Liver Resection
Background
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Lobectomy, segmentectomy, or wedge resection
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Indications for hepatic resection: hepatic metastases, benign & malignant primary hepato-biliary tumours, donation for transplantation, trauma
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Liver = highly vascular; receives 25% of cardiac output; 80% supplies by portal vein, 20% by hepatic artery
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↑ risk of multi-organ dysfxn if underlying hepatic dz
Considerations
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Potential for massive blood loss
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Need for invasive monitors & access
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Risk of postop liver dysfxn & coagulopathy
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Risk of hypoglycemia during vascular occlusion & after resection
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Altered drug metabolism in setting of liver dysfxn
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Temporary occlusion of blood supply during liver resection (surgical technique to minimize bleeding) --> ↓ CO up to 10%, ↑ LV afterload by 20-30%
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Surgical manipulation may cause transient IVC compression & ↓↓ venous return
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Potential co-morbidities: cancer 4M's (mass effects, medications, metastases, metabolic abnormalities), liver disease, EtOH, hepatitis C, carcinoid
Goals & Conflicts
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Overall goals are to avoid & manage postop liver dysfxn, & minimize blood loss
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Avoid hepatotoxins
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Preoperative:
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Assess adequacy of preop cardiopulmn fxn to tolerate surgery
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Determine risk of postop liver failure
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Depends on extent of resection & underlying liver dz
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likely safe to remove 50-80% of liver in young pts w/ nl liver parenchyma
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↑ risk if sig EtOH consumption
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Assessment of extent of liver dz
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Child-Pugh B & C --> liver resection likely contraindicated
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Pts may have portal vein embolization to induce liver hypertrophy preop
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Intraoperative:
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Arterial & central venous access, large bore IV access, rapid infusion system immediately available +/- minimally invasive CO monitoring
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consider cell salvage esp if non-malignant lesion
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Thoracic epidural must be carefully considered w/ risk of postop coagulopathy
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Single-shot neuraxial opioids, IV opioid PCA, continuous wound infusion catheters are alternatives
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Minimize CVP to ↓ blood loss
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Minimize pre-resection IV fluids (max 1 ml/kg/hr)
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titrate vasopressors to maintain optimal perfusion pressure
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Reverse Trendelenburg positioning
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Diuretics (Mannitol, furosemide)
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NTG infusion
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Minimize PEEP
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Consider TXA
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Maintain normothermia, nl pH, nl Ca2+ & normoglycemia
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Monitor for & correct coagulopathy
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Consider N-acetylcysteine to limit ischemia-reperfusion injury (mixed evidence)
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Atracurium/cisatracurium preferred (unaffected by liver dysfxn)
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Postoperative:
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Monitor for postop liver dysfxn, coagulopathy
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Glucose infusion, correction of coagulation & electrolyte abnormalities prn
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Common to develop sig ascites (self-limiting) during 1st 48 hrs --> monitor for hypovolemia
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Avoid acetaminophen until liver fxn returns to nl
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References
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Krige A, Kelliher LJS. Anaesthesia for Hepatic Resection Surgery. Anesthesiol Clin. 2022 Mar;40(1):91-105. doi: 10.1016/j.anclin.2021.11.004. Epub 2022 Feb 11.PMID: 35236585 Review.
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Andrew Hartog, Gary Mills. Anaesthesia for hepatic resection surgery. Continuing Education in Anaesthesia Critical Care & Pain, Volume 9, Issue 1, February 2009, Pages 1–5, https://doi.org/10.1093/bjaceaccp/mkn050