Consensus and controversy in hepatic surgery: A survey of Canadian surgeons

Abstract

There is variability in some techniques and approaches used by hepatobiliary surgeons. Future research focusing on areas of uncertainty including techniques of blood conservation and post-operative analgesia are needed.

Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid

“…This trial included mainly patients undergoing minor liver resection, with only 18% of patients having major liver resection (greater than two segments), and the results have not changed practice in North America. 32 The trials included in the meta-analysis all evaluated the impact of TXA on clinical outcomes, but only a few of them examined the impact of TXA on laboratory measures of hemostasis. In one trial of TXA in patients undergoing total hip arthroplasty with concomitant hydroxyethyl starch, patients randomized to the control group demonstrated significant fibrinolysis on TEG, and this effect was attenuated by TXA.…”

“…7,27-31 It has not been well studied in patients undergoing liver resection, and it is rarely used in that setting. 32,33 Our objectives were to characterize the impact of liver resection on systemic fibrinolysis, and to define the impact of TXA at two different doses on fibrinolysis.…”

The impact of portal pedicle clamping on survival from colorectal liver metastases in the contemporary era of liver resection: a matched cohort study

“…In addition, the use of PPC is associated with decreased blood loss and the need for blood transfusions . Despite these benefits, adoption of PPC varies widely around the world, perhaps because of concerns regarding its oncologic impact in overall and recurrence‐free survival . The present study was designed with a view to address this issue.…”

“…Despite evidence of the efficacy and safety of PPC with regards to post‐operative morbidity and liver failure, the uptake of PPC is highly variable. While 30% of Canadian hepato‐pancreatico‐biliary surgeons use PPC, 40% do so in the United Kingdom, 50% in Japan and 70% in Continental Europe . Concerns remain regarding the long‐term oncological effects of PPC due to ischemia–reperfusion injury to the liver remnant .…”

Tranexamic acid: a clinical review

“…Although a Cochrane review addressed use of pharmacological intervention for blood conservation in liver resection, and found that aprotinin and TXA significantly reduced the risk of allogeneic blood transfusion compared with a control [108], this review included a few small RCTs. A survey of Canadian hepatobiliary surgeons showed that even though low central venous pressure strategy was used commonly during liver resection, other conservation strategies including TXA were rarely employed [109]. High quality RCTs on perioperative morbidity and mortality are needed to assess pharmacological intervention for blood conservation in hepatectomy.…”