocellular carcinomacarcinoma

CholangiocarcinomaCholangiocarcinoma

Metastatic tumorsMetastatic tumors

Colorectal cancer Colorectal cancer

NeuroendocrineNeuroendocrine tumorstumors

Benign diseaseBenign disease

Symptomatic giant Symptomatic giant hemangiomahemangioma

Hepatic adenoma (risk of rupture and malignant Hepatic adenoma (risk of rupture and malignant degeneration)degeneration)

Living donors for liver transplantsLiving donors for liver transplants

Most commonly left lateral for pediatric recipientMost commonly left lateral for pediatric recipient

R R hepatectomyhepatectomy for adultfor adult--adult in some centersadult in some centers

BackgroundBackground

Indication for resection may inform you Indication for resection may inform you about condition of underlying liverabout condition of underlying liver

HCC almost exclusively arises in setting of HCC almost exclusively arises in setting of cirrhosiscirrhosis

CholangioCaCholangioCa often associated with often associated with cholestasischolestasis

ResectabilityResectability

Determined by CT or MRIDetermined by CT or MRI

Function of location, underlying parenchyma, and Function of location, underlying parenchyma, and future remnant size future remnant size

Will the patient have Will the patient have

enough functional liver left to survive?enough functional liver left to survive?

Relevant AnatomyRelevant Anatomy

Liver gets 25% of cardiac outputLiver gets 25% of cardiac output

Blood flow from the portal vein Blood flow from the portal vein (75%) and hepatic artery (25%)(75%) and hepatic artery (25%)

PostPost--hepatectomyhepatectomy survival requires survival requires only 30% of functional liver only 30% of functional liver remainingremaining

Liver can be divided into 4 lobes Liver can be divided into 4 lobes based on surface anatomy:based on surface anatomy:

RightRight

LeftLeft

CaudateCaudate

QuadrateQuadrate

But liver resections refer to a more But liver resections refer to a more complicated system of classificationcomplicated system of classification


Note the clockwise Note the clockwise numberingnumbering

No surface markersNo surface markers

Caudate: Caudate: 11

Left liver: Left liver: 2, 3, 42, 3, 4

Right liver: Right liver: 5, 6, 7, 85, 6, 7, 8

The Couinaud classification divides liver into 8 segments, each with its own vascular supply and biliary drainage:

Ligamentum Teres


Major Major hepatectomyhepatectomy: resection of 3 : resection of 3 or more segmentsor more segments

Right Right hepatectomyhepatectomy: : 5, 6, 7, 85, 6, 7, 8

Right Right lobectomylobectomy or or trisegmentectomytrisegmentectomy: : 4, 5, 6, 7, 84, 5, 6, 7, 8

Left Left lobectomylobectomy: : 2, 3, 42, 3, 4

Left Left trisegmentectomytrisegmentectomy: : 2, 3, 4, 5, 82, 3, 4, 5, 8

NonNon--anatomic resection (wedge anatomic resection (wedge resection or resection or segmentectomysegmentectomy) ) possible for small tumorspossible for small tumors

Segment 1 has its own (variable) Segment 1 has its own (variable) blood supply and can be blood supply and can be resectedresected with any other lobes/segmentswith any other lobes/segments

7 8 2

4 3

6 5

or right lobectomy

Righthepatectomy

Preoperative ConsiderationsPreoperative Considerations

Liver functionLiver function

Synthetic Synthetic funtionfuntion ((TbiliTbili, albumin, , albumin, coagscoags))

TransaminasesTransaminases

If elevated in setting of viral hepatitis, may be If elevated in setting of viral hepatitis, may be marker of poorer regeneration postmarker of poorer regeneration post-- hepatectomyhepatectomy

Correction of Correction of coagulopathycoagulopathy

Vitamin K and/or FFP infrequently Vitamin K and/or FFP infrequently required for elective resectionsrequired for elective resections

Tumor markers: AFP (HCC), CATumor markers: AFP (HCC), CA--1919--9 9 ((cholangiocholangio) and CEA (colon CA)) and CEA (colon CA)

Assessment for Assessment for resectabilityresectability and and metastasis (CT/MRI)metastasis (CT/MRI)

IncisionIncision

A: Bilateral subcostal incision, which may include excision of the xiphoid. B: J-shaped incision along 8th, 9th, or 10th intercostal space facilitates exposure of segment VII/VIII or tumor involving right diaphragm, and may be extended to the left or lower abdomen.

Anesthetic ConsiderationsAnesthetic Considerations

Consider epidural for postConsider epidural for post--op pain controlop pain control

Check Check coagscoags/platelets and discuss w/ surgeon first/platelets and discuss w/ surgeon first

PostPost--op op coagulopathycoagulopathy related to extent of resectionrelated to extent of resection

EndotrachealEndotracheal intubationintubation

Use Use cisatracuriumcisatracurium in in cirrhoticscirrhotics

Carefully titrate Carefully titrate hepaticallyhepatically cleared drugs to effectcleared drugs to effect

Positioning is usually supine with arms tucked, so Positioning is usually supine with arms tucked, so place lines early and make sure they runplace lines early and make sure they run

Anticipate hemodynamic changesAnticipate hemodynamic changes

CirrhoticsCirrhotics often have low SVR with compensatory often have low SVR with compensatory increase in CO at baselineincrease in CO at baseline

Have Have vasoactivevasoactive meds readymeds ready

Maintain Maintain normothermianormothermia

Hypothermia can worsen Hypothermia can worsen coagulopathycoagulopathy

More on EpiduralsMore on Epidurals

See syllabus for detailed infoSee syllabus for detailed info

Large upper abdominal incisionLarge upper abdominal incision

and high risk for postand high risk for post--up up pulmpulmcomplications suggest epiduralcomplications suggest epiduralanalgesia would be helpfulanalgesia would be helpful

At Stanford, epidurals for liver resections At Stanford, epidurals for liver resections are controversial due to concern for postare controversial due to concern for post--op op coagulopathycoagulopathy

This is NOT the case at most other institutionsThis is NOT the case at most other institutions

As always, discuss plan for As always, discuss plan for neuraxialneuraxial anesthesia anesthesia with your attending and the surgical teamwith your attending and the surgical team

Fluid and Blood ManagementFluid and Blood Management

Anticipate significant blood loss in major resectionsAnticipate significant blood loss in major resections

300300--500 ml in healthy livers, 400500 ml in healthy livers, 400--800 ml in cirrhosis800 ml in cirrhosis

High risk of tearing vessels during mobilization of liverHigh risk of tearing vessels during mobilization of liver

Unable to use cell salvage in cancer patientsUnable to use cell salvage in cancer patients

T&C 2 units PRBC (95% of resections at Stanford use T&C 2 units PRBC (95% of resections at Stanford use <<2 units)2 units)

2 large2 large--bore IVs and abore IVs and a--line almost universallyline almost universally

Consider central line and Level 1 or Belmont in roomConsider central line and Level 1 or Belmont in room

CordisCordis more useful than triple lumen when large losses are predictedmore useful than triple lumen when large losses are predicted

Always consider risks/benefits and discuss with attending and suAlways consider risks/benefits and discuss with attending and surgeon; rgeon; not all resections have large blood losses and require such measnot all resections have large blood losses and require such measuresures

However, keep in mind that transfusion is associated with poor However, keep in mind that transfusion is associated with poor outcomesoutcomes

Infectious diseases, tumor recurrence, postInfectious diseases, tumor recurrence, post--op mortalityop mortality

Try to avoid transfusion unless Try to avoid transfusion unless HctHct <25<25

Low CVP AnesthesiaLow CVP Anesthesia

Low CVP (<5) is strongly associated with Low CVP (<5) is strongly associated with decreased blood loss and better outcomes in decreased blood loss and better outcomes in experienced centersexperienced centers

Almost all bleeding in liver resection is from Almost all bleeding in liver resection is from hepatic veinshepatic veins

Not all resections require a central lineNot all resections require a central line

Usually surgical team will help guide your decision Usually surgical team will help guide your decision as they will anticipate whether low CVP anesthesia as they will anticipate whether low CVP anesthesia will be helpfulwill be helpful

See section on invasive monitors for a critical See section on invasive monitors for a critical discussion of CVPdiscussion of CVP

ComplicationsComplications

Major resections may require ICU careMajor resections may require ICU care

Mortality should be <2Mortality should be <2--5% in experienced hands5% in experienced hands

Virtually all patients have some respiratory Virtually all patients have some respiratory complicationcomplication

AtelectasisAtelectasis, effusion, pneumonia, effusion, pneumonia

AscitesAscites occurs in 20occurs in 20--30% of patients30% of patients

Liver failureLiver failure

Poor baseline hepatic function is a risk factor for Poor baseline hepatic function is a risk factor for worsening of liver failure postworsening of liver failure post--operativelyoperatively

Elderly people are at higher risk due to smaller livers and Elderly people are at higher risk due to smaller livers and fatty replacementfatty replacement

Early signs include hypotension, Early signs include hypotension, pressorpressor requirement, and requirement, and metabolic acidosis toward the end of the casemetabolic acidosis toward the end of the case

Special ConsiderationsSpecial Considerations

Pringle maneuverPringle maneuver

Occluding contents of Occluding contents of hepaticoduodenalhepaticoduodenal ligament ligament (portal vein, hepatic artery, and common bile duct) (portal vein, hepatic artery, and common bile duct) to minimize blood lossto minimize blood loss

Used during Used during transectiontransection of liver parenchymaof liver parenchyma

Keep track of Keep track of ““Pringle timePringle time”” similarly to tourniquet similarly to tourniquet time and notify surgeons q5 mintime and notify surgeons q5 min

Clamp for 15 min, unclamp for 5 min, repeatClamp for 15 min, unclamp for 5 min, repeat

Up to 120 min total ischemia timeUp to 120 min total ischemia time

Consider 10 min clamp, 5 min unclamp in Consider 10 min clamp, 5 min unclamp in cirrhoticscirrhotics

Sometimes the inflow and outflow tracts are Sometimes the inflow and outflow tracts are both occluded (total vascular occlusion)both occluded (total vascular occlusion)

6060--90 minutes usually minutes usually tolerated, 90 minutes usually minutes usually tolerated, though not well and thus performed infrequentlythough not well and thus performed infrequently

Board Review QuestionsBoard Review Questions

Which of the following statements regarding Which of the following statements regarding the anesthetic management of the patient the anesthetic management of the patient with advanced liver disease is TRUE?with advanced liver disease is TRUE?

A. Physical examination of the patient with A. Physical examination of the patient with chronic liver disease is not valuable because chronic liver disease is not valuable because patients do not appear ill before laboratory patients do not appear ill before laboratory evidence of hepatic dysfunction.evidence of hepatic dysfunction.

B. Increased magnitude of liver dysfunction B. Increased magnitude of liver dysfunction does not correlate with higher morbidity and does not correlate with higher morbidity and mortality.mortality.

C. Drugs administered to patients with C. Drugs administered to patients with advanced hepatic disease require careful advanced hepatic disease require careful titration against effect.titration against effect.

D. Decreased doses of vasoconstrictors are D. Decreased doses of vasoconstrictors are needed in these patients.needed in these patients.


Answer: C.Answer: C.

Physical examination of the patient is particularly valuable Physical examination of the patient is particularly valuable because patients may appear ill before there is laboratory because patients may appear ill before there is laboratory evidence of hepatic dysfunction. If no suspicion of liver evidence of hepatic dysfunction. If no suspicion of liver dysfunction arises, then routine laboratory testing for liver dysfunction arises, then routine laboratory testing for liver function is not necessary.function is not necessary.

Regardless of cause, increased magnitude of liver dysfunction Regardless of cause, increased magnitude of liver dysfunction correlates with a higher morbidity and mortality.correlates with a higher morbidity and mortality.

Drugs administered to patients with advanced liver disease Drugs administered to patients with advanced liver disease require careful titration. require careful titration. EncephalopathicEncephalopathic changes are changes are associate with clinically important alterations in associate with clinically important alterations in pharmacodynamicspharmacodynamics and pharmacokinetics of various and pharmacokinetics of various medications. Plasma clearance of medications. Plasma clearance of fentanylfentanyl is significantly is significantly lower in cirrhotic patients.lower in cirrhotic patients.

An increase in plasma concentrations of An increase in plasma concentrations of vasodilatoryvasodilatory substances in cirrhotic patients results in reduced responses substances in cirrhotic patients results in reduced responses to to catecholaminescatecholamines and other vasoconstrictors.and other vasoconstrictors.


The liver receives its blood supply from:The liver receives its blood supply from:

A. The hepatic artery onlyA. The hepatic artery only

B. The portal vein onlyB. The portal vein only

C. Both the hepatic artery and the portal veinC. Both the hepatic artery and the portal vein

D. Vessels that run in the center of the lobulesD. Vessels that run in the center of the lobules

E. The superior mesenteric arteryE. The superior mesenteric artery


Answer: CAnswer: C

The liver receives blood from the hepatic The liver receives blood from the hepatic artery and the hepatic portal vein. The artery and the hepatic portal vein. The hepatic artery is a branch of the celiac trunk. hepatic artery is a branch of the celiac trunk. The vessels, except for the central vein, run The vessels, except for the central vein, run in the interlobular spaces.in the interlobular spaces.


In the patient with cirrhosis:In the patient with cirrhosis:

A. The serum albumin level will be elevatedA. The serum albumin level will be elevated

B. Excessive sodium is lost in the urineB. Excessive sodium is lost in the urine

C. C. PancuroniumPancuronium is more effectiveis more effective

D. Serum gamma globulin level will be lowD. Serum gamma globulin level will be low

E. Less thiopental is required for inductionE. Less thiopental is required for induction


Answer: EAnswer: E

Decreased plasma albumin levels decrease the Decreased plasma albumin levels decrease the bound fraction of thiopental and result in a bound fraction of thiopental and result in a greater fraction of free thiopental.greater fraction of free thiopental.

Serum gamma globulin is higher in cirrhosis, and Serum gamma globulin is higher in cirrhosis, and pancuroniumpancuronium has a larger volume of distribution; has a larger volume of distribution; therefore, it is less effective for a given dose.therefore, it is less effective for a given dose.

Patients with cirrhosis excrete sodiumPatients with cirrhosis excrete sodium--poor or poor or sodiumsodium--free urine.free urine.

ReferencesReferences

Special thanks to Dr. Special thanks to Dr. VisserVisser for editing slidesfor editing slides

BusqueBusque S et al. (2009). Liver/Kidney/Pancreas Transplantation. In JaffS et al. (2009). Liver/Kidney/Pancreas Transplantation. In Jaffe e RA, Samuels SI (Eds.), RA, Samuels SI (Eds.), AnesthesiologistAnesthesiologist’’s Manual of Surgical Proceduress Manual of Surgical Procedures (4(4thth Ed., pp. 680Ed., pp. 680--712). Philadelphia: Lippincott Williams and Wilkins.712). Philadelphia: Lippincott Williams and Wilkins.

Connelly NR and Silverman DG. (2006.) Connelly NR and Silverman DG. (2006.) Review of Clinical AnesthesiaReview of Clinical Anesthesia, 4, 4thth

ed. Philadelphia: Lippincott Williams & Wilkins.ed. Philadelphia: Lippincott Williams & Wilkins.

Fan ST, Lo CM, and Liu CL. (2007). Major Hepatic Resection for PFan ST, Lo CM, and Liu CL. (2007). Major Hepatic Resection for Primary rimary and Metastatic Tumors. In Fischer JE (Ed.), and Metastatic Tumors. In Fischer JE (Ed.), Mastery of Surgery Mastery of Surgery (5(5thth Ed., Ed., pp. 1076pp. 1076--1091). Philadelphia: Lippincott Williams and Wilkins.1091). Philadelphia: Lippincott Williams and Wilkins.

GozzettiGozzetti G et al. Liver resection without blood transfusion. Br J G et al. Liver resection without blood transfusion. Br J SurgSurg 1995;82,11051995;82,1105--11101110

KhatriKhatri VP and VP and AsensioAsensio JA. (2002.) JA. (2002.) Operative Surgery ManualOperative Surgery Manual. . Philadelphia: Saunders Co.Philadelphia: Saunders Co.

So SKS, So SKS, OberhelmanOberhelman HA, and HA, and LemmensLemmens HJM. (2009). Hepatic Surgery. In HJM. (2009). Hepatic Surgery. In Jaffe RA, Samuels SI (Eds.), Jaffe RA, Samuels SI (Eds.), AnesthesiologistAnesthesiologist’’s Manual of Surgical s Manual of Surgical ProceduresProcedures (4(4thth Ed., pp. 550Ed., pp. 550--567). Philadelphia: Lippincott Williams and 567). Philadelphia: Lippincott Williams and Wilkins.Wilkins.

6-liver resection revised

Documents