The role of endovascular treatment of pelvic fracture bleeding in emergency settings.

PURPOSE: To evaluate the role of endovascular treatment for controlling haemorrhage in haemodynamically unstable patients with pelvic bone fractures and to relate clinical efficacy to pre-procedural variables. MATERIALS AND METHODS: From March 2009 through April 2013, 168 patients with major pelvic trauma associated with high-flow haemorrhage were referred to our emergency department and were retrospectively reviewed. Pelvic arteries involved were one or more per patient. Embolisation was performed using various materials (micro-coils, Spongostan, plug, glue, covered stent), and technical success, complications, treatment success, clinical efficacy, rebleeding, and mortality rates were assessed. Factors influencing clinical efficacy were also evaluated. RESULTS: The technical success rate was 100%; no complications occurred during the procedures. Treatment was successful in 94.6% cases, and clinical efficacy was 85.7%. Three patients had to undergo a second arteriography due to recurrent haemorrhage. Fifteen patients died. Pre-embolisation transfusion demand was significantly associated with clinical efficacy. CONCLUSIONS: Percutaneous embolisation of pelvic bleeding may be considered a safe, effective, and minimally invasive therapeutic option. As haemodynamic stability is the first objective with traumatic haemorrhagic patient, arterial embolisation can assume a primary role. On the basis of our results, pre-procedural transfusion status may be considered a prognostic factor. KEY POINTS: • The series presented is one of the largest in a single centre. • Arterial embolisation is a life-saving procedure in patients with pelvic haemorrhage. • In pelvic traumas associated with haemorrhage, prognosis is dependent upon prompt treatment. • Transfusion status is significantly related to clinical efficacy.

Microwave ablation of lung tumours: single-centre preliminary experience.

PURPOSE: This study was done to evaluate the feasibility, effectiveness and safety of microwave (MW) ablation of lung tumours. MATERIALS AND METHODS: Twenty-four patients underwent percutaneous MW ablation of 26 intraparenchymal pulmonary masses. All patients were judged to be inoperable on the basis of tumour stage, comorbidities, advanced age and/or refusal to undergo surgery. Ablation was performed using a microwave generator (Evident Microwave Ablation System, Covidien Ltd., Dublin). Lesions with a diameter ≤ 3 cm were treated with a single antenna, lesions with a diameter >3 cm were treated by positioning two or more antennae, simultaneously. All patients underwent computed tomography (CT) follow-up with and without contrast administration at 1, 3 and 6 months and then yearly in combination with complete blood and metabolic tests. RESULTS: Technical success was 100 %. No major complications were recorded. Asymptomatic grade-1 pneumothorax was recorded in 9 patients (37.5 %). One case of asymptomatic pleural effusion and one of haemoptysis, not requiring transfusion, were observed. No patients were diagnosed with a post-ablation syndrome. Complete necrosis was observed in 16 of 26 lesions (61.6 %). Partial necrosis was obtained in 30.8 % (8/26 lesions); in one case (3.8 %) a progression of the disease was recorded and in another case (3.8 %) a stability was observed. CONCLUSIONS: Our preliminary experience may be considered in accordance with literature dates, in terms of efficacy and safety.

Usefulness and safety of biliary percutaneous transluminal forceps biopsy (PTFB): our experience.

AIM: To evaluate the usefulness and safety of percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction. MATERIAL AND METHODS: Forty consecutive patients (21 men and 19 women; mean age, 71.9 years) underwent forceps biopsy through percutaneous transhepatic biliary access performed to drain bile. Lesions involved the common bile duct (n 8), common hepatic duct (n 18), hilum (n 6), ampullary segment of the common bile duct (n 8) and were biopsied with 7-F biopsy forceps. Final diagnosis was confirmed with pathologic findings at surgery, or clinical and radiologic follow-up. RESULTS: Twenty-one of 40 biopsies resulted in correct diagnosis of malignancy. Thirteen biopsy diagnosis were proved to be true-negative. There were six false-negative and no false-positive diagnoses. Sensitivity, specificity and accuracy in aspecific biliary obstructions were 85%, 100% and 88,7% respectively. Sensitivity of biopsy in malignancies was higher than in benign obstructions (100% vs 68,4%, CI = 95%). Sensitivity was lower in the hilum tract and in the common bile duct than in other sites (CI = 95%). No major complications related to biopsy procedures occurred. CONCLUSIONS: Percutaneous transluminal forceps biopsy is a safe procedure, easy to perform through a transhepatic biliary drainage tract, providing high accuracy in the diagnosis of malignant biliary obstructions.

Microwave ablation of pancreatic head cancer: safety and efficacy.

PURPOSE: To evaluate the safety and efficacy of percutaneous microwave (MW) ablation treatment in locally advanced, nonresectable, nonmetastatic pancreatic head cancer. MATERIALS AND METHODS: Ten patients with pancreatic head cancer treated with percutaneous (n = 5) or laparotomic (n = 5) MW ablation were retrospectively reviewed. The MW generator used (45 W at 915 MHz) was connected by coaxial cable to 14-gauge straight MW antennas with a 3.7- or 2-cm radiating section. One or two antennae were used, with an ablation time of 10 minutes. Ultrasonographic (US) and combined US/cone-beam computed tomographic (CT) guidance were used in five patients each. Follow-up was performed by CT after 1, 3, 6, and, when possible, 12 months. Tumor response was assessed per Response Evaluation Criteria In Solid Tumors (version 1.1) and Choi criteria. The feasibility, safety, and major and minor complications associated with quality of life (QOL) were recorded prospectively. RESULTS: The procedure was feasible in all patients (100%). One late major complication was observed in one patient, and no visceral injury was detected. No patient had further surgery, and all minor complications resolved during the hospital stay. An improvement in QOL was observed in all patients despite a tendency to return to preoperative levels in the months following the procedure, without the influence of minor complications. No repeat treatment was performed. CONCLUSIONS: Despite the small number of patients, the present results can be considered encouraging, showing that MW ablation is a feasible approach in the palliative treatment of pancreatic tumors.

Percutaneous sonographically guided radiofrequency ablation of medium-sized fibroids: feasibility study.

OBJECTIVE: The purpose of this study was to assess the feasibility and safety of percutaneous radiofrequency ablation under sonographic guidance as a unique procedure in the management of symptomatic uterine myomas. SUBJECTS AND METHODS: Six premenopausal women with symptomatic submucosal or intramural uterine myomas underwent percutaneous radiofrequency ablation under suprapubic sonographic guidance. Relief of symptoms and reduction in the diameter and volume of the myomas were measured every 3 months. RESULTS: The location of myomas was anterior and submucosal in one of the six patients and intramural in the other five (one posterior, one anterior, two fundal, and one on the left side). Five of the patients had pelvic pain, and four had menorrhagia. The median baseline diameter was 4.8 cm (range, 4.4-5.2 cm), and the mean volume was 58.57 cm3 (range, 44.58-73.58 cm3). The mean follow-up time was 9 months (range, 3-12 months). At follow-up, the median diameter was 2.3 cm (range, 1.20-3.2 cm), and the median volume was 8.97 cm3 (range, 0.90-18.81 cm3). The median preoperative symptom score was 47.2 (31.8-67.30), and the median health-related quality of life (QOL) score was 63.92 (37.20-86.00). The median symptom score during follow-up was 5.15 (range, 0-26), and the mean QOL score was 96.2 (range, 86.30-100). Four of six patients were symptom-free at the last follow-up visit. CONCLUSION: Percutaneous sonographically guided radiofrequency ablation alone is a feasible and efficient procedure in the management of medium-sized uterine myomas.

Bleeding after percutaneous radiofrequency ablation: Successful treatment with transcatheter embolization.

PURPOSE: This knowledge will provide an ability to earlier detect bleeding complications after radiofrequency ablation (RFA), to manage these complications appropriately with endovascular procedures and minimize the sequelae. MATERIALS AND METHODS: From 2002 to 2005, 96 patients with 150 hepatic tumours underwent 126 RFA sessions. Fifty-eight patients had HCC, 34 had liver colorectal metastases and 4 had cholangiocellular carcinoma. Sixty-one patients were men and 35 were women (mean age 69.82 years, age range 39-89). The lesions number ranged from 1 to 7 per patients (mean 1.6 nodules) with a mean diameter of 28.5 mm (range 80-10 mm). Seventy-seven patients underwent a single ablative session, 13 patients underwent 2 sessions, 4 patients underwent 3 sessions and 2 patients underwent 4 sessions. The number of tumours treated in each ablative session was 1 in 106, 2 in 18 and 4 in 2 patients. RESULTS: Two cases of serious haemorrhages occurred after the procedures in two patients treated for liver metastases. An endovascular embolization was proposed for both patients using polyvinyl-alcohol and micro-coils. The absence of bleeding was first confirmed during angiography and then by CT performed the day after the angiographic procedure. CONCLUSION: Transarterial embolization (TAE) represents the treatment of choice in the management of iatrogenic bleeding after RFA since it is minimally invasive, have a high success rate and a low incidence of complications compared to the more complex and dangerous surgical or laparoscopic options in patients who are often haemodynamically unstable and therefore at high anaesthetic and surgical risk.

Predictive features associated with thyrotoxic storm and management.

Thyroid storm (TS) is an endocrine emergency characterized by rapid deterioration, associated with high mortality rate therefore rapid diagnosis and emergent treatment is mandatory. In the past, thyroid surgery was the most common cause of TS, but recent preoperative medication creates a euthyroid state before performing surgery. An active approach during perioperative period could determine an effective clinical treatment of this life-threating diseases. Recently, the Japan Thyroid Association and Japan Endocrine Society developed diagnostic criteria for TS focusing on premature and prompt diagnosis avoiding inopportune e useless drugs. This review analyses predictive features associated with thyrotoxic storm highlighting recent literature to optimize the patient quality of care.

Emergency endovascular stent-graft treatment for acute thoracic aortic syndromes.

OBJECTIVE: We report the results of our ongoing experience of urgent and emergency stent-graft implantation in acute thoracic aortic syndromes. METHODS AND RESULTS: In the last 5-years, 19 patients were treated for acute thoracic aortic syndromes. Traumatic rupture was diagnosed in 7 patients, complicated acute type B dissection was present in 5 patients, penetrating ulcer in 4, and symptomatic thoracic aortic aneurysm in 3 patients. There were 17 male patients with a mean age of 54 +/-26 years (range 18-87 ; median 63). Patients were treated in the theatre suite under general anesthesia. Stent-graft placement was technically successful in all patients. The early postoperative mortality was 10.5 %. Neurological events or upper arm ischemia due to overstenting of the left subclavian artery were not observed. Average intensive care unit and hospital stay were 18 and 21 days, respectively. Major complications occurred in 6 patients. Follow-up ranged between 3 and 60 months (mean 25) and included clinical examinations and serial CT-angiography at 1, 4 and 12 months, and every year thereafter. Only one type II endoleak was detected and treated by coil embolization of the left subclavian artery. CONCLUSIONS: Our experience suggests emergency stent-graft repair in patients with acute thoracic aortic syndromes is a less-invasive attractive alternative, showing encouraging early and mid-term results.

Infected pancreatic necrosis.

BACKGROUND: Infected pancreatic necrosis is a late infective complication of acute necrotizing pancreatitis in which infection tends to spread from the pancreas to the peripancreatic tissues, retroperitoneum, and, more rarely, the peritoneal cavity. Severe and rapid deterioration of the clinical condition may lead to septic shock and multiple organ dysfunction syndrome. CAUSATIVE ORGANISMS: The microorganisms most frequently isolated in cases of acute bacterial pancreatitis have been historically gram-negative bacteria of enteric origin. However, gram-positive cocci are isolated with increasing frequency. Enterococci are the single most commonly isolated species. TREATMENT: Aggressive multimodal therapy in the early stage of severe necrotizing pancreatitis improves survival; patients with infective complications tend to die later from multiple organ dysfunction syndrome. Initially, the treatment consists of fluids, analgesics, and oxygen supplementation. Surgical debridement should be limited to proved infections and delayed as long as possible to allow necrotic tissue to become demarcated. When surgery is necessary, blunt debridement of necrotic tissues is the procedure largely utilized and usually is not accompanied by excessive bleeding. Pancreatic resection should be reserved for massive necrosis of the gland substance. In many situations, the abdominal incision can be closed primarily. Treatment by the "open abdomen" technique should be reserved for those patients in whom further laparotomies are planned, mainly because of incomplete unsatisfactory debridement or uncontrolled bleeding that necessitates packing of the lesser sac. CONCLUSION: Modern management techniques have reduced the mortality of infected pancreatic necrosis to 15-20% from historical rates that were twice as high. Aggressive resuscitation and surveillance of infection are crucial for successful outcomes, although fewer patients are undergoing surgical debridement.

Recommendations and reports about central venous catheter-related infection.

BACKGROUND: Central venous catheters (CVCs) are used to deliver a variety of therapies, as well as for measurement of hemodynamic parameters. The major associated complication is catheter-related blood stream infection (CRBSI). METHOD: Review of the pertinent English-language literature. RESULTS: The incidence of CRBSI depends on how such infections are defined. Generally, the term includes all BSIs in patients with CVCs when other sources can be excluded, and if a culture of the catheter tip demonstrates a substantial number of colonies of the organism found in the blood stream. Important pathogenic determinants of catheter-related infection are the material of which the device is made and the intrinsic virulence of the organism. The site at which a catheter is placed influences the risk of infection. The types of organisms that most commonly cause hospital-acquired BSIs have changed over time. Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection. Good hand hygiene before catheter insertion, combined with proper aseptic technique during its manipulation, provides protection against infection; maximal sterile barrier precautions during insertion reduce the incidence of CRBSI. Catheters that are coated or impregnated with antimicrobial or antiseptic agents can decrease the risk and the associated hospital costs. No studies have demonstrated that oral or parenteral antibacterial or antifungal drugs reduce the incidence of CRBSI in adults. Use of anticoagulants might have a role in the prevention of CRBSI. Catheter replacement at scheduled intervals has not lowered rates of local or systemic complications. CONCLUSIONS: Central venous catheters are used commonly to deliver a variety of therapies, such as large amounts of fluid or blood products during surgery or in intensive care units, chemotherapy, and parenteral nutrition, as well as for measurement of hemodynamic variables. The major complication associated with CVCs is CRBSI.

Treatment of secondary hyperparathyroidism with ultrasonographically guided percutaneous radiofrequency thermoablation.

We present a case of a 63-year-old woman with a recurrent secondary hyperparathyroidism hyperplasia with absolute contraindication for surgery, treated in 2 sessions with percutaneous ultrasonographically guided radiofrequency tissue ablation. The complete pathologic tissue ablation was confirmed by contrast-enhanced ultrasonography performed before and after the treatment and by clinical and laboratory follow-up. Furthermore in work progress, the percutaneous ultrasonographically guided radiofrequency tissue ablation can be considered a feasible and effective nonsurgical alternative treatment for symptomatic secondary hyperparathyroidism in high-risk patients.

Uncommon Case of a Post-Traumatic Portal Vein Pseudoaneurysm Treated with Percutaneous Transhepatic Stent Grafting.

We describe a man who presented with a traumatic portal vein pseudoaneurysm, which was subsequently managed with a percutaneous transhepatic stent graft. This case demonstrates a rarely seen condition in the traumatic population and a novel management strategy, which should be considered in the management of this challenging injury.

Endovascular repair for concomitant multilevel aortic disease.

OBJECTIVE: Patients with multilevel aortic disease represent a small subgroup with the need for extensive surgical treatment at considerable risk. We present our experience of endovascular exclusion for simultaneous thoracic and abdominal aortic disease in four patients. METHODS: Between January 2002 and January 2005, four patients underwent endovascular repair for simultaneous thoracic and abdominal aortic disease. Mean age was 69+/-10 years (range, 60-81). Thoracic lesions included penetrating aortic ulcer (n=2, ruptured=1), atherosclerotic aneurysm (n=1), and chronic type B dissection (n=1). Abdominal aortic disease included atherosclerotic infrarenal (n=3) and juxtarenal (n=1) aortic aneurysms. Thoracic aortic stent-grafts had been the following: Excluder/TAG (n=3) or Talent (n=1) straight tube devices. Abdominal aortic stent-grafts used were as following: Excluder (n=3) or Zenith (n=1). All patients were followed-up with CT-angiography and chest X-rays 1, 4, 12 months after the procedure, and once per year thereafter. RESULTS: Stent-graft deployment was technically successful in all cases. Intraoperative mortality was not observed. Mean procedure time was 94+/-34 min (range, 70-145). Early postoperative complications occurred in one patient that developed acute renal failure but dialysis was not required. Mean hospitalisation was 8+/-5 days (range, 4-15). Late death occurred in one patient for an undetected ruptured thoracic type 1 endoleak. All three survivors are currently well 16.5 months (range, 3-36) after surgery. No neurological complications developed. CONCLUSION: Simultaneous abdominal and thoracic endovascular repair for multilevel aortic disease is feasible and could be a viable alternative in high-risk patients, who otherwise may not be suitable candidates for conventional repair.

Influence of new technologies on thyroid surgery: state of the art.

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between 1873 and 1910. In general, the essential objectives for thyroidectomy are conservation of the parathyroid glands, avoidance of injury to the recurrent laryngeal nerve, an accurate hemostasis and an excellent cosmesis. In the last 20 years, major improvements and new technologies have been proposed and applied in thyroid surgery; among these are mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia and intraoperative neuro-monitoring.

Intraoperative aspects and complications for the anesthesiologist in the management of patients undergoing thoracic surgery for lung cancer.

Surgery, when feasible, rappresents the treatment of choice for lung cancer. Several problems can come to the attention of the anesthesiologist in relation to the respiratory function with implications in airway control (double-lumen tube for lung collapse required for better surgical exposure of the pulmonary tissue), mechanical and gas-exchange aspects (increase in airway pressure of the dependent lung, increased blood shunt). The effect of these disorders, with no compensatory mechanism (pulmonary hypoxic vasoconstriction) and in the absence of an anesthesiologist (higher FiO2, low tidal volumes, allowing "permissive hypercapnia", CPAP to the non-dependent lung), normal arterial oxygenation (hypoxemia) is impaired. Right heart failure is the major risk particularly in preexisting pulmonary hypertension Supraventricular arrytmias can often occur in case of history of cardiovascular disease, metabolic and mechanical intraoperative alterations (type and duration of surgery, pericardial and autonomic nervous system manipulations). Unusual complications are cardiac herniation and pulmonary re-expansion-edema.

Open abdomen management of intra-abdominal infections: analysis of a twenty-year experience.

BACKGROUND: No conclusive results on the efficacy and timing of open abdomen (OA) are available, particularly in the setting of intra-abdominal infections. We analyzed outcomes and risk factors retrospectively in a large series of patients managed with an OA during the past 20 y in an effort to clarify this issue. METHODS: We reviewed the records of 133 patients who underwent treatment with an OA, considering factors related to patient, disease, medical management, and surgical treatment. The end points of the bi-variable analysis were 1-y mortality, calculated from the time of an initial OA procedure, and definitive fascial closure. RESULTS: Most patients (112/133) managed with an OA had one of several types of peritonitis. Many patients had severe clinical conditions (mean Acute Physiology and Chronic Health Evaluation [APACHE] II score was almost 9 points for the study population). With regard to surgical management, the mean (+SD) number of abdominal revisions was 5.9+9.3 during a mean duration of treatment with an OA of 14.3+11.6 d. The overall mortality in the study was 26% (35/133). Bi-variable analysis revealed factors associated with overall mortality to be age, renal and respiratory co-morbidities, edema on an initial chest radiograph, blood pressure, blood glucose and creatinine concentrations; and APACHE II score. The rate of definitive fascial closure was 75% (100/133). Factors associated negatively with fascial closure were respiratory co-morbidity, edema on a first chest radiograph, post-operative mesenteric ischemia as an indication for OA, blood glucose and creatinine concentrations, and duration of an OA. CONCLUSIONS: Patients' pre-operative clinical status influences strongly their response to surgical treatment. The management of OA does not affect adversely the survival of patients with intra-abdominal infections, but factors related to the management of OA (duration of OA) seem to affect the possibility of definitive fascial closure.

Single-antenna microwave ablation under contrast-enhanced ultrasound guidance for treatment of small renal cell carcinoma: preliminary experience.

The purpose of this study was to determine the safety, effectiveness, and feasibility of microwave ablation (MWA) of small renal cell carcinomas (RCCs) in selected patients. Institutional review board and informed consent were obtained. From December 2007 to January 2009, 12 patients (8 male, 4 female) were enrolled in a treatment group, in which percutaneous MWA of small RCCs was performed under contrast-enhanced ultrasound guidance. The tumors were 1.7-2.9 cm in diameter (mean diameter, 2.0 cm).Therapeutic effects were assessed at follow-up with computed tomography. All patients were followed up for 3-14 months (mean, 6 months) to observe the therapeutic effects and complications (according to SIR classification). Assessment was carried out with CT imaging. No severe complications or unexpected side effects were observed after the MWA procedures. In all cases technical success was achieved. Clinical effectiveness was 100%; none of the patients showed recurrence on imaging. In conclusion, our preliminary results support the use of MWA for the treatment of small renal tumors. This technology can be applied in select patients who are not candidates for surgery, as an alternative to other ablative techniques.

Ultrasound-guided radiofrequency thermal ablation of uterine fibroids: medium-term follow-up.

Previous studies have shown that radiofrequency thermal ablation (RFA) of uterine fibroids through a percutaneous ultrasound (US)-guided procedure is an effective and safe minimally invasive treatment, with encouraging short-term results. The aim of this study was to assess the results in terms of volume reduction and clinical symptoms improvement in the midterm follow-up of fibroids with a diameter of up to 8 cm. Eleven premenopausal females affected by symptomatic fibroids underwent percutaneous US-guided RFA. Symptom severity and reduction in volume were evaluated at 1, 3, 6, 9, and 12 months. The mean symptom score (SSS) before the procedure was 50.30 (range 31.8-67.30), and the average quality of life (QOL) score value was 62 (range 37.20-86.00). The mean basal diameter was 5.5 cm (range 4.4-8) and the mean volume was 101.5 cm(3) (range 44.58-278 cm(3)). The mean follow-up was 9 months (range 3-12 months). The mean SSS value at the end of the follow-up was 13.38 (range 0-67.1) and the QOL 90.4 (range 43.8-100). At follow-up the mean diameter was 3.0 cm (range 1.20-4.5 cm), and the mean volume was 18 cm(3) (range 0.90-47.6 cm(3)). In 10 of 11 patients we obtained total or partial regression of symptoms. In one case the clinical manifestations persisted and it was thus considered unsuccessful. In conclusion, US-guided percutaneous RFA is a safe and effective treatment even for fibroids up to 8 cm.

Radiofrequency thermal ablation for pain control in patients with single painful bone metastasis from hepatocellular carcinoma.

OBJECTIVE: The aim of this study was to assess the safety and the efficacy of radiofrequency thermal ablation (RFA) for pain relief and analgesics use reduction in two patients with painful bone metastases from hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Two patients with lytic metastases from HCC located at the left superior ileo-pubic branch and at the middle arch of VII rib, performed RFA displacing a LeVeen Needle (3.5 and 4.0 cm diameter) under US (ultrasonography) and fluoroscopic guidance. Two methods were used to determine the response of both patients: the first method was to measure patient's worst pain with a Brief Pain Inventory (BPI) 1 day after the procedure, every week for 1 month, and thereafter at week 8 and 12 (total follow-up 3 months); the second method was to evaluate patient's analgesics use recorded at week 1, 4, 8 and 12. Analgesic medication use was translated into a morphine-equivalent dose. RESULTS: The RFA were well tolerated by the patients who did not develop any complication. Both patients obtained substantial reduction of pain, which decreased from a mean score of 8 to approximately 2 in 4 weeks. In both patients we observed a reduction in the use of morphine dose-equivalent after a peak at week 1. CT (computed tomography) imaging, performed at 1 month after RFA, demonstrated that both procedures were technically successful and safe because consistent necrosis and no evidence for complications were observed. CONCLUSION: RFA provides a potential alternative method for palliation of painful osteolytic metastases from HCC; the procedure is safe, and the pain relief is substantial.

Effect of perioperative blood transfusion on clinical outcomes in hepatic surgery for cancer.

Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of different types of complications: infectious complications, tumor recurrence, decreased survival. Even if there is clear evidence of transfusion-induced immunosuppression, it is difficult to demonstrate that transfusion is the only determinant factor that decisively affects the outcome. In any case there are several motivations to reduce the practice of blood transfusion. The advantages and drawbacks of different transfusion alternatives are reviewed here, emphasizing that surgeons and anesthetists who practice in centers with a high volume of liver resections, should be familiar with all the possible alternatives.