Anesthesiafor Hepatobiliarysurgery: Chris Snowden,, James Prentis
Anesthesiafor Hepatobiliarysurgery: Chris Snowden,, James Prentis
Anesthesiafor Hepatobiliarysurgery: Chris Snowden,, James Prentis
H e p a t o b i l i a r y Su r g e r y
a,b, a
Chris Snowden, MBBS, FRCA, MD *, James Prentis, MBBS, FRCA
KEYWORDS
Hepatobiliary Anesthesia Hepatectomy Enhanced recovery Intrathecal
Opiate
KEY POINTS
Reduced mortality after hepatobiliary surgery is related to improved patient selection,
introduction of preoperative embolization techniques, improved intraoperative surgical
techniques/equipment, and reduced operative blood loss.
Alternative therapies (eg, radiofrequency ablation) are being introduced in patients who
are unable to tolerate extensive hepatic resections.
Lowering the central venous pressure during hepatic resection reduces blood loss but
must be optimized to avoid hypovolemia and excessive use of vasoconstrictor
medication.
Intrathecal opiates may provide an alternative postoperative pain control regimen to
epidural analgesia, especially where there is abnormal coagulation.
INTRODUCTION
Hepatobiliary (HPB) surgery, variably defined to include pancreatic surgery, and liver
and pancreas transplantation, has become a major surgical specialty with explicit
training opportunities, mainly as a response to poor surgical outcomes in the early
1970s. The subsequent improvement in HPB surgical outcomes (now usually <5%
mortality) has been associated with:
1. The concentration of HPB surgery to large volume centers
2. Better preoperative treatment, including radiologic venous embolization and che-
moradiotherapy regimes
3. Introduction of newer surgical techniques and equipment to minimize blood loss
(eg, Cavitron ultrasonic aspirator [CUSA] or harmonic scalpel to dissect the liver
parenchyma).
HEPATIC RESECTION
Outcomes of Hepatic Resection
Hepatic resection is performed for a number of underlying pathologies, including
benign or malignant primary tumors, secondary metastases (predominantly colo-
rectal), and liver trauma. Surgical criteria for patient selection are important.1 If hepatic
malignancy is involved, operative resection is established as the only currently avail-
able modality of treatment with curative potential.
Patients with untreated but potentially resectable hepatic malignancy have been re-
ported to have a median survival time of less than 6 months,2 with virtually no 5-year
survival. Surgical treatment for hepatocellular carcinoma prolongs 10-year survival to
15%.3 Five-year survival after hepatic resection for metastases is 33%,4 compared
with 11% in those not undergoing operative resection. The aim of hepatic resection
is to effect clear tumor margins, while ensuring adequate remaining residual liver to
prevent postoperative hepatic insufficiency. The relevance of a clear resection margin
is reflected in survival. For patients with tumor-free margins greater than 1 cm, a
5-year disease-free survival rate of 35% can be expected. Survival rates are 21%
for patients for whom tumor margins are less than 1 cm, and no 5-year survivors
can be expected when the margins are involved by tumor.5
Hepatic Regeneration
Residual liver volume after surgery is important to postoperative hepatic dysfunction.6
The volume of liver that can be safely resected in humans is approximately 80%,7
assuming good function in the remaining liver, although there are early reports of sur-
vival after resections of 90%.8 The potential for these massive resections (or extensive
ablations) relies on postoperative hepatic regeneration, which has a complex mecha-
nism.9 Under normal circumstances, the human liver initiates regeneration within
3 days and has reached its original size by 6 months,10 although some studies have
shown full restoration at 3 months. Rapid regeneration may allow complete functional
recovery within 2 to 3 weeks.11
PREOPERATIVE CONSIDERATIONS
Table 1
Child-Pugh scoring system
Jaundice
The importance of preoperative jaundice is owing to its prominent association with
perioperative renal impairment.37–39 The mean incidence of postoperative renal
impairment in surgical patients with jaundice is 8%, but may be as high 18%. Whereas
the overall postoperative mortality rate in surgical patients with jaundice ranges from
0% to 27%, the mortality for jaundiced patients who go on to develop acute renal fail-
ure is estimated at 65%. Thus, development of postoperative renal failure is a poor
prognostic sign. The etiology of postoperative renal failure in the setting of liver dis-
ease is multifactorial and includes central volume depletion, defective renal vascular
reactivity, vasoactive mediator imbalance (in which local prostaglandins play a prom-
inent role), and the effect of endotoxin. This makes the renal vasculature susceptible to
renotoxic drugs such as nonsteroidal anti-inflammatory drugs and contrast media.
Preoperative measures to prevent the onset of renal impairment have included
adequate preoperative hydration, mannitol infusion, bile salts, and lactulose. How-
ever, none have demonstrated consistent benefit in adequate clinical trials. Preoper-
ative percutaneous or endoscopic biliary drainage before major HPB surgery does not
improve perioperative outcome consistently and may increase the incidence of chol-
angitis, known to be a poor prognostic factor for outcome. However, preoperative
biliary drainage followed by portal vein embolization has been advocated as a bene-
ficial strategy for major hepatectomy in perihilar cholangiocarcinoma.40 Prolonged pe-
riods of preoperative drainage may allow for the resolution of jaundice, but does not
lead to improved perioperative outcome. Therefore, biliary drainage should be limited
to 2 weeks before surgery.41
Coagulopathy
Correction of coagulation before liver resection is essential where central neuraxial
blockade is being considered. Vitamin K, fresh frozen plasma, or cryoprecipitate
may be required to correct liver-related coagulopathy preoperatively. Reduction in
platelet counts in these patients is common, but abnormalities in platelet function
are often more relevant. Therefore, the preoperative administration of platelets is bet-
ter guided by laboratory testing (eg, thromboelastogram) results than by clinical
judgment.
Ascites
The development of ascites is a poor prognostic sign in cirrhosis and may
adversely influence perioperative respiratory mechanics. Furthermore, ascites, sec-
ondary to splanchnic arteriolar vasodilatation, develops at the expense of circu-
lating intravascular fluid. In conjunction with medical therapy, including diuresis
and paracentesis, there is a real risk of significant intravascular hypovolemia. At-
tempts should be made to correct this state preoperatively and it is important to
recognize that perioperative fluid limitation does not prevent the development of
postoperative ascites.
Encephalopathy
Subclinical hepatic encephalopathy is present in 30% to 70% of cirrhotics and can be
detected by subtle psychometric testing. Elective hepatic surgery should be deferred
130 Snowden & Prentis
INTRAOPERATIVE CONSIDERATIONS
Excessive surgical blood loss is related to adverse short- and long-term postoperative
outcomes after liver resection.42 Because resting total hepatic blood flow represents
about 25% of cardiac output (1200–1400 mL/min; w100 mL/min/100 g), surgical tran-
section of liver parenchyma carries a high risk of blood loss. Reduction of blood loss is
therefore a major consideration during the intraoperative period. Advances in surgical
technique, equipment, and anesthetic measures have all been useful in reducing
blood loss and are detailed herein.
Fig. 1. Isolation of the portal triad before hepatic inflow occlusion. Yellow, bile duct; red 1,
right hepatic artery; red 2, left hepatic artery; blue, portal vein.
Anesthesia for Hepatobiliary Surgery 131
Anesthetic Technique
Intraoperative
Anesthetic techniques during hepatic resection aim to reduce the need for vascular
occlusion techniques by minimizing the potential for blood loss through optimum fluid
132 Snowden & Prentis
Fig. 2. Hepatic resection using combined Cavitron ultrasonic aspirator (CUSA) and
diathermy techniques.
normovolemia (stroke volume variation). Wherever low CVP practices are used in an
attempt to reduce blood loss, there may be the requirement for supplementary vaso-
constrictors (eg, phenyl ephedrine, vasopressin, or norepinephrine) to maintain sys-
temic blood pressure for perfusion of other organs. However, vasoconstrictors may
lead to splanchnic vasoconstriction and secondary hepatic ischemia. Nevertheless,
in most reported series where a low CVP technique has been used, with or without
the judicious use of vasoconstriction, there does not seem to be an increased inci-
dence of organ (especially renal) failure. Another possible complication of low CVP
techniques is air embolus.73 Diligence in monitoring sudden changes in end-tidal
CO2 and in cauterizing open hepatic vessels is vital.
Management of coagulation The coagulopathy associated with liver disease can
contribute significantly to the potential for perioperative bleeding. The liver is the
site of production of all coagulation factors (excluding von Willebrand factor) and
many coagulation inhibitors, fibrinolytic proteins, and their inhibitors. The liver is
also responsible for the breakdown of many of the activated factors of coagulation
and fibrinolysis. In addition, platelet abnormalities and thrombocytopenia secondary
to cirrhosis and hypersplenism are common in liver disease. Hence, it is clear how a
complete range of coagulation abnormalities from hypocoagulability, accelerated
fibrinolysis, through to disseminated intravascular coagulation and hypercoagulable
states associated with low protein C and S levels can be encountered perioperatively.
The complex clotting abnormalities of liver disease are succinctly reviewed by Kang.74
Preoperative assessment of coagulation is a mandatory part of the workup for major
hepatic resection. However, the complex interactions of the numerous aspects of
coagulation system often make for uncertain significance of single factor levels.
Thromboelastography provides a method for assessing clot formation, coagulation
processes, and fibrinolysis. It provides clinical information within 10 to 20 minutes
and is therefore used as a point-of-contact guide to appropriate perioperative man-
agement of coagulopathy in major hepatic resections.
The natural choice for correcting coagulopathy in liver disease is fresh frozen
plasma because it contains all the coagulation and inhibitory factors. However, its ef-
fects are relatively short lived and it has the disadvantages of a large volume load and
potential cross-infection concerns. Cryoprecipitate is a good source of fibrinogen and
tends to be administered for documented hypofibrinogenemia. Platelets transfused
during major resections often have only a transient effect, because they undergo
splenic sequestration. The antifibrinolytic agent, tranexamic acid has shown promise
in reducing transfusion requirement in liver resection and can be used in hepatic sur-
gery with anticipated high blood loss.75–77 However, a Cochrane review was less sup-
portive in their role during resection.78 Newer agents such as activated factor VII have
been used to good effect in liver failure with active hemorrhage,79 but a role in elective
liver resections remains uncertain.80
Other considerations for coagulopathy Because the liver is the site of citrate meta-
bolism, it is important to ensure adequate serum calcium levels during severe coagul-
opathy and where large volumes of citrated blood products are being transfused.
Because major liver resections are often prolonged, the infusion of large fluid volumes
and an “open” abdomen provides an efficient heat sink. Invasive temperature moni-
toring (esophageal or rectal) and scrupulous attention to active warming of the patient
and all infusions must be undertaken perioperatively. Even mild hypothermia can lead
to increased blood loss, particularly through impairment in platelet function. Labora-
tory tests of coagulation are performed at 37 C, and may remain normal requiring
adjustment where hypothermia exists.
134 Snowden & Prentis
POSTOPERATIVE CONSIDERATIONS
Surgical Drains
Surgical practice has traditionally placed a drain in the subphrenic space close to the
resection surface. The main proposed advantages are the prevention of subphrenic
fluid collection, early identification of postoperative bleeding83 and bile leak,83,84
and prevention of ascitic fluid accumulation. However, the evidence that surgical
drainage is conflicting. A Cochrane review of surgical drainage after liver resection sur-
gery85 found that bleeding and bile leakage that required emergency surgical or radio-
logic intervention was uncommon in the early postoperative period after hepatic
resection and that prophylactic drainage did not help in the identification or manage-
ment of these complications. Drainage did not influence mortality rates, and there was
an increase in both chest complications and postoperative wound infections. In
conclusion, there is no evidence to support routine drain use after liver resections.
resection, with acceptable retained liver function, often leads to a procoagulant post-
operative state. Thromboelastogram monitoring also demonstrates a state of postop-
erative hypercoagulability after living donor hepatectomy.88 Reduction in liver function
leads to a decrease in both procoagulant and anticoagulant factors by up to 50%.89
Therefore, venous thromboembolism may occur even in the presence of elevated
standard measures of anticoagulation such as International Normalized Ratio and par-
tial thromboplastin time.90,91 In a retrospective review of 415 patients undergoing ma-
jor hepatectomy, administration of pharmacologic thromboprophylaxis lowered the
rate of venous thromboembolism but did not increase the rate of blood transfusion af-
ter hepatectomy.92 On balance, it is recommended that pharmacologic thrombopro-
phylaxis should be part of an enhanced recovery program unless there is an obvious
contraindication.
Analgesia
The risks and benefits of any mode of analgesia need to be considered for each indi-
vidual in deciding the best treatment of postoperative pain. Because this group of
patients is at risk of renal impairment and coagulation defects, nonsteroidal anti-
inflammatory agents should be avoided wherever possible. Opiates that are metabo-
lized in the liver and excreted renally have the potential disadvantage of accumulation
with cerebral depressant effects in a population with a tendency to encephalopathy.
Use of epidural techniques have been the preferred postoperative analgesic option,
given the proposed benefits on postoperative recovery after major surgery and use
of large surgical incisions during hepatic surgery. However, a major concern is the
associated prolongation of prothrombin time that may develop during surgery. It is
debatable whether this coagulopathy increases the risk of epidural hematoma, but it
often delays epidural catheter removal and increases administration of corrective
blood products.93 Several studies have suggested that intrathecal opiates are a suit-
able alternative to epidural analgesia and have a number of advantages, especially in
terms of embracing the enhanced recovery ethos.94 A recent prospective, observa-
tional study95 compared thoracic epidural with intrathecal morphine and fentanyl
patient-controlled analgesia. Although CVP and blood loss were lower in the epidural
group, in contrast, time to mobilization, fluid requirements, and length of stay were
lower in the intrathecal morphine plus fentanyl patient-controlled analgesia group.
Pain scores were not different in the first 5 postoperative days.
SUMMARY
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