Prolonged lactic acidosis after extended hepatectomy under in situ hypothermic perfusion

Abstract

A 46-year-old woman underwent right extended hepatectomy under total vascular occlusion with in situ hypothermic perfusion for colorectal metastasis. Immediately after surgery, she developed severe lactic acidosis, which required correction with sodium bicarbonate solution and ventilatory support for 36 hours. After 2 days, her lactate normalized, and the acidosis was corrected. She made an uneventful recovery. Persistent lactic acidosis after major hepatic resection under in situ hypothermic perfusion is a rare but reversible problem.Copyright 1999 by the American Association for the Study of Liver Diseases T otal vascular occlusion (TVO) with in situ hypothermic perfusion has been described for major hepatic resections for malignant primary and secondary liver tumors, as well as for benign liver disease. 1,2 Lactic acidosis occurs during vascular inflow occlusion and reverses with revascularization. 3 Persistent but reversible lactic acidosis after hepatectomy under TVO with in situ hypothermic perfusion has not been reported. Case ReportFour months after a low anterior resection for Dukes C stage carcinoma of the rectum, a 46-year-old woman was found to have a hepatic metastasis replacing segment 5 through 8 of the liver with a separate lesion in segment 4. The Tumor involved the right and middle hepatic veins and was adjacent to the left hepatic vein. There was no extrahepatic disease. Extended right hepatectomy with possible local resection of the left hepatic vein was planned under TVO. Venovenous bypass was used. The left liver was perfused with 3 L of University of Wisconsin solution at a temperature of 4°C. TVO continued for 75 minutes, during which an extended right hepatic resection was completed and the tumor was removed without resection of the left hepatic vein. There were no hypotensive episodes during the surgery, and circulating volume was maintained by using crystalloid and transfusing 7 U of blood. Body core temperature was 35.5°C immediately after surgery. Intraoperative and postoperative monitoring by pulse oximetry and arterial blood gas analysis showed that oxygen saturation was maintained within the normal range. After surgery, the patient was found to have metabolic acidosis, with a pH of 7.19, a base deficit of 13, and serum lactate level of 13.9 mmol/L. The acidosis was corrected with 50 mmol/L of sodium bicarbonate in a single dose intravenously, and artificial ventilation was maintained. Although the patient remained acidotic for 36 hours, with a lactate level of 11.7 to 14.8 mmol/L and a pH of 7.2 to 7.27, she did not require further sodium bicarbonate because her pH remained greater than 7.2. Liver function test results and lactate levels are listed in Table 1. DiscussionVascular isolation and hypothermic perfusion allows extensive hepatic resection to be performed with reduced blood loss and ischemic injury. 1 The liver is the principal organ responsible for the removal of plasma lactates, accounting for 40% to 50% of whole-body lactate clearance under basal conditions. 4 In this ...

Complex Liver Resection Using Standard Total Vascular Exclusion, Venovenous Bypass, and In Situ Hypothermic Portal Perfusion

“…11,27,41,42,51,57,62,64,65,70,72,[79][80][81][82][83][84][85][86][87][88][89][90][91][92][93][94] Postoperative mortality occurred in 8 cases (6.3%). Including our 77 cases, postoperative mortality occurred in 23 of 205 cases (11.2%).…”

Management of colorectal liver metastases

“…In these specific circumstances it is also possible to reconstruct the venous outflow, replacing venous segments with autologous vein or prosthetic grafts. The use of veno‐venous bypass with in‐situ hypothermic perfusion, and ex‐situ resection and autotransplantation, have both been described, although the patient groups most suited to these techniques have not been clearly defined [80–83].…”