Strategies to Optimize Surgical Success

Given that a small FLR is correlated with an increase in morbidity, we have been interested in developing methods to initiate hypertrophy of the FLR before resection. Portal vein embolization (PVE) has been proposed to induce hypertrophy of the anticipated liver remnant. This concept emerged from the recognition that portal invasion by tumor leads to ipsilateral hepatic lobar atrophy and contralateral lobar hypertrophy. At our institution, PVE involves the percutaneous cannulation of the ipsilateral portal vein under direct fluoroscopic control followed by portography and selected PVE using polyvinyl alcohol and microcoils. PVE is safe, with a < 5% complication rate, causes little periportal reaction, and generates durable portal vein occlusion, especially when used in combination with coils. Others have shown that PVE increases both the size of the FLR and the function of the remnant liver, as demonstrated by an increase in biliary excretion (Uesaka et al, 1996). In addition, in patients with chronic liver disease, PVE has also been reported to decrease the incidence of postoperative complications, intensive care unit stay, and total hospital stay after major hepatic resection. Thus, we use PVE selectively in those patients in whom a remnant volume of < 20% (normal underlying liver) or < 40% (diseased underlying liver) is anticipated. After PVE, repeat CT scans are obtained at 3 to 4 weeks to assess for the extent of compensatory hepatic hypertrophy. Surgical decision making is then appropriately based on post-PVE CT volumetric analysis.

After the selection of appropriate candidates for operative resection, the next most significant determinant of morbidity and mortality in patients undergoing liver resection is the intraoperative course. Expert anesthetic support is critical in obtaining a good surgical outcome. In most cases, general anesthesia is accompanied by a thoracic epidural regional anesthetic. This allows for decreased intraoperative anesthetic use and decreased postoperative narcotic use, which facilitates early mobilization and postoperative pulmonary mechanics. All patients have large-bore intravenous (IV) access established and have a central venous catheter placed to allow for continual intraoperative assessment of central venous pressure. Although there are no data to support their routine use, most patients routinely receive perioperative IV antibiotics. One group of patients who clearly should receive antibiotics are those patients with biliary stents because there are data to suggest that patients with biliary stents are at a significantly higher risk of infectious complications (52% versus 28%) (Hochwald et al, 1999). Blood loss and transfusion requirements are well-established independent intraoperative predictors of patient morbidity. Multiple studies have shown that as the blood loss and transfusion requirement increase, there is a significant corresponding linear increase in the risk of serious morbidity and death from surgery. Massive blood transfusions can add to the risk of coagulopathy and exert immunosuppressive effects. Given this, a familiarity with the techniques to minimize intraoperative blood loss becomes critical. Arguably, the most important factor relating to intraoperative blood loss is the pressure within the inferior vena cava (IVC). In a prospective study examining blood loss and IVC pressure, there was a direct linear correlation between mean caval pressure and blood loss (Johnson et al, 1998).

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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