Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: a single centre retrospective observational study.

BACKGROUND: Right hepatectomy is a complex procedure that carries inherent risks of perioperative morbidity. To evaluate outcome differences between a low central venous pressure fluid intervention strategy and a goal directed fluid therapy (GDFT) cardiac output algorithm we performed a retrospective observational study. We hypothesized that a GDFT protocol would result in less intraoperative fluid administration, reduced complications and a shorter length of hospital stay. METHODS: Patients undergoing hepatectomy using an established enhanced recovery after surgery (ERAS) programme between 2010 and 2017 were extracted from a prospectively managed electronic hospital database. Inclusion criteria included adult patients, undergoing open right (segments V-VIII) or extended right (segments IV-VIII) hepatectomy. PRIMARY OUTCOME: amount of intraoperative fluid administration used between the two groups. SECONDARY OUTCOMES: type and amount of vasoactive medications used, the development of predefined postoperative complications, hospital length of stay, and 30-day mortality. Complications were defined by the European Perioperative Clinical Outcome definitions and graded according to Clavien-Dindo classification. The association between GDFT and the amount of fluid and vasoactive medication used was investigated using logistic and linear regression models. RESULTS: Fifty-eight consecutive patients were identified. 26 patients received GDFT and 32 received Usual care. There were no significant differences in baseline patient characteristics. Less intraoperative fluid was used in the GDFT group: median (IQR) 2000 ml (1175 to 2700) vs. 2750 ml (2000 to 4000) in the Usual care group; p = 0.03. There were no significant differences in the use of vasoactive medications. Postoperative complications were similar: 9 patients (35%) in the GDFT group vs. 18 patients (56%) in the Usual care group; p = 0.10, OR: 0.41; (95%CI: 0.14 to 1.20). Median (IQR) length of stay for patients in the GDFT group was 7 days (6:8) vs. 9 days (7:13) in the Usual care group; incident rate ratio 0.72 (95%CI: 0.56 to 0.93); p = 0.012. There was no difference in perioperative mortality. CONCLUSIONS: In patients undergoing open right hepatectomy with an established ERAS programme, use of GDFT was associated with less intraoperative fluid administration and reduced hospital length of stay when compared to Usual care. There were no significant differences in postoperative complications or mortality. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: no 12619000558123 on 10/4/19.

Lymphatics and colorectal liver metastases: the case for sentinel node mapping.

BACKGROUND: Hepatic resection remains the treatment of choice for patients with colorectal liver metastases (CLM). Indications for hepatic resection have been extended to include extrahepatic lymph node groups, resulting in increased survival benefits. The identification of specific lymph pathways and involved nodes is necessary to support the development of guidelines for a more focused approach to the management of this disease. The feasibility of sentinel node mapping should be investigated to define specific lymphatic groups involved in CLM. METHODS: Scientific papers published from 1950 to 2012 were sought and extracted from the MEDLINE, PubMed and University of Melbourne databases. RESULTS: Several studies have reported microscopic lymph node involvement in 10-15% of patients undergoing hepatic resection for CLM in which no macroscopic involvement was evident. In retrospect, over 80% of lymphadenectomies are proven unnecessary. Traditional imaging modalities have limited predictive value in detecting lymph node involvement. Sentinel node mapping has proved an extremely accurate tool in detecting lymph node involvement and can identify patients in whom lymphadenectomy may be beneficial. CONCLUSIONS: Current imaging techniques are inadequate to detect microscopic lymph node involvement in patients with resectable CLM. The use of sentinel node mapping is proposed to identify nodal groups involved and provide management strategies.

Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial.

BACKGROUND: The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. METHODS: We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications. RESULTS: Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45-1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed. CONCLUSION: In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified.

Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah's Witness undergoing left hepatectomy.

INTRODUCTION: Major liver resection in a Jehovah's Witness presents unique clinical challenges requiring multimodal blood minimization strategies to reduce perioperative complications. We report a case where complete left hepatic lobe devascularisation was undertaken to minimize bleeding in a Jehovah's Witness undergoing left hepatectomy. PRESENTATION OF CASE: A 65-year-old male Jehovah's Witness presented for open left hepatectomy for a large left-sided hepatocellular carcinoma involving segment IV of the liver. Three weeks prior to surgery, the patient underwent left portal vein embolization. To isolate and devascularise the left lobe, the gastroduodenal artery and left hepatic artery were then occluded with coils. The bed of the left hepatic artery was then embolised to stasis with particles. Finally, the anastomosis back to the right hepatic artery was also occluded by coils. The patient underwent uneventful surgery with an estimated blood loss of 450mls. DISCUSSION: Left hepatectomy in a Jehovah's Witness patient is feasible but requires careful planning and a multidisciplinary approach. Major liver resection represents a well defined but complex haemostatic challenge from tissue and vascular injury, further complicated by hepatic dysfunction, and activation of inflammatory, haemostatic and fibrinolytic pathways. In addition to the haemoglobin optimization strategies utilized preoperatively, the use of interventional radiology techniques to further reduce perioperative bleeding should be considered in all complex cases. CONCLUSION: Combination of portal vein embolization and hepatic lobe devascularisation to produce total vascular occlusion of inflow to the left lobe radiologically allowed a near bloodless surgical field during major liver resection in a Jehovah's Witness patient.

Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial.

We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. "precision" fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.

The prognostic significance of lymphatics in colorectal liver metastases.

Background. Colorectal Cancer (CRC) is the most common form of cancer diagnosed in Australia across both genders. Approximately, 40%-60% of patients with CRC develop metastasis, the liver being the most common site. Almost 70% of CRC mortality can be attributed to the development of liver metastasis. This study examines the pattern and density of lymphatics in colorectal liver metastases (CLM) as predictors of survival following hepatic resection for CLM. Methods. Patient tissue samples were obtained from the Victorian Cancer Biobank. Immunohistochemistry was used to examine the spatial differences in blood and lymphatic vessel densities between different regions within the tumor (CLM) and surrounding host tissue. Lymphatic vessel density (LVD) was assessed as a potential prognostic marker. Results. Patients with low lymphatic vessel density in the tumor centre, tumor periphery, and adjacent normal liver demonstrated a significant disease-free survival advantage compared to patients with high lymphatic vessel density (P = 0.01, P > 0.01, and P = 0.05, resp.). Lymphatic vessel density in the tumor centre and periphery and adjacent normal liver was an accurate predictive marker of disease-free survival (P = 0.05). Conclusion. Lymphatic vessel density in CLM appears to be an accurate predictor of recurrence and disease-free survival.