Perioperative factors and outcome associated with massive blood loss during major liver resections

Abstract

Background: Mortality and morbidity rates from major liver resections have decreased sharply over the past 25 years. This improvement is due to a better understanding of liver anatomy and the introduction of new operative techniques, but also to improved anesthetic perioperative support. Certain cases are still associated with voluminous blood loss. These patients may be at higher risk for postoperative problems and increased length of stay (LOS) in hospital.

Methods: We have retrospectively reviewed 115 patients undergoing major hepatic resections (three or more anatomic segments) with respect to operative blood loss (EBL). Those with an EBL >or=5000 ml (group 1; n = 39) were compared to those with an EBL <or=2000 ml (group 2; n=42). Type of resection, age (>or=70 years), tumor size, mortality, morbidity, and hospital LOS were examined. Operative reports were examined for any explanation for excessive blood loss. Anesthetic support often entailed the use of a rapid infusion system.

Results: The EBL was 7692+/-3848 ml for group 1 and 1359+/-514 ml for group 2. Primary liver tumors were resected in 20 patients in group 1 and in 18 patients in group 2. The remaining resections were for metastatic tumors, primarily colorectal in origin. In group 1, 13/39 patients had a left hepatectomy compared to 10/42 patients in group 2 (p=0.34). The overall mortality was 5/1 15. Four deaths occurred in group 1 and one in group 2 (p=0.16). Two deaths in group 1 were intra-operative (hemorrhage, air embolism). There was no difference in the number of patients with complications, 12/ 39 in group 1 and 8/42 in group 2 (p=0.22). Two patients in group 1 required re-operation for bleeding; there were none in group 2. Largest tumor size did not differ between the two groups (p=0.08), nor did the proportion of patients aged 70 years or older (p=0.06). There was no difference in hospital LOS (10.54+/-6.1 vs 8.90+/-4.7 days, p=0.2l). Review of operative notes in group 1 indicated no unusual problems in 13/39, large tumors or proximity to the inferior vena cava in 10/39, and bleeding from the middle hepatic vein in 7/39. Three patients in group 1 required total vascular exclusion for tumor removal; there were none in group 2.

Discussion: Massive EBL during major liver resection seems to be provoked by tumors near the inferior vena cava or major hepatic veins, or injury to the middle hepatic vein during operation, and not by patient age, tumor size alone, or type of hepatectomy. However, by avoiding prolonged hypotension and hypothermia with the use of rapid infusion devices, the perioperative course of these patients does not differ from those with much less EBL.