The intra- and early postoperative courses of 142 consecutive patients who underwent liver resections using vascular occlusions to reduce bleeding were reviewed. In 127 patients, the remnant liver parenchyma was normal, and 15 patients had liver cirrhosis. Eighty-five patients underwent major liver resections: right, extended right, or left lobectomies. Portal triad clamping (PTC) was used alone in 107 cases. Complete hepatic vascular exclusion (HVE) combining PTC and occlusion of the inferior vena cava below and above the liver was used for 35 major liver resections. These 35 patients had large or posterior liver tumors, and HVE was used to reduce the risks of massive bleeding or air embolism caused by an accidental tear of the vena cava or a hepatic vein. Duration of normothermic liver ischemia was 32.3 +/- 1.2 minutes (mean +/- SEM) and ranged from 8 to 90 minutes. Amount of blood transfusion was 5.5 +/- 0.5 (mean +/- SEM) units of packed red blood cells. There were eight operative deaths (5.6%). Overall, postoperative complications occurred in 46 patients (32%). The patients who experienced complications after surgery had received more blood transfusion than those with an uneventful postoperative course (p less than 0.001). The length of postoperative hospital stay was also correlated with the amount of blood transfused during surgery (p less than 0.001). On the other hand, there was no correlation between the durations of liver ischemia of up to 90 minutes and the lengths of postoperative hospital stay. The longest periods of ischemia were not associated with increased rates of postoperative complications, liver failures, or deaths. There was no difference in mortality or morbidity after major liver resections performed with the use of HVE as compared with major liver resections carried out with PTC alone, although the lesions were larger in the former group. It is concluded that the main priority during liver resections is to reduce operative bleeding. Vascular occlusions aim at achieving this goal and can be extended safely for up to 60 minutes.

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In conclusion, infusion of warmed fluids, combined with skin-surface warming, helps to prevent hypothermia and reduces the incidence of postoperative shivering.

Intrathecal morphine, as compared with intravenous PCA morphine alone, improves immediate postoperative pain and reduces parenteral morphine consumption but does not improve postoperative recovery in elderly patients after major colorectal surgery.

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The efficacy of leg skin warming in preventing hypothermia and shivering was evaluated in two separate prospective, randomized trials in patients undergoing abdominal surgery. In the first trial, 22 patients were randomized to receive no hypothermia prevention (control group) or active warming with an electric warming blanket (electric blanket group). In the second trial 33 patients were randomized to receive no hypothermia prevention (control group) or forced-air warming (Bair Hugger group) or forced-air warming with insulation of the air blanket from the environment (insulated Bair Hugger group). The core and skin temperatures were measured and changes in body heat content calculated. In the first trial, core temperature was 34.6 +/- 0.3 degrees C at the end of surgery in the control group vs 36.4 +/- 0.1 degrees C in the electric warming blanket group (P < 0.001). Shivering occurred in nine control patients and in one warmed patient (P < 0.05). In the second trial, core temperature was 35.1 +/- 0.2 degrees C at the end of surgery in the control group, 36.3 +/- 0.1 degrees C in the Bair Hugger group (P < 0.01) and 37.1 +/- 0.1 degrees C in the insulated Bair Hugger group (P < 0.01 versus control; P < 0.05 versus Bair Hugger). Shivering occurred in one patient of each warmed group and in seven of the control group (P < 0.05). Skin-surface warming limited to the legs provides sufficient heat (ranging 34 to 43 watts) to counterbalance heat losses during abdominal surgery.

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